Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: I want to start today's episode
Speaker: of the podcast by thanking all our listeners and all our critical care colleagues at the bedside intensivist nurses, respiratory therapists, and advanced practice providers who have really been working tirelessly to take care of COVID-19 patients and have been an instrumental response to this devastating pandemic.
Speaker: We have touched on many clinical topics in the podcast related to COVID and recently some non-related to COVID.
Speaker: Today's episode, we'll take a little bit of a break from those clinical topics, and I'll share with you some thoughts from a previous webinar I did recently on thinking beyond burnout on this idea of professional transcendence and how we can find a path
Speaker: to really overcome not only the issues related to burnout, but to build careers that are meaningful and that provide us joy.
Speaker: This pandemic has clearly showed the public how important critical care providers are in the fabric of healthcare, but it's also tested all of us to limits that we have never experienced before.
Speaker: And as many of us are still dealing with very high number of patients and surges,
Speaker: I do believe that the upcoming months as hopefully we get out of COVID-19 will be very important in us kind of redirecting our purpose, finding joy again in what we do and really working and picking up some of our colleagues, but also creating better working environments.
Speaker: And really the hope from my perspective is that we can go beyond burnout and really find ways to transcend professionally, but also find tremendous purpose and joy in what we do every day.
Speaker: So we'll share, like I said, a webinar that we shared with our colleagues earlier.
Speaker: There will also be a link in the show notes to the video portion if you want to see the slides.
Speaker: And I hope that this is a little bit of a break for a lot of you and that there might be some actionable items that you can implement in your practice today to try to move the needle back towards a more joyful professional experience.
Speaker: With that, I also want to thank our listeners.
Speaker: for supporting the podcast.
Speaker: If you find the podcast useful, please take some time to write a review and share it with others.
Speaker: That's a way that we can reach more intensivist at the bedside.
Speaker: And again, thank you for all you've done during these very, very trying months with the COVID-19 pandemic.
Speaker: So stay safe, take care, and I hope that you enjoy the presentation.
Speaker: With everything that's going on in the country,
Speaker: in the world, COVID, natural disasters, intense political environment, racial disparities, and systematic racism, among many other issues, some people might question, well, is this tone death or is this really the right topic to talk about?
Speaker: And I would say that this is more important than ever.
Speaker: We spend an enormous amount of time at work as a clinician,
Speaker: We spent not only a lot of time at work now, but we've spent years of our life preparing and working in our careers.
Speaker: So I think that even when things are very difficult, it's probably even more important to talk about what can we do to have the best careers?
Speaker: What can we do to be the best versions of ourselves professionally and make the greatest impact towards others?
Speaker: So with that in mind, I'll start with a quote.
Speaker: from one of my personal heroes and mentors, which is Epictetus.
Speaker: He was born a slave in the Roman empire, became one of the most influential philosophers, stoic philosophers for his time, but also for many, many people who have read his work for many, many decades and centuries.
Speaker: And he says that happiness and freedom began with clear understanding of one principle,
Speaker: Some things are within your control and some things are not.
Speaker: And I think that that is not only a very valuable principle to guide our lives, and definitely I try to abide by this principle, but it's going to be the foundational principle for which I will talk today about finding joy in our work and the path to professional transcendence.
Speaker: What we'll do in the next 45 minutes
Speaker: is talk a little bit about the why, understanding the why.
Speaker: I want to dive into motivation and understand what motivates clinicians, but ultimately applies to all knowledge workers and all careers.
Speaker: And finally, share with you some thoughts on the path to professional transcendence, what it means, how we can get there, and some actionable items that I think are great to have as part of a toolkit at work every day.
Speaker: It's impossible to talk about this topic in medicine and probably in many other areas of work without recognizing the elephant in the room, which is burnout.
Speaker: Burnout is obviously a problem that we've had for years now growing in medicine.
Speaker: It is also known as the burnout syndrome and really has three areas that are very important.
Speaker: or three domains that include exhaustion, depersonalization, and reduced personal accomplishment.
Speaker: And there's a host of psychological and physical symptoms associated with burnouts that include frustration, anger, hopelessness, lack of empathy, feeling insufficient at work among the psychological symptoms.
Speaker: And then on a physical domain includes exhaustion, fatigue, insomnia, muscle tension, headache, and many others.
Speaker: So this is something that, unfortunately, over the last several years we have recognized is very common among clinicians.
Speaker: This is last year's Medscape burnout report, and you can see different specialties.
Speaker: When we think of critical care, which is our specialty, according to this survey, which included thousands of responses from colleagues, 44% of our critical care colleagues report at least one of those symptoms related to burnout.
Speaker: Doesn't mean that they have the full blown syndrome as defined by the diagnostic criteria, but clearly feel those symptoms and are having difficulties with their career or with their work.
Speaker: And you can see that this really spans a whole gamut of different specialties.
Speaker: When you talk with hospitals, this is a survey from the Journal of Medicine from their Catalyst website.
Speaker: They looked at, they spoke with different
Speaker: hospital suites, clinicians, and many other, you can see that the vast majority, over 80% of respondents consider burnout to be a serious or at least a moderate problem in their hospital.
Speaker: What's also very important for us in the ICU and in sound is that it is also a significant problem for our nurses, our nursing colleagues, our APPs, and our clinical leaders.
Speaker: So clearly impacts
Speaker: everybody who's in healthcare at the bedside, but also is a problem for executives.
Speaker: So clearly a universal problem that I think is worth exploring and understanding.
Speaker: There's been a lot of discussion about what are the factors that lead to burnout and understanding those factors ultimately I think can guide us into what are the appropriate interventions or target interventions.
Speaker: A lot of the emphasis initially was placed on providers and clinicians, trying for them to solve the problem.
Speaker: I think more and more we recognize that burnout itself is a systemic problem.
Speaker: And the two most commonly attributed factors are increased clerical burden.
Speaker: And the EMR is a big part of that.
Speaker: The feeling that we are doing clerical work and taking away from caring for our patients more and more.
Speaker: And also, I think, with a current healthcare system that is asking for increased productivity, requirements, expectations from documentation, from all sorts of activities that ultimately take us away from what we really want to do, which is care for patients and have that human connection.
Speaker: When you recognize these systemic problems, when asked most people,
Speaker: support the idea that what we need in terms of target for interventions are organizational at a system level, infrastructure enhancements, and also regulatory from the standpoint of payers and documentation requirements.
Speaker: That's probably where we need to put the most emphasis on burnout itself, and I think it's very important.
Speaker: Now, burnout has significant consequences, and that's why it's an important topic not only for clinicians, but for patients and for society.
Speaker: Burnout leads to increased job turnover with COVID-19.
Speaker: A lot of our programs have seen that at a nursing level, at a respiratory therapies level.
Speaker: They have been stretched and really worked exceedingly hard during the last several months.
Speaker: And we've seen a lot of turnover in many hospitals.
Speaker: It also leads to decreased quality of care as an organization that has as its sole mission to improve quality
Speaker: and reduce cost, this obviously has a tremendous impact on what we're trying to do at the bedside.
Speaker: And finally, it has significant impact on decreased patient satisfaction, not to mention the satisfaction of the careers of the individuals in healthcare.
Speaker: So clearly, it has important consequences that go beyond just the clinicians, and I think makes it relevant for this to have a systemic approach, a systematic approach, and also a great concern for society in general.
Speaker: All this was happening before COVID and then COVID-19 came.
Speaker: And for the last six months, we have been living in many of our hospitals at different times, situations that we have never seen in our careers, situations that really have exceeded what we would expect to see in our ICUs, in our hospital teams, in our emergency departments.
Speaker: So clearly now it's all exacerbated, magnified and amplified, and it remains a big problem.
Speaker: So again,
Speaker: I don't think that talking about joy and professional transcendence is out of touch with reality.
Speaker: I think it's needed more than ever and really taking a focus on that first quote from Epictetus on what we can do, what we control as individuals to help us get to a better place and where we are with our profession.
Speaker: So before we go on to the next section, I think it's worth thinking if the elimination of burnout is enough.
Speaker: So clearly burnout is a negative and removal of any negative is always, I think, a positive movement.
Speaker: But in terms of when you consider the amount of time that we spent preparing to be intensivist, when you consider the amount of time that we spent working week in and week out and the number of years that we are professionals, it would seem that we would be selling ourselves short if all we wanted to do was
Speaker: eliminate burnout.
Speaker: I think we need a lot more than that and what we really want is to move towards professional transcendence and make the most of our careers but also make sure that through our careers we can find the best version of ourselves and making a positive impact on the world.
Speaker: I think there's a couple of things that are worth exploring a little bit more because burnout is a term also that's thrown a lot around and everybody says that they're burnout and a lot of things get attached to burnout but understanding
Speaker: some aspects of burnout and other important aspects of what makes work meaningful is probably worthwhile.
Speaker: I want to start with a study that was published by Herzberg and collaborators back in the 1960s, late 1960s, Harvard Business Review.
Speaker: This was a earth shattering study on motivation.
Speaker: In the 1970s, we were moving towards a knowledge economy.
Speaker: And what he found out is that when you survey thousands of workers, the items or the factors that make them satisfied or make them motivated to do a better job and to keep growing are different categories than those that make them miserable or dissatisfied.
Speaker: So I think that what's very important to understand is that
Speaker: The opposite of dissatisfied is not engaged.
Speaker: The opposite of dissatisfied is just satisfied.
Speaker: And satisfied is average.
Speaker: And I think that that is okay for a large number of people being measured.
Speaker: But ultimately, like I talked about in our team's talk, nobody wants to be average.
Speaker: And I think as an individual, we would thrive for more than that.
Speaker: So understanding that there are intrinsic or motivator factors that usually move us in the positive direction at work.
Speaker: and they're what he called hygiene factors, which is the work environment that usually move us in the negative direction, it's important to see that even if we removed all the negatives, we might still not have engagement or motivation, which is ultimately, I think, a required condition to truly be fulfilled at work.
Speaker: Another misconception where I think a problematic generalization is every time I hear people talk about burnout,
Speaker: I hear them talk about physician suicide.
Speaker: Physician suicide is a critical issue in our profession.
Speaker: We lose more than one physician a day to suicide.
Speaker: Now, I think that burnout can be associated with mental illness, with depression, and with suicide, but it's not the same thing.
Speaker: And I think that not only we
Speaker: we risk not having the right solutions when we mix things together, but I think we undervalue the real significance of mental health and the real gap that we have in our healthcare profession and recognizing when somebody needs help, providing that help, and also recognizing when we need help.
Speaker: This is an amazing opinion piece that was shared by Michael Weinstein.
Speaker: Michael Weinstein is a trauma critical care colleague from Philadelphia.
Speaker: He came out with this a couple of years ago.
Speaker: And really, I mean, when you read it, it gives you chills and bumps.
Speaker: He was a trauma surgeon who had depression, became burnout, who tried to commit suicide and had to be committed to a psychiatric inpatient facility for treatment and eventually found a way to come back to his work at trauma and find joy again.
Speaker: So I think that it's important for us to
Speaker: to have that strength and courage to ask for help, but also to recognize that this is no different than other diseases.
Speaker: And even though it might be related to burnout, it's a separate and very, very important issue.
Speaker: We also have seen that COVID-19 has really increased the strain on clinicians and mental health issues have become very important within the first-line providers, nurses, physicians, APPs,
Speaker: RTs.
Speaker: And it's important to recognize that in our teams.
Speaker: There are a host of negative mental health outcomes that go from anxiety, loneliness, substance abuse, very common in clinicians, post-traumatic stress disorder, depression, and suicide.
Speaker: And I think that we have to recognize that although sometimes burnout might overlap with some of these issues, there are distinct problems
Speaker: and they require distinct therapies and distinct approaches.
Speaker: So I think it's very important for us to keep educating our colleagues and ourselves and our families on the importance of recognizing issues with mental health and providing the appropriate support for those who are suffering.
Speaker: So we can see that we're talking about multiple dimensions that are very important to understand.
Speaker: On one hand, we have personal well-being.
Speaker: The positive of that is when you're well.
Speaker: The negative is being unwell.
Speaker: An extreme example of personal well-being on our eye is somebody who has depression and even goes to think about suicide.
Speaker: We also talked about work hygiene and the environment, the systemic environment for a given work, a type of work.
Speaker: And the positive would be satisfied
Speaker: The negative would be dissatisfied.
Speaker: And again, an extreme manifestation of this is burnout.
Speaker: So burnout is clearly something that is associated or driven mostly by the environment and the work hygiene that we are lacking in that environment.
Speaker: And finally, there's professional motivation, which is what we're talking about today, our professional careers.
Speaker: And the positive of that is motivated.
Speaker: And the negative of that would be unmotivated.
Speaker: And when you think of both extremes, on one extreme you have fulfilled professionals who are highly engaged in making a difference.
Speaker: And on the opposite, you have actively disengaged people who probably also share many of the features of burnout or might be burned out as well.
Speaker: So when you put this into a construct that allows us to understand how things interface, you can see that our whole professional
Speaker: capsule or world is really the intersection of our personal well-being, our work hygiene or the environment in which we work, and our professional motivation.
Speaker: And when you think about these, I think that they have a different weight on where we end.
Speaker: But when you think of one axis, which is the personal well-being, the extreme positive is joy, the extreme negative is distress or suffering.
Speaker: When you think of work hygiene,
Speaker: The extreme positive is satisfied.
Speaker: The extreme negative would be dissatisfied.
Speaker: And when you see the axis of motivation, the extreme positive is engagement and the extreme negative is disengagement.
Speaker: So you can almost think about this as maybe a three-dimensional grid.
Speaker: And what we see is that burnout lives in the left lower quadrant.
Speaker: professional transcendence lives in the right upper quadrant.
Speaker: And what we need to do is find ways to move these accesses towards the right upper quadrant and really try to live in that area.
Speaker: And they're not going to be all equal, but sometimes what you'll find is that people or professionals who are truly transcending their careers might have a different combination of these three factors, but ultimately that combination one way or the other puts them in the right upper quadrant.
Speaker: So the second part of our talk relates to what motivates clinicians or what motivates people in general.
Speaker: And I think that obviously this is a tongue in cheek picture about money, but the reality is that workers today and society have equaled motivation to money, have equaled worth to money.
Speaker: And over and over again, science proves that to be wrong.
Speaker: And I think that there is obviously a minimum number and a minimum amount of pay, which is fair, that people need according to what the market dictates.
Speaker: But what we also see is that it's not uncommon when people are unhappy or distressed or are trying to improve their situation that the first thing they think about is raise or asking for more money.
Speaker: Now, when you look at the studies, this is one large meta-analysis that was published some years ago that looked at the relationship
Speaker: between your pay and job satisfaction.
Speaker: This included 61 studies throughout the years and it's actualized to $2009.
Speaker: But basically what you can see is that there's really no correlation after a certain amount with pay and job satisfaction.
Speaker: So people who were making 20,000 could be as satisfied as somebody who's making eight times more than that at 160,000.
Speaker: And I think that it's an important reminder that we tend to think about pay only in relationship to somebody else.
Speaker: And we tend to only look at people who make more and we're unhappy.
Speaker: But the reality is that I would guarantee that every single person who's listening to this presentation today makes more than the vast, vast majority of people in the world.
Speaker: And I think that we also, when we compare, we should look at the whole and also look at those who are less fortunate.
Speaker: But anyway, there seems to be no relationship with your overall pay or raises in pay and your overall job satisfaction.
Speaker: But let's talk a little bit more and go into some other interesting studies that I think give us a little bit more of a better picture of the relationship between incentives, pay, motivation, and performance.
Speaker: So everywhere we go, we see carrots and sticks.
Speaker: We see it, it's very common.
Speaker: People ask for it, businesses believe in it, yet every time it's been looked in any scientific way with an experiment or with any type of study, it's been shown to not really work.
Speaker: But let's look at some of these experiments, which I think if anything are just counterintuitive and are very, very smart and very shrewd in showing certain relationships that we have with motivation and incentives.
Speaker: So this is actually data from an Intel core processor factory in Israel.
Speaker: They produce Intel chips, and basically what they have is they have a four-day shift.
Speaker: People come in for four days.
Speaker: They produce the chips, which is very meticulous work, and then they're off for four days, and they come back in four days, and they go on and off, not dissimilar to some of the rotations that we do in clinical inpatient.
Speaker: where people work in shifts and maybe take some time off and then come back again.
Speaker: And one of the concerns that they had at this factory in Intel was how could you make sure that when people come after four days are not working, there's not a drop off, a voltage drop in their productivity and you get people incentivized.
Speaker: So they were thinking about this and what they thought was, well, maybe on day one, we should tell the workers that if they exceed their quota, which is the normal quota or the baseline,
Speaker: for chips for that day, they would be paid a cash bonus.
Speaker: And over time, that incentive bonus or that contingent bonus, if you do this, you get this, they thought would stimulate people to really work harder and be more productive.
Speaker: Now, Dan Ariely and his team from Duke, which are very interested in incentives and studying not only incentives and motivation, but our relationship to work and observe several of the experiments that they have done,
Speaker: convinced the C-suite to try and experiment at this plant.
Speaker: And they said, well, why don't we break up this into four groups?
Speaker: So there was a control group that basically would just work for four days, be off four days and come back for four days.
Speaker: That was the control group.
Speaker: And they were used as to see what the base to the quota, that would be kind of the baseline.
Speaker: Then they had group one, which was the incentivize with cash group,
Speaker: which basically what they had is if they exceeded that quota on day one, they were paid a bonus and that would happen every time they came back on day one when they exceeded the quota.
Speaker: For group two, what they wanted to do is send a pizza to the family if they exceeded the quota for that night's dinner, but delivery was a little bit complicated with HR.
Speaker: So at the end, what they got was a voucher, which they could just click and order pizza for delivery for their home
Speaker: And they could be the heroes at home with their kids providing great pizza that night that they got because they did a great work at their job.
Speaker: They did a great job at their work.
Speaker: And finally, the third group was basically the kudos group in which they would get a text and an email from their manager and boss just appreciating their effort.
Speaker: recognizing that they went above and beyond what was expected for them in the quota and that their contributions are really important to make the company and the organization successful.
Speaker: So what happened?
Speaker: What happened is that on day one, this is what happened in terms of relationship to the control group.
Speaker: So the three incentivized groups went up as we would expect.
Speaker: The control group stayed the same.
Speaker: There was no difference.
Speaker: And even though the non-cash, the non-monetary incentives did a little bit better, you could argue, well, maybe that is just a small difference.
Speaker: It's hard to say that statistically significant, but it was still something that was worth observing.
Speaker: However, what happened over the subsequent days is much more interesting.
Speaker: The team that got cash dropped significantly on day two, then recovered a little bit, but was still weighed down on day three, and then came back up.
Speaker: on day four, but was still below what was considered to be the quota and what the control group was doing.
Speaker: The other two groups did decrease their production on day two, day three, and day four, but they slowly basically exceeded on day two and day three and then came back to baseline on day four.
Speaker: So at the end of the day, if you had no incentives, your net was zero, you did what was expected.
Speaker: If you had monetary incentives,
Speaker: your net was negative and you produce significantly less than if you were not incentivized.
Speaker: And when you had either the food incentive, the feel good pizza, or just the kudos communication from the boss, you had a positive net compared to the other two groups.
Speaker: So very interesting that sometimes contingent incentives or mantra incentives might actually have negative effects towards what we're trying to accomplish.
Speaker: And this has been shown multiple studies.
Speaker: This is an interesting study.
Speaker: It's a meta-analysis of over 50 studies at the London School of Economics.
Speaker: And what they found that with overwhelming evidence is that financial incentives result in a negative impact on overall performance.
Speaker: And what they found is that if you incentivize people with money, it erodes their intrinsic motivation and erodes their ethical behavior towards concepts such as fairness and duty.
Speaker: So over time, they keep expecting more and more money for the work that they should be doing, and it has a negative impact and does not motivate people overall.
Speaker: So just interesting that when you look at study after study, that contingent incentive of carrots and sticks does not really work that well.
Speaker: What are other things that we can learn from our relationship to work?
Speaker: And I think, again, I'm just going to share a couple of experiments that I think are very clever
Speaker: from Dan Ariely and his group and others, but this is called the Bionicle or the Lego experiment.
Speaker: And the idea was that you would give somebody a Bionicle and you would pay them $5 to build it.
Speaker: And then there were two groups, the Meaningful Condition and the Sisyphus Condition.
Speaker: And the Meaningful Condition, as soon as you finished building the Bionicle, I would pay you the $5, I would put the Bionicle under the table, give you another Bionicle and offer you $470.
Speaker: little bit less.
Speaker: And you would go on until you said, I've had enough of Bionicles, take my money, and I leave.
Speaker: In the Sisyphus condition, as soon as you finish building Bionicle, I would disassemble the Bionicle right in front of your eyes and then offer you that disassembled Bionicle that you just put time putting together and offering it for you to build it for less money.
Speaker: And then the idea is, at one point, you would stop.
Speaker: And they had all sorts of
Speaker: of controls, including people who really love Legos, this and that.
Speaker: And at the end of the day, when they repeated the experiments throughout multiple groups and different universities, they found the same thing.
Speaker: The meaningful condition always built significantly more bionicles than the Sisyphus condition before stopping.
Speaker: So basically what we learned from this small experiment is that seeing the fruits of our labor makes us more productive.
Speaker: And even in an experiment, well, you know the Bionicle is going to be disassembled later.
Speaker: That impact of it being disassembled in front of you has a very negative connotation in terms of your intrinsic motivation.
Speaker: Another example, another experiment that I think is also quite telling was initially conducted at MIT, but was repeated in many other universities and other companies.
Speaker: And the idea is that you have a piece of paper with multiple letters, and the task is
Speaker: for the person in the experiment to identify all the pairs of letters and circle them.
Speaker: And for the first paper you do, you get X amount of dollars, and then you would go into one or three conditions.
Speaker: What was known as the acknowledged condition, in which you were asked to write your name on the paper, you would finish and give it to the
Speaker: to the tester or the examiner and they would basically read through the paper.
Speaker: They would not, aha, and they would put the paper on a stack and offer you another paper for less money.
Speaker: The second condition or the ignored condition, you are not allowed to write your name.
Speaker: You would basically fill up all, complete your task, give the paper to the examiner.
Speaker: They would get your paper and without looking at it would put it in a pile and would offer you another paper.
Speaker: And the third condition called the shredded condition,
Speaker: You were not allowed to put your name.
Speaker: You would complete the task, give it to the examiner, and they would take the paper and right in front of you shred it in a shredder and then offer you another piece of paper.
Speaker: So again, no surprise, the people who were acknowledged and put their names in did significantly more papers or would take less and less money to continue to do the task.
Speaker: What's very interesting though is that in the ignored and shredded condition, even though
Speaker: people could figure out very quickly that nobody's looking at this, you could just circle anything and give it and just collect the money, they still had significantly lower number of papers completed than the acknowledged condition.
Speaker: And what it really teaches us is that the least appreciated we feel our work is, the more money we want to do it.
Speaker: And it really has to do with feeling that that's going to compensate for the lack of intrinsic motivation and the lack of dissatisfaction that we have professionally.
Speaker: The other thing that is very interesting about this paper and for all the managers on the presentation, I think it's very important, is that ignoring people's efforts is the same as shredding their efforts right in front of them.
Speaker: So we need to keep that in mind and acknowledge people for everything they do in our ICUs and in our hospitals.
Speaker: Finally, the last study that I want to share with you on this topic
Speaker: is called the IKEA effect.
Speaker: And the whole concept is that many of us have been to IKEA, especially when we were residents, and you would buy a table or a desk and you would take it home.
Speaker: And usually the males don't look at the instructions.
Speaker: They end up building something that's sort of crooked, has extra parts that we don't know where they go.
Speaker: But at the end, we're very proud of what we built.
Speaker: And we really are very, very close to that piece of furniture.
Speaker: What they tried to capture in a study was how does that relate to pay?
Speaker: And they called the origami study.
Speaker: And what they did is they had two groups of people.
Speaker: They had builders and evaluators.
Speaker: And the builders were giving instructions for origami.
Speaker: They weren't very good at instructions.
Speaker: So the origami were not so nice.
Speaker: And at the end of building the origami, they were asked, how much would you pay for this?
Speaker: And then they had a second group of people who were independent evaluators.
Speaker: And they would take that piece of origami and ask them, how much would you pay for this piece of origami?
Speaker: And as you can imagine,
Speaker: there was a gap between the builders and the evaluators.
Speaker: The builders consistently thought that the origami was worth paying more than the evaluators.
Speaker: Now, they did a second group in which they basically eliminated several of the steps in the origami instructions, which made that now the resulting origami were even more awful.
Speaker: And they were truly horrible pieces of origami, but they were a lot harder.
Speaker: So when they conducted the same experiment, now they found that the gap
Speaker: was significantly higher when the origami was hard.
Speaker: And what it really teaches us is that the harder the project, the prouder we feel.
Speaker: So when people talk about others being lazy, they don't understand what intrinsic motivation is really all about.
Speaker: And people who actually put a lot of effort into what they do feel very proud of what they've done.
Speaker: And they feel that it's worth usually a lot more than people who are not aware of the effort.
Speaker: So again, something to take into account, not only in our own work,
Speaker: but in the work of others around us.
Speaker: And this really moves and is an ongoing debate in cognitive psychology and in behavioral economics about the whole idea of contingent incentives, string sync rewards versus intrinsic rewards or intrinsic motivation.
Speaker: And as we move from the industrial revolution where we're just building pins to a knowledge economy, which includes everybody who's on this call, the reality is that over and over again, what's been demonstrated
Speaker: is that purpose-based rewards and intrinsic motivation are significantly more compelling and significantly more powerful than intrinsic or contingent rewards, which are still pervasive and very common in the workforce.
Speaker: So what really motivates physicians?
Speaker: What really motivates clinicians?
Speaker: And I think that there's three things that ultimately motivate every human being.
Speaker: It's purpose, autonomy, and mastery.
Speaker: And I think it's worth talking a little bit more about these because ultimately these should be the cornerstone of what we do for ourselves in our careers.
Speaker: So Viktor Frankl and his book Man's Search for Meaning, if you have not read it, I think definitely among some of the top books ever, said that those who have a why to live can bear with almost any how.
Speaker: And really alluding to the whole
Speaker: idea that he created of Logotherapy, which is therapy based on purpose, understanding what is your purpose in life, what is your purpose at work.
Speaker: And when we think about purpose, I like to think about purpose with a capital P and purpose with a small p. Purpose with a capital P relates to my work is meaningful to me and will make a difference in the life of others.
Speaker: It transcends my self-interest.
Speaker: And purpose with a small p is the tasks I do are important
Speaker: If they are not done, it will matter to others.
Speaker: And that is really more about meaning of what I'm doing and what is work that is in accordance to where I trained versus work that doesn't really make a big difference.
Speaker: And there's a lot of that, unfortunately, in medicine, but unfortunately in every field.
Speaker: And a cardiac arrest is a great example.
Speaker: During a cardiac arrest, there is definitely a capital P purpose, which is trying to bring that patient back to life.
Speaker: That person might be the father of somebody, the spouse of somebody, is loved by many, is friends to many.
Speaker: And there's tremendous amount of purpose in the team in trying to bring that person back.
Speaker: On the other hand, every single person who's doing something in that room, whether it be chest compressions, managing the airway, administrating drugs, calling the family, is doing a task that is important and would be noted if done poorly or not done at all.
Speaker: So again, it captures both of these scenarios in
Speaker: in healthcare.
Speaker: There are multiple studies that for the sake of time, I'm not going to go into that talk about the relationship of purpose to individual burnout.
Speaker: The more purpose you find, the least likely you're to burn out.
Speaker: To individual productivity, the more purpose you find, the more productive you are at work.
Speaker: And finally, to the organizational financial performance where organizations where people feel their work is meaningful,
Speaker: are usually organizations that outperform their counterparts financially and results.
Speaker: So clearly a lot of reasons why purpose is valuable.
Speaker: There are many studies that have looked at the relationship between purpose and our pay.
Speaker: This is one that I really like from Better Uploads a couple of years ago from San Francisco, where they interviewed thousands of workers across the United States.
Speaker: And nine out of 10 of these career professionals
Speaker: would be willing to sacrifice 23% of their future earnings for work that is always meaningful.
Speaker: And we always see that people who are really satisfied and find their work meaningful are usually much less concerned about small pay raises or if there's more money in another place.
Speaker: And we also know of friends and we maybe have experienced it that when we go to a different position or a different organization or work, we might get a big raise in our pay
Speaker: But if the meaning and purpose are not there, it quickly becomes a sour experience and is not very satisfying.
Speaker: Finally, with purpose, I think that it's worth understanding how do we find purpose in our work?
Speaker: And this is the concept of job crafting, which is something that I like to talk about a lot with our teams and comes from Amy Wojnarski and her team at Yale.
Speaker: And basically the idea is that the way we think about our work
Speaker: is very important in determining whether we find purpose or not.
Speaker: And one of the groups that she studied in this particular study were hospital janitors.
Speaker: And what they found is that on average, hospital janitors were as or more satisfied as their corporate lawyers, for example, but that they could identify those who were highly satisfied and engaged based on how they thought about their work.
Speaker: Those who think about their work just in terms of tasks
Speaker: usually have less likelihood to be engaged or fulfilled or find purpose.
Speaker: Those who think about their work in terms of who are they making a difference for usually are highly engaged and find tremendous purpose in their work.
Speaker: And what's amazing is that if you start thinking about your work, not in terms of what you do on a daily basis as a task, but in terms of who do you impact, you can actually measure in multiple studies
Speaker: that this actually changes your perception about your work.
Speaker: And many exercises or studies have shown that if you start by having everybody in an organization use name labels that have a description of their work based on who they help and how they see their contribution, the overall wellbeing of that task force and purpose goes up significantly.
Speaker: So for example, if you were to ask me, what do I do?
Speaker: Instead of describing all the tasks that I do on a daily basis,
Speaker: I would like to think that my job as CMO of sound critical care is basically helping other clinicians and hospitals take better care of critically ill patients and have better careers.
Speaker: That is kind of the way I think about my job as it impacts others.
Speaker: So finally, the second thing is autonomy.
Speaker: And I think with autonomy, there's a lot of misconceptions.
Speaker: People believe that autonomy is to do whatever they want.
Speaker: nobody has 100% autonomy.
Speaker: Even if you're a solo practitioner and you own your practice, you have to deal with rules, you have to deal with CMS, you have to deal with the hospitals.
Speaker: If you are the founding CEO of an organization, you have to deal with a board, with investors.
Speaker: So there's always people who are around you with whom you have to have a relationship that doesn't allow you to do whatever you want.
Speaker: However, true autonomy can be achieved in any job.
Speaker: Now, from the perspective of the system,
Speaker: when we micromanage or manage people, the best we can expect is compliance.
Speaker: But if we provide empowerment and self-direction, what we can ultimately achieve is engagement.
Speaker: And what we really want in our jobs is the autonomy to be engaged, to identify what is important about our jobs, what are the skills that we can utilize to make a difference in the life of others.
Speaker: And that is an autonomy that we have every day at the bedside.
Speaker: And I think everybody has no matter where they lead from in sound because you always have an opportunity to make a difference.
Speaker: And that's the autonomy that ultimately, I think, creates motivation and creates value for us as individuals.
Speaker: There's a concept I think is very important, and that is of deep versus shallow work.
Speaker: This is something that Cal Newport has really popularized.
Speaker: Deep work are the efforts that create new value, improve your skills, and are hard to replicate.
Speaker: Deep work for me as an intensivist are things that people who are not intensivists shouldn't be able to do.
Speaker: Shallow work on the other hand are efforts that tend not to create new value in the world and anybody could replicate.
Speaker: So when you spend an enormous amount of time documenting an EMR, that is shallow work.
Speaker: When you have to just click boxes for forms, that is shallow work.
Speaker: So the autonomy
Speaker: to increase our deep work and decrease our shallow work is ultimately the empowerment that we need to be able to create value for our patients, but also for ourselves.
Speaker: There's also plenty of literature and studies in how to increase autonomy in the workspace from a system perspective.
Speaker: So there's a whole theory for burnout on demand control and support.
Speaker: And really it's about if you want to have active
Speaker: So you look at learning and strain.
Speaker: So what you want to have is high learning with low strain.
Speaker: And that is ultimately the way you do that is by decreasing demands and giving people more control.
Speaker: And EMR, SoundConnect are all examples of systematic issues that we can all work on making better so that the demands on our providers decrease, but the control of them to be able to provide high value care elsewhere goes up.
Speaker: And one thing that I think is super interesting that we've implemented in many of our ICUs are trying to implement through practice guidelines is this whole concept of getting rid of stupid stuff.
Speaker: So working as a group with the nurses, with the respiratory therapist, this is a publication that was a couple of years ago at New England Journal of Medicine from an experience in Hawaii.
Speaker: And obviously we shamelessly stole that and many people have been doing that.
Speaker: And the idea really is that there are a lot of things that we can fix ourselves
Speaker: that would definitely decrease the proportion of shallow work and allow more time for deep work.
Speaker: And it has a tremendous impact on the overall ICU, the overall team, and on burnout.
Speaker: So again, recognizing that if we build towards autonomy, we make a difference.
Speaker: Finally, in terms of mastery, which is the third component, mastery really is, I think, the key to keep growing.
Speaker: Those people who are always learning are never disengaged, whether it be an older grandfather who's retired but is learning new things, their vitality is just palpable.
Speaker: And the same applies to our work.
Speaker: We should be learning and improving our mastery and the skills that we care about till the last day we work and then continue doing it outside of work.
Speaker: And the key is that no matter what you do, it's an asymptote and you never get to perfection.
Speaker: So there's always room for growth.
Speaker: no matter how deep you go in any skill, mastery always is available for us.
Speaker: And what we know is that in terms of growth, learning and mastery for the individual, the top box, you need humility, the ability to reflect on what you just did and deliberate practice, which is recognizing where the elements are the key elements of any skill or any process and practice those deliberately.
Speaker: In terms of helping others
Speaker: grow in mastery.
Speaker: And many of us on this call obviously have that opportunity.
Speaker: It's about meaningful recognition to others, immediate feedback when they do things well, especially, and also providing the opportunity for people to grow and to be empowered to have that autonomy and make a difference for others in the way that they find most effective.
Speaker: Another aspect that I think is very important when we talk about joy, we talk about burnout.
Speaker: is the whole concept of post-traumatic stress versus post-traumatic growth.
Speaker: This is something that we've learned from our brave men in the battlefield, men and women in the battlefield.
Speaker: And we know that the incidence of PTSD in a lot of soldiers is very high, but there are also some that are exposed to the same trauma or even more difficult situations and they come back and they grow.
Speaker: They are even more engaged and more
Speaker: willing to make a difference than they were before the trauma.
Speaker: And that really leads us to the whole concept of resilience, which is something that a lot of people have talked about.
Speaker: We keep hearing about that not only in burnout, but also in COVID.
Speaker: And I just wanted to share with you, this is a very interesting study on resilience.
Speaker: So resilience is the capacity we have to recover and grow from difficulties or severe difficulties.
Speaker: That's what makes us resilient.
Speaker: And this is a study that was published literally a couple of days ago from ADPRI.
Speaker: It's a workplace resilience study where thousands of people were evaluated during COVID-19.
Speaker: And what they found is that the percent of highly resistant, sorry, highly resilient people is the same by gender, whether male or female.
Speaker: There seems to be no relationship in terms of ages.
Speaker: So there's highly resilient people at all ages.
Speaker: Yet what they really found, which I think is very interesting and speaks highly to our critical care team,
Speaker: is that proximity to COVID-19 increased resilience.
Speaker: So in terms of the percent of people being highly resilient, the closer you were living to COVID-19, people seeing people sick and being interacting, the more resilient you would be.
Speaker: And that really talks about resilience as being a reactive state that is triggered after suffering.
Speaker: And the other thing that they found, which is super interesting,
Speaker: is and applies to all our business colleagues as well is that the more changes you experience at the workplace during the last six months the more likely you are to be highly resilient and that really speaks about the more tangible a threat is the more resilient we become a lot of times the stress and the lack of resilience is because of the unknown but once we are experiencing the the difficulties the challenges
Speaker: we become very, very resilient.
Speaker: And that I think is important just to keep in mind, but also something that we keep talking about in medicine.
Speaker: So the last part of this presentation relates to the path to professional transcendence.
Speaker: So professional transcendence, from my perspective, is a journey, not a destination.
Speaker: The path is based on the deliberate effort every day at work.
Speaker: to rise above our self-interest, the challenges we face, and our doubts.
Speaker: The journey leads to a connection with a greater purpose, autonomy to make a positive impact on the world, and the relentless pursuit of mastering our craft.
Speaker: It is hard, yet I think it's something that is joyful.
Speaker: And this is really ultimately what I think we should all strive for on a daily basis.
Speaker: Abraham Maslow worked on what he called his Theory Z at the end of his life.
Speaker: And he was really interested in identifying beyond the pyramid, but what really led people to self transcendence.
Speaker: And at the beginning, he was very interested in peak experiences.
Speaker: And then he realized, however, that there's also plateau experiences.
Speaker: So a peak experience is a once in a lifetime or a really major event.
Speaker: And a lot of people plan their careers around peak experiences like this big promotion, this big award, this big, this is big, that, and that may or may not happen.
Speaker: Yet what Maslow found and what I believe, based on my personal experience, is that the plateau experiences are the ones that we fabricate, that we deliberately create on a daily basis.
Speaker: And those are the ones that ultimately, I think, will basically pave the path to professional transcendence and to really enjoy our work.
Speaker: I also, as an intensivist, like to always relate things to the ICU.
Speaker: So you can see that this is no different than thinking of peak inspiratory pressures and plateau pressures.
Speaker: They're both relevant.
Speaker: But ultimately, what we care about is the plateaus because those are the ones that have the greatest impact on what we're trying to look at.
Speaker: So these are some actionable steps that I have experienced myself.
Speaker: And that's not only an end of one, but there's multiple evidence in others that they also work.
Speaker: that when I think applied on a daily basis can help move the needle and over time can really make a difference and provide a roadmap towards professional transcendence and towards finding joy in what we do and purpose.
Speaker: So it's accept the whole self and job and we'll talk about that.
Speaker: Practice EBM, play to your strengths, practice deliberate gratitude, and finally, amur fati.
Speaker: So, except the whole self and job, I think people usually think of their best self and they talk about the worst parts of themselves, that's not me.
Speaker: And we do the contrary when we talk about our work.
Speaker: We usually think of the negatives, but we never remember the positives.
Speaker: And that probably is based or at least influenced by the fundamental attribution error, which is a common bias that we all have where we actually think that the positives in ourselves are personality traits.
Speaker: and that the negatives are due to the environment and we think the opposite in other people.
Speaker: So in others, when they have a negative, it's because of their personality trait.
Speaker: We never think of the circumstances.
Speaker: And when they have a positive, it's not uncommon for us to think that they were just lucky.
Speaker: So that fundamental attribution error can be expanded or influences the way we think about ourselves and work.
Speaker: And I think that we need to accept everything.
Speaker: I accept my best self, but also my worst self.
Speaker: That's one person and recognizing my evils.
Speaker: and my failings helps me be a better person.
Speaker: And on the other hand, I think it's easy to complain about what I do on a daily basis, but there's also, I think, a lot in that that is positive, and we should embrace both.
Speaker: Within this whole, I think it's important to take self-care seriously.
Speaker: We've been talking a lot about this in the pandemic, but it's the whole concept of you put your oxygen mask on yourself first, and then you help others.
Speaker: That means different things for different people, but it starts with appropriate sleep,
Speaker: with exercise, with healthy eating, with relationships, with having hobbies, with learning, with taking care of your own health.
Speaker: Those are all things that we have to really be deliberate about and find time for because ultimately they enhance our performance at work and they enhance our ability to be great members of our family, our community, and our organization.
Speaker: The second one is Practice EBM.
Speaker: which is not evidence-based medicine, but evidence-based motivation.
Speaker: And we talked extensively about purpose, autonomy, and mastery.
Speaker: And whenever you're feeling down, think about those and how you can create that through job crafting, through recognizing where you have an opportunity to make a difference, through learning new things, and also helping those around you move in that direction because ultimately that is what really creates motivation and self-fulfillment.
Speaker: Number three is playing to your strengths.
Speaker: And I think this is very important and it's something that we don't do very well in the workplace.
Speaker: A strength is not necessarily something that you do very well.
Speaker: That's an ability.
Speaker: A strength is something that makes you feel very good about yourself in terms of makes you feel proud and makes you feel that you're growing.
Speaker: Now, it happens that a lot of times those are the areas that will grow the quickest, so you will become pretty good at them.
Speaker: But the reason why I think this is important is because there's multiple studies that have shown that there's a positive relationship
Speaker: as you go from weakness to strength with the growth you have as a professional, but also with your performance and the impact you can have on others and on your organization.
Speaker: Not only from that perspective, but from a manager perspective or administrator perspective, Gallup has shown over and over again that those workers in whom nobody spends time to talk with them about how they can grow or get no attention are
Speaker: one out of 20 are likely to be highly engaged and 20 are likely to be disengaged.
Speaker: Those that get a regular sit down or one-on-one with their managers or their mentors, but they focus mostly on one of the things that they can improve are two to one engaged, disengaged.
Speaker: There's a significant improvement, but not good enough.
Speaker: And those in whom the focus of the one-on-one is the attention to their strengths,
Speaker: so they continue to grow and deliver at a high level, they are 60 to one likely to be engaged, disengaged.
Speaker: And I think it just applies to the world of sports.
Speaker: I doubt that Barcelona's manager will tell Messi to work more on his right foot
Speaker: when his left foot obviously is his genius.
Speaker: And I doubt that he would spend a lot of time improving his skills on the right side when he can do so much with his left.
Speaker: So really playing to your strength and putting yourself in positions where you can have a greater contribution and greater growth would also make your professional career much more joyful.
Speaker: Number four is the concept of deliberate gratitude.
Speaker: Some years ago,
Speaker: I tried this board in one of our ICUs where I really wanted everybody at the end of a 12 hour shift to reflect before they left and write something on a post-it that they were grateful for, something that was positive.
Speaker: So I felt that people usually have five bad minutes and then they milk it for 10 hours and they leave very upset.
Speaker: But the reality is there's always a lot of good that happens.
Speaker: It was hard to get people to do it, but eventually people done it.
Speaker: But it also was hard to keep it going and eventually disappeared.
Speaker: But I definitely had pushed this based on multiple studies that have shown that a practice of gratitude helps depressed patients feel better.
Speaker: It helps people feel less anxiety.
Speaker: It helps people feel much more optimistic about their lives.
Speaker: And I have had a practice of gratitude for many years now that I can tell you has confirmed those studies and has helped me tremendously.
Speaker: So every morning I journal.
Speaker: And one of my three prompts or the last prompt is I am grateful for, and it's usually something very specific, a lot of times related to my family, obviously, a lot of times related to work.
Speaker: And being able to recognize what we're grateful for is very powerful in that path to self-transcendence and professional transcendence.
Speaker: The other thing that I learned, and I published this in a blog a couple of years ago in our op-med blog, was that when you thank others, so the first thing
Speaker: practice of journaling for yourself.
Speaker: But when you thank others and you're genuine about it, it's always a positive feeling.
Speaker: And what I started doing is I created, those who know me know that I like lists of threes, lists of five sometimes, but mostly threes.
Speaker: But I created a checklist for my night shifts because that was a big change when I came to this job.
Speaker: In the past in academics, I never did night shifts, but I started doing night shifts and they were tough on me.
Speaker: So I created a checklist to kind of lift my
Speaker: my spirits.
Speaker: And one of the things on that checklist is to find a colleague at night, in the middle of the night, anybody who works in the hospital, and genuinely be grateful and thank them for something that they're doing that is helping my work.
Speaker: And I have found that I don't do that every single time, I have to be honest, but every time I do it and the more I do it, the better I feel.
Speaker: And it's just, I mean, finding gratitude and being deliberate about sharing it with others.
Speaker: And finally, the last thing on my list
Speaker: is amor fati, which in Latin means love for your fate.
Speaker: And this is a stoic philosophy precept that many have adopted over the centuries.
Speaker: I think it's really as powerful as that initial quote I shared regarding identifying what we control and what we don't control.
Speaker: And amor fati is a mindset that you take on for making the best out of everything that happens.
Speaker: Treating each and every moment, no matter how challenging,
Speaker: as something to be embraced, not avoided.
Speaker: To not only be okay with it, but to love it and be better for it.
Speaker: So that like oxygen to a fire, obstacles and adversity become fuel for our professional potential.
Speaker: And this is really, I think, very relevant to COVID.
Speaker: It's very relevant to what we do in the ICU.
Speaker: And it's really relevant in terms of everything in life.
Speaker: But I think it really is basically saying that what we need is the power of framing.
Speaker: We need to be able to frame things in a different way.
Speaker: So instead of having a passive framing of what have others done for me to have clear goals and objectives at work, it should be active.
Speaker: Did you do your best to set clear goals and objectives at work for yourself?
Speaker: So the system is not going to provide these things.
Speaker: You have to set conditions and do your best to put yourself in that position.
Speaker: Another way of thinking about this is
Speaker: As opposed to to me, things happen to me.
Speaker: Why is this happening to me?
Speaker: Right?
Speaker: We had 10 patients come in.
Speaker: Why is this happening to me?
Speaker: Is to think by me and recognize that it's hard, but also ask yourself, what can I do to make a difference?
Speaker: And thank FATE for giving you that opportunity and that test because you know that as you make a difference through this challenge, at the end, you will be better for it and you will grow.
Speaker: So we talked about the why.
Speaker: in terms of why I think that talking about joy and talking about professional transcendence is always relevant in our careers, even in these very difficult times.
Speaker: There's a lot about talk about burnout, but there's much more to talk than just burnout.
Speaker: We talked about motivation and what really motivates clinicians and what really moves us forward and propels us to do our best and be our best.
Speaker: And even though money is important for life, it's a tool and people obviously need it for many reasons.
Speaker: the value that we give it, I think, is misplaced.
Speaker: True motivators for professional growth are intrinsic and they include purpose, autonomy, and mastery, and we should really work on those as well.
Speaker: And finally, we talked about this concept of professional transcendence as a journey, and I shared with you five things that I think we can all do that are practical, that are actionable, that would definitely move the needle and would make things better for everybody.
Speaker: So I'll finish with a reminder of what we said at the beginning, that happiness and freedom begin with a clear understanding of one principle.
Speaker: Some things are within your control and some things are not.
Speaker: Thank you very much.
Speaker: Thank you for listening to Critical Matters, a sound critical care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
