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Burnout in Healthcare
6 Plays6 years ago
In this episode of Critical Matters, we discuss burnout in healthcare. Burnout is an increasing problem in critical care that impacts growing numbers of providers, nurses and healthcare professionals working in the intensive care unit. This episode is based on a webinar I presented on the topic followed by a panel discussion with physician leaders.
Additional Resources:
An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action: https://bit.ly/2M1PGFq
Why Doctors Hate Their Computers by Atul Gawande, MD: https://bit.ly/2JCw1uz
Institute for Healthcare Improvement White Paper – Framework for Improving Joy in Work: https://bit.ly/2zHs16F
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Transcript
Introduction to Critical Matters and Episode Focus
00:00:09
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Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
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And now, your host, Dr. Sergio Zanotti.
00:00:22
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Burnout occurs in all types of healthcare professionals and is especially common in individuals who care for critically ill patients
00:00:30
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in the intensive care unit.
00:00:32
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Burnout has been recognized as a growing and very important problem in healthcare.
00:00:38
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Today's episode of the podcast will address burnout in healthcare.
Understanding Burnout in Healthcare
00:00:43
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It is a recording of a webinar that was presented previously and will include two parts.
00:00:48
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First, a presentation on burnout in healthcare that will define the burnout syndrome, talk about some of the causes of burnout in the ICU, and also some potential solutions.
00:01:00
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followed by a second part, which is a panel discussion with physician leaders from different specialties, addressing their personal experience and potential solutions for burnout.
00:01:11
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And I will be starting the first half of our webinar with a presentation on burnout in healthcare.
00:01:17
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Every day, a colleague, a physician commits suicide.
00:01:21
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That is an alarming statistic that really should make us ponder of what is going on in our profession.
00:01:27
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It's been shown that physicians or
00:01:30
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or people in the medical profession have significantly higher incidences of suicide, depression, and now, as we'll see today, of signs and symptoms of burnout.
00:01:40
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I just wanted to share this very powerful piece that was published earlier this year titled Out of the Straightjacket, published in the New England Journal of Medicine by a critical care trauma colleague, Michael Weinstein, who's out of Philadelphia.
00:01:54
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He describes, I think, in a very brave piece his ordeal or his journey
00:01:59
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from being burned out to becoming very depressed, having to be committed for suicide ideation, and then more importantly, his journey back to being a fulfilled physician, taking care of critically ill patients.
00:02:11
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I think that it is very timely for us to talk about this topic, not only burnout, but there's other aspects of mental health in our profession that are very important.
00:02:21
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And I would encourage all of you to look up this piece and really read Michael's piece, because I think it is extremely powerful.
00:02:28
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What we'll do today is we'll talk about burnout syndrome, talk about the syndrome itself, how is it defined, diagnosed.
Prevalence and Impact of Burnout
00:02:36
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We'll, in the second part of this presentation, review some of the evidence that might be available in terms of understanding what motivates people, what are things that we can learn from other fields, and what has been done so far in trying to combat burnout.
00:02:50
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And finally, have a couple of words on what we can do to make things move in the right direction.
00:02:56
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Although, as we'll see once we start the panel discussion, there is a lot that needs to be done at a systemic level that might be out of our control, but there's definitely multiple interventions that we can start immediately to try to address this issue and make things better for ourselves and our colleagues.
00:03:13
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Burnout has been a topic of intense discussion, I would say, for the last several years with increasing appearances.
00:03:20
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One thing that I think is very important to emphasize is that it's not unique to medicine.
00:03:25
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If you were to read at other aspects or business journals in the last couple of years, the topic of burnout keeps appearing.
00:03:32
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I think the levels of engagement in general and the working force continue to decrease.
00:03:38
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And this has become really a problem of modern society that keeps growing.
00:03:42
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And I think that has finally gained a lot of attention because it's becoming a crisis, as we'll see, in medicine.
00:03:49
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In medicine, particularly, burnout is extremely frequent.
00:03:53
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And there are different surveys out there.
00:03:55
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This is one that is often published by Medscape based on large thousands of patients and providers interviewed.
00:04:03
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And what you can see is that a lot of the specialties represented by some physicians, such as critical care, internal medicine, hospitalists, emergency medicine, have very high levels of burnout.
00:04:16
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The last number show 48%.
00:04:17
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I've seen numbers that go up to 55% in critical care.
00:04:22
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So really, it's a frequent problem that I think that we have recently come to recognize as a real challenge for our field, and not only for our field, but other fields in medicine as well.
00:04:34
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It's not endemic to the United States.
00:04:36
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It's universal.
00:04:37
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I'm showing you data that's almost a decade old, but this is a famous study that kind of started this whole discussion in critical care, looking at the levels of burnout in French ICUs.
00:04:46
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And again, I mean, using similar tools that we'll talk about today, they've been shown that in other countries, this perception of burnout or the growing incidence of burnout is also a problem
Global and Systemic Aspects of Burnout
00:04:56
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in healthcare.
00:04:56
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So it's not unique to our system, and I think it can be found throughout the world.
00:05:02
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Recognizing that this has become a true problem, two years ago, an associate task force from the American Association of Critical Care Nurses, the American Thoracic Society,
00:05:13
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the American College of Chest Physicians and Society of Critical Care Medicine put on an official critical care statement or white paper calling out the situation with burnout and really asking for interventions at all levels.
00:05:26
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So a call for action at the provider, administration, hospital system, healthcare system level, and calling for an agenda to really try to understand this better, but also to find interventions
00:05:41
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that can help decrease the incidence of burnout.
00:05:46
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Burnout is usually measured or diagnosed through a very exhaustive 22 point inventory called the MassFatch Burnout Inventory that really looks at different domains.
00:05:59
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But before we get into the exact definition of the burnout syndrome, I think it's important to understand that burnout usually occurs when there's a misalignment between personal
00:06:10
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expectations and capacities maybe, and what the job is offering.
00:06:15
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And it's not something that happens immediately.
00:06:18
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It's actually a gradual process.
00:06:20
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And it's also not something that happens after years of working.
00:06:24
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And a matter of fact, younger physicians, especially trainees, residents and fellows have higher incidences of burnout.
00:06:33
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So it's not something that as in the past, we would believe would happen after you've been in practice for 20 or 30 years and working too hard.
00:06:39
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There's more to it than just working hard, as you'll see.
Diagnosing Burnout and Its Causes
00:06:43
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And as I mentioned, it's a gradual process that starts when you get a new job, you slowly start developing increased emotional stress that leads to decreased job satisfaction that might lead to negative attitudes that feed that loop back over and over again and can eventually lead into a full-blown-out burnout syndrome.
00:07:02
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As I said before, the burnout syndrome is diagnosed most commonly
00:07:06
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with a inventory, the Maslow's Burnout Inventory, that has 22 questions that really center around the perceptions and feelings of the worker, in this case, the provider, in terms of three domains.
00:07:20
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And they are the evidence of exhaustion, where the provider just feels that there's no energy, that at the end of every day of work, they feel exhausted, they take a very common exhaustion symptom
00:07:35
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is when people feel that they always have work that they have to take home to complete their medical record.
00:07:41
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That's something commonly seen in primary care offices.
00:07:44
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The second kind of classic presentation is the area of depersonalization, when really there's detachment,
00:07:53
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of our humanity and how we relate to others.
00:07:56
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And you'll see that people who are burned out in the hospital, for example, might react in forms that seem disproportionate to what happened, can be very disrespectful to their colleagues, can be very disrespectful and antagonistic to patients.
00:08:11
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And I think that that is something that often people who are burned out will feel and exhibit.
00:08:16
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And finally, the third major symptom of the burnout syndrome is a reduced personal accomplishment.
00:08:23
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where people feel that they spend hours at work and really accomplish very little.
00:08:28
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And these three, I mean, can really lead to a very difficult situation that's associated with a platitude of psychological symptoms and physical symptoms, including frustration, anger, anxiety, inability to feel satisfied with your work, like I said, unprofessional behavior, that constant feeling of overwhelmment where you never feel that you're going to catch up,
00:08:53
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disillusionment with being in medicine.
00:08:55
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I mean, that's when you hear people recommending others not to join medicine, lack of empathy with patients, and just feeling insufficient at what we do and not feeling respected.
00:09:05
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Something I commonly hear from some of our young providers is if the nurses don't respect me, the CT surgeons don't respect me, a lot of these feelings come from these forces that might be causing or might be promoting a burnout syndrome.
00:09:22
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And there's also a whole set of physical symptoms, including exhaustion and fatigue, which are real, inability to sleep, muscle tension, headache, GI problems.
00:09:31
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So when people have these three major symptoms, and this can be categorized or diagnosed with an inventory like the Maslow's Burnout Inventory, is when they have a full burnout and burnout syndrome.
00:09:46
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When people cite
00:09:49
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55, 48% of physicians in critical care, providers in critical care, exhibit symptoms of burnout.
00:09:55
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What they're probably saying is that they have one of these three, not necessarily the three at the same time and the full-blown symptom.
00:10:01
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And that's important to understand.
00:10:04
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But people who develop the three of these and the true syndrome are the ones who are much more likely to leave their jobs, to become depressed, and has even been associated with increased rates of suicide.
00:10:15
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So it's a real, real problem.
00:10:17
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In the ICU specifically, but we'll see that these apply to all specialties, there are certain risk factors that include personal characteristics that I'll review in a second.
00:10:28
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The ICU environment itself, some ICUs are much more supportive than others.
00:10:32
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Some might have just because of the nature of what they do or the nature of how they're organized in an environment that is more likely to produce burnout.
00:10:41
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However, there's also organizational factors in terms of workflows, what's expected from the hospital, from the healthcare system.
00:10:49
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I think it's a big part of what we'll see.
00:10:51
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The electronic medical record can be part of that.
00:10:54
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And then there are particular situations in the ICU that I think have been associated with burnout, not only in providers and physicians, but also in our bedside nurses and our respiratory therapists and pharmacists.
00:11:06
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And that might be the feeling of moral distress when we feel that we are providing futile care
00:11:11
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to patients who will not benefit, or when we feel that we are providing care that goes against the wishes of patients, those are things that can be very problematic and can lead to that increased stress and that loop that we talked about at the beginning.
00:11:26
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Also, the term of compassion fatigue, I think that we all recognize that when we started medicine or when we started this journey, compassion was a big element of that.
00:11:36
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And yet, over and over again, when we hear patients talk about their experiences,
00:11:41
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there is an alarming lack of compassion within the healthcare system, and that compassion fatigue can be something that can also increase the risk of burnout.
00:11:51
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Burnout syndrome, when it develops, is associated with a whole list of problems, and we'll talk about those in a second.
00:11:59
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But one of the things that people have also talked about is the presence or the development of post-traumatic stress disorder, PTSD, in providers and nurses in healthcare providers.
00:12:11
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who developed the burnout syndrome.
00:12:15
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So when people ask executives, clinical leaders, and clinicians about the causes of burnout, overwhelmingly the increased clerical burden seems to be at the
Organizational Causes and Solutions
00:12:25
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top.
00:12:25
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So there is a perception about executives, but also clinicians and leaders that that unfulfilled promise of automation and medicine has become a great problem.
00:12:37
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So what do I mean by that?
00:12:38
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In most other fields,
00:12:40
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Automation and technology has taken away menial work from the people who create value.
00:12:47
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In medicine, the overwhelming feeling right now is that automation, the electronic medical record, electronic billing systems have really added menial work that detracts from us providing value to our patients and time away from our patients.
00:13:05
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And over and over again, that is cited as a top cause for burnout, and we'll talk a little bit about it.
00:13:10
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increased productivity requirements and expectations, the ever-changing rules, or every week there seems to be a new core measure or a new thing that we have to now check and a new box to check.
00:13:24
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I think that individually these might have good intentions, but when they keep adding and make it overwhelming for the providers and for the bedside nurses, I think it becomes a big problem.
00:13:34
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As you can see, those two far and above are cited as important causes
00:13:39
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in terms of organizational causes.
00:13:41
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And there are things that have come up are an erosion of professionalism, excessive quality metrics, excessive work hours, but overwhelmingly it seems that the medical record is something that requires attention.
00:13:53
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So we have met the enemy, it seems.
00:13:55
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However, I just want to point out that it's a little bit more complicated and nuanced maybe than just say that the devil is the medical record.
00:14:04
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And it's very interesting because many
00:14:06
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Many people have worked around this electronic medical record by adding scribes to their practice, and it seems to at least short-term increase a little bit of satisfaction because physicians spend a little bit more time with their patients.
00:14:18
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But I just want to point you out to a very recent paper or write-up from Atul Gawande, Why Doctors Hate Their Computers, published in the New Yorker.
00:14:29
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And it's very interesting because he actually goes through his own journey, but
00:14:35
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points out to three aspects that I had not considered before when I evaluated the electronic medical record that gave me a little bit of pause in terms of what's the best way forward.
00:14:46
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So the three things that he points out in this article that I thought were interesting or novel was that, number one, after a decade of using medical records, there is finally data that suggests or that shows that outcomes of patients, if you do them by specific diagnoses in Medicare patients,
00:15:04
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have actually improved.
00:15:06
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So there seems to be an association with the use of electronic medical records and improved patient outcomes.
00:15:12
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And that is something that I think all providers will appreciate, that anything that really makes a positive impact on outcomes is something that we should consider to keep doing.
00:15:24
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Number two is that the fact that the largest and fastest growing users of electronic medical records
00:15:33
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are our patients.
00:15:34
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And they were exactly discussing this in Washington in terms of new laws that will enable patients more open access to their medical records.
00:15:44
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So clearly providing information for our patients also is a plus.
00:15:48
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And finally, one of the things that I found encouraging in the piece by Atul Gawande was that there are small examples of very engaged physicians, physician groups
00:16:00
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that when working with the IT counterparts and really putting the time to identify what are the barriers and how they can make the medical record work for them, have accomplished really, really amazing results.
00:16:12
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And I think that it might require work from us, but I think for those colleagues who have the opportunity to get engaged at a very intimate level and really work on modifying our workflows to try to improve them, it's something that definitely can help patients
00:16:27
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and can help us, but clearly the medical record continues to be a big problem.
00:16:32
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So we talked about external and internal factors.
00:16:36
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External factors, like I said, include the workflows, your electronic medical record, the increasing workloads, lack of control over the work environment, a lot of people perceive that, insufficient rewards or misalignment maybe in incentives, and a generally breakdown in the work community.
00:16:50
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And this you see in a lot of ICUs that are short staffed, work with nursing and physicians.
00:16:55
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it's very difficult to keep that spirit of corbs high.
00:16:59
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And those are areas where maybe burnout is more prevalent.
00:17:04
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However, what's also very interesting is that wherever I've been or wherever I've worked, I've seen people who are burnout and people who are not.
00:17:13
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So even when exposed to the same set of organizational factors, there's some people who are more likely to be burnout than others.
00:17:21
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And that brings the internal factors.
00:17:23
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There are aspects of
00:17:25
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of high-performing professionals, such as being very self-critical or not having helpful coping strategies, sleep deprivation, something that I think that more and more people are talking about, especially in the medical field.
00:17:39
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I mean, sleep is a health necessity.
00:17:41
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I think in general, with working night shifts and working long hours, we have not, as a community, taken good care of that, work-life imbalance.
00:17:51
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But there's also some of the characteristics that might make us
00:17:54
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great providers, which is idealism, perfectionism, and commitment that sometimes can increase the risk or be in a factor that increases the risk of burnout.
00:18:06
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Why should we care?
00:18:07
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Why is burnout important?
00:18:09
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Well, when this was asked, I mean, in a large survey initiated by the New England Journal of Medicine and their Catalyst series, number one was decreased quality of care.
00:18:19
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And more clinicians than executives cite that as the most important cause.
00:18:23
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So clinicians recognize that when they're burned out, they're more likely to have medical errors.
00:18:28
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They're more likely to provide lower quality of care.
00:18:32
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And then other things that were mentioned are the effect on the attitude of the rest of the healthcare team.
00:18:37
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We know that somebody who has a very negative attitude in a small team can have a contagion effect, and it really brings down the team very quickly.
00:18:45
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It requires...
00:18:46
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a lot more positive energy to overcome negative energy in any human interaction.
00:18:50
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So that's a problem.
00:18:52
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The duty of organizations to care for people, I mean, obviously as a large healthcare organization, some physicians not only is here to provide the best care for our patients, but we're also here to provide the best environment that we can for our colleagues.
00:19:06
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Turnover is a problem, decreased patient satisfaction, decreased productivity, and again, I mean, mentioned physician suicide, which is a real problem
00:19:16
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for our community.
00:19:18
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The main consequences, job turnover, very frequent.
00:19:22
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If you look at ICU nurses, it's estimated that replacing an ICU nurse can cost north of $60,000.
00:19:29
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So if you have a regular ICU that has 20 beds and uses 100 nurses to cover those 24 hours a day, and they have a 17%, which is an average turnover rate,
00:19:42
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that would cost them every year over a million dollars just in turnover.
00:19:46
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So clearly it adds tremendously to the cost of care, not only to mention that when you have new people, you have to retrain them, the quality of care might suffer.
00:19:55
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But also as burnout levels increase in specific areas of the hospital, the quality of care will decrease.
00:20:03
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And there are multiple studies now that have shown that there's an association between levels of burnout and the likelihood of a medical error.
00:20:11
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the level of burnouts and the likelihood of a medication error, of perceived poor quality care.
00:20:19
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So clearly, as we saw before, it's a big problem in terms of providing value when our quality or our outcomes start going down because of the levels of burnout.
00:20:29
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And finally, patient satisfaction goes down.
00:20:31
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I think we talked about that, compassion fatigue.
00:20:34
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But over and over again, there's a tremendous emphasis on
00:20:38
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as part of our value equation, better patient outcomes, better patient experiences at lower cost to assess this.
00:20:45
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And we're hearing from our patients that a lot of times they feel their doctors are not compassionate.
00:20:51
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They feel the nurses might be too overwhelmed.
00:20:55
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And it has a negative impact on their satisfaction with their health care.
00:20:59
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So these are things that are very important that really, I mean, I think make it a crisis for us to really pay attention to and try to improve.
00:21:09
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Let's move to the second part of this talk in terms of what can we look at in terms of evidence to guide us?
00:21:16
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What are some things that we
Intrinsic Motivators and Resilience
00:21:17
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can look at?
00:21:17
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And just a couple of things that I wanted to talk about was looking at a little bit of human motivation, a little bit of PTSD and what we can learn from our colleagues in the uniform services and also studies on interventions that have been employed to reduce burnout.
00:21:34
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So a lot of people believe that money is a motivator, but over and over again, that's been debunked.
00:21:39
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And what we know today is that the whole idea of carrots and sticks only leads to compliance.
00:21:45
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So the whole idea of contingent rewards or extrinsic rewards, if you do A, I'll give you B, only leads to some compliance.
00:21:55
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And it may have worked in the Industrial Revolution, where people were part of an assembly line and had a very simple task of maybe putting a pin in a certain position.
00:22:03
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So the more you rewarded them, the more likely they were to put effort in putting that pin at a more efficient way.
00:22:09
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And that has really, I mean, been translated for years now into the way we align incentives, the way we talk about providers.
00:22:17
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But the reality is that over and over again, you will see people who, despite their pay, despite their incentives, are very miserable, or on the contrary, people who might not be getting the highest pay, but are very motivated and are very passionate about their work.
00:22:32
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And what people have come to understand now is that in the knowledge economy, which is what we do in medicine,
00:22:38
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It's intrinsic rewards or purpose-based rewards that really make a difference.
00:22:42
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So motivation really starts with an assumption that you're paid fairly, but it's really much more important than the pay in terms of do you have meaning in your job?
00:22:53
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Are you allowed to put the effort that you want to put?
00:22:56
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Are you giving creativity?
00:22:58
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Is it challenging?
00:23:00
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Do you have pride?
00:23:01
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So all these internal motivators are much more important.
00:23:03
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And I think that ultimately we have to recognize that, but also build
00:23:08
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teams that encourage and incentivize people and give them the opportunities to really work where they're motivated.
00:23:15
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Because I think at the end of the day, we could all agree that the opposite of a burnout provider is an engaged provider.
00:23:23
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And if we can get people engaged and motivated in providing value for their patients,
00:23:28
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I think that the risk of burnout will go down.
00:23:31
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So what ultimately motivates physicians?
00:23:33
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I think that Daniel Pink has talked a lot about this and written about this in his wonderful book, Drive.
00:23:39
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There's three things that really, I think, matter long-term and being engaged and motivated in what you do as work.
00:23:46
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It's autonomy, mastery, and purpose.
00:23:49
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And I'll talk a little bit about autonomy, but mastery is really the ability to keep learning, to keep improving our craft.
00:23:55
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I think that...
00:23:57
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Activities such as this webinar are part of trying to provide our teams and our physicians with the ability to expand their horizons, to keep learning.
00:24:05
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I mean, those people who are, you always see this actually in friends, family who are retired.
00:24:11
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The older friends who are always learning something are usually much more engaged and seem to be much better health.
00:24:18
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So the day you stop learning, I think it's a problem.
00:24:21
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And it's very true for life and it's very true for work.
00:24:24
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So expanding that knowledge base that we have in critical care or whatever field you are, I think is very important.
00:24:31
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And finally, a purpose in terms of understanding why you're doing what you're doing and what impact it has on others.
00:24:39
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Purpose, I think it can be categorized into two types of purpose.
00:24:43
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Like purpose with a capital P is my work is meaningful to me and will make a difference in the life of others.
00:24:50
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And purpose with a small P
00:24:52
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is the tasks that I do are important.
00:24:54
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If they're not done, it will matter to others.
00:24:57
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And I think a way of summarizing that look at purpose is when you look at a cardiac arrest.
00:25:02
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In a cardiac arrest, the team is centered around the capital B purpose of saving a life.
00:25:08
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And we've all been in situations in a cardiac arrest that might be very dramatic, but the team is very focused on a purpose.
00:25:13
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And if that patient walks out of the hospital, I think everybody who was involved will feel tremendously thankful and tremendously grateful
00:25:22
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motivated that what they did made a big difference.
00:25:25
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But during the cardiac arrest, there's also a purpose with a small p. And it's the person doing the CPR knows that that task is very important.
00:25:33
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And if they stop, it's going to be a problem.
00:25:35
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The person who's managing the airway, same thing.
00:25:37
Speaker
The person who's providing the drugs.
00:25:39
Speaker
The person who is talking with the family.
00:25:41
Speaker
The person who's noting down what's been done.
00:25:44
Speaker
Every person has a task that is important and that if not done, will matter.
00:25:49
Speaker
So finding purpose in healthcare would seem to be easy, but it's very interesting that a lot of people doing the same jobs find very different levels of meaning and purpose.
00:26:02
Speaker
And this is a paper that I find fascinating.
00:26:04
Speaker
I've often shared with colleagues in different contexts.
00:26:07
Speaker
It's from Amy Wojcinski.
00:26:09
Speaker
She's from the Yale School of Management.
00:26:11
Speaker
And what she did is she was trying to understand how do people find meaning in their jobs.
00:26:16
Speaker
And she specifically studied
00:26:18
Speaker
a group of hospital janitors.
00:26:20
Speaker
And what she identified was that she could predict who found purpose and meaning in their job by the way they described their job.
00:26:32
Speaker
So those janitors that described their job in terms of their tasks that they accomplished or basically regurgitated the job description were much more likely to
00:26:42
Speaker
to feel that their job was just a job that anybody could do and was not an important job.
00:26:46
Speaker
They really didn't find a lot of purpose in their job.
00:26:49
Speaker
However, those who described their jobs in terms of the people they helped and the things they did to make patients better, to make the family experience better.
00:27:00
Speaker
For example, one of the most interesting examples was a lady who worked in a traumatic brain injury recovery ward
00:27:09
Speaker
And every couple of days, she would change the hanging art in the patient's room.
00:27:16
Speaker
She would move it around.
00:27:17
Speaker
And the reason she would do that is because she felt that by moving it around, she would help stimulate the patient who was recovering, and it would be actually something that would help them recover.
00:27:26
Speaker
That's not part of her or his job description, but that type of license to make a difference really gave these janitors tremendous purpose.
00:27:38
Speaker
And they really felt that they were there to make a difference in the patients and the families who were in that hospital.
00:27:44
Speaker
And this whole idea evolved into what's called the job crafting.
00:27:50
Speaker
And what's very interesting in posterior studies, Amy Worsoski and her team showed that people who start describing their jobs in a way that really speaks about the people for whom they make the greatest difference, start finding more purpose.
00:28:04
Speaker
So it's the whole idea
00:28:05
Speaker
that you can act yourself into a different way of thinking much easier than you can think your way into a new way of acting.
00:28:12
Speaker
So really, the way you start describing what we do in healthcare and the difference we make for other people might be a good way of rekindling or refinding that purpose in terms of healthcare.
00:28:26
Speaker
We also mentioned post-traumatic stress disorder, PTSD, as something that has been very common since the 90s and talked about in our military
00:28:35
Speaker
with all the wars and deployments that we've had over the last 15 years.
00:28:40
Speaker
And what's very interesting though is that more recently there's been a growing literature of something called the post-traumatic growth syndrome.
00:28:48
Speaker
So basically the question is why do some soldiers exposed to these really catastrophic environment or circumstances develop PTSD, yet others who might even have a worse fate from our perspective come back and really flourish?
00:29:05
Speaker
and find meaning and find a way of making a difference for others.
00:29:09
Speaker
And what a lot of people have boiled this down to is to the whole idea of resilience.
00:29:15
Speaker
A resilient is the capacity to recover quickly from difficulties and toughness, right?
00:29:20
Speaker
So some people actually will grow from difficult situations and other people's will have PTSD.
00:29:26
Speaker
Now, this has led to a whole new area in medicine.
00:29:31
Speaker
We've hear a lot about resilience training.
00:29:34
Speaker
And we recognize that those who have post-traumatic growth are very resilient.
00:29:38
Speaker
But the real question is, how do you become resilient?
00:29:41
Speaker
Or how do you help somebody else become more resilient?
00:29:44
Speaker
And I think that some of the characteristics that people have found in very resilient individuals is a very strong source of purpose.
00:29:52
Speaker
So we said that you can kind of job craft or create purpose.
00:29:55
Speaker
That's something that you can work on.
00:29:57
Speaker
People who are very resilient are very thankful.
00:30:00
Speaker
They have humor.
00:30:02
Speaker
They are very focused on their well-being.
00:30:03
Speaker
They accept the fate that has happened to them, and they do the best they can with the things they can control.
00:30:10
Speaker
The whole idea of mindfulness, really living in the present moment and thinking about what you can control.
00:30:16
Speaker
And I think mindfulness comes to speak to me very powerfully in critical care.
00:30:22
Speaker
And I challenge the listeners to think about this.
00:30:25
Speaker
When are you most frustrated or stressed out in a clinical day or a clinical shift?
00:30:32
Speaker
I think it's when you're thinking of what's to come or thinking of what you need to do or thinking about you're trying to finish a note and you got three calls that interrupt you.
00:30:40
Speaker
However, when you're in the middle of an intubation or when you're in the middle of a very intimate, difficult family discussion, you don't feel that same level of stress or you don't feel that same level of anxiety because you are present 100% in that moment.
00:30:57
Speaker
And I think that
00:30:58
Speaker
This is probably what people speak to about the medical record.
00:31:02
Speaker
The medical record and all the electronics we have have created more distractions and have separated us from those very intimate tasks with our patients and those very intimate discussions with our patients that really are mindful in terms that they're present and you're 100% there.
00:31:18
Speaker
So just something to think about.
00:31:20
Speaker
And then finally, with resilience, learning from our failures.
00:31:26
Speaker
Finally, are there any interventions to address burnout?
00:31:29
Speaker
And here I'll just show you a couple of studies, but the real intention is not to go into detail about these studies, but there's been several publications over the last years, actually, after the last decade, talking about the association of certain mindful communication program educations with burnout, the association of training and resilience with burnout.
00:31:51
Speaker
And there's been like meta-analysis published a couple of years ago that have looked at all these RCTs and cohort studies.
00:31:56
Speaker
And really what they say is that in general, when you do interventions in an organized way, they do move the needle, at least during the study period.
00:32:05
Speaker
Nobody has done long-term follow-up in terms of does it make a difference forever or as soon as you stop the intervention or go back, does it revert to old systems?
00:32:15
Speaker
But what I wanted to point out here is that most of the studies in the medicine literature really focus on intervening on the provider.
00:32:25
Speaker
trying to fortify the internal aspects of burnout.
00:32:29
Speaker
Very little has been studied on the organizational factors, and more and more, I think that people have recognized that we need more than just yoga and mindfulness to really make a difference.
00:32:41
Speaker
We really need that changes that come from the very top of policymakers in terms of how we are pushing forward with our healthcare.
Systemic and Individual Approaches to Combat Burnout
00:32:51
Speaker
And we'll hear a little bit more about that in the panel when we talk about what sound is trying to do or how sound looks at this as well.
00:33:00
Speaker
So as you can see, there are several concentric circles of influence of factors that might make an individual burn out.
00:33:08
Speaker
So in our critical care example, it's the ICU you work in.
00:33:12
Speaker
Within that ICU, there's a lot of other providers and factors that might make it more or less likely that you're burned out.
00:33:18
Speaker
There's the individual factors that we talked about,
00:33:21
Speaker
but also there's also the sound critical care group, the sound physician circle.
00:33:25
Speaker
Then you have the hospital that you work in.
00:33:27
Speaker
Maybe there's a hospital system within that hospital, that hospital's within.
00:33:32
Speaker
And then we have the whole healthcare.
00:33:34
Speaker
And as these circles get bigger, I think our sphere of influence obviously becomes more limited.
00:33:40
Speaker
But I think that the point I wanted to make is that we have to work on all of these.
00:33:45
Speaker
And what I'll share with you in the last five to 10 minutes of the presentation
00:33:49
Speaker
is some of the things that I think that we as individuals can start doing to make things a little bit better, but recognizing that without more done at a healthcare system level, at a hospital level, at sound physicians level, it's not gonna be enough to eliminate or decrease burnout significantly, but it has to start somewhere.
00:34:10
Speaker
So I would start with that first concentric circle of the individual.
00:34:14
Speaker
So I always believe that excellence is the next five minutes,
00:34:18
Speaker
So whatever you do in the next interaction, I think is very important.
00:34:23
Speaker
I think that for, I'm sure some of you will be working clinically tonight, some of you will work clinically tomorrow.
00:34:29
Speaker
What you do in that next shift, in that first interaction you have with a patient, with a nurse, with a colleague, how you think about it is going to be very important.
00:34:37
Speaker
So the three things I want to talk about real quickly are to start with I, the practice of EBM and broadcast plus or positives.
00:34:45
Speaker
So start with the individual.
00:34:47
Speaker
I think that we always hear that if you are in an emergency in an airplane, put the oxygen on yourself first and then think of others.
00:34:54
Speaker
And I think that's true for us as providers.
00:34:58
Speaker
Martin Selman and the group of the University of Pennsylvania and many others that have followed Shan Anker and Harvard have really revolutionized the way we think of psychology with this concept of positive psychology.
00:35:09
Speaker
And one of the things that they talk about over and over again is this concept of flourishing.
00:35:14
Speaker
So human beings, I mean, we always say, what's your goal to be happy?
00:35:17
Speaker
Well, happy is not something you can measure, but flourishing can be measured in different domains.
00:35:22
Speaker
And it talks about positive emotions, engagement or flow in different activities, not only at work, but for example, if you're a marathon runner, why do people like to ride marathons?
00:35:31
Speaker
It's because at one point they're in flow.
00:35:34
Speaker
Nothing else matters.
00:35:34
Speaker
Same thing for people who ride their bikes, who do photography.
00:35:38
Speaker
Positive relationships, no question about that.
00:35:41
Speaker
investing in your work-life balance, making sure you're there for the people that are important for you, making sure you call friends, you call parents.
00:35:50
Speaker
These are all things that are very important.
00:35:52
Speaker
Again, the meaning or purpose comes around, recognizing that that's something that's internal.
00:35:58
Speaker
People can find purpose in any job, but they have to think about it in a special way.
00:36:02
Speaker
And for me, it's very, very sad sometimes that with what we do, making a difference for so many lives, there's still people in our field
00:36:10
Speaker
who cannot find purpose in their jobs.
00:36:12
Speaker
And finally, accomplishment, which goes beyond, I mean, the traditional in terms of accomplishment, but losing weight, putting yourself a goal to maybe run a 5K and doing that, putting yourself a goal to call your parents every day or every week and doing that.
00:36:27
Speaker
There's a lot of ways that you can really get accomplishment, but I think what they're trying to say is that we have to take care of ourselves and really think about what are the things that are important for us and give them the importance that they deserve.
00:36:40
Speaker
Another important aspect that I think is worth mentioning here is taking care of your health.
00:36:46
Speaker
And sleep hygiene is something that more and more people have talked about.
00:36:52
Speaker
It's something that we have recognized that most Americans are sleep deprived on average, right?
00:36:59
Speaker
There's plenty of evidence that we need eight hours or more of sleep on average.
00:37:04
Speaker
And I think for those of us who work night shifts and for those of us who work long hours, I think making sure that you treat sleep as an exercise and you really work on having routines that maximize your rest are going to be important as well.
00:37:19
Speaker
The second part is practicing evidence-based motivation or EBM.
00:37:23
Speaker
And that is really focusing on autonomy, mastery, and purpose.
00:37:27
Speaker
So autonomy, we have plenty of autonomy.
00:37:30
Speaker
even though we always have to respond to somebody, when we're making decisions and patient care, when we're rounding, there's plenty of opportunity for us to find things to fix and really enjoy and really embrace that autonomy to make a difference.
00:37:45
Speaker
Mastery, I think that there's different ways of learning, but the day we stop learning, the day I think that we get in trouble and that we should really always be looking not only to learn new things, but to learn through teaching.
00:37:58
Speaker
How can we teach the nurses that work with us?
00:37:59
Speaker
How can we teach younger providers that work with us?
00:38:02
Speaker
But really keep improving our craft and learning about how to provide the greatest value.
00:38:08
Speaker
And finally, we talked about purpose, and I won't go into details about that, but I do think that job crafting can be a very good tool in terms of how we think about our jobs.
00:38:19
Speaker
Think about not the tasks you do, but the people with whom you're making a difference.
00:38:23
Speaker
And it's a lot more than patience.
00:38:25
Speaker
for those of us who work in the hospitals, who work in the ICU.
00:38:31
Speaker
Bad news, I think, is pervasive.
00:38:34
Speaker
It sells a lot more.
00:38:36
Speaker
It's all you hear on the news.
00:38:37
Speaker
I mean, it's one of the reasons why I don't listen to TV.
00:38:40
Speaker
I don't watch TV anymore.
00:38:41
Speaker
But I do think that there's also a lot of positive that can be broadcast.
00:38:46
Speaker
And I think that being a positive broadcaster doesn't mean that you're neglecting what is real and problematic.
00:38:53
Speaker
We're talking about burnout.
00:38:55
Speaker
But I think it's making sure that we also promote and talk about some of the things that are very positive in our day and positive in our daily work.
00:39:06
Speaker
One of the things that I really enjoy is understanding how to build better cultures.
00:39:11
Speaker
And building the nice youth team that is engaged and fulfilled is possible.
00:39:15
Speaker
It takes a lot of effort.
00:39:17
Speaker
But I think that whether you get there or not, the journey is worth a try.
00:39:20
Speaker
And there's three things that really matter here.
00:39:23
Speaker
Building safety for your team.
00:39:25
Speaker
that sense of I belong, sharing vulnerability, which means it's okay if I'm not perfect, and finally establishing purpose, my work has meaning.
00:39:35
Speaker
So in terms of building safety, you have to dial into those small subtle moments and deliver targeted signals at key points.
00:39:42
Speaker
You have to make sure that people understand when you're listening, right?
00:39:46
Speaker
I think that waiting for your turn to talk is not listening.
00:39:50
Speaker
Hearing what somebody says and trying to understand why they might have a point that is listening,
00:39:55
Speaker
making sure you overdo your thank yous.
00:39:57
Speaker
And in every team intervention encounter, make sure everybody has a voice.
00:40:03
Speaker
It doesn't mean that everybody gets to decide, but I think everybody should talk during rounds, during meetings, in a code.
00:40:09
Speaker
If somebody has something to say, they should feel comfortable saying that.
00:40:12
Speaker
And these are some of the things that build that safety of belonging.
00:40:17
Speaker
Share vulnerability.
00:40:18
Speaker
Group cooperation is created by small, often repeated moments of vulnerability.
00:40:22
Speaker
There's been a lot of talk about the vulnerable leaders
00:40:24
Speaker
And you have to be authentic, obviously.
00:40:26
Speaker
But I think that the most important words that as a leader, which we all are when we're in the ICU, we can have is, I made a mistake or I screwed up.
00:40:35
Speaker
I think it's important for people to understand that we're not perfect, that we can make mistakes, people can question us, and that people are allowed to ask questions and not be perfect.
00:40:46
Speaker
I think it's very important for us to communicate or over-communicate our expectations.
00:40:49
Speaker
People are very clear on what they need to do.
00:40:52
Speaker
And finally, a way of becoming really vulnerable and learning from each other is when we have these true debriefs or candor-generating practices, which sometimes take a punitive kind of approach when you do these root cause analysis.
00:41:05
Speaker
But even if you just had rounds that day, you could ask, I mean, the team, what did we do well?
00:41:11
Speaker
What could we do better?
00:41:12
Speaker
What should we change for next time?
00:41:14
Speaker
And just encouraging people to point out things that can be improved.
00:41:18
Speaker
That's how vulnerability becomes important.
00:41:20
Speaker
an important builder of an engaged ICU.
00:41:24
Speaker
And finally, establishing purpose.
00:41:26
Speaker
So people don't buy what you do, they buy why you do it.
00:41:30
Speaker
So name and rank your top priorities.
00:41:32
Speaker
Make sure that those priorities are 10 times as clear and repeat them over and over again.
00:41:36
Speaker
And I think that we often forget why we're in the ICU, but I think it's very easy to redirect people.
00:41:43
Speaker
And Roten will talk a little bit about this later, but one of the things that I think has helped a lot of our teams
00:41:48
Speaker
and reestablish purpose is events such as a celebration of life and other things where we really reconnect with the people with whom we're making the biggest difference for.
00:41:59
Speaker
So we talked about the burnout syndrome.
Panel Discussion on Broader Solutions
00:42:01
Speaker
We talked about some of the evidence behind what motivates people, PTSD versus post-traumatic growth, resilience, and some of the things that I've done in medicine.
00:42:12
Speaker
And finally, I talked about some of the things that we as individuals for ourself or for our immediate team can do.
00:42:17
Speaker
But what I want to do now is introduce our panel and have a little bit of a broader discussion of what can we do at a larger level and also hear from some of our colleagues in other lanes.
00:42:30
Speaker
So please feel free to send messages and we'll start by introducing our panelists, which are Mark Rudolph, our Chief Experience Officer for Sound Physicians.
00:42:41
Speaker
He started as a hospitalist many years ago with Sound and has been very involved
00:42:47
Speaker
with improving the experience of our providers, but has really served all capacities in sound.
00:42:54
Speaker
Fabian Moore, who's our VP for Physician Development, and she has joined us a bit over a year now and has really been involved in our learning and development initiatives, both the onboarding, Crucial Conversations, CSI.
00:43:11
Speaker
She has a background as a surgeon in clinical care.
00:43:15
Speaker
So we'll hear from Fabian.
00:43:17
Speaker
We have Rotem Freed, who's our regional medical director and a practicing intensivist out of Philadelphia.
00:43:23
Speaker
And Rotem started the initiative called the Celebration of Life, which I think has had tremendous effect on the morale and levels of burnout of the staff, both nursing and physicians.
00:43:35
Speaker
So we'll hear from her.
00:43:36
Speaker
And finally, Nathan Runch, who's our newest addition to our sound team and has joined us in the last six months, is the emergency medicine associate chief medical officer
00:43:47
Speaker
and is also based out of Pennsylvania.
00:43:49
Speaker
So welcome all to the panel.
00:43:51
Speaker
I hope that you're all unmuted now.
00:43:56
Speaker
Thanks, Sergio.
00:43:57
Speaker
Yes, thanks, Sergio.
00:43:59
Speaker
Happy to be here.
00:44:01
Speaker
Excellent.
00:44:02
Speaker
So for our listeners, if you have specific questions, please put them in the chat and let me see, make sure that I am able to see them here.
00:44:19
Speaker
Maybe David or our technical can make sure that we can see that.
00:44:22
Speaker
But I would like to start with maybe going around the table and just getting a little bit of your insight or perspective on burnout in general.
00:44:31
Speaker
And we'll start with Mark.
00:44:33
Speaker
Mark, do you want to share with us, I mean, just in general, your perspective as a provider at one point and how you see this problem?
00:44:42
Speaker
Sure.
00:44:42
Speaker
Thank you, Sergio.
00:44:43
Speaker
Thanks for that very comprehensive presentation.
00:44:47
Speaker
I think I'll start by saying that I definitely don't have all the answers even after all these years of practicing.
00:44:54
Speaker
I think, you know, when I think about burnout, I think that the problem that we face really is more than we even know from assessing burnout syndrome formally.
00:45:05
Speaker
There are so many experiences that people have that may cumulatively lead to a sense of burnout and even singular experiences that may be very traumatic.
00:45:15
Speaker
I think that that is
00:45:17
Speaker
a reality of the work that we're doing, no matter how many hours or how many patients we necessarily see.
00:45:23
Speaker
So we have to have a way to be able to deal with those experiences.
00:45:29
Speaker
I think for the Organization for Sound Physicians at large, we, from the beginning, wanted to create sustainable careers for providers, and particularly on the hospital medicine side.
00:45:43
Speaker
And I think
00:45:44
Speaker
Very similarly, emergency medicine has followed this path even from its beginnings, which are long before hospital medicine, and maybe a little less so on the critical care side, have tried to structure work that is sustainable, meaning shifts that are reasonable and a reasonable number of shifts per week and per month.
00:46:06
Speaker
So that structurally, in terms of the way that we think about our practice, was done intentionally to create careers that were sustainable.
00:46:16
Speaker
That being said, things are not always predictable in the hospital, and so we have to be able to respond to the changes that occur, whether it has to do with patient volume, staffing volumes, so that we can make sure that providers aren't faced with unreasonable workloads or things that threaten their ability to provide good care, because I would agree with you
00:46:36
Speaker
that that is a huge part of what leads to burnout over time is a sense that I am not doing a good job.
00:46:43
Speaker
And so that combined with a number of the things that you mentioned and something really important that this webinar is itself evidence of is just the idea of bringing these feelings out into the open and kind of normalizing them.
00:46:59
Speaker
And I'm actually going to
00:47:00
Speaker
ask Fabien to comment on that because she and I were just talking about this the other day.
00:47:05
Speaker
Fabien, you want to maybe elaborate on that?
00:47:07
Speaker
Yeah, absolutely.
00:47:10
Speaker
Happy to jump in.
00:47:11
Speaker
Thank you, Mark.
00:47:12
Speaker
And also, I will second the kudos to Sergio for such a fantastic overview of where we are as a profession in an industry and what we know.
00:47:21
Speaker
And I would say more than anything, Sergio, your talk highlighted how many questions we are still in the process of asking.
00:47:30
Speaker
One of the questions that Mark and I spend a lot of time asking and sitting with and exploring is, what can we as sound do to support our providers' resilience, given that so many of the drivers of experience and both burnout and resilience are local?
00:47:47
Speaker
And a model that we are finding very helpful and that we're also hoping to normalize with our leaders across sound is one that was developed by a group of thinkers in the New England Journal's Catalyst.
00:48:00
Speaker
And this group has identified what they call three domains of resilience.
00:48:05
Speaker
And those domains are efficiency of practice, culture of wellness, and then personal resilience.
00:48:11
Speaker
And they are all mutually reinforcing.
00:48:15
Speaker
So when all are present, they can amplify each other.
00:48:18
Speaker
If any one of those domains is weak, then that can actually, that will undercut all of the other two and increase the risk of burnout.
00:48:25
Speaker
And so, as you pointed out, Sergio,
00:48:29
Speaker
the power of this model is that it goes beyond simply talking about personal resilience and self-care, which are undeniably important and essential.
00:48:38
Speaker
And let's be honest, skills that very few of us were ever, you know, encouraged to acquire over the course of our education and training, much less taught.
00:48:48
Speaker
So that absolutely is part of it.
00:48:49
Speaker
And yet this broader context of
00:48:52
Speaker
efficiency of practice and how our work is set up.
00:48:55
Speaker
And that's, you know, I think that's everything from what Mark was just speaking to about workload and scheduling to Sergio, what you alluded to with the EMR and what, you know, Atul Gawande highlighted so eloquently in his article.
00:49:08
Speaker
And then that third domain, this idea of a culture of wellness is all about changing our group norms so that it becomes acceptable to have conversations
00:49:20
Speaker
And it moves us past the reality that I think most of us, quote unquote, grew up with as clinicians.
00:49:26
Speaker
And I think many of us still live with, which is the fact that we're all very often suffering in silence and believing still that we're the only ones who are struggling.
00:49:36
Speaker
We're the only ones who are having a tough type coping.
00:49:39
Speaker
And so we just need to kind of buck up and get it together.
00:49:42
Speaker
It's sort of like that iron dock archetype and stereotypes.
00:49:46
Speaker
The idea of moving beyond that and recognizing that the same compassion that we expect of ourselves and each other for our patients, that we and our colleagues are also worthy of that same kind of compassion and care.
00:50:01
Speaker
And how do we start to shift the norms within our practices so that that becomes acceptable?
00:50:08
Speaker
And how do we make, create,
00:50:12
Speaker
this is kind of a squidgy term, but safe spaces, if you will, where folks can have conversations about the challenges, about the very real everyday struggles of being, you know, I'm fond of saying like a carbon-based life form who's doing a very high pressure job where the stakes are high.
00:50:29
Speaker
And all of that, you know, I think in the context of critical care is even more amplified.
00:50:35
Speaker
Excellent Fabian and Mark.
00:50:37
Speaker
And I would like to hear from Nate, um,
00:50:40
Speaker
of the ED perspective, the emergency medicine providers have a high incidence of burnout as well, but they also seem to have a high incidence or proportion of satisfaction with work-life balance.
00:50:54
Speaker
I think it's kind of a little bit of a paradox, but Nathan, can you tell us a little bit about what's going on in the EM lane?
00:51:01
Speaker
Sure.
00:51:02
Speaker
I think EM is somewhat insulated from some of the issues of burnout faced by
00:51:09
Speaker
other houses of medicine because it's more scalable than some other careers in medicine, but the patient interactions and staff interactions that we have are often more intense.
00:51:21
Speaker
So I think the prevalence of burnout remains quite high, even though it perhaps has a little bit more manageable lifestyle than some other specialties.
00:51:32
Speaker
I think that like many careers in medicine, if everything in your life is going well,
00:51:39
Speaker
you know, things are okay.
00:51:41
Speaker
But when you have, you know, a sick child at home or a significant relationship problem or, you know, some other stressor in your life, you know, that's often when folks run into trouble.
00:51:52
Speaker
And I think that you touched on something in the presentation that is really important, which is destigmatizing the idea that, you know, it's okay to communicate struggle and show vulnerability.
00:52:07
Speaker
And I think that's key.
00:52:09
Speaker
I feel like I know since I trained a number of decades ago, there's been a shift there, and I think things are moving in the right direction, and that's certainly a positive sign for the future.
00:52:21
Speaker
I think it's incumbent on certainly everyone on the panel and all the leaders within sound, but also for everyone listening to really actively seek out and listen for signs of trouble in burnout with colleagues.
00:52:39
Speaker
I know many folks have been touched by suicide by coworkers and by co-residents and people on medical staffs.
00:52:51
Speaker
And often these things seem to come as a surprise, but I think in retrospect, perhaps there were signs there that could have been acted upon.
00:53:02
Speaker
And I think learning to listen to that is important.
00:53:07
Speaker
You know, there's a lot of talk about resilience and what that means.
00:53:11
Speaker
And, you know, I think you touched on another thing that's especially an issue for hospital medicine, critical care and emergency medicine, which is what are best practices for sleep hygiene as it relates to shift work?
00:53:23
Speaker
And there certainly is a lot of research there.
00:53:26
Speaker
And lately, sleep has gotten, I think, a lot more attention in the lay press than it's gotten previously.
00:53:32
Speaker
But I'm not sure that the best practices for
00:53:36
Speaker
sleep hygiene among shift workers are known.
00:53:38
Speaker
And I think that's something, you know, we certainly need to focus on as an organization moving forward.
00:53:44
Speaker
Excellent.
00:53:45
Speaker
And I think that we'll talk a little bit more about that, but you did a hit on, I mean, there's a lot more talk about sleep hygiene in general, but also how do we address that for those of us who have practices that involve shift work at night?
00:54:00
Speaker
And that is something I think that where we can probably learn more and might be topics for us to discuss further.
00:54:05
Speaker
So before we go to some of the questions that our audience is sending, I would like to ask Rotem to probably share with us.
00:54:13
Speaker
And Rotem, I have a specific request
Creating Supportive and Purpose-Driven Work Environments
00:54:15
Speaker
for you.
00:54:15
Speaker
Definitely would like you to share your experience with the Celebration of Life.
00:54:21
Speaker
in Philadelphia and we've now replicated that in other institutions following your lead.
00:54:26
Speaker
And it seems that it does help, especially for the nursing staff and the physicians.
00:54:30
Speaker
Can you just tell us your experience with that?
00:54:32
Speaker
Sure.
00:54:33
Speaker
Thanks.
00:54:35
Speaker
So we started it about three years ago and it was basically an effort to reconnect with patients and their families after they had left the intensive care unit.
00:54:46
Speaker
And there were several objectives.
00:54:49
Speaker
to the event.
00:54:50
Speaker
One was just to have an opportunity to see patients because, as you know, once they leave the confines of the ICU, most of us do not follow them out there.
00:55:01
Speaker
And then to serve as a support for families that may have lost loved ones, but we had formed a close bond with them during their ICU stay.
00:55:11
Speaker
So we basically invited patients and their families and
00:55:17
Speaker
it was obviously the families of, of patients who, uh, who had passed away, um, to come and join us.
00:55:24
Speaker
And, um, it was a, it's basically has a program.
00:55:28
Speaker
So, uh, a mindful component to it.
00:55:31
Speaker
Um, we work for the mercy health system.
00:55:34
Speaker
And, um, so obviously there's a religious component.
00:55:37
Speaker
Our chaplains are involved.
00:55:39
Speaker
Um, we have our physical therapists come and they do some low impact exercise and, uh,
00:55:46
Speaker
some yoga and meditation, and it's sponsored by the executive director of the hospital.
00:55:51
Speaker
But the highlight, I think, of the event is really the opportunity to hear the experiences of both the families and the patients and what they felt and the bond that was formed for them.
00:56:06
Speaker
And I think as people taking care of them, you know, you sort of, you take care of the patient, they get better, they leave.
00:56:13
Speaker
You know, you're grateful that the outcome was good.
00:56:17
Speaker
You cry with those families that lose their loved ones.
00:56:19
Speaker
But once they kind of move on, you sort of move on.
00:56:23
Speaker
But it just reminds you why we do what we do.
00:56:27
Speaker
And that, yes, there is this huge burnout component.
00:56:31
Speaker
And again, I think there's a ton of importance for discussing it.
00:56:35
Speaker
But just it takes you back to your roots.
00:56:37
Speaker
Why the why of our careers?
00:56:41
Speaker
Yeah.
00:56:41
Speaker
And I think that having experience, I mean, the event, the same thing, it brings some of the things that we talked about today, redefining purpose.
00:56:50
Speaker
People see why they're making a difference.
00:56:53
Speaker
Also, shame, vulnerability.
00:56:55
Speaker
In our event, one of our nurses who lost her husband last year in the ICU shared her experience.
00:57:02
Speaker
And it really gives you a different light of that person's experience and kind of makes me reflect, Mark and Fabian, on that.
00:57:09
Speaker
a video that we show and onboarding that from the Cleveland Clinic that really shows you, I mean, that sometimes we don't know what's going through somebody's life at that point, but also a little bit more empathy towards the people who work with us.
00:57:22
Speaker
We have several questions from the audience.
00:57:25
Speaker
A question that came up here relates to how do we create safe environment norms living in a society that embraces unfiltered disclosure of thoughts, feelings, and personal attacks?
00:57:36
Speaker
Anybody want to take that Fabian, maybe?
00:57:39
Speaker
Oh, so you're throwing me the softball, huh?
00:57:41
Speaker
Yeah.
00:57:43
Speaker
Well, I'll add to that.
00:57:44
Speaker
I'll add to it.
00:57:45
Speaker
I'm trying to, I want to actually reread the question and I'm not seeing it in the chat box on my screen.
00:57:50
Speaker
Will you read it again for me?
00:57:52
Speaker
Yes.
00:57:53
Speaker
How do we create safe environment norms living in a society that embraces unfiltered disclosure of thoughts, feelings, and personal attacks?
00:58:01
Speaker
So it really speaks, I think, to the living environment in our country, obviously, is not one that makes people feel very safe.
00:58:08
Speaker
So how can we create that environment within our own bubbles or within our own, or where do we start, I guess, would be the way I would kind of paraphrase that question.
00:58:16
Speaker
It's a great question.
00:58:17
Speaker
Yeah, it is.
00:58:19
Speaker
It is a great question.
00:58:20
Speaker
I'm happy to offer perspective.
00:58:22
Speaker
I will by no means presume to have the capital A answer to the question.
00:58:26
Speaker
I would say it's two things would compose my initial response.
00:58:31
Speaker
And I would say that those two things are intention and authenticity.
00:58:37
Speaker
And what I mean by intention, I think it's probably pretty apparent, which is setting the intention about, particularly when we think about ourselves as leaders, and I include all clinicians in the bucket of leader, whether we have a leadership title or not, folks on the care team look to us, we set a tone, we set a standard.
00:58:59
Speaker
So having a very clear intention for how you want to show up and
00:59:05
Speaker
what tone you're going to set, what note you want to strike.
00:59:09
Speaker
And I think that's everything from how you interact with folks, what kind of stories you tell about your work, about the organization, those can go a very long way towards either helping to shift the narrative in a positive direction or to further reinforce and echo the often very negative narrative.
00:59:31
Speaker
that we hear from so many of the other sources of information coming at us.
00:59:35
Speaker
And then the second part, the authenticity for me is it speaks to the fact that like you Sergio, I'm a huge student of a lot of the writers of positive psychology and I think it's wonderful that Western psychology has finally turned its attention to how do we go from good to great, not just how do we address pathology.
00:59:53
Speaker
And at the same time, I see that sometimes the conversations about
00:59:57
Speaker
positive psychology and flourishing can become something of a slippery slope that leaves folks with the impression that we have to always be positive and almost like this relentless good cheer, even in the face of difficulty and struggle.
01:00:15
Speaker
And I'm a firm believer that being authentic about when a thing is difficult
01:00:21
Speaker
and when there is struggle involved, it's an essential and a very powerful starting point for the conversation.
01:00:27
Speaker
So yes, this is difficult, and this is hard for either me personally as a provider or us as a care team.
01:00:35
Speaker
And even in the face of that difficulty, we can acknowledge it and still decide how we're going to talk about it, what story we're going to tell about it, how we're going to contextualize the work that we do together.
01:00:50
Speaker
Those are the two things that we always have choice about.
01:00:54
Speaker
Absolutely.
01:00:55
Speaker
And I think that it really goes back to, like you said, I mean, it's not that we're trying to show a rosy picture.
01:01:02
Speaker
And I think that everything is fantastic.
01:01:04
Speaker
But I do think that recognizing that what I always say is when people say, oh, I had a terrible shift.
01:01:10
Speaker
And the question really is, well, did you have a terrible shift or did you have a terrible moment and you've been milking it for 12 hours?
01:01:18
Speaker
Because every shift has definitely difficult portions.
01:01:23
Speaker
But almost in every day that you work, there are good things that, I mean, you need to focus.
01:01:28
Speaker
And I think it's a balance.
01:01:29
Speaker
And I think that when you look backwards, it's always a combination of good and bad.
01:01:34
Speaker
But when we look forward, we only expect good.
01:01:36
Speaker
And I think that's kind of the misalignment that causes a lot of frustration and stress.
01:01:44
Speaker
Nate, any comments?
01:01:45
Speaker
I think that, you know, you're...
01:01:46
Speaker
Go ahead, sorry.
01:01:47
Speaker
Sorry, quickly, your point about rumination, Sergio, goes right back to something Nate said, which is, you know, Nate, you mentioned sleep hygiene and all of the, you know, the fundamentals of have I slept, have I eaten, am I hydrated?
01:01:59
Speaker
If we haven't attended to those basic physiologic needs, we're setting ourselves up to not be able to engage with and redirect our thought stream in the way that we would like to.
01:02:10
Speaker
Yeah.
01:02:12
Speaker
Absolutely.
01:02:13
Speaker
Um,
01:02:14
Speaker
Nate, any comments on what's happening in the emergency medicine sound world right now?
01:02:20
Speaker
I mean, obviously, we're probably growing very fast in that service line.
01:02:24
Speaker
It's our newer service line, but it seems to be growing by leaps and bounds.
01:02:28
Speaker
Any comments of the Pulse on our providers and your role as associate CMO, what you're looking into?
01:02:33
Speaker
Yeah, no, things are going great in emergency medicine.
01:02:38
Speaker
I think we're officially the fastest-growing emergency medicine practice in the nation.
01:02:42
Speaker
And I
01:02:43
Speaker
you know, are now over a million visits per year, which is a big milestone for us.
01:02:48
Speaker
And I think, you know, really our challenges are not unique.
01:02:53
Speaker
I think all the things you touched on in your presentation are, you know, relevant to emergency medicine.
01:02:58
Speaker
I don't really see this as a siloed problem.
01:03:02
Speaker
You know, certainly the incidence is different between specialties and there's some nuance related to shift work and other things with different, you know, species of medicine.
01:03:12
Speaker
But
01:03:13
Speaker
I think the issues that we're facing, you know, need to be tackled together and having open dialogue like this is a great way to move that fight forward.
01:03:23
Speaker
Yeah.
01:03:25
Speaker
And I think that one of the things that clearly will take, I mean, from this presentation to our leaders is really working on trying to make the workflows more user-friendly.
01:03:37
Speaker
I mean, I think at the end of the day,
01:03:39
Speaker
Automation is supposed to improve our workflows, not add to our workflows.
01:03:44
Speaker
But I think that also understand that there might be reasons why the investment now is going to make a big difference in the future.
01:03:52
Speaker
And it might be something that's positive that we'll need to discuss.
01:03:56
Speaker
Rotem, you also have the opportunity to round with residents.
01:04:00
Speaker
And I think that a common misconception that people have a burnout that only occurs to people who've been in the field for a long time.
01:04:07
Speaker
Clearly, there's a growing incidence of burnout and dissatisfaction at the trainee level.
01:04:14
Speaker
Any comments on your experience or things that you have done that found that help with that population of younger physicians and providers?
01:04:23
Speaker
I think there's a big push from the residency programs themselves to include a curriculum that's focused on resilience and mindfulness and taking them out of the
01:04:36
Speaker
high stress work environment.
01:04:39
Speaker
So it's very different than those of, you know, then it's a different approach than it was for those of us who trained many years ago.
01:04:47
Speaker
But that plays a huge part in pretty much all the residencies that, that we interact with.
01:04:53
Speaker
Mark, any, any comments from your perspective on the younger physicians and, and what are other things that you're looking at in your role, in your, in your role as chief experience officer?
01:05:04
Speaker
Well, for sure, I think that something that you mentioned when you talked about motivation, and we frequently assume that money is number one on the list, and it's definitely not.
01:05:18
Speaker
In fact, most of the time when you do surveys about this sort of thing, recognition for the work and the effort that somebody's making is really at the top of the list.
01:05:28
Speaker
So I think particularly with the younger generation, recognition and acknowledgement of
01:05:33
Speaker
what they are accomplishing, what additional efforts they're making, what it means to you as a leader, what it means to the group, to the hospital, et cetera.
01:05:43
Speaker
To me, that's critically important.
01:05:46
Speaker
I've seen that firsthand simply from interacting with people and having an opportunity to either thank them or just acknowledge something interesting or valuable that they've done.
01:05:58
Speaker
I often hear from people that no one has ever said thank you.
01:06:03
Speaker
And we've seen this at many of the hospitals in the Pacific Northwest where we've done some activities similar to what Rotem described, which is really an incredibly moving activity where people have taken the time to just pay gratitude and take advantage of the relationships that have been made and the experiences they've had and sort of take a break from the work to enjoy those things.
01:06:30
Speaker
So I think that recognition and an opportunity to take stock in what we're doing and how much value we're providing is really, it's important to everybody.
01:06:41
Speaker
But I think particularly the younger generation needs that from the start to get a good foothold at the beginning of their career.
01:06:47
Speaker
Absolutely.
01:06:49
Speaker
And one of the things that I've noticed, and maybe Fabian can comment on this, is that every time we go to a CSI, a Crucial Conversations, even onboarding,
01:06:59
Speaker
but especially when there's learning involved, I think that the sentiment or the energy in the room after the event is very positive.
01:07:09
Speaker
And my question is always, how do we put that in a little bottle and take it to our programs and disseminate that magic pixie throughout?
01:07:17
Speaker
But I think it speaks to that whole idea of mastery, right?
01:07:20
Speaker
People are motivated when they're learning new things.
01:07:22
Speaker
Any comments you can make in that lane, Javian?
Personal Practices to Reduce Burnout
01:07:25
Speaker
I think it absolutely ties back to mastery, Sergio.
01:07:28
Speaker
And one of the things that I have been noodling on is what it might look like to create, I've been using the phrase learning pathway in my head.
01:07:36
Speaker
I don't even know that that's the right language.
01:07:39
Speaker
But the concept is some follow-up learning experiences, both to reinforce for the learner and potentially provide them with resources that they can use
01:07:48
Speaker
Like in the case of CSI, you know, a medical director could go back and share it with the rest of the team in the ICU, and then they could all, you know, adopt that framework or that leadership paradigm.
01:07:59
Speaker
So it's definitely something that's on my mind, both for the sake of disseminating some of that energy and also, frankly, supporting our learners and really integrating the new learning into their, you know, into their leadership practice moving forward.
01:08:15
Speaker
Yeah, I agree.
01:08:17
Speaker
And I think it's something that's very interesting also is that in general, people equate busy or long hours and effort to burnout.
01:08:27
Speaker
And I think that it's really necessarily that that's true.
01:08:31
Speaker
People who might not, a lot of people, and we see different practices, a lot of people are very burnout.
01:08:35
Speaker
And when you compare the busyness of their practice to some of our other practices, it's not even close.
01:08:42
Speaker
So I think that
01:08:43
Speaker
all these other things that are motivators can also help, I mean, improve that feeling in terms of, I mean, yes, it adds three minutes to each patient when you have to do the electronic billing.
01:08:54
Speaker
That is true and we have to find ways to make it better, but there's also a lot of other things that are occurring that can help, I mean, make the overall experience or the overall job more enjoyable.
01:09:06
Speaker
For our audience, I mean, I don't seem to see any other questions coming in, but what I would like to do is maybe
01:09:13
Speaker
go around one more time with our panelists.
01:09:17
Speaker
And if they want to share something that for them has been useful or most important as an example in terms of working with burnout and mitigating burnout for themselves, I think it just, I mean, more tapping not on your official roles, but as each one as you as an individual.
01:09:36
Speaker
And I guess we'll go back to it and start with Rortim.
01:09:42
Speaker
Okay, thanks.
01:09:44
Speaker
So, you know, I definitely think burnout is real.
01:09:48
Speaker
I think from the work perspective, you have to prioritize.
01:09:53
Speaker
I think you, you know, the electronic medical record is definitely an issue, but it's really important to spend that time with the patients and just really form that relationship and make sure you're giving the best care that you can.
01:10:08
Speaker
So I think that's number one.
01:10:10
Speaker
And I think then the other thing is, is, is just in your personal life, you know, making sure you, you take time out to do the things you enjoy and to, to really make sure that you're, it's just, you enjoy life.
01:10:23
Speaker
You know, I think our world is already high stress and very demanding and, and, and just sometimes you just need to kind of know when to say no for, for too many things piling up, prioritize.
01:10:39
Speaker
and just take time to do what is enjoyable.
01:10:44
Speaker
Absolutely.
01:10:45
Speaker
Fabian?
01:10:47
Speaker
The most powerful lever that I have found and finding on my journey is...
01:10:56
Speaker
committing to some deliberate and strategic work on increasing my EQ, my emotional intelligence.
01:11:03
Speaker
And so whether it's increasing my ability to sit with and process the challenging emotions that came with when I was a surgery resident and dealing with a really challenging trauma case to even some of the demands that are on me now as a senior leader in sound really
01:11:20
Speaker
consciously engaging in practices that both increase my self-awareness, so what are my patterns, how do I tend to react, and building the skills that allow me to more frequently convert those reactions to responses to situations.
01:11:34
Speaker
Absolutely.
01:11:36
Speaker
Mark?
01:11:36
Speaker
Yeah, you know, my approach to dealing with the circumstances that I think over time cause burnout is to
01:11:47
Speaker
in some ways to kind of just embrace it or even dive in a little deeper.
01:11:51
Speaker
Like as an example, if the emergency room gives you a handful of admissions, some people stomp their feet and complain about the emergency room and you hear about it for a week.
01:12:06
Speaker
My reaction is to go down to the emergency room and I work with all those people and I like working with all those people and I'll chat with them and I just feel like
01:12:16
Speaker
I'm going to spend some time down here.
01:12:18
Speaker
And so I engage in the relationships with the people in the emergency department and with the patients.
01:12:23
Speaker
And I kind of just give into it because there's no value in the frustration.
01:12:29
Speaker
Don't get me wrong.
01:12:30
Speaker
I have my moments.
01:12:32
Speaker
But I think when you really do enjoy the work and feel good about the work and the people that you work with, then it's
01:12:40
Speaker
as you pointed out, Sergio, whether it's hard or whether it's long, that's not so much of an issue.
01:12:45
Speaker
You can cope with it and still enjoy it.
01:12:48
Speaker
Absolutely.
01:12:50
Speaker
Nate?
01:12:50
Speaker
Sure, I have a couple things.
01:12:51
Speaker
So, you know, for me personally, I think, you know, exercise is the thing that's helped me cope the most over the years through training and practicing and in my executive work.
01:13:03
Speaker
I think my youngest son's fourth grade teacher has a practice which I think
01:13:10
Speaker
is really powerful in a way that I didn't think it was, and that is cultivating gratitude through a conscious journaling of things that you're grateful for.
01:13:22
Speaker
And it sounded fairly hokey to me, but I would encourage anyone who's skeptical to try it for a little while.
01:13:29
Speaker
Just write down three things every day, and I think that can be transformative in your thinking and the way you approach things.
01:13:39
Speaker
I also think that there are a lot of foundations and organizations out there which provide structure that can be useful, and I'll give one example.
01:13:46
Speaker
So at a hospital where I was working clinically outside Philadelphia, they partnered with something called the Schwartz Foundation to create Schwartz Rounds, which are multidisciplinary rounds.
01:13:58
Speaker
And this is a meeting where it's almost like an M&M conference
01:14:05
Speaker
where you talk nothing about the technical aspects of care or the science, but you talk about the emotional and social impact of the job that everyone in the room is doing.
01:14:16
Speaker
And this was attended by everyone from housekeeping to the CEO of the hospital to clinical caregivers of various stripes.
01:14:24
Speaker
And it's really useful.
01:14:26
Speaker
I would encourage everyone to check it out.
01:14:28
Speaker
And maybe to the presentation notes, we can add a link to the Schwartz Foundation because I think they're onto something.
01:14:34
Speaker
Absolutely.
01:14:35
Speaker
And I think that that same sharing of vulnerability is one of the things that we've captured with Rotem's example of the celebration of life.
01:14:45
Speaker
And I think that we actually, in one of the podcast episodes from Critical Matters, talked about compassionomics and talked about Schwartz rounds.
01:14:55
Speaker
And we'll add some links.
01:14:56
Speaker
I mean,
01:14:57
Speaker
to that foundation.
01:14:58
Speaker
It's a very powerful tool that some of our hospitals within Sound are actually implementing or already utilizing.
01:15:05
Speaker
And I think from my perspective, I think that I agree, I mean, and echo all the things that our panelists have said.
01:15:13
Speaker
I don't, as a leader in Sound Critical Care, don't want to minimize the pain that transitions to the Sound Connect, for example, have caused for people.
01:15:21
Speaker
And I think that we have to find better ways to make it more efficient and work together to make it a tool that not only helps our workflows, but can improve care as we have more programs that are multiple service lines from sound and sharing information.
01:15:36
Speaker
But I do think that on a personal level, one of the things that Mark alluded to was the gratitude and the recognition
01:15:45
Speaker
And what I have found is that it's a lot more powerful instead of asking yourself why nobody recognizes my work to try to be deliberate about recognizing other people's work.
01:15:55
Speaker
And I have the privilege of working tonight after this webinar.
01:16:02
Speaker
And one of the things that I have made a point of when I work my night shift is to find somebody in the middle of the night and just thank them for what they're doing for our patients.
01:16:13
Speaker
And it has to be sincere and has to be obviously
01:16:15
Speaker
authentic.
01:16:15
Speaker
But I think that by doing that, it really helps.
01:16:19
Speaker
And I would echo Nate's suggestion of the journaling.
01:16:22
Speaker
I have tried that.
01:16:23
Speaker
I have done that.
01:16:24
Speaker
I still do it.
01:16:25
Speaker
And I think it's a very powerful way of refocusing and just making sure that you understand that, yes, there's a lot of difficulties and bad things, but no matter how bad the situation or the day, there's always things to be thankful for that I think help reframe a little bit of how we think about this.
01:16:42
Speaker
But I'm
01:16:43
Speaker
I don't know if any of our panelists have any other last comments.
01:16:47
Speaker
I don't see any additional questions.
01:16:50
Speaker
I think that we'll put the links for the Schwartz-Rohns that Nathan suggested.
Conclusion and Continued Discussion on Burnout
01:16:56
Speaker
And any other comments from our panelists?
01:17:01
Speaker
I'll take that as a nay.
01:17:03
Speaker
And I want to thank everybody who attended.
01:17:05
Speaker
I want to thank especially our panelists for sharing with us their thoughts and look forward to
01:17:12
Speaker
continuing this discussion with all of you in terms of what are the things that we at Sound Critical Care and Sound Physicians can do to improve things.
01:17:22
Speaker
Thank you very much, and with this, we'll conclude the broadcast.
01:17:28
Speaker
Thanks again for listening to Critical Matters.
01:17:30
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.