Ruth Adewuya, MD: Hello, you're listening to Stanford Medcast, Stanford CME's podcast where we bring you insights from the world's leading physicians and scientists. If you're new here, consider subscribing to listen to more free episodes coming your way. I am your host, Dr Ruth Adewuya.
This episode as part of the COVID-19 mini-series, and in today's conversation we are talking about physician wellness. I am joined by Dr Daniel Murphy, who is a professor of pediatrics cardiology at the Lucile Packard children's hospital and the co course director for the Stanford. Well MD physician director course. Dr Murphy, thank you for chatting with me today.
Dr Daniel J. Murphy, Jr: It's a pleasure. Thanks for inviting me to be on the podcast, Ruth.
Adewuya: I am so pleased to be speaking with you today about a very important topic around physician wellness. While physician burnout has been an ongoing problem in the medical community, the pandemic has unsurprisingly exacerbated the situation. Physician wellness is increasingly recognized for its importance to patient care practices and to the integrity of the health care system, as well as to physician workforce. To frame our conversation, let's start with understanding, how would you define physician wellness?
Murphy: Physician wellness, I think, takes into account the physical, emotional, personal wellbeing of a physician. But overall wellness also includes their resilience and their satisfaction with their life in general. I think at Stanford we recognized early on that our goal is not just to prevent burning. Our goal is really to enhance professional fulfillment and overall wellbeing, which I think is a little bit different than wellness. People think of wellness frequently in the physical and mental sphere, but we recognize that burnout is a product of the workplace environment, and professional fulfillment has as much to do with values alignment, organizational culture, and other factors, as well as an individual's overall physical, mental, spiritual wellbeing. And they're all important.
At Stanford we have a Well MD center and we focus a lot on physician wellbeing, but we recognize the importance of teams, and all members of the clinical team, and all members of the health care organization, looking at the entire team and the effects of the workplace on them, the importance of their own wellbeing. So when we talk about physician well-being, we're not excluding the rest of the team, we're actually including them, but that also requires a little different science, a little bit different approach to understanding the drivers and the impacts of various workplace features on those team members.
Adewuya: That's a really great point. And thank you for highlighting the importance of not only calling out physician wellness, but really the wellness of the entire health care team and taking that into account. So perhaps I should actually change the language as I ask you some of the questions to not just focused on physician wellness.
In line with how you talked about the challenges that the health care team faces around wellness and professional fulfillment, what have you heard about the challenges that the physicians and the other members of the health care team have been facing around wellbeing around and during the pandemic?
Murphy: Well, needless to say, the pandemic caught all of us by surprise, but fortunately our interest and structure related to physician fulfillment and wellbeing preceded the pandemic. But last year, initially immediately, this had an impact on everybody. I would say that the anxiety level rose appreciably, the stress level rose substantially, and this relates to the entire population, the whole country, the whole world. Physicians had significant challenges when it came to, how do you keep practicing? Do you practice in an environment that may not feel safe? Are you being protected in that environment? Or if you practice in a different environment, are you not able to come to work? Did you shift to a virtual practice, and does that work for you and your patients? So can you still be a physician in the midst of all of this chaos and change?
Additionally, physicians are human beings with lives outside of our profession. And we learned very rapidly that the impact on particularly our parents who are also physicians, and especially mothers, was profound. And childcare, school, with those supports withdrawn there was a substantial need for support from the organization and from each other. And I would say the first initiative after personal safety for us was to make sure that people in their home environments had the support they need, but even as people started to adjust to life at home as a working from home parent, and a schooling from home parent, and a caregiving from home parent, we also know that many people are challenged by spouses losing jobs, people's jobs being cut back, financial supports, family obligations. So I would say that the intersection between our professional practice and our home lives and our personal lives became very close. And those lives were no longer blurred. They were absolutely combined. And we're still seeing that. That's still a substantial issue.
Adewuya: If we look even farther back from the pandemic and look at specifically system factors that contribute to burnout, what are some of those system factors?
Murphy: At Stanford we have a model of professional fulfillment that integrates personal resilience with culture of wellness and the efficiency of the practice that we're engaged in. And even though personal factors play a role in our own wellbeing and self care is important, it's very clear that the culture within which we practice can support us or not. The clinical practices in which we engage, if they're inefficient, if they keep us from doing the job that we're trained to do or put roadblocks in our way, that becomes immensely frustrating and very challenging for physicians. And the day after day feeling of lack of support, or not being able to get the job done, or trying to be three places at once, or doing things that don't benefit the patient but are required, those are all elements that can absolutely over time lead to an immense amount of stress and actually produce burnout.
So as we look at the system level issues, even something as seemingly simple as support from your leadership is an immensely powerful factor when it comes to my own professional fulfillment, my wellbeing is actually directly related to the wellbeing of my leader and that leader's behaviors with respect to me. So it's another thing that we've focused on at Stanford, is how do we help train our leaders so that they're actually behaving in such a way that's supportive to the faculty and the physicians involved so that their wellbeing is taken into account in everything we do.
Adewuya: Absolutely. That's a really great point. The importance of training of the leaders and the impact of the leaders' wellness on the rest of the team. And you've alluded throughout our conversation about the professional fulfillment model, and I just wanted to recap that for our listeners, because I've heard you mentioned three things. And let me know if this is correct, but it seems like the professional fulfillment model is comprised of this culture of wellness that you mentioned, personal resilience, and efficiency of practice. Is that correct?
Murphy: Those are the three aspects of the model. And we know from fairly detailed statistical analysis of serial surveys, that each of those aspects of the model are interrelated. So a certain person's professional fulfillment status is impacted by their own personal resilience, but also the culture in which they work. And their fulfillment or their burnout is also affected by the efficiency of their practice and the culture. So the interplay of the factors in that model, I think, is substantially the reason why it works, that one person is not responsible for their own wellbeing. And there's not a single solution. All aspects of our practice, both from the culture within which we practice, the way we practice, and what we bring in terms of our own resilience to that practice, all drive our wellbeing and fulfillment as individual physicians.
Adewuya: What should the health care system leader, or maybe the department chair, or even think smaller, someone who is in any position of leadership, what should they be doing or thinking about to support the wellbeing of physicians or other health care professionals?
Murphy: Yeah, it's a great question. And the good news is, you don't have to get an executive MBA to be a good leader. And you don't actually have to do hours, and hours, and hours of complex training or read a thousand business books on leadership to be a good leader in this setting.
Tait Shanafelt, our Chief Wellness Officer, when he was at the Mayo Clinic, he and his colleagues examined the leadership behaviors of the leaders at Mayo. And these are division level leaders. So these are leaders in a specific sub-specialty responsible for a group of physicians. And what they documented was that the behaviors of those leaders on about nine questions predicted the wellbeing of their faculty for whom they were responsible and a small increase in their leadership score, meaning they demonstrated those behaviors more consistently, a small increase in their score provided a substantial increase in fulfillment and a decrease in burnout amongst their physicians.
The other piece of good news is it didn't relate to providing more salary, or better parking, or building a gym in the office. It really was about recognizing work that was done well, expressing interest in a physician's career, supporting them for a job well done, keeping them up to date, really in general just listening and communicating with that individual as a human being, and expressing an interest in their career and support for their career. Leaders have other jobs. They have to keep the finances straight, they have promotions issues, they got research processes that they have to track, but when it comes to physician wellbeing, it's pretty much about taking care of the people. And I think that that can be taught. It's certainly well within any of our abilities to do that as leaders.
And you were right in asking your question, because it really comes down to who's the person that's most responsible for me? Who do I view as my boss, because that's the person that's going to have the biggest impact on my wellbeing, which means that it's not a leader for a thousand people. It might be a leader for 10 people or 15 people. And that's certainly doable.
Adewuya: It's very exciting to hear that incremental steps, small steps, can affect change, that it doesn't have to take an MBA or several hours of training to be able to affect change. What support resources have been helping physicians and other health professionals the most?
Murphy: I would say that the most important thing from my point of view is what we just discussed. It's supportive leadership. I really believe that that is the cornerstone of culture of wellness. And if I had to snap my fingers and make one thing happen, it would be to improve the quality of leadership across the board, because supportive leadership builds community. And we know that community and collegiality are very strong drivers and contributors to wellbeing. We're social beings. Physicians really need that community of like-minded people, people who've been through the same training, who are committed to the same profession. Very powerful.
Other resources for people. I think it depends what they need, ruth. When I was an Interim Division Chief, my question for the faculty individually, “What do you want to do? And what do we need to do to help you do that? What do we need to get?” And I had had limited resources at my availability. But that doesn't mean there's zero resources, because sometimes it's just a matter of a little bit of help with scheduling to get somebody freed up to do what they really love doing. Sometimes it's a little more flexibility. Sometimes you reach into your pocket and you provide some help with them with their grant writing. But again, it gets down to alliances.
I have a role as a medical director of our clinics, and I know that everybody wants and needs more support in the clinics. We need more nurses, we need more nursing assistants. Well, how do you get more help? I would say you get more help by building collaborations, by building collaborations with those administrative leaders who have their own challenges. But if we can help them see how we can do this together and help each other, much more likely to work together and get the support that you need.
I must say when I approach a group of physicians and sense that there's a high level of disengagement, a high level of frustration, and emotional exhaustion, and cynicism, I almost always find that there's a big challenge in the culture. There's either a strong misalignment of values, there's an absence of supportive leadership, or another problem in the culture that physicians are very sensitive to, and working through that in spite of that, is just not feasible day after day after day. And we know what happens. People burn out, they leave the organization, they cut back their clinical work, and that's a cost to all of us and a cost to our patients.
So when you ask about resources, for me, it's not usually a big laundry list to go on the budget this year, although small things help. And maybe some of that budget is time for people to actually spend time together.
Murphy: When we propose a lunchtime community group and someone says, “Sorry, you can't do that because you have to see patients through the lunch hour,” that sends a message that this isn't important to us. We know of a physician recently that told me that she went for a walk during the lunch hour out of her clinic every noontime and the practice manager came and said, “You can't do that anymore because it looks like you're not working.”
Murphy: “The staff are thinking that you don't really care.” Well, what that person was doing was taking care of themselves. It should have been held up as an example to take care of themselves, and take their lunch hour, and get outside. And again, that's misguided, but it's not rare. And so how do we help people help themselves? Because that's another key issue, is we don't blame the individuals for their burnout. We just don't do that. But having said that, the pandemic taught us nothing else if it didn't teach us the importance of resilience.
When every day is a change and every day you're faced with unknowns, we don't know what this virus is going to do, we don't know if we'll get a vaccine, we don't know if the vaccine will work. We don't know what's going to happen with our job, or our spouse, or our family. It takes an immense amount of resilience to get up each day and take a deep breath and say, “Okay, I can do this.” And we know that we have a lot of work to do with physicians, with self-evaluation, and take care of yourself. Put that oxygen mask on yourself first. If you don't take care of yourself, you can't be there to take care of everybody else.
Adewuya: To the point you mentioned about kind of the pandemic and taking care of oneself, do you anticipate seeing long-term effects of the pandemic around physician burnout? What are your thoughts on that?
Murphy: Yeah. I'm not a mental health expert, for a start, but my colleagues who are mental health experts, they've told us that mental health issues have become more apparent during the pandemic amongst the population in general, but amongst physicians as well. We have a very powerful, very effective support program for physicians here called WellConnect. And it's phenomenal how many of our mental health providers have stepped up to volunteer to work in that, but they've been very busy. Our colleagues have needed a lot of help. And that's different than burnout. Mental health issues, severe anxiety, depression, those are slightly different issues, but they've become much more apparent anyway during the pandemic. And the mental health experts tell us to expect a much longer term effect of this, perhaps as a late surge in that if you will as people get out of the acute phase, but perhaps have to deal with loss, or deal with change, or deal with other issues that they've been holding back and then not able to hold back anymore.
So I think we're attuned to that. I know that around the country mental health providers and organizations are well aware of the risk to the population and also to the physicians as well. I think that for burnout, I think it depends how we respond to this, tell you the truth. I think it depends on how do our leaders, and our organizations, and our practices respond? If they respond to it in a supportive, compassionate way, and physicians are able to recognize they can live their passion of being a physician in a new way, under new circumstances, and perhaps even different circumstances, they may be better off than they were before. If we can figure out this issue of parents responsible for childcare while pursuing full-time medical careers, I think we'll have taken a giant step forward. We knew it was a problem before. It's become so obvious during the pandemic.
I think that the issue of chronic stress and anxiety is something that the mental health professionals, I don't know that they're sure about that yet. It may have lightened a little bit, but I don't know personally when that will be lifted for people. Everybody has their own story. So I think that's the other thing. If you don't ask someone's story, and this gets back to partly leadership, but I don't know anybody's story until I talk to them, know what their challenges have been.
We've had a process here at Stanford during the pandemic where we have personally contacted every single physician who's become infected. And we've had a series of conversations with members of the Well MD team with those individuals to make sure they have what they need, that their work's not being adversely affected, that they're being supported by their clinical bosses, that their family is safe, that their finances are under control, whatever it turns out to be. And everybody is challenged by that. I've been impressed with the responses of those physicians, to that what I would consider minimal support, but at least tangible evidence that the organization and people in the organization care about me, love me, support me. And if we've learned that from the pandemic, we've learned a lot.
So we'll see what happens. I think that it isn't going to be an off on switch with clinical care or with wellbeing after the, if there is an after the pandemic. I think that a watchword is, let's continue to stay very close in touch with our colleagues and their needs.
Adewuya: I think it's important to highlight and reflect on some of the points that you made. You've highlighted some of the things that Stanford has done, but also other organizations have done. And that it doesn't have to be unique to Stanford. The ability to listen, do a listening tour, focus groups, the idea of supportive leadership and those incremental steps are universal themes regardless of what organization or institution that you are a part of.
Murphy: One of the biggest things we've tried to do at Stanford through Well MD is what I would consider distributive leadership. We want physician wellbeing, clinician wellbeing, to be a lens through which we view every project. A quality improvement project, the budget process hiring. Similarly, I think to our colleagues who are engaged in efforts around diversity, equity and inclusion, that's a lens that we need to bring to all of our activities. And since we know that physician wellbeing contributes to safety, quality affordability, all of those aspects of top level health care, it's our job to bring that lens to bear on all of those activities.
We've launched and completed recently a wellbeing directors course for individuals who are responsible for a physician wellbeing in their organizations, in the attempt to level set the knowledge base to prepare them within their own institutions to bring that focus and that lens to the activities in their own organization.
So at Stanford, we have a dual mission. One is to bring wellbeing and the science of physician wellbeing to Stanford physicians in the Stanford community. But we also feel the need, as all of Stanford does, which is bring new discovery, and new science, and new knowledge outside of Stanford for the benefit of others.
Adewuya: Last question for you is, how are you staying well through the pandemic as a clinician and as a physician?
Murphy: Well, thanks for asking. The first thing I would say is that no one's immune, and to anybody that told me during the pandemic that they were sleeping well was probably not telling me the truth because it's weird times. So I've had my own challenges in my career with burnout. I've had my own frustrations with systems. And I would say that to some extent, in all fairness, I've done what others have done. My clinical practice is smaller than it used to be. Whereas that's good for me, if everybody did that it wouldn't be good for medicine. Fortunately, I'm old enough that it's not completely expected that I have to be full-time clinician. I have a large administrative responsibility at the Children's Hospital too. And I would say that focusing on meaningful work has always been important to me. It's one of the things that I'm most grateful for.
And so recognizing that during this pandemic the work I was doing was meaningful, whatever it was, was helpful. And I think the connections with physicians through the pandemic, through Well MD helped me develop a sense of gratitude, but I also have attended to my own wellbeing. I try to get out and exercise as much as I can. I sleep well. I try to surround myself with friends and family and keep that community wellbeing. I don't have a meditation practice, and I don't do yoga, but I am mindfulness trained. And I think I bring mindfulness as much as possible to every activity during the day, which being aware of what's going on. I practice gratitude on a daily basis.
So I've been very much aware that my own wellbeing was important and challenged. And frankly, I'm not going to be any good to anybody else if I don't take care of myself at the same time. But it's been a very, very tough year. And I would say you don't know how tough it's been for anybody till you talk to them.
Adewuya: Thank you for sharing how you've maintained your own wellness as well.
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Stanford University School of Medicine
Co-Director, Department Wellbeing Directors Council; Medical Director, Ambulatory Services, Stanford Children's Health, Stanford Medicine