2021 Physician Leadership Virtual Journal Club: Wellness and Wellbeing: What Physician Leaders Should Know

Daryl Oakes, MD: Welcome to the August session of the Stanford CME Physician Leadership Virtual Journal Club. I am Daryl Oakes.

Ruth Adewuya, MD: And I am Ruth Adewuya, and we will be your host today. The format of the series is a live facilitated webinar with pre-assigned topics and articles for discussion. Each month, we will ask for registrants to submit their questions in advance of the session. There will also be opportunities for you to add to the discussion by using the Q&A portion of the Zoom webinar. The goal of the program is to provide practicing physicians in all levels of leadership, some insights and management skills to help them be more effective in their clinical environments.

Oakes: Today's discussion will be on what physician leaders need to know about wellness and wellbeing. And for this session, this session is certified for CME credits, and you will receive an email two business days after the session with instructions for how to claim your continuing medical education credits.

The session will start with a review of the articles that we will be discussing today to summarize and provide some background for our conversation. And then we will move on to meeting our expert panelists today and having our Q&A session, which will be utilizing questions that have been submitted by our registrants as well as questions that you can add to the Q&A chat during this session. We're going to start with our summary and Ruth is going to provide us with this discussion. So if you'd like to start Ruth, this would be wonderful.

Adewuya: Thank you Daryl. Today we're going to go over two articles that are related to our topic, and we will start with the Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-being and Professional Fulfillment. This article begins with describing the current landscape and the challenging times in which physicians practice. They indicate that there are numerous complex factors that have contributed to extensive changes in the practice environment that have altered the nature of physicians' interactions with patients and their role in the health care delivery system. Some of which are that physicians are increasingly employed by large health care organizations, which is a fundamental shift from the solo or small group practice model of the past. In addition, the structure of these organizations are more complex than in years past, often involving large integrated systems with a matrix structure.

This evolution, the author state has attenuated physician's sense of autonomy and control over their work. They state that while most physicians derived great meaning and purpose from their work, many also feel as if they are cogs in the wheel of corporations. In addition, physician performance is now assessed by an array of metrics that can overshadow the appreciation and respect of patients and colleagues that have traditionally served as physicians main source of feedback. Unfortunately, some organizations attempt to motivate, change worsen things, because they rely on shaming tactics that leave physicians feeling disrespected and micromanaged by a bureaucracy that fails to recognize the nature of their work. The problem is then further compounded by extensive regulatory oversight administrative burden, the implementation of sub optimal EHRs used to reinforce to enforce oversight mandates and other factors that can erode meaning and purpose in work. And so even though physicians have readily identified these and other problems in the clinical practice environment, they often feel disempowered to improve the system.

The authors believe that all of these factors contribute to high levels of burnout and a decline in professional fulfillment among physicians, and that all of these factors represent leadership issues. Physician leaders, who then ignore these challenges, perpetuate misalignment between organizational strategy and physicians deeply held professional values.

So how did health care organizations get here and where do health care organizations to go from here? The author state that this void a physician leadership in medicine should not be surprising. First, developing physician leaders was a low priority in the era of solo and small group practice or in large academic practice models of the past, where physicians were managed with benign neglect that allowed unfettered independence.

Over the last one to two decades, some health care organizations have invested in the development of senior physician leaders. However, they rarely invest in developing the leaders that have the greatest impact on physicians' well-being and professional fulfillment, which is those leaders that are most proximal to care delivery. These first-line leaders often have not been prepared for this role and may have had limited past leadership experience.

Second, physicians' natural tendencies and professional training can be an Achilles' heel to being an effective leader. An example given in the article is that physicians tend to be attentive to detail. And in leadership positions, this tendency can lead some to be micro-managers. Additionally, because of their problem-solving role in clinical contexts, physician leaders often assume it is their responsibility to come up with the answers and to drive change through authority rather than influence.

Finally, leading physicians can be quite challenging. Leaders of physicians must help oversee and direct a group of experts who are trained to think critically, be problem solvers, have opinions and demand evidence for decision-making. Effective leadership of such a group then would require skills that are counter to many of the natural tendencies and training experiences of physicians.

So where do we go from here? The authors highlight that there is a reason why there's no single model of effective leadership or leadership development. In fact, there are several effective philosophies and approaches and many models of leadership have been proposed. The article provides a table summary of major schools of leadership philosophy over the last 70 years.

In this article, the authors harness those key components and contributions of each of these schools, along with evidence on the relationship between leadership and physician well-being to construct a new integrated model of wellness centered leadership. And the most essential element is empowering relational leadership that produces outcomes consistent with the altruistic values of the profession, involving identifying and enabling implementation of improvements that advance the ability of physicians to provide high quality, compassionate care to patients in an equitable and just practice environment.

Let's talk about these three elements of wellness-centered leadership. The three are; care about people always, cultivate individual and team relationships, and inspire change. For element one, care about people always, this is the foundation of the subsequent elements. Wellness-centered leadership starts with leaders recognizing the pivotal role their behaviors play in the professional fulfillment, vitality and wellness of their team members. According to the authors, caring about people always is the only reliable foundation on which to build relational leadership skills that inspire individual and team performance. Caring about people always begins with caring for self, and caring for self is integral to performance. However, they emphasize that although caring for self is foundationally necessary, on its own it's insufficient to achieve the first element of wellness-centered leadership. Leaders must also nurture the leadership behaviors that demonstrate that they are committed to the professional development and well-being of individuals and have empathy for team members.

Element two is cultivate individual and team relationships. Wellness-centered leadership demands a deep respect for individuals, recognizing that people are both good and capable now and immensely able to grow and improve. And that leaders must embrace that the primary function of a leader is to unleash the talent of those they lead and harness that talent to accomplish the mission of the group. Evidence also indicates that the individuals who spend at least 20% of their professional effort dedicated to the activity that they find the most meaningful are at markedly lower risk for burnout. [inaudible] being a critical leadership opportunity to harness each individual's passion and talents in ways that serve the needs of the team, such efforts by leaders to optimize career fit, also typically make individuals more willing to take on other tasks for the good of their team, because they feel like their personal needs have been overtly recognized and respected.

At the system level, organizations committed to wellness-centered leadership must integrate attention to productivity with concern for people, resulting in efficiency, focus cultures that encourage a strong working relationships and make it easy for physicians to provide the care that their patients need.

The last element is inspire change. The final component of wellness-centered leadership requires that leaders inspire change by encouraging teams to think beyond the status quo, empowering them to drive change and helping them achieve meaningful results. Organizations that cultivate wellness-centered leadership primarily rely on intrinsic motivators to drive results rather than primarily focusing on aligning incentives using a carrot and stick model. Overtime relying in extrinsic motivators will lower motivation and can transform a motivated individual who pursues their work with a sense of calling into a disengaged worker who views their work through a transactional lens.

So each element is broken down into mindset, behaviors and outcomes. Mindset focuses on the attitude and intention of the leader. Leaders who show up with curiosity and humility, open to opinions and opportunities are far more effective at promoting wellness than experts who think they know best. Behaviors focus on the leadership actions that bring about the desired outcomes, and outcomes are interim measures of effectiveness that when taken together can lead to cultures of wellness for individuals, teams, and organizations.

The article provides an extensive list of specific examples for each element, and I'll just highlight a few here. Under element one, the care about people always, an example of the mindset is recognition of the role leaders play in well-being, professional fulfillment and vitality of team members and the team as a whole, with behavior such as role modeling concern for sleep, rest vacations and interpersonal relationships, leading to an outcome of improved health for the team member and the community, as well as psychological safety for individuals.

Under element two, cultivate individual and team relationships, examples of mindset is humility and deep respect for the individual as both unique and capable, and two, immensely able to grow and improve, with behavior such as demonstrating respect for the choices others have made, resulting in greater retention and engagement, more effective recruitment, and some examples of other outcomes are values being aligned between team members.

Under the last element is inspired change. An example being providing team members with the ability to shape and help lead change, building a sense of community and meaning and purpose. Some examples of behaviors are delegating tasks that others can perform and interested in doing, follow up in a way that is empowering, resulting in some outcomes such as sense of co-ownership of work unit among team members and were improved results and patient confidence in physicians.

In this article, the authors proposed the new integrative model of wellness-centered leadership. And some of the take home points are that leadership is a complex set of skills that are required to motivate individuals and teams to help an organization accomplish its mission. Wellness-centered leadership will empower individual and team performance to address current problems faced by health care organizations, as well as the iterative innovation needed to address challenges that may arise in the decades to come.

Then we move on to our second article, which is the association of burnout, professional fulfillment and self-care practices with their independently rated leadership effectiveness. Although leadership behavior, physician supervisors is associated with the occupational well-being of the physicians, they supervise the factors associated with leadership behaviors are poorly understood. As such, the objective stated in this article was to evaluate those associations. Although popular leadership books often discuss the importance of caring for self, empirical data on how positive and negative dimensions of the leader's own well-being affects their leadership performance are available. In addition, little is known about whether a leader's own well-being and self-care behaviors are associated with the self-care and well-being habits of those they supervise.

Let's take into the methods and measures explained in this article. The Stanford University conducted a survey to inform organizational efforts to improve professional fulfillment and wellness among its physicians in the spring of 2019. And all 2,656 clinical faculty and affiliated physicians were invited to complete this electronic survey. The survey was completed by practicing physicians as well as first line physician leaders. And the survey included measures of positive and negative dimensions of well-being, including professional fulfillment, self-evaluation, sleep related impairment and burnout.

I'll just go over some of the tools that were used here. The professional fulfillment index was used to assess burnout. The National Institutes of Health patient reported outcomes, measurement information system, short form version. Sleep-related impairment scale was used to assess sleep-related impairment. The author has defined self-evaluation consisting of a growth mindset in combination with the ability to prioritize self-care and personal well-being, and self-valuation was assessed using the four-item clinician self-valuation scale. All participants were asked to select the name of their immediate supervisor from the dropdown menu that listed the names of their department chair, division chiefs and medical clinic directors. They then evaluated this leader using the Mayo Clinic Participatory Management Leadership Index.

So just the brief overview of some of what they reported. Among the 2,656 clinical faculty and affiliated physicians invited to participate, 60% returned surveys. Of the 1,924 faculty physicians invited to participate, 66.8% returned surveys. And among these 50.7% were women and 49.3% were men, and 56% were 40 years or older. And among the 117 physician leaders evaluated, 57% had their leadership behavior independently evaluated by at least five physicians from their unit, and among the 67 leaders, 57 of them personally completed their wellness survey.

So they report that, although the difference in the professional fulfillment scores persisted after adjusting for age and sex, the difference in burnout scores between physician leaders and physicians who were not in leadership positions was not significant after adjusting for age and sex. And no significant differences in self-evaluation or sleep-related impairments of course were observed between the physician leaders and physicians who were not in leadership role.

So what they did find is that the overall level of burnout, professional fulfillment and self-evaluation of physician leaders were associated with their leadership behavior score as independently rated by the physicians they supervised. And you can see on this screen the point increase related to each of the burnout score, the professional fulfillment scale, and the self-evaluation score. The authors say that these findings have critical implications for organizational efforts to enhance leadership effectiveness and reduce occupational distress among physicians and other health care professionals.

So what are the key take home points? That leaders own levels of burnout, professional fulfillment and self-evaluation are associated with their leadership behavior. A leader's personal behavior with respect to sleep health, also may have an important role modeling effect on those they lead. And lastly organizations should prioritize the well-being of leaders as an important driver of leader effectiveness and provide training, skill building, and additional support to improve leader well-being as an integral element of leadership development efforts. That wraps up the review of the two articles for today's discussion, and I'll turn it over to Daryl.

Oakes: Thank you, Ruth for that really excellent summary of the articles. And that's a really nice way to frame our discussion today. I would now like to introduce our expert panelists, who will be helping us understand these concepts and how we as physician leaders can help promote the wellness and well-being of our team. First, I would like to start with introducing Dr Leah Backhus. Dr Backhus trained in general surgery at the University of Southern California and cardiothoracic surgery at the University of California, Los Angeles. She practices at Stanford Hospital and is chief of thoracic surgery at the VA Palo Alto. Her surgical practice consists of general thoracic surgery with special emphasis on thoracic oncology and minimally invasive surgical techniques.

She's also the co-director of Thoracic Surgery Clinical Research Program and serves on the board of directors of the society of Thoracic Surgery. As an educator, Dr Backhus is the associate program director for the Thoracic Track Residency and is the chair of the ACGME Residency Review Committee for Thoracic Surgery, which is the accrediting body for all cardiothoracic surgery training programs in the US. Welcome.

We also have Dr Mickey Trockel. Dr Trockel is the director of Evidence Based Innovation at the Stanford University School of Medicine WellMD Center. His development of novel measurement tools has led to a growing focus on professional fulfillment as a foundational aim of efforts to promote physician well-being. And his scholarship also identifies interpersonal interactions at work as a modifiable core determinant of an organizational culture that cultivates wellness. Dr Trockel serves also as the chair of the Physician Wellness Academic Consortium Scientific Board, which is a group of academic medical centers that are working together to improve physician well-being. So a welcome to both you Dr Backhus and Dr Trockel. Thank you so much for being here.

To start our conversation out, maybe we'll generally start in light of the two articles and discussions we've had. Maybe we could just start, and I will probably have one of you start and then I'll have the other one of you also give an answer so you both get a chance to respond. Maybe we'll start with you Dr Trockel, what can physicians leaders do, and this is physician leaders at all levels of leadership, what can they specifically focus on doing to support their teams? And I know we've had some techniques laid out in these articles, but maybe what are ones that you think should be highlighted. And that would be helpful to physicians that they're managing, find meaning in the sort of somewhat stressful work environments.

Dr Mickey Trockel: There are many. I'll just mention one quick thing, and that is an inclusive leadership style. The [inaudible] demonstrated that teams that have an inclusive leadership style are more likely to have all team members engaged in quality improvement efforts. And so if there's one thing that I can think that's a method for a leader to run forward with in improving the function of their team, it's that. And what does that mean? That means appreciative inquiry, actually engaging the individuals who are leaders leading in thinking about the problems that they face at work and the solutions to those problems and ongoing improvement effort.

Oakes: No, I think that makes a lot of sense. Dr Backhus, do you have anything you would like to add to that?

Dr Leah Backhus: It's so awkward because these are Dr Trockel's articles. I feel like they were so very eloquently already laid out there. Now, that one point that he raised is something that is huge and can be expanded upon all by itself. But no, I think that's a solid, single one to point out for sure.

Oakes: Yeah. I guess the one place that I also wonder too, is the article talked a little bit about this concept, I think we're often thinking about inclusivity and I'm wondering also whether or not we should be thinking about inclusivity in a term in broader terms. I was thinking a little bit, what are some of the risks of burnout that you have seen as being high factors for burnout in physician groups for either of you? I think Dr Backhus works in a highly intense work environment and Dr Trockel you study this, so I'm just curious from both of your perspectives where you have seen risks for burnout being highest.

Backhus: I think that that whole cog in a wheel adds to depersonalization and a lack of accountability, even for one's actions. On the one end of the spectrum, it can just be reflected as apathy, but on the other extreme end of the spectrum, it can be totally mal productive and really completely undermine the agenda of a team, of an organization where you don't feel that your actions are truly going to translate into anything meaningful. And in fact, some of them could be harmful. And particularly in medicine, we're talking about patient safety and medical errors and things where the stakes are incredibly high. So there are many layers that accountability piece, but I think that kind of cog in a wheel really, and the deep personalization that comes along with that can be hugely detrimental if left unfettered.

Trockel: That's a great answer. I'll add just a little bit to that. In thinking about what happens in the context of the apathy that Dr Backhus is talking about, the apathy and the cog in a wheel is just one more thing, just one more thing is added to what physicians have to do in order to provide the care that they want to provide. And other factors that in some settings at least can contribute to an unreasonable set of demands. One of the things that can lead to a sleep-related impairment has people have more to do simply than they can get done in a reasonable timeframe. And they're doing their work with pajama time on an electronic health record at night in other ways eroding their sleep.

What happens when the sleep is eroded is physicians in that context, like every other human being actually drop off in their cognitive performance. Then they're less able to focus. One of the key early indicators of decreased cognitive performance is that the ability to engage the frontal parietal network in the brain, which is needed to make really key decisions and process information in ways that physicians have to do all the time as they practice medicine in almost any context. The ability to engage that part of the brain versus what happens in the default is actually called the default mode network. The default mode network is more of a daydream state, but probably is engaged in almost exclusively as people fall asleep.

When we're well rested, we're able to focus and engage the right brain centers. So the frontal parietal network readily. As soon as we missed our sleep by 24 hours of insufficient sleep, two nights in a row of only five hours of sleep or a multiple nights in a row of less than six hours sleep, which happens all the time for physicians in some contexts, then we really lose capacity to focus. Notes take longer, but more importantly, the focus that we need to avoid making mistakes falls off. Then physicians are subjected to this really difficult, awkward circumstance where they're legally responsible for what happens. They deeply care about what happens. That's why they went into medicines to help people. And yet they've been put in an environment where they're not able to take care of their basic human needs enough to be at the top of their game. And that is a real problem. They are in that context, and in addition have apathy from leaders and others they work with, things are really hard for docs.

Oakes: Those are both excellent points. And I'll just briefly say, I remember the early studies on residents and sleep duration. In fact, some of them were done in my residency training group. I think we have a lot of data to say that performance does decline and mistakes occur. And it's interesting we haven't totally translated that into the professional work-life environment. We focus mostly on the training environment for controlling that. So I think it's a very important point to bring to light that just because we're out of training doesn't mean we stop needing to sleep regular hours though our work environment doesn't necessarily support that.

And I think a little bit to your point, Dr Backhus, I think one of the article on a wellness-center leadership does point out and I'll quote it, “Teams and individual team members should be provided with the greatest possible flexibility and control over how they accomplish group and organizational aims as sort of a overarching principle.” And I really think that what we often see in these organizational structures in hospitals that might be frustrating is these top-down decision-making systems that the physicians are sort of, they learn, they get told what is going to happen and they aren't part of those discussions. And I think that rather, maybe there's an opportunity for us to switch that, to think of it as a role as our leaders to be empowering and supporting physicians to do the innovation themselves and create those changes. But I'm just curious your response and thought about how decisions are made in hospitals and how that impacts our practices.

Backhus: It's funny that you mentioned that. I always held on to this dogma from general surgery days of training that the culture of your team, every place as a team in microcosm, it just your little team, trauma A team, that the culture of the team was highly predicated on the chief resident, and that the efficiency of the team was predicated on the intern or the medical students or the [inaudible]. I do think that it's important for the leaders to create the culture that they think is going to be the most conducive to get the team to perform the best that they can. And that will look different for different teams, for different purposes that a given team has, but I think it's impossible to have a culture of change if you don't have that buy-in from the top. That's not to say that's the only place it comes from and can emanate from, but the leaders have to be engaged and fully committed to it.

And likewise, they've got to then have that trickle down and diffuse into all layer of the team in order to get it accomplished, but having a change M&A from the bottom up I think is a bit of a losing battle, which sucks for those people that are at the bottom of the pyramid. And I myself have been at the bottom of several pyramids and understand what that feels like. Again, that disempowerment, that cog in the wheel feeling all of that is going to lead to that apathy and despair and asking the people who'd otherwise benefit the most to affect change for themselves is just like really awful circular argument that doesn't win for anyone.

Oakes: That's a really good point. I want to respond to it and I will in a second, but I'm going to let Dr Trockel also respond.

Trockel: Oh, so well said. That's what happens when we go and give wellness talks to individuals. Sometimes we actually engender rage because they feel that, they feel that they're being asked to on top of all everything else they're possible for and feeling like a cog in a wheel, they're telling them no, they need to suck it up and show up happy to work, and they better fix it because it's incumbent on their professionalism to do so and that doesn't go over well, so the organizational systemic factors have to be addressed. And that's where leaders have a really important role.

Adewuya: I think to that point, I don't know if either of you've heard, there's a business leader who does a lot of speaking, Simon Sinek. And he discusses the concept in business that if we want productive, successful companies, we actually need to invest in our workforce. And that you can't expect the workforce to produce well if you aren't supporting it and nurturing it, and that it will do things for you, you can't expect, and you can't mandate, but that those will come if you start with them as the most important thing to build and support, as opposed to a lot of the focuses on the financials or the customers. And I'm curious, I know medicine is somewhat different in a sense that, I don't know, maybe leading physicians is kind of like herding cats. We all want to be the head of the line. We all have our own ideas. That's how we were trained and that's how we got here.

Maybe leading physicians is different, but I wonder if there's a similar principle that we could put into success in our environment, if you invest in the individuals. That may be an argument for the physician leaders, that if you invest in the frontline physicians, they will solve the problem for you. But I don't know if that resonates with either of you.

Backhus: It truly resonates with me, because as I feel like probably 50% of what I do on a daily basis I didn't learn in medical school nor was I really ever even, it wasn't even an inkling of a thought in my head that I spent so much time in meetings and all the interpersonal interactions that aren't just patient-physician. And I wonder how much of the angst, if you will, that many physicians who are experiencing burnout can be attributed to sort of lack of preparation. And that we're being asked to do things that we had no idea we were going to be asked to do, nor that we had any amount of training to do and to do it well. It's like you get spit out at the end of this training pipeline, of which very little has been infused in terms of physician leadership and wellness, et cetera, more so now, but historically so, there's been very little devoted to any of this. A little bit of professionalism, like, yeah, make sure you complete your charge and stuff like that, and be a good Samaritan, but not really the actual concrete skill building exercises and tools to truly hit the ground running, but then you're kind of expect to hit around running. And just because you've got an MD and a board certification behind you, that you're now expected to lead and be leader and do it well.

I don't know where that assumption comes from, but like you said, Dr Oakes, physicians are very special, so a selected group of people. And so maybe some of us kind of gravitated and totally believe in that anyway, but I suspect even the ones that do believe in it could stand to have a bit more training in this area.

Oakes: I think the see one, do one, teach one model maybe a little broken. I think I just to piggyback on that. I feel like that's often true, that we have basically trained up physicians with all of these wonderful desire to make a difference in the world of our patients. We've given them all these skill sets, and then we threw them into an environment for which they were completely not prepared. We work in a medical business. We don't understand even how the business is organized. Many of us don't realize how the hospital is structured and how decisions are made. And so, I do feel like, to your other point too, is there's multiple [inaudible] of leadership within these structures. There is need for leadership skills at all levels of physician functioning. My bias is that we could all benefit from having more of these skillsets part of our general curriculum.

But I think to Dr Trockel, along those lines, in terms of burnout being maybe related to not having those skillsets, it brings me to a question with the study looking at burnout in physicians and leadership scores, whether or not, we maybe assume in this, the burnout is leading to poor leadership scores, but is there maybe a reverse possibility, which direction is the causality in that relationship? Is that something we should be thinking about?

Trockel: Yeah, we don't have good data to demonstrate direction of causality. Yes. And almost every other study where we've looked at causality and factors in a social science setting like this, we find that relationships are reciprocal. So it's hard to imagine a world where the causation doesn't go in both directions, certainly feeling inept at one's job leads to burnout. And when one feels poorly prepared for roles assigned, then that's going to be hard. It's going to make it hard to feel professionally fulfilled and increase risk for burnout. And it's also true that burnout leads to psychological states that are going to lead to poorer performance as a clinician and certainly as a leader.

Oakes: No, I think that's all true.

Backhus: I do wonder to your question and it's more of a hypothetical point, but what's to be said about the composition of the teams and the responsibility of team leaders to be very pointed and directed about how it is that they acquire and place people on their teams. So not just cultivating the existing personnel, but how do you recruit and actually select the right people for the team. And we have this affinity bias, where people want to connect with folks that they've got commonalities with, which sort of flies in the face of diversity and what we all know to be true. And that diverse teams just are better by many, many performance metrics. So how do you reconcile that, particularly with that second study, do they just perform poorly because you picked people who also devalue sleep and therefore not very well? I don't know.

Trockel: Yeah. Is that a question to me?

Oakes: Go ahead.

Backhus: It was sort of.

Trockel: Great. I think that your last point is a really good one, that if we're picking people who are chosen to be leaders because they have the most NIH grants and they're the most productive, they might not be valuing their own health and wellbeing in some ways. And you mentioned sleep. And as you can tell, that's something I'm interested in specifically. Another effect of sleep deprivation on cognitive performance is a fallout of emotional intelligence essentially. The regulation of emotional intensity goes way down. There's prefrontal cortex areas that regulate the amygdala output during distress that aren't very functional in the context of sleep deprivation. And people are less able to be an empathetic mirror, accurately perceived and reflect back the emotional state of somebody else. Both of those things suggest decrease emotional intelligence.

We know what happens when people have poor emotional intelligence at work. And if they're more emotional to begin with, they'll be more reactive and all things go bad, and it certainly doesn't lead to a culture of wellness. And we can turn that around with careful attention to our own basic human well-being. And that's a biological based neuroscience argument for the causality well-being leads to improved leadership through the mechanism of emotional intelligence.

Oakes: I think that's absolutely true. And I guess maybe I can ask pointed personal questions for both of you around environments. And I think to the point that, Dr Backhus you work in an intense environment of the operating room, which I know well as a cardiac anesthesiologist myself, you not only work in a very intense environment, but you are also unusual in that environment as being a woman of color in an environment, a profession where there it's has historically been very male dominated. I'm just curious, how do you maintain your wellness and well-being in those environments? Because there's obviously a lot of pressure and a lot of pressure not to sleep too. I'll throw that in there too.

Backhus: Sorry. I don't know that I have some stellar recipe per se. I do try to very much practice a culture of inclusiveness. And I'm terrible with names, but despite that severe handicap, I wish I had like a ribbon or a sticker or something, so people could know that. But despite that, I do still try to have a connection with everyone in the room, with our anesthesiologist, the anesthesia resident, actually speak to them by their names rather than calling them anesthesia, to my medical students or any nursing students, especially because I think that can be an incredibly intimidating environment for students to try to flourish in, which is, how do you just walk in an operating room as a medical student if you've never been there before and try to be a rock star, that's pretty intimidating.

One of the tricks that I do there for others is to give everyone like a task, specifically that medical student to I say, listen, this is this retractor, we're sitting it here. It's kind of precarious. Your job is to make sure it doesn't fall. Or, I would like you to suture this chest tube in and put this one stitch in, and then I ask them, how do you feel about it? Do you feel pretty secure? Do you feel pretty confident? It's not going to fall out and blah, blah, blah. And then they're totally fixated on the task the rest of it. If they weren't engaged before, they're totally engaged now, because at minimum they don't want to get in trouble. But I don't put the fear in them, I just want to make sure they understand that everyone in the room has a responsibility to the patient and they're all part of this team.

So little things like that in that microcosm or environment to try to create inclusion. And to the extent that I'm able to, I don't necessarily endorse this for everyone because is not so comfortable with that. But I do try to connect with people outside of work when possible, when feasible. It's never anything that should be forced on somebody because that's not a part of your job, but it can be additive. It can be a bonus if it's there, if it organically otherwise can happen.

Oakes: I love that. I think appreciating the multidimensionality of our lives. We go up as one person, but there's a whole lot of pieces of us that are not in the room necessarily at that time. So it's nice to recognize that.

Trockel: Can I ask a follow-up question?

Oakes: Oh yeah, sure.

Trockel: Dr Backhus mentioned specifically a relationship with anesthesiologists. And we all hold one share in the culture of medicine that we're a part of. And relationships across teams, that's critical for our culture of wellness. And I'm thinking about that at least a moment of the tension. And we have right here anesthesiologist and a surgeon. I wonder in this cross-discipline interaction what you've seen that goes poorly and what goes well. And this is great for thinking about how to cultivate those behaviors that are effective in improving our culture of wellness.

Backhus: Well, and I think to the other point about kind of different context within which you're able to interact with people is critical to help fortify those relationships. So the fact that I am out in committees and meetings and things like that, and interacting with my, just using anesthesia example, with my anesthesia colleagues outside of the immediacy of this case that we're trying to get through with this patient, I think is incredibly important. It doesn't have to be, Hey, we're going out for beers. It can just be, Hey, we're working together on this other outside project, blah, blah, blah, all of those things. And again, that speaks to the diversity issue, where you need diversity of specialties, of ages, of genders, of everything in as many places as you can to create those touch points that will fortify those relationships when you're in those more critical environments.

Oakes: Yes. I think those are wonderful ideas. I think maybe just to follow up from your research Dr Trockel, anything that you do in your life that sustains your professional work and wellness?

Trockel: Well, I'll mention one factor that we haven't talked about yet. And that is attention to personal relationships in my life. This is a research domain that's really exciting to me. We have a paper coming out hopefully soon that we just submitted that demonstrated that in fact, when physicians feel like their personal relationships are being eroded by work demands, that that's a huge risk factor for burnout and has some implications for what happens in their patient care as well. And those implications for what happens in the patient care is something we're excited about because it, and for the first time presents the possibility that this too might be something worthy of consideration by leaders in organizations. Because if in fact, an unpredictable schedule in the OR means that physicians in the OR, the surgeons and anesthesiologists are going home at random times, and even on days they're not on call, they have no way to predict when they're going to get out, then that might create problems that could in turn eventually affect patient outcomes, affect the way in which they're able to practice medicine. So that's an exciting vein of research for me. I'm looking forward to seeing what we can do in that space.

Oakes: No, I think our personal environments and our personal experiences are incredibly important to how we perceive and experience our environments. And I think that brings me to one of my thoughts and observations from the literature is that there is actually considerable evidence that marginalized groups or groups that are minorities in various fields, whether it's gender or race or ethnicity have been documented to have increased rates of burnout. And even to the point of mental health related depression experiences, increased rates of suicidal [inaudible] and things like that. And this was, I think some research that was done in physician trainees specifically. But I guess that raises the question to me that how can we disconnect these efforts to improve well-being and wellness from this inclusive. We're talking a lot about how important it needs to be inclusive from general efforts for diversity equity and inclusion.

Backhus: I've already spoken a little bit about that diversity piece that I think is pretty critical. And if you are an NF1, then it's very difficult for you or not very difficult, it can be difficult, more difficult to feel that connectedness, both from that the side of the individual who may just have some walls up because they don't see the obvious connection points, but as well from the larger group, from the majority group who may not have the insight to actually make better connections and things like that too.

So like Dr Trockel mentioned earlier, these things are often bidirectional. They're not really just occurring in isolation. But for me as a member of multiple minority groups, if you will, one of the things that's helped me is to foster those external communications and relationships with people. If I can't find the fellowship that I need, and that's important to nourish my soul at this location and this meeting and this whatever, the onus is on me to try to find it elsewhere, because if I at least recognize that I need it, then that's half the battle.

I think part of the issue is not having sufficient self-awareness to even think that it is important for you. And sometimes you don't until someone steps up and says, Hey, do you want to try X or whatever? And you're like, you know what? That's so much better than what I've been doing. It's like that sleep deprived thing, where Dr Trockel is like, you know what, when I sleep more, I feel better. But for many, it could be like this news flash because you're just so entrenched the rabbit hole of what you do every day, that it's hard to take your head out of the sand and look around a little bit more. And so having those external relationships helps to serve as a sounding board. Sometimes you're not your own best friend, but a best friend can be helpful to kind of say, do you really see what you're doing here? That doesn't look healthy.

Oakes: Do you think there's a role? And I think there's a question here in the chat, in the Q&A that reflects on it. It relates to training physician and providing, and I'm going to shorten the question, but are you familiar with studies that have shown how leadership programs and maybe executive leadership programs can improve physician leadership skills and capabilities that might help with burnout, these feelings of burnout and frustration? I don't know if you have seen this or there been any studies on it or just sort of observations.

Backhus: Dr Trockel may have a better hand on literature in this space. I can speak from the side of the ACGME to say that it is certainly a priority and is built into the hardwired into the evaluation process of a given program that at minimum they've got to have practices in place and resources in place for residents, which is about as far as we've gone from an accrediting body standpoint, but at least there's some acknowledgement and recognition that it is important.

Trockel: There's not a ton of good literature yet looking at training leaders and the impact of leadership training on professional well-being among those [inaudible], it's mostly observational correlations that we have so far. There're some efforts that are underway and we'll see what pans out.

I wanted to just put something really briefly about your previous question. And that is that a lot of what we see in the falling out of equity and inclusion or the most egregious departures from that area of mistreatment is not from our colleagues. The The most predominant problem is how patients, sometimes patients and their families treats individuals who they perceive as different from them in some way. That's just one component that leaders need to be aware of and address systematically and figure out how to help in that domain. If we focus only on what's happening with our colleagues [inaudible] important, that misses the biggest problem that we're seeing, at least empirically the biggest in research that we've been doing recently, that's an important piece to address.

Oakes: And I think the mistreatment by patients is such a complex issue because our mission is to take care of them and support them. I would also throw in the complicating factor if we find our health care systems frustrating as providers, patients also find them frustrating. And so they then take their frustration out on the person most available, which would be the first-line frontline provider. And I think that is just a very complex issue to know how to not only manage, but also address and fix. So I agree.

We have maybe time for one or two more questions here. Thinking about how the last year and a half has gone, and there's been a number of things that have come up in the last year and a half and that both have been the pandemic, which has obviously had an enormous impact on medicine and on our lives in general, but also the realignment, or maybe more visibility of discussions of race and ethnicity disparities in our country. I'm curious how that plays out in this conversation and whether or not it's changed maybe what some of the drivers are, burnout for physicians or whether the principles are still the same. It's just a more intense environment now.

Backhus: I think the principles are the same. I don't think that they've changed all that much. I think that they've just had a new contemporary spin on some them, but that the overarching themes are still there. I certainly don't mean to say that there's been zero progress made, because there has been, we have a long way to go still. One of the novel areas I think as a member of underrepresented group, that myself and many colleagues would report upon after George Floyd and the whole Black Lives Matter movement really took a foothold was the fatigue associated with people checking on you and wanting you to be the spokesperson and wanting to have cathartic conversations of their own. All of that was just, like Dr Trockel said, one more thing, just one more thing or several more things to add to your plate. That certainly died down some, but not to pre George Floyd levels, I would say.

Oakes: No, I think the social anxiety, and again, there's a lot of water being carried by some in our professional community. So thank you for calling that out. I think it's really true.

Well, we're at the end of our time and I want to respect everyone's time. This has been a wonderful discussion. Thank you again for coming and joining us. We have so enjoyed having your perspectives on this really important topic that obviously has a number of complex dimensions. Again, I want to just remind everyone, thank you for coming and that please join us next session which will be September 28th, and we will send out a mailing list again.

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Authors

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Ruth Adewuya, MD

Managing Director, CME

Stanford University School of Medicine

Leah Monique Backhus, MD, MPH

Associate Professor

Stanford Health Care

Daryl A. Oakes, MD

Clinical Associate Professor of Anesthesiology, Perioperative and Pain Medicine

Stanford University

Mickey Trockel, MD

Director of Evidence Based Innovation, WellMD & WellPhD Center; Chair, Physician Wellness Academic Consortium Scientific Board; Clinical Associate Professor, Psychiatry

Stanford University School of Medicine