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Listening Campaigns: Engage Physicians, Uncover Sources of Burnout

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Speaker: Hello and welcome to the AMA's STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA's STEPS Forward® Program is open access and free to all at stepsforward.org.

Jill Jin, MD, MPH: Hello everyone and welcome to the AMA STEPS Forward® podcast. This is Dr Jill Jin, your host for today. Today on the podcast, we are joined by Dr Sarah Richards, a practicing hospitalist at the University of Nebraska Medical Center and senior medical director of Clinician Experience at Nebraska Medicine. Our topic of discussion will be using listening campaigns as a tool to engage practicing physicians in creating positive change and combating burnout. Dr Richards, thank you so much for being with us today.

Sarah Richards, MD: Thanks so much for having me. I'm looking forward to it.

Dr Jin: Why don't we start with you telling the listeners a little more about yourself and your background?

Dr Richards: All right. Well, I am an Omaha, Nebraska, native. Went off to California for undergrad, but quickly made my way back to the Midwest and have been here ever since. I went to the University of Nebraska Medical Center for medical school and residency and have been with the organization ever since. A practicing hospitalist, usually working with residents and students on the teaching service, and then have had leadership roles in both patient experience and now my focus is primarily with clinician experience.

So I get to advocate on behalf of our physicians and advanced practice providers, and try to make life a little better for all. So thank you so much for having me. Also, a mother. I think that's important to say because we are so much more than our profession, and it affects what we do in our work. So a proud mom of 12-year-old twin daughters and a 9-year-old daughter and have a wonderful supportive husband as well.

Dr Jin: Oh, wonderful. Thank you so much for that. So you co-authored one of our recent STEPS Forward® toolkits on the topic of listening campaigns, which is a well-being initiative that you helped establish at your organization. So tell us more about what a listening campaign is and what motivated you to develop it.

Dr Richards: Great. So I do want to acknowledge my co-author, Dr Lowndes, who was a fabulous partner through all of this. But our why was really recognizing that we knew that a problem existed. We had started to survey our physicians and APPs. We recognized that burnout existed and we knew some of the key drivers. So our survey data was telling us some of these key drivers, but it was very general, so we really felt the need to get some very detailed and specific information that was actionable back to these departments, these divisions in these groups.

And so our main why in developing these listening campaigns was to really hear the voice of our frontline providers. We also recognize that not everyone feels heard and feels safe to speak up about issues or concerns that they might have. And so we really wanted to create a way for everyone's voice to be heard in a very confidential way that felt very safe.

And so I would say those are our 2 main why's to why we created it. So what did we create? It's actually quite simple, but it's been very effective. So over the past several years, we've completed upwards of 30 of these sessions. So a session is really the big part of the listening campaign, but really what it is a initial reach out to our leaders of our chief, our chiefs, our chairs, our department division leaders for a specialty practice.

This could just be the medical director, whoever's overseeing the physician group and said, hey, would you like to learn more about key issues and really help move things forward for your providers? Have an initial meeting with that leader to find the best time and how to best set up the session. We recommend that we don't add on additional time, but try to weave this into an already scheduled meeting.

We also have made this very flexible, so we can have a short or a long version, so it can be anywhere from 15 to 20 minutes up to 45 to 60 minutes, and we kind of work with a leader to work that in, kind of give them a heads-up about what to expect. We send a note to the group ahead of time so they can start to think about the types of questions that are going to come up. But really the big part of what we do is called the listening session, a high level, and then you could ask any follow up questions that you think what might be relevant to our listeners.

But the listening session is really simple and straightforward. Number 1, the first thing we do is why are we here? Why is this important and what are we going to do with this information? I think it is absolutely crucial that our physicians, our APPs recognize we're not just coming to hear you and then moving on. We're actually going to follow up and we're actually going to make some real change, and here's what to expect in terms of how that happens.

Then we start by opening it up to the group and saying, what's going well? This is the positive psychology aspect of this, and this is actually the only time during a session where people are speaking out loud as a group. We jot down some notes. I can tell you that a lot of people comment on the supportive colleagues and the team dynamics and just how much they feel valued in their roles because of the way that their leaders or their teams support them. Then we move into what we call an individual reflection. So each participant has the opportunity to answer 3 questions, and they get about 6 to 8 minutes to do this.

So not a big time, not a lot of time, but they think about number 1, what's the best part of your job? We kind of set this up and say, think about the last 2 to 3 weeks, but what's the best part of your job? The second question is, what gets in the way of the best part of your job? And then a third question, what's the worst part of your job? And so if we're in person sitting in a room, they jot that down on a piece of paper. If we're doing this via Zoom or Hybrid, there is a link in the chat that they're able to click on and able to type their responses. That also kind of helps get their thoughts really focused around the next activity, which is my favorite part and is a fan favorite for our participants and for our leaders is it's called the one wish activity.

So each participant is asked to think about the one thing that if this one thing changed or if this one thing were different tomorrow when I walked into work, it would most enhance my work experience, my professional satisfaction. And they're asked to write that down again, if we're in person, which is the preference for sure, but if they're in person, they write it down on a 3-by-5 index card. So everyone has a couple of minutes to write down their one wish. The index cards are collected and shuffled up. There's no names. We don't know who wrote what, but we place those cards out around the room and we have everybody stand up and go to a card. And then we move around the room and each participant is asked to look at that wish and give it a score or a rating on a scale of 1 to 10. A 10 is this would absolutely enhance my professional satisfaction too. This is a really good one. I'm going to give it a 10 versus a 1 or a 2. You know what? This really wouldn't have much of an impact on me at all, or it's just not as important to me. And they're also asked to leave it blank if it just doesn't apply to them for some reason. Then we are able to average all of those wishes and put them in order to report back to the group.

Sometimes we can do this in the same meeting if I have somebody there to help or within a day or 2 getting that back out to the participants. And then we close and talk about next steps. So that's kind of a high level. We also do a follow-up at about 6 months, and we also do a follow-up meeting with the leaders. But before I get too far into anything else, I wanted to just share that's the high level overview of the listening campaign.

Dr Jin: Yeah, wonderful. I think that structure that you have created and optimized over the years is so key because of course leaders know that listening is such an important part of being a good leader, and physicians want leaders who listen, et cetera. But as you mentioned, sometimes they just don't know the structure in which to do it or they don't have the opportunity. So providing this type of established session or campaign is really such a key part of well-being, physician well-being. Can you go over in a little bit more detail, who ideally is at one of these listening sessions?

Dr Richards: Yeah. I think that anyone can do this. Because of my role at our organization, I have participated in all of them. I view it as such a key and integral part of what I do. Do I need to be at all of them? No. Have I started to, quote, train the trainer? Actually, some of our other roles and team members have been interested. So we have worked with some nursing directors, some pharmacy directors, some other areas where I've actually taught them the process and then they can go do it on their own.

So ideally 2 people lead. We try not to have the session facilitated by the team's leader just to make it feel a little bit more safe. For example, maybe your leader is sitting right next to you and you just feel like, although we do everything in our power to keep things confidential and anonymous, there are no names, there might be a concern, well, what if they saw my handwriting and recognized it? Or what if they peered over my shoulder? Or what if they could tell that was my wish because of the—I don't know.

But there's even just the time when we're talking out loud about what's going well, just having the leader not there just seems to kind of open up the conversation a little better. And although I said that's the only time we really talk out loud is about what's going well, there's inevitably follow-up conversations, kind of the meeting after the meeting where people talk about the ideas and the thoughts and the issues afterwards. And I just think having that direct leader not there is really, really helpful. So any wellness champion, any person who wants to help facilitate it. Now that being said, a leader can surely do it, especially one that is really interested in learning more and can create that safe space for their team.

Dr Jin: That is actually quite interesting that your recommendation that the site leader or the medical director or the immediate leader as a, I guess a division chief, for example, is not present because I don't think that's natural for many groups to think about that. I mean, I think if practicing physicians are wanting to speak up, I think they would naturally want their leader to be there to listen. But what you're saying is perhaps having the leader not be there actually creates more authentic conversation, which I think is interesting.

Dr Richards: I mean, we've been doing this a lot. And the great thing about this is the flexibility within how these work. And what I've recognized in the years that I've been in my role is that every group is different, and the dynamic of every group is different, and the relationship with and the trust and the leader is different and the size of the group and how well they know their leader, all of these variables are important things to consider.

I actually have groups that are quite small. We actually just go out to dinner and I do the listening session, but we do it around the dinner table with the leader sitting right there because it's this small closeness group, and that leader has developed this very open, people can talk about anything versus other groups where they may be bigger or maybe people are intimidated or maybe there's a lot of younger faculty that are part of the group that just don't feel comfortable speaking up yet. There's so many different variables.

Often what I do do is I ask the leader what they would like to do, do you want to be there or not? And it's about 50/50. And a lot of people just say, what do you recommend? And I would say, you know what? It can go either way, but if you really wanted my opinion, it'd be that you are not there, because I do think that conversation and just sharing is a little more authentic.

Dr Jin: And then in terms of the facilitator, which you mentioned you typically take the role of, do you need any special training in order to take that role?

Dr Richards: No. I would say that if you have a minute to spend with the AMA toolkit, it has everything that you would ever need to know about leading a session. I will also say that I personally would be more than happy to walk any leader within or outside my organization through it, because sometimes it's helpful to just kind of highlight, gosh, these are the 3 really, really, really important things. They're all in the toolkit, but the toolkit is detailed. And so there's a handful of things that are just maybe wanting to highlight, but anybody can do this. And that's kind of why we created the toolkit. The idea is that you can read it and then do it.

Dr Jin: Yes, yes. And then just before we get into a little bit more, the nitty-gritty, the topic of getting buy-in from leadership, because I guess I can see that this has so many benefits, but as a leader, convincing them of investing the time and perhaps getting the facilitators and resources necessary to conduct these regular listening sessions, what would you say is a good way to convince senior leadership that these listening sessions are worth it?

Dr Richards: Well, Dr Jin, you just asked one of my favorite questions because this is absolutely, I think one of the most important things before you embark on any sort of listening campaign at your organization is that. So first of all, one thing that I did and that I learned through my awesome mentors is before we even launched or even thought or even talked about listening sessions and listening campaigns is developing trusting relationship with those leaders.

And so getting to know people, getting to know about their division, their department, what's important to them, getting maybe to know something about them personally, the care team, how everything interacts, and then letting them get to know you as well. I think especially with Covid and Zoom and everything, we've kind of lost that when people get to know people, they're more likely to trust them no matter what it might be.

And this holds really true for something like this because I'm basically asking leaders, “Hey, would you like to hear from your faculty?” And here's what we're going to ask them. And honestly, a lot of the things that the leader hears in response and after these sessions is not always positive. It's work that needs to be done. And it's not always easy and fun. So you can't just barge in and say, “Hey, we're going to do this.” It's like, let's get to know each other, and so that they view you or whoever's doing this as somebody who can be trusted and who cares about this for all the right reasons.

So that would be kind of upstream before you even launch. That being said, if you just also want to launch, the thing that we did was we worked with the willing first. And so I actually went to my own division chief, chief of hospital medicine. I went to my own department chair, chair of medicine. I went to a couple other leaders that I just happened to know really well and just said, “Hey, we're piloting this. I think this can be really helpful. Would you be willing to go first?” And so to have a few people that said yes, sure, but that they were also kind of a safe place to start was really, really helpful for us because then I could get some feedback, make some tweaks early on, and do so in a more comfortable situation.

So working with the willing was really, really important. And then what I had, which I think was really helpful was some of those earlier sessions, I had those leaders share back with the other leaders to say, here's how it went, here's what it was like, here's how helpful it was. Here's a couple of things that we're working on because of this session. I would highly recommend it. Rather than me trying to say it, having them hear from their own peers and colleagues about how helpful it was. So those would be the 3, kind of, main things I would think about in terms of engagement in the process.

Dr Jin: Did you find any difficulty in gaining buy-in or engagement from the practicing clinicians?

Dr Richards: This actually is one of those things that goes back to every team is different and the culture of every team. So I'll be honest with you, there were groups that we met and we had 100% attendance and 100% participation, and people showed up and they were chatty and they were saying, “Thank you for coming,” and “What a cool experience.” And then there were a handful of groups that I went to that I felt like, not everyone really wants to be here. We had a few people no show. We even had people show up that were kind of on their phones, really, not participating.

And so both can happen. Luckily at our organization, the vast majority had pretty full attendance and high engagement. But again, I just think that speaks a lot of times to the leader and the culture of the group at that time. And it may just be that the group's not in a great place. Maybe they got some bad news, maybe they're short-staffed, maybe things just aren't good right now. And so this might feel as though, oh gosh, this is just one more thing. This is just lip service. Nothing's really going to change.

And those are the groups that just require a little bit more time upfront of developing that trusting relationship. But again, I think it kind of goes back to that. I will say too, that when we did these virtual during COVID, participation in the activities, so filling out the individual reflection, through a link in the chat, doing the wish rating activity, which we can do virtually, we would have lower participation. I think that makes sense because when you're in-person, everyone's just kind of looking at each other and it'd be really obvious if you didn't submit a wish and stand up and walk around. And so that's why I highly recommend the in-person, but those are just the things to expect. I can't promise you that it'll be perfect with every group.

Dr Jin: Of course. I do think what you mentioned earlier about having it replace an already scheduled team meeting is a key point. So it's not like you said, just one more thing, one more hour that they have to devote to their organization as opposed to their families.

Dr Richards: Yes, absolutely. And I will tell you too, that for those groups that you're not maybe feeling the love right off the bat or maybe not high engagement, or maybe they've got packed agendas, or maybe it does feel like one more thing, I tend to recommend to the leaders for the very first time to do a shortened version of the listening session. And so you can see this in the toolkit, but one of the recommendations that I frequently meet is, hey, let's just do the wish activity. I can be in and out in 15 to 20 minutes, and so it doesn't feel like a lot of additional time.

We can get that prioritized list back out to the group right away. So they were like, oh, this actually matters. And then we can promise to follow up. And even if we just say, we're going to pick one goal and it's one of the top priorities that came out in the wish rating activity. So at that point, gosh, you're not asking for 45 minutes or an hour. You're just saying, let's start small. Let's just do this wishlist activity. And then oftentimes that's the hook that gets the group engaged in the process because they actually see that something happened and then they're willing to do more formal or longer sessions in the future, or just do a lot of more follow-up sessions as things evolve and issues change over time.

Dr Jin: So let's talk a little more about the wish activity. Do you have a specific example of one session and some of the wishes and how you sorted that and then the next steps as you were talking about the follow-up, the actions that happened after that?

Dr Richards: Yeah, absolutely. So once we get the prioritized wishlist, so you can envision, let's say I met with a group of 15 cardiologists. We've got the 15 wishes. We've got them rated number 1 to 15. The top wish might have gotten an average score of a 9.7. The bottom one's maybe a 2.3. It's been shared back with the group. So that's the context. We have a meeting where we sit down with the leader, and so this is the chief, the chair, the group leader, and if they would like somebody in their group that has been designated as a quality or a wellness champion.

We will meet and we'll go through the qualitative individual reflection data that we had kind of categorized in themes, and then we'll kind of work through the wishlist. And we do kind of a quick and simple prioritization exercise using an impact feasibility matrix. So basically, which of these that we're looking at here that are kind of falling towards the top of the list, which of these would have the biggest impact and are also feasible from a resource time commitment funding perspective?

And so we kind of take it through that exercise to identify, OK, here's maybe 1 or 2 things where we really want to dive in and focus. And having that is really, really important. What I have found in terms of the types of wishes that come through is that they generally fall into, and not all of them, but they generally fall into kind of 2 categories. One category is, oh my gosh, this is a wish that we can act upon. This is what we call low-hanging fruit, and this is going to make a meaningful difference. Maybe not change the world, but it's going to make a meaningful difference.

And it's something that we can see through relatively quickly. Versus a wish that says, I wish my clinic was fully staffed 100% of the time. So as you could imagine in health care right now, most health care organizations are facing staffing shortages that are impacting most frontline physicians and APPs. And so when that wish comes up, I put that in a separate category because that is not a simple, easy, quick win and is not something new or different that isn't already being worked on.

And so a couple specific examples. So one example of a low-hanging fruit, quick win type wish that's really fun to see is we had a group of physicians that said, you know what? Our patients are frequently coming late to their clinic appointment and it's causing things to back up, the effect on the last patient scheduled in the day or getting bumped, and I'm staying later and people are frustrated and overwhelmed, and I'm starting to hear from patients that it's because they couldn't find their way from the parking garage to our clinic.

And so that was real popular amongst this group. Many people kind of brought up the same concern. We did a deeper dive. We met with the clinic manager, we looked at some of the patient experience comments from our patient experience surveys, and we found out that the way finding for those poor patients was abysmal. And so after that came up, there were walking tours with marketing and communications and with the clinic manager and the medical director, and the signs were changed, and patients started showing up on time.

So that was, sure, there was the cost of the signs and a little bit of a time commitment, but it was something that we could clearly see through and made a substantial difference. And it was just one of those things that just hadn't come up because it hadn't been dedicated time or enough people all agreeing that, gosh, this is a really significant issue that we want to bring to the top.

Dr Jin: And that's a perfect example of, like you said, the quick wins, which no one would ... I mean, people would feel silly bringing that up probably outside of a formal listening session.

Dr Richards: I mean, it was about signs, new signs, but it had a profound impact on patient experience and clinician experience. And so oftentimes we just don't provide the time or the space for people to really sit and think about, wow, what could make something better? The other thing is along the lines of we get a lot of wishes about staffing. General internal medicine references the Apex model, and could I have 2 MAs and a nurse and all these different wishes around staffing support, which is really valid and really important, and there's a lot of literature that would tell us that makes a big difference in terms of efficiency and for our providers and patient access.

That being said, these are really, really tough complex things to solve. And so usually our approach that we have found the most helpful in this scenario is to invite the most senior leader. So this could be the chief operating officer, this could be the vice president who oversees ambulatory operations or inpatient operations, whoever is the most senior leader, we've actually even had our CEO do this as well, come to a follow-up meeting and sit down with the team and hear directly from them what the issues are, what the concerns are, what they're hoping for, but also come prepared to provide very, very clear, transparent communications about where we've been, where we are and where we're going.

And oftentimes that senior leader will bring somebody closer to it, a manager director who has the actual data about the open FTEs and the recruitment strategies and projections and all of this stuff. And they'll have done their homework before. So they're coming in with a, here is exactly where we're at, here are the 3 things that we're doing to try to improve things. Here is the timing when things are going to improve and what else should we be doing? What else could we be doing better? And now, all of a sudden, you've done so many things, you've created that, OK, now our frontline providers have actually met a senior leader.

And so now it's just not a nameless, faceless organization. It's an actual human being that's there to listen. And then you are also having these frontline providers hear the real story because it's like the game of telephone in health care, especially within big organizations, you might not always hear the truth or you might not hear anything at all. And if you don't hear anything at all, what I commonly hear from physicians and other health care providers is if I don't hear anything, my assumption is that nothing's being done. And we know that especially with staffing as an issue that a ton is being done and that it's a really complex problem. And so when you bring people together in a room to have that conversation, even if you're not fixing the problem tomorrow, that communication helps make people feel heard and understood, and oftentimes gives them hope.

Dr Jin: And going along with that follow-up piece. So even if nothing is able to get done, let's say there's no low-hanging fruit among those wishes that are able to be accomplished in the next 6 months or whatnot, do you have a follow-up meeting with the whole group to update them on what is being done?

Dr Richards: A status update is so appreciated. Here were the 2 goals that we picked based on this activity, here's the work that's being done. Here's the task force that's been set up, here's who's on the task force. Here's how many times the task force has meant. Hey, by the way, do you want to be on the task force? Those types of updates, seemingly I've heard from administrators and operational leaders, we just don't want to bother the doctors. We don't want to tell them about small updates, like, they've got more important things to do.

And I'm like, you have no idea how helpful it is for people to hear that things are being done and that progress is being made and be part of that journey. Because again, if they don't hear anything, the assumption is that nothing is happening. And so those touchpoints after that initial meeting are absolutely crucial. In fact, I wouldn't even do a session if you can't commit to coming back. I will never forget this. It was so powerful. We had our chief medical officer at a follow-up meeting addressing an issue, and it just kept coming up and coming up. And you could tell that the group was frustrated.

And he said to the group, humbly and openly, “I don't know what to do. I don't know the next step to take. I don't have a solution to this problem.” And this is a very well-respected CMO who makes a lot of things happen, and does a lot of great things and has great street cred. But for him to be able to say, “I don't know,” he turned it back on the group. And he goes, “What ideas do you have?” Because it humanized him. And it helped the group understand that, gosh, we have these wishes, we have these problems, but they don't always have easy solutions.

And so how can we be creative and work together? We're actually the physicians doing the work. We may be in the best position to come up with some creative solutions, not somebody further removed from our day-to-day operations. And so there can be some really powerful moments, and I think most organizations know who kind of those key leaders are that are really good at that, and being open and kind of humble in some of these tough situations because the challenges facing health care are not simple, and sometimes we just need to say that.

Dr Jin: Yes, yes. Agreed. Thank you so much, Dr Richards, for your time and your expertise today on this very crucial topic of how to listen.

Dr Richards: You're so welcome. I hope you all have a wonderful day.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA's STEPS Forward® podcast series, stepsforward.org.

Audio Information

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If applicable, all relevant financial relationships have been mitigated.

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.


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