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What Does the Future Hold for the Culture of Medicine?

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Speaker: Hello and welcome to the AMA 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 STEPS Forward program is open access and free to all at stepsforward.org.

Dr Hopkins: All right, well thank you for those of you who are listening in the room and also online for joining our AMA STEPS Forward podcast team for ACPH's. First ever live podcast discussion. We're talking about the 2023 conference theme for ACPH, which is building on the workplace of the future. I'm your host and moderator, Dr Kevin Hopkins. I'm a family physician at Cleveland Clinic. I've been there for 19 years, an operational physician leader. I'm the vice chief of the Primary care Institute, so my team oversees clinical operations of all of our primary care ambulatory practices. For the past 4 and a half years, I've been fortunate to serve as a senior physician advisor to the AMA for Professional Satisfaction and Practice Sustainability.

So when we think about the conference theme, thinking about building the workplace of the future, the workplace implies not just location—it does include that—but not just location and physical environment. It's really the culture of the practice of medicine. When you think about culture, I think of it in terms of what is it like to work here and what's it like to be a patient here? What does the future hold for the culture of health care delivery?

We have 3 outstanding guests who are joining us today. Dr Brian Bohman from Stanford. Brian's the associate chief medical officer for Workforce Health and Wellness at Stanford, and has also been involved in the founding of the Stanford WellMD Center back in 2015.

Next to him is Dr Colin West from Mayo. Dr West is an internist by training, a prolific quantitative health sciences researcher who focuses primarily on physician well-being, evidence-based medicine, biostatistics, and medical education. In 2003, he co-founded the Mayo Clinic Internal Medicine Well-Being Study ... It's a prospective longitudinal study of personal well-being of Mayo Clinic internal medicine residents. So he had interest in that way before it became cool to have interest in well-being. He's also the director of the Mayo Clinic program on physician well-being.

And then we have Lotte Dyrbye. Dr Dyrbye is the senior associate dean of Faculty and chief well-being officer at the University of Colorado, formerly about a year and a half ago transferring from Mayo to University of Colorado. She's formerly the co-director of Mayo Clinic program on physician well-being. She's authored more than 130 publications related to physician well-being. She co-developed Well-Being Index and her work was an impetus for the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience. She also delivered the opening keynote address here at ACPH on day 1, building the workforce of the future. So thank you all for joining us. Thank you.

So thinking about the environment and the culture of health care delivery in this country, my first question is for you, Dr West: How would you describe the current state of our health care delivery system? And specifically, what would you say are the most significant opportunities for redesign and improvement?

Dr West: So I try to hold 2 things together. The current state, I think all of us feel, is stressed and fragmented, but we also hold that at the same time with common core values across medicine in terms of wanting to have deep relationships with our patients, continuing to care about those outcomes. So it's not all about the negative aspects. And I think really the challenge in terms of where people are right now and why those stresses of fragmentation cause so much discomfort for people is because they interfere with that desire, that aspirational goal, which I think continues in medicine, that we have this connection with our patients that we're helping our patients. That's where the meaning in our work shines through. That's where the years of dedication and study, the long hours, that's where those really continue to give us that drive, that motivation. And everything in medicine that goes on that we hear about at this meeting and all live in our practices, that interferes with that physician-patient relationship—is what leads to the distress and keeps us a little bit separated from that ideal.

Dr Hopkins: So thinking about value of relationships, if you go back probably to when we all applied to medical school and residency—and I was on my admissions committee in medical school—and you read every med school application, they all say the same thing, right? Why do you want to go into medicine? Because I want to help people. And implied in that is a desire to have relationship. And a lot of the ways that our system functions today have engineered the relationship out of it. Am I wrong in saying that? What do you guys think?

Dr West: I think there are barriers, and I'll just say one thing and then have my colleagues chime in, but earlier today at ACPH, we heard about EHR and opportunities for re-imagining how the EHR can serve our relationships with patients, as opposed to what we so often feel, is that we have to adapt to serve the EMR. We have all of these things that have entered into practice that all have their reasons, but often are distractions that separate us from, I want to help patients.

And medical students when they're applying to medical school, they're not just writing that because, oh, that's what I have to say. The vast majority deeply believe it. They're committed to trying to help other people. And then they get into training and into practice and there are all of these things that are the hassle factors, the distractions that don't allow them to fully connect with that aspirational goal.

Dr Hopkins: In 2010, I changed my practice model to get some help with documentation in the exam room, and part of the impetus for that was a response that I got on a patient experience survey that said the doctor spent more time examining the computer than examining me. As a primary care doctor, that was like a knife to the heart, the exact opposite of what and who I aim to be. Yet I found that this piece of technology very useful in a lot of ways had come between me and my patients and it wasn't a good thing.

Dr West: That's exactly right.

Dr Dyrbye: I think that is the lived experience as, also, a primary care physician. The electronic health record is also a great tool and it's a great asset. I remember the days of paper charts, that it was hard to read notes from the cardiologist. It was impossible to find the last electrocardiogram. In many ways, the electronic health record is a great thing, but we also know from studies done by Krasinski and others that for every 1 hour of patient care, we are spending 2 hours on the electronic health record doing various forms of documentation or filling out this, that or the other thing. That gets in the way of meaning, value and purpose, which is really what drives all of us.

Dr Bohman: I like the way you put that because I think there's understandable stress and frustration with the status quo, but the answer is not to throw the baby out bath water and just condemn the electronic medical record and condemn care pathways and condemn a lot of things that are really important for the progress of medicine to go where it needs to go. But also along the way, if they're implemented wrong, if they're implemented in a culture that doesn't pay enough attention to the effect on both experience, they can be detrimental of course.

Dr Hopkins: Most of those things that you just mentioned aren't going away, right?

Dr Bohman: No.

Dr Hopkins: So that's a good segue to my next question for you, Dr Bowman. Thinking about the opportunities that we have for improvement in our health care delivery system and how far we have come, how do you imagine the ideal future state of the culture for the practice of medicine? What does that look like in your mind?

Dr Bohman: Yeah, it's a very broad question.

Dr Hopkins: It is.

Dr Bohman: But thank you for it.

Dr Hopkins: It's a 30-minute podcast.

Dr Bohman: And I guess I would think... Yeah, exactly. You guys can go now. But I would take one step back and not just dive immediately into culture of wellness, which is what we like to talk about and it's critically important. But what are we there for? We're there to take care of patients, we're there to do it affordably, we're there to do it equitably, we're there to do it with high quality and a high patient experience. So all those things have to be inculcated into the culture. And the quadruple aim concept was invented to point out that you're not going to get any of those things done effectively if you don't take care of your people, if you don't have a culture of wellness as well.

So what is a culture of wellness? It's easy to say that, right? But it's so many things, but it's partly modifying our own physician culture in terms of a culture that doesn't elevate. We want a compassionate culture, but we want to have a self-compassionate culture. We want to have a culture of respect, equity, those other things. We want to have a culture of continuous improvement, which is critical to achieve all of the quadruple aim, including the well-being part, and a culture where leadership is wellness centered and takes accountability. Leaders take accountability for the well-being of the people who report up to (them).

Dr Hopkins: That's helpful to think about, even though it's in broad strokes to think about what the culture should look like and could be even today if we were to prioritize it, right?

Dr Bohman: Yeah.

Dr Hopkins: There's been so much great work that's come out of Stanford in this realm, the WellMD model, those types of things that a lot of organizations are adopting or figuring out how to adapt it for their own organizational culture. But how important do you think it is to have that investment buy-in from the top of an organization? Because it seems to me it would be very difficult to do this from anywhere other than the very top levels of leadership in most health care organizations.

Dr Bohman: I think that's true, and the origin story of our wellness center at Stanford, it was a little bit of a grassroots effort at the very beginning with just bringing together physicians mostly across the organization. And can I just stop right there? Because I caught myself. Always, when we're talking about physician well-being, I think we all want to make sure that everyone understands that's important. It's also important that nurses have well-being. It's important that the food service workers have well-being. We need that culture to spread across the entire org. And that's my job now at Stanford, is trying to translate some of what we've done with our physician center to the rest of the employees.

But to get back to the question of grassroots, we started with a little bit of a grassroots effort. What we found is that people were just doing things like meditation retreats and medicine and literature stuff—that's really good, but it wasn't organizationally hefty, let's say, or coordinated.

And very fortunately at Stanford, I would say, we got together and we thought, this isn't good. We need to build something more systematic, and it needs to be more about reading the great work that these folks were producing at the time, along with their colleagues, Tate and others in the field, we're like, this is not the way we build wellness, sustainable wellness program. And very fortunately, we were blessed with some leaders at the time, our dean and our 2 CEOs at Stanford and board members who saw this, and the board actually pushed us to develop something more substantial, and that's where our wellness center came from.

Dr Hopkins: Yeah, that's terrific. Personal resilience is the thing that is talked about in a lot of organizations, and yet we know the people that go into careers in health care—and specifically physicians—among some of the most resilient professionals. There are certainly the wear and tear of the grind of our career, and the work that we do every day can wear away at that personal resilience. But I think we're far more effective looking at systemic changes that can favorably affect physician well-being and affect the well-being of our entire health care organization.

What do you think are the most critical first or next steps that can be taken to move us in the right direction? We talked about, a little bit, about what that ideal state would be, what our current most significant opportunities are, but if I'm in a small private practice or a smaller health care organization or even a larger one that maybe has more resources, but I don't know where to start, what are the first things that I should consider?

Dr Dyrbye: I think the first piece, just building off of what Brian says, there needs to be the leadership commitment and willpower to do it, or else it's really hard to get out of the gate and get anything done. And then I would say the second step is really around measurement. Just like we think about with quality and safety, we have to know where we're at. We have to know what some of the contributing factors are in administering a survey to the health care workers within, whether it's a small practice or a big practice is a great way to get that starting point. What is the current state? What is the well-being? What are some of the potential contributing factors to either people doing really well and having high professional fulfillment, or not doing so well and having a high degree of burnout? And then using that data really to find your hotspots because you might have parts of your organization where people are thriving and doing really well, and then you have other parts where work stress is too high. And it's important to be able to have that kind of lay of the land because the reality is that there are limited resources to address some of the contributing factors. So you're going to get further spending your money wisely in areas that have really high levels of distress.

And then the approach, whether you look at the AMA Joy in Medicine program or you look at the CDC Total Worker Health program, if you look at the IHI Framework, it's all the same. And it really boils down to “nothing about me without me” as a summary. As a general internist, if I can't go into dermatology and say, “You need to fix these 2 things, then everybody will be happy.” That's just not going to work. Rather, we need to have conversations with the physicians, the nurses, the team members, the boots on the ground to say, OK, what are your pebbles in your shoe? What are the boulders in your pack? And more importantly, what do you see as opportunities? What are things that are in the sphere of influence of the individual health care worker, within the leaders of that work unit within the organization? And then what are these bigger external factors?

And then drive improvement by local action planning at the level of the work unit, action planning at the level of leaders and CMOs and within the organization. And for academic medical centers where I am, feeding forward, what are the things that we need to do from the dean's office to help improve the work environment? So it really requires that strategy of the leadership commitment, having the data and then really doing what we call human-centered design to figure out how do we improve the work environment in the most feasible, timely way?

Dr Hopkins: So Dr Dyrbye, you mentioned resources, limited resources, and we know from a lot of the great work the 3 of you and others have done in the research domain, things like the estimated annual cost of physician burnout at $4.6 billion. It's a huge financial issue, let alone the psychosocial issue that it causes. And when we think about research spend, $120 billion a year is estimated to be spent on practice science compared with $500 million a year on practice transformation. So literally, we spend 1/2 of 1% of the amount spent on clinical research researching the environment in which the clinical care is delivered. So recognizing that resource allocation and availability is always going to be an issue. Is that the biggest challenge that impedes transformation to the ideal future workplace that Brian talked about? Or are there other significant barriers to achieving that transformation?

Dr Dyrbye: Well, the drivers of burnout are complex, and they're multifactorial and they transcend a work unit. There's things outside of dermatology and neurosurgery that impacts the well-being of dermatologists and neurosurgeons. And depending on what system you're in, whether you're an academic medical center, you're in an integrated practice or in a corporate model, there are so many factors that impact the well-being of 1 person. And then unfortunately, in many health care settings, there's no 1 driving the bus, right? So you don't have a chief well-being officer or a senior medical director of well-being. You don't have a WellMD program. So you have what we call a wicked problem.

And frankly, in medicine, we are very busy othering each other. We're very busy pointing the fingers at it's the CMOs fault, it's the CEO's fault, it's the CFO's fault, and it's important that we all step up and do our part, whether that's as a practicing clinician or that's as a work unit leader, or that's as CMO, we all need to do our part if we're going to have any impact at bending the needle and turning this tide around.

Dr Hopkins: Dr Bowman, Dr West, either of you have thoughts on the biggest barriers to achieving true meaningful practice transformation to support our well-being of our care teams?

Dr West: I think we're further along than we were even 5 years ago, but I still think understanding and awareness, particularly for those who are making the decisions that shift, that cause the tectonic plates in medicine to move, that awareness and understanding needs to continue to grow. And some of that comes back to almost realigning our philosophy in medicine around what our core values are. One of the common things that I hear from smaller practices, and it's true in large institutions as well actually, especially given the financial pressures with the pandemic, is we would love to invest in our health care staff, but we've got other things right now to keep the lights on. We can't afford to invest in these well-being efforts. It's incredibly shortsighted. Because the people who actually make the mission in medicine are your health care workers. They are your single greatest resource. Don't invest in them at your peril. In the short term, you might save a few pennies. In the long term, you erode your culture. That's where the financial arguments come in. We've argued for years that the moral case for investing in health care professional well-being should be fairly obvious.

But there's also a really strong financial case, and it's not that we can't afford to invest in well-being. When you understand the financial situation, especially over longer than the next quarter's line item, we can't afford not to invest in well-being, because we are paying into this problem as a constant tax and drain on our system. But understanding and awareness of that bigger picture and then having enlightened leaders pick up on that and say, I want a different future for my organization, that requires that I invest in my people because they are my single greatest resource. That's a leadership philosophical shift that I think has been not common enough across.

Dr Bohman: Yeah, I want to double down on that. I think it also points out the connection with quality. In so many things, there's analogies between the quality movement and the well-being movement, but it's like saying you don't have enough time or resources to get better at what you do, to invest in getting better or more efficient or to do it cheaper. And we see that in quality. We see it in well-being, but it's in both cases equally shortsighted. It doesn't mean you put 90% of your budget to those efforts, but you better be investing in them where you have opportunities or you're just going to be languishing.

And the two efforts, if we're going to transform practices, you've got to have a really sound quality improvement framework. That's another thing we were lucky with. One of the hats I wear at Stanford is to help teach quality improvement courses. And we had a lot of support for that too.

And the two things came up together and the way they work right now is our well-being directors. And every department works with our physician improvement leader in every department who's a trained quality improvement person and a trained well-being person. And that's how we generate improvement. And those fundamental principles aren't that different either.

If you go back to W. Edwards Deming, I don't know how many people know of him, but he's a great thinker of the 20th century, and he invented modern quality improvement, one of a few. And one of my favorite sayings of his is not really a saying, it's just a statement is, “Everybody deserves joy in work.” That's it. And he came to that conclusion not because he was going to meditation retreats, he was trying to improve quality. He was rebuilding the auto industry in postwar Japan and found out that that's the way you could get better quality and more efficient auto production, is by treating people with respect.

Dr Hopkins: Yeah. It turns out that people that are happy, that are content that feel valued, they're more productive, they deliver a better experience, higher quality, better outcomes, right?

Dr Bohman: It's a win-win.

Dr Hopkins: Yeah. It is.

Dr Bohman: And people always think, “Oh, can we afford can afford to improve quality?” It's the opposite. You can't afford not to. And literally not just because pie in the sky 10 years from now, but it costs more to have a defect in the medical system than it does to prevent the defect by far. And I would say the same thing's true with human well-being. If we allow a defect in the human well-being in the organization, that's going to read down through the whole organization. And I'll tell you another reason that we got a Well-Being Center at Stanford was we were starting the quality work. And what we found is it was hard to get people to do the quality work on some of our units because they were burned out. And what are burned out physicians really good at? Cynicism and undermining and saying, “No, not on my unit.” And so that was actually an impediment to quality improvement.

Dr Hopkins: What if we don't do anything? What do you think the consequences of that are?

Dr Dyrbye: I think quality is going to continue to go down. We know that surgeons who are burnt out are twice as likely to be involved in medical malpractice litigation too. We know from work by Dr West that physicians who are burnt out are more likely to perceive they've committed major medical errors down the line. We know that doctors and nurses who are burnt out are much more likely to reduce their time taking care of patient care. That impacts access to care. We know from our large studies with collaboration with the AMA and Stanford and Mayo Clinic, that burnout has dramatically gone up post-pandemic. So burnout's going to go up, quality, safety, access to care is going to go down. So if we do nothing, we're not serving the needs of the patient.

Dr West: To build on that, and in a very simple statement, if we do nothing, medicine will become increasingly transactional because we will not be able to engage in the deeper interpersonal connections that are the heart of everything that we do. Medicine won't be medicine anymore. It'll be transactional rather than relationship-centered. And we won't recognize that future. And I worry that the very best people who are still signing up for this incredible career are going to look at that and say, “Eh, maybe that's not for me, because it doesn't speak to my deeper sense of meaning, values, and purpose anymore.” And I really hope, Kevin, that you're going to rescue us from this, and also ask us if we do this right, what's it going to deliver?

Dr Bohman: And there's my cue. Not only do we need to think of how burnout is going to impair our progress and allow the system to actually deteriorate, but the flip side of that is professional fulfillment. And who is it that's going to be leading the improvement efforts and changing the culture and implementing well-being in a way that we're doing at our organizations as best we can? It's going to be people who are professionally fulfilled. And so the bigger the pool that you can build up by attending to reducing burnout, and at the same time improving professional fulfillment, the faster you're going to improve.

My last question to wrap us up: If large systemic-scale practice redesign takes place to support physician well-being, if that really happens across the board, what would you expect to be the consequences of that? Dr Dyrbye, what do you think?

Dr Dyrbye: I think top diverse talent will want to be physicians. I think patients will receive better care, higher quality, safer, less expensive from compassionate, committed, highly competent health care workers. I think we'll have a reduction in our disparities, and I think we'll be in a much better place.

Dr West: I think we would start to see an upward spiral along all of the dimensions that Lotte just mentioned. More satisfied health care professionals who are able to engage with their patients and their communities in a more fulfilling manner that increases both individual patient health and the health of communities. And I think you start to see better return on investment. And our health care system as a whole becomes less overwhelmingly expensive, because everything is working more harmoniously.

And I think a really important point just to reemphasize something that Lotte said there as well, is that we actually compete more effectively for that incredibly bright young talent that right now might be looking at medicine and wondering, “Eh, can I do this?” We need those people, and I think those people actually need medicine, and we need to show them that this is actually the best possible career that you can bring those talents to bear fruit.

Dr Bohman: Right on. And can I just say, now is the time to invest in this. We've taken a huge hit in health care, professional well-being in the last 3 years. The data are very clear on that, and we don't want to get into the vicious cycle of burnout. We need to invest in our people and get into a virtuous cycle of fulfillment where those fulfilled people elevate the entire system.

Dr Hopkins: I want to thank you all for being our guest today. Dr Colin West, Dr Brian Bowman and Dr Lotte Dyrbye for joining us on this episode of the AMA STEPS Forward podcast live from ACPH.

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 STEPS Forward podcast series, stepsforward.org.

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