Have you ever wondered what your slugging percentage might be at work? How often do you really connect with a patient? Baseball fans might know what I mean. There are so many stats that we must pay attention to – CAUTI, GLOS, for example – maybe it’s a good thing our stat book isn’t updated every time we pitch a plan of care.

On the other hand, sometimes you might want to know a bit more about your performance. If you’ve ever struck out with a patient – and I have – it might leave you with questions, if not questioning yourself. Maybe a coach who’s been in the same exact situation could help.

A physician coach can help you work toward a professional goal like improving your communications skills or finding opportunities for making an empathetic connection with your patients.  They can help you interpret the stats that are tracked, like HCAHPS, Top Box, Communication with Doctors.  Many private physician coaches exist, and a few health systems have physicians trained as coaches.

In a slump? A trained colleague may be able to help you work through it. Get in touch with your hospital’s Medical Director or Chief Medical Officer, or contact me directly.

In 2020, the effects of the viral pandemic were inflicted not just on the general populace, but also specifically on the physicians and nurses dedicated to (caring) for (them). This quote might have been lifted from a New York City or Seattle newspaper. However, it wasn’t this pandemic that Nichol Baird, MD, and her coauthors had in mind when they wrote about this idea of physicians supporting physicians in 1995.2 In their article, they specifically advocated for the creation of hospital based physician wellbeing committees, to focus on “normal,” rather than only responding to distress and impairment.

Similarly, in 2009, Jodie Eckleberry-Hunt, PhD, et al, wrote about moving beyond the pathological focus on burnout to proactively having a conversation about what makes a physician well. They defined wellness as “a dynamic and ongoing process involving self-awareness and healthy choices resulting in a successful, balanced lifestyle.”3 As the American Medical Association notes, “at a time of dynamic change in medicine, improving the experience of the caregivers is essential, and is dependent on recognizing the costs of burnout and the value of a fulfilled professional workforce.”4

We have seen that many of the shortcomings of our healthcare system have been laid bare during this pandemic. Making a commitment to physician wellbeing will help bridge one gap. By helping physicians achieve fulfillment at work, balance, and a sense of wellbeing, we can build what the AMA calls the ‘organizational foundation for Joy in Medicine.’ In doing this we can help achieve the “Fourth Aim” of wellbeing of medical staff, consistent with the obligation of MHS to protect patients, ensure quality of care, and support medical staff functioning.

In other words, without the Fourth Aim there can be no sustained achievements in the other three areas we seek to improve: patient experience, patient health, and cost. The Institute for Healthcare Improvement, the originator of the Triple Aim, recognizes that “raising joy in work is a key strategy in the pursuit of the Triple Aim.”5 This makes developing a committee a crucial step for a hospital or health system, as well as an opportunity to differentiate itself.

To begin making an impact, an organization must effectively address physician wellbeing.6 Creating a wellbeing committee is a concrete first step an organization can take to foster a culture of clinician wellness.7 An organizational commitment to physician well-being typically begins with recognition of the physician as a precious resource by the executive leadership team.8 According to the American College of Physicians, addressing physician wellbeing sends a powerful, culture changing message:

we acknowledge this work is stressful

we acknowledge that burnout is an issue and we want to help you avoid it

we are providing this training because we care about you too … not just the patients

we can talk about stress and burnout rather than treating the subjects as taboo

it is OK to ask for help and support2

Dike Drummond, physician, coach, and author, describes the failure to address physician burnout as “an industry wide blind spot.”9 Failing to address workplace stress and physician burnout proactively can result in lower patient satisfaction and quality scores, higher error rates and malpractice risk, disruptive physician behavior, and higher than normal physician and staff turnover and associated costs.10 Therefore, clinician wellbeing is necessary for sustainably enhancing patient safety, and important for recruiting and retaining physicians as well.11

According to the ACP, many factors contribute to stress and burnout in the medical workplace including: Increasing internal and external complexity, greater pressure and accountability, lack of work/life balance, loss of autonomy and control, rising number of malpractice suits.12 Additionally, hospital systems face unique challenges on each campus and within each unique entity within the organization. At times these separate entities can be too compartmentalized, siloed, to their detriment. However by establishing a wellbeing committee at each campus or organization – or a physician champion at the smaller entities – and sharing ideas and resources, health systems can achieve economies of scale, capitalizing on shared lectures or speakers, and making use of virtual and tele-conference platforms to shrink distances, and educate physicians on dealing with stress, life-balance, and other issues.

The Mayo Clinic Department of Medicine in Rochester, Minnesota, created their Program on Physician Well-Being in June 2007. The mission of the program is to promote physician well-being through research, education, and development of individual and organizational well-being initiatives that optimize physician satisfaction and performance. The multi-disciplinary endeavor aims to improve the work lives of physicians, cultivate an environment where physicians flourish, and in turn improve the care they provide to patients.

Similarly, at Stanford, the guiding principle of the wellness committee – the Committee for Professional Satisfaction and Support – has been that the professional satisfaction of physicians and other caregivers is inextricably linked to quality, safety and patient-centeredness. Their vision is to:

“Create a practice environment that supports optimal physician wellness

and professional satisfaction by ensuring the organization’s leadership,

goals, structures and systems facilitate a healthy professional work-life.”13

Three domains of physician well-being have been identified: efficiency of practice, culture of wellness and personal resiliency.14 A healthy, balanced workforce of physicians reduces burnout, reduces medical errors, reduces disruptive behavior, and is vital to a large diverse organization such as MHS. By proactively addressing each domain, instead of being merely reactive, we can increase awareness and reduce stressors, potentially addressing (or preventing) problems before they rise to the level of reportability. By strengthening the culture, a hospital creates a location where physicians want to work and serve, we reduce turnover and create lasting relationships with loyal, engaged physicians. This translates into greater consistency within departments and on committees, and reduces turnover for the facility and its contract groups, which reduces costs.

Dr. Baird’s group identified three primary objectives for their wellbeing committee. The first function is to raise awareness and educate physicians. Such efforts might include sponsoring an awareness campaign, hosting wellness seminars, or CME programs. Research shows that learning certain skills can increase a physician’s sense of self efficacy and lower burn-out levels.

The second function, alleviating distress, is partially accomplished through the first, but also by creating or promoting preventive programs, and generally fostering a culture of wellbeing. Mindfulness training for example, supporting and working with other efforts such as hospital Critical Incident Stress Management teams, peer groups, and physician coaches. All will further aid the development of a sense of community and support.

The third function is advocating for efficiency in the workplace. The committee accomplishes this by identifying existing and emerging workplace needs or concerns, and making recommendations to those who can exact change in our organization. Not only does this reduce stress and potentially reduce triggers for disruptive behavior, it also creates an engine for efficiency of operations and practice that benefits the entire hospital.

The AMA also recommends looking at system interactions involved in physician wellness – individual, the organization and the culture.15 Specifically, the AMA notes that attempts should be made to address issues causing and fueling physician burnout, including time constraints, technology and regulations, at the system-level.16 This is very similar to the process outlined by Stanford as The Reciprocal Domains of Physician Well-Being.17 Similarly, while at the Mayo Clinic, Tait Shanafelt, MD and John Noseworthy, MD, identified and outlined nine organizational strategies to promote physician engagement and reduce burnout, many or all of which could successfully be implemented at any hospital.18

The optimal structure and size of the physician wellbeing committee has not been described. The ACP recommends inviting clinicians – physicians and advanced practitioners – from various departments with a mix of in terms of age, years worked at institution and gender, so all voices are represented. Dr. Baird’s committee, for example, was composed of physicians and two psychologists. Others also recommend inviting various professionals with specific expertise to serve on the committee, such as counselors, nutritionists, and clergy members, in order to better implement and execute the first and second functions of the committee.

In their paper “Physician Well-Being,” published by the New England Journal of Medicine, the authors conclude that “the quality and safety of patient care, and indeed the very vitality of our health care systems, depend heavily on high-functioning physicians.”19 Furthermore, that “professionally fulfilled physicians are better equipped not only to practice…clinical care, but also to lead the effort to identify and implement much needed improvements to our systems of care.” They also note that “physicians who feel supported by their organizations tend to contribute more to improvement efforts that increase the efficiency of their practice.” In this way, physician well-being efforts not only benefit the individual physician, they benefit the patient, and in turn, support the institution.

June 1, 2020

1. Baird N, Fish JS, Dworkind M, Steinert Y. Physician, heal thyself. Developing a hospital-based physician well-being committee. Can Fam Physician. 1995;41:259‐263.

2. Baird N, Fish JS, Dworkind M, Steinert Y. Physician, heal thyself. Developing a hospital-based physician well-being committee. Can Fam Physician. 1995;41:259‐263.

3. Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs. J Grad Med Educ. 2009;1(2):225‐230. doi:10.4300/JGME-D-09-00026.1

4. Sinsky C, Shanafelt T, Murphy ML, et al. Creating the Organizational Foundation for Joy in Medicine. Creating the Organizational Foundation for Joy in Medicine | Professional Well-being | AMA STEPS Forward | AMA Ed Hub. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed May 15, 2020.

5. Feeley D. The Triple Aim or the Quadruple Aim? Four Points to Help Set Your Strategy. Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy. Published November 17, 2017. Accessed June 2, 2020.

6. Berg S. Physician burnout: The pledge your organization should make now. American Medical Association. https://www.ama-assn.org/practice-management/physician-health/physician-burnout-pledge-your-organization-should-make-now. Published June 12, 2019. Accessed May 2, 2020.

7. How to Create a Clinician Wellness Committee. ACP. https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/how-to-create-a-clinician-wellness-committee. Accessed May 2, 2020.

8. How to Create a Clinician Wellness Committee. ACP. https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/how-to-create-a-clinician-wellness-committee. Accessed May 2, 2020.

9. Drummond D. Physician Burnout – 7 ways your Physician Wellness Committee will FAIL. Stop Physician Burnout Tools, Coaching, Training – Physician Wellness Program Design and Implementation – The Happy MD. http://www.thehappymd.com/blog/physician-burnout-7-ways-physician-wellness-committees-fail. Accessed June 2, 2020.

10. Drummond D. Burnout Basics. In: Stop Physician Burnout: What to Do When Working Harder Isn’t Working. Collinsville, MS, MS: Heritage Press Publications, LLC; 2014:15.

11. How to Create a Clinician Wellness Committee. ACP. https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/how-to-create-a-clinician-wellness-committee. Accessed May 2, 2020.

12. How to Create a Clinician Wellness Committee. ACP. https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/how-to-create-a-clinician-wellness-committee. Accessed May 2, 2020.

13. Wellness Committee. WellMD. Stanford Medicine. https://wellmd.stanford.edu/center1/committee.html. Accessed May 23, 2020.

14. Sinsky C, Shanafelt T, Murphy ML, et al. Creating the Organizational Foundation for Joy in Medicine. Creating the Organizational Foundation for Joy in Medicine | Professional Well-being | AMA STEPS Forward | AMA Ed Hub. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed May 15, 2020.

15. Berg S. Physician burnout: The pledge your organization should make now. American Medical Association. https://www.ama-assn.org/practice-management/physician-health/physician-burnout-pledge-your-organization-should-make-now. Published June 12, 2019. Accessed May 2, 2020.

16. Berg S. Physician burnout: The pledge your organization should make now. American Medical Association. https://www.ama-assn.org/practice-management/physician-health/physician-burnout-pledge-your-organization-should-make-now. Published June 12, 2019. Accessed May 2, 2020.

17. Bohman, B., et al. “Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience.” New England Journal of Medicine: Catalyst, April 26, 2017. Accessed May 2, 2020.

18. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129‐146. doi:10.1016/j.mayocp.2016.10.004

19. Bohman, B., et al. “Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience.” New England Journal of Medicine: Catalyst, April 26, 2017. Accessed May 2, 2020.

His article is not just about how to talk to people about wearing masks, it’s a reminder to always treat people (and patients) with dignity and respect.  It’s about talking to scared people about COVID, vaccines, public health, and meeting them where they are.

Mr. Warzel writes about Dr. Niang, a Senegalese medical anthropologist who was instrumental in addressing the Ebola outbreak in Guinea in 2014 by building trust with the local people.  He also spoke with Dr. Julia Marcus, a Harvard Medical School epidemiologist, who feels institutions such as the C.D.C. and W.H.O. should draw from lessons learned from the H.I.V. epidemic.  Warzel specifically references Dr. Marcus’s recent Atlantic article about men who don’t wear masks, and how to talk with them empathetically.

These issues are dealt with daily by many physicians.  He also addresses building trust on big picture issues, writing about his conversation with Dr. Rhea Boyd, a pediatrician who teaches at Stanford.  She argues that we need public health solutions that actually work in order to build trust.  To read about how Texas has specifically been impacted in this regard, see this piece by Jeneen Interlandi.

How we manage the epidemic is, at the base, the same as how we should practice medicine every day.  As Dr. Niang told Mr. Warzel, “An epidemic is not only technical and medical — they are not cured only by science or vaccines.”

An excellent doctors-eye-view of this problem comes from Dr. Danielle Ofri, who practices at Bellevue Hospital, New York.  Her opinion piece was published yesterday in the New York Times.  Dr. Ofri says that the work ethic of doctors and nurses is about all that is holding our health care system together; and there is a danger that they are being squeezed too much.  According to her, “This status quo is not sustainable — not for medical professionals and not for our patients.”²

Read her entire opinion piece here: https://nyti.ms/31ma6Qz, or visit her website: https://danielleofri.com/.

To combat this cycle, the American College of Physicians has developed some interventions intended to help reduce burnout and improve physician well-being, in part based on research from the Mayo Clinic.^3,4  Other resources, like the American Medical Association’s “Steps Forward” exist. 

Read Dr. Ofri’s piece and tell me, what do you think we should be doing here?

1 https://www.physicianleaders.org/news/mayo-clinic-researchers-physician-burnout-is-an-institutional-challenge

2 https://nyti.ms/31ma6Qz

3 https://www.acponline.org/practice-resources/physician-well-being-and-professional-satisfaction/top-10-culture-change-interventions-to-reduce-burnout-and-improve-physician-well-being

4 S, Kabcenell A, Shanafelt T, Clinic M. Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience. J Healthc Manag. 2016;61(2):105-127. PMID: 27111930.  https://www.aan.com/siteassets/home-page/conferences-and-community/live-well/17mayoclinicexperience_cc.pdf

I suspect you may have already read or heard some “bad news” today.  This post is full of “good news,” even if it is a really harsh subject.

The AMA says that the Opioid Epidemic is “turning around,” according to Medscape write Megan Brooks.¹  And according to the AMA’s report, leadership and action by physicians is helping.²  Further, there was a 22% decline in the number of opioid prescriptions written from 2013 to 2017.  The same article sites a report by data company IQVIA that shows the same 22% decrease for Texas.³

Of course, there’s still more to be done.  That is why I want to let you know about a unique opportunity that is coming up in September.  Methodist Mansfield Medical Center is going to host a tele-conference roundtable  – a kind of “grand rounds” – with Mayo Clinic on opioid prescribing, Thursday, September 13^th at noon, (our usual physician’s journal club time).

This is a one-of-a-kind pilot program with the Mayo Clinic; the first time this has been done!  Opioid prescribing and the potential detrimental side of opioid use affects us all, and I want to encourage anyone who can possibly attend to do so.  Not to mention that this will be a really unique opportunity for MMMC!

For the discussion and question & answer session, we will be joined by a panel of expert physicians from the Mayo Clinic, including: 

Casey Clements, M.D., Ph.D., Emergency Medicine Services Consultant

Halena Gazelka, M.D., Anesthesiologist, Periop Medicine Consultant

Holly Geyer, M.D., Hospitalist, Mayo Arizona

The panel discussion will be based on a podcast by Dr. Casey Clements, “Opioid Edition: Acute Prescribing: Emergency Room Prescribing.”  This is episode five, of an eight part series.  The podcast, just 23 minutes long, is available now on iTunes, and I encourage you to listen in advance (link).

According to iTunes, in this episode Dr. Casey Clements, an emergency physician and practice leader, who works in the opioid stewardship program at Mayo Clinic-Rochester, shares his insights on opioid therapy from the Emergency Department perspective.  In the sixth episode, Dr. Clements discusses what to do if you suspect opioid use disorder or addiction, and shares his insights on treating opioid misuse in the emergency setting.

I hope many of you will plan to attend.  Room announcement and other details will be forthcoming.  Feel free to contact me with any questions.   Please check Twitter @doctorsserving or the MMMC physician’s only group on Facebook for announcements.

See you in September!

Paul Lansdowne, MD

¹https://www.medscape.com/viewarticle/897847

²https://www.end-opioid-epidemic.org/wp-content/uploads/2018/05/AMA-2018-Opioid-Report-FINAL.pdf

³https://www.texmed.org/uploadedFiles/Current/2016_Public_Health/Opioids/IQVIA%20Opioid%20state%20and%20payer%20views%202017%20FINAL.PDF

Doctors,

You may know about Methodist Mansfield Medical Center’s Patient and Family Advisory Council which began meeting in August, 2017.  The aim of the Council (PFAC) is to enable collaboration between patients and family members (about a dozen community members), hospital leadership, and staff.  PFACs allow patients and families to have a formal avenue to provide input into various processes that impact patient care and services in order to improve care delivery and meet hospital quality and patient experience target goals.  In short, PFACs allow patients and families “to advocate for their care by sharing their input.”

The conversation of the January PFAC meeting centered around physician communication with discussion about the HCAHPS “physician domain” questions and the hospital discharge process.  I want to share with you the comments relevant to the physician experience that came to light from the January Patient and Family Advisory Council meeting.  This email and post is being sent to the entire medical staff, sub-specialists, and consultants, and I hope it will stimulate some conversation at our various department and section meetings.

Broadly two themes emerged from our January meeting:

• Patients want to know that we care about them
• They want things explained so they can understand

CARE (and RESPECT)

Right off, the community members said they wanted us to know that they are impressed by the fact that our physicians make the effort to fully meet patient’s needs and expectations, and that the community perception of MMMC has always been very positive.

That said, they want their physicians to be helpful, comforting, and understanding.  When they come to the hospital they want to feel welcomed, and fully valued.  For example, they don’t want to feel like they are being bothersome when they go out to the desk to ask a question.

They said that when you come in to the hospital or E.D. room, you’ve got to be prepared to spend time and answer questions.  They expect their primary doctors and consultants to know what is going on.  They want to know that you have read the chart or communicated with the other doctors involved in their care.

Also, one question they almost always want to know: When are you coming back?  And they have a suggestion: Use the whiteboard!

EXPLAIN

Another theme involved having things explained in a way that patients and their families can understand, and they want to know what to expect each step of the way.  Patients prefer to have things explained up front: “I don’t want to ask you questions…I want you to tell me exactly what’s going on.”  As one member expressed: “you may do a good job, but you need to explain it so I can understand it.”

Another “huge issue” was clear communication regarding medications, especially if a patient is going home with big changes to their medication regimen.  They said it needs to be explained clearly, both verbally and written, and again, they suggested using the white board.

To summarize in their words: “explain”, “show pictures”, “spend time,”  “help me to understand exactly what was going on with mom’s heart,” and use simple terms like “it’s a heart problem,” or “it’s a water pill.”

PFAC, HCAHP, WTW?

These messages are very consistent with what you might hear from national patient advocacy organizations like the Southlake based Beryl Institute, and those organizations known for service excellence, like the Studer Group, or Cleveland Clinic.  Importantly, these are also the themes that the Methodist system is focusing on for patient care, and that we are working on right here at Mansfield; take for example the introduction of the Physician Code, and the “Three Things” that can make a difference:

• Introduce yourself every time you see patients.
• Show patients that you listened to them and are concerned.
• Show patients that you took the time needed to help them understand.

Some issues raised by patients fall more to the responsibility of the hospital.  Like improving the discharge process, connecting better with patient’s primary care physicians and making it easier for patients to follow up with them and specialists after discharge; and constantly striving to improve the patient’s understanding of medications.  However, in all this, the “hospital” side of the equation needs our input and ideas.

The next PFAC meeting is in April.  Members will be expecting to have some follow up and they’ll want to hear what we’ve done with this information.  So, again, I hope this feedback from the community will spark some good conversation, even if it’s just in the physician’s lounge — maybe that’s the best place for it.  In the meantime, try out these “Three Things,” see if you think they make a difference, and let me know.

Thanks,

Paul Lansdowne, MD

This month, Methodist Health System will debut a new effort in patient experience.  This initiative is based upon the reality that patient care and outcomes are improved, and the idea that Methodist can distinguish itself, by providing a better patient experience.

Physicians across the system have been involved in developing the “MHS Physicians’ Promise:”

We are devoted to caring for our patients and their families.  Earning their trust is important to us, and we will do our best to treat everyone with compassion, respect, and empathy.

Along with our nurses and staff, we will show how we value every patient by:

                Inspiring them to be active participants in their care

                Explaining medical conditions thoroughly

                Helping them make shared decisions about their treatment

                Teaching them about health and wellness.

You will also be hearing about concrete steps you can take each time you interact with a patient.   For starters, we’ve chosen to focus on “Three Things” you can do to make a difference:

                Introducing yourself every time you see patients.

                Show patients that you listened to them and are concerned.

               Showing patients that you took the time needed to help them

understand.

As part of this new paradigm at Methodist, coaching will be available for physicians who want or need some additional help in those areas of the patient experience that they find difficult.

We want these ideas to reach all of the physicians at Methodist Mansfield, and you will be hearing about this from your Department Chairs and Heads of Sections at your upcoming department meeting and section meeting.  I want to encourage all of us to strive to make these ideas a part of our daily practice.  You will be seeing some new material (posters, cards, etc.), designed to familiarize patients and family members with these ideas, and to serve as reminders to physicians.  Also, I will be using @doctorsserving on Twitter to help share this information as well.

Please feel free to call me if you have any questions or if I can be of any help.  I welcome your feedback and any suggestions.  Thank you!  I love being a part of our Methodist Mansfield family!

Sometimes you come across something so worthwhile you just have to share it.  My wife first shared this idea with me some time ago.  I came across it again just recently.

Bryan Sexton, PhD, with Duke School of Medicine, shared his research on the Three Good Things concept, in a blog at Duke Today (https://today.duke.edu/2016/02/resilience).

What is it?  In short: better sleep, better relationships, better work, better life!  According to Dr. Sexton, promoting positive thoughts and building resilience can be as easy as writing down three things that happened during that day that went well and your role in the positive outcome.  Best results for the exercise come after 14 consecutive entries, and the results can last for more than a year!  Dr. Sexton compares the results to using Prozac.

Almost too easy, right?  Here is former American Psychological Association president Martin Seligman, PhD, explaining in a one minute video: https://youtu.be/ZOGAp9dw8Ac.

Want to see more, here is Dr. Sexton in a short video that includes the research and data that supports this claim: https://www.youtube.com/watch?v=hZ4aT_RVHCs.

My notebook is already on my nightstand, waiting for me to start.  Let’s try it together.

On October 1, I will be leaving my traditional office based practice for a position as an Obstetrics and Gynecology hospitalist at Methodist Mansfield Medical Center.  Although I am very excited about this opportunity to be a part of an new program, it is with mixed emotions that I announce I’m discontinuing my office practice and leaving WHSNT (also on October 1st).  It has been a great pleasure providing for my patients’ health care needs over the years, but as of October 1, I will no longer be available to see patients in a clinic setting.  I will be maintaining my website (drlansdowne.com) and facebook (drlansdowne), so check back for frequent updates!  I’m looking forward to blogging and having a little more time to blog!  I have greatly valued the relationships I have built over the years with my patients and thank everyone for the loyalty and friendship.