Improving Clinician Experience: Fixing a Broken System

December 9, 2022

Transcript

Dr. Angela Kade Goepferd:  This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.

Welcome to Talking Pediatrics. I’m your host Dr. Angela Kade Goepferd. Burnout, moral injury, resilience, wellbeing. How many of us working in health care are so tired of hearing about how much we seem to be collectively struggling? And at the same time, all of the strategies to improve how we’re struggling seem to be personally directed at us. Working to reframe the problem of burnout and change the systems that we are working in, rather than the individual clinicians actions and reactions is Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association. It is my honor and pleasure to have Dr. Sinsky with us on Talking Pediatrics today. Chris, welcome to the show.

Dr. Christine Sinsky: Thanks, Angela. It’s a pleasure to be with you.

Dr. Angela Kade Goepferd: So can you start out by telling us what exactly does a vice president of professional satisfaction do for the American Medical Association?

Dr. Christine Sinsky: My husband calls me the veep of joy, and I feel like I have actually one of the best positions that a person could have. I see as our collective goal, the team that I work with, is to help to create the conditions where joy, purpose and meaning in work are possible for physicians, nurse practitioners, physicians assistants and other health care professionals.

Dr. Angela Kade Goepferd: That does sound like a great job, and I have met you personally outside of our shared collective work together, and I know you have a really relatable origin story for sort of how you got involved in this work. And I wonder if you could share with us how things like clinician experience and wellness and burnout came to be an area of focus for you.

Dr. Christine Sinsky: Angela, I can remember seven years into my practice as a general internist standing at the end of the day looking out the window at the fall colors and having a stack of charts to document and feeling like if I was going to stay in this work, I would have to do something different. I felt like I had become a documentation drone, a guideline following automaton, and I wasn’t doing the work that I found valuable, and equally as important, I realized I wasn’t doing the work that my patients found valuable. And so over time I continued to ask what matters to the patient, what matters to me, and how can we modify the work environment to maximize those things?

Dr. Angela Kade Goepferd: There are a lot of people who talk about wellness and burnout relative to physicians and clinicians. And one of the things I really like about how you talk about burnout is that you talk about burnout manifesting in individuals, but originating in systems. And why is it so important to you to frame the problem in this way?

Dr. Christine Sinsky: Really it is important that while burnout manifests in individuals, it originates in systems. And that’s important because otherwise we frame the problem as the person and not the system. And it’s important for us to realize we have to fix the workplace rather than fix the worker. It’s not the worker who’s broken, it’s the environment in which we’re working. And I fear if we focus on individual efforts at wellbeing, as important as things such as mindfulness and yoga are, we blame the victim in a sense. We blame the individual who’s experiencing occupational stress for not having tried hard enough when that’s not really what the problem is.

Dr. Angela Kade Goepferd: Heard you talk about this image of don’t fix the canary, fix the coal mine. And I think that’s a lot of where we find ourselves in healthcare is focusing on the canary and why couldn’t they get out of the coal mine successfully instead of improving the structure of the mine itself.

Along these lines, I want to talk a little bit about this idea of resilience. When we talk about resilience, for me as a pediatrician, akin to the canary in the coal mine, it reminds me about how we talk about children being resilient in the face of childhood trauma rather than talking about the need to fix the trauma so that kids don’t have to be quite so resilient. And you’ve spoken about this relative clinicians as that we don’t have a resiliency deficit here. That something else is going on. Can you talk a little bit more about that?

Dr. Christine Sinsky: We did a study in 2020 looking at resiliency in the physician population versus the general population. And resiliency is higher in physicians than the general population and at a significantly higher level, which just underlines the fact that this is a systems problem and so we need systems solutions. So I like to talk about organizational resilience. How do we create organizations that are resilient and that protect and support the individuals within rather than how do we create individuals who are more resilient to deal with a dysfunctional environment?

And I think it’s worthy of noting that we can identify physicians in terms of their resilience into eight different categories. And even those physicians who have the highest resiliency score, 30% of those physicians experience burnout. And so again, it’s not a resiliency deficit, it is a problem with the environment.

Dr. Angela Kade Goepferd: One other thing that I’ve read, speaking of the problem with the environment is that we become less resilient over time the longer we are in this coal mine of a bad environment. And correct me if I’m wrong, but what I have read is that people who are entering medical school, for example, tend to be people who are highly resilient individuals and then by the time they get through medical training and into practice, they’re overall less resilient by the end of that training. Is that right?

Dr. Christine Sinsky: Well, I think the actual metric is burnout and depression. That medical students enter medical school with a stronger mental health profile than age-matched peers who are in other fields outside of medicine. But within two years of training, those mental health scores and burnout scores decrease for physicians. So something does in fact happen during the course of our training and our early practice that takes this highly resilient group of physicians and worsens their burnout levels and their mental health profiles. So I think we stay resilient, but we’ve just been accosted by more challenges in the course of training and practice.

Dr. Angela Kade Goepferd: And I think why that’s striking to me is, as you know, I’m someone who works in clinical practice, does primary care and gender healthcare, but also has a role as our chief education officer and so oversees a lot of our training programs of medical students and residents and fellows. And so it sounds to me like the systems that we have to fix are both within our hospital walls, but also probably within the systems in which we train those who are becoming part of our professional staff.

Dr. Christine Sinsky: I think that there is a role for multiple stakeholders to share an accountability for the wellbeing of the workforce, and those stakeholders include trainees and those who train the trainees. So educators, it also includes regulators, it includes technology vendors, it includes health system leaders, and it includes clinic managers. So I think there’s a role for multiple stakeholders to look at how can I, in my sphere of influence, contribute to a better work environment for medical students, residents, other trainees, and then for practicing clinicians.

Dr. Angela Kade Goepferd: Speaking of stakeholders, let’s talk a little bit about the stakes of burnout. I think sometimes, again, we individualize the stakes of burnout in terms of an individual clinician’s mental health or suicidality, and we talk about that, but there are real costs to multiple stakeholders of physician burnout. And can you talk to us a little bit about what it costs our systems and all of those folks that you mentioned when the physician workforce becomes burned out?

Dr. Christine Sinsky: I think that if you care about many outcomes, you have to care about burnout. So if you care about safety, if you’re the chief safety officer for an organization, you have to care about burnout because when physicians and others are burned out, we make more mistakes. For physicians, there’s good evidence that when we’re experiencing burnout, we make twice as many mistakes as when we are not. Patients are less satisfied with our care. Twice as many complaints for physicians who are burned out as physicians who are not.

If you’re the chief financial officer and you’re responsible for the economic stability of your organization, you have to care about burnout because when physicians are burned out, there are higher rates of malpractice, there are higher costs of care, there is greater turnover, and all of that has a high financial cost for the organization.

Dr. Angela Kade Goepferd: And in terms of turnover, I know it’s very expensive to replace a physician member of the workforce. Do you have any sense in terms of dollars what this problem is costing hospital systems?

Dr. Christine Sinsky: We do. In fact, we know that collectively across the US burnout is costing about 5 billion dollars every year in excess cost. And that’s a very conservative estimate. It doesn’t include all the potential sources of excess cost. And we can also look at this at the individual health system level.

So if you are an organization of a thousand physicians and you have average rates of burnout, you have average rates of turnover, and we put in a very conservative estimate of a $500,000 cost to replace a physician who leaves, and that cost is probably closer to a million or 1.3 million for many physician specialties, but using that conservative estimate, an organization of a thousand physicians is already investing over 13 million dollars every year replacing those physicians who leave because of burnout. 13 million a year. And we know that if you invest a portion of that upstream at addressing some of those remedial drivers of burnout, you have a really positive return on investment.

Dr. Angela Kade Goepferd: So let’s shift our conversation to some of those drivers of burnout and what we can do about it. One of the concepts I’ve heard you talk about is this increasing cognitive workload for clinicians, how the task load for clinicians has steadily increased since the introduction particularly of the electronic health record. Can you tell us more about this great work transfer that you’ve talked about and what it means for clinician wellbeing?

Dr. Christine Sinsky: Well, I’ll tell it to you in personal terms first. I practiced for 32 years general internal medicine, both inpatient and outpatient care. Sixteen of those years were in the paper world, much of the last of those 16 were looking forward to the implementation of an electronic health record to make care safer and more efficient. So the second 16 years were with two different EHRs.

And what I came to recognize is the EHR both created more work, there were more tasks to be done, more steps to be done, and it also transferred work to the physician. So work that previously was done by the receptionist, a ward secretary, a pharmacist, a transcriptionist, suddenly became the work domain of the physician. And underlying that was almost this expectation of superhero capabilities among physicians. And physicians, for our part, we sort of stepped up and took it on and took on more and more work responsibilities, but the end result has been unsustainable.

And we know, for example, that a time motion study that we did where we trained medical students to follow physicians, we found that physicians were spending two hours on EHR and desk work for every one hour of direct face time with patients. And despite this, physicians in primary care were taking one to two hours of work after work home every night of EHR work to be done at home. And this has created both a time pressure for physicians, but also a cognitive workload. If your mind is on six channels at one time, it’s really hard to give undivided attention to the patient in front of you or the thought that you’re working on the task that you’re doing. And so I think that that’s created this very stressful cognitive work environment in which we are doing this complex work.

Dr. Angela Kade Goepferd: I think that the perception among people who are not in health care is that the work of being a doctor or the work of clinical care takes place with the patient. And I think the reality and the experience for many of us is that the work and the time happens completely outside of the exam room. And while we may spend a significant abortion of our day face-to-face with patients, we spend just as you described, two or three times that doing documentation, billing, answering phone calls, responding to inbox messages, filling out forms, all of that additional work.

Dr. Christine Sinsky: I think that one of the sources of burnout and really of moral distress that physicians and others feel is that we know we are often spending our days doing the wrong work for our patients. That the mandatory work of filling out tick boxes and forms and performance measures and the multiple steps to do an order entry, all of that mandatory work has pushed the important work to the margin. And so we know that we are having to shortchange some of the most important work that we do in order to do the mandatory work to get past the hard stops that are built into our technology environment. And that puts us at odds with our aspirations as professionals. And so I think that that really is an underlying source of moral distress and burnout for physicians and other health professionals.

Dr. Angela Kade Goepferd: I absolutely agree with you, Chris, and I have a story to share relative to that where I was having a text exchange with a friend of mine who has a daughter who had recently been to the pediatrician, and she sent me a picture that this child had drawn of her visit to the pediatrics office, and it almost mirrored exactly a relatively well-known picture out there of a child visiting the doctor.

But the child was sitting on the exam table. And when I looked for the pediatrician in the picture, the pediatrician wasn’t standing by the child wasn’t examining the child wasn’t talking to the child, the pediatrician was sitting across the room at a desk with a computer in front of them. And I think while this was not the intention of my friend who sent the picture, I think I experienced a moment of that moral distress that you referenced where I realized that how the world and how my patients see me as their doctor is not at all how I intended to be seen.

One of the related concepts to this is the shift that you’ve mentioned of our work being more transactional and less relational. And I wonder if we could talk a little bit more about that and how we might start to shift that back.

Dr. Christine Sinsky: I have observed over the course of the last several decades that healthcare has become very transactional, that the conceptualization that people have of healthcare is very transactional. So all of our infrastructures are built on a mindset that there’s this transactional interaction generally in between the physician and the computer. There’s not even a recognition that there might be a patient involved. So we have tick boxes and just a variety of transactional activities. And yet at its core, our work is relational. And I think we are more effective clinicians when our work is based on a deep relationship with a patient.

And so I wonder, how would healthcare look differently if we prioritized relationships? And not just relationships between the patient and the physician, but between the physician and their colleagues, between nurses and nurses, between nurses and physicians. What if we prioritize the relationships between inpatient and outpatient physicians and inpatient and outpatient organizations? And so I believe that one of the ways that we will get to the outcomes we seek, the other outcomes that we seek, is to consider how will care look differently in every decision if we were to prioritize relationships.

Dr. Angela Kade Goepferd: I love that and I think that that could make a huge difference. I’ve seen just in my own personal work, when I shifted from doing exclusively primary care to doing some specialty care and working in the gender health program, I was spending more time and was afforded more time with my patients and also a smaller care team that I really developed deep relationships with. So not only was I able to develop deeper relationships with my patients, so was my entire team, and we in turn developed deeper relationships with each other. And as you may be aware, doing pediatric gender health work right now is a challenging space to be in. And I really think that we’re able to weather it so well because we have such great relationships both with each other and with the patients that we’re caring for.

Dr. Christine Sinsky: And there is so much that we could do differently if we just started to ask the question, how would this look differently if we prioritize relationships? How would the OR look different if we prioritize relationships? We might put people’s names on their bonnets so that the OR staff would automatically know each other’s names. We might prioritize team stability in the outpatient and inpatient arenas so that it’s the same nurses and medical assistants and physicians who work together as a core team and get to know each other, and we know that that’s safer and more efficient to do that. How would the physical space look differently if we prioritize relationships? So there’s many, many ways that we could build in more support that would organically contribute, I think, to a stronger healthcare system when we had stronger relationships.

Dr. Angela Kade Goepferd: Let’s talk about a few more of the upstream solutions to help fix this problematic system that we’re in. One of the analogies that I’ve heard you use is around an airplane cockpit and how those spaces, those physical spaces, are designed intuitively to be the most safe, the least accident prone, for pilots to be able to safely fly planes and how we might be able to use that analogy in healthcare. So can you walk through some examples of ways we could improve the cockpit so that we are able to do our work better?

Dr. Christine Sinsky: At Boeing, we actually have a group of engineers whose job it is to decide whether certain alerts are worth bringing into the cockpit or if in some, it creates too many distractions for the pilot. And we don’t have that in healthcare. And so we have the cumulative effect of many well-intended efforts that taken in some are simply overwhelming for physicians. In addition, there’s been this history of optimizing around a single goal. And so we might suboptimize around compliance but actually make it much harder in the long run to take care of patients. Or we might suboptimize around some smaller objective and make it harder to reach the overall objectives. And I think we need to look at the big picture as to whether the work is actually doable.

Dr. Angela Kade Goepferd: I think an example that comes to mind when you talk about that is a recent implementation in our clinic setting of online scheduling and how the suboptimization goal was patients have a better experience. They’re able to go in schedule their own appointment, they don’t have to call, they don’t have to wait on hold, but we didn’t think through the flow of what that would do to the clinical care team.

And so when patients are scheduling their own appointments, often if we’re not careful about how that’s done and we don’t set it up right to keep the cockpit manageable, what happens is now we’ve got too many checkups scheduled in a row. So now we can’t effectively room patients because they need more time to get all of their pre-work done, or there’s too much cognitive or medical complexity burden on the clinician because the patients aren’t appropriately spaced. So I think that concept of really trying to keep the cockpit manageable at all times is a good lesson for us.

What are some of the examples that you’ve learned in your work as kind of the person in charge of restoring joy to medicine at the AMA? What are some examples of things that have been successful for systems and teams that they’ve been able to implement that have made a difference?

Dr. Christine Sinsky: There are some practice fundamentals that we recommend that physicians, particularly physicians in outpatient practices, consider in their own practice. And it’s my belief and observation that most physicians in most specialties and in most settings can save three to five hours every day by re-engineering the way the work is done and by more strategically delegating some of the work to upskilled team members.

So for complex patients, doing labs ahead of the appointment can save 30 minutes a day for most physicians. Taking a systematic approach to how you manage chronic illness prescriptions can save about 30 minutes a day. Expanding and making more meaningful the rooming contributions of our staff, of our nurses and medical assistants that can save about an hour of physician or APP time a day. Sharing the inbox work more strategically with staff can save a half an hour a day sharing documentation with our team, having team documentation can save between one and three hours of physician time per day. So those are some examples.

And we summarize that in a playbook that we’ve put together at the AMA called the Saving Time Playbook, and we’ve found that that’s been a really wonderful resource. We have podcasts and webinars that supplement that, but that’s a place that people can go and find specific guidance on how to save time every day so that you have more time to look your patients in the eyes so you have more time to go home and be with your friends and family.

Dr. Angela Kade Goepferd: Yeah, I’d love to maybe have you elaborate a little bit more on some of the resources that are available through the AMA. I wasn’t aware prior to my engagement with you about all the things that are there. I know there’s a similar playbook to what you mentioned about taming the EHR. Can you go through just a few resources for folks who are listening and thinking, yeah, I really do need to bring some of these concepts to my clinic or to my organization.

Dr. Christine Sinsky: So we have over 70 toolkits at stepsforward.org. These toolkits are practical, actionable, one-step resources to help a physician, practice manager, other clinician reorganize and redesign how they do their work. And each of these toolkits has a step-by-step approach to how you might adopt the principle that we’re speaking of. And we have success stories so you can see how other organizations have adopted and adapted the concept.

So for example, we have one on taking a more systematic approach to prescription management. And a group from Bozeman Health developed an initiative called Having More Great Days. And they found that by doing 90 days plus four refills as the standard approach to their prescriptions, that they decreased the number of inbox messages for their nurses by 65%. By having a printer in every room, they saved $10,000 a year. They were able to decrease the amount of pajama time for their physicians by 25%.

And so the Steps Forward resources have just a wealth of information of how you can tackle one particular aspect of workflow or organizational culture and how others have done something similar.

Dr. Angela Kade Goepferd: Those are really wonderful resources and I’m glad that they’re available, so thanks for helping me highlight those for our listeners.

The last concept I’d like to close with, because I always like to focus on what we want, not what we don’t have. And what we want is joy in our work. And what we want is to feel good connections with each other. And one of the concepts I’ve heard you talk about is a joy score. Which I love because our organizations are filled with scorecards that we’re always trying to keep up with and make sure we’re meeting metrics on. And tell us a little bit more about a joy score and how that might help us work toward our goal, which is for our healthcare teams to thrive.

Dr. Christine Sinsky: So we created a program called the Joy in Medicine Health System Recognition Program. And that program is meant to serve as a roadmap for organizations as they deal with the fact, ugh, I see burnout as a problem, but I just don’t know where to start. I don’t know what to do.

And so if you are a member of an organization, if you’re a mid level or high level leader within an organization, you can be like many others who’ve used this to structure their conversations with their leaders, to structure their activities.

And what we do is we have three levels of achievement, bronze, silver, and gold, and six domains of activity, including things like assessment, are you checking burnout rates at your organization, practice efficiency, leadership attributes, teamwork attributes, peer support. And at each level, there are different criteria.

We recently recognized another 22 health systems at either bronze, silver, or gold. So now there are 70 organizations across the country that have attested to their organization’s specific programming and accomplishments in these areas that we believe help to create a resilient organization, help to create the conditions where their clinicians can thrive. And I’ve actually been really thrilled to learn from people who haven’t yet applied to the program that they are using this guide, this roadmap, to orchestrate their events at their organization and to set out their strategic plan to address wellbeing among the workforce.

Dr. Angela Kade Goepferd: That’s great. Well, I appreciate so many things, Chris. Your time today with us, the work that you’re doing in this space, and really, I think at the end of the day, these really practical toolkits and guidelines for people. This seems like such an overwhelming problem at the moment. I think especially when we’re in the middle of staffing crises and a Covid pandemic, and those of us in pediatrics are in the middle of a horrible kind of respiratory surge right now with RSV and influenza. And so we have so many competing priorities, but we can’t let go of the thing that got us here in the first place and let the work kind of get the better of us. And so I appreciate folks like you who are really championing this work and organizations like yours that are helping to give us some guideposts along the way for making this better. So thanks again for your work and for joining us on Talking Pediatrics.

Dr. Christine Sinsky: Thanks, Angela. It was a pleasure.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.