Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online https://clinicalcenter.nih.gov INSURING THE WELL BEING OF HEALTHCARE PROVIDERS IS NOW A PRIORITY FOCUS, NATIONALLY WITHIN THE GRADUATE NATIONAL EDUCATION COMMUNITY BASED ON IRREFUTABLE EVIDENCE THAT RESIDENTS, CLINICAL FELLOWS AND FACULTY MEMBERS ARE AT RISK FOR BURN OUT, AND DEPRESSION, POTENTIALLY LEADING TO ADVERSE PERSONAL AND PROFESSIONAL OUTCOMES. THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION HAS ACKNOWLEDGED THAT THE PSYCHOLOGICAL EMOTIONAL AND PHYSICAL WELL BEING OF TRAINEES ARE ALL CRITICAL FACTORS IN THE DEVELOPMENT OF COMPETENT, CARING AND RESILIENT PHYSICIANS. THE ACGME NOW REQUIRES TRAINING PROGRAMS AND SPONSORING INSTITUTIONS TO FOCUS ATTENTION ON QUALITY OF LIFE ISSUES BOTH INSIDE AND OUTSIDE OF MEDICINE THAT PROMOTE A SENSE OF FULFILLMENT AND JOY IN THE PRACTICE OF MEDICINE WHILE EFFECTIVELY ADDRESSING AND MANAGING REAL LIFE STRESSORS. TODAY DR. COLIN WEST WILL SPEAK ON PHYSICIAN WELL BEING FROM BURN OUT TO THRIVE NOTHING MODERN MEDICINE. DR. WEST RECEIVED BOTH HIS M. D. AND PH DEGREES FROM THE UNIVERSITY OF IOWA. HE COMPLETED HIS MEDICAL RESIDENCY AND SERVED AS CHIEF RESIDENT IN THE DEPARTMENT OF INTERNAL MEDICINE AT THE MAYO SCHOOL OF GRADUATE MEDICAL EDUCATION IN ROUGH ATOM CHESTER MINNESOTA. SUBSEQUENTLY JOINED THE MAYO CLINIC FAC ALL THEY AND GENERAL INTERNAL MEDICINE. HE CURRENTLY HOLDS APPOINTMENTS WITH PROFESSOR OF MEDICINE AND EDUCATION AND BIOSTATISTICS AT MAYO CLINIC WHERE HE DIRECTS THE EVIDENCE-BASED MEDICINE CURRICULUM FOR MAYO CLINIC SCHOOL OF MEDICINE, SERVES AS AN ASSOCIATE PROGRAM DIRECTOR OF THE MAYOR CLINIC INTERNAL MEDICINE RESIDENCY TRAINING PROGRAM AND IS THE RESEARCH CHAIR OF GENERAL INTERNAL MEDICINE IN THE DEPARTMENT OF INTERNAL MEDICINE. DR. WEST FOCUSED ON CLINICAL WELL BEING, AND DIRECTOR OF CLINICAL PHYSICIAN WELL BEING WHERE HE DOCUMENTS EPIDEMIOLOGY, CONSEQUENCES AND APPROACHES TO MITIGATING STRESS HAVE BEEN PUBLISHED WIDELY. HIS MEMBERSHIPS INCLUDE THE AMERICAN COLLEGE OF PHYSICIANS, AND THE SOCIETY FOR GENERAL INTERNAL MEDICINE AND HAS BEEN RECOGNIZED WITH THE ARTHUR RUBEN STEIN AWARD FOR LEADING WITH INTEGRITY FROM THE ARNOLD P. GOLD FOUNDATION RESEARCH INSTITUTE AND NOW, IT'S A PLEASURE TO WELCOME HIM TO THE PODIUM. [ APPLAUSE ] >> THANK YOU VERY MUCH THIS IS MY FIRST VISIT TO THIS REMARKABLE FACILITY AND I'M DELIGHTED TO BE HERE. I DON'T HAVE ANY FINANCIAL DISCLOSURES, I DO WANT TO MENTION, I AM HAPPY TO SHEAR A COPY OF MY SLIDES WITH ANYONE IN THE AUDIENCE WHO'S INTERESTED. JUST SEND ME AN E-MAIL AT THE E-MAIL LISTED OR DIRECT MESSAGE ME AT THE TWITTER HANDLE THERE, IF YOU WOULD LIKE. FOUR MAIN LEARNING OBJECTIVES FOR THIS SESSION, WE WILL TALK A BIT ABOUT THE SCOPE OF THE PROBLEM. I KNOW THAT YOU'VE SEEN THIS DATA BEFORE SO I WON'T SPEND A TON OF TIME ON THAT FIRST PART BUT IT IS IMPORTANT FOR A FOUNDATIONAL PART OF THINGS. WE WILL TALK A LITTLE BIT ABOUT WHAT WE KNOW ABOUT CONTRIBUTORS TO AND THE CONSEQUENCES OF THIS DISTRESS AND THEN WE'LL FOCUS THE LAST HALF AT LEAST OF THE TIME ON EVIDENCE-BASED INSIGHTS INTO LOCAL AND NATIONAL EFFORTS TO TRY TO MITIGATE TO STRESS AND PROMOTE WELL BEING IN THE MEDICAL PROFESSION. IF WE HAVE TIME WE'LL TALK A LITTLE BIT ABOUT HOW THIS BLENDS TO AN ENLIGHTENED LEADERSHIP APPROACH. I ALSO MENTIONED I WILL FOCUS MOST OF MY TALK HERE ON PHYSICIAN BURN OUT AND THE PHYSICIAN TRAINING PIPELINE. BUT THE ANALOGY IS CLEAR TO OTHER MEMBERS OF THE HEALTHCARE PROFESSIONS. SO FIRST, GETTING OUR DEFINITIONS STRAIGHT. ALMOST ALL OF US HAVE A COLLOQUIAL VERSION OF THE WORD BURN OUT THAT WE THROW AROUND LOOSELY FROM TIME TO TIME. WHEN WE USE BURN OUT IN OUR WORK, WE'RE BEING FAIRLY SPECIFIC, WE'RE USING A DEFINITION DEVELOPED FROM THE WORK OF CHRISTINA MAZLACK AND COLLEAGUES, BURN OUT IS A SYNDROME WITH 3 MAIN DO MAINS, DEPERSONNALLIZE IEGZ, EMOTION EXOFF THE UNION AND LOW FEELING OF ACCOMPLISHMENT THAT LEADS TO DEFECTIVENESS AT WORK. THIS IS A WORKPLACE PHENOMENON. SO WHAT ARE THESE ELEMENTS? EMOTION EXHAUSTION IS ILLUSTRATED BY 1 OF THESE QUOTES FROM THE MAZLACK BURN OUT INVENTORY HAD IS THE BEST ACCEPTED GOLD STANDARD MEASUREMENT TOOL FOR BURN OUT. I FEEL LIKE I'M AT THE END OF MY ROPE. THIS IS EMOTIONAL WEARINESS, FEELING YOU HAVE NOTHING LEFT EMOTIONALLY TO GIVE YOUR PATIENTS IN PARTICULAR IN MEDICINE. THIS IS MEASURED AS OTHER DOMAINS IN THE MAZLACK INVENTORY ARE MEASURE OFFICE OF DIVERSITY A SCALE WITH NUMBERS FROM 0 TO A CERTAIN CONTINUOUS UPPER LIMIT. FOR EASE IN COMMUNICATION, WE DICHOTOMIZE THIS BASED ON EXPERIENCING THESE SYMPTOMS AT LEAST ONCE A WEEK. DEPERSONALIZATION IS A SENSE OF BECOMING CALLOUS TOWARD THE EXPERIENCES OF OTHERS OR OBJECTIFYING OTHER HUMAN BEINGS. THIS IS A PARTICULAR INTEREST TO ME BECAUSE IT IS SO ANTITHETICAL TO THE CORE IDEALS IN MEDICINE THAT ALL OF US BEGIN OUR CAREERS ESPOUSING AND AGAIN IF THIS IS ENDORSED AT LEAST ONCE A WEEK, THAT'S CONSIDERED MEANINGFUL SYMPTOMS OF DEPERSONNALLIZATIONAISE DOMAIN OF BURN OUT. I WILL NOT SAY MUCH MORE ABOUT PERSONAL ACCOMPLISHMENT, NOT BECAUSE IT'S UNIMPORTANT BUT BECAUSE IN OUR WORK IT'S NOT LINKED AS DISTINCTLY WITH KEY OUTCOMES AND SO, FOR COMMUNICATING OVERALL SYMPTOMS OF BURN OUT, IF SOMEONE IS EXPERIENCING EITHER EMOTIONAL EXHAUSTION OR DEPERSONNALLIZATION OR BOTH AT LEAST ONCE A WEEK, THAT PERSON IS CONSIDERED TO BE EXPERIENCING MEANINGFULLY IMPACTFUL SYMPTOMS OF OVERALL BURN OUT. WE LEARNED IN RECENT YEARS THAT MEDICAL STUDENTS BEGIN MEDICAL SCHOOL ACTUALLY WITH BETTER WELL BEING THAN THEIR AGE MATCHED COLLEGE GRADUATE PEERS. THIS IS IMPORTANT BECAUSE HISTORICALLY IN MEDICAL EDUCATION, 1 OF THE MIND SETS WAS THAT WE WERE SIMPLY RECRUITING THE WRONG PEOPLE INTO THE MEDICAL PROFESSION. AND I THINK THAT IS CATEGORICALLY NOT THE RIGHT APPROACH TO BE THINKING ABOUT THIS. WE ARE TAKING VERY BRIGHT, VERY PASSIONATE, VERY DEDICATED INDIVIDUALS AND WE ARE DOING SOMETHING WITHIN OUR SYSTEM TO CHANGE THEIR WELL BEING. THEY'RE STARTING OFF WITH LOWER BURN OUT LEVELS, LOWER RATES OF DEPRESSIVE SYMPTOMS THAN THEIR AGE MATCHED PEERS. BY THE END OF THE SECOND YEAR OF MEDICAL SCHOOL AND CERTAINLY BY THE END OF THE THIRD YEAR OF MEDICAL SCHOOL, THESE PADERNS HAVE FLIPPED. AND NOW OUR MEDICAL STUDENT VS HIGHER RATES OF BURN OUT SYMPTOMS AND HIGHER RATES OF DEPRESSIVICISMATTOLOGY, QUAL OF LIFE IN EVERY DOMAIN FOLLOWS THE SAME SCRIPT. AT THE START OF MEDICAL SCHOOL AND STUDENT VS BETTER QUALITY OF LIFE IN THE MENTAL QUALITY OF LIFE DOMAIN, PHYSICAL QUALITY OF LIFE DOMAIN, EMOTIONAL QUALITY OF LIFE DOMAIN AND SO ON, BUT SECOND AND THIRD YEAR OF MEDICAL SCHOOL SOMETIME IN THAT FIRST 2 OR 3 YEARS THAT REVERSES AND THEY'RE NOW WORSE THAN THEIR AGE-MATCHED PEERS. WHEN WE LOOK AT RESIDENTS, THE MOST ROBUST NATIONAL DATA COMES FROM INTERNAL MEDICINE BUT THERE HAVE BEEN REVIEWS ACROSS ALL SPECIALTIES, IN INTERNAL MEDICINE IN 2008 IN A STUDY THAT'S CURRENTLY UPDATED, THE BURN OUT RATE WAS 51%. THAT DEPERSONNALLIZATION RATE, TREATING PATIENTS AS OBJECTS, BEING CALLOUS TOWARDS THEIR EXPERIENCES AT LEAST ONCE A WEEK, NEARLY A THIRD. CERTAINLY NOT WHAT WE'RE LOOKING FOR FROM A PROFESSIONAL IDEAL STANDPOINT FOR OURSELVES OR OUR NEXT GENERATION OF COLLEAGUES AS THE PEOPLE TAKING CARE OF ALL OF OUR PATIENTS AND TAKING CARE OF US. WHEN WE LOOK AT PRACTICING PHYSICIANS, WE'VE PARTNERED WITH THE AMERICAN MEDICAL ASSOCIATION FOR A NUMBER OF YEARS NOW, THERE HAVE BEEN 3 NATIONAL SURVEYS HAVE BEEN STUDIED PUBLISHED OUT OF THIS AND WHAT I'LL NOTE HERE IS THAT IN 2011 FOCUSING ON THE RED LINE HERE, THE OVERALL BURN OUT RATE WAS ABOUT 45%, FROM 2011-2014 BURN OUT WORSENED IN EVERY DOMAIN AND THEN IN 2017 THINGS SEEMED TO DROP DOWN TO THE 2011 LEVELS. WE'RE NOT SURE EXACTLY WHY THAT IS. ONE ARGUMENT IS MAYBE PEOPLE ARE GETTING USED TO SOME OF THE CLERICAL BURDEN ELECTRONIC HEALTH RECORD SORTS OF IMPACTS ON MEDICINE AND MAYBE WE'RE ACCOMMODATING FOR THOSE BETTER BUT IT'S ALSO POSSIBLE THAT BECAUSE THESE SURVEYS REQUIRE THAT PEOPLE BE ACTIVELY PRACTICING THAT A BIG CHUNK OF OUR PHYSICIANS WHO WERE BURNED OUT ACTUALLY HAVE RETIRED OR LEFT PRACTICE. AND WE'RE STILL LOOKING TO EXPLORE THAT A LITTLE BIT MORE AND I'LL SHOW YOU DATA A BIT OR AT LEAST ALLUDE TO DATA THAT THAT'S A LIGET MATE CONCERN BECAUSE PHYSICIANS WHO ARE MORE BURN OUT ARE LIKELY TO REDUCE RETIRE EARLY. EVEN IF THE BURN OUT RATE HAD IMPROVED FROM 2014 TO 2017, THERE ARE OTHER AREAS THAT MAYBE CAUSE FOR CONCERN. SO RATE OF A POSITIVE DEPRESSION SCREEN, THESE ARE USING PRIME MD AS AN INSTRUMENT, THOSE OF YOU WORK NOTHING PSYCHIATRY AND PSYCHOLOGY WILL RECOGNIZ THIS IS NOT A RATE OF DEPRESSION, IT'S ESTIMATE THAD A QUARTER TO A THIRD OF THESE INDIVIDUALS WOULD MEET CRITERIA FOR DEPRESSION IF THEY UNDERWENT A MEDICAL EVALUATION BUT WE SEE THAT THIS RATE HAS INCREASED BY A COUPLE PERCENTAGE POINTS OVER EACH SURVEY. AND THEN FINALLY SOME OF THE OVERALL DEMOGRAPHICS. BURN OUT IS SLIGHTLY MORE COMMONLY REPORTED BY WOMEN BUT IN ABSOLUTE TERM THIS IS IS A FAIRLY MODEST DIFFERENCE, 48% VERSUS 42% IN 2017. RATES ARE HIGHER AMONG YOUNGER DOCTORS BUT THIS IS SUBJECT TO THAT SURVIVOR BIAS THAT I MENTIONED JUST A COUPLE OF MINUTES AGO, OUR OLDER PHYSICIANS MAY BE RETIRING EARLY IF THEY'RE MORE BURNED OUT, SO IT'S POSSIBLE THEY ARE UN--UNDERREPRESENTED IN SOME OF THESE DATA AND THERE IS SOME SUGGESTION THAT THERE MIGHT BE A BIT OF A J-CURVE AROUND AGE, WITH MAYBE MIDCAREER PEOPLE WITHIN THAT YOUNGER MIDCAREER ZONE BEING AT THE GREATEST RISK. FRONT LINE SPECIALTIES SUCH AS EMERGENCY MEDICINE AND PRIMARY CARE DISCIPLINES, SEEM TO BE AT HIGHER RISK IN MOST STUDIES. INCREASED NUMBER OF WORK HOURS PER WEEK PARTICULARLY AS THAT STARTS TO MOVE ABOVE 55 OR 60 HOURS A WEEK AND INTERESTINGLY PHYSICIANS WORKING IN PRIVATE PRACTICES OR PURELY INCENTIVE HAVE HIGHER RATES OF NOT JUST BURN OUT BUT OTHER DIMENSIONS OF DISTRESS. PEOPLE SOMETIMES WONDER, WELL, ISN'T THIS JUST A SOCIETAL ISSUE, IS THIS A REFLECTION OF PROBLEMS THAT ARE EFFECTING ALL OF US AND AS PHYSICIANS AREN'T WE PROTECTED? REALLY WE'RE GENERALLY WELL RESPECT INDEED SOCIETY, WE HAVE GOOD INCOMES WITH GOOD JOB SECURITY SO MAYBE PHYSICIANS ARE ACTUALLY BETTER OFF THAN THE REST OF THE SOCIETY DESPITE THESE NUMBERS. SOPHISTICATEDY WE LOOKED AT THAT œFOCUSING ON THE ROWS IN GOLD WHAT WE SEE FROM THE 2017 DATA USING AN ABBREVIATED VERSION OF THE MAZLACK BURN OUT INVENTORY, THE PHYSICIAN USING THIS TOOL WAS 40%, THE GENERAL PUBLIC WAS 28%. DISSATISFACTION WITH WORK-HOME INTERFERENCE OR WORK-LIFE BALANCE WAS TWICE AS COMMON AS AMONG PHYSICIANS AND AS AMONG THE GENERAL PUBLIC AND EVEN AFTER ADJUSTING FOR WORK HOURS THESE DIFFERENCES WERE STRONGLY STATISTICALLY SIGNIFICANT SO THERE IS SOMETHING DIFFERENT ABOUT PHYSICIANS THAN THE GENERAL POPULATION NUMBERS AROUND BURN OUT. WELL WHAT ABOUT OTHER HIGHLY TRAINED SPECIALTIES, POTENTIALLY WORKING IN JOBS THAT HAVE HIGH LEVELS OF PROFESSION DEMAND. SO AFTER ADJUSTING FOR A NUMBER OF FACTORS THAT ARE ASSOCIATED WITH BURN OUT IN THE LITERATURE AND USING HIGH SCHOOL GRADUATES AS THE REFERENCE, WE FOUND THAT THOSE ARE THE BACHELOR'S DEGREE OR A JOB THAT REQUIRES A BACHELOR'S DEGREE HAD LOWER RISK, LOWER ODDS FOR BURN OUT, THOSE ARE THE MASTERS DEGREE, THE ODDS DROPPED EVEN MORE AND THOSE WITH A DOCTORATE OR NONMEDICAL PROFESSIONAL DEGREE HAD THE LOWEST RISK OF BURN OUT. THERE WAS IN FACT ONLY 1 PROFESSIONAL GROUP AS A WHOLE THAT HAD A HIGHER RATE OF BURN OUT THAN THE GENERAL PUBLIC. AND UNFORTUNATELY IT'S THE PHYSICIANS. NOW THIS DOES NOT MEAN THAT THERE AREN'T POCKETS WITHIN OTHER PROFESSIONS WITH HIGH DEGRES OF DISTRESS AND BURN OUT, 1 OF THE THEORIES IN BURN OUT WAS THE RESOURCE MODEL OR JOB DEMAND RESOURCE MODEL THAT WHICH SUGGESTS THAT BURN OUT AT WORK RESULT WHEN IS THE DEMANDS OF THE JOB CHRONICALLY OUTSTRIP THE RESOURCES AVAILABLE FOR IT. AND BY THAT DISCIPLINARY DYNAMIC THERE ARE CERTAINLY PROFESSIONS WE COULD ALL THINK OF WHERE THE DEMANDS CHRONICALLY OUTSTRIP THE RESOURCES. ONE THAT COMES TO MIND FOR ME, NO DATA TO MY KNOWLEDGE THIS HAS EVER BEEN STUDIED BUT PUBLIC DEFENDERS IN THE LEGAL PROFESSION, SO LAWYERS AS A WHOLE HAVE A LOWER BURN OUT RATE THAN PHYSICIANS. THE PUBLIC DEFENDERS TYPICALLY VERY HIGH CASE LOADS, RELATIVELY UNDERRESOURCED I WOULD PREDICT THEY HAVE VERY HIGH BURN OUT RATES BUT AGAIN, NEVER BEEN LOOKED AT. WHY DOES THIS MATTER? OKAY, PHYSICIANS HAVE HIGHER BURN OUT RATES, IT'S DIFFERENT THAN OTHER HIGHLY TRAIN PROFESSIONALS BUT YOU KNOW AGAIN WE'RE COMPENSATED REASONABLY WELL, WE ARE RESPECT INDEED SOCIETY, WE BUILD GOOD LIVES FOR OURSELVES AND OUR FAMILIES. WHY DOES IT MATTER. WELL IT MATTERS BECAUSE NO MATTER WHICH STAKEHOLDER YOU'RE MOST INTERESTED IN, THERE'S AN IMPACT AND A CONSEQUENCE THAT'S ADVERSE. SO FROM A PATIENT STANDPOINT, MEDICAL ERRORS IMPAIRED PROFESSIONAL BEHAVIORS AND REDUCED PATIENT SATISFACTION HAVE BEEN LINKED WITH BURN OUT. FROM AN ACCESS STANDPOINT AND FROM AN INTEGRITY OF OUR HEALTHCARE SYSTEM STANDPOINT, STAFF TURNOVER AND REDUCED HOURS ARE LINKED SO PHYSICIANS ARE MARKEDLY TO GO DOWN IN FTE, SWITCH JOBS OR RETIRE FROM MEDICINE ALTOGETHER IF THEY'RE DEALING WITH BURN OUT. MENTAL HEALTH CONCERNS AMONG PHYSICIANS WITH DEPRESSION AND SUICIDAL IDEATION AND EVEN PUBLIC SAFETY ISSUES WE'VE STUDIED INTERNAL MEDICINE AT MAYO THAT RESIDENTS WITH BURN OUT EVEN AFTER ADJUSTING WITH FATIGUE WERE MORE LIKELY TO BE INVOLVED IN MOTORCYCLE VASHS OR NEAR MISS INCIDENTS. IN TOTAL THIS HAS BEEN ESTIMATED TO COST AT LEAST 4.6 BILLION DOLLARS A YEAR TOWARD OUR HEALTHCARE SYSTEM, JUST FROM PHYSICIAN BURN OUT ALONE USING FAIRLY CONSERVATIVE MODELING PARAMETERS FROM A STUDY THAT WAS RECENTLY PUBLISHED IN COLLABORATION WITH THE HARVARD BUSINESS SCHOOL. SO, THIS SHAKES OUT TO AN INDIVIDUAL PHYSICIAN IN A PRACTICE THAT'S SOMEWHERE IN THE NEIGHBORHOOD OF 6 OR $7000 A YEAR PER PRACTICING PHYSICIAN IN THIS COUNTRY AS A COST OF BURN OUT AT BASE LINE TODAY. THAT 4.6 BILLION DOLLARS OF COSTS DOESN'T APPEAR IN ANY LINE ITEM OR ECONOMIC ANALYSIS IN OUR HEALTHCARE SYSTEM AT THIS POINT. SO WE'RE JUST WATCHING THAT MONEY GO AWAY WITHOUT ACCOUNTING FOR IT BUT IT ALSO SUGGESTS THERE'S POTENTIAL FOR RETURN ON INVESTMENT FROM EFFORTS TO IMPROVE THINGS AND CONVERT PEOPLE FROM BURN OUT OVER INTO BEING MORE ENGAGED, THRIVING, FLOURISHING DERIVING MEANING FROM THEIR WORK. SO I CAST THIS AS A PUBLIC HEALTH CRISIS BECAUSE OF THESE IMPACTS AND BECAUSE OF THE MAGNITUDE OF THE ISSUE SO WHEN WE THINK ABOUT THE BURN OUT PREVALENCE DATA THAT'S OUT THERE WE HAVE MORE THAN 40,000 MEDICAL STUDENTS IN IN COUNTRY AT ANY 1 TIME DEALING WITH SYMPTOMS OF BURN OUT, MORE THAN 60,000 RESIDENTS AND FELLOWS AND NEARLY HALF A MILLION PHYSICIANS. THAT'S NOT EVEN COUNTING DATA ON NURSES OR OTHER HEALTHCARE PROFESSIONALS. THERE ARE MORE THAN 3 MILLION NURSES IN THIS COUNTRY AND EVEN THOUGH THEIR BURN OUT RATE SEEMS TO BE LOWER THAN THE BURN OUT RATE AVERAGE AMONG PHYSICIANS, IF ONLY 30% OF NURSE US ARE EXPERIENCING SYMPTOMS OF BURN OUT WE'RE TALKING ABOUT A MILLION NURSES DEALING WITH THESE ISSUES. WITH LIKELY SIMILAR POTENTIAL CONSEQUENCES FOR OUR PATIENTS AND FOR OUR HEALTHCARE SYSTEM. THE OTHER POINT TO THIS IS, WHEN DEALING WITH THESE KINDS OF PREVALENCE NUMBERS, IS THIS A PROBLEM THAT'S ROOTED IN OUR INDIVIDUAL'S PRIMARILY OR IS IT ROOTED IN OUR SYSTEM. AND I THINK THIS BECOMES A RHETORICAL QUESTION WHEN WE'RE TALKING ABOUT PREVALENCE DATA THAT'S THIS EXTREME. NOW THERE IS A ROADMAP TO START THINKING ABOUT SOLUTIONS FOR SYSTEM PROBLEMS LIKE THIS. AND ABOUT 20 YEARS AGO TO ERR IS HUMAN CAME OUT AND THINK ABOUT HOW WE CHANGE WITH PATIENT SAFETY. LIKE MANY PARADIGM SHIFTS IT WAS RETROSPECTIVE AND OBVIOUS ABOUT WHY WEREN'T WE THINKING THIS WAY BEFORE BUT TO ERR IS HUMAN RECOGNIZE THAT ERRORS IN PATIENT SAFETY WAS AT HEART LARGELY A SYSTEM RESPONSIBILITY. CERTAINLY THERE IS INDIVIDUAL RESPONSIBILITY TO PROVIDE GOOD CARE, TO BE PROFESSIONAL BUT THE SYSTEMS WERE NOT ALLOWING PEOPLE TO FUNCTION AT THEIR BEST. AND DARYL KIRCH, THE PAST PRESIDENT OF THE AAMC HAS CAST THIS AS TO CARE IS HUMAN, WITH THE IDEA THAT THE SAME ANALOGY APPLIES. WE HAVE WELL MEANING PASSIONATE DEDICATED PEOPLE WHO ALL TOO OFTEN WORK IN A SYSTEM THAT DOES NOT ALLOW THEM TO MEET THEIR FULLEST EXPECTED INTERNAL POTENTIAL FOR THE BENEFIT OF THE PEOPLE THAT THEY'RE TRYING TO HELP. PAUL BATALDEN SAID EVERY SYSTEM IS DESIGNED TO GET THE RESULTS IT GETS. OUR SYSTEM IS PERFECTLY DESIGNED TO LEAD TO THE DISTRESS OR FLOURISHING THAT WE GET. AND IF WE'RE NOT GETTING THE OUTCOMES THAT WE WANT, THEN WE NEED TO REDESIGN OUR SYSTEM. SO WHAT DO WE KNOW ABOUT THE DRIVERS THAT COULD HELP US THINK ABOUT HO WE MIGHT REDESIGN OUR SYSTEMS. SO FOR ALL OF THESE, IF WE TAKE THEM IN THE WRONG DIRECTION, WE GET BURN OUT, WE GET DISENGAGEMENT, WE GET CYNICISM, WE GET DISTRESS, BUT IF WE CAN TURN THESE AROUND MORE POSITIVELY SO THIS ISN'T A GLOOM AND DOOM TALK, THIS IS A OKAY, LET'S LEARN FROM WHAT'S NOT GOING GREAT AND BEND THIS BACK IN THE RIGHT DIRECTION, THEN WE CAN SHIFT TOWARDS ENGAGEMENT FLOURISHING, THRIVING, PERHAPS EVEN TO SOME EXTENT AS THE AMA HAS TRIED TO PROPOSE SOME DEGREE OF JOY IN OUR PRACTICE. SO WHAT ARE THESE DRIVERS? WELL, WORK LOAD AND JOB DEMANDS WE'VE ALREADY MENTIONED BRIEFLY, CONTROL AND FLEXIBILITY. SO DO WE HAVE AUTONOMY IN OUR WORK DAY, NOT THAT THIS IS A LIBERTARIAN WE GET TO DO EVERYTHING WE WANT EVERY MINUTE OF EVERY DAY BUT DO WE HAVE A SAY OR ARE WE DONE, TOO. WORK LIFE INTEGRATION, SO WE ALL HAVE LIVES OUTSIDE OF MEDICINE ALTHOUGH BEING A PHYSICIAN TENDS TO BE PART OF THE FABRIC OF WHO WE ARE AWZ PEOPLE WE HAVE LIVES OUTSIDE OF THESE WALLS. SO HOW DOES THAT INTEGRATE WITH OUR WORK RESPONSIBILITIES? IS THAT RESPECTED? IF WE NEED TO TAKE THE KIDS TO DAY CARE AND NEED SOME FLEXIBILITY IN OUR MORNINGS OR IN OUR AFTERNOONS OR THERE'S A BIG SOCCER GAME OR THERE'S SOMETHING ELSE GOING ON IN THE FAMILY, WHAT'S THE FLEXIBILITY AROUND THAT, OR DOES WORK ALWAYS COME FIRST. EFFICIENCY AND RESOURCES SO IN OUR JOBS AS PHYSICIANS ARE WE ALLOWED TO FOCUS ON WHAT WE'RE REALLY AND UNIQUELY GOOD AT? I'M A GENERAL INTERNIST, MY UNIQUE PROCEDURAL SKILL IS BEING A DIAGNOSTICIAN, I SEE REFERRED COMPLEX PATIENTS FROM ALL OVER THE WORLD NOT DISSIMILAR TO MANY RESEARCH PATIENTS THAT YOU WILL SEE. OTHER PRACTICES, OTHER PHYSICIANS HAVE DIFFERENT FOCAL POINTS BUT A LOT OF THE CLERICAL BURDENS IN MEDICINE, WHAT MARK LINDSAY DRAPERROR OF HENNEPIN COUNTY SAID THE HASSLE FACTOR, DISTRACT FROM OUR ABILITY TO PROVIDE THAT CORE SKILL TO OUR PATIENTS. ORGANIZATIONAL CULTURE IS IMPORTANT, THIS IS NOT JUST ABOUT THE HIDDEN CURRICULUM THAT LEARNERS EXPERIENCE AS THEY WALK THE CORRIDORS, THIS IS ABOUT A PRACTICING PHYSICIAN LEVEL AT A RESEARCH SCIENTIST LEVEL IS LEADERSHIP'S VALUES ALIGNED WITH THE VALUES OF THE EMPLOYEES? ARE LEADERSHIP STATED VALUES ALIGNED WITHED WELLERSHIP ACTIONS, THOSE ARE IMPORTANT TO LOOK THROUGH. SOCIAL SUPPORT COMMUNITY AT WORK, I WILL SAY MORE ABOUT IN A FEW MINUTES AND ALL OF THIS IS BUILT AROUND WHAT I THINK IS THE HUB OF ALL OF THE WELL BEING FACTORS. MEANING, VALUES AND PURPOSE. SO THE MVPs FOR WELL BEING ARE MEANING, VALUES AND PURPOSE FOR PHYSICIANS. SO HOW DO WE PRIORITIZE THOSE BOTH INDIVIDUALLY AND ORGANIZATIONALLY TO PROMOTE FLOURISHING IN OUR CAREERS. THIS IS AN ILLUSTRATION OF THE POTENTIAL FOR HASSLE FACTORS IN OUR PRACTICES, SO, THIS IS A STUDY FROM ANALs OF INTERNAL MEDICINE PUBLISHED LAST YEAR LOOKING AT THE LENGTH OF U.S. NOTES FOR A BASIC AMBULATORY CONDITIONS, COMPARED WITH THE LENGTH OF NOTES IN OTHER COUNTRIES. AND THEY LOOKED AT, I THINK 13 OR 14 INTERNATIONAL CLINICS, THEY LOOKED AT 60 OR 70 U.S. CLINICS AND FOR A LANDFUL OF STANDARD AMBULATORY PRESENTING CONCERNS, LOOKEDDA THE CHARACTER LENGTH OF THE DOCUMENTATION. AND THERE ARE A COUPLE OF INTERESTING POINTS ABOUT THIS SLIDE. FIRST OF ALL, YOU WILL NOTICE THAT THE NOTE LENGTH FOR THE INTERNATIONAL CLINICS ON AVERAGE OF MARKEDLY LESS THAN THE NOTE LENGTH FOR THE U.S. CLINICS. THE AVERAGE FOR U.S. CLINICS WAS SOMEWHERE IN THE 4000 CHARACTERS LENGTH. THE AVERAGE WAS ABOUT 1500 CHARACTERS FOR THE INTERNATIONAL CLINICS. A SECOND POINT HERE THAT I THINK WAS INTERESTING IS THAT THERE WAS ABSOLUTELY NO OVERLAP IN THE AVERAGE LENGTHS ACROSS THESE CLINICS ISSUES THERE WAS AN INTERNATIONAL CLINIC, TOP LENGTH INTERNATIONAL CLINIC WAS JUST SHY OF 2000 CHARACTERS, THE SHORTEST IN THE U.S. CLINIC WAS JUST OVER 2000 CHARACTERS. WE WOULD ACCEPT THIS PERHAPS IF WE COULD SHOW THAT AMBULATORY OUTCOMES OR AMBULATORY COMPLAINTS, OUR OUTCOMES WERE BETTER IN OUR U.S. CLINICS. BUT MOST OF US ARE AWARE THAT THE LITERATURE DOES NOT SUPPORT OUR OUTCOMES ARE BETTER FOR THESE AMBULATORY COMPLAINTS. SO IF WE DON'T HAVE BETTER OUTCOMES, AND THERE'S NO EVIDENCE THAT FOR THESE AMBULATORY COMPLAINTS THAT OUR PATIENTS OR MORE COMP LITICATED THAN THESE PATIENTS IN THE INTERNATIONAL CLINICS THEN REALLY WHAT'S THE PURPOSE OF THIS EXTRA CHARACTER LENGTH. IT'S NOT HELPING PATIENS SO WHY ARE WE DOING IT, THIS IS AN EXAMPLE OF UNDUE CLERICAL BURDEN, EXCESS HASSLE FACTOR IN OUR MEDICAL PRACTICES. AND SO, AS THIS ADDS UP FOR AMBULATORY VISITS, VISIT AFTER VISIT, IT'S BEEN TERMED DEATH BY A THOUSAND CLICKS, IT DOES ADD UP TO LEAD TO DISTRESS BUT IT'S FIXABLE. AND THE AMA HAS BEEN WORKING ON EFFORTS WITH OTHERS AROUND THE COUNTRY TO TRY AND IMPROVE INTERACTIONS WITH OUR SYSTEMS SO THAT WE'RE PROVIDING THE RIGHT LEVEL OF DOCUMENTATION TO PROMOTE PATIENT CARE BUT NOT MORE THAN IS NECESSARY. SO I'VE MENTIONED INDIVIDUAL AND ORGANIZATIONAL STRATEGIES AND A LARGE LEVEL THIS IS MORE A SYSTEM PROBLEM THAN AN INDIVIDUAL PROBLEM. THAT SAID, THERE ARE IMPORTANT INDIVIDUAL STRATEGIES IN DEALING WITH WHAT WILL ALWAYS BE A STRESSFUL PROFESSION. AND SO IN BROAD STROKES WHAT ARE SOME OF THESE STRATEGIES SO IDENTIFYING OUR OWN PERSONAL VALUE SYSTEM IMPORTANT. IT'S REMARKABLE HOW OFTEN IN MEDICINE WE DON'T ACTUALLY EACH TAKE A MOMENT TO REFLECT WHY WE'RE HERE, WHY DO WE DO WHAT WE DO? GO BACK AND FOR THOSE OF YOU THAT ARE YOU KNOW PHYSICIANS, GO BACK AND LOOK AT YOUR MEDICAL SCHOOL PERSONAL STATEMENT. OR YOUR RESIDENCY PERSONAL STATEMENT, IS THE PERSON WHO WROTE THAT STATEMENT OR THE PERSON WHO SHOWS THROUGH IN THAT STATEMENT, WOULD THAT PERSON RECOGNIZE WHO YOU ARE TODAY IN YOUR PRACTICES AND WHAT YOU VALUE? HOPEFULLY YES, BUT WE DON'T REFLECT ON THAT VERY OFTEN. OPTIMIZING MEANING AND WORK AS WE TALKED ABOUT AND NURTURING PERSONAL WELLNESS ACTIVITIES RECOGNIZING THESE WILL LOOK DIFFERENT FOR EVERY INDIVIDUAL PERSON. FOR SOME PEOPLE YOGA IS A VERY IMPORTANT CENTERING ACTIVITY, FOR OTHER PEOPLE IT'S NOT RELEVANT AND THAT'S OKAY. BUT IT'S IMPORTANT THAT EVERYBODY HAS THE OPPORTUNITY TO THINK ABOUT WHAT PROMOTES THEIR OWN WELLNESS FROM AN INDIVIDUAL STANDPOINT. WE'RE FAMOUS IN MEDICINE FOR PUTTING OFF BENEFITS. FIFTY% OF RESIDENTS IN A STUDY CONDUCTED BY [INDISCERNIBLE] WHEN SHE WAS AT HOPKINS, SHE'S NOW AT UCSF REPORT WHAD THEY TERMED A SURVIVAL ATTITUDE, PUTTING THEIR LIFE ON HOLD UNTIL THEY COMPLETE L RESIDENCY. A STUDY THAT MY COLLEAGUE TATE SHANNEN FELLED FOUND THAT 37% OF PRACTICE RESEARCH IT-SHERLOCKING ONCOLOGY THAT LOOKING FORWARD TO RETIREMENT WAS NOT JUST A PROMOTION STAT EDGY BUT AN ESSENTIAL WELLNESS PROMOTION STRATEGY. NOW, WHAT'S STRIKING ABOUT THESE DATA IS THAT THAT 37% WAS EXACTLY THE SAME FOR ONCOLOGISTS THAT WERE THEIR FIRST 5 YEARS OUT OF FELLOWSHIP. SO WE NEED OUR PHYSICIANS TO BE ENGAGED IN THEIR CAREERS FOR 2, 3, 4, DECADES. I'M NOT SURE YOU CAN SEE THE TIMELINE OUT TO ITS CONCLUSION AT 3 OR 4 DECADES IF FROM DAY 1 WE'RE LOOKING FORWARD TO RETIREMENT AS AN ESSENTIAL WELLNESS PROMOTION STRATEGY. SO THAT'S GOTTA GET REFRAMED INDIVIDUALLY AND ORGANIZATIONALLY SO THAT WE'RE NOT LOOKING FOR AN ESCAPE HATCH FROM THE BEGINNING. IF WE'RE GOING TO TALK ABOUT INDIVIDUAL STRATEGIES WE HAVE TO BE ABLE TO RECOGNIZE DISTRESS, SOPHISTICATEDY THERE'S BEEN A FAIR BIT OF WORK ON THIS IN THE LAST FEW YEARS, THERE'S WELL BEING INDICES THAT MY COLLEAGUE HAS DEVELOPED, TOOLS AROUND SUICIDE PREVENTION, DEPRESSION AWARENESS AND MODULES THROUGH THE AMA. THE WELL BEING INDEX IS INTERESTING BECAUSE THESE ARE 7 OR 9 ITEM TOOLS, THEY'VE BEEN STUDIED IN THOUSANDS OF INDIVIDUALS AND THEY'RE RELEVANT BECAUSE AS PHYSICIANS WE'RE NOT VERY GOOD AT EVALUATING WHY WE ARE IN OUR DISTRESS, SO FROM A LARGE STUDY OF SURGEONS JUST TO GIVE YOU AN EXAMPLE, 89% OF THEIR WELL BEING AS BETTER THAN AVERAGE OF THEIR PEERS. SO MATHEMATICALLY THAT DOESN'T WORK. NOW I'M IN MINNESOTA IN THE LAKE TERRITORY WHERE EVERYONE'S ABOVE AVERAGE BUT IT'S NOT STATISTICALLY POSSIBLE, YOU DON'T NEED MY Ph.D. IN BIOSTATISTICS TO KNOW THAT 89% OF SURGEONS CAN'T BE ABOVE AVERAGE IN WELL BEING, EVEN MORE CONCERNS, 70% OF THE PRACTICING SURGEONS WHO WERE IN THE BOTTOM 30% BY THE WELL BEING METRICS THOUGHT THEY WERE ABOVE AVERAGE. DID EMPLOY SO THERE'S A SKEWED INTERNAL REFLECTION ON WHERE WE ARE. THESE TOOLS HELP PEOPLE BY PROMPTING THEM WITH DASHBOARDS LIKE THIS. SO THIS IS AN EXAMPLE, THE WEBSITE IS HERE FOR INDIVIDUAL USE. I HAVE NO CONNECTION WITH THIS INDEX BY THE WAY. BUT FOR INDIVIDUAL USE THIS TOOL IS FREE. YOU HAVE YOUR OWN PASSWORD, YOU HAVE YOUR OWN LOG-IN, YOU GET YOUR OWN DATA, NO 1 ELSE SEES IT AND IT'S FREE FOR YOU TO USE AS AN INDIVIDUAL SO YOU CAN PLAY AROUND WITH IT BUT YOU FILL OUT THESE 7 OR 9 QUESTIONS, THEY'RE VERY BRIEF, TAKES LESS THAN A MINUTE FOR MOST PEOPLE, AND THEN IT WILL TELL YOU HOW YOUR NUMBERS COMPARE WITH THE APPROPRIATE PEER GROUP BASED ON NATIONAL DATA AND YOU CAN MAKE YOUR OWN JUDGMENTS ABOUT IF THERE'S ANY CHANGE THAT MIGHT BE PROMPTED BY THAT. AND THIS CAN BE TRACKED OVER TIME AS WELL. LET'S SAY YOU DECIDE TO INITIATE SOMETHING, YOU GO TO A MINDFULNESS BASED STRESS REDUCTION SERIES, YOU TAKE A LEADERSHIP POSITION TO MOVE ORGANIZATIONAL CHANGE FORWARD. AND YOU WANT TO SEE HOW THAT'S EFFECTING YOUR WELL BEING POSITIVELY OR MAYBE NEGATIVELY. YOU CAN TRACK THAT. THERE IS HOWEVER RISK OF AN EXCLUSIVELY INDIVIDUAL FOCUS. I'M CERTAINLY NOT ANTIINDIVIDUAL FOCUS, IT'S AN IMPORTANT FOUNDATIONAL ELEMENT BUT IF IT'S THE ONLY ELEMENT THAT PEOPLE SEE, THERE'S A CONCERN THAT THIS MIGHT DEEPEN CYNICISM BY SENDING THE MESS THAJ WE INDIVIDUALLY JUST HAVE TO GET TOUGHER. AND IN ESSENCE THAT'S BLAMING THE VICTIMS OF A SYSTEM THAT HAS ESTABLISHED A CULTURE THAT'S UNHEALTHY AND WE HAVE TO MOVE PAST THAT. SO WHAT CAN ORGANIZE NIEGZATIONS AND SYSTEMS DO, THEY HAVE TO BE CONGRUENT, SO THE PLAQUE OR THE MISSION STATEMENT HAS TO BE SOMETHING WALKING THE HALLS, SOMETHING THAT PEOPLE WALKING THE HALLS CAN ENDORSE AND THEY CAN SEE AROUND THEM. RESOURCES TO PROMOTE EFFICIENCY ARE CRUCIAL, FLEXIBILITY AND INPUT, ENGAGEMENT IS CRUCIAL SO WHEN WE TALK ABOUT DEVELOPING SOLUTIONS, TOP DOWN LEADERSHIP APPROACHES ARE NOT AS IDEAL AS LEADERSHIP FACILITATING SOLUTIONS AND LEADING PEOPLE AT THE GROUND LEVELS ACTUALLY DOING THE WORK THAT'S LEADING TO DISTRESS OR CONTRIBUTING OR PART OF DISTRESS, THEY'LL TELL YOU WHAT THEY NEED, THEY NEED LEADERS TO FACILITATE THAT. WORK HOME INTEGRATION, WE TALKED ABOUT IN ALL OF THIS WITH AN ULTIMATE GOAL OF PROMOTING MEANING AND WORK. WE'VE PUBLISHED ON ORGANIZATIONAL STRATEGIES TO GUIDE INSTITUTIONS. THESE ARE ASPIRATIONAL. WE'RE NOT DOING ALL OF THEM WELL AT MAYO, NO INSTITUTION IS DOING ALL OF THESE WELL BUT ACKNOWLEDGING AND ASSESSING THE PROBLEM IS THE FIRST STEP, SO PUTTING OUR HEADS IN THE SAND AND SAYING THAT'S 2 BIG A PROBLEM, WE DON'T KNOW WHERE TO START WE'LL JUST TALK ABOUT IT THAT DOESN'T WORK, PRETENDING THAT YOU'RE ALREADY GREAT. TEMPTATION AT REALLY RENOWNED MEDICAL CENTERS, BUT WHAT IF YOU'RE NOT, HOW DO YOU KNOW IF YOU DON'T ASK. SO ACKNOWLEDGING AND ASSESSING THESE ISSUES THAT ARE NATIONALLY PREVALENT IS IMPORTANT. LEADERSHIPS CRUCIAL, CULTIVATING COMMUNITY AT WORK, FLEXIBILITY, YOU SEE A LOT OF OVERLAP HERE AND AS WE TALK ABOUT ORGANIZATIONAL APPROACHES OR SOLUTIONS, WE NEED ORGANIZATIONAL SCIENCE, I AM NOT AN ORGANIZATIONAL SCIENCE EXPERT, THAT'S A FIELD THAT IS GROWING AND WE NEED MORE OF THAT INPUT TO GUIDE US ON SOLUTIONS FOR THE BENEFIT OF OUR ENTIRE HEALTHCARE SYSTEM. WHEN WE LOOK AT THE EVIDENCE IN TOTAL, THERE HAVE BEEN A COUPLE OF SYSTEMATIC REVIEWS ON THIS, WE PUBLISHED 1 IN LANCIT IN 2016. [INDISCERNIBLE] PUBLISHED 1 A YEAR LATER IN JAMA INTERNAL MEDICINE, BOTH GAME VERY SIMILAR RESULTS OURS WAS COMMISSIONED BY THE GOLD FOUNDATION, WE FOUND 52 INTERVENTION STUDIES. IN THE 2 OR 3 YEARS SINCE THIS STUDY WAS PUBLISHED THERE HAVE BEEN MANY MORE INTERVENTION STUDIES. WHAT WE FOUND AND FOCUS ON THE RATES DATA RATHER THAN THE ABSOLUTE POINT SCORES WAS THAT OVERALL INTERVENTIONS IMPROVED EMOTIONAL EXHAUSTION BY 14 ABSOLUTE PERCENTAGE POINTS. DEPERSONALIZATION SHOWED SOMEWHAT MORE MODEST IMPROVEMENT BUT WAS STILL STATISTICALLY SIGNIFICANT AND OVERALL THESE INTERVENTIONS COULD REDUCE BURN OUT BY 10 ABSOLUTE PERCENTAGE POINTS. ALL OF THESE INTERVENTIONS, EXPECTATIONS SENTIALLY ALL OF THEM WERE INDIVIDUAL IN NATURE, MEANING THEY WERE 1 STRATEGY EMPLOYEDAD A TIME. SO WE DON'T HAVE LITERATURE ON HOW DO THESE SUPPLEMENT 1 ANOTHER. CAN WE IMPROVE BURN OUT 15, 20, 25% BY LAYERING A FULL MENU OF SOLUTIONS? AND BRINGING THAT TO BEAR FOR OUR HEALTHCARE PROFESSIONALS. THE BENEFITS WERE SIMILAR FOR INDIVIDUAL FOCUSED AND STRUCTURAL INTERVENTIONS, THERE'S SOME SUGGESTION THAT STRUCTURAL INTERVENTIONS OR ORGANIZATIONS MAY BE SOMEWHAT MORE BENEFICIAL SO WE NEED TO DO MORE WORK IN THOSE AREAS BUT WE NEED BOTH. SO WHAT ARE THESE INTERVENTIONS THAT HAVE BEEN SHOWN IN THE LITERATURE, MANY OF THEM YOU WILL BE FAMILIAR WITH, I KNOW THERE'S ACTIVITY GOING ON HERE ALREADY. MEDITATION TECHNIQUES, MINDFULNESS STRESS REDUCTION, COMMUNICATION KILLS TRAINING AND CURRICULA THAT ARE BUILT AROUND COMMUNITY, CONNECTIVENESS AND MEANING. IT'S VERY COMMON FOR PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS DESPITE BEING SURROUNDED BY HUNDREDS OF LIKE MINDED COLLEAGUES TO FEEL ISOLATED AND ALONE. SO HOW HAS A SYSTEM DO WE HELP PEOPLE REMIND EACH OTHER AND HELP OUR LEADERS DEMONSTRATE THAT WE HAVE A SHARED PURPOSE AND THAT WE SUPPORT EACH OTHER AND OUR SYSTEM SUPPORTS US. AND SO THAT'S REALLY WHAT A COUPLE OF MAYO STUDIES HAVE FOCUSED ON THAT I'LL TALK ABOUT IN A FEW MOMENTS. THE STRUCTURAL INTERVENTIONS HAVE BEEN HARDER TO STUDY. AGAIN, THIS GETS TO THE ORGANIZATIONAL SCIENCE NEED. DUTY HOUR REQUIREMENTS HAVE HAD PRETTY CLEAR BENEFIT ON FATIGUE. SOMEWHAT MORE MODEST BENEFIT ON WELL BEING FOR OUR TRAINEES AND UNCLEAR BUT POSSIBLY NEGATIVE IMPACT ON OTHERS IN OUR HEALTHCARE PROFESSIONS WHO DON'T HAVE DUTY HOUR REQUIREMENTS OR LIMITATIONS. SHORTER ATTENDING ROTATIONS HAD BEEN DEMONSTRATED TO REDUCE BURN OUT FOR ATTENDING PHYSICIANS, PARTICULARLY IN ICU SETTINGS, BUT OF COURSE THERE'S A LIMIT HERE BECAUSE IF YOU REDUCE THE ICU ROTATIONS TO TOO SHORT A LEVEL THEN THERE MAY BE TOO MUCH OF A COMING AND GOING DISTRACTION, TOO MANY HANDOFFS AND AN INABILITY EVALUATE LEARNERS ON TEAMS ADEQUATELY. SO IF AS AN ATTENDING I'M ONLY ON SERVICE FOR HALF A WEEK AT A TIME, AND MY LEARNERS HAVE THEIR OWN DUTY HOUR REQUIREMENTS I MIGHT ONLY INTERACT WITH A LEARNER FOR 12 HOURS, IS THAT ENOUGH TIME TO PROVIDE A MEANINGFUL EVALUATION? ON THE OTHER HAND WHEN I WAS IN MEDICAL SCHOOL OUR ATTENDINGS MONTH AT A TIME. WELL, THERE'S EVIDENCE THAT A MONTH AT A TIME ON A SERVICE INCREASES BURN OUT TO RELATIVE SAY WOWEEKS OR 1 WEEK SORE FINDING THE RIGHT BALANCE THERE CAN BE TRICKY. LOCALLY DEVELOPED PRACTICE INTERVENTIONS ARE IMPORTANT. I MENTIONED MARK WINDSOR AT HENNEPIN COUNTY EARLIER HE HAS CHAMPIONS THESE PRACTICE INTERVENTIONS IN THE COMMUNITY. AND THE INTERVENTIONS HERE REALLY REVOLVE AROUND A MENU OF SOLUTIONS THAT ARE DEVELOPED BY THE HEALTHCARE PROFESSIONALS IN A PRACTICE THEMSELVES. SO IT'S DIFFERENT FROM PRACTICE TO PRACTICE. THE LEADERS AT THE INSTITUTIONS IN MARK'S STUDIES HAVE BEEN RESPONSIBLE FOR FACILITATING RESOURCES TO ALLOW THE CHOSEN INTERVENTIONS TO MOVE FORWARD. SO THEY HAVE TO BE REASONABLY FEASIBLE, BUT WITHIN THOSE FEASIBILITY BOUNDS, EXCUSE ME, THE LEADERS JOB IS TO FACILITATE ACTIVATION OF THOSE POTENTIAL SOLUTIONS AND WHAT DR. LINDSAY DRAPERROR HAS SHOWN IN A COUPLE OF STUDY SYSTEM THAT BURN OUT RATES AND SATISFACTION AT WORK RATES IMPROVE FAIRLY DRAMATICALLY IN CLINICS THAT ARE ABLE TO LOCALLY DEVELOP THESE SOLUTIONS. IT MODELS ENGAGEMENT AS PART OF THE SOLUTION. LOOKING AT OUR STUDIES AROUND CONNECTEDNESS, COMMUNITY AND MEANING, WE FOUND THAT IN A FACILITATED SMALL GROUP ENTERVENTION THIS IS 6-10 WITH A TRAINED FACILITATOR A SMALL PROTECTED AMOUNT OF TIME FOR ALLOWING THEM TO MEET FOR AN HOUR EVERY OTHER WEEK FOR 9 MONTHS LED TO IMPROVED MEAN FREE RADICALS GENERATED WORK AND REDUCED BURN OUT RATES. WE WENT TO OUR INSTITUTIONAL LEADERSHIP AND SAID, YOU KNOW THERE'S A SMALL COST TO THIS BECAUSE YOU'RE TALKING ABOUT AN HOUR A WEEK AWAY FROM PATIENT CARE DUTIES. BUT IT'S GOT BENEFIT FOR WELL BEING. AND OUR LEADERSHIP SAID, WE'RE CONCERNED ABOUT PATIENT ACCESS, BUT, WE WILL COMMIT RIGHT NOW TO SUPPORTING THIS IF A MORE EFFICIENT APPROACH WON'T WORK. BUT CAN YOU TEST A MORE EFFICIENT APPROACH THAT MAINTAINS PATIENT ACCESS? SO RATHER THAN GIVING PHYSICIANS MORE TIME CAN YOU MAKE THINGS MORE FLEXIBLE, MAYBE PAY FOR MEALS OR SOMETHING LIKE THAT AND IF DOESN'T WORK WE WILL PAY FOR THEIR TIME. AND WE THOUGHT THAT WAS A FAIR COMP PROMISE. SO THE FOLLOW UP STUDY TO THIS WHICH IS SHOWN ON THE SCREEN HERE ACTUALLY WORKED EVERY BIT AS WELL. SO WE HAVE A PROGRAM AT MAYO CALLED PHYSICIAN ENGAGEMENT GROUPS. THIS IS AN EXAMPLE OF BRIEF LITTLE INTRODUCTORY VIDEO WE HAVE FOR MAYO AT ALL OF OUR PHYSICIANS AND RESEARCH SCIENTISTS, THE HOPE IS TO EXPAND THIS TO ALL EMPLOYEES EVENTUALLY, BUT THESE ARE GROUPS THAT SELF-FORM AND THEY MEET EVERY OTHER WEEK FOR 6 MONTHS AT A TIME, THEY HAVE A TOPIC BASED CURRICULUM. THE TOPICS ARE AROUND ASPECTS OF THE PHYSICIAN EXPERIENCE THAT ARE FAIRLY UNIVERSAL. THE DPROWPS --GROUPS DECIDE WHICH TOPIC THEY WILL SELECT FOR THE GIVEN WEEK BUT AT LEAST FOR 15 MINUTES OF EACH SESSION, THEY WILL TALK ABOUT THAT TOPIC, THEY WILL NOT TALK ABOUT WHATIA GOING ON AT HOME, OR GRIPE ABOUT THE ELECTRONIC HEGHT RECORD, THEY WILL TALK ABOUT THE TOPIC AFTER THE FIRST 15 MINUTES THEY CAN DO WHAT THEY WANT BUT THEY WILL SPEND THAT HOUR TOGETHER AND AGAIN, THE DATA FROM THIS SUGGESTS THAT BURN OUT IMPROVED SOCIAL CONNECTION IMPROVED, MEANING FROM WORK IMPROVED. WE WENT BACK TO OUR INSTITUTIONAL LEADERSHIP AND THEY SAID WE NEED TO ROLL THIS OUT. WE HAVE 37 OR 3800 PRACTICING PHYSICIANS AND RESEARCH SCIENTISTS ACROSS THE MAYO ENTERPRISE. AT THIS POINT MORE THAN 2200 HAVE PARTICIPATED IN AT LEAST 1 OF THESE 6 MONTH PHYSICIAN ENGAGEMENT GROUP PILOTS OR SESSIONS. SO THE UPTAKE HAS BEEN QUITE GOOD. ALSO SPEAKS TO THE FACT THAT FOR THE OTHER 1600, THEY NEED OTHER ELEMENTS OF THE MENU. SO SOME SAMPLE DISCUSSION TOPICS, MEANING AND WORK, SO THINK ABOUT 1 OF YOUR MOST SATISFYING DAYS AT WORK OVER THE LAST MONTH? WHAT MADE THIS DAY SO PROFESSIONALLY SATISFYING AND SHARE WITH YOUR COLLEAGUES? SO THIS ISN'T ABOUT WALLOWING IN NEGATIVE IV THERAPY OR TALKING ABOUT EVERYTHING THAT BOTHERS US IN OUR WORK DAY BUT IT'S ALSO NOT ABOUT BEING A POLIA ANNA AND PRETENDING EVERYTHING'S WONDERFUL WE HAVE A MIX OF TOPICS BUT IT IS HELPFUL TO THINK ABOUT THE AMAZING THINGS WE DO, EVERY SINGLE DAY. WE HELP PATIENTS, WE HELP THEIR FAMILIES, WE HELP THEIR COMMUNITIES, THE RIPPLE EFFECT OF WHAT WE CONTRIBUTE TO OTHER PEOPLE'S LIVES IS SOMETHING WE DON'T GIVE OURSELVES OR OUR COLLEAGUES CREDIT FOR NEARLY ENOUGH. AND SOMETIMES HEARING IF FROM A VALUED COLLEAGUE BECAUSE WE WON'T OFTEN SHINE THAT LIGHT DIRECTLY ON OURSELVES, THAT'S CONSIDERED HUBERISTIC BUT OUR CLEEPGS CAN RECOGNIZE WHAT WE DO AND THIS PROVIDES A VENUE FOR THAT. AROUND TEAM WORK, HOW CAN YOU BRAINSTORM WAYS TO PROMOTE LIEGIALITY IN YOUR HALLWAY WHERE YOU WORK, BUT YOU WORK NEXT DOOR TO SOMEBODY BUT YOU NEVER SEE THEM. WHY? IF YOU WANT TO SEE THEM MORE, DO MANAGE ABOUT THAT AND THE GROUP CANS HELP BRAIN FORM THAT AND THEN CHOOSE A STRESSOR YOU CAN CONTROL, COME UP WITH 2 CONCRETE WAYS YOU CAN REDUCE IT, AND COMMIT TO TRYING 1 APPROACH WITHIN THE NEXT WEEK. AND THE NEAT THING ABOUT THESE GROUPS AND THEY HOLD EACH OTHER ACCOUNTABLE AND THEY MEET IN 2 WEEKS AND YOU SAID OKAY, YOU SAID YOU WOULD DO THIS IN THE NEXT WEEK, DID YOU? AND IF YOU DIDN'T OKAY, LET'S CERTAINTY YOU HOW CAN WE FIGURE OUT HOW TO GET PAST THOSE BARRIER SPECIALIZATION OF SPECIFIC ENDOTHELIAL CAN YOU PUT THIS IN PLAY, SO EVERY GROUP'S DIFFERENT, EVERY STRUCTURE'S DIFFERENT, THESE ARE SELF-FORMED. PEOPLE GET TO PICK WHO THEY WANT TO BE WITH BUT THERE'S VALUE IN IT. WHEN WE THINK ABOUT APPROACHES AND SOLUTIONS HERE, WE FOUND THAT A MATRIX LIKE THIS CAN BE HELPFUL IN ORGANIZING YOUR THOUGHTS SO THESE ARE 5 OF THOSE 7 DRIVERS IN THE HONEY KOAM DIAGRAM I SHOWED EARLIER, WORKING AND SO ON DOWN TO VALUES. THERE ARE INDIVIDUAL FOCUSED SOLUTIONS FOR EACH OF THESE. AND THERE ARE ORGANIZATIONAL SOLUTIONS. AND SO, IN YOUR LOCAL WORK UNIT OR IN YOUR ACADEMIC ENVIRONMENT, YOU CAN THINK ABOUT, WELL, WHAT'S MOST RELEVANT IN MY LOCATION? IT'S GOING TO BE DIFFERENT THAN THE LOCATION OF THE NEXT BUILDING OVER OR THE NEXT LAB OR NEXT HALLWAY BUT IN MY AREA, WHAT ARE THE ISSUES AND WHAT ARE THE POTENTIAL SOLUTIONS? AND YOU BRAINSTORM ON THIS AND YOU FILL OUT THIS MATRIX? AND IT MIGHT END UP LOOKING SOMETHING LIKE THIS, IT MIGHT LOOK DIFFERENT BUT FOR WORK LOAD AS AN INDIVIDUAL HOW CAN I CONTROL MY WORK LOAD? WELL, 1 WAY IS TO GO PART-TIME. THAT MIGHT NOT BE A VIABLE SOLUTION FOR A LOT OF PEOPLE BUT HAVING IT ON PAPER GIVES YOU SOMETHING TO THINK ABOUT. FROM AN ORGANIZATIONAL STANDPOINT HOW DO YOU CONTROL WORK LOAD AND I RECOGNIZE THINGS MAY BE DIFFERENT IN AN ENVIRONMENT LIKE THE NIH CLINICAL CENTER THAN IN A PRIVATE PRACTICE OR AT ANOTHER UNIVERSITY CENTER--SETTING, BUT IN MANY PLACES, PRODUCTIVITY TARGETS ARE SET, WELL, WHY ARE THEY SET WHERE THEY ARE SET? SO ARE THEY 2 DEMANDING? ARE THEY NOT DEMANDING ENOUGH? WHERE'S THE SWEET SPOT FOR THAT? FROM AUTONOMY FLEXIBILITY AND CONTROL, WHAT AN INDIVIDUAL STABBED POINT MINDFULNESS AND STRESS MANAGEMENT TECHNIQUES CAN BE IMPORTANT. FROM AN ORGANIZATIONAL STANDPOINT, HOW ACTIVE IS LEADERSHIP IN PRIORITIZING PHYSICIAN ENGAGEMENT IN DECISIONS THAT EFFECT PHYSICIANS WORK LIVES. ALL TOO OFTEN THAT ENGAGEMENT IS ABSENT BUT IT NEEDS TO BE THERE TO PROMOTE WELL BEING. AND FROM A MEANING STANDPOINT SIMILARLY AT AN INDIVIDUAL LEVEL, PRINCIPLES FROM POSITIVE PSYCHOLOGY CAN BE IMPORTANT BUT AN ORGANIZATIONAL LEVEL, CORE VALUES AND PROTECTING TIME WITH PATIENTS WHICH IS THE SINGLE MOST MEANINGFUL ACTIVITY FOR MOST PRACTICING PHYSICIANS ARE THINGS THAT ORGANIZATIONS CAN HOLD THEMSELVES ACCOUNTABLE FOR. YOU'RE NOT MEANT TO READ THIS SLIDE. IT'S A POWER POINT FOUL, I KNOW SOMEONE HAS A RED CARD, CAN YOU GO AHEAD AND THROW IT ON THIS 1. THE PURPOSE OF THIS SLIDE IS TO SHOW YOU THE COMPLEXITY, NOT THAT YOU READ ANY OF IT, THIS COMES FROM THAT SAME MAYO PAPER ON 9 MAYO ORGANIZATION STRATEGIES, AND THE PRINCIPAL HERE IS THEY'VE ADDED SOCIAL SUPPORT COMMUNITY AT WORK AND CULTURE AND VALUES BUT THE INDIVIDUAL LEVEL, THE WORK UNIT, ORGANIZATION AND AND AT THE NATIONAL LEVEL THERE ARE DRIVERS AND ASSOCIATED SOLUTIONS FOR EVERYONE 1 OF THESE CELLS IN IN MATRIX. AND SO NOT KNOWING HOW TO PROCEED REALLY ISN'T SOMETHING THIS YOU CAN ALLOW YOURSELF. THERE'S A HUGE MENU OUT THERE AND THIS IS JUST A PARTIAL MENU RIGHT THERE, THE FIRST STEP IS YOU'VE GOT TO ASK THE QUESTIONS AND LOOK IN THE MIRROR. SET UP YOUR WORK GROUPS, HAVE FOCUS GROUPS IN YOUR LOCAL WORK UNITS, AND HAVE LEADERSHIP STEP BACK, FACILITATE THOSE FOCUS GROUPS, FACILITATE THOSE DISCUSSIONS AROUND THOSE COMMITTEES AND THEN LISTEN TO WHAT THOSE COMMITTEES COME UP WITH. AND FIGURE OUT HOW TO RESOURCE THOSE SO THAT YOU CAN TURN YOUR FACULTY MORE IN THE DIRECTION OF THRIVING FOR THEIR BENEFIT AND FOR BENEFIT OF YOUR PATIENTS. SOME OF THESE SOLUTIONS ARE CATEGORIZED ON VARIOUS WEBSITES FROM VARIOUS ALPHABET ORGANIZATIONS SO VCG, AMAAND NAAM, AND I WILL SHARE THESE WITH ANYONE WHO WANTS THEM. YOU CAN CLICK ON THESE LINKS AND LEARN MORE ABOUT THESE COLLECTIONS OF RESOURCES. BUT I WANT TO SPEND THE LAST COUPLE OF MINUTES HERE BEFORE OPENING UP TO QUESTIONS, SAYING JUST A FEW WORDS ABOUT THE ROLE OF LEADERSHIP AND IN PARTICULAR ENLIGHTENED LEADERSHIP AROUND PHYSICIAN WELL BEING. SO ENLIGHTENED LEADERSHIP REQUIRES ALIGNING OUTCOME ASSESSMENT NOT JUST WITH THE TRIPLE AIM THAT WE'RE ALL FAMILIAR WITH BUT WITH THE QUADRUPLE AIM. SO THE QUADRUPLE HAIM, ENHANCE PATIENT EXPERIENCE OF CARE, REDUCE PERCAPITTA COST OF HEALTHCARE. THE QUADRUPLE AIM ADDS IMPROVING THE LIVES OF OUR HEALTHCARE PROFESSIONALS, AND YOU CAN'T DELIVER THAT IF THE FOURTH LEG ISN'T SOLID. SO THIS MEANS PHYSICIAN WELL BEING HAS TO GET THOUGHT OF AS A QUALITY MARKER BECAUSE IT DRIVES QUALITY. THE IMPACT OF OUR POLICIES HAS TO BE CONSIDERED ON ALL OF THESE AIMS. WE'VE BEEN WEAKER AS A MEDICAL SYSTEM AT THINKING ABOUT THE WELL BEING OF OUR HEALTHCARE PROFESSIONALS, WHEN WE'RE ROLLING OUT POLICIES. WE'VE DONE BETTER IN THE LAST COUPLE OF DECADES IN MY OPINION SINCE TO ERR IS HUMAN ABOUT THINKING ABOUT OUTCOMES FOR PATIENTS AT AN INDIVIDUAL AND SYSTEM LEVEL. BUT WE'RE NOT THINK BEING ALL THE DRIVERS OF OUR HEALTHCARE OUTCOMES AND OUR PROVIDER WELL BEING IS AN IMPORTANT PART OF THAT. HOW DO WE DEFINE SUCCESS? IS SUCCESS A BIGGER MARGIN SO WE CAN PUT UP ANOTHER PARKING GARAGE NEXT YEAR? OR IS SUCCESS GREAT PATIENT CARE WITH ENGAGED HEALTHCARE PROFESSIONALS? OBVIOUSLY, YOU KNOW WHERE MY BIAS LIES, BUT I THINK WE NEED TO BE INTENTIONAL ABOUT THAT FROM A LEADERSHIP STANDPOINT. TO FACILITATE THAT I WAS PART OF A TEAM THAT DEVELOP THE CHARTER ON PHYSICIAN WELL BEING, THIS WAS PUBLISHED LAST YEAR IN JAMA, THIS OUTLINES KEY COMMITMENTS AND GUIDING PRINCIPLES FOR INDIVIDUALS AND ORGANIZATIONS AROUND WELL BEING. THIS WAS A REMARKABLE CONSENSUS PROCESS, WE HAD 25 LEADERS OF HEALTHCARE ORGANIZATIONS AND SOCIETIES IN A ROOM IN CHICAGO AT THE ACG ME HEADQUARTERS OVER A DAY AND A HALF. AND IN A DAY AND A HALF, 24 OF THOSE 25 INDIVIDUALS CAME TO AN IMMEDIATE CONSENSUS AROUND WHAT THE CORE PRINCIPLES NEEDED TO BE, ANY OF THAT YOU HAVE EVER BEEN INVOLVE INDEED A REALLY BIG ENDEAVOR WITH THAT MANY STAKEHOLDERS, WILL RECOGNIZE THAT THIS SPEAKS TO A RESONANCE OF THIS ISSUE ACROSS THE MAJOR STAKEHOLDERS IN HEALTHCARE. THE 1 INDIVIDUAL WHO WOULD BT SIGN ON IN THE ACTUAL CHARTER ACTUALLY PRIVATELY ENDORSED IT BUT DIDN'T FEEL LIKE HIS ORGANIZATION WAS QUITE READY SO IT WASN'T THAT THEY WERE AGAINST IT, HE JUST WASN'T QUITE READY TO BRING IT TO HIS CONSTITUENTS. SO A PRETTY REMARKABLE CONSENSUS PROCESS. THE GUIDING PRINCIPLES, REALLY ARE SELF-EVIDENT BUT THEY NEED TO BE STATED AND ENDORSED BY ORGANIZATIONS. EFFECTIVE PATIENT CARE BOTH PROMOTES AND REQUIRES PHYSICIAN WELL BEING. THIS IS AN INTERPROFESSION ISSUE. IT'S A QUALITY MARKER, AND IT'S A RESPONSIBILITY THAT SHARED BY INDIVIDUALS AND THE ORGANIZATIONS AND HEALTHCARE SYSTEM WITHIN WHICH THEY WORK. THE KEY COMMITMENTS RANGE AT THE BOTTOM FROM AN INDIVIDUAL LEVEL COMMITMENT TO PRACTICE AND PROMOTE SELF-CARE. UP THE CHAIN TO SYSTEMATIC AND CULTURE BASED FOCUS, TRUSTWORTHY AND SUPPORTIVE CULTURE, POLICIES AT THE SYSTEM LEVEL THAT PROVIDE SUPPORT ASK ENHANCE WELL BEING. INTERPROFESSIONAL TEAMS, PRIORITIZING MENTAL HEALTHCARE, DESTIGMATIZING MENTAL HEALTHCARE, MAJOR EFFORT THAT NOT JUST OUR GROUP BUT MANY OTHERS ARE WORK OTHER ON IN RECENT YEARS. IT'S BEEN ENDORSED BY DOZENS OF MAJOR SOCIETIESA THE THIS POINT. IT'S HOSTED NOW AT THE AMA AND INSTITUTIONS WILL BE SIGNING ON IN THE NEAR FUTURE BUT THE MAIN PURPOSE OF THIS CHARTER IS TO GIVE PEOPLE A LITTLE BIT OF A FRAMEWORK FOR THINKING ABOUT HOW ORGANIZATIONAL SOLUTIONS SHOULD LOOK. THIS IS A COMPLICATED SLIDE FOR THE PHYSICIAN WELL BEING, THIS IS A SIMPLIFIED VERSION OF IT THAT SHOWS BROADER IMPACTS ARE YOU AS AN ORGANIZATION, WHAT DO YOU THINK ABOUT? AT THE NOVICE LEVEL YOU'RE THINK BEING INDIVIDUAL INTERVENTIONS IN ISOLATION, SO AGAIN THEY'RE NOT IMPORTANT BUT CAN'T BE ALONE. YOU MIGHT BE DEVELOPING A WELLNESS COMMITTEE AT THE BEGINNER LEVEL, YOU START TO THINK ABOUT DOING SURVEYS. AT THE COMPETENT LEVEL YOU'RE REGULARLY ASSESSING WELL BEING AND YOU'RE THINK BEING WORK UNIT LEVEL INTERVENTIONS. AS YOU KEEP GOING UP TO THE EXPERT LEVEL, WELL BEING INFLUENCES ALL MAJOR OPERATIONAL DECISIONS AND IT'S CONSIDERED A STRATEGIC INVESTORMENT. THERE IS ALMOST NO INSTITUTION, I CAN'T CLAIM THAT MY HOME MAYO CLINIC IS AT THE EXPERT LEVEL, THIS IS ASPIRATIONAL. BUT THIS IS WHERE WE NEED ON GO IF YEAR GOING TO OPTIMIZE OUR HEALTHCARE SYSTEM FOR ALL OF ITS STAKEHOLDERS. I'M GOING TO SKIP THE ELEVATOR PITCH AND I WILL CLOSE WITH JUST A COUPLE OF RECOMMENDATIONS AND THEN STOP. THIS IS AN IMPORTANT ISSUE WITH ENOUGH DOWN STREAM CONSEQUENCE THAT WE ARE PROFESSIONALLY OBLIGATED TO ACT UPON IT. IT'S AIR THREAT TO OUR PROFESSION AND IT'S UNPRFULG OF US TO ALLOW THIS TO CONTINUE. IT'S A SHARED RESPONSIBILITY WE'RE ALL IN THIS TOGETHER. WE HAVE TO BE ABLE TO ASSESS DISTRESS, WE HAVE TO BE ABLE TO ASSESS WELL BEING AND THERE ARE TOOLS TO MAKE THIS PART OF AN INSTITUTIONAL DASHBOARD. THIS CAN BE DONE ANONYMOUSLY, IT CAN BE DONE CONFIDENTIALLY AND YET IT CAN BE DONE IN AN ACTIONABLE FASHION. THE TOOL BOX IS DIVERSE, A BROAD MENU OF POETIC AT THE PRESENT TIMEICAL SOLUTIONS. THIS IS DAUNTING FOR LEADERS SOMETIMES, WELL, HOW DO I KNOW WHICH 1 TO PICK? TALK TO YOUR CONSTITUENTS THEY'LL TELL YOU WHAT THEY WILL BENEFIT MOST FROM AND THEN YOU TRY IT AND IF IT DOESN'T WORK IT DOESN'T WORK, IF IT DOES WORK, YOU'VE GOT SOMETHING THAT'S HELPFUL BUT EITHER WAY YOU WILL HAVE ENGAGED PEOPLE AND ENGAGEMENT ALONE CAN PROMOTE WELL BEING SO THERE'S NO 1 SOLUTION BUT MANY APPROACHES OFFER BENEFIT AND IF YOU FOCUS ON THESE DRIVERS WHETHER IT'S JUST THE 5 DRIVERS FROM THE MATRIX I SHOWED EARLIER OR IF YOU PREFER THIS SORT OF HONEY KOAM MODEL BUILT AROUND MEANING AND WORK. IF YOU CAN FOCUS ON THESE DRIVERS IN A POSITIVE DIRECTION, YOU WILL MOVE FROM BURN OUT TO THRIVE NOTHING YOUR MEDICAL ENVIRONMENT. AGAIN MY E-MAIL IS HERE, MY TWITTER HANDLE IS HERE, I WILL STOP THERE AND TAKE QUESTIONS UNTIL THEY BANG THE GONG TO MOVE ME OFF THE STAGE. THANK YOU ALL VERY MUCH. [ APPLAUSE ] >> ALL RIGHT. SO WE'RE OPEN FOR QUESTIONS. AS YOU COME TO THE MICROPHONES--MY FIRST QUESTION THOUGH IS RELATED TO COLUMN AND THAT COMPLEX SLIDE, NATIONAL, I REALIZE YOU DIDN'T HAVE MUCH TIME TO TALK ABOUT BUT IT'S THE CO MODIFICATION OF MEDICINE AND A HUGE DRIVER. I THINK RELATIVE TO DISSATISFACTION. WHAT CAN ACADEMIC MEDICAL CENTERS ACTUALLY DO ABOUT THE CO MODIFICATION OF MEDICINE? WOP CLASSIC EXAMPLE IS THE CLOSURE OF HONOMAN HOSPITAL. SO WHAT IS 1 TO DO? TALK ABOUT WURN OUT, THE THREAD, CLOSING AN ENTIRE INSTITUTION WHICH IS OWNED I THINK BY A NONPUBLIC COMPANY, OBVIOUSLY CAN REALLY DESTROY THINGS. DO HAVE YOU ANY THOUGHTS ABOUT THAT? >> YEAH, SO, I'LL FIRST SAY THAT I DON'T HAVE A SIMPLE ANSWER TO WHAT'S A VERY COMPLEX QUESTION, BUT IT'S AN IMPORTANT QUESTION. I THINK NOT TO BE FATALISTIC ABOUT IT, I DON'T THINK EACH OF US AS AN INDIVIDUAL HAS THE ABILITY TO CHANGE SUCH A MASSIVE ISSUE, BUT I THINK THERE IS--THERE IS POWER IN OUR ORGANIZATIONS AND IN OUR COLLECTIVE WEIGHT AND I THINK SOMETIMES WE TAKE THAT VIEW OF--AS INDIVIDUALS WE CAN'T REALLY EFFECT THAT MUCH CHANGE AS 1 PERSON AND WE STOP THERE, WE FEEL DEFEATED BY THAT. I THINK WE NEED TO DEMAND FROM OUR ACADEMIC MEDICAL CENTERS AND A LEADERSHIP OF OUR ACADEMIC SOCIETIES THAT THEY BE ADVOCATING SO THAT FOR EXAMPLE, THE HONOMAN SITUATION, IT'S MAYBE WELL DEFINITELY A LITTLE SLOWER THAN I THINK THE RESIDENTS AND THE FELLOWS IN THAT ENVIRONMENT HAVE NEEDED BUT THE DOUBLE AMC AND OTHER GROUPS ARE STARTING TO PUT VOICE TO CERTAIN THINGS THAT HAVE HAPPENED THAT THEY'RE DEEMING COMPLETELY UNACCEPTABLE. I MEAN READING THIS MORNING, ACTUALLY ABOUT SALES OF THINGS WHERE THE RESIDENTS THEMSELVES MAY HAVE BEEN TREATED AS PROPERTY IN A WAY, THINGS LIKE THAT. SO THERE IS POWER IN AAMC LEADERSHIP, IN THE AMERICAN MEDICAL ASSOCIATION LEADERSHIP AND THAT'S WHERE SOME OF THOSE HIGH LEVEL CHANGES COME FROM AND I'LL GIVE YOU JUST 1 EXAMPLE FROM THE AMERICAN MEDICAL ASSOCIATION AND I WILL--I'M A MEMBER OF THE AMA BUT I WILL TELL YOU FOR 15 YEARS I WAS NOT. SO I'M NOT, YOU KNOW SORT OF IN THEIR THRALL SO TO SPEAK. IN RECENT YEARS, THEY HAVE TURNED A FAIR BIT OF ATTENTION TO TRYING TO IMPROVE THE PRACTICE ENVIRONMENT FOR PRACTICING PHYSICIANS, WE'RE PARTICULARLY CONCERNED ABOUT CLERICAL BURDEN AND DISTRACTION OF ELECTRONIC INTERFACES THAT ARE PROMISED TO HELP US TAKE CARE OF PATIENTS BUT OFTEN GET IN THE WAY SO CHRIS CINSKY ISSUES THESE MET WITH JAMCO, AND CMS OFFICIALS AND WHEN PEOPLE HEAR THAT THEY THINK WELL CMS AND JAMCO, THEY'RE THE ENEMY. WHAT CHRIS FOUND, AT LEAST WHAT SHE TOLD ME IS THAT THOSE MEETINGS HAVE BEEN REALLY EYE OPENING FOR HERE, YES THERE ARE THEY THINKS THAT JAMCO THAT ARE REQUIRED OR CMS REQUIRES THAT ARE ANNOYING AND MAYBE NOT AS EFFICIENT AS THEY NEED TO BE, BUT THERE ARE A LOT OF THINGS THAT INSUPON TUITIONS INTERPRET FROM THOSE REQUIREMENTS THAT AREN'T REQUIREMENTS AND WE DO THIS TO OURSELVES AND WE BLAME CMS FOR IT AND WHEN SHE HAD THESE MEETINGS AROUND CERTAIN TYPES OF REQUIREMENTS, THE CMS REPRESENTATIVES WOULD PULL OUT THE ACTUAL TEXT OF THE REQUIREMENT AND THEY WOULD SAY IT'S NOT WHAT IT SAYS. IF PHYSICIANS ARE HAVING TO DO THAT WE GET WHY THEY'RE UPSITE. WE'RE UPSET AT WHY THIS IS INTERPRETED SO THIS IS CLEARLY A DISCONNECT. HOW DO YOU BREAK THAT DOWN? YOU GET EVERYONE TO THE TABLE TOGETHER. STOP SILOING THINGS. THAT WILL NOT FIX THE CO MODIFICATION OF MEDICINE ALL BY ITSELF BUT IT WILL GET THE DECISION MAKERS IN THE ROOM TOGETHER AND MAYBE PRIORITIZING THE NEEDS OF OUR PATIENTS AND WILL RESULT FROM GETTING THE RIGHT PEOPLE TOGETHER SO EVERYONE CAN SEE THE FULL IMPACT OF THE DECISIONS THAT ARE BEING MADE. >> ALL RIGHT. THANK YOU. >> OKAY I HAVE 1 FINAL QUESTION. FOR INDIVIDUAL STRATEGIES, I SAW 1 BRIEF MENTION OF THE WORD RESILIENCE. IS RESILIENCE AN INTERNAL CHARACTERISTIC THAT CAN BE TAUGHT, TRAINED, ET CETERA OR IS RESILIENCE SOMETHING THAT IS SORT OF GENETICALLY DETERMINED AND NOT MUTABLE IN ORDER TO EFFECTIVELY WORK AS A COPING STRATEGY? >> YEAH, THIS IS SORT OF LIKE THE AGE OLD DEBATE ABOUT WHETHER EMPATHY IS A DEBATE VERSUS NATURE OR IMMUTABLE CHARACTERISTIC AND I'M A PSYCHOLOGIST OR SOCIOLOGIST TO KNOW FOR SURE, I DO THINK IF THERE IS SOME INTERNAL INNATE LEVEL OF RESILIENCE THESE THINGS CAN BE TRAINED, MAINTAINED, SUSTAINED. PART OF THE REASON I DIDN'T SAY A WHOLE LOT ABOUT RESILIENCE IS BECAUSE BY VIRTUE OF SUCCEEDING AS MUCH AS WE HAVE, THIS GOES FOR NOT JUST PHYSICIANS BUT ANY HEALTHCARE PROFESSIONAL, ANYONE WHO'S AN NIH FUNDED RESEARCHER FOR EXAMPLE WITH PAY LINES BEING WHAT THEY'VE--WHAT THEY ARE, MY WIFE IS AN NIH FUNDED INVESTIGATOR, THERE'S AN UNBELIEVABLE AMOUNT OF GRIT AND RESILIENCE THAT OUR MEDICAL PROFESSIONALS ALREADY DISPLAY ON A DAILY BASIS. NOW THAT CAN ALWAYS BE OPTIMIZED BUT WE'VE GOT TO BE CAREFUL BECAUSE THE POWB LICK PERCEPTION SOMETIMES COMES OUT FROM RESILIENCE EFFORTS IS, OH, I'M BEING TOLD THAT THE FAULT IS INTERNAL TO ME IN A RESILIENCE SOLUTION AND THE SYSTEM ISN'T TAKING RESPONSIBILITY FOR TAKING A PASSIONATE RESILIENCE GRITY PERSON AND GRINDING ME DOWN. SO RESILIENCE TO ME IS STILL IMPORTANT, I THINK WE SHOULD ACTUALLY GIVE EACH OTHER CREDIT FOR HOW RESILIENT WE ALL ARE ON THE WORK WE DO ON A DAILY BASIS. I THINK WE CAN UPLIFT EACH OTHER IN REMINDING OURSELVES HOW VALUABLE WHAT WE DO IS AND I THINK RESILIENCE TRAINING DOES HAVE A PLACE. IT'S IMPORTANT. I DO THINK IT'S TRAINABLE TO AN EXTENT OR AT LEAST IT'S SUSTAINABLE SO WE CAN MAYBE MITIGATE THE EMOTION ROSIONS OF RESILIENCE THAT PEOPLE EXPERIENCE AS THEY GET DISTRESSED BUT IT'S GOT TO BE PART OF A LARGER MENU. , ALL RIGHT. SO WE ARE OUT OF TIME, FOR THOSE WHO WANT TO CONTINUE THE CONVERSATION OUR WELLNESS SUBCOMMITTEE OF THE GRADUATE MEDICAL EDUCATION COMMITTEE WILL BE MIGHTING WITH DR. WEST AT 1:15 IN IF, AES ROOM 5 IF YOU WANT TO JOIN THE CONVERSATION YOU'RE WELCOME TO COME. IF NOT WE WILL SEE YOU NEXT WEEK FOR OUR THIRD PRESENTATION IN OUR SERIES. THANKS VERY MUCH.