Join Alex McDonald, MD, and Charu Soni, MD, for a conversation on helping patients stay engaged in their health beyond the exam room.
In this PermanenteDocs Chat episode, host Alex McDonald, MD, and guest Christine Sinsky, MD, vice president, Professional Satisfaction from the American Medical Association, discuss the terminology related to physician well-being, including burnout and moral injury. They also highlight the impact of external constraints on health care professionals and the need to address these challenges.
Christine Sinsky, MD, Vice President, Professional Satisfaction American Medical Association
Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.
Alex McDonald, MD: Hello everyone. Welcome to our PermanenteDocs Chat today. Thank you all for joining. I’m your host, Alex McDonald. I practice family and sports medicine here in Fontana, California as part of the Southern California Permanent Medical Group. Today is another collaboration between the Permanente Medical Groups and the American Medical Association. We’re going to be talking about physician wellness and burnout and joy in practice and autonomy and whatever term you want to use. There’s lots of terminology. We’ll get into that later. And joining us today is Dr. Christine Sinsky, who is the vice president of Professional Satisfaction at the AMA. Welcome Dr. Sinsky. Thank you for joining us and noting, a return guest also. So, braving coming back and seeing us once more.
Christine Sinsky, MD: Thanks so much, Dr. McDonald. It’s a pleasure to be back with you.
AM: Wonderful. Those of you who are here live, please drop any questions in the Q&A. We’ll get to as many as we can. This is, again, a short chat. We only have about 20 minutes, so get those questions in early and we are going to just jump right in here. Dr. Sinsky, tell us a little bit about who you are and what you do both professionally as well as within the American Medical Association.
CS: Sure, my pleasure. I’m a general internist. I practiced for 32 years in Dubuque, Iowa in a multi-specialty clinic. For the last 10 years, I’ve also been working at the American Medical Association, leading our work on improving professional satisfaction as vice president of Professional Satisfaction. And our team thinks of our mission as helping to create the conditions where joy, purpose, and meaning and work are possible for physicians and their teams. So that’s our north star.
AM: Great. And I have to say, the Southern California Permanente Medical Group was just honored with an award from the American Medical Association Joy in Medicine Recognition Program at the gold level. So, I’m very proud of that for our medical group. Can you tell us more about that program specifically and the Joy in Medicine recognition program that you help oversee?
CS: Sure, sure. Well, first of all, congratulations. It’s actually a really big deal to achieve any level, bronze, silver, or gold. But to receive gold, you’re in the top tier of organizations across the country. In fact, only 10 organizations were recognized as gold, and that’s the most that we’ve recognized in any year since the program developed. So again, congratulations and a lot of credit I think has to go to your leadership. Dawn Clark as the chief wellness officer [of the Southern California Permanente Medical Group] has been working on this for many years. It’s a rigorous program, and again, congratulations.
AM: Thanks. No, I mean you’re absolutely right. Dr. Clark has done so much work there, but it’s really been supported throughout our organization from top to bottom. And I think being physician-led within the Southern California Permanente Medical Group has really made sure that the physician voice is always at the center of our wellness program, if you will. But then also closely following that is the patients too, because we are here because of patients and really want to make sure we take care of patients, but to do that, we have to take care of ourselves first and foremost. I always like using the analogy of when you’re on the airplane and they tell you in case of loss of oxygen, you got to put your own mask on first before you can put someone else’s mask on. And I think a lot of times physicians are really struggling personally and professionally, and that hurts patients unfortunately.
CS: You are so right. My way of saying that is that care of the patient requires care of the care team, that when the care team is doing well, we’ll go the extra mile for individual patients. We’ll be at our best and we’ll stay in practice so that patients have access. So, I think of care of the care team, joy in medicine is the shortcut to getting to the other organizational objectives that we may have, whether they’re financial or quality or satisfaction objectives.
AM: Yeah, no, I completely agree with you. And let’s, again, I kind of alluded to this earlier, but let’s talk about the terminology. We all know that language really matters, and there are several terms to address this and the challenges both professional and mental, that physicians face. Joy in medicine, burnout, wellness, resilience, moral injury. There are so many terms floating out there. Can you help tell us what are your preferred terms when we address this issue and maybe why we’d use one versus another?
CS: And I think there isn’t a single term that’s going to service all of our needs here, but I think of burnout as an occupational distress disorder, and it’s occupational distress that’s related to the external environment. The problem isn’t the individual, the problem is the environment. I often say that while burnout manifests in individuals, it originates in systems. So, burnout, occupational distress, the flip side of that is professional well-being, joy in medicine, and they’re not opposed to each other. They’re just two sides of a coin. And I also say it’s not enough to eliminate burnout and sort of get to zero. We want to get to a point where people are thriving because that’s where that positive energy helps us to be the kinds of clinicians that we aspire to be. That’s how I look at those two terms. Some people don’t like the term burnout because feel they blamed by it.
And I think it’s important to call out that that’s how some people interpret it. And yet actually its use is used in the context of identifying the source is almost always in the external environment. Moral injury is another term that’s sort of come on the scene more recently. And I think it represents a slice of the sources of burnout. It’s not all burnout is not moral injury, but some of the occupational distress comes from the sense of moral distress or moral injury where we feel like we know the right thing to do, but we’re not able to do the right thing because of external constraints. But that’s not all of burnout. Some of burnout is related to just the mismatch between the demands of the job and the resources we have to do the job. In fact, I think that’s where the majority of burnout originates.
AM: Yeah, I think that is such an important point to touch on, is that mismatch between what the expectation is or what the physician really wants to do versus what they’re able to do. We know that only about 10, maybe 20% of someone’s health is actually directly related to physician care. And so much of it, 80% of it, is due to circumstances far beyond the control of our hospital and our clinic and a lot of those social determinants of health. And I think I can speak from my own personal experience and with some of my colleagues is that’s where it’s really stuck. If somebody comes in with an infection that’s easy. I can prescribe an antibiotic and treat that. If someone comes in and can’t afford their medications or lives in an unsafe neighborhood and can’t go for a walk, that is more concerning to me and much, much more challenging to treat.
CS: It’s my hypothesis that if you work in a system where together with others you are able to meet those patients’ needs, then your feeling of efficacy is greater and your feeling of professional satisfaction is greater, and your burnout is less. And also sort of analogous to that idea, about 20% of health is related to what happens in the health care system, 80% is the environment. It’s my observation that about 80% of burnout is related to the external environment, and only about 20% is related to individual factors. I think we can be very confident that our nurses and our physicians and our other health care professionals are not deficient in resiliency. We know that from studies that physicians have much higher resilience levels than the general population, and we can presume that for our colleagues in other professional domains within health care. So, it’s not the person that’s broken, it’s the system generally.
AM: Yeah, no, you’re right. It’s really the system is where we need to think about this. Can you go into a little bit more detail about those intrinsic versus extrinsic factors, both within an individual physician or within a group or even a health system that’s really going to either alleviate or exacerbate burnout or wellness or joy in practice or whatever term you want to use?
CS: Yeah, yeah. So, Alex, something that you said made me think of a framework that I really like. So, if you will, let me share that framework with you. It’s called Knights, Knaves, and Pawns. And there was a JAMA article with that title a number of years ago. And I like it because I think about how is the environment approaching physicians: as knaves not to be trusted? So, there’s lots and lots of constraints and controls. As pawns to be manipulated or as knights to be entrusted in their service and empowered in their service of patients. And we need a balance, I think. But we’ve kind of gone way over and rather than seeing physicians as knights that can be empowered to do their mission, seeing nurses in that same light, I think the external environment approaches us so much more as if we’re knaves not to be trusted or pawns, that we can just manipulate and force through a series of dropdown boxes and hard stops and things like that. So that’s a framework that for me has always resonated. And getting down into the specifics, I think drivers come from the loss of meaning in work, from work overload, and then from a loss of professional autonomy that so often … physicians, when you take the highest trained individuals in the organization and you give them almost no control over the day-to-day of their work lives, that’s actually a recipe, I think, for burnout. So, I would put the drivers in those bigger buckets and would also include, then, practice efficiency and organizational culture as two domains for the countervailing interventions to address those drivers.
AM: I love that framework of knaves, pawns, and knights. I actually wrote it down. I’m going to remember that. And I think it’s interesting. You can think about that from a systems point of view as a physician who is an employed setting and they’re viewed as a knave, pawn or a knight from their employer. But I think also from the patient perspective, especially in this day and age post COVID, there’s a lot of lack of trust just from the general public towards physicians, whereas physicians were honestly held on a pedestal for a number of years. Whether that’s was appropriate or not, we could probably have a whole conversation about that. But really you can think that of that framework from both the patient perspective and kind of those patient demands which are being placed on the physician, as well as sort of the health system demands. So, I really like that framework.
CS: Well, and I’ve never thought of it from the patient perspective, but just to riff off that for a minute. We published in November, so actually about a week ago, in Mayo Clinic Proceedings, a paper on the politicization of medical care during COVID, and it’s contribution to burnout. And over 90% of physicians have experienced increased stress in the course of their work related to conversations about vaccines and masks and unapproved therapies. And that intrusion of politics into the exam room is something that’s maybe been there in the past, but never to this magnitude. And it is strongly associated with levels of burnout.
AM: I can speak to that from a personal point of view. I can say that the last couple of years have been much more challenging from that perspective compared to pre-COVID and during some of my training. I really think that thinking about this from a systemic level is really important. We know, I always like saying the analogy of you can take a beautiful canary, but if you put in a coal mine, it’s going to suffer. Right? I think the same thing goes with physicians, and one of my good friends always says, no amount of yoga is ever going to solve this crisis. And so, what are some of the things we can do from a systems point of view, and what are some of the things that AMA is doing to help reduce those extrinsic pressures, which are kind of driving physician burnout?
CS: So, no amount of yoga, no amount of ice cream bars. And someone, a good friend of mine actually, Jillian Horton from Canada, has coined the term “muffin rage.”
AM: Muffin rage. I like that.
CS: Yeah. When the source of the problem is the culture or the workflow and the solution that you’re offered is muffins, then that can generate rage. But there’s so much that can be done. So, I mean, that’s what drives our team is that we just know that there are so many things that we can do better. As a country, we invest over 250 billion every year researching new tests and new treatments, and we invest less than one half of 1% of that on the practice model. And so, I really believe that most physicians in most specialties and in most practice settings, can save three to five hours every day by re-engineering the way the work is done and by more strategically delegating work to an upskilled team. But you need that upskilled team, and you need enough structure to that team, you need enough bodies on that team.
So, I think of team structure, how many, team stability, and team skill level. And if you have a half of an MA per physician, you’ll be able to perform at a certain level. But if you have 2 highly trained MAs or even one RN and one MA per physician, you’re able to perform at a much, much higher level, provide access to more patients, have professional satisfaction for a job well done. So now it doesn’t all take more people. Some of it just takes doing the work better. Stable relationships increase your capacity by 11% according to one study that was done by a group in Chicago. So, they didn’t hire anymore MAs, they just intentionally supported the stability of those relationships. And they had 11% higher RVU [relative value units] generation. They also had better quality. And I just checked in with Dr. Nadim Ilbawi, and a few years later, those who had the stable MAs, that was their intervention group, those practices are not short staffed.
They did not lose staff through the pandemic, whereas the rest of the organization where they weren’t in that pilot with the stability, they had a lot of turnover. And I attribute that to that stability of relationship meant that the work was meaningful to the MAs as well as the physicians. So, some of the practice efficiency relates to just having stable teams, and some of it means get rid of some of the work that doesn’t need to be done. Do 90 plus 4 on the prescriptions, do that once a year, all at the same time. That eliminates all that unnecessary work throughout the year.
AM: I think that point, and that’s great to hear that those studies done regarding that relationship within the medical team in the medical home is so viable. I’ve sort of intuitively experienced that within my own teams here. And obviously, practicing sports medicine I always like using my sports analogies, the physician really needs to sort of be the quarterback of the team. But medicine really is a team sport, and you need everyone doing their job, really talking, working at the top of their license most efficiently. I think for me, when I get questions or messages or things sent to me, which is like, hey, can I get my labs done? And their labs were already ordered in the system, why is that getting to me? My back-office staff or even the call center agent should be able to say, yep, labs are there. Go to the lab.
And so, I really love that idea of the team aspect and those relationships within the team, and sometimes just even saying thank you. As physicians, we tend to get bogged down a lot in our day, and I always try to make a point of thanking my LVN, thanking my RN who work with me, and I try to do it in front of other people too. That really goes a long way in building morale and that relationship. But that’s my own style and seems to help me also with my own professional wellness, because I feel like I am giving some gratitude, they’re showing me gratitude, and it just really builds that sense that we’re all working together, and we’re not stuck on islands by ourselves doing this work.
CS: Yeah. We had a thing in our practice called “The reason I came to work today,” because one day a patient had told me she wasn’t planning to come back. She’d been a new patient, and then she realized how kind one of our nurses had been to her, and she said, and because of that kindness, I decided to come back. She’d seen us as an urgent care visit, but domestic violence was uncovered. On the return visit, when the patient told me that, I praised our nurse in front of the rest of the team. And what she said was, well, the patient told me that too, and what I told the patient back was, you are the reason I came to work that day, and you are the reason I came to work today. And every day I try to find at least one patient encounter that was the reason I came to work today. So, we started at the end of the day to have, did anybody have a reason? Or if you come out of a room and you felt connected to your purpose, you now had cultural permission in a sense, within our social group there to say that was one of those reasons, that thing that we just did. So little things like the gratitude that you talked about, identifying the reasons, seeing the big picture while we’re going through the details, I think is important.
AM: So, we have an interesting question in the chat here actually, which might be a little bit off-topic, but I want to get your thoughts on it. So, how can I as a patient support my physician? And are there models including patient support and communication regarding how that impacts physician wellness and burnout?
CS: Well, I think that’s an interesting question. And I think as patients we intuitively know, or we sense that we will get better care if the team taking care of us likes their work. And I think when the team taking care of us is sharing their respect for each other, that also builds trust for the individual patients. So, what can patients do? First of all, I don’t think it’s the patient’s responsibility to take care of us, but I do think patients can do things like be clear about what they want. If what they want is an appointment and they think the appointment is what they need, I think scheduling that appointment as opposed to going through a lot of inbox communication with their physician when what they really want is an appointment, just saves everybody time. However, if they’re not sure, then communicating through the portal is ideal.
But sometimes I think we have made the patient portal the path of least resistance, and we don’t know just by reading text, we can’t read their verbal and visual cues as well. And so, as a patient, you just really want to come in and be evaluated in person, to go through the scheduling route, so that people are clear or to just be clear about what it is that you’re after, what your objective is. But again, I loved my relationship with my patients, and they did try to take care of me in some ways, and that’s nice. It’s part of being socially connected, and yet that happens organically, I think, when we are curious about the people that we’re with.
AM: Yep. No, I completely agree with you. So, I want to maybe dovetail a little bit on that, and especially coming up with the holiday season, it added both personal and family stress to physicians’ workloads. Do you have any tips to help doctors stay healthy both physically and mentally during the busy holiday season and also with winter respiratory illness season around the corner? Any tips or recommendations?
CS: Sure, sure. For me, that brings up the whole idea of unplugging and recharging and thinking about have I personally, has my work unit, has my larger institution, provided ways that systematically allow individuals to unplug and recharge? So, when I’m on vacation, do I totally unplug? Well, you can do that if you’re in a system where there’s inbox coverage when you’re gone, if the expectation is that you continue to manage your inbox while you’re gone. Well, I think you need to know that upfront, and maybe you want to know that even before you choose that particular position. But if you do have inbox coverage, then it does take a little bit of self-discipline to say, wait a minute to be good for my patients when I come back, I have to build back up. I have to recharge my battery. And I can’t do that if I’m constantly thinking and spending 2 hours of family time on my inbox while I’m away. So that’s my biggest thing, is if you’re on vacation, be on vacation, be fully present with your friends and family. But I think that organizations have a role in helping make sure that that’s possible by having that built-in coverage.
AM: And I think the other piece here, and what I’m hearing you say basically is make sure you take your vacation. Don’t try to work and do holidays and family at all the same time, and making sure you take that time. There was an interesting study I was looking at a number of months ago looking at across organizations, employees were happier and healthier and more productive if they were almost forced to take their vacation versus just kind of save it up. Sometimes we have a culture where you sort of wear that as a badge of honor to, oh, I’m tough, I don’t have to take vacation. But in fact, it actually probably hurts us in the long run. Not to take that vacation on a regular basis or save it up and take it all at once is probably not the best thing for our own mental health. But we can again go on a soapbox there for a while.
CS: If you don’t mind though, please, we have a study that’s currently under review around vacation and burnout. And what we’ve learned is that the majority of physicians don’t take all the vacation that’s allotted to them. The vast majority of physicians do patient care work while they’re on vacation, and that the least burned out physicians are those who do take at least three weeks of vacation a year and who don’t do work on vacation. So, I think underlining what you’ve just said as your hypothesis, at least our data will support that. So hopefully it’ll be in print at some point.
AM: I’m good at making things up and speaking from my own experience, but it’s always good when there’s data to support up what I pontificate about. So, this has been wonderful. I really appreciate your time. So last question here. What makes you most proud to be a physician?
CS: I am so sorry, but I didn’t hear you for some reason.
AM: I apologize. What makes you most proud to be a physician?
CS: Oh, oh my gosh. I think that our work is so chock full of meaning, and so to be invited into the intimate space of a patient’s life and needs and being able to fully attend to that and listen to that, and then to care for that patient over years and years and years, and in my case, both inpatient and outpatient, when they got sicker and when they got better, their family members. Staying true to that mission, to me, that’s what gave meaning to my work. I guess that’s what I’m most proud about as an individual physician.
AM: Wonderful. Well, thank you so much Dr. Sinsky, for joining us today, sharing your expertise. We really appreciate your time.
CS: Well, thank you, Dr. McDonald. It was a pleasure to be back with you today.