Physician and provider wellness

AS A RESIDENT OR FELLOW EMBARKING ON (or in the thick of) the search for your first job, odds are good you know it’s important to prioritize your own well-being—and that the competing demands of a busy practice and your desire to nurture what you love outside of work can make thriving as a physician a challenge.

Even though burnout has long since been identified as an epidemic affecting virtually every corner of the health care world, there’s plenty of encouraging news, too.

Led by research at major institutions (and countless well-conceived in-house experiments, too), health care organizations are learning the right ways to help. Their efforts to help you and your colleagues stay healthy, fulfilled and productive are becoming more focused and meaningful. Above all, they’re becoming more effective— and they’re proliferating as the good news gets around.

Cultures evolving toward wellness

Cultural change, both within organizations and across health care, takes time. But the seeds of change that were first planted years ago are now starting to bear fruit, as organizations invest more in physician wellness efforts—and invest more wisely.

Kristin Jacob, M.D., medical director of the Office of Physician and App Fulfillment at Corewell Health West in Michigan, says that the office was created in 2019, but her own experience with physician wellness work began years before that.

“I had unique exposure to physician well-being work as a resident myself. I served on a national committee at the national accrediting body, the ACGME. When Istarted in 2014, right before our first meeting, sadly, two first-year residents died by suicide in New York City. It got a lot of attention and demanded a response from national organizations [like ACGME],” she says. “Research efforts around physician wellness and best-practice interventions were just beginning. I was lucky to be part of and see that evolution, when these conversations grew louder in our national organizations.”

Five years later, Jacob says that her office at Corewell Health has grown to include a “small but mighty” team that has built a portfolio of services to help their audience of morethan 4,000 physicians and Apps in Corewell Health West stay healthy and motivated. Now they’re scaling their efforts, working with other wellness leaders on the Corewell Health East side of the organization.

Importantly, Jacob adds, her team’s existence is a strong signal from the highest levels of Corewell Health that the system is serious about protecting physician well-being.

Sean Maiorano, D.O., chief medical officer of Enloe Health in Chico, California, says his organization’s adoption of the Planetree philosophy of “person-centered” health care in 2007 ushered in a holistic transformation of Enloe’s culture, with attention to wellness increasing organically as part of that process.

“…It’s not just about taking care of that patient,” he says. “It’s also about taking care of those who are taking care of that patient.”

Guideposts on the path to change

A common criticism of wellness efforts is that they focus too much on physician resilience (leading to wry jokes about “yoga and pizza parties”). An important part of effective physician wellness work is bringing more attention to cultural and system-related change.

“Eighty percent of burnout is attributable to system-level factors,” Jacob says. “We do not have a resiliency deficit [in health care]. Studies show that health care workers are some of the most resilient people, yet we still have high rates of burnout. This is an occupational hazard problem, and that fundamental understanding is needed by our leaders at all levels so that you can have an approach that’s really getting at the core.”

Diane Sliwka, M.D., chief physician experience officer at University of California, San Francisco (UCSF), says, “Generally speaking, there are three factors we work toimprove on in our organization: systems-related factors, cultural factors — things people do because that’s how they’ve always been done, and that we can modify— and then the third piece is the individual, and what the individual can do to feel better in a stressful work environment.”

Meaningful intervention starts with measurement

To create, evaluate and sustain their evidence-based wellness initiatives, organizations at the forefront of this work rely, unsurprisingly, on data. Regular surveys and assessment tools help organizations learn more about what clinicians need while also helping them check on their own well-being.

“One of the most important interventions we started instituting was a validated assessment tool,” Jacob says. 

Corewell Health offers the Mayo Well-Being Index to all physicians and APPs. They can use it as often as monthly to measure their well-being. The tool itself also connects to local and national mental health resources. 

“We promote it as a system once per year, to identify and uncover the unique drivers of burnout at our organization, and then use that data to tailor interventions for high- risk teams,” Jacob says. “It’s been a really important platform to elevate the work, bring awareness to the work, and really promote education and awareness about the resources and the effort.”

Sliwka says, “I think the most important learning [we’ve experienced at UCSF] is that continuous measurement, transparency of the data, and helping leaders across the system to feel a sense of responsibility for improvement within their scope of work have been effective because the problems are very multi-factorial,” she says.

Engaging leaders locally helps ensure that responses are tailored to specific practice settings.

Maiorano says that at Enloe, they embrace surveying their teams on many dimensions, and each instance provides an opportunity to gather wellness clues.

“Every time we do surveys, it’s a chance for a little check-in with people,” says Maiorano.

Scheduling flexibility tops lists

It’s no surprise that given the challenge of juggling work, family and outside interests, wellness- related physician requests commonly focus on work schedules and time off.

“In fact, in the last system-wide assessment [survey] that we did, when we asked people what they need most to improve their well- being, content and comments around schedule flexibility was the highest response and biggest ask,” Jacob says.

But responding to that request requires multiple approaches, since requirements to ensure coverage and patient safety are so different across groups and departments. That’s why Jacob says efforts to improve flexibility in her organization have been most successful when change is driven by local teams themselves.

“The definition of flexibility looks very different for a primary care physician versus a hospitalist,” she says. “So we really do look towards our local leaders and empower them.”

Hospital scheduling innovations: swings, stints, and virtual moonlighting

Based on hospitalist input, UCSF has implemented ideas like adding swing coverage, reworking stints and offering more schedule choice.

As much as possible, Sliwka adds, UCSF allows people some choice between working nights, evenings or days and different services with varied schedules and work.

Jacob says that wellness innovations are burgeoning in Corewell Health’s hospitals, too.

“We’ve seen some really creative things from our hospitalist team,” says Jacob. “They’ve created moonlighting shifts where people can work from home. They’re prepping discharge summaries, and they’re helping prep charts for the people who are in the hospital. They’re doing some of that administrative work that still takes a lot of expertise to do, but that can be done remotely.”

Telemedicine: taking back commute time

In outpatient settings, the scheduling concerns are different. Staff and clinicians need to be available during normal clinic hours. Schedules need to be kept full to ensure cost efficiency and patient access.

“We’re trying to figure out how to create efficient systems that best serve patients, but also allow for people to have flexibility,” Sliwka says. “The ability for many providers to see patients through video has created a very beneficial type of flexibility.”

With full or half days of telemedicine visits scheduled in advance, outpatient physicians are able to avoid commuting on those days — gaining time with family, recreation or any other non- work activities.

Workflows and efficiency

“One of the greatest workload challenges for physicians is in-basket related—messaging from patients and other virtual sorts of work that has to be done, that aren’t part of the clinical encounter and are not accounted for in the time people spend in a workday. These are always added on at the end of the workday, creating many hours of work after work that people struggle with,” says Sliwka.

Sliwka adds that one way UCSF is addressing this problem is through team-based care, and through encouraging clinical support staff to take on more responsibility where possible.

“We’re trying to make sure that every team member is able to work at the top of their license, to grow in what they’re doing, and to do what’s possible for them to do. Often, letting them do more kinds of responsibilities helps their own joy in work because they’re learning and growing as well,” Sliwka says.

For example, organizations are finding that email can be triaged by staff of various levels who can quickly handle messages within their scope and ensure that others get the right attention.

Jacob says that at Corewell Health, dedicated teams of “inboxologists” handle electronic messages for primary care physicians.

Technology: from foe to friend?

Besides human triage of electronic information, some organizations are turning to technology to help— specifically, artificial intelligence. AI algorithms can sift through the river of messages flowing to physician inboxes, further streamlining the process and minimizing physician involvement with tasks that don’t require their expertise.

Ambient AI scribes — similar to Siri or Alexa — are poised to reduce physician documentation burdens dramatically.

Less loneliness at the top

Physicians may not be the CEos of their organizations, but they are ultimately responsible for the care of their patients. Like senior executives, they feel pressure to show strength and conceal doubts and emotions. Sitting on top of a pyramid alone can create feelings of isolation more easily avoided by colleagues in other roles who have peers to lean on.

What’s more, as physician work has become more computer- based, with email replacing face-to-face communication, everyday opportunities to connect with peers at work have greatly declined. The loss of those casual interactions has eroded a support system for physicians that used to occur naturally.

Back to the future: the doctors’ lounge

The doctors’ lounge was once standard fare in hospitals, but in recent decades, trends toward cost- cutting and better utilization of precious space helped push it out of favor. Then along came CoVID and social distancing protocols, and the once commonplace sanctuary for physicians was rendered all but extinct.

Now some hospitals and health systems are recognizing that a relatively small investment in a safe space can be invaluable in promoting physician well-being, and they’re bringing a modern version of the doctors’ lounge concept back to their organizations.

UCSF created theirs before the pandemic. “From some of our early survey data, we saw a theme coming out that our inpatient physicians didn’t feel like they had a place to go and work and rest and eat, perhaps,” says Sliwka. “Often, staff and nursing have break rooms on every unit, so they have a place to go, put their things, eat, and just get away from the unit for a little bit. The physicians didn’t really have anything like that, so it became a very easy, concrete thing to do.”

The space was designed to be “basic,” Sliwka says— computers, seating, coffee and a television — but comfortable and reflective of the physicians’ feedback. It has nonetheless been very popular.

Maiorano says that at Enloe, they previously had a small lounge that didn’t offer much in the way of ambience or amenities. But when they were looking to revamp foodservice for the entire organization, they discovered they could provide a significantly elevated experience for their physicians without adding to their costs.

Enloe’s new lounge, open to physicians and Apps, includes chef-prepared meals that people look forward to. The space is also much larger, with separate areas for dining and working on computers. There’s even an area dedicated to a rotating exhibit of medical staff artwork.

“It’s a really nice sort of bonding experience,” Maiorano says. “…It’s just been a very cathartic sort of place.”

Informal programs can be invaluable

Sometimes, hospitals and systems may simply provide encouragement, and perhaps a little funding, for physicians to proactively establish and maintain connections with each other.

Cooper Stone, D.O., a fourth-year psychiatry resident at Thomas Jefferson University and a member of his program’s wellness committee, says that the committee routinely organizes fun activities to help physician peers stay in touch—with some financial support from his residency program.

“Wellness doesn’t just come to you. You have to be intentional, to make time for it,” he says. “We set aside time to do team-building activities and get-togethersoutside of the workplace. This way, we get to know each other on a more personal level. We get to know who we’re working with, and I think it helps build a more collegial atmosphere.”

Stone says his group has done all sorts of activities, from improv and comedy classes to terrarium building and apple picking. The team also provides supports for colleagues on 24-hour calls, making sure the call room is stocked with snacks. Financial support from their employer pays for the food and coffee.

Peers helping peers

Over the long arc of a demanding career, every physician is likely to encounter unexpected episodes of extraordinary stress. Serious safety events, a malpractice suit, workplace violence or other traumatic experiences almost certainly will amplify stress, disappointment and detachment. And, of course, even when a single traumatic event hasn’t occurred, burnout can be a risk for any physician.

“We have a peer support network that consists of a number of members of the medical staff, both physicians and Apps. We’ve taken on some additional education on how to interact with folks and provide support to people who are going through difficult times, whether they had a challenging clinical event or maybe personalthings going on,” Maiorano says, adding that physicians can contact a hotline themselves or colleagues who are concerned for them may refer them.

Wellness is a work in progress

The physicians leading wellness efforts at their organizations know that there will always be more work to do—that it’s about continuous improvement, not reaching an end goal of perfection. They’re aided by their data- and evidence-driven approach, and by the honest input of colleagues. And as their work to improve the culture of health care progresses, more opportunities to create a work environment that works for everyone are emerging. •