The Good Doctor Read online

  Passion and perseverance are what University of Pennsylvania psychologist Angela Duckworth describes as the key ingredients of grit. These physicians are gritty. They are great. And they are good. In Chapter 1, I will introduce some of the language and knowledge needed to put these physicians’ stories in perspective.

  And then we’ll get to the good part—the stories themselves.

  CHAPTER

  1 The Good Physician

  THE GOOD DOCTOR

  WHY EXPLORE WHAT it means to be a good physician in the modern era, when there is so much to admire in traditional notions? Can we really do better than hope for empathic doctors who take pride in easing the suffering of patients and their families? Responsible people who ensure that every “i” is dotted and every “t” is crossed? Hard workers, who love what they do and will settle for nothing less than excellence in the care of their patients?

  In truth, those characteristics have never gone out of style. They remain the core of the ego-identities of most physicians, nurses, and pretty much everyone else who works in healthcare. Patients hope for nothing less. But clinicians find that these noble characteristics are increasingly difficult to sustain.

  The reason is a perfect storm of good news. The scientific good news is that progress has made medicine more powerful. But research advances have also made medicine more complex—in fact, so complex that no one can deliver state-of-the-science care by themselves anymore. Physicians must collaborate with colleagues even for routine conditions such as diabetes.

  The demographic good news is that people are living longer, and as they do their health is dominated by chronic conditions that do not surrender easily to the right drug or the right operation, or simply working harder and longer. When numerous clinicians need to collaborate for long periods on difficult challenges, “coordination” and “compassion” become potential failings. Patients feel the effects of those failures when they occur, and caregivers are pained by them, too.

  To deliver care that really meets patients’ needs, good physicians need good teams around them—and that means they themselves must be good team members. That requires time, energy, emotional intelligence—and some new skills. In the old days, a good physician had to explain things well; today, a good physician has to listen well, too. Everyone on the team, physicians included, has to keep everyone else informed and pay attention to what everyone else has done.

  Being a good physician today also requires use of information technology tools. There is, quite simply, too much to know. New drugs and new tests are constantly emerging, and the best ways to use them are often far from clear—even to experts. In theory, electronic medical records (EMRs) help by enabling physicians to access information about their patients and tap into the wisdom of experts. The problem is that physicians are overwhelmed by the amount of information on almost every patient and by the amount of wisdom thrust in their faces by their EMRs.

  It isn’t hard to understand why many physicians have focused their ire on the EMRs that bring the flood of data to them. These EMRs seem to frustrate physicians daily with small humiliations as they try to accomplish simple tasks.

  I am thinking of my own recent exasperation as I tried to get rid of a reminder to give a patient a flu shot. Like many physicians, I try to do everything I am supposed to do, and a reminder to give a patient something that should benefit them bugs me until the task is completed and the reminder has disappeared. In this case, the patient had already had a flu shot at work, but to make the reminder go away, I needed to tell the EMR that the task had already been done.

  I looked and looked, but I could not find a way to document that the patient had already had his flu shot. I tried clicking on this, clicking on that, and got nowhere. Finally, I saw a nurse practitioner on our team and said, with obvious exasperation, “How the hell do we document past immunizations?” She paused and then showed me a button in the middle of the task bar near the top of the screen. It said, “Document Past Immunizations.”

  I could swear that until that instant the button had been invisible. It was embarrassing. It was one more episode in which I was revealed to be something less than the capable, all-knowing, all-powerful healer I liked to think of myself as being.

  Adjusting to using new information technology is just one of the potential insults to physicians’ self-images. The widespread dissemination of medical information is another. Many people used to hold their doctors in awe and would defer to their judgments on almost anything. That’s over. Today, patients do their own web searches before agreeing to go to a recommended physician or facility, or have recommended tests.

  Most physicians understand that increased patient engagement with their care constitutes change for the better. Having patients learn more about their conditions and treatments, and speak up about their questions and concerns—who can be against that? But still . . . that moment of hesitation while patients weigh whether physicians’ advice is worth taking can feel like part of a multipronged attack on our dignity—on our ability to feel consistently good about our work and ourselves. That makes it harder for us to sustain our passion for medicine.

  The result is an epidemic of burnout and the need to understand the nature of resilience.

  Burnout and Resilience

  Burnout is a term tossed around loosely, and one can find wildly varying “data” on its prevalence—in part because many different definitions are in use. It isn’t a disease that can be diagnosed or excluded with a lab test; it is a type of stress and is usually related to work. It is characterized by three key types of symptoms—exhaustion, feeling ineffective, and depersonalization.

  Almost everyone has some of these feelings some of the time. Problems arise when their frequency increases and when symptoms of burnout spread within a society like a contagious disease. In fact, burnout is behaving like an epidemic in healthcare today—its prevalence is higher than ever in the past and still rising. And there is also evidence that the presence of burnout symptoms in one person increases the risk of development of such symptoms in others.

  Burnout is more than a morale issue—it causes harm to patients as well as to the clinicians themselves. Burned-out doctors and nurses deliver care that is lower in quality and less safe. Burnout among doctors is believed to contribute to an unusually high suicide rate, but the emotional toll is real and measurable in other ways, too. For example, clinicians who are burned out are more likely to leave their jobs; why would they stay if they feel so unhappy? The financial consequences of high turnover are enormous. Some organizations estimate that every time a physician leaves, the cost of replacing that physician is one and a half times their salary due to the cost of hiring temporary help, recruiting a replacement, and the delays involved in getting the replacement credentialed with health plans, and so on. With clinical and financial stakes so high, virtually every organization in healthcare is worried about the problem of burnout in physicians.

  Interest in physician burnout and concern about its impact raises the question of resilience. Why are some physicians less likely to show symptoms of burnout and more likely to remain charged up about their work through years and decades? It’s as if they have been injected with a vaccine that has given them complete or partial immunity. What can the rest learn from their apparent immunity?

  * * *

  One thing that becomes clear as soon as one looks closely at physician burnout is that no magic bullet will cure it. More compensation isn’t the answer. “Mindfulness training”—which helps clinicians “be in the moment” and thus do a better job easing the fears of their patients and receive the psychological rewards of doing so—does have some impact, but it is not enough to stem the tide alone. If there are information technology fixes that will reduce burnout, I haven’t seen them yet.

  The reason there is no magic bullet is that burnout is a complex multidimensional problem, with multiple causes, and thus can only be addressed through multidimensional solutions. My colleague at Press Ganey, Deirdre Mylod, developed a framework for “deconstructing” the drivers of burnout—that is, breaking them down and placing them into simpler categories that can be addressed individually. In the following figure, this framework categorizes stressors and rewards according to whether they are inherent to the role of care provider (bottom row) or are a function of external forces. Further, it acknowledges that other factors influence how individual clinicians experience the balance of stresses and rewards—that is, how resilient they might be when stresses increase.1

  Let’s start with the bottom row of the figure—the rewards and stresses inherent to taking care of patients. The fact is, it’s a tough job—inherent stresses include the emotional toll of caring for suffering patients and their families, and the burden of taking responsibility for the safety and effectiveness of patients’ care. But it’s a great job, too—the inherent rewards include the respect from friends, family, and the community that results from clinicians’ role in helping people, and the personal pride that comes from doing work that has meaning.

  Figure 1.1 Framework for Deconstructing Burnout

  This framework distinguishes rewards and stresses inherent to the role of caring for patients (bottom boxes) from those that are added (upper boxes). Resilience is a moderating influence that nudges the fulcrum to a point where more stress is bearable. EMR indicates electronic medical record.

  One key insight from this framework is that these inherent stresses and rewards are intertwined—that is, decreasing one’s sense of responsibility or one’s empathy in an effort to decrease the inherent stresses also decreases the ability to enjoy the rewards. The implication is that to improve the balance between inherent stresses and rewards, the emphasis must be on the rewards side of the figure—for example, increasing
individuals’ sense that their work has meaning and is respected by the people who surround them.

  Keep that bottom left box in mind—we’ll be coming back to it.

  The upper row of the figure focuses on the external or added rewards and stresses. The term added is used to differentiate the inherent stresses and rewards. Most clinicians respond to descriptions of inherent stresses by agreeing, “This is what we signed up for.” But when they see a list of external stresses like the burden of documentation, managing EMR systems, and coping with inefficiencies in the practice environment—they say, “No one told me I was signing up for that!” The oft-quoted estimate is that physicians spend two hours of bureaucratic catch-up work for every hour of patient care. The former represents added stress, while the latter represents what they signed up for.

  External rewards are real, too, and include financial compensation, the prestige of membership in a trusted profession and affiliations with respected organizations, and positive working relationships with peers and health system leaders. However, in contrast with the inherent rewards and stresses, there is essentially no direct relationship between external rewards and stresses. For example, increased compensation cannot allay the frustration that results from a dysfunctional EMR. The implication that follows from this lack of connection between external rewards and stresses is that organizations must take on the “upper right box”—they cannot mitigate the angst that results from external stresses by increasing external rewards. Instead, organizations must show that they understand that these stresses are real and an enormous problem, and that the organization is working to ameliorate them.

  Collectively, these stressors and rewards define the clinician experience, and the balance between them influences clinicians’ vulnerability to burnout. But it is not the only influence. The fulcrum upon which stressors and rewards are balanced is where resilience is determined. There are some individuals for whom stressors have less impact, and there are times in any individual’s life when they can better deal with stresses. In such people and in such situations, the fulcrum is moved to the right, resilience is greater and more stress can be absorbed while still experiencing the rewards of patient care and avoiding burnout.

  There are thus three opportunities in this framework for reducing burnout: reducing the added stresses, enhancing inherent rewards, and increasing resilience. A key takeaway is that resilience is not the opposite of burnout; it’s an improvement in the ability of clinicians to absorb the stresses that occur through their work, and not “tip over” into burnout because the stresses are overwhelming the rewards. Organizations need to reduce the added stresses and enhance inherent rewards, but they should work to improve resilience as well.

  These approaches are not theoretical. An example of an organizational initiative to reduce added stress is Hawaii Pacific Health’s Get Rid of Stupid Stuff (GROSS) program, through which the organization asks personnel to identify work that does not add value—such as documentation that was either never intended to be performed routinely with every encounter—or could be accomplished more efficiently in some other way. Clinicians and other personnel have been vigorously appreciative of this program. This program was described in a New England Journal of Medicine article in November 2018,2 and GROSS went viral. The Cleveland Clinic had already started its GROSS program in February 2019.

  Researchers at the Mayo Clinic developed and evaluated an intervention to increase inherent rewards by giving physicians a chance to talk about their work with each other. They randomized 74 physicians to two groups, both of which got an hour of protected (paid) time off every other week. The control group could use that hour however they liked. The study group spent that hour participating in small-group discussions over dinner that incorporated elements of mindfulness, reflection, and shared experience. The trial showed that physicians who participated in regular small group meetings had a 5.6 percent increase in engagement and a 15.5 percent decrease in depersonalization symptoms, while the control group had little improvement in either.3 Based on such data, many organizations now support dinners and other gatherings that foster socialization among clinicians.

  To increase resilience, interventions targeted at the individual can be helpful; for example, “mindfulness” programs have been shown to be associated with small reductions in burnout. But my belief (and it is a belief, because evidence from research in this area is sparse at best) is that a larger sustained impact can result from strengthening an individual’s interpretation of their role and connection to the organization. If clinicians identify strongly with their organization and that relationship brings them pride and respect, the fulcrum moves to the right. If clinicians believe that the leaders and other personnel of the organization share values that make them proud, like a commitment to zero harm and reducing patients’ fear and suffering, that also helps the fulcrum move to the right, where stress feels more manageable. But if clinicians feel like they are being used as “RVU (relative value unit) machines” by an organization that is mainly concerned with margin growth, the fulcrum moves to the left, and they are destabilized by even minor increases in stress.

  Two of my favorite interventions that have strengthened a sense of “why we are here” among individuals within organizations are the Cleveland Clinic Empathy video and the Grady Health System turnaround campaign, “Atlanta Can’t Live Without Grady.”

  The first was an internal training video that used scenes showing patients, family members, and caregivers on a typical day at a healthcare facility. There were no spoken words, only captions that expressed their thoughts and emotions. It ends with the question, “If you could stand in someone’s shoes . . . Hear what they hear . . . See what they see . . . Feel what they feel . . . Would you treat them differently?”4

  It was made in 2013 with $40,000 for Cleveland Clinic’s personnel. At its debut showing, CEO Toby Cosgrove simply said at the end, “This is why we are here.” It went viral almost immediately; nearly 5 million people have watched the YouTube version. Mention the video to anyone who has seen it, and they are likely to respond, “I still get choked up when the little girl pets the dog.” Like everyone at Cleveland Clinic who watched the video, you will have established that you share the same values and that they are noble ones. You’ve also experienced the fulcrum moving to the right.

  The Grady Health System campaign occurred during the first decade of the century when the Atlanta safety-net provider was on the verge of bankruptcy. Financial performance was only part of Grady’s problems—quality and morale among the personnel were both in terrible shape. Leaders from Grady and local government developed a brilliant, moving public relations campaign with the tagline “Atlanta Can’t Live Without Grady.” It began with black-and-white photos of patients or prominent Atlantans (like baseball star Tom Glavine) with the Grady logo over their hearts and the “Atlanta Can’t Live Without Grady” tagline. Then other images and videos of patients whose lives were saved at Grady appeared, each with the quote “I Wouldn’t Be Here Without Grady.” The campaign continues to this day.

  Many other initiatives were undertaken to improve quality of care and business performance at Grady during this time. But talk to people who work there, and they will tell you that this campaign did more than change the way politicians and other Atlantans looked at Grady. It also changed the way Grady personnel viewed the place where they worked, and that was critical to the turnaround.

  Is this real or is it hype? Here is a small “biopsy”—information posted by a former physical therapist on Glassdoor.com on June 18, 2018, about working at Grady.5 The therapist acknowledged the stress of working there, but used the campaign slogan in the post, and ended her description of the “Pros” with “pride in the mission of serving everyone who walks through the door.”

  The path forward suggested by this framework is multidimensional. Organizations should work to reduce clinicians’ work that isn’t related to patient care, reinforce individual clinicians’ ability to find meaning in their work, and define an organizational culture with values that make clinicians proud. They need to work relentlessly to reduce stress and increase rewards; they cannot just suggest to individuals that “the problem is you—you need to become more resilient.” But they should understand how to measure and improve resilience, because healthcare is a field in which the unpredictable happens, well, predictably. Doctors, nurses, and other personnel need to be resilient to deal with the resulting stress.