This is a transcript from Trench Tested Podcast. Listen here
Being a family doc is one of the toughest jobs on the planet. Seriously, 50% are struggling with burnout and 38% are thinking about cutting back, retiring, going to concierge medicine, or quitting altogether. There are a lot of reasons: prior authorizations, electronic health records, etc. Finally, something is being done. There are some really smart people that are committed to making a difference.
My guest today is Dr. Clift Knight. He's been a member of the American Academy of Family Physicians since 1984. In 2012, he was elected to the board of directors where he served until he took on his role as Senior Vice President of Education at the AAFP. He oversees organizational activities related to medical education and continuing medical education, including the education and training of medical students and residents and C.M.E. curriculum development. He's a busy guy but in the midst of all that, he has a passion for physician well-being. He's a member of the National Academy of Medicines Action Collaborative on Clinician Well-Being and Resilience where he chairs the work group on Messaging and Communication. Dr. Knight, thanks so much for taking time out of your busy schedule to meet with me today.
Dr. Knight: It's my pleasure Dan, I appreciate it.
Dr. Diamond: Burnout and provider well-being are certainly hot topics right now and rightfully so. Why has the AAFP put such a high priority on these issues?
Dr. Knight: Our Board of Directors at the American Academy of Family Physicians listens to our members when they set priorities. About a little over a year ago, we had a strategic planning session and looked at feedback from our members and looked at a variety of issues. We recognized that as we look at the family physician workforce, the importance of the care that our family docs in America provide for our communities, and the families and patients that entrust their care to us, there is one thing we know: there's a shortage of family physicians. Our health system needs to be appropriately based on a strong foundation of primary care and preventive health. We need a vibrant family medicine workforce, and so we're always working to increase the amount of student interest in family medicine and help training residents in family medicine. One of the things we've recognized is that our family docs out in practice are suffering. They let us know that the system is beating them down and we see family docs leaving practice. This limits the access to a high-quality, safe care for patients and communities. We see this as a critical issue for our members, and rightfully so our board of directors identified this as one of our top four priorities along with:
(1) Improving pay for primary care services and shifting our payment system from focused on rescue care to focus on prevention, and that's one of our priorities.
(2) Another one is helping our members in that transition to a quality pay. For quality practice, such as MACRA and some of those programs and we know our members look to us to help them in that transition.
(3) The third priority is being a leader in addressing health equity issues in the United States. A focus on addressing diversity issues and improving health through improving health equity.
(4) Then the fourth area is to help our members to have a much more meaningful sustained career in family medicine through which, helping them achieve their well-being and so you know that's how we landed on making this as one of our top priorities.
Dr. Diamond: It is so important for family practice and emergency medicine since this are two of the highest risk specialties for burnout.
Dr. Knight: Absolutely.
Dr. Diamond: There's a lot of causes when it comes to burnout both on a personal level, if we just look at the individual and then on a system wide perspective, and everything in between, that's complicated. How does the AAFP prioritize where to start?
Dr. Knight: Yeah, that's a great question, Dan, because there are so many aspects of this. There's isn't one silver bullet that will take care of this and so the way we're approaching it is where using a framework, that we call the Family Physician Ecosystem. Think of it in multiple levels, and we recognize that the health system as a whole has systematically set up a series of burdens and barriers that our members tell us they encounter to providing high-quality care in maintaining relationships with their patients.
We look first at the Health System Level and the things that as an organization we can do to advocate for our members around decreasing the burden of administrative requirements and reporting requirements.
The second level then in that framework is the Organization Level and we know that our most recent survey of our members, 68% of our members report being employed rather than owning their practice. We know those organizations have aspects of them that can increase stress and burden on positions, and so we look at those Organizational Level issues.
The next level down is at the Practice Level where our members physically spend their time. Where the environment that they practice on a day-to-day basis and try and help identify the issues that come up at the Practice Level that are sources of frustration and stress and trying to find solutions at that level.
Then there's the Individual Level, and we know that we need to address the system, organization, and practice issues that are causing a burnout and decreasing a sense of professional satisfaction and well-being. But, at the same time you know folks are in the middle of this milieu of a dysfunctional health system. They're looking for help with coping and so we are working to help individuals find solutions from that standpoint as well as an increase in improved habits that may improve their well-being and sense of professional satisfaction.
Then the fifth level in that ecosystem is a little harder to define it but that's the Physician Culture, and that's when you’re a fish swimming in the water you don't even see the water, and that's how we approach the physician culture. I think the majority of physicians don't even realize how different our culture is and that makes us a bit more susceptible to this because of the stigma and admitting when you're feeling stressed or feeling sometimes of burnout or worse feelings sometimes of depression. The physician culture, a lot of times, is not very supportive or forgiving or nurturing from that standpoint. There's traditionally been just sort of an “if you're not tough enough to practice medicine without getting burned out then there's something wrong with you”. It leads to the sense of shame and guilt, and so we believe that we need to acknowledge and address those Physician Culture issues as well.
Again, here are the five levels of that Family Physician Ecosystem:
( 1 ) The Health System Level
( 2 ) The Organization Level
( 3 ) The Practice Level
( 4 ) Individuals
( 5 ) Physician Culture
That's the framework that we're approaching in this organization as we try to identify and promote solutions that our members can access.
Dr. Diamond: Don't you think that at the Physician Level, the culture level is changing recently? I mean there's more talk now about burnout, especially in the US health care. In my experience, working with different hospital systems around the country, people are not only more willing to talk about it but, they are more eager to speak of the fact that they're feeling burned out and they can't keep doing with their doing.
Dr. Knight: Yeah, I think you're right. There is more acknowledgment of that, but the habits that are so deeply ingrained, especially in physicians. I trained in the late 80's. I finished medical school in 87, finished residency in 1990 and you know the habits we learned then, I think it continues to persist and in some ways. The work that I did before coming to the AAFP was I was Chief Medical Officer for a health system in Indianapolis that has 8 hospitals and when I would start talking about this, it was just really uncomfortable for folks especially those that had been in practice for a nice long established career. Even just talking about trying to develop opportunities to bring support groups together was just met with real disdain. I agree that it's more out in the open now, and it's more acknowledged, but I think there's still this embedded sense that those physicians who can't cope with this, think there's something wrong with them. This sense of blaming the individual rather than saying, we need to focus on what are all of those other things that are leading to this.
Dr. Diamond: I agree enthusiastically. There was an article in April in the Harvard Business Review saying that when burnout happens, it's never the fault of the individual, it's always the fault of the organization. And, I think that pendulum is swinging way too far the other direction. If we just say, “well this is only an organizational problem”, then we miss out on the opportunity to equip people with the tools to help them in this difficult environment. We need to look at the whole spectrum all the way across. I'm glad that you're doing that.
Dr. Knight: Absolutely! We’re all responsible for fixing the system, finding opportunities for improvement, and focusing on helping ourselves as well. I mean it's OK to help ourselves, and that's again part of the physician culture that pushes back. If you're paying attention to your own exercise, and nutrition needs, sleep needs, family needs, then somehow you're failing because you're not abiding by this long held belief that self-sacrifice is important in being a physician. And we all get it, I mean, we do make sacrifices, but we also have to be reasonable and do that in a way that sustainable.
Dr. Diamond: You know it reminds me of going into big disasters. When I lead a teams into a disaster like Haiti, or the Philippines, or even Katrina, one of my top priorities is to make sure that we're safe because if I don't keep my team safe, then we can't keep continuing to take care of people. It's so obvious when you're in a disaster zone. I think we dismiss it sometimes when it's on the ongoing practice day-to-day work when we're just doing our normal jobs. But, in the disasters, it's obvious if you don't take care of yourself: you're done, you're going home, or you don't survive.
Dr. Knight: Right. Right.
Dr. Diamond: It's striking in that situation, when I think about the role of the individual, I believe that one of the things that happens is that people have a mindset shift. They go from thinking that they can make a difference, and they want to take care of other people to becoming somewhat disillusioned, and thinking, “well maybe I don't have the power to make a difference” or “it's all about me and nobody's taking care of me”. Then once people make that shift, it's easy to no longer feel fulfilled at work, and then the burnout follows.
Dr. Knight: Yeah.
Dr. Diamond: When I'm speaking with some of my colleagues there is some pushback from some people about things like mindfulness, and gratitude practice, and exercise, and sleeping, eating right. They say, “oh that's just a bunch of fluff, that's a bunch of woo-woo! You just need to buck up like I did. Get through it or maybe you're not cut out for this”. I think that's unfortunate because those are some very well validated tools that we can all use to help you through these difficult times.
Dr. Knight: Yeah. I think that there's more and more evidence all the time on the benefits of meditation, mindfulness, yoga, and intentional gratitude. When I talk with groups of physicians about this, I try to help them understand that I'm not saying that all these things are right for you, but I am saying is that it's important for you to think about the options seriously. That you have to find those things that are most meaningful and helpful for you. When I give presentations and reach out to the audience and ask who's had a good experience with mindfulness, meditation, and intentional gratitude, I think people are feeling brave enough to stand up and share their stories about that. I think that helps because again in physician culture there's a stigma against some of those things that people would have looked at in the past as softer or unexplainable. Then now there's a data that shows that these things can be very beneficial. What we try to do, is help challenge folks to think about what's most appropriate, what's going to be the most helpful for them and that there isn't a one size fits all.
Dr. Diamond: There's a good solid data to back it. One of the things that we did in one of the organizations where I worked is one of our staff members came up with an idea of keeping a team gratitude journal. Every day members of the team would write three things into that journal on what they were grateful for. It had an impact on the culture of our team. It was fabulous to see the impact that she made, just this simple idea "of hey everybody write the Gratitude Journal today! What do you have? Try not to have any repeat so you can’t be thankful for the same person or thankful that we had electricity every day?" We had to start looking for things to be thankful for.
Dr. Knight: Somewhere along the line, probably my parents, taught me to be grateful, and this resonates with me. I think I was doing this sort of subconsciously before I ever knew there was such a thing as intentional gratitude but I can remember many times at the end of the day feeling tired and ready for that day to be over. Then stepping back and saying, as bad as this day may have felt to me, the people I was taking care of today, it was a worse day for them. We sometimes take for granted simple things like delivering the news to a patient that they've got early onset diabetes. Even though our message is we're going to help you with this, and we're going to keep you as healthy as possible. For that patient, to hear that they've got diabetes even though that's a routine thing for us in the healthcare team to live with, that kind of news day in and day out for them may be one of the worst days of their lives to hear. It's always important for us to keep that perspective, that no matter how tough it is for us, there's a lot that we can be thankful for.
Dr. Diamond: We have the opportunity to make a difference in the lives of people.
Dr. Knight: Absolutely and that's a blessing!
Dr. Diamond: It is! If you and I were sitting in the coffee shop right now and one of our colleagues pulled up a chair and said, I'm just not sure I want to keep doing this, what would you say?
Dr. Knight: Yeah. First of all, I think I will acknowledge that it's a real concern and I'd say sorry to hear that. Tell me what's going on, what's causing this and I'd want to understand from their perspective. Where's the mismatch because we hear this all the time from our members that they say, this isn't what I signed up to do. When I hear people say that, I say help me understand that. And a lot of times what I hear from people is, “I chose family medicine for the relationships and the scope of practice. What I find myself doing is looking at the clock because I always feel like I'm behind. I can't keep up with how many patients I have to see and then there's always all this documentation that I've got to do by the end of the day. There's this sense of ‘this isn't what I signed up for’”. So then I would encourage them to talk about it. “If you envision what would the practice of medicine look like that would be most filling for you and why?” Then help them start revisioning that and then challenging them to say, “what's one of the barriers to preventing it from being the way you want it to be?” If we identify organizational issues, then you now encourage them to feel empowered to try and influence those decisions in their organization that is causing us problems. If they feel like they're chained to the Electronic Health Record, I challenge them to let them know that there are models out there of team documentation and using scribes. It's unusual for me to talk to a family physician who is using a scribe or has team documentation well-in-place that hasn't found that fairly transformational for them to free up extra time during the day and allows them to have more face-to-face time with their patients. Then sometimes you just have to challenge people that maybe they're not in the right setting, in the right model of care. We've got a small percent but a significant number of family docs who are switching to a direct primary care model. Where they have found a way to maximize their time focused on patient care and less on all of the reporting and that because typically they don't do the insurance billing services. Again, an approach would be to find out individually how somebody got to the point where they're thinking about leaving practice. Then helping them recognize that there are solutions, not necessarily easy solutions, and there are big decisions to make -- but that perhaps that will let them get back to connecting with really the calling that took them into medicine, to begin with.
Dr Diamond: We're seeing a lot more medical students and residents that are burned out. In my last episode, I interviewed Anna Liotta (she is a generational expert) and we were talking about this subject. She said that she believes that it's because this generation of millennial doesn't know how to cope with obstacles because their parents protected them and wanted them to have such a good experience and a good life. Then they are also used to having their lives jam-packed in 15 minutes increments when they grew up and they were doing school, and select soccer, and ballet, or whatever. Then they get into medical school, and they start hitting some pretty intense challenges, and some of them feel like they can't make it. They think that there's something wrong with them. What's the AAFP doing to address medical education both from the students perspective and from residents?
Dr. Knight: Yeah. Dan, I listened to your discussion with Anna and what a great discussion and such a provocative way of thinking about generations. I just thought that was a great discussion; the AAFP recognizes that that students and residents do have their own individual sets of stresses and issues.
We're fortunate that we have on our Commission on Education a subcommittee on resident and student issues. We engage a nice group of students and resident leaders and have done some focused look at this to help make the AAFP have a broader basis of awareness of these issues. We've offered some workshops. We have several days each spring where we have the residency education symposium, and this is primarily focused at program directors for family medicine residency programs, as well as, faculty and staff at the residency programs. This past year we had several specific workshops related to improving not just student and resident well-being but faculty well-being. We believe it's important for faculty to be well so that they have the capacity to teach wellness and to role model well-being and healthy habits. That’s the approach we've taken to this point is to help through those avenues. Then for our student resident members, they have access to anything that our other members have access to through the website even the conferences that they would attend.
I'd say that’s what we would like to do as we progress further along in the development of resources and programming and activities around well-being, is to continue to keep the students and family medicine residents in that scope of planning.
Dr. Diamond: Good. I think that it is important to help them in a way to come alongside. We have learned from the experiences that we've gone through especially as older docs and we want to help and be part of the solution to make medicine a better career for people.
Dr. Knight: I think finding role models is just such an important aspect of this.
Dr. Diamond: Can you tell me a little bit about the conference that you have planned coming up?
Dr. Knight: Sure. As we looked at well-being for our members, and have done couple of surveys over the last few years, we are trying to identify the gaps (which is one of the things that the AAFP can do for our members that isn’t already available out there), a couple of things surfaced. One was helping them with finding resources and developing a plan and so we're we're working on that for our website. And, that will be releasing on our website over the next several months. Another gap that was exposed was that a family doc would like an opportunity to meet with other family docs and learn about things to improve their well-being. In April of 2018, we will be hosting our first family physician health and well-being conference, that will be April 18th to 21st. The site is yet to be determined but we've got the dates locked down, and so we will have more information about that very soon so that folks can start registering. I can tell you it's been amazing how many people have heard about this and have reached out to me. The idea is that over about three and a half days, we will again using the Family Physician Ecosystem Framework Approach and we will acknowledge the problems of burnout and the ramifications of burnout, but then we will quickly shift from acknowledging that to focusing on what are potential solutions. Our goal is that anyone that attends the conference in three and a half days is going to walk away with a solid plan on what they want to do to address those issues that they see as important to their well-being. We are planning three tracks:
One would be to help attendees identify organizational issues that they want to address and help empower them with some leadership development skills to take an active role within their organization of making well-being a priority for the physicians and other clinicians in their organization.
A second track then will be focused on practice level improvements and things that you can do to get back time in your day to help you more efficiently take care of your patients and provide care. At a team setting, that is very satisfying and solidifies the relationships of your team members and again really focuses on multiple potential solutions, at the practice level.
A third track is going to be for individual skills that can help you cope so we will have information about meditation, mindfulness, intentional gratitude and other opportunities to focus on developing individual skills.
Resilience has this negative connotation, right now. So, you're telling me I have to be tougher or you know I've got to toughen up instead of fix the system. It's a both from our standpoint, so we do want to work with individuals as we're working on developing the improvements in the big system. At the organization of practice level, we do want individuals to feel more resilient and able to bounce back after you know significant stress or events. We believe that it's important to help folks find resilience as well as improved connection to their purpose in medicine. We'll have those three tracks as well as some dynamite general sessions. The goal is going to be that as folks leave that conference; that they've been able to organize their thoughts about how to improve their well-being and the well-being of other physicians and clinicians that they work with. We want to make it a practical and important three and a half days. We'll be looking forward to the feedback we get from folks that attend and make sure that we're hitting the mark on helping them move forward with their own planning.
Dr. Diamond: I'm enthusiastically nodding up and down and realizing that you can't see me. I appreciate the broad approach to it from a systems perspective as well as an individual and a team perspective. I think this is awesome. I'm excited about April 18-21st, 2018 and that's going to be open not just family practice folks, but it's going to be open to other providers as well. True?
Dr. Knight: Absolutely. Absolutely. yeah.
Dr. Diamond: That's fantastic, and it goes along with the National Academy of Medicines action collaborative on clinician well-being and resilience and you're a member of that. I listened to your presentation at the first public meeting which was fantastic by the way, even if it was at five o'clock in the morning. I just want to vote for maybe a little later start which would be helpful for those of us on the West Coast. I'm super excited about that big project as lots of organizations are involved. Can you tell me a little bit about the process and being involved? What have you learned and how it is interfacing with these other organizations? My second question is, how can the rest of us get involved?
Dr. Knight: Well first of all when the American Academy of Family Physicians was approached about the potential interest in participating, we enthusiastically joined at the table to have the initial discussions. At first, they weren't sure that anyone would sign on, but they quickly recognized that the National Academy of Medicine is a real vehicle for combining energy and multiplying effort. Our Board of Directors enthusiastically supported our signing on as a sponsor. That collaborative kicked off earlier this year and is very similar to what I've mentioned before that the National Academy of Medicine has a recognition that there are system issues that we need to be addressing as well, as helping individuals. Raising awareness of the importance of this, not just to those clinicians who may be struggling with some burnout and struggling to improve their well-being, more importantly, the downstream effect is how it affects the quality of care and safety of care that patients receive. It is exciting that with the National Academy of Medicine, which used to be known as the Institute on Medicine the IOM, there's a real opportunity -- just like the IOM report on “To Err is Human" and the recognition that the medical safety and medical errors were having a significant impact on quality of care. I think likewise the National Academy of Medicine has an opportunity to raise the awareness of the importance of a clinician well-being. We believe that when clinicians are at their best everyone wins and so we're working to identify those resources that are already available. Help collate, collect, curate those resources and one of the real deliverables for this is going to be a hub that will be available through the National Academy of Medicine. Then another real deliverable is policy statement that will challenge those folks of authority and decision making and influence within organizations to make clinician well-being a top priority. My role previous to this was Chief Medical Officer of a health system. I reported directly to the CEO of a health system and worked closely with our chairman of the board. I can tell you that when the CEO and the Chairman of the Board recognize that something is a priority and decide to put resources towards it, a lot can be accomplished and right now it feels like that hasn't risen to that level of priority for a lot of organizations. I think the National Academy of Medicine coming out publicly and stating this level of importance will catch some people's attention. I believe that will rightfully shift some focus on what do we do as an organization and what can we do to improve the wellbeing of our clinicians on behalf of providing the highest quality and safety care that we can provide? So yeah! I think that the National Academy of Medicine has a great opportunity here and we're going to work hard to make sure that we totally optimize on that
Dr. Diamond: Fantastic! Any resources that you would direct people to?
Dr. Knight: Of course for our members, I direct them to the www.aafp.org which is our home page for the American Academy of Family Physicians. In addition to that, the National Academy of Medicine has some great resources specifically related to the action collaborative that's underway the AMA (American Medical Association). Their Step Forward program is a useful set of modules that folks can utilize to help address of a variety of practice in organizational and individual improvements. I've found that the resources to Stanford are particularly well done as well
Dr. Diamond: Fantastic! I'll put links to all those in the show notes that people will be able to access that so thank you so much. Any final comments that you have for us today?
Dr. Knight: I hope anyone listening, recognizes that their incredible dedication to helping others is really important and that's really what this is all about. I encourage you not to feel guilty about wanting to take care of yourself so that you can be in top shape to provide care for others, so thanks. I want to thank everybody for what they do to help others and encourage them to recognize they're not alone in this. There are a lot of us out there trying to help develop and promote resources that folks can find and help them achieve their missions in life.
Dr. Diamond: I like to thank my guest today Dr. Cliff Knight of the American Academy of Family Physicians. You've been listening to Trench Tested. I'm your host Dr. Dan Diamond if you'd like the links Dr. Knight mentioned, please go to trenchtested.com and check out the show notes. Thanks to those of you that subscribe to the podcast, a special thanks to those that have taken the time to leave a review at the iTunes store that means a lot to us and helps us get the word out. If you're finding these episodes helpful, please go to reviews.trenchtested.com. If you have any questions you would like me to address or if you're interested in having me speak at your event please drop a note at email@example.com. Thanks again will see you next time.
Here are the resources Dr. Knight mentioned in this episode: