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Flourishing in Medicine: From Surviving to Thriving Episode 6 Colin West, MD, PhD · Flourishing in Medicine: From Surviving to Thriving

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Welcome to Flourishing in Medicine from Surviving to Thriving.
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I'm your host, Dr. Mick Krasner.
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This podcast produced by EmPRO is a medical professional liability insurance carrier headquartered
0:35
in New York State.
0:37
It came about because of EmPRO's deep commitment and actions to support the physicians they
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protect.
0:43
This commitment includes many wonderful learning opportunities that they have developed, and
0:47
I hope you explore these podcasts and others of their offerings.
0:52
I'm very excited to share with you my conversation today with Colin West, MD, PhD, Professor
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of Medicine, Medical Education, and Biostatistics at the Mayo Clinics in Rochester, Minnesota,
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where he also serves as Director of the Mayo Clinic Program on Physician Well-being.
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Dr. West's research has focused on medical education and physician well-being and has
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been widely published in prominent journals including The Lancet and JAMA, Annals of Internal
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Medicine and JAMA Internal Medicine.
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Dr. West's research aims to improve patient care by promoting physician well-being and
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reducing physician distress.
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The discussion today highlights for all of us how physician well-being and excellent
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patient care are interconnected, forming a virtuous cycle.
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And Colin has been at the forefront of building the data that shows the degree to which physicians
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and health professionals are distressed, the impact of that distress, and innovative ways
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to address it.
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Colin expresses a deep understanding that our health systems and organizations face
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tremendous pressures, very often to simply survive and continue to carry out their mission
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of being a source of health care for their communities.
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However, he points out that addressing physician and health professional well-being should
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nevertheless be a central part of their response to these pressures.
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And now, our conversation with Colin West.
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Well, thank you Colin.
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It's really nice to see you and nice that you're taking the time to speak with me and
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have our listeners listen to what you have to say.
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I wanted to start with a question about what has brought you into medicine in the first
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place.
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You know, the experiences of I've had facilitating and teaching students and practicing clinicians,
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teachers, academics, and so on.
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I've heard some really interesting stories about what it was, sometimes from early experiences
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in their lives of what brought them in to health care and especially to become a physician
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and for you, in your case, academic physician, physician researcher.
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So if you could tell us a little bit about how this happened, what were some of those
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early formative events perhaps, if there were any that you recall, and how it contributes
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to your life, how it's helped form your life's purpose at this point.
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Wow, there's a lot there.
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First of all, thanks for having me on the podcast, Mick.
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It's always great to visit with you, whether it's formal or informal.
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So I'm looking forward to chatting during this session.
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You know, my story in getting into medicine is a little bit like my story of getting into
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well-being work in medicine, not a direct path.
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I did not come from a science family.
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I am the first in my family to sue a science degree of any kind.
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My mom was an English professor and my dad worked in journalism.
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He was a very skilled headline writer and copy editor.
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I was an accelerated student early on, very interested in math and in science and in reading
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and as part of that, when I was in college at an early age, I started thinking about,
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well, I really like this intersection of science and analytics.
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What's the best way to continue to learn about science in a way that applies to people?
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Because as I got a little bit more into education, I became more interested in applications to
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other people and what those might look like.
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I did not have a background in medicine to have a context for what purpose in medicine
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really was about.
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I didn't have a seminal event in my past, you know, a family illness or a personal experience
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that said, oh my goodness, I've got a role model that's going to, that's who I want to
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be when I grow up.
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It was more about chasing the science and the intellectual curiosity.
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And I got into medical school really not sure about where this was going to go.
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And in reality, you know, training in the early 1990s, when I started in medical school,
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the standard curriculum was, you know, for the first year and a half, sometimes even
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two years at many medical schools, you wouldn't see a patient.
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It was, in my case, three semesters of four to eight hours in a lecture hall or a lab
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learning this immense volume of background material with only indirect connections through
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text paragraphs to other people.
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I questioned whether I'd made the right choice.
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The science was there, certainly answering questions that, you know, expanded knowledge
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horizons.
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That was always there.
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But the meaning behind it, the why does this matter piece was not clear at all.
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And then in the fourth semester of medical school, and I was in a combined MD, PhD program,
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so I was getting close to the end of before I would spill out into my graduate phase.
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So the clock was kind of ticking for like, is there going to be a spark here at some
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point?
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When is this going to happen?
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The fourth semester at the University of Iowa, where I went to medical school, was all about
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foundations of clinical medicine.
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That was the name for the course.
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And it was an entire semester where basically they took the first three semesters of book
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work and lab work, and it all became centered on patients.
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And suddenly it was like the light bulb turned on and it was, wow, this is why this matters.
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I can spend four hours listening to clinically relevant content lectures.
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And then the afternoon, I'm learning how to do a physical exam.
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I'm actually visiting with patients and engaging with their experiences.
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And thank goodness that resonated so strongly with me to where I then got into some clerkships
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and I was really excited as I went out into the graduate phase of things to finish that
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part and then come back to the clinical side of things and be able to be sort of energized
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for the rest of it.
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But again, I didn't really know what the future was going to hold.
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I wanted to chase the intellectually curiosity, fulfilling aspects of things.
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And I was hopeful that that connection with helping other people was going to provide
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a context that would be valuable, not just for me, but for the people I was hopefully
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going to be helping.
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And thankfully medicine delivered that.
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And in retrospect, although I would have liked to have seen a little more patient contact
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early in the curriculum and most medical schools have changed now to do that earlier, which
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I think is really powerful and important.
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The background in those first three semesters in a lot of ways made me hungrier for that
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patient interaction, that application, the translation of all that knowledge to patient
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care, which I think I've held with me now.
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I mean, we're 25 or more years later and I still feel that spark of excitement and enthusiasm
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of, wow, it's amazing that we have all of this knowledge that we can connect with and
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we're able to bend that in a direction to help other people.
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That's incredible.
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And that's the spark behind medicine for me.
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So I'm going to ask you just to dig a little deeper into that.
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You discovered that it really resonated, really came together when you started to apply or
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see the applications toward clinical care.
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Now in retrospect, looking back, do you have any idea?
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And you may not really know where it came from, where that came from, that it did resonate
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in the end.
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There must have been something about humanism, the human element that was in you when you
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started on this path, when you started formally studying science and then applying to medical
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school to an MD, PhD program.
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Any reflections now looking back?
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So I think that's probably true, but I was not reflective in any way at the time about
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some of those deeper purpose-laden kinds of motivations.
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That's something that I feel fortunate to have stumbled into, frankly.
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And again, I started medical school because I wanted to learn more about the science and
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it was the best way to continue to learn deeply about science, especially in relation to people.
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What that would turn into with relationship dynamics and meaning from work and things
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like that, I'll be honest, I was not the slightest bit reflective about.
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It took three really hard, I mean, a year and a half, three really hard semesters of
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wondering, where is the deeper meaning behind all of this?
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I mean, I can take multiple choice examinations forever and ever and ever.
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And I can read 20 pages of a really dry medical textbook and regurgitate answers in a vacuum.
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But why does it matter?
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That was something as I grew up a little bit more, maybe I gained my own sense of a little
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bit of personal maturity.
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I began to sort of ask those questions a little bit more intentionally.
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Why am I doing this?
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And where is this going to go?
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I think without actively labeling it, I was questioning after that third semester of medical
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school, what is the next step here for this?
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Maybe I'm going to go into the graduate phase and I'm going to go into, you know, my PhD
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was in biostatistics, a little bit unusual for an NIH funded MSTP program, especially
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30 years ago.
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But maybe I'm going to be a biostatistician and I have the medical background, but I'm
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not going to really use it to see patients.
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And I was starting to wonder about that.
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And then again, this aha moment of, oh, when this is actually in front of a patient, their
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ability, I think unexpected to me to a large degree, I found that deeply fulfilling in
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ways that I would not have predicted.
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I mean, fast forward a couple of years after my PhD, when I went back into the wards, there
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were rotations that I would not have expected to have enjoyed the way that I did.
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I didn't know anything about kids and yet pediatrics was one of my favorite clinical
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experiences as a medical student.
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Being able to just go into those experiences with my eyes open to say, I'm going to embrace
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and absorb whatever's going on here.
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I knew early on, I didn't want to be a surgeon, but I could go to surgical clerkships and
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still see the amazing things that were going on and appreciate that and be part of that.
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Even if I knew, you know what, this isn't quite the right career line for me.
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And medicine just kept offering that.
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There are so many experiences.
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And to be able to anchor those experiences in something that I hadn't predicted or anticipated.
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We all write it in our application letters and our personal statements that we want to
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help other people.
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And I think I believed that when I wrote my medical school applications, but I didn't
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really understand it.
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And medical school and those clinical experiences actually connected me with understanding,
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yeah, the words that you put in that personal statement, they weren't just words to get
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into medical school.
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You didn't know quite what the context was, but there was something there that now you've
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finally been able to tap into.
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That's what medical school delivered for me.
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And I would be misrepresenting my path to medicine if I said it was any deeper than
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that because I really did not have a deeper plan or I know this is going to go the way
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that I want it to go and I just need to get through these few years to get to that other
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side.
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I was hopeful, but not particularly, again, reflective about it.
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I was a put your head down and get through it and hopefully something on the other side
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is going to be worthwhile kind of student.
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Well, you just spoke about something that I really connected with, which is this curiosity.
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What I heard was an immense amount of curiosity across all of medicine that began to develop
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and take shape in you and was very exciting.
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And I think for many, maybe most of our colleagues, that's there.
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Whether you're an internist or a surgeon or a pediatrician, we do appreciate and really
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have respect for all these different areas in medicine.
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So that was really interesting.
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I wanted to go back to something you said when you first started answering the first
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question, which was you alluded to how what you're going to share also has led you to
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what you eventually wound up being a focus of your academic career, at least part of
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your academic career, which was and is well-being in health professionals, especially physicians.
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Can you walk us through how that took shape, how that developed, how you began to identify
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this was a really interesting, worthwhile and important area of investigation?
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Yeah, absolutely.
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And again, at risk of disappointing listeners out there, this was not a grand plan that
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in five years in my career plan, I will be doing this and in 10 years, I'll be doing
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this and in 20 years, I'll be doing this.
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I think the common thread is that constant intellectual curiosity.
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But as I mentioned, I was really a put your head down and get through it kind of student.
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And there are incredible experiences that we all have in medical school, in residency,
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in our practices.
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But I think anyone who says that every moment of those training and practices experiences
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is a joy, is delusional.
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And they're lying either to themselves or to the people they're speaking with.
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The reality is that training is tough.
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And you are in stressful situations with other people who are also under intense stress.
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And we are often not our best selves in those situations personally.
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And we are the recipient of other people who aren't their best selves in those situations.
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And that makes the environment really fraught for people that are in the middle of it.
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And so for me, it was look, there's so much to learn.
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Each step that you take in a medical career, you realize how little you actually know.
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And you have to be open to that new learning.
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Medicine is constantly changing, you have to be open to that.
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And so for me, as I was going through residency at Mayo, where I did my internal medicine
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residency, I was trying to be as open to those experiences as possible, even when frankly,
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I wasn't having a great week or a great month.
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Q3 in the ICU was not my favorite period of time in life.
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People who love critical care, bless you because we need you.
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But I was not one of those people.
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And there's a lot to learn.
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Patients need you.
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You try and embrace that as best you can.
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I didn't really think about well-being.
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Then as a chief medical resident, things changed.
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And there were a couple of key factors.
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The first is just the context of being a chief medical resident.
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Mayo is a very large internal medicine training program.
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And suddenly you see in a leadership role like that, where you have responsibility as
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part of a team for 170 trainees, you realize people are on different places on the spectrum
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of well-being and not everyone can grin and bear it.
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And it's completely normal for people to struggle and sometimes really seriously struggle as
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part of the human condition.
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So as someone who was responsible for the experiences of these other trainees, again,
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not alone as part of a team, but suddenly my eyes are opened to, you know, you really
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can't just expect people to put their head down and get through this.
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They have other complexities in their lives.
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They bring individual characteristics to this.
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There was a sense of, you know, there's a little bit more suffering and struggle out
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there than I had appreciated.
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And then at the same time, my colleague, Tate Shanafelt had come out to Mayo for his HEMOG
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fellowship and he had done some early work as a resident at the University of Washington.
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He was interested in pushing that a little bit further.
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And he approached our program director and said, you know, I'm interested in furthering
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this.
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Is there a pathway for this at Mayo?
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And my program director, a guy who's now at Michigan named Joe Colars, basically said,
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well, I don't really know where you could take this, but it sounds interesting.
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And if you're talking about doing this the right way, you really need to study it.
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And I've got a chief medical resident who has a PhD in biostatistics.
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Isn't that convenient?
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So he said, you two need to meet.
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And my program director, Dr. Colars, he calls me up and says, you know, I don't know much
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about this character, but Tate Shanafelt has come here for training.
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He's working with some other people in graduate medical education leadership as well.
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He's got energy.
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I think he's going to get some things done here.
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I'd like you to take a meeting with him to explore where some of this wellbeing work
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might go.
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And I've told this story to others and I've shared it with Tate as well, actually.
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I didn't want to take the meeting because I was busy.
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I'm the chief resident with 170 people that I'm responsible for.
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How am I supposed to fit this in?
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And I'm not looking for other research projects.
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I've got five on my plate as it is.
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But the program director says, I want you to meet with this person.
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So you meet with this person.
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And so set up some time, 30 minutes.
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That's all I was going to make available.
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And two hours later, we were still talking and planning our first study.
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It was just one of those, he had an energy.
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I had a skill set and I was receptive to, again, that intellectual curiosity of, you
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know what?
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This is actually something.
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We don't know where it's going to go, but it is worth pursuing.
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And again, a little bit like getting into medical school, the intellectual curiosity
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around the science and the questions was the first driver.
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There was a context of, yeah, other residents are struggling and maybe we can learn more
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about that.
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There is a humanistic aspect to can we maybe improve the environment for everybody in medical
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school?
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I had been, I had really tried hard to be a keen observer of my environments and I would
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try to stay out of the line of fire.
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But I made a lot of mental notes about observations from residents and attendings.
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Here are some things that I really like that they do.
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And here are some behaviors I hope I never emulate because they're not productive.
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They're actually abusive and that's not going, it's not appropriate.
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It's not helpful.
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So I had a little bit of that background.
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We designed the first study and basically a little bit like, you know, a positive hydra.
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Every question that we lopped the head off of sparked several more and just a steady
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growth from there to very local internal medicine residency investigation to then, well, what's
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going on in the faculty at Mayo Clinic to what's the national picture?
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And then suddenly the switch flips and people are asking us questions about, well, what
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are the solutions?
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If you've now suddenly shown this is prevalent as an issue, why haven't you fixed it?
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And it was a whole progression to this that has led to building an entire community and
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a dialogue around well-being that 20 years ago was not nonexistent because this has bubbled
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periodically over decades, but was receiving very little attention to where now we have
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National Academy of Medicine reports on this.
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We have Surgeon General advisories.
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It is well understood that the path to delivering the care that our patients need runs through
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making sure that our healthcare professionals are themselves well enough to deliver optimal
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care.
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Yes, thank you.
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There are a few things I wanted to comment on.
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One was this notion of not having a grand plan.
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I think it's so true for us in medicine in general, for human beings in general.
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You may have known this in April, last April I walked the Camino in northern Spain, 850
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kilometers.
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And on the Camino I see these graffiti everywhere, this Spanish poet from the early 20th century
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saying walker or path maker or pilgrim, there is no path.
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You make the path as you walk.
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And this was all over the place.
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And it was just the notion that you begin and you take us, all you know is what your
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next step is, but you don't know how you're going to fetch up on the horizon.
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So I really connected with that.
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That's been my experience.
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And I think that's probably true for many of our colleagues.
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The other thing is that one of the things that help, I think physicians flourish is
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effective teamwork.
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Teams are really important and more and more we're moving into collaborative models of
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care and medicine.
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So the team is not only important, it's the way forward, it's the way we care.
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They can be very meaningful, positive experiences.
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They can also be very difficult.
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You mentioned Tate Shanafelt.
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Maybe you can just say more a little bit about the team of West Shanafelt and Derby.
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I'm interested in how teams work.
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And I think our listeners listening to this podcast called Flourishing in Medicine could
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be enlightened a little bit by the collective work, your collective work that has been so
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inspiring and maybe some aspects of working as a team like that.
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Definitely.
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And I think all of us, Tate, Lottie and I would all endorse that we would have been
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nowhere near as successful in exploring wellbeing issues and trying to understand a deeper narrative
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that isn't all about burnout.
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It's really about how do we mitigate distress and push people toward our real objective,
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which is thriving and flourishing in their learning and working environments, in their
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careers in medicine.
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It has required the team.
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One of my favorite quotes, which although it's sometimes in the popular literature been
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ascribed to Oprah, actually I think comes from Seneca, is luck occurs at the intersection
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of skill and opportunity.
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And I think a common thread for most successful people is they do work really hard to develop
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a skill set.
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And it can take different forms, but you have to have some ability to get things done.
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And then you have to be open to opportunities when they cross your path.
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And when you're able to put those things together, some people call that luck.
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I don't think it's luck at all because luck to me implies something random.
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You put yourself in the best position for success by attending to skills and being open
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to the opportunities.
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So by that definition, I've been incredibly lucky throughout my career, even when I haven't
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known what the next step is going to be.
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I've worked hard to build a skill set that has been relevant to other work.
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And I've tried to be an observer and be open to opportunities, even if sometimes they've
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required that I take a meeting that I didn't want to take at my program director's behest.
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But even there, within 10 minutes, it was clear that something was happening there.
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What Tate Lottie and I have in common is first a commitment to doing work properly.
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So there's a methodological rigor.
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It's not purely touchy-feely kind of work.
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It's science.
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And this isn't about simply taking subjective feelings and generating anecdotal narrative
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reports around those feelings.
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There's value in those kinds of human personal stories, by the way.
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I'm not diminishing them.
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But in terms of advancing knowledge of a field, those really more provide context for the
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why we do the work that we do.
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They don't give you answers to understand what's driving those things or where solutions
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might lie.
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And so being committed to methodologically being as rigorous as possible is a common
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sort of theme for the three of us.
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I think another piece to this is there's an underlying motivation that has actually never
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been about, well, I need to increase my H index.
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I need to advance my academic rank.
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I need to get a grant or increase my salary or get consulting fees or things like that.
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It's really always been about chasing that intellectual curiosity that we all share and
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that I keep coming back to, but importantly, in service of something larger than the three
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of us.
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Because this is really about buying into something that all three of us had under the Mayo umbrella.
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Primary value at Mayo Clinic is the needs of the patient come first.
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How do you honor that primary value?
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And although that's the primary value statement for Mayo, I would argue that that's actually
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a core professional value across medicine that almost every physician and other healthcare
28:21
worker holds dear.
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That's been a fundamental motivation.
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We try to understand what's going on in this environment for our healthcare professionals.
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That is not allowing them to fully connect with meeting the needs of patients.
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What does that mean from a professionalism standpoint?
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What does that mean when we think about other related issues like how far does altruism
28:51
go as one of our core ethical tenets in medicine, for example?
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Is it professional to grind yourself into dust in service of your patients?
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Or is it paradoxically, in some situations, you can put your patient first to your own
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detriment in a way that feeds forward to disserve your patient because you're not actually able
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to empathize or connect or be available for them when they truly need you.
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I think the three of us really were motivated by those deeper questions, but wanted to get
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at those answers in a rigorous sort of way.
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Then we were really fortunate as we connected with leaders at Mayo who helped us get some
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of this research work started that when it was ready to expand beyond Mayo's borders,
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we had some really important connections with people like Chris Sinski at the AMA, who has
29:51
been longstanding vice president for professional satisfaction among many other roles and contributions.
29:59
She was able to build on several decades of experience as a general internist in her own
30:05
practice.
30:06
She had context and awareness of this is lived experience, but also a connection through
30:13
the AMA to this national discussion in a way that we didn't have.
30:21
Again, we had a skill set to build credibility and an opportunity to partner with someone
30:26
who was like-minded at a national organization, presents itself.
30:31
From the outside, it could look like a lucky confluence of events.
30:35
Wow, how did these people ever cross paths?
30:38
But in reality, we were all staying open to the possibilities as we were marching down
30:46
our own paths, and we stayed open to what that future would look like.
30:50
The team part of it has been absolutely essential.
30:53
None of us could have done what we've done and hopefully will continue to do to move
30:58
all of this forward.
30:59
Even as we've dispersed to different institutions, had we not embraced from the very beginning
31:05
that we are stronger together.
31:07
And that's a theme across all of interdisciplinary teamwork in medicine.
31:11
I think it's a strength of the Mayo environment in particular.
31:14
So we all benefited from that sort of ethos within our structure, but we were receptive
31:21
to that and we've seen it modeled over and over again in such a way that the team is
31:27
actually baked into how we think about these things.
31:30
And I think all of us would feel like we'd lost a limb if we stopped working together
31:34
at this point.
31:35
Yes.
31:36
I think that your discussion of that particular team and what came together, the rigor, the
31:41
agreement on rigor in investigation, your curiosity, all of your curiosities, and the
31:48
values that drove you is very inspiring.
31:51
I would refer the listeners to wonderful series.
31:55
I'm sure you're aware of it in the Newlyen Journal.
31:57
I think 2019, Lisa Rosenbaum, one of the writers for the journal, a cardiologist, a three-part
32:04
series on teamwork in which she really outlined some really wonderful ways of thinking about
32:10
our teams in medicine and how we can improve them.
32:13
I did want to ask something about where this all begins in terms of the challenges to well-being.
32:20
You've investigated not only physicians, residents, fellows, trainees, as well as medical students
32:27
in terms of well-being.
32:29
Maybe can you paint a picture for what seems to be the source?
32:33
I'm sure there's many.
32:35
It's complex, but where is the source, as you see it, of some of these challenges to
32:43
our well-being collectively?
32:47
Maybe you can weave in a little bit about the program on physician well-being at the
32:51
Mayo Clinic that you direct, how that came about maybe as a result of trying to address
32:57
root causes, we can say.
33:00
Yeah, so as I start thinking through this, I will anticipate that I may need you to remind
33:06
me about the second part because I'll go off on tangents potentially.
33:12
Where does this all start is actually a complicated and controversial question.
33:20
I think stepping back a little bit, one fairly simple way to think about well-being in medicine
33:28
is that there are both individual and environmental contributors.
33:33
Historically, we've paid the most attention in medicine to the individual contributors.
33:39
In fact, there's a very common mindset that has only started to change in the last 10
33:44
years or so that if someone is struggling in medical school or residency or subsequently
33:50
in their practice, maybe they chose the wrong profession and they weren't prepared for
33:55
the rigors or they didn't self-assess their personal characteristics accurately enough
34:02
to be able to withstand what they should have known was going to be a challenging career
34:07
path.
34:08
Unfortunately, that sends a message to people really that we're going to blame the victim
34:14
as an individual for their experiences during training.
34:19
The analogy that I think we should learn from is from quality and patient safety.
34:25
Where if you go back prior to 1999 when the Institute of Medicine put out to air as human,
34:32
the most common approach, not universal, but the most common approach to dealing with errors
34:37
that affected patients and patient safety issues was to identify the individual who
34:43
was deemed most responsible for that error, isolating and identifying that person.
34:49
We would have M&M conferences where they would be brought up onto a podium to defend themselves
34:55
against the indefensible and they would be humiliated, frankly, and that was supposed
35:01
to be instructive.
35:02
They would never want to make that kind of mistake again and everyone in the audience
35:06
would be terrified and that would prompt them to be more attentive, be more dutiful.
35:13
We know that in the short term, fear can be a powerful motivator, but we also know in
35:17
the long term, it's a terrible educational strategy and yet that was the norm.
35:24
And then to air as human came out and said, wait just a minute here.
35:29
Let's think about who goes into medicine.
35:31
The vast majority of people who choose medical careers are dedicated, committed, bright,
35:39
passionate individuals who want to help others.
35:43
So how can it be that when mistakes happen that they don't want to have happen, we then
35:50
turn on them and isolate them and suggest that they are defective?
35:57
Why aren't we taking responsibility for a system that doesn't protect both patients
36:02
and healthcare professionals from human fallibility?
36:06
That's really my sort of nutshell of what to air as human was all about and, you know,
36:12
Deming, one of the leaders of the quality movement has identified 85% of the reasons
36:18
for failure are rooted in systems and workplaces.
36:24
And I think that that's probably fair in wellbeing as well.
36:29
There is a 15 or 20% part of this that comes from the individual and we have to take responsibility
36:36
for bringing our best selves to our work.
36:39
But the majority of this is about taking well-intentioned, highly skilled, intelligent people and putting
36:47
them in untenable learning and working environments where they almost have to be superhuman to
36:53
survive and when they're not superhuman, even for a moment, we turn on them and say, see,
37:01
you're deficient.
37:02
Now, where does all that start?
37:03
Well, from an individual standpoint, there is a physician personality that's been described
37:09
going back decades and it's variable, obviously, because we're all different.
37:14
But some common threads are that we have perfectionistic tendencies.
37:19
We thrive on positive feedback.
37:22
We are trained over years and years and years to strive for the perfect score and the praise
37:27
that we receive for getting straight A's and things like that.
37:31
And it is easy to be seduced into thinking that those are the primary outcomes that matter.
37:38
When in reality, as you get into medicine proper, you realize, much like I illustrated
37:43
in my own story, it's not about the grades or the multiple choice questions.
37:49
It's about your interaction with a patient on their journey of hope and healing in whatever
37:55
form that takes.
37:56
And that is subjective.
37:58
And for people, it's informed by your knowledge base, but it's so much more than that.
38:04
And that can be incredibly daunting.
38:08
Or if you're able to get your arms around it a little bit and dance with the uncertainty
38:13
that medicine brings, it can be deeply meaningful.
38:18
And the purpose behind a career in medicine is unparalleled.
38:24
So that perfectionism doesn't start in medical school.
38:29
It may not even start in undergraduate because we're going back even in elementary school,
38:34
perhaps.
38:35
There are no studies, good studies of this to my knowledge, tracking over decades of
38:40
a medical career.
38:42
But some of these tendencies, these innate characteristics, I say innate, but they're
38:47
also learned.
38:49
These are brought into the medical school environment.
38:52
And they may put people at risk of then being in an environment that is not able to support
38:59
them fully.
39:00
And they're not able to achieve the same level of relative success.
39:06
For example, most of us had the experience in our first few weeks of medical school being
39:10
told by somebody, now remember, all of you were the top students in your colleges, but
39:17
half of you are now below average.
39:21
And that seems like a ha ha, what a funny thing to say.
39:27
It's not if you're one of those people that for the first time in your life is below average
39:32
in your peer group by somewhat artificial metrics, but you don't know they're artificial
39:38
until you have a larger view into what medicine is really all about.
39:43
And so that individual piece of it is part of what drives this.
39:47
And then the bigger part is environmentally, we have not taken enough responsibility for
39:52
putting people in situations where they actually can tap into what I call the MVPs of well-being,
39:59
meaning values and purpose.
40:01
And instead, we run them through a gauntlet of examinations and presentations on rounds
40:11
where if you make a mistake, you're worried that you're going to be ridiculed.
40:16
And I'd like to think that our training environments have progressed immensely in a positive direction,
40:22
even in the last couple of decades.
40:24
But we know it's still not perfect.
40:26
There's still a lot of that sort of blame and shame, lack of respect for fellow human
40:32
beings.
40:33
And the idea is we don't have time for that.
40:37
We need to serve our patients and you need to get better.
40:41
But in reality, we get better, faster and more effectively when we're nurtured and cared
40:47
for along the way.
40:49
And so I think those are some of the background kind of contextual elements.
40:54
And then those also inform solutions.
40:58
And that's where the program on physician well-being comes into play, because that's
41:01
a research program at Mayo.
41:03
It started in 2007.
41:06
And it started as a direct result of the then Chair of Medicine, Nick LaRusso, at Mayo in
41:11
Rochester, Minnesota, I should clarify, that he said, look, you've done this work on internal
41:18
medicine residents.
41:20
What do we know about the staff, the physicians at Mayo?
41:25
Because aren't they dealing with the same environments and the same pressures and the
41:29
same stresses?
41:31
And our answer at the time was, we don't know anything about the attending physicians.
41:36
It's never been looked at, certainly not in the Mayo environment and minimally nationally.
41:43
And so our Chair of Medicine said, we need to start something to allow you to look at
41:49
those questions.
41:50
And I'd like you to start with Mayo, because that's where our current questions are.
41:56
But I think this should expand rather rapidly to beyond Mayo's borders.
42:02
Tate Lottie and I were supported, it was pretty modest.
42:06
I mean, we're talking 10% protected time for each of us to be able to launch this program
42:14
to further the research first and foremost, and then serve as kind of an advisory group
42:20
in an informal way for leaders across Mayo, as some of these well-being issues would come
42:27
up around learning and working environments.
42:31
All of that's informed by this balance between what are individual physicians or learners
42:38
bringing to the table themselves?
42:39
What are their personality characteristics around perfectionism or I'm going to say
42:45
narcissism.
42:46
I don't mean that in a personality disorder level for the most part, but a tendency toward
42:54
needing that positive feedback to sustain ourselves.
42:58
And as we've learned more recently in studies that we didn't know 15 years ago, despite
43:04
all of our accomplishments and our skills, we actually, we grind ourselves down.
43:09
We don't self-value as highly as the general population.
43:13
We have higher rates of imposter phenomenon in medicine.
43:17
Some of that's because we think our peer group is amazing and it is, and we don't include
43:22
ourselves in our peer group.
43:24
And it's an amazing thing that you can think all of your colleagues are incredible and
43:29
wow, just wait till I'm found out.
43:32
And they're thinking exactly the same thing about how incredible you are.
43:36
And neither group is ever telling the other group how amazing they are.
43:42
And so we have this sort of silence around our feelings of self-worth that feed into
43:49
that perfectionism, those individual characteristics.
43:54
And that informs potential structures and solutions.
43:58
And as you said, it's complicated, but you start to see where some of this, it takes
44:03
a little bit of shape out of the ether.
44:07
And you can start seeing where some of these dimensions that drive not just distress, but
44:13
if we turn them in the right direction, engagement and thriving, we can see where some of those
44:19
levers are.
44:20
You talked about teams, building community connection.
44:25
It's remarkable how isolated healthcare professionals actually often feel in what is an incredibly
44:31
social and team oriented profession.
44:34
And yet, unless we're intentional about building that sense of community and even beyond that,
44:41
true, excuse me, true belonging, we can lose that.
44:46
How do we manage our workloads in a way that we can cope with?
44:49
Do we attend to that?
44:50
Or we just say you work until the work is done.
44:53
Well, that's laughable in medicine because the work is never done.
44:57
There has to be some boundary that allows you to recover and be able to come back and
45:02
bring your best self forward for your patients.
45:05
And the team piece of it, and then I'll take a pause, the team piece plays into that as
45:09
well because historically the culture of medicine has been the buck stops with me.
45:15
I am ultimately responsible myself.
45:19
And that's been considered part of dutifulness and commitment to the profession and your
45:25
patient's needs.
45:26
We have to evolve that to say, I cannot deliver that and sustain that 24 hours a day, 365
45:35
days a year.
45:36
I need time to recover.
45:38
I need restorative periods.
45:40
My patient should not experience those gaps, however.
45:44
So how do we keep the patient supported 100% of the time?
45:48
Well, we have to make set up structures where we have, okay, I'm in a restorative period
45:55
right now, but I've got a team and my colleague is just as skilled and equipped and rested
46:02
and prepared as I am so that when quote unquote my patient, really our patient collectively
46:10
has a need, there is somebody there so that they don't experience a drop in the service
46:16
or care that they receive.
46:19
We can still have primary care panels where we have patients that are, you know, mostly
46:24
hours individually.
46:26
But we then develop safety nets as teams for when we need ourselves to rebuild, recover,
46:36
just take time for the non-work aspects of our lives that are necessary for us to be
46:40
fulfilled as complete human beings.
46:43
That's a frame shift culturally for medicine that I think we're struggling with right now
46:49
across the profession, but it's a necessary shift.
46:53
How do we maintain personal responsibility, but link that with a context of team-based
47:01
safety structures for our patients?
47:03
Yeah, well said.
47:05
I think it can be done as I'm sure you do.
47:08
It's just getting there.
47:10
I would say that the nascent seeds that were planted in those early days of the program
47:15
on physician well-being have really had profound impact across medicine.
47:20
I want to just shift a little bit towards solutions.
47:23
You and I have spoken, Colin, before about the concept of Chief Wellness Officer and
47:28
what role that office can have in affecting systemic change for the better.
47:34
If you can, maybe describe what you see as the resources that that office needs and the
47:39
approaches that it requires to be effective and maybe discuss if we are anywhere near
47:47
close to a critical number of CWOs, Chief Wellness Officers, with such resources and
47:53
approaches.
47:55
One more thing, an individual and office like the Chief Wellness Officer cannot possibly
48:01
fix all the woes that physicians and other health professionals experience in terms of
48:05
their well-being.
48:08
Maybe add to that what other ideas should we be considering?
48:11
Yeah, so the first thing I'll respond to in terms of are we approaching or have we achieved
48:17
a critical mass where Chief Well-being Officers, leaders in this space who are embedded in
48:24
the executive functions of an organization are present?
48:28
It's an easy question to answer.
48:30
We are nowhere near a critical mass.
48:32
We are woefully deficient nationally, actually.
48:35
And again, I go back to the quality and patient safety analogy.
48:39
We need to learn faster for well-being.
48:42
Almost every organization has a Chief Quality Officer or a Chief Patient Safety Officer
48:48
when 20 years ago that didn't exist.
48:51
The most important reason there is because there's been an increasing understanding that
48:57
patient safety is not something that happens without specific attention.
49:02
No matter how skilled we are, human fallibility, uncertainty, random chance, all of these things
49:08
are part of medicine.
49:10
So you need to have a structure that isn't responsible itself for ever getting to zero
49:16
errors.
49:17
That's not achievable or reasonable, even though it's an aspirational goal we still hold, but
49:22
is responsible for setting a strategic framework for an organization and even nationally around
49:30
how do we minimize errors, maximize patient safety, and make sure that this is something
49:35
that institutional processes connect with.
49:40
And that's where I think well-being leadership needs to be nationally.
49:44
You mentioned a CWO is not going to fix all well-being issues by themselves.
49:50
That's absolutely true.
49:52
What a CWO offers is a formal recognition that the well-being of your healthcare teams
50:00
is a foundational priority that serves your organizational mission.
50:07
And I view the CWO role as actually a role of facilitation more than anything else.
50:14
This is a role that helps your executive leaders who have other areas of responsibility deliver
50:21
on those longer-term mission objectives.
50:25
What's their vision for the well-being of the organization?
50:30
I have yet to meet a CEO or an executive leader at an institution who gets up every morning
50:38
thinking, how can I make my healthcare professionals struggle today in delivering great care for
50:44
patients?
50:46
They have their own challenges, and the financial world in medicine is very messy.
50:53
There's a lot of personnel management and workforce shortages that are tied up in well-being
50:59
actually.
51:00
They've got a lot of challenges for them to deal with, to expect them to weave well-being
51:07
naturally into all of those other considerations when there's an entire depth of knowledge
51:12
behind well-being is not reasonable.
51:16
And so a chief well-being officer, in my view, having that person at the table when those
51:22
executive C-suite type discussions are happening keeps this fundamental human value in the
51:29
conversation.
51:30
And I think it actually allows well-intentioned leaders to maintain that focus that I think
51:37
they all really want to have.
51:40
But if it's not formalized and part of the conversation, it risks becoming almost an
51:46
option when you're faced with emergencies that are financial or staff-related or whatever
51:53
the different dimension may be.
51:57
And you're going to put out the fire that's in front of you.
52:01
That's human nature in leadership as with anything else.
52:04
And so well-being leadership fits that role.
52:09
Patient safety leadership, I think, is a similar idea.
52:12
DEI leadership is similar.
52:15
You make sure that these foundational core values of an organization are represented
52:23
in the executive decision-making.
52:25
And that's really how I view well-being in medicine.
52:28
It is a values statement for an organization.
52:32
And you elevate the visibility of what you stand for as an institution or as a practice
52:38
when you have well-being considerations in that C-suite for those discussions to be on
52:47
the table.
52:48
It doesn't mean that every decision an institution makes is going to maximize well-being to the
52:56
detriment of other considerations.
52:59
There's a trade-off and there are balances.
53:01
But right now, we are rarely having the conversation.
53:04
I'll be very narrow.
53:05
I'll speak about, for example, a margin target.
53:08
We are very rarely having the conversation about setting a margin at X percent as a goal.
53:14
And what are the benefits and the risks in terms of our staff of setting that margin
53:20
versus, what if we set the margin one percent lower?
53:26
What are the risks to the financial or growth needs of the organization versus the potential
53:33
benefits to well-being of our staff?
53:36
And conversely, what if we turn the treadmill up more and we make the margin goal even higher?
53:42
What are the benefits financially?
53:45
We can build a new parking garage.
53:47
We can update medical equipment that is falling apart.
53:50
There are some key objectives that are reasonable and fair to talk about.
53:55
But we need to hold those in balance with what are the potential costs to our people?
54:01
And make no mistake, the single greatest resource any healthcare organization has is its employees.
54:11
They deliver the mission.
54:13
And any leader that forgets that is destined to not achieve their objectives.
54:19
And I think having well-being represented in leadership conversations can remind leaders
54:25
of their best objectives, their best goals, and keep them connected to that.
54:31
So that's why I think we need more of this.
54:33
We don't have enough institutions that have been able to or have committed to fully embracing
54:39
this.
54:40
And that needs to be a mesh work across the organization as well.
54:43
You need to have leaders not just in the C-suite, but at the division and department level,
54:47
at the work unit level, who also are bringing that well-being voice.
54:53
And I want to be clear, that's not an adversarial voice against other objectives or initiatives
54:58
at the institution.
54:59
It is a complementary and supportive voice.
55:03
Because engaged employees deliver your organizational mission on behalf of your patients much more
55:10
effectively.
55:11
The business world has understood this a couple of decades ahead of medicine.
55:15
And we have really in some ways, you know, Danielle Ofri wrote about this a number of
55:20
years ago in the New York Times, we have in some ways weaponized the notion of professionalism
55:27
with this idea, as I hinted at earlier, that it's selfish for us to be concerned about
55:33
ourselves.
55:35
It's unprofessional.
55:36
It's not altruistic.
55:38
And I think we need to step back and take a broader view.
55:41
If we're talking about sustaining our service to patients, that requires that we take care
55:47
of ourselves.
55:49
In professional athletics, for example, I know it's controversial right now in the NBA, for
55:54
example, the mandatory rest days for players.
55:58
But really, that's a guide to say, if a professional athlete overextends themselves over and over
56:06
and over and over again, they will break down and in the long run, not be their best self.
56:13
In medicine, we're the professional athletes of caring for other human beings.
56:19
We need those recovery periods and we need to be building our structures to support us
56:24
for the long haul, because that's what our patients truly need.
56:28
I'm reminded by an article in I think it was in JAMA, you may be able to remember it.
56:34
That was about Captain Sully and flying the plane into the Hudson River and comparing
56:41
how we handle challenges and these kinds of experiences with health professionals, physicians
56:46
in particular.
56:47
Do you think Captain Sully went back to work the next day or the next week or the next
56:51
month?
56:52
No, not at all.
56:53
It's a safety issue.
56:54
It's a well-being issue.
56:56
I have two questions I'd like to get to in the time that we have remaining.
56:59
If you could describe several related things.
57:03
One is what would it be like to be a patient in an encounter with a health professional
57:07
who's flourishing, energetic, committed, compassionate, attentive, robust?
57:13
What would the experience be like for you?
57:15
Then as a health professional in a patient encounter, what would the experience be like
57:21
for you being the health professional who is that person flourishing, committed, compassionate,
57:27
attentive and robust?
57:29
Then I have one more question after that.
57:31
I love the way you framed that question from both perspectives because they actually cannot
57:36
be separated.
57:38
We wrote a consensus document, the Charter on Physician Well-being published in JAMA
57:42
in 2018 and the first guiding principle in that charter, which was agreed upon and signed
57:50
off on by 25 major healthcare organizations in the country who, and anyone who's ever
57:56
been in a leadership environment will sort of drop your jaw at this a little bit, within
58:03
12 contact hours achieved consensus.
58:07
This resonates with people.
58:08
The first guiding principle was that healthcare professional well-being and excellent patient
58:17
care are symbiotic.
58:21
They form a, as been called a virtuous cycle and the more we feed both of those, the more
58:29
we move away from what sometimes feels like a downward spiral in medicine to an upward
58:35
spiral.
58:36
So as a patient, and I've been a patient myself, when you are cared for by somebody who has
58:43
the capacity because they are supported personally and professionally in being able to deal
58:51
with you, deeply engage with you, they've got those resources to bring to bear for you.
58:59
You are truly cared for by that person.
59:03
It's not lip service.
59:04
You feel that your well-being as a patient really is the only thing that matters.
59:13
It builds trust.
59:15
It's calming.
59:18
And I think even before you have undergone a test, taken a medication, had a procedure,
59:27
your healing process as a patient has already begun by the nature of that interpersonal
59:33
connection with whoever that individual is.
59:36
Doesn't have to be a physician either, by the way.
59:38
It can be the person at the desk.
59:40
It can be the parking attendant.
59:42
When that person is able to engage with you in a way that comes from a place of a capacity
59:50
for empathy, it's incredibly powerful.
59:54
I'll just leave it at that.
59:56
And the converse is patients feel when their healthcare professionals can't engage with
1:00:03
them.
1:00:04
It's one of the single greatest dissatisfiers in medicine right now for patients.
1:00:08
The physician who feels rushed, the physician who didn't listen, the physician who doesn't
1:00:14
seem to care about my experience.
1:00:17
I had to repeat myself three times about things that are actually fundamentally important.
1:00:22
And because they're distracted constantly, I don't have much confidence that the next
1:00:27
steps in my management plan are going to be the right ones.
1:00:32
And that is disconcerting for patients.
1:00:35
It adds stress to patients that is counter to what we want for our patients.
1:00:40
As the healthcare professional in those situations, what do I derive meaning, values, and purpose
1:00:45
from in my work as a physician?
1:00:48
Helping my patients.
1:00:50
And the more I'm able to deeply connect and understand their context and engage in their
1:00:59
stories, which are fascinating.
1:01:02
People live sometimes very difficult, but complicated and beautiful lives.
1:01:09
And for us to be able to be part of that for whatever period of time is an incredible privilege.
1:01:18
But if we are disengaged, if we're languishing or even in distress, we can't connect with
1:01:25
that privilege.
1:01:27
And there's a sense of loss there that happens.
1:01:30
Because we know we want to, and the gap between what we can do and what we want to do is where
1:01:35
other terms that we could get into in another session, like moral injury, start to enter
1:01:39
the picture.
1:01:40
So taking great care of patients, being able to be fully present for patients is uplifting
1:01:48
for the healthcare professional.
1:01:50
And experiencing that as a patient is a key part of the healing journey.
1:01:56
Thank you.
1:01:57
And finally, what does Colin West like to do for fun and enjoyment?
1:02:04
Don't worry if some of the answers may be work related.
1:02:07
That's okay.
1:02:08
For example, for me right now, I love listening to podcasts that interviews interesting thought
1:02:13
leaders who kind of think outside the box.
1:02:16
And then I get inspired to write about it and write blogs and things like that at this
1:02:20
point in my work life.
1:02:23
So for me, that's fun.
1:02:24
So I know it sounds weird, but it's true.
1:02:26
I also like to walk to nowhere in particular.
1:02:29
So these are things I like, but what do you like to do, Colin?
1:02:33
Yeah, this is a great question.
1:02:35
And as you've mentioned, what works for each individual is very individual.
1:02:42
I thrive on variety.
1:02:43
So whether it's work or outside of work.
1:02:47
At work, I am most fulfilled when I have multiple irons in the fire.
1:02:53
And I'm working on medical education projects and I'm working on wellbeing and I'm seeing
1:02:59
patients and I'm teaching residents and I'm grading master's exams in the graduate school.
1:03:05
And just lots of different things.
1:03:08
And staying connected with that work and seeing it have an impact that hopefully is positive
1:03:16
and frankly fighting the feeling that it's selfish for me to derive a feeling of reward
1:03:23
from seeing the impact of the work that I do in all those different domains, if I'm
1:03:27
honest.
1:03:28
I mean, we have a problem with that in medicine, like giving ourselves the latitude to take
1:03:34
credit and pride in the work that we do.
1:03:37
I try to maintain a balance on that, but it is meaningful when you help a graduate student
1:03:45
move to the next phase of your career.
1:03:47
You teach a physical exam skill to a medical student and you see three years later that
1:03:54
they've taken it and they're doing it better than you did because they've continued to
1:03:57
grow that skill set.
1:03:59
Or you're doing wellbeing work and advocating on a national or international stage and you
1:04:04
see things progress to where major national groups are taking these threads and tying
1:04:13
them together and changing the culture of medicine in ways that will benefit healthcare
1:04:20
professionals and patients.
1:04:22
I try to connect with that.
1:04:24
Outside of work, variety is also important.
1:04:27
I try to stay physically active.
1:04:29
As I get a little older, it's harder to do things that I used to do all the time, like
1:04:33
play tennis seven days a week.
1:04:35
But for me, it's like, you know, my wife got a Peloton and I'm not a Peloton junkie, but
1:04:40
I'm on it a couple of times a week because it's variety.
1:04:43
I try to do a little bit of light jogging or run.
1:04:48
I can't call it running because I'm not fast enough to really call it running.
1:04:51
And I do that because I'm bad at it.
1:04:53
And cardiopulmonary wise, it's painful a little bit, which tells me I need it.
1:04:59
So I keep doing that kind of stuff.
1:05:00
I play tennis a couple of times a week.
1:05:02
I try to stay physically active and I try and stay engaged with my work colleagues.
1:05:08
I try and stay engaged with my wife.
1:05:10
I have two teenage kids and they've got busy lives as well.
1:05:16
And just trying to stay connected and engaged with all of these other facets of being as
1:05:23
fully formed a human as I can be.
1:05:26
That's what keeps me engaged and present to the greatest possible extent.
1:05:31
Doesn't mean every day is perfect or even great.
1:05:34
I have bumps in the road as I think we all probably do.
1:05:39
But there's a larger picture there of this aspirational goal of trying to make sure that
1:05:45
the work that I do and how I spend my time connects with meaning, values, and purpose.
1:05:51
And that's what I try to hold as my North Star in what I work toward.
1:05:56
Well, this has been a most wonderful conversation.
1:05:59
Thank you so much.
1:06:01
Very generous of you to share the professional and the personal because in many ways they're
1:06:05
not really separate.
1:06:07
It's all a continuum of who we are as people, as human beings.
1:06:14
Thanks for listening.
1:06:15
We will include a summary of today's podcast and links about Dr. Colin West and other references
1:06:21
that were discussed in the show notes.
1:06:24
I would like to conclude by sharing another practical exercise to help you flourish during
1:06:29
your workday.
1:06:31
To add to others that I've shared in prior episodes to the toolbox of skills that you
1:06:36
can draw upon to enhance purpose, meaning, and well-being.
1:06:41
This exercise is a reflection exercise about teams, teamwork, the teams we work on.
1:06:48
Given the discussion with Colin about individual and organizational aspects of well-being,
1:06:53
let's take a few minutes to reflect on teams we work with in healthcare.
1:07:00
Think of a team you work with.
1:07:03
Think of one in particular that's functioning optimally.
1:07:08
One in which communication, which we know correlates with quality, is clear and fluid.
1:07:17
One in which there exists a sense of psychological safety where each member of the team feels
1:07:23
safe to express ideas, share information and opinions relative to their role on the team.
1:07:32
Think now on what it's like for you working with such an optimal team.
1:07:36
What would you notice about this team, about you on this team?
1:07:43
What words would you use to describe that?
1:07:46
What qualities and values in you would be present with this team that may be reflective
1:07:53
in how you function in it?
1:07:57
What would others notice observing this well-functioning team?
1:08:05
Reflections such as these can help us recognize when our teams are actually functioning well,
1:08:09
motivating us to continue to function well.
1:08:13
And it also helps us to recognize when things are not functioning so well.
1:08:17
What elements may need to be recognized, addressed, or changed?
1:08:23
I hope you found this podcast and the simple exercise useful to you and look forward to
1:08:27
having you join us for the next episode of Flourishing in Medicine from Surviving to
1:08:32
Thriving.
1:08:34
If you'd like to learn more about EmPRO, please visit www.myempro.com, M-Y-E-M-P-R-O.
1:08:43
And for more information about me and the work I do, please visit www.mickkrasnermd.com
1:08:51
or www.mindfulpracticeinmedicine.com.
1:08:58
Thanks for listening and I hope to have you listen to a future episode.