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Flourishing in Medicine: From Surviving to Thriving Episode 18 Navigating the Burdens of Medical Practice: A Journey Towards Systemic Change: A conversation with Dr. Jane Fogg of the AMA · Flourishing in Medicine: From Surviving to Thriving

0:00
And the word joy has different connotations for all of us.
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You know, it's surface, it can imagine someone skipping through life joyful, everything's
0:13
great.
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But I think joy, you know, for me is a deeper emotion.
0:18
And there is joy in helping someone die in the way they wish and with the peace and harmony
0:24
around them that they desire.
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There's joy in taking care of a patient with a horrendous case of, you know, vascular disease
0:32
who has chronic ischemia and pain and you're helping them alleviate their symptoms.
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There's still joy in that.
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And I think that the joy we take in being physicians is both being there in good health
0:47
and in sickness and in knowing that we in some small way helped or alleviated a pain
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or helped a patient achieve their own goals.
0:59
Welcome to Flourishing in Medicine From Surviving to Thriving.
1:02
I'm Mick Krasner, your host, and this podcast is produced by EmPRO, a medical professional
1:08
liability insurance carrier headquartered in New York State, committed through a number
1:13
of peer support offerings to supporting the physicians they protect.
1:19
The title of today's podcast is Navigating the Burdens of Medical Practice, a Journey
1:23
Towards Systemic Change, a conversation with Dr. Jane Fogg of the American Medical Association.
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Jane is a physician leader and executive with broad experience leading healthcare delivery,
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focusing on primary care, systems redesign, and value-based delivery models, and a senior
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physician advisor for the Division of Professional Satisfaction and Practice Sustainability at
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the American Medical Association.
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Prior to this, she was the executive chair of internal medicine and family medicine at
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Atrius Health, an innovative value-based healthcare leader in Massachusetts, and a member of Optum
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responsible for the care delivery and outcomes of a practice with 350 physicians and advanced
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practice clinicians caring for over 400,000 patients.
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During this conversation, Dr. Fogg reflects on her over three decades career where she's
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grown increasingly aware of systemic deficiencies in the organization of healthcare, especially
2:22
in primary care, which have fueled her commitment to addressing these issues in her many leadership
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roles.
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While grappling with physician burnout and systemic challenges, Dr. Fogg advocates for
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fundamental changes in healthcare delivery, in particular promoting and implementing value-based
2:40
care which aligns financial incentives with quality patient care.
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She emphasizes quite persuasively that the transition to value-based care and data-driven
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decision-making while optimizing clinical operations can enhance physician well-being
2:55
as well as practice efficiency.
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She shares with us actionable strategies such as in-basket workload reduction while championing
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honesty, gratitude, and joy in healthcare practice and leadership.
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Her authenticity, deep commitment to not only patients but to her colleagues whom she described
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as equally committed, resilient, and inspirational has given her the motivation and energy to
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make really tough changes in helping physicians and other health professionals flourish.
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And now my conversation with Dr. Jane Fogg.
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So welcome Dr. Fogg to flourishing in medicine from surviving to thriving.
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We're really thrilled to have you, especially because of your work in very practical ways
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of bringing interventions and thinking about creative ways to unburden some of the things
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that especially primary care physicians experience but physicians in general.
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What I'd like to start with is how I often will start many of these conversations is
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I'd like to hear a little bit about, you know, why medicine for you?
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What was the formative things in your life that you're willing to share that happened
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that brought you to this point?
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Sometimes, you know, these are common stories of experiences that we have at a young age
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in our families, but they also may be formative things that happened during the process of
4:19
your education, the choices you made along the way.
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So I'd love to hear about that background.
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So we kind of get a sense of who's in the room here with us.
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Well, thank you for having me.
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It's really a pleasure to share what I've learned over my three decades journey.
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I did not know that I would be a doctor.
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I had no plan for this.
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I loved math.
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I loved science, but I loved a lot of things.
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Somewhere in college, someone suggested I might think of medical school, and I thought,
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wow, that's funny.
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But I thought about it.
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There's no one in my family in healthcare, and so I had no preconceived notions about
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what doctoring might be.
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I decided to explore what it might mean, and I did some research.
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I dissected cow eyeballs and had a good time doing that, but realized it really wasn't
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teaching me about what it really means to take care of patients.
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So then I took a job as sort of a medical assistant at an organization called Harvard
5:22
Community Health Plant, which is where I eventually ended up working.
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And I worked in the oncology group, and I answered phones, and I put patients in rooms,
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and I coordinated things for the doctors.
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A couple months in, I thought, absolutely not.
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These guys work so hard.
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This is so hard.
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And then the next couple of months, I thought, well, yeah, this is what I want to do.
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And so I feel like I was really fortunate to see what it actually means to take care
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of a patient, especially a patient with a really complex illness, as we did in oncology.
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And that helped propel me to do what I needed to do to apply to medical school.
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So I kind of remember when I told my parents that I was going to apply to medical school.
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I think my mother sat there in silent shock and awe.
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And my father said, and I will never forget, but will you have time to smell the roses?
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And he said that because many of his friends were doctors, and he saw how hard they worked
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and how many family events, personal events they missed.
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And he had that impression.
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And he was not in medicine.
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At my young age, I thought, what a weird, of course I'm going to smell roses.
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But when I reflect on that now, he had a really good point.
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Many doctors are not smelling the roses.
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And so perhaps that was an early push in the direction that I ultimately ended.
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So I'm really curious about what you said about working with those patients, placing
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them in rooms and kind of assisting and supporting the care that was being given in this oncology
6:54
office where you function as a medical assistant.
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There must have been something about that that really drew you in to illness, to complexity.
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And also, even though it may have sounded weird at the same time what your father had
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said, was there already at least a nascent commitment to taking care of yourself as well,
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smelling the roses, so to speak?
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Yeah.
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I think one of the things I learned about being a medical assistant is that the patient
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will tell you something entirely different than they will tell the doctor.
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And that's not a bad thing.
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When I was in the room with a patient, they would tell me how awful things were and what
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was wrong and their grievances.
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And the doctor would walk in and they'd big smile.
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And there was just that bond, that relationship that develops in any of our disciplines where
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there's continuity, certainly primary care, but oncology, absolutely.
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Any of our specialties where you know someone over time during complex illness, the way
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the patient would light up when their doctor came in, no matter how poorly they felt.
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And I think that's kind of what got me the most because I really enjoy being with people.
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And I saw that that kind of relationship was something that held immense value and was
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earned by the physicians and the way that they cared for their patients and the way
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their teams cared for them.
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I also thought the science was really interesting.
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You know, it's a cancer, it's difficult and complicated.
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At the time that I worked there, we were just beginning to see HIV and we had little understanding
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and we did some of the care in the office.
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So I also was witness to an emerging epidemic that was scary and challenging and many were
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not engaged in taking care of patients who were suffering.
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So it was a strong pull about what it means to be a caregiver and what it means to be
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trusted to take care of you.
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So I think that perhaps is the biggest reason, even though the science was really interesting.
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I knew that I was headed towards whatever I did in medicine, it would involve longitudinal
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relationships.
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Yeah, it seems really clear from your story that relationship is really at the center
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of it.
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I'm also thinking some of the things that were coming up for me as you were discussing
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this was a mutuality that it's not all one-sided, that in some ways that smile that the patient
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put on was in a way taking care of the person who was caring for them, that there's some
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need to make sure that person's okay as well.
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You said a little bit about the primary care and that became a big part of your career
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path, but also a movement into leadership and also this interest in systems redesign.
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What was the awareness and the consciousness around wanting to improve things that you
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were seeing that just didn't sit right with you perhaps?
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I also did not know I would end up in leadership.
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If you asked me as an intern resident, even my first year out of residency in my first
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job, I joined as a full-time PCP.
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I think earlier you asked if I had an inkling that I'd be thinking about that balance, that
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work-life balance, that self-care.
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Think actually channel the first 30 years to caring for other physicians and caring
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for the system, caring for the construct in which we all work, not as much as caring for
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myself.
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There are ways to get there to take that time.
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I was fortunate to go to a medical school that exposed me.
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I was in Northern Manhattan.
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I was at Columbia and I had amazing teachers and clinical experiences working in places
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like Harlem Hospital where I saw what really happens when a community doesn't have access
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to excellent and continuous care.
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There was little continuity in the primary care delivered.
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Much of it was episodic.
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I returned to Boston for residency knowing it would be good to be near a family because
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it's a really challenging time.
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In those training years, you go into your bubble and you work hard.
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I don't remember much of those seven years beyond that.
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Again, I had a great mentor who saw who I was and what I was good at and where I might
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land and encouraged me to continue into primary care at a time where out of, I think, 30 of
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us, four of us went into primary care.
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Even one faculty said to me, I was so sorry to hear that you're going to primary care.
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You're so smart.
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I thought the smartest people I've met in my training are these internal medicine.
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We didn't have family medicine in our group, these internal medicine physicians because
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they take care of these complex presentations that involve humans and symptoms and lab tests.
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They try to figure out which way to go.
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That's hard.
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I was a little miffed and maybe put a little chip on my shoulder that primary care was
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something I needed to pay attention to because it was not professionally.
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It wasn't at the top of the hierarchy and I thought it should be.
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I took a job at a community health center.
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I think it was harkening back to my medical school experience.
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I wanted to be in a community that didn't have access to great care all the time.
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I was really lucky.
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My first eight years, I joined what's now called the Dimmick Center in Roxbury, Massachusetts
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and again, was really fortunate to work with some highly skilled, compassionate, amazing
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physicians and we called it the adult medicine department.
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I didn't know how hard it would be.
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My first week of work, they told me that we rounded on our patients in the hospital.
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They did not have hospitalists.
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We took care of our patients.
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I saw 20 patients my first day of work and then they told me that I was rounding in our
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on-site detox center two days a week.
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I didn't realize that in the job description, but I was part of the group of internal medicine
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docs.
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We took care of our on-site detox center.
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We rounded on patients.
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We prescribed medications.
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I was suddenly doing healthcare that I had partial preparation for and really had to
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learn from my mentors and colleagues.
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I absolutely adored it.
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I loved that community.
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I felt like it brought forward in me values that I didn't know I had about the importance
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of community, the importance of respect and meeting people where they're at.
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I just feel incredibly lucky to have started in that direction.
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After the first year, the medical director came to me and he said, Jane, the director
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of adult medicine is stepping down to pursue other things.
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Could you fill in for a few months while we find someone real, an adult?
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As I was one year out, I said, I'll do that.
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I'm an organizer.
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I never left.
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I was the director of adult medicine for the next seven years.
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I learned from mistakes.
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I learned from some success.
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I learned from some mentoring from my colleagues there, but yeah, I made mistakes and I didn't
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have any preparation and leadership.
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But I did know that I got immense joy by fixing problems, by fixing the obstacles that stood
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in the way of our care teams, taking care of patients and our patients.
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Whether it was the on-call system, the phones, the fax machine never had paper, basic things
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sometimes, but I really enjoyed trying to set things right, so to speak.
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So that's really what started my path to leadership.
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I really fell right into it.
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Yeah.
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So 30 years of taking care of others, your colleagues, seeing these problems arise, you've
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named a few of those things.
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Maybe you can speak a little bit more about some of the things that you were experiencing
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in the primary care practice that raised concerns for the need for systemic change.
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Maybe including some of the things that are still problematic and maybe have become more
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prominent now because medicine, of course, has changed so much in that 30-year period.
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There has been a constant evolution in my career, not in the right direction in primary
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care, sadly.
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And I actually thought back in my first job, in 20 years, we're going to see fundamental
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change in this country.
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We're going to figure out that what we have in the American healthcare system is not adequate,
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and we're going to fix it.
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I was a little naive.
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We're not there yet.
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In my first role in a community health center, I saw how things are strung together with
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Band-Aids, how there were programs designed to support specific patients, whether you
16:02
were pregnant or had a certain condition.
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But then if you were a 32-year-old man who didn't have those conditions, you did not
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have that kind of insurance support or access to care.
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It seemed fundamentally wrong to have a Band-Aid at every juncture to try to care for people.
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I moved to my next job to an academic medical center, turned where I had trained.
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My goal was to, with I thought a richer resources environment that I'd be able to really make
16:35
a practice thing.
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I'd be able to make patient care accessible and great, and I learned so much in my community
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health center experience.
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I got there.
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I started a practice.
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I grew up from nothing to about 10,000 or more patients and multiple PCPs and some APPs.
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In those 12 years, Value-Based Care came into our organization.
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What I saw in the primary care sphere was that it was just getting harder and harder
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to care for patients.
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I started to see colleagues burn out.
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I saw some of my colleagues left for concierge medicine, which they were all quite happy
17:19
with and said, it's just a joy to take care of a smaller panel of patients.
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I can spend time with them.
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I feel like I do a good job.
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That was not uncommon in our practice to see that happen.
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That distressed me because fundamentally I believe that money shouldn't dictate your
17:35
access to care and especially primary care.
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That was a real tension that I felt and paid attention to.
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I also had a colleague who was a wonderful physician.
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She took such great care of people and I watched her burn out and leave.
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She was my age.
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I think that's where I got the spark to dig into the systemic causes.
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I did not see ever that burnout was the result of lack of strength or will or just don't
18:07
want to work that hard.
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Every physician I've had the privilege to work with and every physician that I've been
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the leader of, I have seen people work hard and enjoy complexity, enjoy challenging patient
18:20
situations.
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We go into this because we like that, but the frustrations of practice, the obstacles
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before you, the difficulty trusting that your patient can navigate through the system successfully,
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whether it's the specialty hospital, post-acute care, behavioral health.
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It's a PCP.
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You see the cracks in the system.
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You see your patient's journey and it becomes immensely frustrating and you can't help them
18:48
the way you want to.
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There's more pressure to go faster, see more patients, do more.
18:54
When I think about doing a physical exam in 1996, I sat down one day and I tried to remember
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what were all the things we did that were our standard set of preventative measures,
19:04
vaccines.
19:05
Then I did it for 2019 and I was just blown away.
19:09
The physical exam time, has it doubled?
19:12
No.
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Doctors are still doing physical exams in about the same amount of time they did back
19:17
in the 90s, but they're doing three to four times more.
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It takes away from the best part of the physical exam, which is that, how are you?
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What's going on?
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How's your family?
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How are you doing?
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You don't have as much time to talk because you've got to get all these little things
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done.
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That's where seeing those systemic problems and working in an academic medical center,
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I poked my head up and I put my hand up and tried to get some jobs leading systemic change
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and I was fortunate to do that.
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We had an arm of the organization that did the contracting for value-based care and for
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any of our commercial and public contracts.
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They gave me some time to be the medical director of primary care, which was really translating
20:06
value-based care into practice.
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What does it actually mean to do it?
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What does it mean to achieve quality, reduce cost, improve experience?
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At the same time, I also took on a job for our primary care community group, which was
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about 180 doctors maybe at that point, working on practice redesign.
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How do you redesign primary care to be patient-centered, effective, and bring joy back to physicians?
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I had those two arms going at the same time while being a PCP, while running my practice
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and had some successes and then also had some challenges, how we call them.
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That was really what got me started on this journey to fix the systemic problems that
20:48
still plague us today.
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Yes, we're going to come back to both value-based care and this practice redesign, but I wanted
20:56
to take just a little sidetrack, which I think is worthwhile.
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You mentioned something about, we like complexity and I was a primary care internist as well,
21:06
and there's something joyful about it.
21:09
And also the truth that it's not a deficiency we have that burnout is happening.
21:14
It's not because of some flaw that their medical schools are just choosing the wrong people.
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Not at all.
21:20
It's a very complex system that we work in.
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You're now a senior physician advisor for the Division of Professional Satisfaction
21:27
and Practice Sustainability.
21:28
It's a mouthful for the American Medical Association.
21:31
And I want to offer you a quote.
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This is a quote from Joseph Campbell.
21:35
You may know the great mythologist Joseph Campbell.
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And here's what he said, and then I have a question.
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So he said, participate joyfully in the sorrows of the world.
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We cannot cure the world of sorrows, but we can choose to live in joy.
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The warrior's approach is to say yes to life, yes to it all.
21:56
So based on kind of that, how do you hold or understand or frame joy in medicine for
22:03
our colleagues and for yourself?
22:05
Thank you for that question because I think about words because my mother read poetry
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to me as a child.
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So I'm often thinking about how we use words.
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And the word joy has different connotations for all of us.
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It's surface.
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It can imagine someone skipping through life joyful.
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Everything's great.
22:26
But I think joy for me is a deeper emotion.
22:30
And there is joy in helping someone die in the way they wish and with the peace and harmony
22:35
around them that they desire.
22:38
There's joy in taking care of a patient with a horrendous case of vascular disease who
22:44
has chronic ischemia and pain, and you're helping them alleviate their symptoms.
22:49
There's still joy in that.
22:51
And I think that the joy we take in being physicians is both being there in good health
22:59
and in sickness and in knowing that we in some small way helped or alleviated a pain
23:05
or helped a patient achieve their own goals.
23:08
And so that's a little different than skipping through life because sometimes you're holding
23:12
someone's hand at the last visit before they die.
23:16
But I think that that's what we get joy from.
23:19
And it has been diminished when you have to walk out of that exam room as I once did when
23:27
my patient told me it's a time for me to stop chemo.
23:31
I'm done.
23:32
And I want to go to hospice and I want to be in a hospice home.
23:36
And I had to scramble to find the hospice home and get them in.
23:39
If you have a really well working system and a great team, a nurse around the corner says,
23:46
I got this.
23:47
I'm on the phone.
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I'm going to go figure out how to get them.
23:49
You just stay with your patient and have that conversation.
23:52
But today too often the nurse is scrambling, the doctor's scrambling.
23:56
We're all having a hard time getting what our patients need.
23:59
And that's where joy gets robbed.
24:01
Yeah.
24:02
I think you've named some really important things.
24:04
One is this you could call eudaemonic, eudaemonia, the deep joy and satisfaction of something
24:12
that could actually be very, very challenging.
24:14
There was a study many, many years ago of a group of internists and what they found
24:18
most meaningful in their work.
24:19
And they wrote these narratives about their experiences and they were not the great triumphs
24:23
of biomedicine.
24:24
They were stories.
24:25
They were really difficult and really challenging, often involving loss.
24:28
But it was the relational aspects, the presence that one offers, the bit of relief of the
24:33
suffering and being engaged and being there versus this moral distress, which is kind
24:39
of what you're pointing to in knowing what the solutions are, but they're not there
24:44
or they're not easily there or there are so many systemic barriers to make them happen
24:49
that take up so much of our cognitive load and time and energies that it takes away from
24:56
our ability to really have that eudaemonic sense of satisfaction.
25:01
So I appreciate you naming that.
25:03
Back to value-based care and practice redesign.
25:07
Can you talk a little bit about the theory and implementation of value-based care, the
25:11
effects that it's happened on transforming systems within healthcare and in our lives
25:17
and how we actually do our work?
25:18
What are some of the potentials?
25:19
How's it played out thus far?
25:21
What can we expect going forward?
25:23
I think it's the right course, but it's a challenging course because it is quite of
25:26
a shift for so many of us and has been over the last two decades.
25:31
I've been fortunate to work for organizations that are deeply based in value and can make
25:35
it work.
25:36
So I've had that experience of both fee-for-service, which I'll describe in value, and I think
25:43
I've seen what it really takes to make value work.
25:47
Most physicians in this country under a fee-for-service model in which they're paid for each event
25:53
or visit or procedure or surgery that they do and not for the outcome of said event,
26:00
surgery visit.
26:02
In value-based care, which is a broad term, there's many different shades of value, you're
26:08
rewarded for delivering value, whether that might be improving quality, reducing unnecessary
26:13
costs, improving patient experience, and so on.
26:17
And certainly we often talk about it in a financial realm where you're not being paid
26:24
to go faster, you're being paid to deliver great care and be measured on those outcomes.
26:30
But I always say it's gray, it's not a black and white one system or the other's different
26:35
ways to deliver value.
26:37
But at its core, I think the thing that relates primary care, professional satisfaction, and
26:44
value is that there's a real alignment and mission.
26:47
Again, I don't know many doctors, I've come across very few who get joy out of going really
26:52
fast and seeing a lot of patients and having their compensation based on that.
26:57
I think the joy comes in caring for patients, taking care of them, of having a great surgical
27:02
outcome for a patient or helping them through a cancer diagnosis and into remission.
27:08
And so we want our patients to be well, we want to have them achieve what they need and
27:13
to marry the financial model to that feels a little bit more aligned.
27:18
Let me work on taking good care of you.
27:20
I think we also do, we're data driven in medicine, that's how we're trained.
27:26
And in value-based care, you need to be data driven.
27:28
You can't just think you're giving value, you have to measure and know.
27:32
And there's a lot of complexity in that.
27:34
It's not as easy as it sounds.
27:37
And with such a fractured healthcare environment across the country, meaning we're not in one
27:42
universal system, each system might be doing it slightly differently.
27:45
So it's immensely complicated.
27:47
I think a value-based care also stresses the system, not just the physician, but their
27:52
practice or their health delivery system that they work for to be really well run.
27:59
Meaning you close care gaps.
28:02
You get, if patient needs a referral to specialty X, you get them there and you get them there
28:06
efficiently and effectively.
28:08
If the patient is discharged from an outside hospital, you immediately know and you're
28:13
part of coordinating that care and reducing any readmission that could have been prevented.
28:19
You're meeting patients in the home and treating them at home, even home hospital.
28:23
You really have to work well as an organization in a reliable, high quality, safe and effective
28:29
way.
28:30
So it stresses the practice to do that.
28:32
It's not just the doctor by themselves saying, I'm going to give value today.
28:36
I'm going to be a really good doc.
28:39
I think it also brings some honesty into the conversation.
28:42
There's been a lot of great work from many others in my time identifying what good quality
28:49
care is and certainly identifying low value care and campaigns like Choosing Wisely and
28:55
others which been sort of part of my practice growing up, point out when we physicians have
29:02
not brought evidence-based medicine into practice as quickly as we should.
29:06
We might be say doing an MRI of someone's back when they've had pain for a week or two
29:10
and there's no red flags, things like that, learning to say, actually that's not evidence-based
29:15
effective care and we should identify when we can that low value care and make an agreement
29:23
not to do it.
29:24
So it's very much aligned with professional values, I think.
29:29
It is slower to spread.
29:31
For decades I've had, I can't pick up a paper or blog without someone saying value-based
29:36
care is coming.
29:38
But in my last job at Atrius Health, a very value-based care organization, the challenge
29:44
wasn't our desire to do value.
29:46
The challenge was the environment, was the insurance offerings, the employer offerings
29:51
that were not choosing risk, that were choosing something more predictable.
29:56
And that, I wonder a bit, are we really on a journey to value or not?
30:01
I hope so.
30:02
But I don't think it's spread as fast as we like to write about.
30:06
Well thank you.
30:07
One of the things you mentioned was it takes the practice or team or collaborative care
30:12
models really.
30:13
So that's a key ingredient of the value-based care.
30:17
And maybe if we can just magnify that or hone in on that, what are some of the challenges
30:22
in developing these collaborative care models?
30:25
And some of it is the collaboration with having the insurance payers get on board with how
30:30
we're going to incent that as well.
30:31
You just name that.
30:32
But what are some of these challenges in forming these teams in your practice, in your community
30:36
of practices, in your healthcare system that you're working within, as well as the potential
30:41
in terms of one particular thing, particular to this podcast, which is what can they offer
30:47
us in terms of well-being and satisfaction?
30:49
I mean, you've named it in a broad way.
30:51
Are there other ways of looking at that team-based collaborative care model as something that
30:56
really could support our well-being as physicians and other health professionals?
31:01
I think if you design value-based care systems intentionally, mindfully, thinking about well-being,
31:11
you'll find that what you're building for value can actually support well-being.
31:15
But I think it's important to think about what those elements are.
31:19
Teaming is, again, it's another word that's used broadly.
31:21
So what do I mean by teaming?
31:23
First and foremost, I think that medicine is a social sport.
31:26
We enjoy not just our patients, but we enjoy each other.
31:30
And for any physicians listening, if you've ever had that experience where you're working
31:33
with a nurse, a medical assistant, a nurse practitioner, somebody having a really tight,
31:40
high-functioning team experience, it's awesome.
31:44
It's great.
31:45
Because at the end of the day, there's no way to make medicine predictable.
31:49
You might think you're walking into a relatively straightforward day and you get three curveballs
31:55
thrown at you.
31:56
People who need to see you, who have compelling needs, and you've got to deal with it, and
31:59
you don't want to be late for everyone else.
32:02
That first nucleus of team, which I think is your practice team and can be shaped in
32:06
different ways, but those are the people that say, hey, Dr. Fogg, really need you to see
32:12
this patient.
32:13
She's having a really bad asthma flare.
32:14
You know her well.
32:16
Give me your prescriptions.
32:17
I'll go do those while you see her.
32:19
Or let me take that phone call and see if I can triage it for you while you go see that
32:24
patient.
32:26
I experienced that in my practice in Needham that I started.
32:30
We went from a very sort of fee-for-service model to value and from a very undesigned
32:35
to redesigned model.
32:37
And that, when I felt like practice was singing was when there was so much communication between
32:45
my secretary, medical assistant, nurse, my partnering nurse practitioner who shared my
32:51
panel with me, the practice manager, my colleagues.
32:56
We were just all oriented around giving great care and helping each other do it.
33:00
So that's teamwork.
33:01
And a lot of docs, unfortunately, don't have the opportunity to work with the same medical
33:07
assistant or the same nurse, don't get to develop that relationship where you can really
33:11
be helpful to each other.
33:14
And unfortunately results in things like sending a message that says, patient called with a
33:19
cough and fever, please advise, which is very different than I called the patient back,
33:24
I got more detail.
33:26
I think they need to see you.
33:27
I got them into your schedule.
33:29
That's a different message.
33:31
So teaming starts, there's a nucleus of it that for every physician, whether you're primary
33:35
care, surgical, gastroenterology, we all do better when we have a stable, reliable, strong
33:42
team.
33:43
I think they're the next shell that I think of is I think the practice is a team, you
33:47
know, the system I was in charge, I was the chair of internal medicine and family medicine
33:52
for a service line.
33:53
And for me, that next ring around the team was social services support, behavioral health,
34:00
access to specialties, our urgent care team, our on-call team, our clinical pharmacist,
34:05
all that broader team, population health managers who helped care for those panel of patients
34:11
by being available 24 seven by being accessible by when you identify a health related social
34:18
need, having someone who can come help when you identify really sort of severe depression
34:24
that is getting worse.
34:26
And you need you need more guidance as a PCP having somebody who can jump in.
34:31
So I think that kind of functioning that that larger shell is also part of teaming to me.
34:37
And then I think, you know, organizations need to team, we are all in different relationships.
34:41
I practiced in Boston and there are were 14 hospitals that we worked with.
34:45
And how you know, when your patients are going between a colonoscopy at a hospital and the
34:51
practice or an admission, and then a post acute facility, and then back to my practice,
34:57
that's a lot of teaming that needs to happen to make sure we do it well.
35:01
So teaming is, I think one of the highest ideals, but I think there's a lot of layers.
35:06
And the challenge is having people in positions reliably, so you develop relationships.
35:11
There's been so much turnover, we have struggles with nursing, medical assistant, all kinds
35:17
of staff members.
35:18
And it's very hard for folks, I was a medical assistant wants to walk in and get trained
35:24
up in a day, it takes some time.
35:26
And so it's a very challenging role.
35:29
And I think that that's been one of the hardest things that I've seen in the last couple years
35:33
is teaming being affected by staffing shortages.
35:36
You know, you've talked about and written about this, trying to incorporate teaming
35:42
and the other aspects of value-based care and system redesign in medicine.
35:47
My question is about what are some educational pieces that could be helpful in moving this
35:52
transition along?
35:53
I'm thinking of undergraduate and residency education efforts, because in some ways they
35:58
live somewhat protected from this.
36:02
Yet these are core, what you're describing are core competencies to deliver healthcare
36:08
as a health professional, as a physician in particular.
36:11
And if we're not getting them and seeing them in our environment in that educational part
36:17
of our journey, that earlier part of our training, how do we move into them?
36:21
And how can this be moved along as each new cohort is coming in and it's like, they're
36:25
completely confused as to how this works.
36:29
It's very important that it starts in medical education.
36:32
There was a paper written years ago, maybe 20, I think it was Tom Lee, who talked about
36:38
the fact that physicians of the future need to know how to be team leaders and we're not
36:42
training them to be team leaders.
36:44
And that, you know, there wasn't anything in my medical school training or residency
36:47
about being a leader, but if I were designing a curriculum now, I would actually have some
36:53
courses.
36:54
What does it mean to be part of a team?
36:57
What does it mean to be a leader of a team?
37:00
And pragmatic examples, you know, are you exposed to a PCP meeting with their team to talk about
37:08
doing a huddle in the morning to look at who they're going to see with their team and prepare
37:12
quickly in five to eight minutes, how they're going to care for patients as a team.
37:17
Do they see what does it mean when a medical assistant is struggling to take a blood pressure
37:21
and you're pretty sure it's not accurate?
37:24
How do you give feedback in a constructive manner?
37:28
Do we teach doctors to do that?
37:29
And I, unfortunately we don't.
37:31
And so what I sometimes see is some docs get frustrated and they say to the manager, just
37:38
train that MA on how to give a blood pressure.
37:40
I don't have time.
37:41
And if you snap at people as a doc, I've always learned they don't want to help you as much
37:45
if you're somebody who's irritable and snapping.
37:48
But it's also really hard to keep seeing a lot of patients and then stop and teach someone
37:51
how to take a blood pressure.
37:53
So it takes all of us to work together to improve the functioning of a team.
37:57
And I hope that medical schools and residency curriculums would think about how to invite
38:04
a conversation about teaming under talk about psychological safety.
38:09
How do we offer that to our team members so that they're willing to speak up?
38:13
Because maybe they saw a problem coming, but they were afraid to tell you.
38:17
How do we teach psychological safety and the value of that?
38:20
So I think it should start earlier, absolutely.
38:23
And I think the next generation of doctors is going to face having to work with larger
38:28
teams and many of them will be working in larger institutions.
38:33
As so much acquisition has happened, many of them with their first jobs will be in,
38:39
you know, would have been working for me in my last job at a large healthcare delivery
38:43
organization where suddenly you're one of 200 doctors at 21 sites and there's a hundred
38:49
APPs and you're in a big place.
38:52
And what do we need to do to help you be successful in that and still have your agency and your
38:57
engagement because it's a big transition from residency.
39:00
Yeah, yes, it really is.
39:02
I want to, a related question, I wanted to set this up a little bit that physicians and
39:07
other health professionals are indeed looking for actionable items that we can do now to
39:12
enhance wellbeing now.
39:14
And the pace, unfortunately, of systemic changes that needs to happen seems to be glacial at
39:19
best.
39:20
Here on this program, we've interviewed colleagues who work in small and large teams, people
39:25
that work in peer support programs, educational experts working on the antecedents of burnout
39:30
at the undergraduate residency levels, cognitive scientists looking at ways we can use technology
39:35
and self-awareness to improve quality of care and patient and professional satisfaction.
39:40
We've shared some really intriguing interventions that address systems directly and that are
39:45
actionable.
39:46
I'm thinking of the in-basket reduction initiatives.
39:48
I think our listeners would really love to hear about this.
39:51
Can you tell us a little bit about that, how that works and what are some easy steps?
39:55
I've read some of your work and it outlines some things that we can actually do now that
40:01
could help us in managing our in-baskets, which is a big part of our work life and maybe
40:08
some other resources that are available for folks.
40:11
One great resource that is available to everybody without having to join is AMA has a huge compending
40:18
of what's called Steps Forward podcast, Steps Forward toolkits, playbooks, and it's all
40:24
on the AMA website under Steps Forward.
40:27
And if you feel a little lost at first, just look up the playbooks and start there.
40:31
The playbooks are a combination of multiple different toolkits, all aimed at offering
40:37
both examples of best practices as well in compiling evidence from across the spectrum.
40:44
So there's a saving time playbook, there's a reducing the EHR in-basket playbook, there's
40:49
a leadership aimed at wellness playbook, so a variety of resources that really flesh this
40:54
out.
40:55
I think as I, and I've recently joined the organization and it's been a pleasure for
41:00
me to take those 30 years of leadership and trying to fix, as the person in charge, trying
41:07
to fix things and now trying to turn across the nation and both learn from other groups,
41:12
but also offer my experiences and what I've been able to do or hope to do to others.
41:19
So that's a great place to start.
41:21
I just sort of, I'm someone who always categorizes why I'm a PCP.
41:25
I look at you, you tell me 26 things and I'm immediately blocking, tackling, and trying
41:29
to figure out how to organize it.
41:30
But when I think about solutions to physician well-being for every discipline, I think there's
41:36
sort of, I break it down to five categories.
41:39
Certainly leadership is one which we can talk about, a culture of wellness and the practice
41:43
is another.
41:44
But then I think there's three sort of systems categories.
41:47
And I think that our challenges in burnout in this country are mainly due to the systems
41:53
and that's where we need to start.
41:55
So the first system is teaming and we've talked a little bit about that.
41:59
Another system is not just the in-basket, but the EHR, clinical technology.
42:04
There's a lot we can do across the EHR spectrum.
42:07
And my third system is just the clinical operations, the sort of sophistication of the organization,
42:14
meaning do you have central services that support patient care needs?
42:18
Do you have great access for urgent care?
42:20
Do you have on-call 24-7, those kinds of things.
42:23
I did a lot of work in EHR as one of the systems.
42:26
It came about when I was at Atrius Health.
42:29
In my first year there, we, the organization, made a decision to invest some resources and
42:35
time in looking at the burdens that EHRs place on primary care.
42:42
And as the chair of internal medicine and family medicine, I had the opportunity to
42:46
sit down and think, what can we do in this year that will improve the EHR usability and
42:51
reduce the work burden for my PCPs and their teams?
42:55
And there were a lot of things we looked at.
42:57
There were certainly some optimizations we made improving the way certain things get
43:02
documented and such, but we could not ignore.
43:06
It was blaringly obvious without a survey that the in-basket was one of the biggest
43:11
problems.
43:13
The in-basket for a PCP, I like to call it, it's not your doctor's email, but sometimes
43:18
people think it is.
43:19
You saw this, Dr. Fogg will get that.
43:22
But when we started, we had 100 messages per business day, 500 messages per week for a
43:27
full-time PCP.
43:29
When we looked at all those messages, many of them were things that a doctor doesn't
43:33
need to see.
43:34
But the default has been in EHR design and in system design, just route to the PCP so
43:40
they can check it, we'll all feel better, and then off it goes.
43:46
And unfortunately, with so much interoperability, which I fought for for years earlier, there's
43:51
way too much information coming at PCPs.
43:54
And so you look at your 100 messages and there may be four to five that absolutely are critical
43:58
and you need to deal with right now and they're buried.
44:02
And so we read the content of all these messages to get an understanding and we came back with
44:09
there's high variation in message.
44:12
There isn't an intentional sort of system to figure out what goes where.
44:17
And there isn't a single solution.
44:19
I mean, it would have been a really great solution if I could have hired a nurse for
44:23
every PCP, I would have gladly done it and allowed them to manage the in-basket, but
44:27
it wasn't fiscally appropriate nor feasible in terms of finding that many nurses.
44:34
So I developed a framework with our team to help center us on what we can do because we're
44:39
going to have to pick at this problem bit by bit.
44:43
And the framework was looking at what can we eliminate completely, remove it, what can
44:48
we use automation for, where can we delegate within the EHR, meaning force the delegation,
44:54
don't make the doctor do it, but send it right to that person who should do it.
44:57
And where should we collaborate on that in-basket?
45:01
And that kind of centered us a little bit.
45:03
It helped us figure out that this was going to be a journey, a multi-year journey, and
45:08
that it was going to be a combination of clinical, operational, and technical expertise.
45:13
And kudos to my team there because it was an absolutely fantastic group working really
45:18
closely with the CMIO's team.
45:20
I think that partnership made us advance more than I think we even thought we could.
45:27
When we looked at things like eliminate, and these are things, and these are all available.
45:31
I wrote a paper that's in the catalyst and outlines a lot of the details, but there are
45:37
many things you can suppress from going to a PCP's in-basket or a specialist in-basket
45:43
simply by grabbing a governance group, looking what the content is, and working with your
45:48
IT team.
45:49
We did some pragmatic things like not sending every CC chart, which is sort of a FYI, here's
45:56
a letter, I saw your patient, they had a normal skin check.
45:59
We made a decision not to send all those to PCPs unless there was a clinical value, which
46:04
could be a new diagnosis, change of prognosis, or something you need me to do.
46:08
We looked at all the things that were scanned documents, and they go into this folder called
46:12
media manager, and we recategorized and filed many of them silently, insurance forms, why
46:18
does that go to the doctor?
46:20
We did a lot of silent filing and we got a 98% reduction in that folder.
46:25
We looked at the notifications that come in from hospitals, and we very much care about
46:30
our patients being hospitalized and being ready for them to coordinate care, but we
46:35
were getting six messages per hospitalization and many were blank.
46:38
They were sort of without content, no discharge summary.
46:42
We pulled them out of the in-basket and put them into a dashboard that doctors could pull
46:46
at will and see who was in the hospital and who was coming home.
46:49
Those were some... There are other alerts.
46:51
I've learned that some organizations across the country will send their doctors a notice
46:56
every single time a patient doesn't show up for an appointment or something scheduled.
47:00
You can suppress a lot of that.
47:03
I think that kind of work, looking for ways that you can suppress and asking yourself,
47:07
what is the purpose of sending it to Dr. X?
47:10
What is the expected outcome of that?
47:12
Is a great way to start and get a good chunk of messages reduced or removed.
47:19
We were also very lucky.
47:20
Atrius Health is a very nimble and technologically interested organization.
47:26
When we moved to automation, I had the privilege of working with another great team where we
47:30
automated prescription renewals that were routine and that had passed certain checkpoints,
47:36
meaning quality and appointments and such were checked and were there.
47:41
We did this all through an automation platform and with delegation protocols.
47:45
50% of the prescription renewals were removed from my PCP in baskets.
47:51
We did a similar work with normal labs, which were labs that are normal in every situation.
47:58
Those types of things, and there are other things today, PCPs and many others are most
48:03
plagued by unfiltered messages coming from patients to them.
48:07
It's great that patients can email their doctor, but if the message should have been dealt
48:12
with by a secretary or a medical assistant or nurse, it should go there first.
48:16
Unfortunately, many doctors receive all messages and then they send it on.
48:21
It's kind of similar to if we said, well, why don't we have the doctor answer the phone
48:25
for the office and then go find a medical assistant to fill out the form.
48:29
We should reverse the delegation and many across the country are doing good work in
48:34
this regard, having it filtered by the right people who can resolve much of it.
48:38
We piloted it in some areas and found that we had a 45% reduction off the bat, and there
48:44
was more to go.
48:45
It just shows you that if you really look at how you can retune your EHR routing and
48:53
it's not a huge project like automation, I think you can make some pragmatic steps forward
48:58
and I think it's a very common need across the country.
49:03
That is very practical, very helpful.
49:05
We will definitely include both the article from the NEJM catalyst that you wrote as well
49:11
as the links to the American Medical Association steps forward and toolkits and playbooks,
49:16
because I think those could be really useful to our listeners.
49:19
We're going to come to a close shortly.
49:22
I was really touched in a certain way when you described singing.
49:27
Your team was singing and I think that's kind of the way I've experienced it as well.
49:32
There's sort of like you're an ensemble playing music.
49:35
It's jazz because it's improvised in a certain way.
49:39
There's uncertainties involved, of course, but everyone has a voice and the voices are
49:44
different.
49:45
The sounds of the tones are different.
49:46
To use a metaphor, another metaphor I'd like to offer and then just hear from you as we
49:52
come to a close.
49:53
I think I wasn't even planning on this, but I had mentioned Joseph Campbell.
49:57
There was an anthropologist named Angelus Arrien.
50:01
She worked in cultural anthropology and she looked at healing systems across multiple
50:05
indigenous cultures.
50:07
She came up with a formulation of what is it that a healer would ask someone in need
50:12
of healing?
50:13
What are four questions if she could distill all of her studies of indigenous cultures
50:18
and the healing communities within those cultures?
50:21
They were the following four.
50:23
The first was, when was the last time you sang?
50:26
When was the last time you sang?
50:28
Second was, when was the last time you danced?
50:29
When was the last time you danced?
50:32
The third was, when was the last time you were enchanted by story?
50:35
When was the last time you were enchanted by story?
50:38
Then finally, the fourth one was, when was the last time you entered into the sweet silence?
50:45
I'm thinking in terms of us, physicians, health professionals in need of some kind
50:50
of healing to help us heal others that can provide a roadmap.
50:56
If you are moving towards systems and teams that are working together where you're actually
51:01
singing and dancing literally or metaphorically and that you're sharing with each other stories
51:06
and you're able to stay present to the unspeakables that we encounter every day in our practice
51:14
lives, that would seem to me to be something that is moving in the direction of healing.
51:21
Maybe you could just share any thoughts that just come up as you listen to what I just
51:25
shared and what do we need to learn to get there?
51:28
What are maybe the top two or three things that you think that could help us move this
51:32
along in a healthy direction for the benefit of not just health professionals and physicians,
51:38
but ultimately our patients because that's what we're centered on.
51:43
My first reaction is I wonder if you're, you know, people I know, I did a retreat many
51:50
years ago called Courage to Lead that was run by the Center for Courage and Renewal.
51:55
And it came at a time in my life that I didn't know I needed it.
51:59
And it really reset me.
52:02
And this was a series of weekend retreats run by some amazing facilitators where we
52:08
read poetry and responded to it and worked in small group or in larger group discussion
52:15
and use that poetry as sort of a vehicle for more reflection.
52:20
And I saw, I was a little bit younger than some of the others.
52:24
Ours was designed around healthcare leaders.
52:27
Perhaps everyone there was about 10 years ahead of me in their leadership journey.
52:33
And I saw the rawness of broken leaders, of people who had fantastically successful careers,
52:40
but were really drowning on the inside and really questioning where they were and where
52:46
they were at.
52:47
And the purpose of this retreat in my mind was ultimately to help us find our true self.
52:53
What do we want to bring to our leadership and our lives?
52:58
And I still have my journals and I sometimes read them when I kind of need to remember
53:04
who I am and where I'm at.
53:06
And it struck me that I wrote 15 years ago that I got immense joy out of helping physicians
53:13
and teams find a way to effectively care for their patients in a system that felt supportive
53:19
and not obstructive.
53:21
So the gem had started back there, but I think I made a real commitment to integrity, honesty,
53:31
courage, to be the kind of leader that leads with her light and not her shadow.
53:37
And to bring that, even though times are going to be hard and they certainly have been over
53:42
the last couple decades and certainly through the pandemic, caring for a battered workforce
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and a terrified community, to bring that level of honesty there.
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And so when I hope, and I think I had some affirmations from my last practice that my
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style of leadership, of inviting difficult questions, of engaging in hard conversations,
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of being willing to be honest about the tensions that exist in our work, finance versus autonomy,
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all those tensions, that simply that honesty was a gift.
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And also, when I question, well, why do I do this?
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This system doesn't work.
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I can't help people.
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I think what brought me back was that, well, I think I have decent judgment.
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I don't have the best judgment in the world, but I think I have decent judgment and I certainly
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care a lot.
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So I'm willing to stay in as the leader in hard times because I want to bring that.
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I want to have somebody in that seat that really cares and practices good judgment.
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And so when I think of sort of singing and dancing, I think of Penny Williamson, who
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ran my group, who taught me the value of dancing.
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And I've had moments where I have, I'm not a good singer, but I've sung in my car or
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I've danced in my kitchen.
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And they're just moments when I feel like something really went right today or somebody
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said something to me to make me realize I made a difference and I didn't know it was.
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And I think we all need to give that to each other.
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We give it to our patients, but we also need to give it to each other.
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We need to turn to the nurse and the medical assistant and to our fellow gastroenterologist
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and to the hospitalist and all the people that are part of our medical community and
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give those affirmations and say, thank you, I noticed you did that.
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That was amazing.
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When people do that for each other, it does bring some joy back.
55:41
Yeah, I'd like to change the American healthcare system.
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Absolutely.
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That'll take a five hour podcast, but what can you do today?
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And now they show gratitude and respect for those around you who are working hard to do
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this.
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And if you snap at someone, come around later and say, I'm so sorry, I was irritable because
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I am worried I'm going to miss getting to pick my child up at school.
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Just be honest.
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But those kinds of values I think can bring us back to perhaps a more, dare I say, joyful
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time even though we are not going to fix the ills of healthcare.
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And if we can bring that to our practice and to our community, I think we can all advance
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us a little more.
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I would say lastly that I hope for courage of our country to think more creatively and
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more boldly about healthcare reform.
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I don't think a series of band-aids is going to get us what we want.
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We are a incredibly smart and wealthy nation and we have pretty poor marks when you compare
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us against other economically developed nations and we're not going to be better if we just
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keep slapping band-aids on.
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So I encourage people to read and educate themselves and form their opinions, but really
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be courageous because I think it's going to take that for us to have great health for
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our nation and a joyful place to work for all those who care for patients.
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Well, what a wonderful way to conclude this and that has been such a delightful, delightful
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conversation.
57:18
Thank you so much, Jane.
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Thanks for listening today.
57:22
We will include a summary of the podcast with links about Dr. Fogg and other references
57:26
that were made during our discussion in the show notes.
57:29
I'd like to conclude by sharing yet another practical exercise to help you flourish.
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This practice can be done at the workplace or actually in any place where others are
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working.
57:42
The objective is to be aware of what Dr. Fogg described as taming.
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So sometime this week, if you could, please take the time to simply pause for anywhere
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between one and three minutes at a workstation, at your work, in your office with the door
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open, in a hospital ward location, in the clinic.
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It can be a clinical setting or not.
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It could be in any place that you happen to be where others are working together.
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And as you stop and take that pause, simply bring awareness to the sounds of what's going
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on.
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Sounds of people talking to each other, sounds of people on the telephone, sounds of people
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working with the machine or some kind of inanimate objects.
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The sounds of people working together, the sounds of teams working together, doing the
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work that needs to be done.
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Teaming.
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You know, the literature is very clear about teams that the amount of communication correlates
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directly with quality.
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So from time to time, you may want to stop and practice this again, noticing if communication
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is free and flowing or somewhat restricted.
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Are members of the team feeling safe to speak?
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Perhaps reflecting on your own role, if you are observing a team you are part of and how
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you can enhance that safety.
59:19
I hope you found this podcast and the simple exercise useful to you and look forward to
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having you join us for the next episode of Flourishing in Medicine From Surviving to
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Thriving.
59:31
To learn more about EmPRO and support programs, please visit www.myempro.com forward slash
59:39
peer-support.
59:42
If you're a physician or a medical student and in need of urgent support, please consider
59:46
calling the physician support line at 1-888-409-0141 or visiting www.physiciansupportline.com.
59:57
For more information about me and my work, you can visit me at www.MickKrasnermd.com
1:00:05
or www.mindfulpracticeinmedicine.com.
1:00:10
Until next time.