Chris Casey:
Welcome to another episode of Health Science Radio, where we talk with researchers and clinicians at the University of Colorado Anschutz Medical Campus about some of today's most significant healthcare issues. Today we'll discuss the challenge of physician burnout, why this national crisis continues, and we'll look into some of the ways the problem is being addressed. My name is Chris Casey and I'm the Director of Digital Storytelling here at CU Anschutz. It's great to have you back in the co-hosting saddle here, Dr. Thomas Flaig.
Thomas Flaig:
The pleasure is all mine. It's great to be here and a beautiful spring day here in the Mile High City.
Chris Casey:
It is a beautiful spring day. And finally just kind of calm. No hundred-mile-per-hour, hurricane-force winds.
Thomas Flaig:
I like calm.
Chris Casey:
Well, it's good to have you back, Tom. And as I mentioned, today's topic is one of national scope and will have wide-ranging consequences to anyone who relies upon the American healthcare system, which is pretty much all of us. So how big is the problem? The Association of American Medical Colleges estimates that the U.S. will face a shortage of between 38,000 and 124,000 physicians by 2034. Statistics show that the scope of the physician burnout crisis has only worsened since the COVID pandemic. And to dig into this topic, we have two guests, Dr. Adrienne Mann and Dr. Tyra Fainstad, who are on the front lines of tackling this big problem, both here in Colorado and on the national level.
Dr. Mann is an associate professor of hospital medicine at the University of Colorado and the Rocky Mountain Regional VA Medical Center, as well as core faculty for coaching at the CU Internal Medicine Residency program. Dr. Fainstad is an associate professor of medicine at the CU School of Medicine and practices at Lowry Internal Medicine where she is also the resident director. Both Adrienne and Tyra are certified professional coaches and co-directors of Better Together. Better Together is a CU-based life coaching program, serving medical students, residents, fellows and clinicians in practice nationwide. So to start off our discussion here, perhaps Adrienne and Tyra, if you could just kind of give us more of the scope of the national picture on physician burnout. What are some statistics and what are we talking about here?
Tyra Fainstad:
I think no matter where you look the statistics are grim, and have gotten much worse as you pointed out since the pandemic. Physician burnout has been around for a long time, many decades. We know that the problem seems to start pretty early in medical training, and looks like it gets worse throughout training and then into practice. So that's been the center of a lot of attention for many, many years, and then took a huge hit during the pandemic. So there was a prevalence of somewhere around the one-third of all trainees and physicians range – pre-pandemic – that had just been slowly climbing. And then just after the pandemic, those numbers pretty much doubled everywhere. And so two-thirds or more in our own program – our biggest national study – had just over a thousand residents and fellows back in 2022. And we actually showed that over three-quarters of them scored positively for burnout when they entered our program. Those numbers have come down a bit as we get farther away from the pandemic, but they have not hit pre-pandemic numbers. We're hovering somewhere around the 40 to 50% range now.
Thomas Flaig:
We're going to focus on physician work burnout specifically, but just to give some more context, does this affect other healthcare professionals beyond physicians?
Tyra Fainstad:
Absolutely. I mean, it's hard to go anywhere in the healthcare system and not hear about nursing shortages and burnout among pretty much all of the medical professionals and staff. APPs are hit pretty hard. I'd say there's a different variant of who's affected and how, so some people have more moral injury, or some people have really low self-compassion, or some people are more likely to actually leave the field. But I don't think anybody is left out, especially since the pandemic.
Thomas Flaig:
And APPs are advanced practice practitioners. So physician assistants, nurse practitioners – in that realm. If we think about this too, just in terms of context, there is this concern about shortage of physicians in the future. And one thing that I've recognized about that is there's some geography around that – urban versus non-urban. There's an extreme amount of concern over non-urban settings in physician shortages. Does burnout have a differentiator – urban, non-urban? Is it sort of the same or not known?
Tyra Fainstad:
I don't know if we know an accurate picture for sure. There is certainly a big concern around losing our rural physicians. Actually we were contacted to do some research in the sort of border physicians in Texas by the Ministry of Health there, specifically because of that problem. So I think those areas are hit especially hard when people leave. We do also know that there seems to be some bit of protective effect for physicians in academia. And so though we all really like to complain about the intricacies of our jobs, it does seem like, if you have an academic or a teaching role, that can be a little bit protective against burnout. I could talk for a long time about why I think that is, but I think those are all more likely to be in an urban setting. And so that probably contributes to that disparity also.
Chris Casey:
So you're both founders of Better Together, which we referenced earlier. Could you talk about what Better Together is, what prompted starting the program and where is it at today?
Adrienne Mann:
You got it. So Better Together is a life coaching program that Tyra and I both run out of the Department of Medicine here at the University of Colorado. I think it might be helpful just at the beginning to say what do we mean when we're saying coaching.
In academics and especially in medicine, we have really established roles for teachers and educators, and established roles for mentors and advisors and sponsors. And coaching is a little bit new to the scene, but when we're talking about coaching, what we're talking about is a conversation we have with another individual where we don't know the best answer and we don't know the destination and we don't know the path for them to get there. But we use inquiry and questions and curiosity to help that individual define success for themselves, figure out the path to get there, and to really have agency and autonomy and creation of the life that they want and the success that they want. So this is a little different from most of the relationships we have during medical training and even in practice, where we're used to coming to people and saying, "Here's the problem; what's the answer?"
And the person on the other end of the conversation will say, "I know," and tell us the way. So we both came to coaching – I think we'll come to this maybe a little later in the conversation – but through our own experiences with early career burnout and both experienced the transformative impact of coaching on our professional and personal lives, and so thought we needed these skills earlier. And so we built Better Together, which is now a four-month program that we run twice per year for clinicians at all levels of training. So that includes medical students, residents and fellows, MD and DO, faculty and staff clinicians, and also PhD researchers as well as advanced practice providers. And in its current state, we offer this across the country. I think we're at over 50 institutions this year and serving about 4,000 people who opt in to participate in this coaching program, wherein they get to explore what their challenges are as they relate to their work or they relate to themselves in their work, and do that in a community of other people who are going through similar challenges.
Tyra Fainstad:
And what that looks like on a more granular level in the four months, it's sort of framed by a curriculum that we have built and iterated over the years, where we talk about common problems that people in the medical field encounter. So perfectionism, imposter syndrome, trouble with confidence, receiving feedback, microaggressions at work. So it's framed by a curriculum.
And then we have group-coaching calls online on Zoom where people can bring any problem that they're having to a professional coach, come on Zoom, get coached in front of colleagues on a secure platform and kind of dig through that using our coaching metacognitive model. Those calls are stored on a secure podcast for everyone to listen to afterwards, asynchronously, again, secure members only, password protected, but open to all of our participants depending on what arm that they're in. And so it's an incredibly vulnerable act and a generous act to sort of offer yourself for everyone to listen to and benefit from. And that's what the coaching program mainly looks like. There's a couple of other ways to access coaching, including we were able to offer one-on-one calls now since we're lucky to have so many volunteer position coaches on our platform, but that's the kind of nuts and bolts of the program.
Adrienne Mann:
So we built it because it was something we figured later that we needed as trainees. And so we started by building this program for women trainees here at the University of Colorado, and have now expanded that to include all gender identities and people at all stages of training across the country.
Thomas Flaig:
So it sounds like some of your initial interest in work in this area is brought on by some of your own experiences, and particularly early in your training.
Adrienne Mann:
Oh yeah, go ahead.
Tyra Fainstad:
Oh, absolutely. I encountered what I now look back upon as just a classic case of early career burnout. I was the very typical medical trainee that was really just addicted to approval, and pretty good at the hamster wheel of gaining it. And then I started the habit of bolstering my own ego with other people's opinions of me, and just using that to create some sort of self-identity. This is not unique to me. Medical training in its very structure sort of opens itself to this. So I worked my way through medical school and figured out how to get the grade and get everyone to like me and get the right amount of coffee for my attendings, but don't make it seem like I'm being scuttled out, and be eager but not too eager, and not annoying, and ask for the right amount of feedback. I could nail that game and floated myself through residency.
And then I became an attending physician – I'm a primary care doc – and pretty much all forms of other people's opinions of me stopped all at once. I mean, it's rare that you get somebody else watching you when you're an attending. So therefore my constant stream of fuel stopped, and I didn't know how to evaluate myself. I just was left with this incredibly loud inner critic that told me I was probably doing everything wrong, which I had built up to sort of fuel my constant hustle and I didn't have anything to counter that. And became really burned out by the work, lost my meaning at the same time, which is also very common, I had two kids and they were terrible feedback givers to me.
Adrienne Mann:
Not specific, not actionable, not timely.
Tyra Fainstad:
Just screamed in my face for a year straight. And so I made that out to mean that I was bad at being a mom. I actually did reach out. I tried therapy for a while. I did try a couple of SSRIs. I scaled down at work. I was considering a-
Chris Casey:
SSRI?
Tyra Fainstad:
Antidepressants. I thought maybe this is classic depression. If you tell anyone you're struggling in this way, one of the first things they'll do is try an antidepressant, which works for many, many people. And in my case, I didn't find an effect. I tried scaling down at work. That didn't feel good at all, actually, and so I scaled way up at work. And in a place of desperation, actually, I got a phone call from a friend who was going through coach certification, life coach certification, and I rolled my eyes at her automatically. We were on the phone so she couldn't see me, but I didn't believe that life coaching was a thing 'cause I'm an allopathic MD at the University of Washington at the time, and this sounds like you want to cheerlead me, but okay, fine. I will have a conversation with you.
And proceeded to have more of my thoughts challenged for the better in that one 60-minute conversation than over the last, I don't know, decade of my life. Came out of it with a whole new set of beliefs almost immediately and was hooked – pursued professional coaching for myself. I paid for it for the next couple of years. Got my mind managed, fell back in love with my job, fell back in love with being a mom. And then decided, "What the heck, where was this in medical school? Where was this in residency training?" And that's when I met Adrienne.
Adrienne Mann:
My story is really similar. I also knew how to play the game of getting the things, the praise and approval I wanted, as a trainee. I got my dream job right out of residency and I work at the VA hospital and was really... I had a young kid, was going through IVF treatments to conceive our second, and was offered an opportunity to be in a leadership role in my institution. And so I said yes to that. And I was saying yes to all the things I think I was supposed to say yes to. So I was pursuing medical education and trying to do research in med ed, and I was trying to be a leader at my institution, and I was trying to be a mom and that was new.
And after my second kid was born, I was trying to come back to work and realized I didn't recognize myself in any of those roles I was inhabiting, and couldn't imagine going back to them in the same way that I had left them. And I hired a coach and through that began to understand and reconsider my relationships with my work and my personal relationships, and also redefine what success looks like for me in those areas, which I didn't know was my responsibility to do. Which maybe seems silly to say, but it took a real crisis to get there.
Thomas Flaig:
So it's really helpful to hear. Thanks for sharing your own story and your own journey in this way. And it sounds like coaching was an important part for both of you at that time. How would you say that the program you've developed in coaching is similar from what you received a number of years ago as we've gotten smarter hopefully about all of this?
Adrienne Mann:
Yeah, the key component of our program is that we teach people how to deliberately think about their thinking. And so our coaching is grounded in a metacognitive tool, where we help people understand the relationship between the circumstances that they exist within: "I work here, I do this, it's a 70-degree day in Denver"… The thoughts and the story we tell around those circumstances, how we feel when we're thinking that way, the actions we take from there and the results that creates for us. And so in the first part of the program, we're teaching folks how to be specific and thinking about the way they're thinking, which most of us haven't learned how to apply that skill, at least not around our thinking about our jobs. And I certainly didn't learn that until I had hired a coach. So the first month of our program, we talk a lot about what are you thinking, what are you feeling?
How do you process an emotion? In our second month, we focus a lot on applying that metacognitive tool to what's going on outside of us. What happens to me when I receive constructive feedback? Why do I spin out about that for a week when somebody says, "Here's an opportunity for you to improve"? Why is it hard for me to embrace a growth mindset when I'm in struggle with something?
So our second month is really focused around “How do I want to approach and engage with the world around me, specifically at work?” In month three, we turn that metacognitive tool inwards and we think about our relationship with ourself. This is perfectionism, imposter syndrome, approval addiction and my beliefs about myself as an individual. And we invite people to kind of explore those deliberately and carefully. And that's a challenge; that's my favorite month. And in month four, we turn it back outwards and we talk about transitions, both in career and life, confidence and kind of redefining who you want to be as you come out of the program. So our program is really rooted in the concept that people can think about themselves and their work more deliberately, and through that process find agency in creating and defining success for themselves in the life and career they want.
Tyra Fainstad:
Yeah, I would just add that we're lucky to be growing and running this program in an academic setting. And so we've had access to a lot of great researchers on our team, a lot of great educators, and we've iterated the program so much in the moment based on what's coming up, what people are asking for coaching on. We've also been able to apply medical education theory to our curriculum. And so we've used self-determination theory quite a bit to try and create a sense of autonomy and relatedness or belonging and then competence within our participants, which I could talk about for another hour. But I do think, unfortunately, a lot of the structures of medical education and practice itself inadvertently can thwart. And so we're trying to sort of rebuild that hole for people where it might be lost.
Adrienne Mann:
And I think these aren't processes that only doctors didn't learn how to do. I think as a human, these concepts are applicable to everybody. And so I know so many people whose lives have been transformed through having coaching conversations, and there's a tremendous power in that. So to the audience who aren't physicians but who maybe also experienced burnout or that they don't belong at a table or something like that, a coach is a wonderful resource to help.
Thomas Flaig:
Both of you seem like a great team as you're doing this work together. I'm just curious: How did you find each other on this? Because it seems like that's a special part of what you're doing is the work together.
Adrienne Mann:
It really is. Yeah. So Tyra and I were medical school classmates. We were here at the University of Colorado, class of 2011, and were friends, but not really close in medical school. But then I think both of us were having these experiences at the same time, and both of us had found coaching separately, and a mutual friend said, "You guys are obsessed with the same thing. You should do it together." And Tyra was in the process of moving back to Denver, and I was in the process of applying for a grant here within the Department of Medicine, and we had both really written almost identical grants.
Tyra Fainstad:
I had written a grant through the Society of General Internal Medicine to fund the creation of what we thought was going to be a small, 10 or 20 internal medicine resident, group coaching program. I mean, you should look at the grants. It is eerie because we weren't talking (with each other); we were just talking to this one mutual friend who said, "You two are talking about the same weird thing. Go have coffee. It's weird."
Adrienne Mann:
So we remember this conversation, and we were both like, "Okay, great."
Tyra Fainstad:
"Let's do it."
Adrienne Mann:
This could actually be possible doing it together. And so early in, it was 2019 when we both had received those grants, and we each got a little fraction of time and a tiny bit of money to build out the program. And we were lucky in that we were very aligned in what we thought needed to be addressed. And I think just speaking to what partnership has looked like around this in the past five years is we have really worked hard to divide the labor and divide our responsibilities and our expertise and our roles within our team that now includes 40 physician volunteer coaches across the country and 40 researchers across the country who all contribute to this operation. So it's been a blast. It's like the highlight of my career-
Tyra Fainstad:
Life.
Adrienne Mann:
... really. Yeah. Yeah.
Chris Casey:
Outstanding.
Tyra Fainstad:
It's really fun.
Adrienne Mann:
Yeah.
Chris Casey:
That's really amazing. And so obviously you two have great rapport between each other. What made you land on the idea of having your participants be like in group scenarios, group settings where they have interchanges amongst themselves rather than one-on-one?
Adrienne Mann:
Yeah, I can speak to that a little bit. So there's a large body of evidence that supports coaching as an intervention in a one-on-one relationship. Those are really hard to implement, especially at the level of trainees. It's expensive. Coaching is expensive when you're dealing with certified trained professionals, and it's a lot of coordination, especially with the busiest of people. So we started in residency. Residents don't have a lot of time to coordinate four one-on-one meetings over the course of a year, and it's expensive and costly to do faculty development for volunteer coach faculty if that's what you're using. So both of us thought, what if we did it in a group? What if instead of having one-on-one conversations, we invited people to a Zoom call, and whoever felt like getting coached that day could raise their hand and come up. Now it's a tender and a vulnerable ask of that individual, but we could reach so many more people with that one conversation if it were a little bit more public.
And so we have rules that there's confidentiality in the program, and we really hold ourselves and the participants to those rules. And people can participate anonymously if they wish. They don't have to disclose their name or where they're coming from. So the participant really drives what they share and how they share it. But we thought these could reach so many more people if we could have a hundred people in the audience instead of one. And what we've shown is now we can have 4,000 people in the audience and the reach is even further. So I think that's the most powerful part.
Tyra Fainstad:
Yeah, it's incredibly scalable. And what we found from that first pilot study was that actually the impact of our group coaching program exceeded what we were seeing in one-on-one coaching programs, which we weren't necessarily expecting. We were thrilled to sort of even be in the arena with those since we were going for scalability. But what we found after looking at our participant experience qualitatively is that the act of listening to someone else be coached on the stuff that's going on in your own brain sometimes is even more powerful, because they're still getting that coaching.
I mean, the secret is that actually we all are struggling in the same ways. The circumstances might be different, the logistics of the problem that they bring to us are a little bit different, but when we drill down to it the thoughts tend to be the same. And so they're not only getting coaching that's applicable to them, but now they're immediately normalized by the fact that, "Gosh, my colleague or my attending is feeling this way across the country, somebody else that I don't know, but automatically respect because of their title, is feeling the same way." And I think that in and of itself is more effective, more impactful, and probably responsible for the results that we got.
Adrienne Mann:
We should talk about the studies. You want to hear about it?
Thomas Flaig:
It was kind of interesting. I think you mentioned your team and the physician volunteers, but you also mentioned, if I understood you correctly, a large cohort of researchers, which piqued my interest.
Adrienne Mann:
Good.
Tyra Fainstad:
Yeah. And I will start off by saying I never in a million years imagined being in this room talking with you about research.
Adrienne Mann:
Talk about imposter syndrome.
Tyra Fainstad:
Actually it's like happening. That is where my own imposter syndrome comes into play. I mean, when we met, we were both faculty-
Adrienne Mann:
In med-ed.
Tyra Fainstad:
... clinician teachers just doing chalk talks and PowerPoints and mentoring students, and wanted to do this lovely sort of mushy-gushy coaching program to help people come out of their shell and thrive at work. And my own eye roll response to coaching I could see was met across the board in other physicians and trainees. And we knew that to legitimize what we were doing, we were going to have to show that it works.
And so within our first grants, I think we wrote some like, "Oh, we'll do a pre-post survey and look at burnout." Well, we imagined having, like I said, a small group of 10 or 20 residents to try this out on. When the pandemic hit, simultaneous with when our grant funding hit, we pivoted to an all-online format and recruited folks that summer, and we had a hundred responses to our initial email within the first hour asking, "Oh, could you also enroll my cousin, my best friend over in peds? We need this; we need this." So we thought, okay, let's cut ourselves off at a hundred. And then I remember looking at Adrienne and being like, "Should we do an RCT? Are we allowed to just randomize them?"
Thomas Flaig:
RTCs – randomized controlled trial.
Tyra Fainstad:
Randomized controlled trial, and it's like academic gold. And if we're going to really prove that what we experienced is true for other people too, we should do this and we have we think the numbers. What I later found out was actually the tool we were, so our primary outcome, the thing we were trying to improve was burnout. We measured it with the Maslach Burnout Inventory, which is kind of a gold standard way to measure it in healthcare professionals. And I had a statistician that told me, "You probably need 500 or 600 residents to move the needle even one point on the Maslach Burnout Inventory – judging based on prior studies that are out there in residents, they're pretty hard to help." So we thought, okay, well, we don't know yet if we can coach more than a hundred, so let's just do a proof-of-concept survey study.
And we split them into 50 and 50 – coached 50 in the spring of 2021, pre-posted everyone, and then coached the other 50 in the fall after the study was over and looked at our numbers. And actually what we found was that we had a four-point drop in burnout and the emotional exhaustion domain of burnout with our intervention compared to our control group. And in our secondary outcomes, we were able to show that we statistically significantly improved self-compassion, moral injury and also imposter syndrome. So we thought, hey, maybe we have something really powerful. At the same time we realized, "Hey, we definitely have something really scalable." Like Adrienne said, we realized, "Gosh, we're doing two coaching calls a week." Adrienne does one and I do one, and we could have 30 people on the call or 3,000 people on the call, and it's the same amount of our time. So why don't we just go big? Let's see if this thing is real. Let's see if it's generalizable. Let's see if it's feasible to do what we think we can do.
So we did something wild, which was supported by an internal grant that I still remember the grant reviewers saying, "You can't scale up by 10 times. What are you thinking? Nobody does this." And I was like, "Well, I think we can."
Thomas Flaig:
Trust us.
Tyra Fainstad:
"We've got something that's different. It's not Petri dishes. Can we try?" I actually got rejected on the initial grant and I came back and said, "I think we could do it," 'cause they thought we couldn't do it. So then we got the grant and that supported a national study, which is our biggest study to date, where we enrolled over a thousand residents and fellows across the country, 26 different graduate medical education programs, 19 states.
We ran the trial in the same way. We randomized half of them to the coaching program. This time, it was the fall of 2022, and the other half was a wait list control. And we pre-posted everyone on about the same metrics. This time we were powered to find a difference, and we found a difference actually in every single scale that we measured – all three domains of the Maslow Burnout Inventory more so dropped by seven points. This time we had a curative reduction in imposter syndrome. We were able to do things like calculate the number needed to treat, still trying to coin the term number needed to coach to take someone from scoring positively for burnout to negatively. It's somewhere between nine and 11, which as a primary care doctor is very exciting to me. Also, I don't think there's any adverse effects from coaching, so why not? And so that was the big study that really put us on the map. From there, I think two things happened. We realized this works and perhaps we have something here that we could expand and disseminate. And also we can run randomized controlled trials actually.
Adrienne Mann:
Which is wild. Neither of us, if you had asked us in medical school and residency, neither of us would be like, "I'm going to get grants and run RCT." That was not where we were headed. So to be talking about this feels a little surreal, but I think it shows that if you can dream of something and use the resources available to you, you can make a big difference.
Tyra Fainstad:
And then we learned, I think to speak to your point of running a research team through getting those publications, we got people emailing us saying, "What are you doing? Can I help you? I would like in, this is so needed right now." The pandemic is surging still at this time. And so we'd sort of say, "Yeah, sure. Should we get together? Should we meet? Let's talk about what kind of research you want to do." We have all this data. We have so much data. We actually recorded, every single call we've ever done is recorded, so we've got all this qualitative data if we want it, we could pair it with the quantitative data, which is just a massive amount of data.
And so over the last five years we've recruited, I think we have 38 people doing various projects either with our data or with their own research question that they're bringing to the burnout space. We've done scoping reviews; we did a longitudinal analysis of our pilot study. We've done moderation and mediation analyses asking, "Is there a driver here with the various components of well-being that we're looking at?" We've done an RCT in medical students, an RCT in APPs, and so we've become this very evidence-based academic angle in a well-being space, which has carved out a nice niche for us because that's not always the case we have found with well-being interventions.
Thomas Flaig:
There's a certain power of organizing. And so I'm so glad to hear that. I mean, and it is very powerful when you have those results, this is a randomized finding.
Tyra Fainstad:
Yeah right.
Thomas Flaig:
I think that's propelled all the interesting collaborations that you've had around this.
Tyra Fainstad:
Oh, absolutely.
Adrienne Mann:
It's-
Tyra Fainstad:
Without a doubt.
Adrienne Mann:
Yeah. Yeah, I still can't believe it's true sometimes.
Tyra Fainstad:
Yeah.
Chris Casey:
Have you been able to get at what the root issues are in the well-being space for physicians and healthcare professionals as to... I'm looking at these statistics of the Mayo Clinic proceedings that showed that 63% of physicians scored positively for burnout in 2021 – the depths of the COVID pandemic. That's a staggeringly high number. And so folks very early in their career training already feeling burnout, which is very alarming. So wondering what have you been able to ascertain as any of the root causes? What's the culture shift here that needs to happen in this space for physicians, for healthcare professionals? Have you been able to root out anything there?
Tyra Fainstad:
So I will say we do have some qualitative data, and we have a lot of our own personal opinions. So I think we should share both. The qualitative data that we have is around an analysis of the content of coaching calls that we did in one of the years. So we recorded all of our calls and asked the question, "What are people bringing to coaching? What are they asking most frequently about?" And we have some idea of what the common problems are. It tends to be around feedback. We've talked a lot about feedback. It tends to be around challenging relationships at work. And so not being able to talk to someone or you think someone doesn't like you, something along those lines.
And then imposter syndrome and what that looks like in a coaching call, and what I now think is driving probably a big source of burnout is that we know that physicians have overactive negative self-talk centers or what we term the inner critic. And we, I think somewhere along the way, adopted a mindset of, in order to do well, I need to feel bad. In order to be successful, I've got to hang myself on the hook. In order to not let a patient die in front of me, I've got to really beat myself up and make sure that I'm studying all night and-
Adrienne Mann:
Never resting.
Tyra Fainstad:
... never resting. Looking at myself with deficit glasses all the time, where could I be messing up? And some of that is maybe inherent to the type A, perfectionistic people that are drawn to the field, but some of it perhaps is at least fed during our training. The very act of coming up with a differential diagnosis is a form of catastrophizing, figuring out what could possibly be wrong. And so it just feels very natural to continue that with yourself if no one ever tells you to stop doing that when you go home.
In terms of the culture shift, it's so hard to talk about right now because it seems like there's this battle between the system’s need to change and no, this is an individual resilience problem. And we find ourselves right in the middle of that conversation as a, in particular, a coaching program we partner with institutions and hold them accountable. We say, "You should support your people and having access to this resource," but our actual resource is for the individual. And so we are met with a lot of, "Oh gosh, you're going to give the burned-out physician one more thing to do. Now they have to fix their brain that was messed up by the system." How about more MAs? How about an EMR that works? How about don't throw me a free yoga session when I have 20 notes to write? Are you kidding me?
And I think the answer, of course, lies in approaching that with a both-and instead of an either-or approach, and we get lost unfortunately in the blame game when we stay up in the, is it a system or an individual problem. Of course, it's both. Of course, the system should change. Of course, there's systemic problems in every system around the world. Humans are flawed. There's racism and sexism and oppression of all forms that are going to integrate any system. And even if we magically created some utopia of the perfect system, we'd still have all the individual brains that trained there and now have overactive inner critics and are uncomfortable with uncertainty, and haven't been taught how to name and process and emotion. And so we have to help both at the same time.
Adrienne Mann:
Yeah, I think my only addition to that was going to be, I love that a lot of people are interested in fixing a lot of the systemic problems that drive burnout, and where we kind of position ourselves as in a way that institutions can meaningfully invest in an individual resource. And like Tyra said, it's both. And yes, the EMR has to get better, and we can't be expecting people to work all night and all weekend, and we can help people understand themselves and how they relate to their work better.
Chris Casey:
EMR means?
Adrienne Mann:
Oh, sorry.
Chris Casey:
For the non-medical audience, for the non-medical record.
Thomas Flaig:
Electronic medical record. There's been a question whether it's... Just old enough to kind remember hand-written notes.
Adrienne Mann:
Oh, I loved hand-written notes actually.
Thomas Flaig:
It was amazing. Were short and concise. We sort of needed, but has it made it better? Has it made it worse? It's a rhetorical question for me, but it could be better.
Tyra Fainstad:
It could always be better.
Thomas Flaig:
One thing I'll just say here, AI, the obligatory AI question, are there ways in which you can imagine using some technology, AI, to make this better? So ambient listening now this idea that you'd record with the patient's consent, your clinic visit, and it wouldn't transcribe it. It would actually write the note. And again, a few of us are starting to work with that. I hear people having great hope that that's going to be the thing that's going to solve this, probably this non-spoken burnout that they're talking about, these kind of casual conversations. But any sense of how technology can perhaps have a play here or how it fits in?
Adrienne Mann:
It brings to my mind the question of like, "Well, if we just solve this one problem, won't all of us suddenly be happy?" And always, it's more complex than that 'cause we always still have a brain that's going to look for evidence that we should continue to be miserable often. And so is it possible that that AI is going to make writing the note easier? Sure. But if your brain is still like, well, the note has to be perfect before I can sign it, you're not going to leave clinic earlier just because somebody else drafted it for you. And so our work around documentation specifically is in recognizing when people's beliefs around the perfectness of the note or all different people have different reasons that their notes in the chart might go in late. So we help explore what those are for them. I don't think that problem changes just because AI is writing the note.
Tyra Fainstad:
And we've seen this over time. I mean, we started as a graduate medical education coaching program, so coaching residents and fellows. Sort of the hardest, most vulnerable people, the most overworked, they have the least control over their schedule. And that's where we wanted to start this work.
And we have seen, residency training used to look like a complete nightmare compared to what it looks like now. They used to live in the hospital; that's why they call them residents. And there were no work-hour restrictions. They had no vacations, there was no child-care options. Their salaries were much worse comparatively than they are now. All that has to change, absolutely. You got to get people to living working conditions. You have to make them feel like humans when they're at work. All of that has to happen. And we have seen that with the implementation of all of those very necessary things like work-hour restrictions, like more vacation, like a significantly higher salary, the residents continue to be more burned out. And so I think there is more to the picture, and I think we're missing something if we stay in the problem-solve mode.
Adrienne Mann:
It's whack-a-mole.
Tyra Fainstad:
Yeah.
Chris Casey:
Well, I mean, I was just going to say this could go on and on because you get into everybody's personal psychology, what they bring to the situation, and then like you say, they start feedback looping, imposter syndrome. I'm sure it's just each person's case must be extraordinarily complex. You did mention themes that you're looking for. What have folks just told you anecdotally about your program? Are there any kind of thematic areas that you're getting feedback from your participants?
Adrienne Mann:
We can talk about some anecdotal, but we can also talk about what came out of our qualitative research, and the participants like three things in particular about the program. First is that it's very flexible. So we created this for busy doctors and busy doctors in training. So there's no requirements, there's no gold stars. We're not taking attendance. They can come and go within the program in a way that fits for them and they appreciate that. The second thing is this tool for metacognition, which I told you about earlier; they apply that in their lives inside and outside of work. And simply learning that tool is transformative for many. That's what happened with me, and that's what happened with Tyra. So even just understanding, “Hey, I can understand my own thinking.” That opens understanding and compassion for oneself in a way that most of us don't have to start.
And then thirdly, they felt a sense of community, belonging and just being seen and heard, I think in the program. So community, the metacognitive tool and the flexibility are what came out of our qualitative interview data. What we hear from folks is, I mean, I have a folder in my inbox that keeps me going on a hard day where people say, "I have your voice in my head when I'm facing a challenge."
Tyra Fainstad:
Oh yeah, we've heard, "You've saved my life. You've saved my career. You've saved my marriage." This is truly the fuel that keeps us going 'cause we didn't say this at the beginning, but this is not a business. This isn't our side gig. We don't make money off of this. We run this program out of the University of Colorado and it's a labor of love, and the love that we get back is, it has been so transformative for people. We have people that have participated now 10 cohorts in a row with the same program, the same curriculum. They keep coming back and back for more and it shows up differently for them. And we've had people that have gone through the program, loved it so much that they went and got certified as professional coaches and came back.
Adrienne Mann:
And now coach with us.
Tyra Fainstad:
And now they're coaching for us. I mean, it has just been a massive growth of a baby outside of us that feeds itself. And now hopefully is the start of a grassroots culture change in our field. That's the hope.
Adrienne Mann:
I mean, what keeps me going is the idea that somebody learned something from this program, or someone else sharing something in this program that they take to wherever they are. And we're part of ripples that will change some of these toxic, I think, beliefs that we tend to hold as physicians around the need for our own suffering or martyrdom at the altar of the job, and all of these things that really are painful to hold. And we see those things changing through those folks who've been through our program. So it brings tremendous joy.
Chris Casey:
Well, it's very cool to hear how you've both surmounted your own obstacles and your own challenges, and now you've turned it into such a positive. Wow. It's really amazing when something organic just kind of springs up out of a couple people's idea – that just takes off and is so constructive, and it just has all these ripples as you mentioned Adrienne.
Adrienne Mann:
Thank you.
Chris Casey:
Very cool.
Thomas Flaig:
I just say thank you for sharing your journey and your own experiences, and for using those in the service to humanity the way you're doing. I think you're having those impacts and it's great to have that default that keeps you going those other days because I'm sure there's a lot of impacts that you both have made.
Adrienne Mann:
Thank you.
Tyra Fainstad:
Thank you.
