Pulling Back the Curtain
I graduated from medical school , I was pretty sure I would ultimately pursue an oncology fellowship and become a solid tumor oncologist .
However , when I began my fellowship at the Mayo Clinic in Rochester , Minnesota , I met Neil Kay , MD , a hematologist and chronic lymphocytic leukemia ( CLL ) expert . That relationship changed my life and my career . Neil had recently moved to Mayo Clinic and did not have many fellows working with him yet . He became my mentor and still is today . Neil is a brilliant , creative , patient , and humble man . Beyond that , he is an amazing human being . He always looked out for my best interest and opportunities to advance my professional development and career . He has been the ideal mentor and has become one of my closest friends .
I worked with Neil for 3 years as a fellow conducting research projects on CLL , while simultaneously doing research work in solid tumors . At the end of fellowship , I was offered a position at Mayo in both the oncology and hematology divisions . My choice to join the hematology department was absolutely influenced by Neil and his mentorship . Hematology was never the plan – there was no point in the journey of pre-college , college , medical school , residency or early fellowship when I thought I would become a hematologist or would spend my career leading translational research in lymphoid malignancies . Working with an amazing mentor is what directed my career that way .
Physician wellness is another focus of your career . When did that concept enter the picture ? It was a bit serendipitous : It started when I was a senior resident at the University of Washington . This was 20 years ago , which was a different era in terms of the duties and responsibilities of senior residents . The faculty were around for an hour or an hourand-a-half in the morning , and then it was up to the supervising resident to lead the team . I knew the interns I was working with were dedicated , altruistic people who had committed themselves to medicine for noble reasons . But , when I ’ d call them with an admission or we ’ d have a heavy call night , the way they would talk about patients and their responses to patients needing their help was incongruent with those qualities . At the same time , I empathized with them , because I remembered what it felt like being in their position – getting a couple admissions during the last hour of your shift when you ’ ve been up all night and were already staring down a full day of work . It disturbed me , however , because it was abundantly clear that the process of training and practice was eroding some of our fundamental professional values .
In the fall of my third year of residency , I was preparing to start a research rotation with another mentor , Anthony Back , MD , an oncology communications expert . When we met to plan projects , I told Tony that I wanted to study the experience of training . He asked me many questions about what I was observing and why I cared . I told him , “ Because it is affecting our patients .” He responded with , “ I think you ’ re talking about burnout . It ’ s not my area of expertise , but let me pull together a team and we ’ ll try to study this .”
That study was one of the first to look at the link between physician burnout and quality of care . When we published our findings , the paper became a lightning rod – it was on the front page of USA Today and was covered in many newspapers around the country . I was a first-year hematology / oncology fellow on the consult service at Mayo Clinic at the time the paper was published . I remember commuting on the shuttle bus between two hospitals for a consult when Paul Harvey came on the radio and said , “ New study from the University of Washington shows that physician burnout impacts patients ’ quality of care and leads to increased medical errors .” It was an outof-body experience to be listening to the radio and realize , That ’ s our study !
“ As physicians , we are therapeutic instruments for our patients . Just as the PET scan machine needs care and maintenance , we need care and maintenance to best serve our patients .”
It struck me that here was an unfunded study , conducted by a resident , that was galvanizing a national conversation , not only within medicine but at the societal level . Why ? Because we had approached a problem that people knew about and experienced , but that no one had studied in a scientific and methodologically rigorous manner .
One thing led to another , and the Dean of Education at Mayo asked for a meeting to discuss starting an extension of the study there . Seventeen years later , that longitudinal study is still going on . Several national professional societies started asking if I would help lead studies of their members . It kept snowballing , in a sense , and my research on physician wellness and burnout developed in parallel to my CLL research and hematology career .
In 2007 , the chair of medicine at Mayo was retiring and said , “ I want to leave a legacy gift to the department . I want to create a program on physician well-being , and I want you to lead it . Would you bring me a proposal of what it should look like ?” That ’ s when we started looking at the systemic , environmental , and organizational factors driving burnout and began developing and testing interventions to address them . Rather than simply telling physicians to take better care of themselves , we wanted to identify the root causes of burnout – the characteristics of organizational culture , professional culture , and the workflows and work characteristics that contributed to it .
After we and other groups published a series of scientific papers , health care organizations began to wake up to the concept of physician burnout and wellbeing . Around 2012 , more than a decade after we began this research , the entire health care delivery system realized it needed to get serious about addressing burnout because it was not only harming physicians , other health care workers , and their families , it was also undermining quality of and access to care and worsening patient experience .
While my work on CLL had always been my priority , my wellness work continued to grow . The team I led was the first in the field to be doing robust , extensive research in that space , which was clearly the only way to drive change . I am still engaged in CLL clinical trials and research but eventually , physician wellbeing became my focus . In 2017 , I came to Stanford to become its Chief Wellness Officer and Associate Dean of the School of Medicine .
As someone who researches wellness and burnout prevention , how do you practice that in your daily life ? One of the many positive things about being involved in this work is that it forces you to look in the mirror . While 75 to 80 % of what drives occupational burnout is related to characteristics of the work environment , that doesn ’ t mean individual physicians are powerless to make personal choices that can help us navigate those choppy waters .
I organize the key individual strategies into three areas : defining your values and priorities , optimizing meaning in work , and caring for yourself .
Defining values and priorities is about acknowledging that , as physicians , we have an incredibly demanding professional life . Whether we ’ re caring for patients or advancing science to enable better care in the future , our work is vitally important . It can be all-consuming . We do , however , have other things in life we care about – family , children , avocational interests , and or other pursuits . Often , if we map out our full list of priorities , we find that they are incompatible – it ’ s impossible to accomplish all of personal and professional goals . For example , if I say , “ I want to be an expert in CLL ” and “ I want to be a father who never misses a soccer game ,” I have incompatible goals . To make a difference for the patients with the disease I dedicated my career to , I had to miss some soccer games . The question is , “ How many soccer games can I miss to accomplish that goal while still cultivating the relationship I want with my kids ?” In an similar manner , the rubber meets the road for many physicians when we have to ask ourselves , am I willing to take a slower career trajectory or a lengthier path to promotion in order to have a stronger relationship with my family or do something else that ’ s important to me ?
The second strategy , optimizing meaning in work , is key . Our interests evolve and change as we master things , and we need to come up for air every year or two to ask , “ What do I want to do with my career ? What is the most rewarding and fulfilling aspect of my work ? How much time am I spending there ? Where do I want to take that interest ? What do I need to do to spend more time there ?” Asking these questions can help optimize a sense of purpose and meaning in our professional lives . Our research team has found that physicians who spend less than 20 % of their professional time in the aspect of work they find most meaningful are at high risk for burnout .
The third area – and this is where one ’ s mind usually goes before the others – is caring for self . As physicians , we are therapeutic instruments for our patients . Just as the PET scan machine needs care and maintenance , we need care and maintenance to best serve our patients . We need to rest , take breaks , and attend to relationships and interests outside of work
22 ASH Clinical News November 2020