MedPEP

Hi. I’m Dr. Marie Curious from MedPEP, the Medical Professionals Empowerment Program. We’re releasing this one-minute reminder to let you know that MedPEP physician listeners are eligible to receive as many as 20 FREE AMA PRA Category 1 Credits™ for listening to MedPEP.  Just go to MedPEP.org/CME.

This is the 20th and final episode of the first season of MedPEP. Along with the first and eighth episodes, this is one of three episodes in which Marie and Les engage in a two-way conversation without a guest expert. Their two-way exchanges, relative to the more didactic three-way conversations, are particularly personal and heartfelt. In this final episode, they review Marie’s MedPEP journey, which commenced with a focus on the “self” and ended with a broader focus that encompassed teamwork, conflict management, and career development. Marie reveals that the abrupt departure of a valued colleague and mentor from her practice is what prompted her to participate in the MedPEP project. It was professional burnout that led her colleague to leave the clinic, and Marie decided to become proactive so as to avoid succumbing to the same stresses and strains that befell her friend and colleague. In this final episode, Marie and Les take stock of her struggles, her learning, and the mentorship and coaching she received from the MedPEP experts and, most importantly, from her MedPEP guide, Dr. Schwab. In the first MedPEP session she spoke rather poignantly about NOT wanting her children to become physicians. Now, in the last session, she explores with Les the possibility of having her children join her on home visits. She has gone from having a beleaguered and overwhelmed attitude to being more of a “can-do problem solver.” Both she and Les attribute this shift to what they learned on the MedPEP journey, and she expresses a great deal of gratitude to him for his skill, compassion, and support. Their positive connection exemplifies what often happens when a struggling physician is coached by a trained colleague, and the series ends on a hopeful and positive note, with them agreeing to stay in touch

At the beginning of this episode, Marie acknowledges to Les that she is continuing to mull over Dr. Green’s paradoxical suggestion (episode 18) that one way to overcome a sense of powerlessness is to embrace it. In today’s discussion with Dr. Liebschutz, they consider the possibility that some physicians may be able to overcome their sense of being overwhelmed and downtrodden by actually taking on more. Dr. Liebschutz, an accomplished physician leader at the University of Pittsburgh Medical Center, proposes to Marie that she may be able to overcome the frustration of being a “cog-in-the-wheel” generalist by “leaning in” and embracing a subspecialty area, a teaching role, or committee work that might open up the path to medical leadership. When Marie conveys her skepticism to Dr. Liebschutz, they then consider the possibility that Marie might leverage her value to her clinic by pushing for a temporary sabbatical or by reducing her work effort. They also discuss practical ways for getting more help at home. It is clear throughout this podcast that Marie is paying close attention to Dr. Liebschutz’s every word. Dr. Liebschutz comes across to Marie as a wise and experienced veteran physician, wife, and mother who has crafted a meaningful career by overcoming many of the same obstacles that are daunting to Marie. By the end of the conversation, Marie comes across as energized and inspired, ostensibly ready to put into practice many of the tips and strategies offered by MedPEP’s experts. All three physicians seem to share the view that going forward, Marie is going to chart the course of her career.

Every practicing physician has had the experience of feeling powerless in the face of patient expectations that come across as overblown or unrealistic. Addiction psychiatrist Mark Green, MD, shares with Drs. Curious and Schwab that an effective strategy for managing such expectations is for the health professional to join with the patient by acknowledging their shared experience of powerlessness. In this episode, Dr. Green reflects on the work he has done helping primary care physicians manage challenging patients with chronic pain and so-called “drug-seeking behavior.” He observes that sometimes physicians who are rushed for time and feel compelled to “do something” may inadvertently end up hurting their patients, rather than helping. Sadly, this problematic dynamic may be one of the root causes of the opioid epidemic. Although patients may expect physicians to alleviate their pain and meet other expectations, it is the professional’s job to help them differentiate between unrealistic hopes and achievable goals. By taking time to listen to patients and gain a deeper understanding of the causes of their distress, it is sometimes possible to accomplish more by doing less (fewer unnecessary tests, less medication). Empathically engaging with patients, understanding their helplessness, and sharing in patients’ powerlessness all may reduce their suffering, loneliness, and desperation. Although Dr. Green acknowledges that taking the time to forge these kinds of connections to patients may be draining to the professional, he describes it as potentially fulfilling and even invigorating. In fact, he believes that burnout ensues when physicians and other professionals find themselves in practice situations that deprive them of the opportunity to connect with and listen to their patients. Dr. Green recommends acknowledging one’s powerlessness as an act of self-compassion. His counterintuitive perspective provides Marie and Les with much food for thought.

Dr. Steve Adelman, founder of MedPEP and director of the physician health program in Massachusetts, has a frank discussion with Marie and Les about physicians’ use of addictive substances like alcohol and marijuana. In this era of stress, burnout, and medical “battle fatigue,” doctors may be especially susceptible to numbing themselves with substances that have the potential to impede their performance. Steve’s perspective is that physicians are safety-sensitive professionals who are responsible for the health of the public. Consequently, they have an ethical obligation to stay above reproach by avoiding problematic use of psychoactive substances. Physicians with a history of problematic substance use should abstain; others should consider practices like “clean margin drinking,” a minimalistic approach that is fleshed out with specifics. Marie acknowledges that sometimes physicians cross the line in the name of celebration or stress relief. Steve points out that physicians are at risk because they have easy access to controlled substances and may also resist seeking professional help despite needing it. Marie and Steve discuss a specific case involving a patient whose therapist appeared impaired during a psychotherapy session. A guiding principle is that the safety of the public should never be compromised. Les asks Steve to comment on the use of marijuana by physicians. Steve focuses on the downside, advising licensed health professionals to avoid marijuana altogether. He links this MedPEP episode to earlier podcasts by suggesting that health professionals should avoid misusing substances; instead, we should focus on improving our self-care with diet, exercise, meditation, and better work/life balance, all of which may counter personal and professional burnout, and preserve our careers.

Dr. Marie Curious and MedPEP host Dr. Schwab have a rich and engaging conversation on the doctor-patient relationship with primary care physician and writer Dr. Danielle Ofri. The discussion contains numerous clinical pearls, some of which are drawn from Dr. Ofri’s experiences learning to play the cello as an adult. She reflects on her own frustrations with electronic medical records in a way that steers Marie in the direction of valuing and savoring the time she spends with patients, attentively listening to their stories, while judiciously and productively managing the visit length. Dr. Ofri urges physicians to utilize the first few minutes of each outpatient visit for “full frontal listening.” This helps to win the patient’s trust while providing hard data that reveals the patient’s most pressing health concerns. She links this technique of active, empathic listening to two of the holy grails valued by health care business leaders: patient satisfaction and patient safety. Dr. Ofri encourages physicians to adopt a mindset of continuous learning, growth, and professional development, and views this stance as an antidote to personal and professional burnout. And finally, Dr. Ofri advises that “if you really want to feel rejuvenated about medicine, make a house call to one of your frail patients. It makes you feel good about what you are doing.” Drs. Curious and Schwab concur with the importance of reconnecting to the essence of clinical medicine: the doctor-patient relationship.

Dr. Jeffrey Auerbach is a psychologist, coach, and author who has coached health care executives, physicians, and physician leaders for more than 20 years. This episode focuses on the complexities of emotional intelligence (EI). Jeff explains to Marie and Les that there are four broad domains of EI: (1) knowing yourself, (2) managing yourself, (3) understanding other people, and (4) being able to effectively and sensitively manage relationships with others. Specific competencies within each of these four domains are enumerated. Dr. Auerbach makes the case that by developing EI skills and competencies, physicians become better equipped to perform at their peak in today’s demanding and stressful medical environment. By knowing, managing, and regulating themselves, some physicians will be able to avoid becoming overwhelmed and emotionally overloaded by potentially destabilizing interactions that come up in the course of everyday medical practice. The discussion drills down on the topic of burned-out physicians who experience anxiety and dread about going to work. Although it may be helpful to be aware of these feelings, dwelling on them excessively on a Monday morning may be counterproductive. The role of emotionally intelligent leadership and its positive impact on teams and organizations is also touched upon. Research findings indicate that physicians who are led by emotionally intelligent leaders are less likely to experience burnout. Drs. Auerbach, Curious, and Schwab also discuss the role of EI in preventing conflict. Negativity in the health care environment may arise when emotionally unaware individuals blurt things out impulsively in a way that incites others. Consequently, EI may be viewed as a core competency for all members of teams, groups, and organizations.

After learning about the causes of burnout, how to cope with it, and how to convey one’s concerns to the higher-ups in an organization, Marie meets Dr. Helen Riess, a practicing psychiatrist who directs the empathy research program at Massachusetts General Hospital. Helen believes that the rigors and pressures of medical education, training and practice deplete physicians of their natural ability to empathize and connect with patients. She describes how physicians can form meaningful empathic connections to patients during the limited time of an office visit. A quick gaze conveying that “I see you” acknowledges the patient. Actively including the patient in reviewing lab and imaging tests may improve the patient’s experience of the physician and the visit. Helen helps physicians to notice and decode patients’ facial expressions and body postures. When the patient feels understood, this improves the care experience for doctor and patient alike, enhancing the well-being of both parties. Helen coaches Marie to encourage dialogue through open-ended questions, and to artfully and tactfully close discussions in a timely manner without giving the impression of rushing. As these skills are mastered, a mutually satisfying connection may emerge, enhancing the personal and professional fulfillment of the caregiver in a way that may mitigate the stress and burnout that is rampant.  Cognitive reframing and self-regulation are additional skills that help a physician to avoid becoming overwhelmed by the emotions of shared experiences that patients bring to the exam room and office.

The stresses and strains of medical practice burned out Dr. Diane Shannon to the point where she left clinical practice and reinvented herself as a medical writer. She shares her moving, cautionary tale with Marie Curious, explaining to her that medical practice was not what she had expected it to be. She found it to be so chaotic and stressful that it was taking a serious toll on her physical and emotional health. It also detracted from her capacity to sustain healthy relationships. Since leaving the practice of medicine, Diane’s research and writing have led her to the conclusion that her personal crisis had multiple causes: her inability to adequately handle pressure, stress and frustration at work; the lack of organizational support for her and other physicians; and, the bevy of system-wide regulations and requirements that have culminated in the dehumanization of the role of the physician. Diane believes that some leading edge organizations are instituting meaningful changes in processes, culture and leadership that are just beginning to move the needle on physician burnout. Diane gives Marie advice about having effective discussions with leaders and managers about the linkages between physician well-being, patient satisfaction, and organizational success.  She also shares some personal survival strategies with Marie, including informal peer-to-peer support groups.

Marie meets with Dr. Paul DeChant, a former family medicine physician and CEO who now works as a health care management consultant. As a medical leader at the Sutter Gould Medical Foundation, Paul successfully led a system-wide transformation that enhanced clinician well-being and restored joy in caring for patients. Paul is the lead author of Preventing Physician Burnout which focuses on the use of Toyota Lean principles to improve the practice-level processes that have dehumanized the care experience for patients and doctors alike. In his conversation with Marie and Les, Paul focuses on removing the obstacles that come up in the course of everyday office practice. He emphasizes a process improvement approach that respects and embraces the opinions and insights of front-line office staff, stressing the importance of collaborative change initiatives. Paul underscores the importance of physician engagement. Without the buy-in of distressed physicians like Marie, turning around an oppressive practice situation may not be possible. Paul attempts to leverage his experience and track record to empower Marie, and others like her, in office-wide and system-wide transformation efforts.  He stresses the importance of communication between front-line physicians and the medical and corporate leadership, and Marie is somewhat skeptical that her voice will be heard. Dr. DeChant explains that the when physicians and other members of the team are able to implement and sustain meaningful changes at the level of the practice, not only do people feel better about the care they deliver; the practice may even increase its capacity to accommodate more patients at the same time.

Following up on her conversation with Marie on conflict management, a second conversation with Dr. Jo Shapiro focuses on her hospital’s model peer-support program. There, clinicians facing emotionally stressful situations such as safety events, trauma and traumatic losses, malpractice suits, and medical board complaints are offered the opportunity to meet with trained peers, who help them to express and normalize the complex feelings that arise in these situations. Jo demonstrated the Brigham’s peer support paradigm by asking Marie to talk about an adverse outcome that continues to weigh on her. Marie, Dr. Schwab and Dr. Shapiro proceed to have a moving conversation about the so-called “ghosts” who from time-to-time haunt the memories of many, if not most, practicing physicians.  The discussion clarifies the essential differences between informal and formal peer support, and between peer support and psychotherapy. As Marie talks freely about one of her “ghosts,” the relief she experiences in doing so is palpable. Dr. Shapiro asserts that peer support can actually make a physician more resilient after a stressful event, diminishing the psychological wear and tear that may lead to burnout and depression. She shares her conviction that the medical profession should universalize programs of this sort to meet the human needs of dedicated professionals who frequently face significant occupational stresses.

Marie and professionalism expert Jo Shapiro, MD, have a deep conversation about resolving interpersonal conflicts that come up on medical teams and at different levels of health care organizations. Dr. Shapiro, a surgeon at the Brigham and Women’s Hospital, directs the Center for Professionalism and Peer Support there. She believes that conflict in medical settings is inevitable and may be healthy when it allows for a respectful synthesis of multiple perspectives. Dr. Shapiro helps Marie unpack and process her negative feelings about a colleague who at times comes across as overly demanding. They consider this situation from the perspective of both Marie and her colleague, and they embrace the assumption that all team members are trying to do their best. They discuss providing colleagues with behavioral feedback that is both positive and critical, and how tricky it is when others are not aware of how they come across. A careful approach that is helpful, respectful, and tactful is called for. Such discussions should center on observational data, whenever possible, and antagonism should be avoided. When such attempts to iron out interpersonal complexity do not go well, one should promptly obtain help from those with the skill to ameliorate situations of this kind.

Psychologist and Coach Alan Morse focuses on assessing and addressing physicians’ problems from individual, team, and organizational perspectives. He suggests that the same analytical skills that physicians utilize to assess patients’ conditions may be applied to one’s self and one’s practice. Understanding organizational culture is a must, and solutions should be viewed through the lens of the team. Hierarchical differences between team members take a back seat to the good of the patients and the harmonious functioning of the team, and these typically align. Sticking points may necessitate that leaders weigh in on potential solutions, as well as modification of policies. Dr. Curious is somewhat skeptical about her ability to implement this approach in her particular practice situation, which is busy and seems hopelessly hierarchical at times. However, she is willing to start addressing her day-to-day frustrations more openly and seems to be gaining comfort with a more active and assertive problem-solving stance. She is encouraged to stay the course in solving problems at the practice level and is beginning to integrate the perspective of organizational management with her own.

Les and Marie take stock of their first 6 conversations with well-being experts, and they reflect on Marie’s ability to effectively incorporate the torrent of new information, skills and techniques into the everyday flow of a busy life at work and home.  Marie acknowledges how difficult it is to translate knowledge into habit formation, and they discuss the importance of accountability, consistency and practice, all of which support positive behavior change. In a demonstration of mentorship and coaching, Les inspires Marie to attempt to make one consistent positive change, and to monitor her own progress just as she would monitor the progress of a patient. He models a client-centered, positive psychology approach that allows for experimentation and learning, alleviating the kind of self-criticism and pressure that many physicians inflict upon themselves.  Les helps Marie identify a potentially helpful accountability partner at work. Les and Marie acknowledge that because physician burnout is a byproduct of factors beyond the control of individual physicians, many future MedPEP episodes will focus on interventions that are team-based, organizational or systemic. As an individual who aspires to become more empowered and personally effective, Marie is interested in applying what she is learning at the level of her team, work-group and organization.

In this episode Marie meets Beth Frates, MD. Trained as a physiatrist, Beth coaches people to adopt healthy lifestyles, with an emphasis on diet, sleep, stress resiliency and exercise. In this MedPEP episode, Beth focuses on nutrition and healthy eating patterns as critical factors to energize Marie over the course of rigorous days in the clinic. She describes the evidence-based Harvard Healthy Plate - half is comprised of vegetables and fruits, one quarter is whole grains, and the last quarter includes healthy proteins. Beth sings the praises of the health-promoting vitamins, minerals and antioxidants contained in vegetables, as well as the energy-sustaining fiber found in whole grains such as brown rice and quinoa. She underscores the importance of consuming healthy sources of protein such as beans, seeds, nuts, fish and unprocessed, lean meat, all of which sustain energy more effectively than simple carbo-hydrates. Beth engages with Marie in a collaborative and empowering way, enhancing her motivation to make health-promoting changes in her diet, despite her harried work schedule.  Beth also introduces the idea of mindful and restful eating, and by the end of the podcast, Marie finds herself close to taking on the challenge of setting aside 15-20 minutes of clinic time to take a restorative lunch break. Marie continues to struggle with putting her own basic needs ahead of the daily demands of her medical practice.

Dr. Marie Curious reports back to Dr. Les Schwab that her arousal level is unacceptably high in the course of the work day, and he comments that difficult conversations in the clinic may be a contributing factor. He introduces her to Dr. Cathy Lanteri, a practicing psychiatrist and executive coach. Cathy explains that the current environment requires physicians to develop expertise in communication, conflict resolution and team building, and gives Marie pointers for effectively managing difficult conversations. One should take a step back, think about the primary goal, pay attention to one’s feelings, and consider how best to reach the other person. It is important to recognize how the brain responds emotionally when caught in a "limbic loop," and to short circuit that loop by thinking analytically. Cathy demonstrates the I-F-I-A-R (“if I am ready for resolution”) paradigm to help Marie navigate strained interactions more effectively.  I-F-I-A-R focuses on factual, first-person communications to help us maintain our composure and “get to yes.” Marie and Les both find utility in this approach.

After Marie describes her experience with savoring the moment while drinking water — a follow-up activity from the meeting with Dr. Gazelle — Dr. Schwab introduces her to Diana Dill, EdD, who coaches physicians to prevent burnout from feeling stressed and overwhelmed due to unsustainable organizational changes. She points out that people have different stressors and everyone has to assess if they have enough energy to sustain through the day. In the stress management world, energy arousal is measured on a scale of zero to 100; and peak performance can be achieved for two to four hours at a stretch in the mid arousal levels of 40–60. Above 60, one begins to feel frazzled. And at yet higher levels, the body allows only automatic activities, e.g. fight or flight, required for addressing emergency situations. One can, however, modulate the level of arousal energy and bring it in the mid-range periodically with activities such as deep breathing, savoring a moment, etc. that provide a break from sustained high-energy activities. Diana advises Marie to monitor and map out her arousal levels during the course of a day and manage activities both personal and professional using such techniques, enabling herself to think and change the course of action, if and when needed.

Dr. Schwab introduces Marie to Gail Gazelle, MD, a practicing hospice physician and health professional coach, and they review multiple working definitions of mindfulness. She stresses the need for compassion, both for one’s patients as well as for oneself. Dr. Gazelle also emphasizes the importance of being in the present moment, staying focused on the reality in front of us. Marie comes to understand that focusing on the here and now allows one to put a distance between oneself and the downward spiral of negative thoughts that sometimes distract and preoccupy individuals who work in high stress professions. A benefit of practicing mindfulness and other related meditative techniques is that they enable us to effectively focus our attention where it belongs and to tune out the distractions. Another beneficial aspect of mindfulness is critical curiosity about one's own thought processes. By learning to focus on the task at hand, we are able to conserve energy that might otherwise be lost in negative thoughts. Drs. Gazelle and Schwab talk to Marie about incorporating a simple mindfulness practice into the course of her busy days in the office, and Marie agrees to give it a “college try.”

After reviewing Marie’s effort to take time for lunch, Dr. Schwab introduces her to Margaret Moore, MBA (a.k.a. Coach Meg), founder of the first health and wellness coaching school in the United States.  Coach Meg points out that physicians are trained first and foremost to focus on their patients' well-being and often feel guilty when they pause to take care of themselves. "We’re not a healthy society, emotionally or physically. And it’s hard to imagine us getting that [patient care] done without the health care workforce also being well." Coach Meg presents multiple definitions of well-being and delineates the relationship between resilience and positive emotions.  Maintaining an upbeat, open-minded, and flexible perspective may counteract the stress encountered during a busy clinic session. Coach Meg talks to Marie about coaching herself during the course of the work day. Short breaks, deep breaths, and glancing at a pleasant image may be helpful. Meg motivates Marie to take a high-level look at herself and her life, and to start re-examining the path forward and its sustainability. Coach Meg and Dr. Schwab inspire Marie to see if she can begin to locate her own personal “off switch” before the next episode.

In this episode, Dr. Curious meets physiatrist and lifestyle medicine guru Eddie Phillips, MD. Marie describes the draining of cognitive, emotional, and physical energy engendered by rapid multitasking and juggling in the clinic. In response, Dr. Phillips emphasizes the importance of physician self-care to counteract energy depletion. Health professionals should practice what they preach when it comes to a healthy lifestyle, stress management, nutrition, physical activity, and substance use. He then offers multiple tips on how to incorporate good lifestyle practices into one’s daily life. Marie is encouraged both to exercise while interacting with her young children, and to derive joy and pleasure from these healthy interactions. Another way to counter energy depletion is to focus on the joy one derives from helping patients. Finally, Dr. Phillips advises Marie to improve her lifestyle practices by making small changes, building and growing incrementally. Drs. Schwab and Phillips inspire Dr. Curious to test out a lifestyle improvement before the next episode.