Addressing Physician Well-Being in an Academic Medical Practice

October 15, 2019

Information

Marcela G. del Carmen, MD, MPH

Yale Cancer Center Grand Rounds

October 8, 2019

ID4554

To CiteDCA Citation Guide

00:00Where she leads over 3200 M GPO physician members of beyond her many accomplishments doctor del Carmen has the distinct honor of being the first woman Latino to ascend to the academic rank of professor in obstetrics gynecology and reproductive biology and gynecological oncology at Harvard Medical School. She received her medical degree an residency training at Johns Hopkins did or fellowship, and Joanne oncology at mass general and she also holds a.
00:31Masters of public health from the Harvard TH Chan School Public Health. Her work has been in a variety of areas, including underserved populations in rare gynecological agencies. She's received numerous teaching awards and service awards, including the National Council on resident Education Obstetrix and kind of Cology Award. The Golden Eagle Award. the CBS cares where the McGovern toward for Clinical Excellence. And that's the short list as time allows and today, she will be speaking to us about.
01:04The issue of caregiver Wellness and so please join me in welcoming around guest doctor Marcela Del Carmen.
01:15Thank you, it is truly a privilege to be here and I wanted to thank doctor Julie Krohn for making the connection and getting here and it's really a pleasure to be here and I. Thank you for your attention and mostly for your time. We're all busy and the fact that you're taking time to sit with us today. An here by the experience of the MGH around Christian Wellness is really very grateful for your time I wanted also acknowledge Doctor Schwarz said gynecological ecologist. I've been a huge fan and certainly continued to.
01:47Be a big fan of of your career and thank you for all of the work that you've done to advance the care of women and women with cancer in our field So what I hope to do over the course of the next 45 minutes is kind of Kerry you or take you through the journey at MGH of how we've dealt with decision Wellness and how I came into this work. I'm a doctor and recognition and mechanical logic oncologist. I still practice 3 days of the week and 3 years ago was asked to consider taking this role in the organization's Chief Medical Officer came into the job.
02:17Without any training other than being doctor boots on the ground and at first I was a little skeptical about this whole issue of Wellness and burn out. I didn't really think that it was pertinent to what I did I have loved being a doctor every single day of my life. I think that I have the most privileged occupation. I think it is sacrosanct charge to be able to have somebody allow you to be part of their medical care, especially when they're challenged with a cancer diagnosis. But I'll walk you through a little bit of my own journey.
02:48In this work and again share with you, some experiences that I've learned and sort of lessons that I've learned over the course of the last three year or so. Let me start by setting the stage. I don't think I'm going to need to convince you of what I had to be convinced about which is the issue of this epidemic of burnout so this is basically our legacy. Many of us in the room with Gray hair. This is how we were actually taught or trained to practice Medison. This is a picture from William author at Hopkins when.
03:18As you know, he's credited for bringing the teaching of Madison to the bad side and you can see that the focus of the picture is really the patient. He's got a stethoscope is auscultating the patient and you can see that the training for the house officer all essentially focus on the patient so many of us went to medical school because that's what we want to do. We want to take care of patients. We want the patient to be in the center of what we do every day and this is how we practice medicine today, so this is a picture from.
03:46Morning, rounds, you could be Yale Hospital, it could be much generally could be any hospital in the country so a few things to notice in terms of the difference is one thing that is good is that we know how women in Madison. So I would celebrate that as a grade milestone.
04:01But you can see that everyone is reading or focused on a computer screen and in fact, we've gotten so good at practicing medicine that we no longer need a patient right so there's no patient in the picture of the patient is presumably inside a room, but we're rounding. I'm talking about the patient before anybody has actually examine the patient or Asta Tatian about. However, she here, she's doing that morning so.
04:22I appreciate that as someone who turned 50 this year that the model of care is changing and we have to change with the system to be able to continue to do work effectively and efficiently. So why do we have to balance every day and I don't mean to stress anyone out or give you an ulcer as you're trying to enjoy your lunch. But this is what many of you had to face this morning when you woke up and you came into work today. You have to worry about.
04:48Focusing on your patients, but also working in in an increasing complex system where we have every day. A new requirement really feels like every day, we have a new regulation a requirement that we have to adhere to in order to be there compliant with documentation or building. We have to worry about how are we going to get paid and I think that if you haven't thought about that in academic Medical Center you probably haven't done your homework. Every single day, the charge or the challenge of how we're going to continue to provide patient care generating margin so that we can actually subsidized education and research becomes.
05:22Much more imperative, we have to work in teams. Many of us were trained to work as individual providers. But we now have to work with teams that include not only trainees, but also midlevel providers nurses specialist Geneticists in cancer. So the complexity of care that we're delivering is ever growing and the themes of people or the number of people that are required to support this team is also ever expanding.
05:48The models of care are changing so we have at mass general or primary care doctors have moved from a fee for service panel to actually a panel size of patients where they're getting paid for the value of care that they bring so again very different and we have to work in an electronic health record so many of us trained at a time where we actually charted everything on a paper chart. You had challenges if you ever had to see a patient in the emergency Department. You have to call security to open the attending's office and go through their stuff to try to find the chart of the patient.
06:18You were going to take care of in the emergency Department and often times all you saw was RTC in 4 weeks return to clinic in 4 weeks and that wasn't very helpful, so there are advantages to an electronic health record, but it comes at a price of actually understanding how to use this tool to care for our patients, not to belabor. The point but again we have to worry about how we're going to get credential. State licensure requirements are changing and becoming more demanding or re certification requirements. Many of us have had to get re certified and we've had to go back and I'm not. I'm a demonologist and I've had to go back.
06:53Read about of subjects are in practice practice will be so that feels really relevant to my life. But if I want to maintain a license. I need to still do that and then the promotion process. If you have a an ambition or a charge to be an academic physician. Today, you have to worry about taking care of patients educating the next generation of Physicians and also doing research or contributing in some other space that will allow you to get promoted.
07:18So so we know that all of this is essentially con fluent in an experience that now has turned into a labeled experience called burnout. So when you think about burner. This is not unique to Madison and it's not unique to this generation. We probably have all felt burnout. The physicians that came before us probably had something we have burnout. But I think we now have experiences that allow us to actually speak about it as a common experience and I think one of those is epic or the electronic health record so if you've ever been.
07:48In a legacy system and now you're actually on the epic platform, you can talk about the experience of actually converting from one to the other so we know that the nation of the national data suggests that 46% of doctors in the United States are burned out based on the mass like burnout inventory and when you look at the physicians or the specialties that are the highest in that in that space are going to be the doctors that are in the frontline of care so emergency Medison OBGYN. So doctors that are seeing patients in the first line of care are going to be more affected.
08:21By this phenomenon is more prevalent amongst us doctors that in any other space in the US in terms of other work industries. These are data from this year. So when you look at the most burned out. Doctors again critical care neurology family. Medison OBGYN Emergency Medison. So these are the people that are seeing patients day in and day out, so you have to ask the question why are we burned out if we're actually in the front lines of care taking care of patients and I think that my theory on this is that what actually drives us.
08:54Going to Madison is that connection with patients so that's what gets us up in the morning and get this excited to go into work and deal with the enormous amount of paperwork that we have to do to be able to get to that 5 minutes with a patient and that is the fuel that keeps us going so it's no wonder to me that if you're in the frontline of care you're actually doing more administrative paperwork and non clinician work your way.
09:24In a way that you still do it because you still want to have that experience with the patient. But it is eroding into that connection that we have with our individual patients.
09:35So this is what actually convinced me about this being a problem. So when you look at physician suicide. There's one physician committing suicide. Every day in the United States at mass general. We had one about 2 months ago, so it happens. And it happens in your community. We know that we have the highest suicide rate of any other profession. Some Edison is number one. You can see the rates there. The rate among male physicians is 1.4 times greater than the general population of men.
10:06And for female actually who commit suicide at a lower rate in the US population. The rate for female physicians is more than twice as high as the general female population. So when you look at these data you actually begin to realize that we have a problem.
10:23So I don't have to belabor the point. But there is going to be an impact on the price that we pay when we're feeling burned out and we bring that to work so there's created intention of turnover so more doctors are either leaving Madison or going part time or actually retiring early newer emerging data that there are more medical records more more malpractice cases that can be at least associated it's not costly related to vernal lower quality of care lower empathy patient experiences is different.
10:53And then if nothing else, there's a financial cost to institutions by having doctors turnover or retired before their scheduled time to retire.
11:01So when I when I came into this work. Again, I was a little bit dubious about why this was relevant to me as a gynecological colleges. I felt that you went through all of this training because you really want to take care of women with cancer and I didn't think that it was relevant to my specialty and then doctor Jeffrey Fowler, who was president with Society of divine oncology decided the year that he was pressing him to conduct a survey amongst the UN Oncologist. Members of the SDR society and you can see that he did, especially a survey.
11:32Study where he did a cross sectional study of STO full members in 2013. It included the study included 76 items that measure burnout psychological distress career satisfaction and quality of life. 40% of the physicians, who were invited to participate completed the survey for survey work is actually quite a high number and these are the data. So 30% of the society members that responded reported that they had the reported high scores across.
12:03These 3 domains of pronounce so emotional exhaustion depersonalization, low personal accomplishment 30% of our members screen positive for depression.
12:1513% reported they had either thought are intended to commit suicide. At least once that previous year. It's actually an astounding number when you think about the fact that is D1 colleges. We basically like to carry ourselves as being very resilient. This is not a resiliency problem is not that we can handle the work or were not strong enough is that the amount of work that is coming our way is too much and we don't have a date as long enough to accommodate for the work 15% tested positive on the cage questions for alcohol abuse.
12:46And the sadness was that of the doctors that were depressed 61% of them, said that they would not seek help for their depression. The reason is that they were worried about sanctions against them in terms of being able to continue to practice. Medison if they actually sought help to become depressed and so I think there's probably some Association between depression and the way that we medicate that depression with alcohol use or other maybe not so well compensated mechanisms of.
13:18Of management so just to give you before we start talk about the experience at mass general. Let me sort of set the stage for you so we are faculty practice only so we don't have anybody outside of the system practicing at mass general. We have 3000 specialists. An primary practice group of over 230 physicians. You can see that over the course of time actually being able to increase the number of women going back to 1995 when the year after the pier was organized with part of 3rd.
13:49So now about 42% of our doctors are women and we expand across 16 clinical Department, so again it close faculty with an academic appointment at Harvard Medical School.
14:01Harbor medical school I would say problematic for us in terms of our ability to be promoted and this is actually important because I think my humble opinion is that medical schools and institutions have to change the way that we're organizing structure to be able to actually accommodate and compensate physicians today for the work that they're doing.
14:21So we have a faculty across the harbor medical school system of close to 10,000 physicians and you can see that the vast majority of our providers are going to be at the instructor rank. So we have a 4 tiered promotions process and you can see that is a very small minority of physicians, who can actually achieve a promotion level of Professor and that's not because they're not contributing is that that the institution doesn't recognize their contributions as mirrors of being promoted and that I think it's also something that we should.
14:53We should talk about it will highlight some of the work that we are trying to do to move that forward so the way that we actually structured and organized the Wellness work at Mass. General is that we have a survey that is created is diploid every other year. The survey has been around for many, many years and it is designed to actually look for feedback from the faculty to organize the work that the leadership will take honest priorities for the institution over the next 2 years and in 2014 or CEO.
15:23Recognize that Wellness was an issue and he introduced the math inventory for burnout and the work engagement scale into the service. So we have Wellness data from 2014, 2017 and the data that I'm going to show you this afternoon. Our data from the 2019 survey, which closed out in May.
15:43And this year, we actually included a couple of other domains of questions, including diversity leadership. We pay our doctors who take the survey and I was a little bit embarrassing to say that, but because the data are used to drive leadership initiatives and priorities. We think that it is important for us to have a majority of the voice of our doctors recognize so this year. We had 2100. Faculty, who are eligible to be eligible, you have to practice clinical Medison at least 25% of the time.
16:13We had a completion rate of 93%, which you can imagine is exceedingly high for a survey study.
16:21These are the highlights and I want to go quickly through these but essentially despite the fact that were burned out 88% of our doctors are either satisfied or highly satisfied with their career, which is previous to our previous surveys.
16:34We I would say are burnout rate is flat, we had a burnout rate of 46%. In 2017 and he came down to 43%. In 2019 and this is relevant because our highlight the work that we've done between 2017 and 2019 and some of the successes and also some of the failures that we've encounter 52% of our doctors are aware of Wellness work, which is named. The Frigoletto Grant process. This is a problem right so we're getting too.
17:04Only half of our faculty were not able to reach 48% on the faculty and we need to look at that and understand why that is.
17:1040% of those who are aware of the work field that the program actually directly benefited them.
17:18Clinical documentation is the most burdensome daily task lost the previous year was prior authorizations. We took on this as a priority for the organization have done some work that I'll share with you later. And so while we're driving this down something else is creeping out to become the most burdensome activity.
17:35We have an issue with diversity are female, doctors. I'm embarrassed to report 30% of them compared to 4% of the man felt that they had that gender was an issue as to why their careers were not advanced. This is real. These are a doctor speaking up weather is true or not true is the perception that these doctors have and to the degree that it is perception. I think we have to take it seriously, and then as you would imagine more of our doctors who are African American.
18:05Also felt left out of opportunities in advancement that were intrinsically based on their race on Earth. Midcity compared to their Caucasian counterparts. So these are things that we need to further explore to be able to create programs and it's not for lack of trying. We have a lot of programs that you do here around supporting are females and diversity and inclusion is just that. We're not changing. We're not changing demographics and so we can still throw money at the problem. But we've got to come up with initiatives that are actually going to translate to a different experience.
18:3670% of our doctors felt that there supervising attendings empower them to do their job.
18:4548% of our doctors felt that our office, the peo was actually doing a good job of being of caring the ownership of being leaders in the in the organization again half of our doctors, either don't know what we do for them? Don't care or find this completely relevant in their lives. and I think as leaders of the organization, we have to ask the questions and you have to understand why we work for the doctors so we have to figure out a way to make the experience better, so again career satisfaction remains relatively high.
19:17These histogram depicts our 16 clinical departments across the issue of burnout so to be able to so these are departments, the rating of burnout being high in 2 of the 3 scales. This is really high burnout So what I want to share with you here is that when doctors burnout. We burn out hard and we burn out deep right. It takes a lot to get us here. But when we get here is really hard to get us out, so in 2017 are burnout rate was 46% the previous time in 2014.
19:48He was actually 41% and we went up. This is actually the installation of epic is primarily responsible for this bump and then we came down in 2019, but I would say maybe a relatively good news story. But despite the amount of effort and money that we've thrown at the problem. I would say that at best were flat. You know what I mean, so we need to figure out how to drive this number down. I want to share with you that when you look at emergency Medison. I showed you some national data to say that there may be the leading group.
20:19With burnout in the United States. The reason that in our hospital emergency medicine as one of the lowest burnout rates because their Department chair David Brown eye steak and the charge of Wellness to become a priority for him in his tenure as chair and he's not only taken advantage of the central programs at the few has deployed but he's actually created programs within the Department of emergency Medison. To actually address this issue. So I want to highlight the fact that you hear that this is a recurrent theme in my talk, leadership accountability around this issue.
20:51Really really matters.
20:53So these are just SAR data compared to some national Stanford Wellness. The national Stanford Wellness. Survey then and you can see that were basically based on those benchmarks 38% of our doctors are burned out compared to 39%, which is the national benchmark from the Stanford group, so again. We're not different from many of our colleagues around the country. These are the gender data. and I just want to quickly go over them because I think they are important so.
21:23We actually turns out, it turns out that in our community. Our doctors have been in practice for more than 30 years are not as burned out as the young. The younger faculty and again the data. Here are mix. When you look at our group compared to some of the other national data that are reported. But for all this is important because it begins to create an opportunity of a group of doctors that are going to need special programs and attention to be able to get them out of where they are.
21:51Women are more burned out and we had about 7% of our respondents did not identify their gender or their race. Even though the gender question asked across all the different definitions of gender. This is I think a problem because I think we are becoming more and more aware and concern about releasing your identity to any institution and I think in Madison is not the only one.
22:18Obviously, as you could imagine or primary care doctors were more likely to be burned out compared to surgery. Specialties or basically the non medical non sub specialties in medicine, including pathology surgery anesthesiology an emergency Medison and then the physicians would prefer not to disclose to raise were also more burned out than other groups. This is a challenge for us because we don't know who these people are and so it's hard to think about generating programs for them.
22:49Well, we really can identify them.
22:51As I said earlier in our survey clinical note. Load documentation was the most onerous activity done every day and then the ones that are periodic. The hardware promotion process mandatory training requirements and I better if we pull your faculty here. Probably the answers would be very similar.
23:08So you know, I think that when you think of trajectory and career. I would be remiss if I didn't actually. Bring up the fact that everyone of us has had a different experience in trajectory, Medison and some of the conversation that we're going to have today is going to revolve around special programs that we put together to actually address the needs of our female faculty.
23:29You know, I I know that it's hard to imagine because I am a woman and I am a Latino that I don't have a bias in addressing this issue. But I have to say that I do think the experiences at least we can say it's different for men and for women and unless we change the infrastructure around organizations, as to how we support this different needs in different populations of our faculty. We're not going to get this right.
23:55So I share with you the data about the gender issue. In the race issue and I'll come back to that in a minute with some of the programs that we've tried to lift or stand that in order to address these issues, but but I do think that if you're going to take this work on, you have to essentially come from very humble place of saying we need to serve our faculty and understand maybe some specific area tests or pen points better core across certain packets of the faculty that may not be relevant across the entire institution. So when I took this job.
24:27Almost 3 years ago, my first charge from the CEO of the PR was basically to address physician Wellness. And when I came to the MGH to train as a join Oncologist. I'm a very different breed of the wine oncologist because I actually like doing upset tricks and mostly one color. This actually are happy, not to deliver babies anymore. When they complete their cancer training. So when I came to the MGH quickly connected with doctor fickle letter who brought upset tricks to the MG age in 1994.
24:58And I asked him to be a mentor and so when I was asked to do this job. Fred had already retired. You had turned 80, one that year and he was still come into work and I said Friday. No can you help me organize this work and he very quickly said yes and Unfortunately 2 months after we started the work he passed away and the committee that we had organized at that time, decided to name itself after Fred so the work that I'll describe to use the Frigoletto work, but I just wanted to recognize fresh contribution.
25:29To the field and also to this particular work, so the way that we organize. This is that I don't think that were very different at Mass General from what I would expect to be the experience at Yale, which is that we don't think were very different from everybody else like those of us who practice at mass general are very different from the doctors who practice at Brigham and we are unique in the world like we are so special that everything else that has been described in Madison is not relevant to us right, so I understood that because I after all, I practice that much general and I believe that.
25:59So we're very special, and so I thought if we're going to have any legitimacy in this work. We actually have to ask our doctors about the problem. We cannot assume that the data from the Mayo Clinic or standard is going to be relevant to this very special group of people.
26:15And so that created 2 opportunities for us, one is to actually collect the data but also to give doctors agency one of the problems that we have here is that we all feel like we've lost autonomy and we've lost agency over our destiny that we need to have a seat at the table be recognized by administration and be able to say this is the problem and this is how I think we should fix it.
26:37So I'm not very smart, but I'm a quick study so I realized very quickly that this work required diversity inclusion. But you can have a committee of 3200 doctors. That's going to function so we put out a call for participation by email of each went out to all the faculty asking them to volunteer to participate in this committee and we received about 100 volunteers agreed to come in and actually be part of the committee. We picked about 32 of them.
27:08Based on specialty years of experience and diversity across you know ambulatory practice hospitalist surgery non-surgical fields. We also included in the committee. One of our board of trustee members and I picked the board of trustee member in charge of the compensation committee 'cause. We all want to pay our bills and I figured he needs to know how hard it is for doctors to get pay these days. We chose three medical students and 3 trainees and then the compliance officer for the hospital.
27:39And the chief financial officer because we have to understand his doctors. What is legal was not legal and what we need to do in terms of continuing to provide care and Bill because obviously those things are also important.
27:52And so the first meeting. We sat together and it was basically like a therapeutic session. Everyone around the table when on to speak about their experience with burnout and they wanted to upstage the previous person like let me tell you why my burner is actually worse than yours. So I went home and I thought. This is not going to work. So I call John Herman, who psychiatrist and I said John can you be the culture of the committee for me because this is turning into a therapy session and it's just not going to work. So we quickly then drafted a charter that was going to be our compass in how we wanted to organize the work over the.
28:27Following year and we created a timetable and we said in a year. We're going to do all this groundwork. We're going to do this environmental scan of the problem and have some concrete things to deliver back to leadership so on, we went.
28:43And then to try to be inclusive at each step of the way we brought in the space so we started with the Frigoletto Committee. We created 4 subcommittees here each of the sub committees was populated by different people and then we created we did. Another pole across the institution to ask people for feedback and then we had a retreat that included did not include any of those people. But these were 47. Clinical experts that were picked by their Department chairs as being clinical champions in their discipline to be able to then.
29:13Staple we had to still up until that time and help us figure out how we could operationalize it in a clinical setting so this is basically some of the stuff that I described before in terms of the strategy and the plan that we put in place. You can see that it was a very grassroot level effort and the beautiful thing about this is that today. When somebody calls me and says, I wasn't included. I can just show them the slide and it's like if you were not included, is because you did not want to participate but it actually allows us to say there's some legitimacy in the work that we're doing because the work that we prioritize in this space.
29:45Has been essentially led and is being run by physicians so the 3 main buckets of recommendations that we had for leadership after the end of the year was basically one we needed epic fixed epic was not working for doctors and because we're part of a very complicated healthcare system. I know exactly we had. We went from a legacy system that we thought was terrific to this epic system that we never wanted it cost institution 1.5 billion dollars to put in place an because we did it at the partners level when we had a problem with that big.
30:19I could call get a ticket and the person was very polite very nice on the Phone. It was taken over a year for my clinical ticket to be resolved. But if I call with the billing problem they'd fix. It ticket right away right. So to me. I'm like this doesn't sound right and so we had to find a way to go outside of partners because partners became the central hub through which all of the epic problems were fixed so I had. I mean, I'm 5, one and so I had to go meet with the CEO of partners.
30:50Where the time was David Torchiana was a cardiac surgeons about 6 four and I have to say it has been the most terrifying meeting to sit there and say, We want to come out of the E care system at partners and be able to engage it fixed for epic that is centrally managed by the P. Oh, and he said. Fine I said, You know, Torchie said. If I if you don't. Give me permission. I think I have to quit my job because I don't have any legitimacy to go back to our constituents. I say this is what you want, but we can deliver on it.
31:19So we were able to hire A company called Brute Blue Tree Network and they came and they spend time with our primary care doctors. They spent time with our specialist with our surgeons and they're able to go in and actually help you optimize your use of epic and help you fix some of the epic paints that we were having the second one was to recognize that if you're a surgeon your issues around burner going to be very different from what they are for a primary care doctor for a pediatrician. So we said. We want to put some money into the local department's for 2 reasons one is.
31:49They'll get it right they'll know how to create programs that will actually help burnout in their individual communities on domains. But it also makes the point. The leadership that this matters when you're sitting in front of Department chief for a division chief and you said. We're going to give you this money, but you gotta. Show me how you're going to use the money and how are you going to help your faculty feel better about this? It begins to put that in the radar that leadership actually is looking at this and the other one was the sentiment that we could not figure out how we got here like how do we?
32:19Like how do we get to the space where we're talking about burnout and we feel like we had no agency so the request was to create a permanent committee that would own this work and have governance over it and have it be part of the Peo Institute, it to the peo through its by Lawson approved by the board where we would have 10 physicians that we're going to be elected by by our peers. To actually have control of that of that work so the board unanimously voted for this we actually were able to find.
32:503 million dollars to support this work and where did the money come from so the money came from 2 sources.
32:56And this is critical so you need to have leadership say this is a priority.
33:00But you need to find money to support the work so the money came from the hierarchical coding billing that we have done basically our doctors increase the way or change the way that they were building to generate more margin for the institution and then Crackle who's our carrier for liability has a rebate so that if you participate in this training programs, the hospital gets money back because there's a cracker rebate. So our hospital took that money and gave it back to the doctors so it's not like they gave us money they give us money that we had earned for the institution to invest.
33:31In this work because otherwise you know, I don't make that much. I mean, there's no way that I could have done any of this right so this is how we spent the money. So Kitty Hawk is all of the work that we're doing around technology and I'll work I'll walk you through some of those efforts. We also had the local grant funding so these are basically the money that went to the Department connectivity a huge issue for us or doctors were saying on the survey. We don't feel connected anymore. We want to be in an academic medical hospital or practice because we like to have our colleagues.
34:02Around be able to talk to them, but we're so busy doing paperwork and trying to get our epic. Notes in that we no longer able to talk to our colleagues, so connectivity. I think Wellness is important. But you can lead with that. This is not an issue of me not doing yoga or learning how to do soul cycle or meditating. This is just that I don't have enough hours in the day to do my work and the cautionary comment that I would make here is that if you make it about Wellness. You're actually put in the burden of the problem on the individual doctor you're not taking care of yourself.
34:34Right I supposed to it's a problem of national regulatory processes and institutional support for to remedy this.
34:42So this is basically how we spend the money so we have some work around just reducing administrative burden. We created a one 800 epic support line so if you call this one 800 number 24/7. Somebody like the little fairy comes into your screen and they can help you resolve your epic issue right right at the same time, and then they offer you the opportunity to have them come into your office and help you either rebuild your epic Workflow.
35:12Or to do it, essentially to do it through your computer system on a weekend or off hours or whenever you want. We have some additional epic training. We did an optimization for just in basket essentially going to every one of our PC. Peas and trying to help them optimize their use of investing and how you can delegate that work to other providers in the practice so that it's not just the physicians for connectivity. We have of the 3200 doctors.
35:43In our hospital, 84 or female, surgeons that's a very small group very isolated and so we have this dinner programs. We host one every month and we have 4 general receptions at the end over the course of the year where women faculty. Sir just get together, we pay for them to have dinner right across the street from the hospital and they get to share experience about whether you know, and I tried to go to all of them and the conversation is very, very, very interesting it ranges from.
36:14You wanna do something together to collaborate in research to? How did you get your kids through college or I'm having an issue my 2 year old is not sleeping and how do you help me so it's everything from child care to research or clinical practice. We don't have I know that last night at dinner. I heard that you guys have the same problem with space here. We have a challenge as well. And in fact, we don't have any space in the hospital dedicated to physicians group, like a lounge or?
36:45Resource room so we actually have a pop up loud so every month. We stand up. This towns where doctors can come and have lunch and get together. This Russell hours are basically cocktail receptions where all of the faculty are invited and we also have a speaker series. The grant funding. I've explained before now highlight some of the work here is just departmental grants and we now instituted an individual ground where you can apply as an individual. Faculty member for a grant that is either 5 to $10,000 to help you support a program that you think will be helpful.
37:16For Wellness we actually pay for a doctors to either get a ClassPass where they can go and join a gym or we have a soul cycle studio in the yoga studio across the hospital for this 2 programs. We actually pay for you to bring somebody with you so the idea is that you're going to go exercise. We're going to bring somebody with you and actually spend some time. Even if it's just walking having some connection. There are data that if you spend 20% of your time doing meaningful work. You actually can manage the other 80% that is unpalatable this actually striking to me because it tells you about our resilience.
37:47You know what I mean, this is a really problematic exchange. But it is the reality. So we actually we have our Department of Medicine as a program in the?
37:57Sioux nation in South Dakota, so we pay for a doctors to spend one or 2 weeks, helping the Sioux Nation basically deliver clinical care as a way to find meaning and joy in the work that they do, and in the office of women's career. I'll just highlight some of the programs that we have again. I think when you talk to women faculty they'll tell you in the data from our medical school shows it that they're getting promoted but at about a 10 to 15 year lapse from their male counterparts.
38:28So here here's what we've done. We actually pay for up to 40 hours of child care for you to come in and write a manuscript. We have to free up the time for you to be able to ride and be productive. Academically, if your paper gets accepted for publication. We actually contract with an editing office that will take care of all the revisions.
38:46So the manage people since it in your email box for 3 months or 2 months before you turn it in and if you've been invited to speak at a meeting in your specialty society or to present an abstract we pay for another adult and your children to come with you to the meeting, so that you don't have to worry about having to leave your kids behind or having to ask somebody else to take care of them and unless we do that. The experience is so different for men and women that we need to support our women.
39:18To be able to allow them the same opportunities that were affording some of our male counterparts and I don't mean to be.
39:25Disparaging of our male faculty, but but I think is different, especially in those early years when you're trying to have a family, you're trying to raise your children and there are competing interest with your career. An no good pairing will ever choose career over their children. So we have to be able to support that other part of their life.
39:45So let me talk to you about some of the highlights of some of the central programs that we've actually launched This is Money. That was centrally delivered funded at the P Oh so we actually have a company that does abstraction of basically labs an paperwork that comes in paper form and they loaded up into epic. So we actually have taken away that responsibility from 37 of our practices. This is indirectly impacting doctors because maybe you are not the one taking the facts and actually.
40:17Scanning it into epic, but whoever was doing that in your office is now freed up to do something else to support you more directly. We have an automated, centralized prescription renewal for close to 700 providers. So we actually have process over 340,000 central request for medication refills so this is great right because if you have algorithms that actually safely take somebody through how to prescribe or refill a medication.
40:47For a patient with blood pressure problems and at the hypertensive for example, the nurse no longer has to do it in your practice and they can support you in different ways. We have a virtual scribe program and we have an in person. Skype program so the scribble program for us has been a little bit more helpful because this is basically asynchronous so you actually turn on microphone into your on your computer. You don't have to have another physical human being. In the room with you, Anne when we survey our patients about these scribble experience, they love it because why?
41:19When you're dictating into a microphone your medical encounter with the patient.
41:25You have to actually spell out to the patient what you're doing, so, you're going to say Mrs Jones. I'm going to listen to your lungs and your lungs sound clear so the patients feel like they're getting a lot of information in the encounter that the doctor would otherwise just do it. Maybe not let them know they were doing it. And this comes back to the doctor 12 hours later, after the encounter us and know that they can then sign off an epic and they also tell you how to build for the encounter so this program almost pays for itself because by virtue of the fact there collecting more information from the encounter.
41:57They can Cora higher level, there also better coders, then we will ever be. And so they can actually tell you this is how you should code it and it actually almost pays for itself, and then the voice recognition system. I don't know if you have any of you have used that I actually this is what I use you basically have a system where you can dictate into you don't have to type all of your roads so this is some of the data that we've collected you have to collect data to be able to show the return of investment for any institution so these are.
42:28Basically, in green are non scribble user so these are basically controls that were match for the specialty and you can see that when you look at the amount of time that doctors are spending writing. Notes is not surprising to see that there is a huge decrease in those are scribble users overtime in an 18 month pilot that was essentially showing us that there were writing notes or in the epic system in the node entry part of the chart by the 3rd.
42:58Last time when their age than their match controls. We also contract with the group at MGH, who's part of the MGS. There basically are thinking tank or an innovation tag so they helped us with a pre authorization issue. So what they do is they basically organize a group of 30 to 40 physicians. Pharmacists people from CVS care. They bring engineers from MIT is a very diverse group of people they sit together and they think about this is the PA problem. It turns out there are 17 different.
43:30PA forms that anyone of us will have to fill out in our career anything from getting a refill for getting a pre authorization for an anti quag lent to getting medical durable equipment. So this work is very hard. They've met and they created essentially 2 programs. One is this PX. Plorer is basically an app that they came up and they put together So what you do is you actually put in the Scroll down menu. So you can find the patients insurance company. If you choose a drug it actually tells you the quality limits.
44:02And all of the options in that category of drugs that based on that patients insurance will require preauthorization. It actually gives you options for which ones don't require preauthorization that are equivalent to that drug so it's basically an app stream processor before you make the mistake of ordering something that requires a PA is actually gives you some idea of things that are not that are in the same domain of drugs, but don't require a PA. So this is our pop up loud so this basically is not lost on me. The area that we actually had to buy the furniture because this was so expensive.
44:35Do every month and rent the furniture so they gave a space to store the furniture, but not space for the actual loud, but maybe it's just so we're working on still trying to get space. It looks like we've secured a space that is going to be pretty small, will be able to have access to it in April and you can see that people are using it. We have MSU's that come in and they give you half an hour massage. It's very nice and we bring food and you can see that we've had about 1400 visits over.
45:097 pop-up lounges today.
45:12This is the Russell Connectivity, where we actually celebrate the talents of our doctors outside of medicines. So we had one that was basically Medison and the news so people actually play instruments. All came and we had like a little concert and some of our colleagues are actually quite talented. We had another one that was on photography and they get an award for the Top 3 or the best 3. The female program of describe for a female surgeons and then our Department. I want to highlight the Department of Sergey because they were.
45:44When is the best Department leading the local efforts and Keith limos are Department chair has taken on this very seriously and at first I think he was also a little sceptical so they receive ground from the figure letter committee to take the initiative local E.
45:58And so this is basically the demographics of our surgery Department they have 12 clinical divisions over 100. Full-time surgeons and you can see that many of them have to travel across New England to be able to deliver care so again. It's changing the way that we practice no longer are they able to just do their clinical work in one location, so they created a 3 option program through the funding that they received the first one was actually having some time.
46:29With Doctor Freddy's who's a Wellness expert in our community and essentially they received health habits through a video where they were basically trained or educated on nutrition exercise and sleep and then they essentially could respond to questions following each video as to how they were doing with regards to these 3 domains and essentially the idea was to give them something that they could lean on to help the Wellness but that they could do on their own time.
46:59And this is basically some of the data again some difficult space to collect data but 25 faculty members responded and these are some of the feedback. I listen to the podcast between cases their grade information helps me be a better surgeon. A colleague and his spouse. There was a raffle for an Apple Watch and that last me. The competitive nature of our surgeons and enjoy the videos that I want to win the Apple watch.
47:25You know it's fine. The second was with straighten stress resiliency so there's an matter who's in our hospital.
47:33Thus allowed a stress management so basically this were these are the sessions that were offer our doctrine of the participating 6 of them and you can see that there anything from breath awareness to yoga thought distortion social support cognitive help contemplation so again. We had 22 physicians in the Department of surgery that participated and they did at least 6 of the 8 sessions and then the last one was 1. On one coaching, so we actually this is where we had the most fraction 46, faculty members.
48:05Participated they had a coach out of they could pick from a pre selected list of 8 and they had 6 sessions with the cost that were paid for and so very few of the faculty required the assignments with their coaches. Each code had at least 1 faculty continuing coaching at their own expense. When you actually ask the faculty. They felt that having the time just to think about your career or your family whatever it is that you wanted to speak to somebody else about.
48:35Just knowing that you had an appointment to meet with somebody gave you time in your day. To actually kind of regroup because we're going, so fast that we no longer have any. I think at least I'd own perspective or orientation as to where we want to be the year 3 years 5 years from then.
48:52So this is another program that they had they had.
48:58You could submit for up to $400 of reimbursement to get your own Wellness product. They have 2 Wellness lunches in the Department and then they raffled an Apple Watch and we can in and Tuck, it that one of our pattern. Biliary surgeon in his family was able to enjoy when you talk to them what they will say to you is that just getting there. Some of the placebo effect in this so just having a notion that somebody out there cares and they're trying to put money into the problem begins to at least give you the hope that somebody cares.
49:30That somebody is looking into this and you can at least begin the conversation as to what is impacting your community and how do you make that move forward and then as I highlighted before we have class Paso cycles on yoga? I did go to source cycle once because I felt like I had to. It was a five thirty 5:30 AM Class I will solve for about 2 weeks and not going back just going to say that, but we've had over 300 doctors participate. They've taken over 4000 classes.
50:01And most of these have been at the yoga and the Soul Cycle studio across the hospital and then this is the work the meaningful work whether it's through supporting our women through the office of women's career program or giving our doctors 2 weeks of paid leave to spend some time in the Sioux Nation doing what they feel is very meaningful work in taking care of those patients.
50:25Um.
50:26And we have a dashboard. I mean, a lot of these were trying to um essentially design as we go along so this gets essentially posted on our website is constantly being updated. This is or doctors understand how we're spending the money and where we spending the money. I think that there has to be transparency and accountability. We have a lot of work to do as I showed you from the data from the 2019 survey, 48% of our doctors do not know that we're doing this work and one of the things that we did is we created the Frigoletto Grant program, which is a local program we asked.
50:58Chiefs of Department to actually a test in the grand application that they had discussed the plan for the grant funding with their faculty at a faculty meeting or at least by email. And they all are tested, so I'm not a mathematician, but I don't understand if they all attested have 48% of the faculty still doesn't know about what we're doing so. I would say we've had some may be small early wins. But I think about it work ahead. This is again just to give you a sense of our Department.
51:29And some of the departments where we still have very low recognition in terms of the work that we are trying to do or how impactful they think their work is so 52% of our doctors are aware of their local grant program, and 40% of those were aware field. The program is benefited them. But if I flip that around again. 48% of our doctors have no have no clue so this is our charge over the next year. On some of the programs that we're going to continue to support and some of the new programs.
52:00This is a new concept for us a constellation dinner. So we have essentially created a model where we take for example, the pathologist and we have a way to query epic with that. Doctors at the center of the equation and the 8 or 12 physicians for that physician who actually intersect with that doctor, the most over the electronic health record. So we actually find that pathologist and we say, These are the 12 people that intersect your world most frequently based on epic.
52:29And and the doctor will say yes or no actually this other people and we actually pay for them to go out there because a lot of times you know you'll find that the people that because we saw disconnected a lot of the Times the people that are supporting your clinical work, many attempts. You haven't met them or you haven't seen him in a long time and just trying to get the Model Hospital to spend time with colleagues. We hope will be will be helpful so that's the experience that we've had. I would say it's been very rewarding for me to be part.
53:00The work that I showed you today is the work of each of our doctors participated in the committee at an incredible support from a team of project managers that do the daily not only the innovation, but the standing up of these programs literally every single day. The management of the grants. The accountability to try to get those data back. We've done. I think we began the conversation about how to move things forward. But as you see we have a big challenge ahead of us with I would say one is communication, making sure that we touch the other 48% of doctors. I worry that many.
53:35Remember severely burned out and maybe not even engaged and making sure that at the end of the day, we finally wait to deliver these resources in a way that is equitable, respectful of people's experience and also sustainability right like when the Crackle money runs out, we have to find ways to generate the funding to continue this work want to. Thank you again for your time and for this very kind invitation and as I said to many of you have met over the course of last day if there's anything that I or our office or.
54:06Group can do to help you move this work here forward. Please let me know this IP community epidemic and I think that the degree that we can share experience and not have to reinvent the wheel is the same as having access to a drug or medication for a patient and not having it available to people outside of the institution. So thank you. Again, I'll take any questions that we have time thank you. That was remarkably instructive.
54:36Effort and and actually this is important to thank you for giving green rounds. But I also want to say that it's a thank you for what you're doing for caregivers information so before we get to questions. Just wanted to. Thank you very much. Thank you. Thank you so much. Thank you thank you. Thank you.