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In today’s AMA Update, Aman Sethi, MD, director of wellness operations at the Permanente Medical Group in Oakland, California, shares a comprehensive plan, including simple, impactful interventions, for bringing back joy and meaning in medicine and reducing physician burnout. He also discusses the important role recognition plays in that work. AMA Chief Experience Officer Todd Unger hosts.
Applications for the AMA’s 2023 Joy in Medicine™ Health System Recognition Program are now open.
- Aman Sethi, MD, director of wellness operations, Permanente Medical Group
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking to a health system leader who's helping physicians find joy and meaning in medicine. I'm joined by Dr. Amin Sethi, director of wellness operations at the Permanente Medical Group in Oakland, California. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Sethi, thanks for being with us today.
Dr. Sethi: Todd, thank you. I'm very happy and excited to be here. I've watched a number of your podcasts over the course of the pandemic and I'm a big fan. So I'm excited to meet you.
Unger: Well, we have a great team here. And we're really excited to have you here today too. I just thought for starters, kind of back in your description we talked about helping physicians find joy and meaning in medicine. Let me just ask, did they lose track of that? And where are they looking to find it?
Dr. Sethi: Yeah, Todd, that's a great question. Connecting to the concept of joy and meaning in medicine can feel very abstract, especially when you're living through a worldwide, once-in-a-lifetime pandemic. As much as physicians at some point in our journey to become physicians naturally connected to the inherent ideals of being a physician, a healer and found a joy and meaning in that, you can imagine with everything we've been through over the last few years, it's been more and more difficult to connect to that. Our physicians have been through a lot and that's across health care.
It's been three years of surge after surge, moral distress, exhaustion, increases in workload. And as we know, physician burnout was an issue even prior to the pandemic. And it's only gotten worse. So part of what we're doing here at the Permanente Medical Group is ensuring that our physicians are able to make those connections again. And when we talk about joy and meaning, defining it beyond the semantics of that term and really helping people understand what we mean by joy and meaning and how we're going to strategize to make sure that people can find those connections again.
Unger: Yes. And we'll talk about that a little bit later. I'm curious. When you started your own medical career, they probably didn't have a title like director of wellness operations. In fact, titles like that, or chief wellness officer, still relatively new and not fully adopted across health care right now. How did you get to be where you are?
Dr. Sethi: Well, I started my journey in medicine back in college actually. I was born and raised on the East Coast, spent all of my time there and did most of my training in Boston. And I went on to become a urologist and do my surgical training in Indianapolis. And soon after that, I expected to end up on the East Coast and join a private practice there, essentially.
And my very last interview was here in Northern California with the Permanente Medical Group. And as much as—my wife is from the East Coast as well. As much as I thought I would end up back on the East Coast just in a prior practice somewhere, when I came and interviewed with the Permanente Medical Group, I was really struck by not only the integrated model of care that we have here—we're the largest physician-led medical group in the country—but also what I experienced on my interview within the few days that I interviewed, the community, the camaraderie, the genuine connections that my future colleagues had with each other and how that really fostered well-being in their own daily life.
So that changed my life. I since then have moved my entire family to the West Coast. The weather has helped, of course, as well. But this opportunity and the opportunity to invest in my career at a place where people really value their own health and well-being and valued avenues to get there was important.
And so since I joined the medical group, and after settling into my clinical practice and getting my bearings, I started noticing that even in an organization with really robust infrastructure—I'm proud to say we have robust infrastructure and resources to support physician wellness—there were still many opportunities to work smarter and not harder, to look at our work as physicians and think about our long-term health and sustainability.
And so even in my early roles in the organization, I was pretty passionate and vocal about this. So when my mentor gave me my first opportunity, my mentor at the time, to work with physicians on health and wellness, I took the ball and ran with it. And he and I worked closely together in this collaboration. We came to the realization that addressing physician well-being in more meaningful ways was going to mean that we need to have a better understanding of the operational and system issues that impacted it.
So while we were developing a division around this at my medical center, at the same time, at the more broader organizational level, our CEO, our board of directors, our executive staff were starting to think about this topic in very similar ways. And that's when the strategy was born. That's when the regional role of director wellness operation of our organization was introduced.
And when it became available, my mentor really encouraged me to apply. I was fortunate enough to be selected and have dedicated myself to those efforts since. And it's been a journey, Todd, it's been quite a journey of learning, actually, and developing the strategy.
Unger: Well, I want to talk specifically more about Permanente's strategy in the well-being space. You said the operative words, of course, that we talk a lot about here at the AMA, with whom you've been working on this, which is system-level issues and looking kind of deeply at those operational issues and how they impact physician well-being. Let's start, then. Can you give us a quick overview of Permanente's strategy and how it promotes physician well-being?
Dr. Sethi: Yes, Todd. So the evolution of our strategy to support professional fulfillment and well-being, what we call our Joy And Meaning in medicine strategy, or JAM is the affectionate acronym, it actually predates the pandemic. As I mentioned, a number of years back, our CEO, our executive staff, our board of directors very carefully considered the rapidly evolving health care environment and recognized that if we're going to continue delivering on this high-quality, personalized, convenient care that we've become known for in the Permanente Medical Group and Kaiser Permanente, we needed to make sure that the part of our strategy that was aimed at supporting all the incredible people that delivered that care needed to be approached with the same vigor, the same visibility as our other type of priorities.
So we need to be measuring, tracking, addressing well-being at the same level of commitment that we were looking at our operational goals, our quality goals, our excellence in care. And so once we understood this, we knew we needed a strategic framework, and even within that framework, how to prioritize. So to help us with this, at the time I worked with another mentor. And this is our physician executive over people, our people space, physician health and wellness, education development, Dr. ...
She brought together, engaged a task force of leaders from across the medical group. And Todd, this wasn't only wellness leaders. It was operational leaders. It was senior-level executives. It was individual physicians who are passionate about this space. And that group came together as a task force took a really deep dive in the literature the work of other organizations like the Institute for Health Improvement, the AMA. And we developed a strategic framework that is basically based on three main elements, if you don't mind, I'll share.
One is practice support. So the idea here is to design a practice environment where we're really focusing on what systems and tools need to be better optimized to allow people to spend more of their time on meaningful and purpose-driven work. And we can get into some pieces of that as well.
The second was culture. What are the ingredients of a culture that supports this concept of connecting to joy and meaning, everything from leadership development, right? How are we picking our leaders? How are we developing their skills to lead in a collaborative environment? How are we offering a broader spectrum of professional development opportunities for our people across their career arc?
And finally, the third piece was personal wellness. So really continuing to support doctors, physicians and our teams to prioritize their own health through this diverse array of personal wellness programs. So first, we needed to have this comprehensive framework. But from there, what do you do with the framework, right? It's not enough just to have a strategy. You need to put goals and the strategy in motion. So the next step was ensuring that all of our leaders were using this framework to speak the same language, to identify strengths, to identify opportunities in each of their spheres, whether it was their department, their medical center across the organization and to use the strategy to drive tests of change to improve the practice environment.
Unger: Now, just, I guess, as a testament to the success that you've had with your program is you have been recognized through the AMA's Joy in Medicine Health System Recognition program. Tell us a little bit about how you became aware of the program and what your experience has been with it.
Dr. Sethi: Well, Todd, first of all, we're very humbled by the recognition. And we're especially excited with our ongoing collaboration with AMA. It's not that we have it all figured out. This has been an incredibly difficult time. And we have a number of challenges that we, of course, much like all of health care, are still dealing with. But the recognition is credit to the work that is being done by teams across our organization, right?
It's not just one group of wellness leaders or physicians. This is many dedicated people across organization who are committed to physician well-being and committed to driving this strategy. We became aware of the program a couple of years ago. And as we reviewed the program, its criteria, the goal to inspire organizations to focus on the evidence-based priorities and tactics, this struck us as having a lot of synergy with what we were implementing at TPMG.
And actually when you look at the competencies of the program, which I'm sure you've seen, what the recognition is asking organizations to strive for—assessment, so having a measurement strategy, which, of course, we do, and we developed our own with a lot of thought and effort; a commitment, and that's commitment at all levels of the organization, including our executives, which we've had for quite some time, fortunately; efficiency of the practice environment, so we've talked about practice support and the importance of how germane that is to the strategy, leadership, teamwork and support. So these components or competencies were all really specific and intense areas of focus for us. So naturally, we applied for the recognition.
And Todd, the application process was a really powerful exercise for us as well. It helped us to look internally and critically evaluate our strategy and the progress being made. It was reassuring that we were prioritizing the right things, that the AMA and others felt strongly about. And it also—we talked about this earlier. But it also was encouraging, along the aspect of this program, especially the way it calls out the concept that joy in health care should still be an important area of focus.
We talked about that when you're living through a pandemic as a health care provider, it's harder to connect to those feelings of joy. And talking about something like Joy And Meaning in medicine in our organization, or JAM, without the context of what it really means and what the goals can cause some cynicism. And we've experienced this as well.
So that's why for us it's been so important to define and contextualize JAM to help our physicians understand that the strategy goes beyond that branding. And much like that, AMA's Joy in Medicine Recognition program, it's doing the same thing, right? It's highlighting the value of finding joy in your work. But it's also calling out that meaningful change, especially in such a challenging environment, doesn't come easy. It requires widespread leadership commitment. It requires goal setting and it requires organized efforts at all levels of the organization. So all of those struck chords with us as we thought about the recognition and the program itself.
Unger: I'm going to ask you about that question around joy because you mentioned a word like that, that's a pretty high bar, right? I love my job. Joy? That's a very high bar for that.
Dr. Sethi: Right.
Unger: You mentioned it could cause cynicism. So how did you define joy in a way that combats somebody kind of going like, that's not even attainable?
Dr. Sethi: Well, joy is a sustainable feeling you have. And if we can relate it to health care, as a result of your work and the connections you make while you are a physician—and it really is about—the reason we call it Joy and Meaning in medicine, it's the joy that's obtained by connecting to the meaning and purpose of your work. And I think we wouldn't have, as physicians, made it through the trials and tribulations, the mountains that you climb through, residency and training and medical school, if we didn't somehow inherently connect to those principles.
But the practice in medicine is really grueling. And that was true prior to the pandemic. So it's easy to see how naturally coming to work day to day, when your inbox is filled with emails, and you're dealing with your patients that are now in the course of the pandemic expressing some of that frustration, anxiety and projecting it on physicians why some of that joy can be squeezed out. And so our definition of joy really has a lot to do with the strategy itself. Like, let's get back to being able to connect to that meaning and purpose.
But let's also openly call out the fact that, one, it's not going to be easy. And, two, there are evidence-based strategies that can help us get there, right? And here are the components within culture, practice support and personal wellness that we need to focus on. So let's really all focus together and make sure that it's not one individual physician that we're not focused on making the individual physicians more resilient, right? This is all about all of us rolling up our sleeves, committing to a strategy and finding our way forward in an evidence-based way.
Unger: Now, I know, of course, from working with our wellness folks here at the AMA—and again—back to that focus on system-level issues and some things can be very surprising about what you find really drive, let's say, burnout in an organization. When you went through your process, you established that framework, and you engaged all the operational leaders and many people across the organization. What did you find that surprised you about what was, let's say, an obstacle to getting to that joy?
Dr. Sethi: Well, first of all, you mentioned operational leaders. And I want to just point out that a critical part of our strategy is engaging our operational leaders at all levels of the organization so that the program is not living in a silo. I've already mentioned that this is not the sole responsibility of an individual physician or a group of wellness leaders. It's not about making the individual physician more resilient.
And so by engaging the operational leaders, especially chiefs of departments, which the literature shows is the most impactful leader when it comes to physicians' well-being and professional fulfillment, more importantly, these operational leaders are in the best position to understand how to balance providing exceptional care while considering the needs of their own team.
And so one of the things that has been surprising is that we know that this isn't easy and the chief's job is incredibly difficult. So that's why we make it clear to chiefs, the solutions don't need to fall on your shoulders. We provide them with tools and skill building to help them navigate these conversations within their departments and their spheres of influence.
We just asked chiefs to actually provide form and psychological safety for discussions about the data, about the feedback, and then to co-design tests of change with their departments, so the members of their department. And so that's why we capture the data in the first place and get the feedback. But what's really been interesting is that it's often not really dramatic interventions that make the difference. It's often the simplest things that people come up within their own work unit or department.
So for example—I guess I can give you a couple examples. There was a primary care department. After reviewing the data on the measurement that we have the Joy and Meaning in Medicine measure, that they set aside time to regularly have their department technology leads, which exist in every department, to coach physicians who struggle most with charting and time spent in the EHR.
And just through these few sessions, they just dedicated time to work with physicians to set up just some functions and voice dictation with our dictation system and create some templates. And for that pilot, considerably reduced charting time for those physicians. And this was based on, again, getting the feedback, really reaching out and leveraging people that were already there in your department—we have department technology leads in every department—and finding a way forward to improve things.
There was another orthopedics department that looked at clerical burden, which was one of the lowest-scoring items on our survey, and also surveys naturally because of these nonphysician tasks that often get in the way of our practice and get in the way of us being able to spend time with patients.
So when the orthopedics department got together with their chief and discussed this, they identified, well, what do we mean by clerical burden? And they found that placing physical therapy orders was what they saw as the most impactful administrative burden. So they worked together simply to develop new ordering templates so that their medical assistants could easily put in these orders based on the type of patient being treated.
So again, this was a small intervention with a really tangible impact. So one of the surprising things is it's time and time and again, it's modest changes at the level of the individual department that can be really impactful. And it's not, Todd, that—and I'm not saying, by the way, that there are not larger world boulders that we need to lose—sorry, lose or move as an organization.
Even through the course of the pandemic, we were using that feedback to adjust our support systems and move some of those larger boulders. But that conversation at the department level is critically important. And it helps you define the problem and address it in ways that are relevant to the people doing the work in that particular space or department.
Unger: Yeah. And I like, too, the example you used there around charting and EHR usage. And I know in talking to the team here, little things like just how many times people have to log in to the EHR every day and how much time they were spending on that—and a lot of that time, I know, slips into their personal lives when they're doing it, what we call, pajama time after work. So that sounds like an excellent place to focus there.
Last question, given everything that you've learned through the work that you're doing, I'm curious about how you see your program growing this year, kind of what the goals are that you're looking for into the future.
Dr. Sethi: Well, Todd, our people have been through a lot over the last few years. I've mentioned some of the issues that we've dealt with throughout the pandemic. And it's certainly not unique to us. Certainly, there's a level of exhaustion across health care. And I think that much like our broader society, there's also some space for hope as well.
So I've already mentioned that even in the height of the pandemic, we learned that some of the most pressing factors that impact joy and meaning are still those system-levels pebbles and boulders that detract from the day-to-day experience. So we're still very committed, even in the coming year, to addressing those system-level issues. And while we have a comprehensive strategy to help guide us, we also know that we can't possibly prioritize everything all the time.
So there is this process of understanding what we've been through as an organization, how we're going to grow from it, how we're going to learn and adapt and move forward. So we're prioritizing six main areas. And I'm happy to share them, if it's helpful.
One is community and camaraderie. This is a strength for us as an organization. As I mentioned earlier, it's the main reason why, again, my entire family across the country to join this organization. And we've also seen, Todd, over the last few years, something that's been unique, some resentments and frustrations that have bubbled up, even across physicians, across specialties, across departments. And I think this stems in a large part from our inability to stay as personally connected during the pandemic and the loss of that shared human experience.
So this year, the last few months and in the coming year, we're very focused on bringing people back together, especially across specialties to restore these connections, to work on collaborative team-based care and even collaborate together on how do we make them work more sustainable across our departments. And the second part is practice support. We've already mentioned that.
So as an example, this includes each of our medical centers across Northern California, looking at innovations to reduce clerical and administrative burdens. There's certain accountabilities and even allocations tied to that, so reducing those burdens. So that's just one example from practice support. There's also this organizational-wide commitment to invest across the organization to support physicians with their in basket and nonclinical work.
The third is recognition. I already mentioned we've been through a lot. Our physicians have been through a lot. And we need to honor and recognize all of that and make sure people feel valued and appreciated for their contributions and their sacrifices.
The fourth is technology integration. There's so much work being done by our technology teams. Like, there's so many pebbles each day being removed. I think one of our challenges across our larger organization is closing the feedback loop to make sure we can communicate effectively with physicians about what those innovations are and how we're integrating technology to make things better for them. So that's what we're focused on with technology.
The two that are left are professional and leadership development. So we're further expanding on our professional development opportunities. We also, as an example, recently increased our funding for physicians to pursue their own education, professional development. So that's professional leadership development.
And then finally, and I think one that's really critical is physician well-being. There's many aspects of this that are important to highlight. But in the interest of time, I think I want to focus on mental and emotional health. This may be true with others in health care. But working with physicians, I think it's clear that most physicians, I don't know that they've taken the time to process what they've been through. And you may know, it's rare for a physician to reach out for help when they need it most.
So this is a concern for us. And this is why we're working across the organization to increase the awareness of all the resources that exist, but also ensure that we're empowering peer support groups to create safe space for dialogue, to help people process what they've been through, even some of the traumas. And of course, that's an ongoing process. But hopefully all of us, hopefully, are moving on with this feeling of post-traumatic growth.
I think to sum it up, the goal really, Todd, is to continue to create spaces in our work where physicians can discover hope, to be reminded that we do have commitment, we do have the tools necessary to help us rise above these challenges, and also to remind people that about the most important resource we all have I think in health care and certainly in our medical group, and that's each other. It's our relationship. It's our community. It's our shared connection to that joy and meaning that inspired us initially to pursue this career in medicine, to get back to that and create space for that type of dialogue.
Unger: Absolutely. Dr. Sethi, it's been inspiring listening to you. And what a great plan. I can't wait to hear more about it in the year ahead. Thanks so much for being here today. That's it for today's AMA Update. I do want to point out that applications for AMA's 2023 Joy in Medicine Health System Recognition program are now open and they'll close on March 17. If you'd like to find out more information and apply, click on the link that's in the description of this episode.
We'll be back soon with another update. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Dr. Sethi: Thank you, Todd.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.