In this episode of the AMA STEPS Forward® podcast, Kerri Palamara, MD, director of the Center for Physician Well-Being at Massachusetts General Hospital, discusses with Jill Jin, MD, MPH, the important takeaways from her recent article “Four Key Questions Leaders Can Ask to Support Clinicians During the COVID-19 Pandemic Recovery Phase,” co-authored with Christine Sinsky, MD. Read the full Mayo Clinic Proceedings article.
- Kerri Palamara, MD, director, Center for Physician Well-Being, Massachusetts General Hospital
- Jill Jin, MD, MPH, senior physician advisor, American Medical Association
Introduction: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Dr. Jin: Hello everyone. Thank you for joining us today. I'm your host, Dr. Jill Jin, a senior physician advisor at the AMA, and today we're talking about supporting clinicians during the COVID-19 recovery phase with Dr. Kerri Palamara, an associate professor of medicine at Harvard Medical School and director of the Center for Physician Well-Being at Massachusetts General Hospital. Dr. Palamara, welcome. Thank you so much for joining me.
Dr. Palamara: Thank you for having me, Jill. I'm very excited to be here today.
Dr. Jin: Could you tell the listeners a little bit more about yourself and your background?
Dr. Palamara: Absolutely. So I am a primary care general internist at Massachusetts General Hospital. I work in a practice that is a part of the main campus here at MGH. And I also spend a large part of my time directing the Center for Physician Well-Being for the department of medicine at Mass General. And in that role I get to do everything from working one-on-one with leaders and with clinicians. I get to work in teams that go into practices and groups to learn more about what's going on and how we can help.
And we try to help people on an individual level with whatever they may be going through, in ways that we can lighten their load, but then also on a systems level to think about how we can improve the experience for individuals that are part of that system. And along the way I get to do a lot of research and coaching with physicians. And through that work also I have a role with the American College of Physicians focusing on some of their well-being and coaching initiatives.
Dr. Jin: So we are here today to discuss an article you recently coauthored with Dr. Christine Sinsky, that was just published in Mayo Clinic Proceedings, entitled “Four Key Questions Leaders Can Ask to Support Clinicians During the COVID-19 Pandemic Recovery Phase.”
So I guess to start off I just want to know what prompted you to think about this topic.
Dr. Palamara: This is a great example of particularly women physicians supporting other women physicians. So early in the very beginning of COVID, Chris reached out to me actually to just hear about how things were going at Mass General and what types of things we were doing and if we might be interested in using the AMA Caregivers Coping with COVID survey.
And so we were able to implement that at Mass General and did a few of the larger surveys and then a few pulse surveys. And along the way, we checked in and worked with the team at AMA just to process some of the things we were learning and think about what other people were doing. And we were also invited to share what we were doing with the results of the survey and what we had learned.
And actually, it was in one of those round tables where I was describing how we were using the quantitative information we were learning from the survey and then going out and trying to get more information on a more qualitative basis from people in reflection sessions. And I talked about how we over time adjusted the format to try to be the most supportive of people and also hear the most useful information that we could get to be able to help them.
And during it, actually, one of my colleagues I've worked with in other well-being work texted me and was like, "You should really write this up." And then afterwards, Chris emailed me and she's like, "We should really write this up." And I was like, alright, this is my sign. I need to write this up. And so we started working together to write that up. And Chris was an amazing mentor and coauthor throughout the process.
Dr. Jin: That's great, and yes, she is the perfect example of a woman who just supports other women physicians so well.
So back to the survey findings, what were they in particular that led to the writing of this article?
Dr. Palamara: So there were probably two that stuck out the most. One was when people were reporting on the level of—actually I would say there were three things. One was that people were reporting on just the amount of stress that they were experiencing and no shocker there that it was very high.
Two, what I realized though is in some of the ways in the questions on the longer survey that talked about what kinds of supports people thought that they needed, a lot of the things that we guessed that people would need were not actually the things that they thought would help them. Like access to healthy food, or childcare or things that were stressing them out more. It was like people were kind of figuring that part out in whatever way was most in line with their lifestyle, or their resources or where they lived, or who was in their life. And it was really that people wanted us to focus on ways to improve things here.
And then the third thing was the question about value in the survey, which was just so eye-opening of how valued do you feel by your organization. It became very clear that as stress was going up there was a worry that the sense of value was going down. Which then screamed to me that we needed to learn more about how to support people so that they could really believe that we valued them as much as I knew that leadership values them.
Dr. Jin: Which of course is the hardest part because value for each physician is different and you get into that with your questions. So, let's talk about each of the four questions. I will go ahead and list them out first and then give you a chance to walk us through them and tell our listeners why each one is important for leaders to be asking. And then perhaps if you could give an example of a situation where the response to the question was particularly meaningful to you, that would be a helpful context, I think.
Okay. So the four questions are, number one, what are the ways your life has been impacted by the COVID-19 pandemic? Number two, what does value and appreciation at work feel like for you? Number three, what prevents you from doing a job that you are proud of? And number four, what can be done to move forward and help you do a job you're proud of?
Okay. So let's go ahead and focus on each one of them. I'll read out the first one to you again and let you take it from there. So, what are the ways your life has been impacted by the COVID-19 pandemic?
Dr. Palamara: So what I realized—we needed to start with this question because it was very clear that there was not a great space for people to unload and unpack and really name the losses and the grief that they were experiencing and that all of us were experiencing loss. Although most people were just in that mentality and that routine of, I just have to keep going, I just have to keep going. And every time you do that, there's another thing that you're losing along the way. So loss was compounding on top of loss and we were just driving forward. And it struck me that as we were trying to engage with people and just saying like, "How can we help?" People were still kind of cross-eyed or dazed in a way to try to be able to articulate that like, "How can you help me, my gosh, where do I start?"
And I found when we first started with the … “Tell us what this life is like for you, what are the losses that you've had? How has your life been changed?” Then it was easier for people to then identify what it is that would actually help them and help them start to move forward despite those losses.
Dr. Jin: Yeah. I do think it's a combination of, like you were saying, not being able to articulate it because it's so overwhelming and we're not always trained to identify emotions in ourselves very accurately. And then also a sense of not wanting to feel like we're just complaining too much. And I feel like it almost sometimes feels a little bit taboo to start listing all these negative things.
Dr. Palamara: Yes. And for many, we need to give people the permission to actually own that as a loss, like that vacation you had to cancel, that was a loss. That friend you don't talk to anymore, that is a loss. That feeling that you have where you haven't engaged with somebody else all day long and even if you have you're all in masks, that's a loss.
And so helping give examples and empowering people to claim those really then allows the conversation to get going. What I have found when we've done this in retreats and other things is this question, once you get the door open and people start sharing, it is really powerful what comes out, but it just sort of then just rolls and people start unpacking it pretty quickly once you get them going.
Dr. Jin: Yep. Absolutely. Alright, and the second question, what does value and appreciation at work feel like for you?
Dr. Palamara: So I think many of us who work for large organizations probably have an example of something that someone did that they thought was helping. And on the receiving end you're like, "Are you kidding me?" And so a lot of times people are doing the best that they can to try to help but don't actually realize that it's really just a miss. And so with the answers to these questions, what people can do is help leaders understand what are the bare bones that they need to stick to. What are the basic principles that are important to them that will show—that will really express value and appreciation if you can stick with them?
And this can both be a place to start for leaders but can also be the guiding vision for the work as you move forward. And so keeping all this important. One of the examples that we give in the breakdown of example responses in the corresponding table with the paper is transparent communication. If I'm a leader and I hear every single person tell me that this is important, every email that I send, every time I get in front of a room of people or a webinar or Zoom these days, I'm going to remember how can I be as transparent as possible? How can I really help people understand what I said and how that relates to what they need?
And so this question is both a way to make sure you're not missing the mark when you act in a way that you think is helping but really isn't getting at the core of what helps people feel valued and appreciated. And also a way to guide the vision for all the things that you do moving forward.
Dr. Jin: Yeah. Do you have an example of missing the mark?
Dr. Palamara: I think I can speak openly about this because a lot of people will—I'm sure every organization has an example. But in our organization at the end of—it was either the first or the second surge, they had a big day where all the leaders were there, and every employee got a t-shirt and they had cookies there, and the mayor was here and it was like this big thing.
And the hospital leadership truly wanted people to know that they appreciated everything people did. And unfortunately, the phrase, it's like, I don't know what value looks like, but it's not a cookie and a t-shirt—really stuck with people afterwards. Because a lot of people were hurting, a lot of people were feeling losses, a lot of people were feeling like there was more that could be done that wasn't addressed by just giving me stuff.
And I think this gets at, we try to help so often by just giving people things or giving people access to things. But often it's really like, what can you take off of my plate? Rather than helping by adding, how can you help by subtraction? And I know that AMA really tries hard to give people examples of how to do that.
Dr. Jin: Exactly. That is a perfect summary of what we're aiming to do. Yeah, it's not about giving rewards or incentives or whatnot, but more about taking away the unnecessary work, which is a perfect segue into the next question, which is, what prevents you from doing a job that you are proud of?
Dr. Palamara: So what I found that made me want to include this question in the different steps to unpack all of this was we found that we were meeting groups where they were. So, we would come to do these listening sessions. We would come to a work meeting that already existed. So we weren't asking people to take extra time or anything else. And we would ask them, "What do you need?" And people would be like, "You should know what I need. You have to help me." And they just couldn't get there, which I was alluding to earlier. And I found that actually, so many people were just struggling with this concept that they weren't who they used to be and their job wasn't what it used to be and life wasn't what it used to be. And so there were a lot of people feeling like they couldn't be the kind of doctor that they used to be before for a lot of different reasons.
And so a lot of the ways that we could help were just helping people feel like they're doing the best that they can and actually feel like that's happening. That's actually translating to being a good clinician, being a good colleague, being a good family member, a good friend. Getting to the core of this was helping us recognize, what do people need to be able to come to work and feel good about it, so that work is not just adding more stress on top of all the other stressors they're carrying with them throughout the day?
One of my favorite—not favorite, it's a quote that really I should say has stuck with me and has guided me throughout all this work was a woman who said, "I wake up with stress and anxiety that I went to bed with the night before. I come to work with all the stressors of home and all the worries that I have. And then I get to work and I feel like I'm doing a terrible job. And then the stress of what I'm not doing there just compounds on all the other stressors. And then I bring that all home with me and I feel like a terrible mom. And then I go to bed with that feeling that I wasn't good at anything that day. And then I wake up the next day and it all just repeats." And that to me was like, how can we help this person feel like they're doing a job that they can be proud of?
Dr. Jin: Yeah, so tough, that cycle of what you just described. So I know there's no easy solution, but I guess this is the next question. What can be done to move forward and help you do a job you are proud of?
Dr. Palamara: One example that we're actually doing right now in this surge—because I think differently for the current surge that we're in. And it's sort of Chris and I, when we first wrote this article, we wrote it thinking that we were writing it during the surge. And then as these things go, when you finally get something published we're like, "Oh, I guess it should be recovery." And then I'm like, "Oh, I hope it's still relevant by the time it comes out." And then here we are in this next surge. And I'm like, "Oh my goodness, it's as relevant as ever."
But one of the things that we are trying to do in this surge in particular is, I got an email from—so the transparent communication guiding vision, the beginning, I said to our chairman—I was like, “Reach out to everybody and let them know you see them and that you hear them." And that's what she did. And she said, "If you have ideas of how we can help or things we need to know about, send it, basically, my way."
And somebody sent me an email and was like, "I don't think you can help me. This is probably just all vomit in an email, but I'm going to tell you anyway." And she just told me about how stressful things are and how daycare keeps getting canceled and her kids aren't vaccinated. So even though everybody else is all feeling okay about things because even if their kids get sick, they're vaccinated, the five and unders are really stressed out.
And she's like, "With the way this all is going to play out, I'll be lucky if I'm in person in January more than once or twice based on my kids and exposures and quarantines and everything else." And she's like, "How am I supposed to meet the demands of my practice?"
And so we sat down with clinical leaders and said, "You need to hear the message that you can be flexible with people. If people need to cancel an in-person session and make it a virtual session, that's okay. If people need to convert from middle of the day, they get that phone call that they have to go pick up their kid, they can move their patients to virtual at the end of the day. And that's okay."
Just really meeting people with flexibility and saying, "You do what you need to do. And we understand that life is very unpredictable right now." Because in this surge, I think very different from the others is that we as clinicians are affected as patients and our families are as well, which is not that no one was before, but in a much greater volume now. Many more of us are impacted by this. So it's not just about the health of our patients. It's about the health of ourselves, the health of our families and then how that impacts how we come to work.
Dr. Jin: Yeah, yeah, absolutely. And I think that's, what you said is right now, I guess that's all we can do is to create flexibility on an individual level and then taking it to the next step in terms of the organizational level, you know, all the systemic changes that you were talking about with the reducing unnecessary burden, and the communication, the transparency that's perhaps longer term, but at least today here and now for this current Omicron surge, creating flexibility on a practice level, on an individual physician level is something that I think is key, like you were saying.
Dr. Palamara: And one thing that another practice leader did was email all of their clinicians and say, "We know your productivity's going to be lower than it usually is this month. And we understand." Right there, that permission to not be perfect and meet every mark is I think huge for someone who's just trying to get through the day right now.
Dr. Jin: Yes, yes, absolutely. So I think in terms of the longer term success, I think as we were just saying, it's so hard to do anything but taking this day by day right now. But do you have a vision for what long-term recovery could look like down the line?
Dr. Palamara: Yes, so one of the things that I have been so excited to learn about and read about is post-traumatic growth and what that looks like for organizations. I think there's great opportunity for us as individuals to focus on that, but at the core of post-traumatic growth for organizations, and Tait Shanafelt and Christine Olson did an amazing job mapping this out in their article that they published on this, but this idea that at the core you lead with your values for the people that you are responsible for. And so, as an organization, the decisions that you make are really how can we grow? How can we evolve better than where we started? How can we think about this future in a sense that we've never had a chance to completely rethink how we do everything in health care before? And this pandemic has one opportunity that this challenge has provided us with is to think about how could we do things in more nimble ways. How could we do things and really come together and think through problems in different ways? How do we have rising leaders who were really creative during these challenging times and how can we support them and support hope and creativity for the future? So that to me is, I think the guiding vision if we can think about organizations using post-traumatic growth principles as a way to move forward into the future. And at the heart of that, it's really considering how have we as an organization been impacted. How have we grown? How have we changed?
And it's about developing relationships. It's about recognizing strengths. It's about thinking about opportunities, really challenging our previous beliefs and thinking about how those have changed over time. And so to me, I think that that is all I can think about. And my hope is that we'll continue to do these retreats with practices and with divisions and units and get people together to start to give us their version of what that could look like and use that to guide the organizational vision.
Dr. Jin: Yeah. I love how these retreats you mentioned, it sounds like you are very in touch with the practicing physicians, the quote-unquote frontline physicians in the practice and you yourself, you still see patients, correct?
Dr. Palamara: I do for about 40% of my time.
Dr. Jin: Wow. Which I think is … it's so difficult as a leader to also still see patients, but I do think that that perspective is important for what you're describing in terms of being a leader who practices the values that you just described.
Do you have any personal pearls of wisdom from your experience about how leaders could be better at that?
Dr. Palamara: So, I think that at first, I agree. I think seeing patients allows you to just get a glimpse of what are the stressors that people are experiencing and really what does that feel like when one is experiencing it. And also, just get a sense of how teams communicate—when that goes well, when that doesn't, what role you have as an individual in that. And so, in thinking about how I support myself to be the best version of myself during these times as both a leader, as a clinician, as a person, I think one thing that I have learned over time and with a lot therapy is that wherever I am is the only place I can be.
And so, if I'm having a hard day, I don't really try to force myself out of it. It's just really identifying what feels hard about today and acknowledging that and seeing it for what it is, thinking about what might be contributing to that. And then focusing on how I can feel perhaps differently the next day. What are ways that I can support myself?
There's some core principles I've learned that definitely set me up to be the best version of myself, which are making sure I sleep, making sure I eat well, which is actually eating meals at all. When work gets busy, making sure I have food to eat and exercising, which is a huge stress reliever for me. And so figuring out where can I beg, borrow and steal that time to be able to exercise, so that some of my best ideas come then too, when I just have this space and this clarity and there's no texts, and there's no interruptions and there's nobody else who needs me in that time. And it's all for me. And so that's where I have a chance to really think about a lot of these things.
Dr. Jin: That's true. I think personal resilience, this whole idea of personal resilience has been a little bit shunned recently because people are saying, "That's not the solution. Physicians are already incredibly resilient." Which is all true, but the point you make about your most creative solutions and creative ideas coming when you have that space and when you're exercising or meditating or whatnot, that's still actually important as a leader to just have that creative space to come up with the solutions you need.
Dr. Palamara: Absolutely. And what's interesting is like, yes, we are all incredibly resilient people. We would not be here doing this work if we weren't, but we also have to remember what resilience means for us. First of all, it's going to be different for each of us. And that's been changed. Resilience for me today is radically different than it was before the pandemic and what I can do and what feels comfortable and what access I have. And so we've all I think had to, or should really have the opportunity to rethink and reanalyze what resilience means for us today, what well-being means for us today and how connected we are with that.
Dr. Jin: Yeah. And like you said, it means something different every day and that's okay. Sometimes it can be small and sometimes in the future it should be big but get by one day at a time.
Dr. Palamara: Yes. Exactly.
Dr. Jin: But this was fantastic. This was wonderful to hear all your expertise and all your insight. And thank you so much for all your work and this field in wellness and keep on, to move this field forward.
Dr. Palamara: Thank you for having me. It's really fun to sit back and think about what's—oftentimes where you write these things you don't really get the story behind it. And I feel like this has allowed others to perhaps get a sense for what's beyond just the words on the paper and how that might be able to be used in other ways.
Dr. Jin: Yes. And for the paper itself, the article “Four Key Questions Leaders Can Ask to Support Clinicians During The COVID-19 Pandemic Recovery Phase” appears in the January 2022 edition of Mayo Clinic Proceedings. And we will also link the article in the episode description to this podcast.
Outro: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.