Speaker: 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.
Jill Jin, MD, MPH: Hi everyone. Welcome. This is Dr Jill Jin, senior physician advisor with AMA STEPS Forward® today. I'm speaking with Dr Kirk Brower, a physician and professor of psychiatry, and chief wellness officer at the University of Michigan Medical School. We're going to talk about how his personal experience with burnout led to a career focusing on burnout prevention for all physicians. Dr Brower, thank you so much for joining me today.
Kirk Brower, MD: I'm glad to be here.
Dr Jin: Do you want to give any additional introduction of yourself and your background for our listeners?
Dr Brower: Sure. I can do that. I did my undergraduate work at UCLA. I went to medical school at UC Irvine. I did a residency in psychiatry at UCLA, and I've been now at the University of Michigan for about 35 years. I also have a subspecialty in addiction psychiatry. So, I am used to working with people who don't want to change.
Dr Jin: It's funny. We seem to have a few addiction psychiatrists that we interview in roles similar to yours. I wonder if that says something about our field <laugh> and going back to your early days then as a practicing psychiatrist, when did you first notice your own burnout and what signs and symptoms did you have at that time?
Dr Brower: About eight or nine years ago. And I didn't recognize it as such, which I think is common. It was only when I began to have GI symptoms that I went to see my primary care physician and he ran some tests. He referred me to a specialist. This may also be common as we work until we're sick. Something has to grab our attention to slow us down. And so that was the case for me. And once it was confirmed that my symptoms were stress related, I was very relieved not to have cancer or something else that I thought would be more serious. Of course, stress can be very serious.
Dr Jin: That is so interesting. I do think it's so different in everyone, the way burnout manifests. Sometimes it's physical. You take it out on your family. Sometimes it is purely work-related and affects patients. You're right. It's very varied. So, what happened after that point where you were diagnosed with burnout as a cause of your symptoms?
Dr Brower: I thought, well, I'm a psychiatrist. I can deal with stress. I made some efforts to change what I did at work. That was very important for me.
Dr Jin: How did you get from that point of realizing that something had to change to becoming a chief wellness officer?
Dr Brower: So, around the same time that this was happening eight or nine years ago, I was offered a position evaluating physicians in our health system who had engaged in unprofessional behaviors. And my job was to see if a mental health or substance use issue might be contributing. And I estimate that I did more than a hundred of these over a five-year period, and that I started to increase my effort in that part of my work and decrease my effort where I was before. So that was one of the things that happened. And while I was doing that work, I noticed that some physicians did have a diagnosis for which treatment was recommended, could be depression, might have been an alcohol use disorder. Others were burned out. And I was able to recognize that because of my own experience. And for me, as we discussed burnout manifested in physical symptoms for others, it manifested in unprofessional behaviors. So, I became interested in the context of the symptoms and behaviors. In other words, how work conflicts and systems could negatively impact physicians. And I want to emphasize that the work issues provided no excuses for their unprofessional behavior, but it did provide an understanding that improving the work that we do and improving the organizational environment in which we work could decrease burnout.
Dr Jin: Right. It sounds like you were either going to leave practice or do something about it that this opportunity came for you to really use your expertise, to help others, and eventually become a key player in the organization in promoting wellness.
Dr Jin: When did you become chief wellness officer at Michigan?
Dr Brower: As an academic, which I am, I qualified for sabbatical. And that was 2016 to somewhere between 2016 and 2018. And I devoted my sabbatical to learning everything I could about physician burnout. It was a 50% sabbatical for 12 months. I was still working, doing the physician evaluations. And I participated in an initiative at our organization, which we called the faculty and physician health initiative. I worked with part of a group to develop a survey that included items about burnout, mental health, contributing factors. I analyzed those results and the results were appreciated by our leadership. So, our wellness office started in 2019 and the way it came about was that our executive vice dean for academic affairs at that time had formed a civility and well-being task force in using the results of our survey. One of the recommendations was to establish a wellness office, but also to resource it appropriately. I applied for that position and I was accepted.
Dr Jin: I'm interested in what we talked about at the beginning. When you said your experience as an addiction psychiatrist was very relevant to this interest in wellness. And I know you've mentioned at other talks before that transitioning from taking care of patients to taking care of organizations, both of which can be stubborn to change often use the same skills and strategies. So, what are some of those skills?
Dr Brower: Well, patience is always important. Starting where people are at is important, not to get too far ahead of where people are. And I shouldn't say this is easy. I mean, even after years of experience doing it in my practice, I still struggle with that because I have a vision for how things could be, not everyone shares my vision. It's also the case, you know, that if about 50% of the workforce is burned out, that means 50% are not. And they may not even perceive that there's a problem. If you haven't had the experience, it may not make sense to you in the same way as if you have had the experience. And I should say experience with consequences, right? So, I felt sick about it, but I was also feeling ineffective at what I was doing because I felt like it wasn't recognized by others.
Dr Jin: So, I know with just from speaking with others who are trying to make changes, they often feel like they're just hitting a brick wall with either the administration or senior leadership or, you know, their physician managers or whatnot. So how do we get past that brick wall. Patience is one thing. Of course, what else can we do?
Dr Brower: That's a great question because we are part of an organizational culture that can result in burnout. We are also susceptible to that. And so, at the same time that we are trying to improve the culture and improve the environment, we still have our own individual work that we need to do our own self-talk. What we say about these things, our own thinking traps. So, one of those thinking traps is it's leaders, finances, versus well-being. And to recognize that that is a trap because it creates two groups. And what we strive for is to have one group that works together and that as a wellness leader, we need everyone to be our allies. So, we have to be careful about othering our leaders.
Dr Jin: Right, the us versus them.
Dr Brower: Us versus them. And also, it's part of inclusiveness. We serve all of the faculty, staff, and learners at Michigan Medicine, and that includes our leaders.
Dr Jin: Do you ever feel that wellness or your position as the chief wellness officer is viewed differently as opposed to the other C-suite executives or when you're at the table, it feels different or that it is a little bit divided or not really?
Dr Brower: So, one of the most important strategies I think that we aim for as chief wellness officers is to make sure that our well-being at work is institutional priority, a core value, and a daily practice. To do that it's helpful to have well-being represented at decision-making tables.
Dr Brower: It's essential. That decision-making table at the highest level is the decisions that our executive leaders make. And they make decisions based on all sorts of priorities. But if well-being is not in that room, it may not be the impact of the decisions based on other priorities may not be taken into consideration. I am not at that table. I am close to that table. I report to an executive vice dean who is at that table, but that does lend itself to othering, which then I have to manage my own feelings about, I try to be at as many tables as I can. And I have to remind myself that I have a job to do. I'm going to do it the best I can. I will help many people along the way. I will strive to help more.
Dr Jin: I think you have just described why this incremental change is still better than nothing, because all those things you're doing, even though you're not at all the tables is still making a huge difference to create that culture change. What are some of the current initiatives that you're working on for Michigan Medicine?
Dr Brower: So, we have a number of initiatives at the office that support building a structure and processes to improve well-being. It's really too soon to do something that is going to make a large impact on burnout. So, I think instead, what we want to focus on are so-called process improvements, where we're putting things in place that can make that happen. So, we have to pay attention to how we measure what we do as well, but measurement is one of our initiatives. So, we went through the process with our last year's annual survey of interpreting those results through the lens of well-being, because we use a commercial survey vendor. It measures things like teamwork and engagement and quality of care, those kind of things. But we went about extracting those questions and rolling them up into our own domains of wellness, and then using those results to provide feedback to our department chairs, other units, and our executive leaders.
Now that we've put that process in place, we've just completed our 2022 survey. That process is in place. It won't take us a year to do it. So, we can say that that initiative from our point of view was a success. We also have a grant program where we encourage faculty staff, and we also have a learner grant program to come up with pilot interventions that they can try. And so, we're starting now to get some of the results of those interventions. And we have a faculty associate program where we fund up to 20% effort for faculty to focus on a particular area. For example, someone is focusing on caregiver support, someone's focusing on the EHR, someone's focusing on email, which is a huge contributor to stress.
Dr Jin: That's great though. And the 20% FTE funding, that's fantastic. I mean, oftentimes there's no funding for this kind of stuff. So, the 20% is excellent. We talk a lot about the importance of top-down change, but I do think that the bottom-up, these pilot interventions and pilot projects by people who are really passionate about them really can make a huge difference as well. And if you get the small successes on a local level, that can make huge changes across the organization.
Dr Brower: Right. So, burnout is global, but the solutions are local.
Dr Jin: Yeah. Oh, I love that. Yeah. <laugh> I love it. Do you still feel burnt out?
Dr Brower: Burnout for me now comes and goes. So, I may have a few days of feeling burned out, but I don't have the prolonged episode that I had eight or nine years ago, which lasted weeks to, I think it's fair to say months. So, I catch it now, I catch it earlier. I do things to, to counter it.
Dr Jin: And what do you do to counter it?
Dr Brower: I love a quote from Dr Chris Sinsky who says burnout manifests in individuals but originates elsewhere. As an individual I'm susceptible to burnout and being a wellness leader doesn't protect me. The most important thing that I do is to pay attention to what I need to do to sustain my energy levels. I prioritize sleep and relaxation. I relax with meditation, with music. I talk with family members and friends who are supportive. I exercise. How we prevent our own burnout as individuals is very personal because we're really talking about personal well-being at this point. And so, meditation helps me, but it may not help everyone. But the principle I think is universal. What do we need to do to maintain, recharge, sustain our energy? And the particulars will vary.
Dr Jin: I feel like the focus shifts, depending on where you are at your own journey. Sometimes it's going to be the system and you're going to want to make all these high-level changes. And then other times the only thing you can do is focus on yourself and that's what's most important.
Dr Brower: You're absolutely right when I'm burned out. I'm probably not being very effective at work. I have to turn my attention towards myself.
Dr Jin: Yeah. Absolutely. From the frontline physicians to the local leaders, to the senior leaders, they come to us just asking us, where can I start? So do you have any advice or pearls of wisdom for just someone who's interested in making change either for their own practice or for their organization at a higher level?
Dr Brower: First, I'll say now is a great time to start. And that's because everyone knows that burnout is a problem. Prioritizing workplace well-being is the solution. In addition, right now, health care organizations are losing staff. The so-called great resignation, therefore, organizations need to compete to attract health care professionals. And in that process, I believe potential recruits will want to know if the organization cares about my well-being and what are they doing to manage burnout. I think a really good case can be made at this time for organizations to pay attention to this issue or else risk more people leaving, resulting in the people who are left experiencing more burnout and therefore a vicious cycle. So, there are good guides for where to start. And I would refer people to the AMA STEPS Forward® program as a really good place to start. And I would also say, as you said, there's top-down and then there's grassroots.
And I think at a grassroots level, sometimes if you don't have a leadership position, but you're really passionate about this area, find like-minded individuals in your organization. And start to develop a network of people who are interested in the area using a, a snowball technique, because you'll find one or two people they'll know one or two people. And that's a way of organizing. Also accessing the data that the organization already has through its annual surveys, whether or whether not it includes a specific burnout question and working with people to get burnout on there.
Dr Jin: I like that. Creating, informing your own tribe. So important in this day and age. Well, any other final thoughts that you have that you want to share with our listeners?
Dr Brower: Well, I talked about the strategy about having well-being, represented at decision-making tables. I think the next most important thing that we are now focusing on is communications. And that's because people want to feel connected to their leaders. They want two-way conversations. They want bilateral conversations that are transparent and don't have hidden agendas. And another part of communications is having a common language to talk about well-being. And I think it's important to go beyond measuring burnout and to measure various domains of well-being. So, we have five that we measure work/home flexibility, feeling valued, psychological safety, leadership, connection, and professional fulfillment.
Dr Jin: Those are good ones. <laugh> and tough ones. How do you measure being valued, for example?
Dr Brower: I use a variation of a question I got from the AMA survey, which is: I feel valued by my organization. You just ask.
Dr Jin: Just ask <laugh>.
Dr Brower: So, what we were able to show in our analyses as we were figuring out how to analyze our third-party vendor survey data is that feeling connected to leadership is highly correlated with intention to leave the organization and that it is mediated by feeling valued. So, you want to connect to leaders, feel valued by your leaders, or you're about to leave the organization. And I believe that Mark Linzer has a, also a study showing very similar results. The best part about that result, it's not rocket science and it doesn't cost money.
Dr Jin: As a leader. How do you reach out to let your physicians know that you value them?
Dr Brower: Well, you have to round with them. You have to be with them. You have to be willing to listen to what their concerns are. You have to let them know on a personal level. Let me give an example. Sometimes I ask at talks I give, when was the last time your department chair sat you down and said, you know, Kirk, you do a wonderful job. And I really appreciate when you did A, B, and C and you're so valuable. I'm glad that you work in our department. And the response I get is people laugh. So, when was the last time and yet it's not that hard to do.
Dr Jin: Okay. So besides feeling valued, let's just quickly touch on the rest of the five domains, which are work/home flexibility, psychological safety, leadership connection, and professional fulfillment.
Dr Brower: Well, let me start with work/home flexibility and why we call it work/home flexibility. And that's because you really have to have flexibility in order to achieve balance or integration. So, a lot of people call it work-life integration or work-life balance. And again, this is where having a common vocabulary is important from my point of view, I'm alive when I'm at work. So why would I call it work-life balance? But you know, the dichotomy is my work life and my personal life or my home life. And so that's why we use the term work/home and why we use the term flexibility. We measure it the same way, which is I feel I have enough time for my personal life, but we think of it conceptually as a little different, for example, there may be times when I have to be flexible enough at work that I can leave to take care of something at home.
Likewise, there may be times at home where I may have to do some work. It requires flexibility. It's not, it's a dynamic situation. And so that's the thing about flexibility. Feeling valued we talked about. The psychological safety is that feeling of confidence that we have with our colleagues, with team members, when we can be ourselves as much as one could be at work and we can voice our concerns without fear that we will be dismissed or worse, humiliated. I go to my leader and I say, here's something that is really of concern at work. And I have an idea that might help, my leader says, oh, that'll never work. Or we tried that, or I won't be able to convince the powers to be. I've been dismissed. So now I'm in a psychologically unsafe position with that person.
Dr Jin: And then you'll never want to make a suggestion again.
Dr Brower: Correct. That's psychological safety, the leadership connection we talked about, and professional fulfillment is that sense of feeling satisfied with one's work and feeling like you're contributing to work in the ways that you value most and that your work is meaningful. There's a professional fulfillment index comes out of the Stanford group that measures professional fulfillment. I think it's the last thing to go though. We find high levels of professional fulfillment because when all those other things are being taken away, that's what you find your joy in, which is working one-on-one with patients and helping people.
Dr Jin: I agree. And I, I think that others we've talked to have also agreed that it's the patient connection. It's always patient care will be the last thing affected as a manifestation of burnout, everything else, symptoms and other signs come on for us. But patient care is really the last thing. I really like the psychological safety domain, which I don't think is emphasized enough, or it doesn't show up enough in other organizations.
Dr Brower: That's where the field of well-being and the field of diversity, equity, and inclusion intersect.
Dr Brower: Because it's all about being included and feeling that you belong on the same team as the leaders that you are included in the decision-making that you communicate. Psychological safety is one of the things that diversity, equity, and inclusion aims for as well. And so that's an area in which we can work together on well-being and psychological safety. So, one more tip, if you're trying to start from scratch is almost all institutions now have embraced health equity and DEI, very likely you will find like-minded people there.
Dr Jin: Very true. Well, thank you so much, Dr Brower for speaking with me and sharing all of your wisdom and experience with our audience. This was fantastic.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's 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.
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