When COVID-19 hit California, Stanford Medicine’s wellness program was ready and able to assist its health care workers. “We had already prioritized physician well-being and had a team in place to pivot what we were working on to try to support our people with the new challenges of the pandemic,” said hematologist Tait Shanafelt, MD, Stanford’s chief wellness officer.
In the early days of the pandemic, Stanford offered the basics such as food, child care and safety-net resources for people who experienced emotional distress. As infection rates rose among its physicians, the health system provided free lodging, other tangible resources, and longitudinal emotional support to these doctors while simultaneously offering support to short-staffed teams who remained behind, trying to cover their colleagues.
“One of the challenges of the last two and a half years is it seems that every few months, the foremost need for our people shifts. We've had to stay very close to the clinicians on the front line of care, trying to discern what the most critical needs are and determine what can we do within existing constraints to provide meaningful support,” said Dr. Shanafelt.
It’s what an effective chief wellness officer (CWO) does in a day’s work.
As the first-ever appointed CWO in a U.S. academic medical center, Dr. Shanafelt has been working to drive changes at the highest level at Stanford over the past five years.
“It’s a tribute to Stanford that it embraced the fundamental and strategic importance of physician and clinician well-being to the organization’s mission long before the pandemic,” said Dr. Shanafelt, who has led pioneering research on physician well-being for over 20 years and written on the evolution of the organizational approach to this topic.
In an interview, he set the stage for AMA’s Joy in Medicine™ Recognition Program awards this fall by discussing the important role of CWOs in wellness and why the profession should ditch the ‘physician as hero’ mindset and instead embrace a physician as human approach.
AMA: You were the first health care chief wellness officer in an academic medical center in the country. How did it feel to be the first and what inspired you to follow this path?
Dr. Shanafelt: It was inspiring to see Stanford create such a position. I think it represented evidence of the maturation of the field, from a small number of us engaging in the scientific study of this domain for several decades and the nascent organizational efforts to drive improvement over the last 10 years to a point where the evidence and data were so convincing and compelling that organizations needed to embrace clinical well-being and invest in it as critical component of their operational enterprise. Roughly 50 organizations have followed Stanford’s lead and created similar roles over the last five years.
AMA: It’s now been more than five years since you took your role at Stanford. What are some of the biggest wins in health care as it relates to burnout that you’ve seen?
Dr. Shanafelt: If we're speaking at that level of the healthcare delivery system broadly, an increasing number of organizations are authentically working to drive change in their organization at a fundamental level and in a sustained way. Clinician well-being has been elevated as a core priorities for some health systems.
Through the efforts of the National Academy of Medicine, the surgeon general, and organizations like the AMA, there are also executive leaders from the major insurance companies and government payers, executives from EHR vendors, leaders from hospital accrediting bodies, and every major professional society working together to try and get at some of the system factors that drive occupational distress in physicians and other health care workers.
A coalition of stakeholders with the ability to address the critical issues driving this problem exists for the first time. While a major step forward, the proof in the pudding will be the actions that result from the efforts of these groups.
AMA: How have you helped pave the way for other CWOs who have come after you?
Dr. Shanafelt: We've tried to do that in several different ways. We created the Stanford WellMD Center Chief Wellness Officer Training Course in 2018. We've now had four cohorts of executives from organizations around the world participate. Forty to fifty executive-level leaders such as CWOs, chief executive officers, chief medical officers, chief quality officers, and deans of faculty development complete this program each year.
The training is a one-week immersion course that takes place after several months of pre work and is constructed to help these leaders prioritize clinician well-being at the highest level of the organization as well as design and execute an organization-level strategy to drive progress. We’ve had over 170 executive leaders participate to date. We have an alumni community of that group that meets quarterly.
We have also created a training course for leaders at the director level, which we call the Department Well-being Director Course. This training involves a 15-hour online continuing medical education course distributed over six weeks. The course is designed to help equip those leading department or work unit level improvement efforts. We’ve trained over 500 people in the first three cohorts of this training and, to date, we've been able to offer it to participants at no charge with the generous support of the Jensen and Lori Huang Foundation.
In addition to these training courses, we’ve published several peer reviewed manuscripts as well as AMA STEPS® Forward toolkits describing how we've approached things at Stanford, what's worked, and what hasn't, to give those leading efforts at other centers a road map.
AMA: How important is it for an organization or health system to have a chief wellness officer?
Dr. Shanafelt: I think organizations will only get so far in their efforts to improve without appointing a senior-level leader to oversee the organization's efforts in this space. Addressing the challenges and creating an environment that both mitigates work-related distress and cultivates professional fulfillment is a complex endeavor analogous to trying to improve quality or patient experience.
Some organizations ask: Can't we advance clinician wellness without a CWO? Isn't advancing clinician well-being every leader's job? Why do we need a separate leader for this role?”
I would counter: Isn't improving patient experience every leader's job? Isn't improving quality of care every leader's job?
The answer of course is “yes,” but you also expertise as well as dedicated leadership in the institution for these domains. These leaders develop the strategy to guide organizational improvement, and overseeing execution and implementation of the strategy, identify new challenges and opportunities, and assess progress. Just as we need a leader overseeing such efforts for quality, patient experience, and other key domains, we need an executive leader to advance clinician well-being.
AMA: Why should a CWO specifically sit in the C-suite?
Dr. Shanafelt: Positioning your CWO in the C-suite demonstrates that the organization has made this domain a priority and ensures that clinician well-being is considered in every organizational decision. We wouldn't make a major decision as an organization without considering the cost and its impact on quality and patient experience.
Similarly, clinician well-being should be considered. That doesn't mean that clinician well-being will always carry the outcome of that decision, although it may in some cases. It should, however, always be an important variable considered in our decisions and also influence how our major initiatives are implemented. Having a CWO in the C-suite ensures that clinician well-being will be considered in critical organizational decisions in a systematic way.
AMA: You were a key architect of the Joy in Medicine Road Map that the AMA has used as part of its Joy in Medicine Health System Recognition Program. How can health systems use the Joy in Medicine framework to develop their own strategic plans around well-being?
Dr. Shanafelt: The Joy in Medicine Recognition Program provides a guiding framework for the structure and process of organizational efforts to improve clinician well-being. Organizations can initiate or advance their efforts in six key domains: commitment; assessment; optimizing the efficiency of practice; leadership behavior; teamwork, and support.
For each domains, the roadmap provides concrete actions which build from beginner to intermediate to advanced. It helps organizations consider what they should be working on as well as the initial and subsequent steps in each domain. The road map can be particularly helpful when organizations are beginning their journey to holistically advance clinician well-being.
AMA: Where are we—and where are we going—with your concept of physician well-being 2.0? What would your elevator pitch be, explaining this from your recent article?
Dr. Shanafelt: The article talks about how, over the last 20 years, we've reached the current well-being 1.0 phase in many organizations. This phase is built on awareness and tends to focus on creating resources for individuals when they experience distress and to consider the organizational return on investment for efforts to improve clinician well-being.
There’s a need to advance beyond that, to focus on action and working upstream to prevent distress in the first place. This includes redesigning the system through the lens of human factors, considers organizational efforts from the vantage of value on investment, and focuses on system interventions to create an environment that cultivates clinician well-being.
To a large extent, we still have a physician-as-hero mindset. We need to transition to a physician-as-human mindset. We're not immune to the normal limitations that affect all human beings. We also need to reject a culture of perfectionism and instead embrace a commitment to excellence and growth. We must reconnect to meaning in work, create as culture of vulnerability, and support one another.
AMA: What are the biggest opportunities in health care right now as it pertains to supporting our workforce better?
Dr. Shanafelt: The way we deliver care has dramatically changed in the last two years. The pandemic accelerated the transition to virtual care delivery and dramatically increased the proportion of patients using their electronic portals to foster more immediate access their physician. In many ways, this is positive development that enables us to provide care to patients in a timely way.
But it has also created a tremendous amount of additional work and we haven't designed the care team models and staffing to deliver or be reimbursed for care in this way. The result is that, to a large extent, there has simply been a profound increase in unreimbursed work for physicians. That has to change.
There are also fundamental opportunities for accrediting bodies and health care payers to consider their role and responsibility to address this issue. These stakeholders have both a vested interest and responsibility to insure we have an adequate health care workforce. These stakeholders need to ask themselves some key questions.
Are there ways to incentivize and hold accountable individual medical centers, large health care organizations and practice groups to optimize the practice environment, enhance teamwork, improve organizational culture, and address other elements that will not only help us deliver quality medical care in the short term but to do so in a manner that is sustainable and preserves an adequate health care workforce to meet societal needs over the long term?
AMA: What’s next for Stanford?
Dr. Shanafelt: We are working to deepen our improvement work within each department and division to address the distinct needs of different specialists in parallel with broader institutional efforts. Radiologists have different needs than primary care doctors or surgeons and we need to address these distinct needs rather than take pursue one size fits all approaches. We also have a large new effort to mitigate the adverse impact of work on physicians' personal relationships.
We are also deepening our efforts to cultivate what we refer to as “wellness-centered leadership” as well as our efforts to change our culture so that it more holistically embraces self-valuation, excellence, and growth mindset rather than perfectionism.