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.
Marie Brown, MD: Welcome, everyone, to the AMA STEPS Forward® podcast for today. I'm Dr Marie Brown, an internist here in Chicago, and director of practice redesign at the American Medical Association. Joining us today on the podcast is Dr Vanessa Calderón. Dr Calderón is a board-certified ER doc, with an active clinical practice in the San Francisco Bay area. She's also the wellness champion and resiliency director of Vituity, a multi-specialty national physician organization, and past department chief and medical director, and the founder of the Life and Leadership Accelerator, a coaching program for professionals. Dr Calderón, thank you so much for being with us today.
Vanessa Calderón, MD, MPP: Well thank you Dr Brown. It's always lovely to speak with you.
Dr Brown: Physician wellness and burnout was challenging before the pandemic, and our emergency room physician colleagues have just been through so much over the past three years. And we know that the burnout and the well-being of our colleagues there is of paramount importance. You've been through this. You're still seeing patients. How did you approach this time even before the pandemic, and what's changed during the pandemic? And how do you measure? How do you begin if somebody listening in says, “OK, we've got a problem, but where do I start?”
Dr Calderón: You know, it's a really interesting question. I'd say I had already been a department chair for close to maybe seven to eight years before the pandemic hit. And before the pandemic hit, burnout was already a problem. It was a huge epidemic before we had the pandemic. We had close to 50% of physicians across the board reporting burnout some time in their career. We were taking it really seriously at our department and within Vituity.
And so, we had included in our engagement survey questions that specifically asked about burnout before the pandemic had hit. And as a leader in my department—I was the department chair and the medical director—and so I was meeting with my partners once a year to do performance reviews, and I was specifically asking questions about wellness and burnout when I met with them. They were included in the performance review, and then I would just take it a step further, because the stuff really mattered, and I wanted to make sure my docs were working and they were happy.
So I would ask questions like, “So tell me how things are going outside of work.” And I knew who was married, who wasn't married. I knew about their kids. And so I would just ask, “How's your wife? How's your husband? How are the kids?” And just to get a sense of what was going on, and just those really general conversations.
And I think once you're sort of a seasoned leader, and you know that those personal relationships really matter and you prioritize them, you start to get to know what's happening outside of work because a lot of the stuff that affects us in work, we take home—whether we want to or not—and it starts affecting things outside of our work life. But also, the other way around. Things that are going on at home can cause our burnout, and it's not just stuff at work. So, it's really important to sort of understand that.
So that's sort of what we were doing before the pandemic. So then comes the pandemic. And to be … 100% honest with you, the first three months, I had no idea what to do about people's burnout. We were just trying to figure out what the heck COVID was, how to treat it and how to bring the doctors the resources that they needed. And I think for me, that was probably one of the most important things as the leader.
I led the department, but I was also the hospital incident command director. So I was leading the hospital command center during COVID. A lot of the stressors had to do with the uncertainty of dealing with something brand new like this. What if you get sick? What if you bring it home to your family? And all of that was really scary. And there's a lot of that that we had no control over.
I couldn't manage my partner's uncertainty, because I didn't have the answers to it. Things were changing all of the time. We were having a new protocol of what to do with this patient? And then the next day, what to do with this patient? Things were changing within 24 hours. It was always something new and it was frustrating. And it was hard, as a leader and also as a practicing ER doc. What I tried to do is just bring my doctors what they needed. So, what is it that they need that can help them do their job well? So, I ensured that they all had PPE. You know when you're the incident command center and when you're in charge of incident command, it's easy to ask for what you need because you're directing that. You know where the resources are in the hospital and you can sort of divert them to your department.
So, the very first thing I did is I made sure we had scrub service available so everyone could come in and change scrubs in and out, so they never had to deal with like, what happens if I infect my clothes? I made sure that they had a place to place their cell phones, so like little Ziploc® bags, for example, if they wanted to bring their cell phones into the department. And I had PPE for everybody. In the beginning, we had sparse resources. Like at all the hospitals, we were all afraid we were going to run out, so I made sure we had a really good system in place so that people knew where to get it. What happens if we run out? If it was in the department, especially in the middle of the night, because I didn't want to be getting called in the middle of the night if people couldn't find their stuff. We had everything under a lock and key. Everyone knew where the key was.
And so, I just tried to do my best to make sure that the department was set up so that the doctors could do their job in a way, get all the barriers out of their way. And I think that's always how I've approached burnout—which is how can I make this department run as smoothly as possible so physicians can just come in and do what they love, which is just take care of patients?
Dr Brown: Yeah, I think that's a really good point, that what gives us joy is being able to do what we were called to this wonderful profession to do, and that is to be with patients, to have the time uninterrupted to talk and develop a relationship, or at least meet the need, specific to your subspecialty, give them really undivided attention and get out of the way. So, it sounds like you really were very and are very clear about asking the docs what they needed. So, I know that transparency was key and is always key to developing that trust. How did you make sure that they knew you were available, and how did you make sure that trust with administration was as good as it could be at the time?
Dr Calderón: Yeah, that's a great question. I think that's a fundamental leadership quality—transparency. So, when I was leading the department, before COVID, during COVID and after, the number one thing that I always try to do with our site, because we are a partnership. So, though I have the title of department chair medical director, I sort of consider myself just a partner and a servant leader. I'm just there to make the role easier for everybody else, so when they come in, they can do their job. That's sort of how I would approach it. I love operations, it's sort of easy for me because operations was easy. But what I would do to make sure that transparency was always sort of at the heart of what we did is, I would just name it. I'd say, “Listen, you're going to get to know all the information that I know as soon as I know it.”
And I would tell that to my partners. And I would say, especially in the middle of COVID, I would say things like, “Things are changing all of the time, so you're going to probably get a lot of emails. And I'm sorry because I know that's really frustrating, but I want you to have the information as soon as I have it. So, make sure...” And I would be really clear on the emails. I'd date them and I'd number them, and I'd say, “This is the first update, second update, third update. So make sure you're looking at the most recent update when you're reading these emails so that, and it doesn't get confusing in your inbox.” And the same thing the other way around. I was just really honest. First one or two years when you become a department chief, it's kind of drinking from a fire hose, trying to do your best just to stay above water and meet all these people, develop the relationships, but also manage your department and still keep up your clinical skills.
When you become a little bit more seasoned in this, I have always really prioritized the relationships that I have with the C-suite, with the chief medical officer, the CEO and the nurse director. The chief nursing officer for me was always one of my most important allies. When I think about transparency, I've always just had really strong relationships with them and have been really honest about the needs. And because I think I was such a present leader—I was always around, I was always available, my phone was always on, they had my cell phone, people were respectful, too. Unless it was a big fire, I didn't get calls in the middle of the night or anything, but they knew that they could reach me. And I think trust was built because I was a person of my word. I was responsive. When I would get a text, I would respond. When I would get an email, I would say, “I'll solve this problem at this time and it would be solved, or I'll look into it at this time and I'll get back to you.” And I always followed through.
I think that was probably one of the most important things for both the C-suite, but also with my partners. They knew that they could trust me because I always followed through.
Dr Brown: Right. And I think that that transparency, and I like that term, present leadership. And the fact that you were sometimes actually seeing the patients and struggling with the staffing shortage or the PPE or the electronic health record was key. And I think mentioning the C-suite and how very important it is to develop those relationships, especially outside of our physician world, the chief nursing officer is so important. And it's so often, barriers tend to come down, right? You know the face on the other side of the table, and you have a relationship.
What burnout issues are very specific to the emergency room physician?
Dr Calderón: I love that question. I'll say this one is kind of more general trend in all of medicine, but I'm going to bring you back to the ER, so just stick with me. I'll say it's this: One of the biggest systemic issues, and I'd say it's more of a cultural issue, that leads to burnout, is physicians are viscerally uncomfortable asking for help. We were taught in medical school to be strong, to know the answers or where to find them, and any sort of asking for support or help was deemed a weakness. In fact, I look back at my training days. I've experienced real clinical burnout in my life. And I look back at my time before I went through my transformation, coming out of burnout into where I am now—and I remember wearing certain things like a badge of honor. I was pregnant with my first kid and I was in my last year of emergency medicine residency, and I worked every day up until I went into labor and I wore that as a badge of honor.
And with my second kid, I was a medical director and a department chair. Our site was critically short-staffed, and I came in to fill all the night shift holes when I was super pregnant with my second kid. And the nurses would be like, “OK, Dr Calderón goes into labor, who's driving her to the ER or who's driving her to the hospital?” And I wore that as a badge of honor and I'd say that that's really unhealthy, and I know we all do that. So let me bring it back to the ER because the problem is this: that in medical school we were taught how to be really strong and how to find the answers. And what we were never taught was how to be vulnerable and how to ask for help. And I'd say we did a pretty good job of shaming vulnerability in our medical training.
And that, I think, is one of the cultural core issues that has led to the burnout epidemic that we have now, because we have not allowed our physician colleagues, myself included, to be human, to just be human, to ask for help when we need it. And so in the ER, what can happen sometimes, especially in departments where we sort of feel a sense of ownership over our department, we want it really to run smoothly if there are staffing needs—for example, we, the department chair, the medical director in my case, would try to come in and fill all those holes. And then we would see if all of our tapped-out docs that are always standing up raising their hand, they're always super helpful, will fill the holes. And so what do we do? We burn out our strongest, best people because they're always the ones willing to help out.
The problem is, for me specifically, I was the person filling all those holes. We had 17 holes in the schedule because one of our ... trainers got sick, so 17 night shifts that needed to get covered. So you can imagine 17 shifts a night. It's crazy. It was right before I gave birth. So I go, I work all these shifts, and then I give birth. I try to take a maternity leave but we can't get the schedule covered, so I come back to work early and I keep trying to work all those night shifts. And I remember thinking—looking back now—thinking wow, there probably were resources that could have helped. And so now in my role now as the wellness director, the resiliency wellness director for the organization, I go out and I teach medical directors what to do. What are the resources that are out there that are available for you? And the number one thing I make sure (of) is I destigmatize the need to ask for support. We have an entire organization here available to support you. You never have to do this alone.
Dr Brown: I mean, just the fact that you're sharing that you went through a period where you felt burned out is so important for all of our leaders. And more and more are stepping up and sharing, sometimes on these podcasts, how they felt, how they recognized that they were feeling depressed, how things weren't going well at home, talking about that culture, because we are supposed to be invulnerable. And so when leaders say that they are actually going on vacation and be sure that they take that vacation and they're not checking the email, it gives the next person who reports to them permission to do the same.
Dr Calderón: That was so important to me when I came back from burnout. Because I wasn't just feeling burned out, I was clinically burnt out. I had all the symptoms. I had it. But I'll say the nitty gritty of that when I came back from that, because I came back from that thriving. I still am ambitious and I love my career and I love what I do and I love helping patients, and I'm still working. But what I realized is that was exactly right. It's like, how do I show up now as an example? Even though if I was up in the middle of the night, I worked a night shift and it was slow so I was trying to catch up on admin emails, I would never hit send. I would always schedule them to go out (at) regular work hours between 9 and 5, Monday through Friday. And I would do that all of the time. If I was catching up on a bunch of emails on a flight, for example—same thing—I would just schedule them to go out.
I would make sure people knew that I wasn't available on the weekend. When I would take vacation, I would say, “This person's covering for me,” for the same reason that you mentioned, to give people permission to do the same.
Dr Brown: That is so important and I'm glad you shared that. So let's move to some of the more specifics, little changes that you were recognized or were brought to your attention that you were able to achieve without a lot of resources, without going through 10 different committees that made a difference for the patient's experience, as well as the physician's experience. Can you share a few examples for our audience, so that at the end of the listening to this podcast where I hope they're commuting home listening to it or sitting down having a meal, or even working out, that they could say, “I could do that”?
Dr Calderón: Oh yes, of course. One of the things I would always ask myself is, I guess there's two questions. “Does this require a physician brain?” And “What's the downstream or sort of on-the-ground impact of the change we want to make?” Because sometimes as the leader, you're in these sort of larger hospital throughput committee meetings, for example, and people are like, “Oh, we should just do that,” or “That would be really simple.” And in my mind, I'm always like, “Hold on a second. How is this going to affect the physician? How is this going to affect the physician when they're trying to do that?”
I'll start with, “Does this require a physician brain?” So we were fortunate because we had scribes in our department. And when you have scribes in your department, you can use them creatively. There's certain regulations. They're not allowed to touch patients, for example, but you can use them creatively to do other things around the hospital.
What really mattered for our patients and for patient experience was that they were checked up on and that they were updated regularly. Because you're in the emergency department for hours at a time and sometimes you have no idea what's going on. “It's been this long; this patient doesn't have results yet. Do you mind going, taking them a blanket and just letting them know we're still waiting for their results?” And so the scribe would do those little things so that I could just focus. ERs are various sizes and it doesn't matter where you're working. The point is that all of the patients are going to experience the same thing. They want to know what's happening. They want updates and they want to see the face of the provider. So when I would go in there, I would actually introduce the scribe as, “This person is my assistant today, they're helping me out today, so you're going to probably see a lot of them. And just know if you have any questions, feel free to ask them. They're going to direct then everything to me.”
When I would ask myself, “Does this require a physician brain?” I was able to use that question to help us reroute certain things. A good example is during COVID. During COVID, if somebody tested positive, the county needed to know. And so they're like, “Oh we have this county form. Can you fill it out?” And I was like, “Wait, hold on a second. We're going to have to fill out this form for every patient that tests positive for COVID?” In the beginning, we didn't even have tests so it wasn't that big of a deal. But then as soon as we started having tests and everyone started testing positive, I was like, “There's no way we're going to ask the physician to do that on top of everything else we're already doing.”
We tried to figure out where would this fit in the bigger … workflow picture of everyone on our team. We have the ED clerk, we have the nurse, we have the physician. So where does this sort of fit? For example, my nurse manager was another one of my biggest allies. When you make these people your allies, you can work together to troubleshoot these things. And so for us, we realized that it fits in really nicely with registration or with the clerk. One of them can probably do this without any problem. And so we shifted that work away from the physician brain onto somebody else that was already sort of in that part of the chart, and they could just click on those boxes.
And then the same thing with “What's the downstream or on-the-ground impact?” So I'll give you an example. One of the most important things in the emergency department is throughput because we can't pull people into the ER from the waiting room if we don't get people out of the ER upstairs or home. So throughput is incredibly important. And so one of the things we were trying to measure is how long is it taking a hospitalist to come down to see patients, to put the admission order. And so we needed to know when does a physician, when does the ER doc decide the person's going to be admitted? And from that decision, how long does it take for the hospitalist to come down? So at a big throughput committee where there's multidisciplinary, ton of different specialties, we had one person say, “Oh, why doesn't the ER doc, why don't we turn on this thing in the EMR? It's called the intent to admit order. We can just turn it on in the EMR and the ER doc can just order that every time they decide they're going to admit the patient.”
And everyone's like, “Oh, great idea. That solves the problem. Great idea. It's time stamped.” So then I'm like, “Hold on a second. Let's see what happens. Let's turn on the computer right now and let's go through the steps. Let's say I'm going to admit somebody. Let's see how long it takes me to hit that intent to admit order.” Turned out it was three different screens, four different clicks. Even if it's only two or three minutes, all of those little things add up. And it's not just the time it takes. It's the frustration and the fact that you are now having to devote more energy to one other thing. And the physician also needs to now learn that and remember to do that, as opposed to just all the medicine—everything else they're already doing.
And so I asked myself that same question. Where else would this fit in our workflow? And who else could do this that's already doing this that it wouldn't be a huge strain on what they're doing? And for us, it was the clerk, because the clerk had to be the person that turned on the bed request anyway when the person got admitted and it was already part of their workflow. So we said, “As soon as you hear that we're admitting the patient, that's part of your workflow already, add this order intend to admit.” And so they would add the order, intend to admit order, and it sort of saved the physician brain from doing that.
And then there are all these simple things. And so these last things are probably the most important. And I didn't put them at the end because they're not important. I put them at the end to sort of emphasize because they're probably the most important thing, which is (to) get the docs what they need to do their job.
If there's something broken; we had a broken printer that would always jam. And everyone would jiggle it around and the clerk would come and everybody would try to fix it, and it would always jam a few days later. So get that out of there. Get a printer that works for the physicians. We had the same thing with a computer that was just always running slow. So I went through the proper channels. I had people come down from our hospital IT department. They looked at it. They tried to fix it. And I'm like, “Listen, we've been working on this for a few weeks now. It's not working. We need a new computer.” And as soon as you just say, “We've done all those things. We need a new computer,” we got a new computer. Solves the problem. Same thing with a dictaphone not working. All of those little things.
For us, a big example also was otoscopes. So we had 40 or 60 different ER rooms and we need otoscopes in all the rooms to work with the lights on, so that when we put a patient in there and we do the exam, the otoscope is working. And one of the biggest stressors is if you put a patient in that room, you need to do the exam, and now the otoscope isn't working, what do you do? You have to walk out of the room, go find an otoscope that works. If it's transportable, you bring it back. If not, you have to pick up the patient. “Excuse me, patient, follow me to this other room where I can do your ear exam.” And that was incredibly frustrating. So we just prioritized those little things. We had an ultrasound machine that was a little fidgety. So anything that you can do to fix those things. Sometimes you can just send them out to biomed to get them fixed.
Other times, you've got to budget for them. And when we did have to budget and get something new, that's obviously, you need resources, you need money, you need time because it takes a while to get that done. But I would just say, “Listen, that's coming. We just ordered this machine. It's coming. I'm so excited. Here's the timeline.” And I worked directly with biomed to make sure it's been ordered, and we would celebrate those things when they would happen.
Dr Brown: Those are great examples. And I think the fact that you were the one who was experiencing that the otoscope didn't work, and then you had to move the room, but not always can we rely on one person to find out all these kind of easy wins, right? Quick wins. How did you ask the other physicians to find out what was the pebble in their shoe?
Dr Calderón: For us, I had a regular agenda item. We met monthly at our department meetings, and I had a regular agenda item for wellness. And that wellness conversation always included paper cut files. It's like all these little things that are just so frustrating. And let me tell you, docs are not shy to tell you what they need or complain. And I would be really specific. I'm like, “Listen, tell me all. What are the pain points? What happened this week? I want to know.” And sometimes I would say, “OK, some of this is going to be out of our control.” We would put it in buckets when we would talk. So in real time, I would be updating it on my computer or our admin assistant would be updating it on the screen when we would have the meetings, and we'd say, “This is out of our control. This is something we might be able to fix right away. Oh, this is an easy win.”
Dr Brown: And I love that when somebody said, “Oh, we'll just add this other form,” you said, “Well let's see. Let's see how many clicks it is.” I think you said it was three or four screens and so many clicks. And I've heard some groups ask their quality colleagues and their colleagues in other departments, let's make a promise. I'll never say it's only three more clicks. Because you add up three more clicks across the continuum, across the day, and it can be an hour a day saved if we get rid of those clicks. So moving upstream and making sure that nothing goes into somebody's set of tasks or their inbox that doesn't need the brain of a physician. The pushback was, “Well, we've always done it this way.” How do you overcome that mentality?
Dr Calderón: People can't see my face right now because this is a recording on a podcast, but I have a huge smile on my face because that was probably one of the most frustrating things as a leader. And it's something that you just have to create peace with. People are going to say “We've always done it this way,” because change is hard. So honestly, I would say the solution for me was approaching that with love and kindness. In the beginning, I was not like that. In my first two years, I would get frustrated when people would say that, and I was like a bull in a china shop. But wait, and I would be frustrated and I would try to be headstrong and (we've) got to get this done. And what I've realized is, when people say that and I'm like, “Huh, yeah,” and I'll just smile. And people know me as being practically optimistic. I'm practically optimistic about everything.
So I would just smile and I'd say, “Oh that's interesting. Yeah, OK. Well, what if we just piloted this?” And so that was my go-to all of the time is switch “We've always done it this way,” because the biggest fear when you say, “We've always done it this way,” is that “I'm afraid to do something else. I'm afraid to try something different.” That's what's underneath that statement. So to support them in that fear that they have that this is going to be a permanent change, I just would sort of brand it as a temporary trial. “We're just going to pilot this for a while.”
Dr Brown: Yes. I think it trying a pilot, and saying, “If it doesn't work, we could go back to the old way.” It's hard to say no to, “Let's just try something.” Were there any specific challenges? You mentioned the hospitalists, right? And the ER physicians work so closely with the hospitalists to get the patient once a decision is made to admit them. Were there any particular challenges there or lessons learned?
Dr Calderón: Yeah. I think the biggest challenge is that we really depend on all the other departments that (are) around us, lab, radiology, our specialists that are on call, and registration, for example, security. And so it really gives you sort (of) this unique perspective when you lead an ER. Because I'll say the biggest challenge is that all of these other departments, they don't know what they don't know, right? And so I'd have to say that that was probably, for me, so eye-opening when I understood that, oh, radiology can't transport all our patients between these hours because there's only one person there or because they have two people, but that other person's upstairs doing X-rays in the ICU, and so now there's only one person. And sort of understanding that was so helpful.
So what we did to support the emergency department is we created these multidisciplinary throughput meetings, ER-specific. We met once a month, and we had members of all of these other departments. We had somebody from radiology, from lab, from registration, from security. Our hospitalist colleague would show up, we had our nurse director show up. And we had all these people there from all these other departments, and we would sit and we would always start by grounding ourselves in what matters. Like, “Listen, the reason why we're having this meeting is because X person”—and I would give a patient example every time and always start off with the patient example, because at the end of the day, we are all here to do the same exact thing, which is give our patients the best care possible. Everybody wants to do that, including EVS. The biggest lesson learned is get everybody on the same page. Make sure you all understand each other and ground yourself in the same mission. We're all there to take care of patients.
Dr Brown: I just really want to highlight how you clearly listen and are such a great advocate. Is there anything you want to end this podcast with? Wisdom for our audience?
Dr Calderón: Everyone listening, I want you to know, whether you're a physician practicing medicine right now, whether you're a physician leader, whether you're a hospital administrator, the bottom line is we all decided to do what we're doing to take care of human beings when they're at their most vulnerable. And just remembering that that's our purpose really helps me every day when I'm on my way to work, is like, “What can I do today to make sure that I'm doing the best thing for these patients?” And the second thing is, for the physicians and physician leaders listening, you're not alone. I don't want you to think you're ever alone. And if you're struggling right now, if you're feeling exhausted, stressed, overwhelmed, if you're feeling like, “How in the world am I going to get through this? How does everybody else have it together?” And our ego likes to isolate us, but I want to just highlight that you're not alone and I want you to know that there's help out there.
The AMA has a ton of wonderful wellness resources. If you are listening to this and you're part of Vituity, we have incredible resources. I offer a ton of free stuff on Instagram. So if you follow me on Instagram, www.vanessacalderonmd.com, a ton of free stuff that I offer, just because I don't want anyone to ever experience that same level of stress that I did or have to experience that burnout. I guess that's what I would say is, “If you're not alone, take care of each other, and just remember that we're here because we want to help other people when they're at their most vulnerable.”
Dr Brown: Dr Calderón, thank you so much for joining us today. Resources that Dr Calderón mentioned are completely open access at the AMA. Don't even need to give us an email. Many of the tools are available at www.stepsforward.org. Thank you for joining us today. And thank you, Dr Calderón.
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's STEPS Forward® podcast series, stepsforward.org.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.