In this episode of the AMA STEPS Forward® podcast, Alfred Atanda, Jr., MD, a pediatric orthopedic surgeon and director of clinician well-being at Nemours Children’s Hospital in Delaware, discusses minimizing unnecessary patient transfers using digital technology and how small interventions can lead to big changes in professional satisfaction and patient care. To learn more on reducing or eliminating unnecessary work, access the AMA STEPS Forward® “Getting Rid of Stupid Stuff” toolkit.
- Alfred Atanda, Jr., MD, surgical director, Center for Sports Medicine; director of clinician well-being, Nemours Children’s Health
- Marie Brown, MD, internist, director of practice redesign, 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. Brown: Welcome to the AMA STEPS Forward® podcast today. Thank you for joining us. Hopefully you're exercising, or eating or commuting to or from someplace so that you can listen and make most efficient use of your time. I'm Dr. Marie Brown, an internist with experience practicing internal medicine and geriatrics for over 30 years here in Chicago. In my role today, I am the director of practice redesign at the American Medical Association and help lead the free open-access AMA STEPS Forward® toolkits and podcasts.
Today we're speaking with Dr. Alfred Atanda, an orthopedic surgeon at Nemours Pediatric Hospital in Delaware. Dr. Atanda, thanks for joining us today.
Dr. Atanda: Thanks for having me, Dr. Brown. This is a great honor. I've heard a lot of great things about the STEPS Forward® podcast and I know it's been a couple of months in the making, but I'm finally here and I'm glad that we got our schedules aligned and everything. I'm very excited to chat with you all today.
Dr. Brown: Right, and you and I have been working together on a few other projects, and I'm excited to be able to highlight some of the wonderful work you've done, but why don't we start by you telling the listeners a little bit about yourself and your background?
Dr. Atanda: As you mentioned, I'm a pediatric orthopedic surgeon. I specialize in sports medicine, working in the Northeast in Delaware and just always been a regular surgeon for many years. And in the last two years, I have now added the role of the director of clinician well-being to my repertoire. Actually, during COVID, started reading a lot about physician well-being and even personal growth and development, reading things like Brene Brown and different works by non-medical authors, and really trying to learn about how to be a better version of myself and how to gain satisfaction and well-being with the work that I'm doing. I mean, this all kind of coincided with them creating a new position at my hospital. So I applied for it, and I've been doing that now probably about 20 to 25% of my time. And it's kind of hard juggling that and a busy surgical practice, but it's been very fulfilling and very exciting. And we've been doing a lot of cool projects, hopefully some of which I can mention and highlight for you today.
Dr. Brown: Right. And that's, I think, where we began our conversation late last year. I know you work closely with Dr. Mo Leffler and I think before you took this larger role, you were really committed to your colleagues, and I think you viewed it also as an equity issue, especially when it addresses primary care. So can you tell us a little bit about what you did early on in this journey to addressing physician wellness and practice efficiencies?
Dr. Atanda: That's a great point. So, when I started out with Mo Leffler, I didn't know really where to begin and I kind of got a little bit lost because I'm not an expert in well-being necessarily. I don't know anything about mindfulness and stress reduction, anxiety reduction, but what I do know is that health care environments can be very fragmented and chaotic places in order to work. And the systems-level interventions to address burnout, we now know are a key. And once I discovered that, I realized that I had a lot to offer my organization, even if I wasn't really well-versed in individual-level interventions I had done a lot of work with continuous improvements with various CI projects and orthopedics and outside of orthopedics. So, the first thing I wanted to do was really figure out how we can improve the environment that our physicians work in.
Because I think a lot of times, when physicians are burnt out or having issues with well-being, we placed a burden and the onus on them to make themselves stronger, to be able to withstand the chaotic health care environment. And what I wanted to do was really to improve people's environment and support them in the work that they're doing. And we started out with our primary care folks because they tend to really bear the brunt of the health care system. They are the front door of all things medical for the most part outside of the emergency room. And as a specialist, I tend to be very shielded from a lot of that stuff. Folks have to go through two or three barriers just to get to me. So we started working with not just the primary care offices in our hospital, but the small community primary care practices out in the community.
I'm not going to try to act like I know what it's like to walk a mile in a primary care doctor's shoes, because I don't. The first thing I did was as you mentioned, is really just walk amongst them and just go sit in the clinic with them. I took some discretionary time of my own administrative time to really go and see what they're doing. I spent a total of nine hours with the first group that I worked with over the course of several days when I could spare some time.
Dr. Brown: I just want to highlight that because I think so often people in this space think we have the answers and we don't, but our colleagues who are doing the work and are overwhelmed, if we can provide them some time to reflect, they have the answers—they know what they're doing that doesn't add any value to either their team's day or their patient's experience. So I was just so impressed when we first spoke last year that you took nine hours over a course of several days and went to the source and went to listen. And I believe you met with different members of the team, medical assistants, physicians, and really tried to understand and listen first to what the concerns were because they have the solutions if they also are encouraged. And just even you and Dr. Leffler taking the time to listen I'm sure made them feel more valued.
Dr. Atanda: Totally, and one thing I've learned on this journey is that the people that are doing the frontline work often feel like their voices aren't being heard. There are certain metrics and things that they're held to—how many patients they have to see, what kind of collections they have to have, RVUs they have to generate. And they feel like that's all that people are kind of imposing upon them. And then when they're voicing their concerns, it often falls on deaf ears, not because of anybody's fault, but there's a lot of moving parts in a big academic health care system. So just the idea that I would go and sit with them and listen to them was really, really powerful because they know I'm not their boss. I don't have any stake in the game, but I showed a genuine interest and even just doing that was very moving.
And obviously, we spent several hours together. I did meet with their physicians, their nurse practitioners, their RNs, their medical assistants, their administrators. I mean, we made this a multidisciplinary effort to really figure out where those pain points are, where those pebbles in the shoe are, and how we can work together to really improve the environment that they all work in. And I think that's the necessary key. We want to make sure that we're not necessarily improving things just to do it. We want to improve things to ensure that the people who are doing the work are going to benefit from those improvements and get real-time feedback from them. And then obviously monitor the effect of those intervention and those changes as time moves forward. So it was a very exciting process and I definitely learned a lot from working with them.
Dr. Brown: Right. And we're so excited that you're going to share a couple of real examples. And I think that you highlighted one of the important messages here. This is not an individual problem. We know that physicians are more resilient than the average population. This is a systems problem. And as with the staffing crisis and COVID, recognizing that the first thing we need to do is get rid of, tongue-in-cheek, the stupid stuff—GROSS―getting rid of stupid stuff. Some people say get rid of simple stuff. That was coined by Dr. Ashton from Hawaii. And we really wanted to focus on that, and you did, and you found out a lot of things that were unnecessary. And today we're going to just have time to talk about one. So if you would share a simple fix from start to finish, a recognition of an issue that could be improved, how you found it, and what you did about it and what was the result?
Dr. Atanda: One of the issues that us as specialists in a tertiary care academic facility undergo is really patients coming into our facility when they get transferred from other facilities. And then specifically in orthopedics and peds, it's a very common thing that happens, right? Somebody is six years old or ten years old, they go to an adult hospital a hundred miles away with an injury or a fracture. And rightfully so, people are nervous and concerned and they send them over to us. And we started to notice that not all of these fractures and transfers necessitated evaluation by pediatric orthopedics.
There's one case specifically that I wanted to highlight. There was a child who was 15 years old and had an injury to his elbow, had a fracture, big athlete, and he injured himself and he was taken to an urgent care. That urgent care saw that he was a child and that he had a large swollen elbow. They actually didn't really even have the capability to take care of him. They didn't even x-ray him. And they thought he'd be better served at a different urgent care. So he went to another urgent care. That place actually did get an x-Ray. They saw that he had a fracture, it was a medial condyle fracture. They told him he would need emergent surgery, but they don't have the capability to handle that. So they sent him to his local emergency room. That emergency room sees the patient and has the x-rays, he's in a splint already. And they say, “Oh yeah, you need emergent surgery, go down to DuPont.” So, mom's like, okay, but they're nervous.
Dr. Brown: We're on our fourth, now we're on our fourth.
Dr. Atanda: We’re going to our fourth medical institution. And the kicker is when he left that first ER, mom was like, "Okay, well, we'll just put him back in the car and drive." And they were nervous and fear of liability as an issue and they said he has to go in an ambulance because it's such an unstable injury. So he gets in an ambulance. Of course, they have to wait for our ambulance to get there, pick him up and then bring him back. And lo and behold, he comes to our emergency room where he's not getting some really high level of care, he's being seen by an orthopedic resident. And we tell him it's an elbow fracture, but it needs surgery, but it can be done electively. So we of course sent him home.
So you can imagine―they've been to four medical institutions, they've paid four copays. They've waited in four waiting rooms, took a $5,000 ambulance ride. The whole process took about 10 or so hours. All the while the kid is in pain, he's nervous. Mom is being told certain things that aren't meeting her expectations, taking a lot of resources and money. I heard about this because the kid actually happened to be an athlete and followed up with us eventually. So I also noted that not just from a patient perspective, but also from a systems perspective, there's a ton of waste here, right? So a lot of these facilities have physicians that are seeing this patient, documenting on this patient. They have to do paperwork, and people have to take vitals and room the patient. All the while they're not actually adding value or benefit to the patient, but it is giving them more work to do. And they're not actually really even doing anything ultimately for the patient.
Dr. Brown: We know that the number one reason that gives physicians joy is being able to deliver great quality care.
Dr. Atanda: Right, and having appropriate meaning in the work they do. So you can imagine how each one of the physicians at these places feels when they're just kind of passing somebody along, knowing that they don't necessarily are going to provide definitive care. And it's a very inefficient process. Because you can imagine if there was a way that you could move my knowledge and my advice to that very first urgent care via telemedicine or put me on an iPad, we can get an x-ray. I can look at the x-ray, I can counsel that first urgent care doctor. I can counsel the family and appropriately dispo them in a way that is convenient for everybody that's circumventing all of this.
So basically we created a multidisciplinary work group through our value-based systems organization, with our emergency room docs, with our value-based care docs who are actually primary care docs. And also our docs that run the PICU and our transport team, as well as orthopedics. And we came together―this was about a year and a half ago―and really formulated a way that we can create a streamlined system using digital technology to bypass all of this and figuring out the legality, figuring out the financial piece, figuring out compliance and how people are going to be available.
But the idea is long-term, we want to be able to really bring my knowledge as an orthopedic specialist right to the source rather than having people move from one institution to another. Why not move my knowledge so the kid who's hurt and anxious and nervous can stay where they are and get the guidance and reassurance that they have?
And we just submitted this for publication in the past couple of months; we're waiting to hear back how our revisions go. And this is kind of something first of its kind, because as you know, in a system that's fee-for-service, well at the end of the day the hospitals are making money, right? So every single one of these institutions is billing this child and billing this family. So ultimately there's not a lot of incentive to change what's going on, but we know that it's really affecting multiple stakeholders. Obviously, the physicians in the emergency room, us orthopedic specialist physicians who are getting these transfers, and then obviously the health care system, the insurance systems. And we found when we did our research project is upwards of 40% of the time, your average transfer to our emergency room for an orthopedic problem is completely unnecessary. Meaning we don't really need to see them in the emergency setting. Now we can probably see them elsewhere, either in the operating room or in the outpatient clinic, but bringing people to the emergency room isn't necessarily the best way to go about doing that.
And that story really opened my eyes because it made me realize all of the different stakeholders that are involved. And from a physician well-being perspective, these are the sorts of things that contribute to your well-being, and coming up with a systems-level infrastructure to overhaul something like this can have a profound effect throughout the health care ecosystem.
And a lot of times we don't really think that way. We think, “Oh, physicians are burnt out,” “Well, they just need a few days off,” or “They need a respite room” or “We need a retreat where people can go for a few days and have fun,” which are all good things, but it's kind of like the canary in the coal mine. If you don't improve the environment and the day to day and efficiencies and the things that are really nudging and tugging at people and making their work environment unpleasant, you're not really going to overall solve the problem that people are facing. And it's these kind of small interventions that I think are very powerful.
Dr. Brown: That's just such a great example. And what I love about this is you starting with the story, and we know all too well how very important storytelling is. I know in my experience in training, I was taught really not to think of the last patient that had that case, right? That's a way to be unduly influenced. We were sort of told, rely on the data, rely on the data, don't think about the story. But it opened my eyes when I was talking about immunizations and saw with the CDC that they used stories to share and to make a point, and your point about this 15-year-old, I think anybody listening would hear the frustration of that mother, that child and the team who handed this off, as they left, that did not feel good. We were not solving anybody's problem.
So doctors are not afraid of hard work, but when the work we do is meaningful that gives us great joy. And I think mentioning the elephant in the room that the system is set up fee-for-service. The hospital got paid, the urgent care person got paid. When the missions are not aligned―I know this is a bigger issue―but that really digs away and erodes just some of our joy in our profession as well, when our mission to care for the patient isn't aligned financially. So I think that's just a great idea. And you were able to implement that pretty successfully.
Dr. Atanda: Yeah, and I definitely learned a lot and it's not just a win for trying to necessarily improve a particular faulty system, which is a win in itself. But I think one of the main things this story highlights is the fact that as a physician, I was observant of something that was going on in my environment and my administration and my organization is now listening and supporting me to try to do something about it and make a change. Empowering individual-level physicians to take it upon themselves, to use their own time and effort, to really try to improve things and bring awareness to the larger health care ecosystem, I think is something that a lot of physicians don't necessarily feel that they have the ability to do, right? We feel like we're pushing paper, we're doing procedures, we're generating revenue, we're seeing patients, but a lot of that burnout comes from lack of flexibility, lack of autonomy, lack of control and just like hopelessness of not feeling like you can do something about your greater environment.
And it's these stories that I like to share with as many people as possible because it may be hard. It may take a little bit of time and effort, but in most reasonable organizations you can really make some meaningful, impactful change. You just have to kind of persevere a little bit and go about telling your story the right way to the right people.
Dr. Brown: And you're inspiring. So very briefly, the intervention when you got this whole team together, can you share what you implemented, what it looks like now, if that 15-year-old came in?
Dr. Atanda: Yeah. I mean, the big thing that we tried to do is once we got all the stakeholders at the table and presented the story and presented it in a way to show how it would improve each one of their particular situations, I think now people are a lot more direct into how they go about triaging these patients.
So initially it was like the PICU fellow who was in charge of who gets transferred and who isn't. And as you can imagine, if it's an orthopedic patient, the PICU fellow isn't the person that's most well-versed to decide that. It may not be feasible to go straight to the attending specifically if it's after hours in the middle of the night, but we're at least involving the orthopedic resident and orthopedic fellow early and often. And they tend to be busy at times as well, but at least running it by them and saying—"Hey, listen, what does this look like? Does this seem like something you guys would take to the OR tonight? Can I follow up?”
Because even just having even a junior-level orthopedic resident can significantly help with that decision-making. Because prior to this, the PICU fellow was just making that determination and they may not be as well-versed. And ultimately, they were accepting everything that wanted to be transferred.
Dr. Brown: Right, and a PICU fellow isn't an orthopedic PICU fellow.
Dr. Atanda: No, it's an intensive care fellow who is intubating people and taking care of critical patients. So they don't have the bandwidth to really delve into these individual transfer questions. So by involving―just creating a system where orthopedics can be more involved, really helped alleviate things. Personally, when I'm on call, I like to be available even if it is after hours because I know the orthopedic resident’s running around doing stuff, and I can ultimately interact with outside attendings and institutions very quickly and easily.
Dr. Brown: So, from a logistics standpoint, what's the triage system now?
Dr. Atanda: Obviously, it takes a while to overhaul years and years of culture. So it's still kind of filtering through the PICU folks and the transport team. But the transport team is now much more attuned to try to call the orthopedic resident at first glance. Because the transport team is transporting all sorts of kids, not just orthopedic kids, and they do go through the PICU fellow. But depending on who's on call, which attendings are on call, because not all of them want to be receiving these sorts of calls, will dictate. So now we have like a kind of a bypass where the transport team for certain orthopedic conditions will call orthopedics directly. We're trying to pull together some data with the subsequent paper to show―the first paper was more about the actual intervention―how we set it up and the cost-effectiveness of it. And then subsequent research will hopefully show what kind of improvement in the amount of a necessary transfer has transpired. So that's where our future project is going to lie.
Dr. Brown: So, who actually does the triage?
Dr. Atanda: Established transport nurses that are part of the transport system. And I've met with them extensively, all the different nurses and the PICU doctor that supervises them, to really change that culture slowly so that they can now look for orthopedic guidance for those specific orthopedic problems.
Dr. Brown: And before, everything was just going directly to the PICU.
Dr. Atanda: Right, and everything was transferred. As you can imagine, the PICU wasn't necessarily even going to take care of these patients, right? These are normal healthy kids who broke their elbow. The PICU fellow’s making the determination if they should come, but the emergency room doctors were the ones that were bearing the burden of seeing these patients and documenting on these patients and filling up their beds
Dr. Brown: For the fourth time, right?
Dr. Atanda: For the fourth time. And you can imagine mom is upset. So she's not a happy camper when she shows up to our ER, she's not a VIP, she just shows up in the back of the queue coming off of a $4,000 ambulance ride with her son, who's walking and eating a lollipop in a splint. Well he's 15, he's probably eating a candy bar, maybe not a lollipop, but you get the idea. It creates so much downstream effect that the organization and the system itself doesn't necessarily appreciate. The idea is like, okay, let's create a system where people can be transferred, which is great, but oh, there's a lot of nuances that definitely affect the overall well-being of all the stakeholders that quite frankly, we don't necessarily appreciate, understand and try to make sure that it's appropriate.
Dr. Brown: Well, it's really inspiring. That's really just a wonderful practical example of finding the person who knows what the problem is and can easily come up with a solution. And it's a win-win for everybody from the PICU fellow to the orthopedic attending, but most importantly to the mom and the child, right, and that frustration. I would not want to have met that mother after 12 hours and the fourth try to take care of her child. Anything else you'd like to share with us?
Dr. Atanda: No. I mean, we kind of highlighted a lot of what we're doing. This is just a very small example, but I think for all those listening who may be interested in well-being work or who may be doing it themselves, I always focus on really, in order to lead the people you have to walk amongst them before you even try to put any solutions in place. You need to sit with the people who are doing the work and listen to them because you may assume that they have certain gripes and frustrations and difficulties, but they're the ones that are going to tell you the story, and the listening part is extremely powerful.
And then the second phase of that is just working with these individual groups and coming up with a solution again, not that you think is best, but they think will work best for them in their particular situation.
And then last but not least, you have to spread the good word. All of our small wins and small projects, which seems like a tiny little pilot that you're doing with some small satellite PCP office. But that goes a long way to really rally the troops and provide not just inspiration for the other physicians and clinicians, but hope. I mean, as a frontline surgeon myself, I know sometimes you feel hopeless. You're just doing your work and you're slogging through, and you may not even have your values aligned with the greater good of the organization.
But when you hear these little wins of what others were able to do and how they took the bull by the horns and took matters into their own hands to really try to figure out ways that they can improve the environment that they work in, not just for themselves obviously, but for the patients that they're treating. Healthier docs are going to lead to healthier patients and better outcomes. So that's what I always just try to share. And that's the number one thing that I've learned is really just trying to be a servant leader and really walk with the people that I'm trying to help and let them tell me their story. And I can just try to help facilitate and give them some ideas. And it's been a very, very rewarding process.
Dr. Brown: That is the sign of a true leader. And our colleagues, if given the time, do know what the problem is and someone else coming in to try to fix it is not usually going to work. And I think this exemplifies exactly that point, but quite often, just so that we can have the time to rethink more of the practice efficiencies, getting rid of unnecessary work that doesn't add value. It's a good place to start.
And so thank you so much for sharing that. I hope we'll have you back many more times, because I know you have a lot of other very interesting, effective examples that you found and you helped your colleagues find solutions. So thank you so much for being with us today, Dr. Atanda. It's been a pleasure speaking with you and I hope we'll have you back on another podcast in the near future.
Dr. Atanda: Totally, it's been my pleasure, Dr. Brown. Thanks again for having me.
Dr. Brown: And to hear more about ways to identify things that are unnecessary, STEPS Forward® has a open access toolkit called, “Getting Rid of Stupid Stuff.” Thank you all for listening and hopefully you finished your exercise or your lunch or your commute safely. We hope to bring you another podcast soon.
Speaker: 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.