Q1 2022 Bulletin: Reconnecting with Your Purpose - Pathways to Physician Resilience and Wellbeing by SCCMA

Official Magazine of the Santa Clara County Medical Association

Vol. 29 | No.1 First Quarter 2022

INSIDE: SCC

WELCOM M ES 2022 A PRESIDE DR. CLIF FORD W N ANG T,

This issue:

RECONNECTING WITH YOUR PURPOSE: PATHWAYS TO PHYSICIAN RESILIENCE AND WELLBEING

Advertiser Index MIEC ProAssurance/NorCal CAP

In this issue SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.

SCCMA Staff Chief Executive Officer | April Becerra, CAE Deputy Director | Erin Henke, CAE Physician Engagement Associate | Angelica Cereno Facility Manager | Paul Moore

SCCMA COUNCILORS El Camino Hospital of Los Gatos | Shahram S. Gholami, MD El Camino Hospital | OPEN Good Samaritan Hospital | Krikor Barsoumian, MD Kaiser Foundation Hospital - San Jose | David Hensley MD Kaiser Permanente Hospital | Joshua Markowitz, MD O’Connor Hospital | David Cahn, MD Regional Medical Center | Kenneth Phan, MD Saint Louise Regional Hospital | Kevin Stuart, MD Santa Clara Valley Medical Center | Harry Morrison, MD Stanford Health Care/Children’s Health | Sam Wald, MD Managing Editor | Erin Henke Production Editor | Prime42 - Design | Market | Host Opinions expressed by authors are their own, and not necessarily those of The Bulletin or SCCMA. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Erin Henke, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850 Fax: 408/289-1064 erin @sccma.org

Feature Articles 05 48th Annual Legistive Advocacy Day 14 2021 CMA Federal Wrap-Up 18 How My Own Grief Helped Me See My Patients’ Loss Roxanne Almas, MD, MSPH

20 A Path Forward RechargedMD

21 Battling Burnout And Restoring Resilience Thom Mayer, MD

22 Physician Well-Being 2.0 Tait D. Shanafelt, MD

31 Physician Burnout Or Joy Pearl E. Grimes, MD

33 Positive Adaption John Chuck, MD

Quarterly Columns 07 President’s Message Clifford Wang, MD

09 Membership Insider

New and Noteworthy 02 Advertiser Index 34 Upcoming Events

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The Bulletin | First Quarter 2022 | 3

48TH ANNUAL LEGISLATIVE ADVOCACY DAY

Tuesday, April 19, 2022 Sheraton Grand Hotel | Grand Nave Ballroom 1230 J St., Sacramento, CA 95814

For more information, visit cmadocs.org/events.

48TH ANNUAL LEGISLATIVE ADVOCACY DAY Tuesday, April 19, 2022 | Sheraton Hotel Grand | Grand Nave Ballroom

AGENDA - TENTATIVE Monday, April 18, 2022 CALPAC Legislative Advocacy Reception Location: TBD 8:00 pm – 10:00 pm (tentative) TUESDAY, APRIL 19, 2022 Sheraton Grand Hotel Grand Nave Ballroom 1230 J Street, Sacramento, CA 8:00 AM

REGISTRATION & CONTINENTAL BREAKFAST

9:00 AM

CMA WELCOME & REMARKS ROBERT WAILES, MD, PRESIDENT, CMA

9:10 AM

LOBBYING AGENDA REVIEW JANUS NORMAN, CHIEF LOBBYIST, CMA

9:45 AM

GROUP PHOTO – LOCATION TBD

10:00 AM

CAPITOL MEETINGS

11:45 AM

LUNCH – SHERATON GRAND HOTEL

12:30 PM

LUNCHEON KEYNOTE SPEAKER ATTORNEY GENERAL ROB BONTA

1:00 PM

CLOSING REMARKS DUSTIN CORCORAN, CEO, CMA

1:30 PM

CAPITOL MEETINGS

Immediate Past-President Dr. Cindy Russell passes the gavel to 2022 President Dr. Clifford Wang 6 | The Bulletin | First Quarter 2022

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A Message from the President

Rest and Recovery by Clifford Wang, MD

SCCMA President

Greetings and it is an honor to be your 135th president of the Santa Clara County Medical Association (SCCMA). We have a long and distinguished history of pursuing our mission to extend medical knowledge and advance medical science, to elevate the standards of medical practice, to enlighten the public on matters pertaining to public health, to promote the excellence in the provision of quality ethical healthcare, and to promote the betterment of the medical profession. I hope this year we will add to this legacy. As we turn the page on two years of a pandemic and begin a new year, it is useful to take time to acknowledge what we have been through. We are coming out of our fourth surge with Omicron and over 5 million deaths worldwide. We witnessed rapid change in medicine from vaccine development to new medications, fear and uncertainty of each new variant, mixed messages from various sources, loss revenue from declining patient encounters or elective surgeries, and increased video meetings but less direct human connection. As physicians, we stepped up to care for patients in the face of danger but sometimes at the cost of not being available for our families or the worry that we would infect our loved ones. Dr. Gail Wright, a physician wellness leader, posed these questions at a recent wellness session: What would you like to forget about this pandemic, what is something amazing that you would want to tell your grandchildren you witnessed or were a part of with this pandemic, and what is something we

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learned out of all the difficulties that will propel us forward? I encourage you to take time to reflect and answer what this might be for you. We hope that we are moving from a pandemic period to and endemic period with SARS-CoV-2, but I have learned to not underestimate this virus. Burnout

We know that prior to the pandemic, physicians were already experiencing burnout at high levels, but the pandemic propelled us into survival mode to help wherever we could. It gave us the additional purpose, energy, and endurance to keep hospitals and clinics open, to use telemedicine to reach our patients, and to adapt to new guidelines, policies and mandates. However, the hidden toll from this maybe even more burnout as we come out of the pandemic. Dr. Christina Maslach, former professor of psychology at the University of California, Berkley, pioneered research on job burnout. She describes job burnout as an experience of response to chronic job stressors that have not been successfully managed with three components: exhaustion, negativism or cynicism, and professional inefficacy. The six areas that influence these dimensions include workload, control, reward, community, fairness, and values. I like her analogy of these chronic job stressors being like pebbles in your shoe that will not get better unless they are managed. In 2019, the World Health Organization recognized burnout as an occupational phenomenon which can have health implications and the National

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cap and is much broader in its application that could allow Academy of Medicine published Taking Action Against Clinician huge payouts and encourage more lawsuits at a time when we Burnout and the importance of a systematic approach to this already are being challenged from the pandemic and the cost of issue. It is important to recognize that burnout is not a disease, medical care. Kerry Hydash of the Family Healthcare Network and that burnout inventories or indices should not be used to noted that increased costs related to this measure could have label individuals. I have spoken to many physicians who are a trickle-down effect that could result in community clinics experiencing these symptoms, and there is a need to engage our closing their doors, essential health services being slashed and profession in addressing it. Jonathan Malesic, who wrote “The health care providers having to limit new patients. Hundreds of End of Burnout: Why Work Drains Us and How to Build Better organizations are working together to defeat this initiative, but it Lives,” notes that individuals generally are not the cause of their will require a huge effort by local medical associations and the own burnout. The causes of burnout are not a problem within California Medical Association. We will continue to keep you the individual but a larger systemic problem of organizations informed and let you know how you can get involved. and a culture of productivity with an emphasis on greater efficiency without recovery. It will take a concerted effort to DEI change the organizational issues but there are steps we can take. We want to continue the dialogue and education that started At SCCMA, we are committed to helping physicians improve last year regarding diversity, equity, and inclusion. We know their wellness through our Resilient MD program that began there is much work to do to end structural racism and inequity last year. In our first session, we learned from Dr. Seema Sidhu in healthcare and we will be setting up a task force to help guide the 3 spheres of control us. We will continue to and had the chance in break-out sessions to At SCCMA, we are committed to helping provide education such as our webinar series last share with colleagues physicians improve their wellness through year that is still available our strategies, challenges, under the resources tab at our Resilient MD program and experiences with SCCMA.org but also want wellness. In our second to take action. One way session, Dr. Thom Mayer, NFL Hall of Fame inductee, taught us we hope to increase diversity in medicine is offering young to take a page from athletes who perform at the highest levels students in underserved and low-income communities the but incorporate rest and recovery. Our latest speaker, Dr. BJ opportunity to participate in a STEM program to learn from Wells focused on what binds us as human beings underneath Stanford medical students and SCCMA physicians. It is great our roles and how grief can re-frame our experience. These chance for them to learn some science but also to interact with are all available for review on our website, but I encourage you those who are in training and in practice and possibly inspire to join colleagues real-time from different practices and health them towards a career in medicine. systems at these sessions throughout the year. Most importantly There are many other opportunities to participate at SCCMA give yourself some self-compassion and find ways to recover. through our committees and programs from legislative advocacy, environmental health, bioethics, membership services, and MICRA physician wellness. If you would like to get involved, please This year there is a ballot measure called the Fairness for Injured email me at cliffordwangmd.sccma@gmail.com Patients Act or Changes to Medical Malpractice Lawsuits Cap Finally, if COVID-19 conditions improve, we hope to have Initiative which is being led by trial lawyers again to challenge opportunities for in person meetings to reaffirm our connection the Medical Injury Compensation Reform Act (MICRA) that has with one another as physicians. kept medical malpractice liability reasonable in California. This new initiative would create a new category of injury with no

References: WHO COVID-19 Dashboard, February 12, 2022, https://covid19.who.int Schaufeli WB, Leiter MP, Maslach C. Burnout: 35 years of research and practice. Career Development International, 2009;14, 204–220. doi:10.1108/13620430910966406 Maslach C, Leiter MP, How to measure burnout accurately and ethically, Harvard Business Review, March 19, 2021, https://hbr.org/2021/03/ how-to-measure-burnout-accurately-and-ethically National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. https://doi.org/10/17226/25521 Malesic J, (2022) The end of burnout: Why work drains us and how to build better lives, (1st ed.), University of California Press Hydash, K. Medical Malpractice Ballot Measure Would Benefit Lawyers, CalMatters, February 7, 2022, https://calmatters.org/ commentary/2022/02/medical-malpractice-ballot-measure-would-benefit-lawyers/

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Membership Insider County Medical Societies & California Medical Association Prepare for 2022 State Ballot Measure Recently, physician leaders across California joined the California Medical Association (CMA) to discuss an important 2022 state ballot proposition with the potential to negatively impact the practice of medicine. The measure attacks MICRA protections for physicians, with drastic implications for patient access to care and health care costs. The CMA has created a member resource page at www.cmadocs.org/micra, and you can read more about the campaign to protect MICRA at www.protectmicra.org. The SCCMA and CMA are working hard on this issue and will be sharing more information in the coming months.

CMA Recoups $33 Million On Behalf of Physician Members In 2021, the CMA recovered nearly $3.2 million from payors on behalf of physician members. CMA’s Center for Economic Services (CES) is a powerful ally when it comes to dealing with problematic payors. Staffed by practice management experts with a combined experience of more than 125 years in medical practice operations, the CES team has recovered over $33 million from payors on behalf of its physician members during the past 13 years. CMA members can call on CMA’s practice management experts for free one-on-one help with contracting, billing and payment problems by contacting the reimbursement helpline at (888) 401-5911 or economicservices@cmadocs.org. Learn more about how CMA’s practice management experts can help you at cmadocs.org/ces.

Medical Board Expert Review Program The Medical Board of California (MBC) is seeking physicians to serve in their Expert Reviewer www.sccma.org

Program. The MBC established the Expert Reviewer Program in July 1994 as an impartial and professional means by which to support the investigation and enforcement functions of the Board. Specifically, medical experts assist the Board by providing expert reviews and opinions on Board cases and conducting professional competency exams, physical exams and psychiatric exams. An Expert Reviewer is not an advocate for the Medical Board or the respondent physician. Civil Code Section 43.8 provides immunity from civil liability for expert reviewers acting within the scope of their duties in evaluating and testifying in cases brought before the Board. The Board seeks to recruit physicians who practice in a wide variety of specialties. Expert Reviewers are compensated. Learn more at https://bit.ly/36tIyQg.

Senate Passes Historic Legislation Protecting Healthcare Workers’ Mental Health The U.S. Senate recently passed the Dr. Lorna Breen Health Care Provider Protection Act. Now that the legislation has passed in both the Senate and the House, it will head to the president’s desk for signature. The legislation is named after Dr. Lorna Breen, a New York City emergency room physician who tragically died by suicide in Spring 2020 after treating confirmed COVID-19 patients, aims to reduce the stigma of seeking mental health assistance among health care professionals. Backed by more than 70 organizations, including the American Medical Association, the American Hospital Association, and the American College of Emergency Physicians, the comprehensive legislation is the first of its kind to allocate specific funds towards grants for training health profession students, residents, or health care professionals in evidence-informed strategies to reduce and prevent suicide, burnout, mental health conditions, and substance use disorders. Learn more at http://drlornabreen.org/.

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Membership Insider HELP IS AT HAND Access Free Counseling Support The Frontline Workers Counseling Project (FWCP) is an award-winning, Bay Area-based, grassroots charitable organization that connects frontline and essential workers with free highquality psychotherapy and support groups offered by licensed professional psychotherapists. Over 450 licensed and insured professional psychotherapists in the Bay Area have volunteered to offer free services through the FWCP, representing a wide range of personal and professional backgrounds, including psychologists, licensed clinical social workers, psychiatrists, and marriage and family therapists. Learn more at www.fwcp.org.

Physicians’ and Dentists’ Confidential Support Line Northern California: (650) 756-7787 Southern California: (213) 383-2691 About the hotline: We are a confidential service dedicated to assisting physicians and dentists who may feel overwhelmed by aspects of their personal or professional lives. Our goal is to help our colleagues before their lives and practices are in jeopardy. How it works: All calls are completely confidential. Callers are quickly connected to a physician or dentist with extensive experience in helping health professionals having problems with stress,

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substance abuse or mental health issues. Callers receive the support and referrals needed to better manage whatever issues with which they may be struggling. Who should call: If you’re a physician or dentist looking for help with substance abuse or a psychological or emotional problem, we’re here to help. If you’re a colleague, family member or friend of a physician or dentist in need of assistance, please don’t hesitate to call.

AMA STEPS Forward™ Offers Physician Well-Being Toolkits AMA STEPS Forward™ offers a collection of engaging and interactive educational toolkits that are practical, actionable “how-to” guides to transform and improve your practice. These toolkits address common practice challenges and offer solutions that aim to save 2-3 hours a day, reduce physician burnout and improve wellbeing, optimize teambased workflows and enhance patient experiences. Becaue physician well-being is influenced by both organizational and individual factors, the Physician Well-Being collection of AMA's STEPS Forward™ toolkits offer strategies on how to engage health system leadership, understand physician burnout and how to address it, as well as how to develop a culture that supports physician well-being. CME is offered. Learn more at https://edhub.ama-assn.org/ steps-forward.

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Insurance by physicians, for physicians.™ The Bulletin | First Quarter 2022 | 11

2021 Federal Wrap-Up Another Tough Year…But Important Wins for Physicians By Elizabeth McNeil, CMA Vice President of Federal Government Relations 2021 proved to be another challenging year for physicians and a nation continuing to face a raging pandemic. It brought us tough confrontations over COVID-19 mask mandates and vaccination efforts, legal challenges that threatened to overturn the Affordable Care Act (ACA), a renewed fight for racial equity and an insurrection at the U.S. Capitol that challenged our democracy. But through it all, the California Medical Association (CMA) was there, fighting for physicians and ensuring that our nation’s healers were able to continue providing care to patients as the pandemic raged on. The nation inaugurated a new President, Joseph Biden, and the first woman Vice President, California Senator Kamala Harris, who set out to heal a nation experiencing the worst public health crisis in history. As the Biden Administration settled in, key California leaders were placed in important positions in the federal government, giving CMA unprecedented access at the federal level. California Secretary of State Alex Padilla was appointed to the U.S. Senate to fill the vacancy left by Vice President Harris, while and California Attorney General Xavier Becerra was named Secretary of the U.S. Department of Health and Human Services. Californians Nancy Pelosi and Kevin McCarthy were both reelected to their respective positions as Speaker of the House and Minority Leader.

Unprecedented Challenges The COVID-19 pandemic will be remembered as one of the most unprecedented and challenging times in our nation’s history. Physicians rose to their calling in heroic numbers to battle the virus, vaccinate the public, and fight for science and truth to protect public health. Physicians demonstrated their compassion and courage – risking their lives and the lives of their families to care for the sickest of patients. CMA successfully fought alongside the American Medical Association (AMA) and others in organized medicine to ensure physicians were able to continue providing quality care to their patients during and beyond the public health emergency. Many physicians either implemented or expanded their use of telehealth as a treatment modality. CMA worked hard to ensure that Congress and the Biden Administration provided telehealth payment parity and waivers to allow physicians to provide a broad range of telehealth and audio-only services in a broad range of settings. CMA made sure policymakers understood how telehealth allowed physicians to meet their patients’ needs during the pandemic.

A Test of Stamina The second year of the pandemic truly tested physician stamina. Frontline physicians fought burnout and massive health staffing shortages; all physicians worked to sustain the viability of their practices;

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CMA Federal Wrap Up 2021 and physicians began to address the secondary impacts of the pandemic – worsening health conditions caused by delays in care, as well as a tsunami of mental health and substance abuse issues. CMA warned Congress that the long-term fallout from the pandemic would be felt by patients for years to come and fundamentally alter the long-term stability of physician practices. Congress honored the sacrifices made by physicians and responded by dedicating substantial resources to help physicians fight the pandemic and sustain the viability of their practices for future patients. In 2020-21, Congress enacted legislation to address all aspects of the COVID-19 battle providing nearly $2 trillion in funding, including hundreds of billions for physician practices: +

$190 billion to the Provider Relief Fund

$10 billion to reimburse physicians treating the uninsured

$1 trillion to the Paycheck Protection Program and fair tax treatment for such grants

2% Medicare payment increase by waiving the sequestration cuts

Billions in funding for personal protective equipment, mental health, substance abuse, public health, testing and vaccines

Medicare Payment Cuts Stopped As if the COVID-19 pandemic was not enough, physicians also faced 9.75% in Medicare payment cuts on January 1, 2022. It was a perfect storm of Medicare payment cuts resulting from an expiring 2% sequestration waiver, 3.75% budget neutrality cuts imposed by the fee schedule and an unintended 4% cut due to a legislative “pay as you go” budget neutrality rule. In response to intense advocacy from CMA, AMA and other medical societies, Congress recognized that physicians could not continue to fight the pandemic, sustain their practices and care for patients under a 9.75% Medicare payment cut. Led by California physician Congressman Ami Bera (D-CA), Congress enacted legislation to stop most of the 9.75% payment cuts. The 2% sequestration cuts will be phased back in by July 1, 2022. CMA also successfully worked with AMA and organized medicine to rally Congress to: +

Double the Medicare COVID-19 vaccine administration payment rates

Provide a Merit-Based Incentive Payment System quality reporting exemption

Extend the telehealth waivers through the public health emergency

Delay mandatory e-prescribing for controlled substances until 2023

Delay the Radiation Oncology Alternative Payment model and the Appropriate Use Criteria program until 2023

Fighting Back on Surprise Medical Billing CMA continues to fight an ill-conceived federal regulation that disregards the balanced arbitration process in the No Surprises Act (NSA) law and threatens patient access to in-network physicians. While CMA strongly supports the parts of the law that protect patients from surprise medical bills, the arbitration regulation will harm patients and drive up costs in the long term.

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CMA Federal Wrap Up 2021 In the NSA’s statutory language, Congress established a balanced process to fairly resolve payment disputes between physicians and insurers for certain unanticipated out-of-network medical bills, using several different criteria. However, the implementing regulations are blatantly inconsistent with the clear language of the statute and Congressional intent. They effectively upend the law, giving insurers an unfair advantage by relying almost exclusively on the insurers’ self-determined median in-network billing rate, instead of considering the multitude of factors called for under the law. Nearly 200 Members of Congress and the Chairman of the powerful Ways and Means Committee stood with physicians, objecting to the regulations in multiple bipartisan letters. CMA also submitted extensive comments to the regulators warning that the NSA regulations would produce the same unintended consequences that physicians and patients have experienced under California’s Assembly Bill 72. CMA provided detailed evidence from California that demonstrated how insurers cancelled long-standing contracts or imposed significant rate reductions that forced physicians out-of-network and reduced patient access to in-network physicians, particularly regarding on-call panels of physician specialists who treat patients in emergencies. Several lawsuits have been filed against the federal government over its misguided implementation of the NSA. The suits argue that the regulations are a clear deviation from the law as written and all but ensure that hospitals, physicians and other providers will routinely be undercompensated by commercial insurers, and that patients will have fewer choices for access to in-network services. Through the Physicians Advocacy Institute, CMA, along with other state and national specialty societies, filed amicus briefs in support of a lawsuit brought by the Texas Medical Association and the AMAAmerican Hospital Association lawsuit. The American College of Emergency Physicians, American Society of Anesthesiologists and American College of Radiology also filed a joint legal action.

Public Service Loan Forgiveness In 2021, CMA continued to aggressively fight for a legislative or regulatory change to allow California and Texas physicians to participate in the Public Service Loan Forgiveness (PSLF) program like their colleagues in the other 48 states. Congress established the PSLF program in 2007 to improve access to care by encouraging physicians to pursue careers working in nonprofit settings. When implementing regulations were issued, they were severely narrowed to require physicians to be “hired and paid by” hospitals in order to receive loan forgiveness. Because California and Texas law prohibit hospital employment of physicians, most physicians in California and Texas are precluded from participating in the program, while their counterparts in all other 48 states receive loan forgiveness. With an average $250,000 in student loan debt, the narrow regulation places California and Texas at a severe disadvantage in recruiting new physicians, thereby harming patient access to care in our underserved communities. On behalf of CMA, California Congressman Josh Harder (D-Stanislaus) introduced HR 1133, the “Stopping Doctor Shortages Act,” and has led an intense advocacy effort in the House to fix this problem with the

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CMA Federal Wrap Up 2021 support of his co-authors, Congressmen Jay Obernolte (R-San Bernardino), Joaquin Castro (D-TX) and Van Taylor (R-TX). Identical legislation was introduced in the Senate (S 311) by Senators Dianne Feinstein (D-CA), John Cornyn (R-TX) and Alex Padilla (D-CA). Throughout 2021, CMA urged Congress to pass a legislative fix but the high cost has made it extremely difficult. Also in 2021, the U.S. Department of Education reopened its regulations to make changes to the Higher Education Act, which includes the PSLF. CMA testified before the education department and organized a joint bipartisan letter from the majority of the California and Texas Congressional delegations. Speaker Pelosi, Rep. Harder and Senator Feinstein have also met with the Secretary of Education on CMA’s behalf. This is a top priority for CMA; we will continue to urge regulators and Congress to resolve the problem as soon as possible.

Access to Affordable Health Care CMA has urged Congress to address two of our nation’s highest health care priorities in President Biden’s Build Back Better social programs infrastructure legislation – permanent access to more affordable health insurance through the ACA and lowering prescription drug costs. Although the 2021 American Rescue Plan Act (ARPA) expanded eligibility for ACA health insurance tax credits and assistance, these provisions were only authorized for two years. CMA is urging Congress to ensure the long-term affordability and effectiveness of the ACA by making the provisions of the ARPA permanent. The Medicare drug pricing provision in the Build Back Better plan would allow Medicare to negotiate drug prices on many of the highest-priced drugs directly with pharmaceutical companies – including all insulin drugs. The legislation is estimated to save Medicare and privately insured patients 40-60% on drug costs.

Pathways to Practice President Biden’s Build Back Better legislation would also authorize 4,000 new graduate medical education (GME) residency positions. The nation is currently facing a 15,000 residency position shortage. This CMA-supported provision would add residency slots to allow more medical students to match with a residency program and increase the overall supply of physicians. The legislation also includes the new CMA-supported “Pathways to Practice” program – an innovative program that will allow more marginalized and minority students to go to medical school and choose a career in medicine. It provides tuition assistance, living stipends and expands the number of GME positions. It requires such students to serve in underserved areas for six years.

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CMA Federal Wrap Up 2021 This program is a significant step forward in helping our nation address racial injustice and advance health equity. It will lead to real improvements in building a more equitable health care system for providers and patients. Also this year, CMA supported multiple bills that addressed racial injustice and health care disparities and promoted adoption of AMA’s plan to “Embed Racial Justice and Advance Health Equity.”

Conclusion CMA was honored to fight for physicians in the virtual halls of Congress this year and we will keep fighting so that you can focus on your patients and not be hindered by administrative burdens, declining reimbursements or a devastating virus. While Congress did not finalize all of CMA’s priorities, important groundwork was laid for Congress to enact a more stable Medicare payment system that keeps pace with increasing practice costs, Medicare Advantage prior authorization reforms, public service student loan forgiveness for California physicians, the health care provisions in the Build Back Better plan, permanent telehealth waivers and bills that address physician workforce shortages. CMA will continue to stand with you and advocate on your behalf.

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RESTORING JOY TO THE PRACTICE OF MEDICINE TOGETHER

Through the Bay Area Clinician Wellness Collaborative

Physicians passionate about wellness from medical groups, health clinics, medical staffs, residency programs, and other physician organizations throughout the Bay Area are invited to this free online conference over two half-days on April 21 and 28.

KEYNOTE SPEAKERS

JOHN CHUCK, MD Former TPMG Regional Chair for Physician Health and Wellness Leaders

MARIE BROWN, MD AMA Director of Practice Redesign

PAUL DeCHANT, MD Healthcare Consultant

THURSDAY, APRIL 21

THURSDAY, APRIL 28

PRACTICE WISELY AND SAVE TWO HOURS PER DAY (9:00 am)

PURSUING PROFESSIONAL FULFILLMENT: ADDRESSING THE DRIVERS OF BURNOUT IN THE CLINICAL WORKPLACE (9:00 am)

Marie Brown, MD

STRATEGIES AND BEST PRACTICES IN CLINICIAN WELLNESS: THE ROLES OF LEADERS, TEAMS, AND INDIVIDUALS IN PROMOTING JOY AND MEANING (10:00 am) John Chuck, MD

PRACTICE IMPROVEMENTS IN ACTION (11:00 am)

Panel discussion with Vanessa Calderon, MD, Vituity Resiliency Director; Jill Jin, MD, AMA Senior Physician Advisor and Clinical Assistant Professor, Northwestern School of Medicine; Irene Lo, MD, Epic Care

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Paul DeChant, MD

SMOOTHING THE BUMPS ON THE ROAD TO CLINICIAN WELLNESS (10:00 am) Panel Discussion with Linda Hawes Clever, MD, MACP, President of RENEW; Marcia Nelson, MD, Chief Medical Officer, Enloe; Larissa Thomas, MD, Director of Well-being for UCSF GME

TRANSFORMING LEADERSHIP FOR A CULTURE OF WELLNESS (11:00 am) Panel Discussion with Anastasia Klick, MD, MPH, Salinas Valley Medical Clinic; Aman Sethi, MD, TPMG Director of Wellness Operations; Emily Shaw, MD, Sutter Medical Group of the Redwoods

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By Roxanne Almas, MD, MSPH

Photo Credit: Lars_Nissen

How My Own Grief Helped Me See My Patients’ Loss

y day vacillates between two worlds. Every morning, I leave the comfort of my home, family and neighborhood to begin my day advocating for families who begin theirs knowing it will involve struggle. The families I care for as a Developmental Behavioral Pediatrician in a County Hospital are the reason I come to work in-person every single day in the midst of a pandemic. These families are from mostly immigrant communities, work multiple back-breaking jobs, sometimes are single parents and cannot rely on childcare therefore often take their children to work with them. The marginalized communities I serve have endured significant trauma decades before the start of the pandemic. The children have had numerous adverse childhood experiences that have only increased over the last two years given the incredible losses they have suffered from due to Covid. Many of these children have lost a parent, a grandparent, a primary 18 | The Bulletin | First Quarter 2022

caregiver, essentially their lifeline. Some have moved homes to be cared for by other relatives and/or placed in foster care as a result. Dr. Charles Nelson, Harvard University’s professor of pediatrics and psychiatry, refers to these 200,000 + children in the US as “orphans of Covid”. Significant racial and socioeconomic disparities exist among those that are most impacted. Common questions I now find myself asking these days in clinic include “What have you lost over the last two years?” The answers have surprised me and have ranged from lost loved ones to lost friends, to a lost sense of community, lost activities and skills. I usually follow up my question with “And what have you gained?” to instill a sense of hope and resilience in the children I see. Grief is defined as a natural reaction to loss that can influence the physical, emotional, cognitive, behavioral and spiritual aspects of our lives. I was recently confronted with a deep sense of grief myself and nothing about it felt natural, yet everything about it influenced my entire being. What I’ve learned from processing my own grief these past few months after losing www.sccma.org

my mother to an aggressive cancer is that it takes an incredibly strong network of compassionate support to work through it. I continue to rely on my family, my friends, my community, my colleagues, a grief counselor, books, long walks in solitude, podcasts, deep reflection, journaling and so much more to scaffold and hold me in my grieving process. But I’m an educated, multi-cultural, multi-lingual physician in my 40s—which comes with great privilege that I wholeheartedly recognize. I have access to a web of healing at my fingertips and I draw it close to me like a yo-yo on a string when I need it most. My reality is far from the norm. However, having experienced the death of my mother, I feel more connected than ever to my patients, but I am also more compelled to support the grief of my patients and others. The urgency to create a network of grief support for our nation’s most vulnerable children and families has never been greater. Grief took over me like a tsunami. The reaction to losing someone I loved shut down key neuronal connections in my brain literally from one moment to the next. A thick fog settled in and I found myself lost, suspended in the air, unable to feel my own feet on the ground. Nothing prepared me for the stage of grief I like to call the “unable to think” stage. The mere act of making a simple decision became a monumental task for me. The loss of important executive functioning skills required for everyday living took me by complete surprise. While processing my grief, I was able to come back to my baseline of functioning, even though the loss of my mother is felt daily. As physicians, we sometimes experience our own grief alone and we push away this pain. Addressing our own grief as healers and recognizing it as a shared human experience will only serve to help ourselves in the long-run and the work we do daily for others. I have been paying more attention to grief in my clinic. Children grieve differently than adults. The children I serve have common neurodevelopmental conditions like ADHD, Autism, Intellectual Disability, among others. Grief looks different depending on a child’s developmental stage, their language skills, cognitive abilities, and social emotional profiles. I see a continuous flow of unprocessed grief that comes through my clinic doors among these children. I see the impact of loss on newborns’ and toddlers’ developing brains. I see a five-year-old who may be acting out in response to grief because he may not have the words to express himself. I see an eleven-year-old tween who has a ball of fire deep inside that can’t be released because each day of middle school requires a level of survival that only thickens the walls surrounding her pain. I see teenagers whose social media posts paint a picture incongruent with the reality of their daily lives (a universal habit for many of us) and the noise of their devices that deafens their ears to the world of loss around them. Prior to the pandemic, there was already a crisis of service delivery for my patients. Burnout among caregivers, difficulties using telehealth in this patient population, educational gaps with school closures, and the devastating impact of isolation and delays in therapies altogether have worsened the crisis further. Many of the families I meet in my clinic daily also experience complicated grief, with one loss after another loss. The compounding effect of this trauma rarely allows them to return back www.sccma.org

to their psychological baseline thus leading to worsening overall mental health and physical health. These families are surviving one day at a time and their unprocessed grief is the heavy anchor holding them down. It is impacting learning in school, job performance at work, relationships with peers or intimate partners. Dr Bruce Perry, an expert on trauma and its effects on the brain describes the effects of toxic stress as the overactivation of the stress response cycle producing a continuous flow of cortisol in the body leading to further emotional dysregulation and negative impacts on children’s overall development and health. We are headed towards a nation of chronic grief unless we take action. Unless grief is recognized and supported through immediate access to services, the mental health impact on this generation of children and families will have enduring long-term effects. Addressing grief and loss will require a compassionate approach, seen through a trauma-informed, culturally-responsive, inclusive and developmentally appropriate lens, supported by evidence-based research. Given the toll it has taken among our most marginalized communities, we will need to increase our mental health and grief literacy by training a workforce of providers across many sectors. Healthcare providers should also receive their own support to off-set burnout that is so pervasive in our field from as early as our medical training years. The structural changes needed will be significant. Addressing the burden of loss should be a right not a privilege. Recognizing that this collective suffering is a shared human experience has brought me closer to my patients and my colleagues and as a result, has helped me in processing my own grief. It is in our best interest as a county, state and country to view this as a national emergency and one our greatest public health opportunities in order to strengthen self-awareness, build resilience, and ignite growth and empowerment among our next generation.

Dr. Roxanne Almas with her late mother, Danièle Aga

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based resources. However, effective strategies must include safe spaces for physicians and nurses to offer candid feedback without fear of career retaliation, increased access to free mental health care- with blocked time for clinicians to attend these servicesand improved access to child and elderly care. As a result of the turmoil of COVID19, additional resources may include legal guidance for physicians asked to expand their scope of practice and financial safeguards for reduced hours or decreased pay. Healthcare organizations can further bolster clinician wellbeing by engaging in clinician-led quality improvement initiatives that directly impact their practice of medicine. These QI initiatives may include standing order sets and templates to improve EHR efficiency, addressing excess patient caseload, and utilizing other resources to improve clinicians’ daily experience in healthcare. At an organizational level, a culture of wellbeing in which senior leadership truly prioritizes clinicians can set the tone for physician and nurse wellbeing. Leaders can promote work-life balance by offering flexible schedules for clinicians. There are tools currently available to encourage a clinician-friendly culture such as the AMA’s evidence-based module on burnout prevention. Additionally, making a commitment to diversity and inclusion via hiring processes, equitable pay and swift responses to clinicians’ concerns regarding these topics reinforces the notion that the healthcare organization values clinician wellbeing. At a systemic level, healthcare legislation, such as those that address Medicaid, Medicare, and Telehealth reimbursement rates, which directly affect clinicians’ livelihood, documentation requirements and administrative duties, and invasive license renewal queries that ask about clinicians’ utilization of mental health resources. A health system that uses its local and national standing to lobby for clinicians’ interests will send a strong message that it truly values the wellbeing of clinicians within the organization. A singular approach to burnout cannot address its multifaceted causes. Rather, reducing clinician burnout requires a comprehensive approach that addresses its roots from the individual level all the way to the healthcare system and policy level. Within this framework, a guiding principle that puts clinicians first and prioritizes open communication and honest feedback will allow healthcare organizations to take the first steps in promoting wellbeing and much-needed healing.

A Path Forward While COVID has shone a spotlight on burnout in the healthcare community, it is a preexisting condition that predates the pandemic. Burnout is defined as a work-related stress reaction that leads to emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. Long years of training, even longer hours per shift, combined with excessive administrative duties, emotionally charged encounters with illness and death, and inadequate work-life balance has taken its toll on clinicians. The last two years have amplified this imbalance with physicians, nurses, and other clinical healthcare professionals adding personal safety concerns, misinformation regarding the pandemic, and moral dilemmas related to rationing care to their growing list of stressors. Recent surveys indicate that burnout is endemic in healthcarewith surveys citing more than 50% of both physicians and nurses admitting to key signs of burnout such as overwhelm, emotional exhaustion, and irritability. The increased visibility of physician burnoutand its impact on clinicians, their communities, and patients- has led to calls to action that incorporate systemic and policy level mandates, as well as individual-centered approaches to promote clinician wellbeing. Such multi-pronged approaches first provide individual resources that bolster fatigued clinicians while ensuring that the organization’s culture and daily processes actively support clinicians return to the joy of medicine. Traditionally, wellbeing initiatives have focused primarily at the self and people level- with an emphasis on individual and group20 | The Bulletin | First Quarter 2022

www.sccma.org

BATTLING BURNOUT AND RESTORING RESILIENCY Thom Mayer, MD

Whenever job stressors rise or adaptive capacity/resiliency declines (or doesn’t rise fast enough to counteract the rise in stressors), the results are the 3 cardinal burnout symptoms of: • • •

Emotional Exhaustion Cynicism Loss of a Sense of Meaning at Work

So, armed with this definition, how do we battle burnout and restore resiliency? (Resiliency is simply adaptive capacity or the ability to counteract those stressors.) Simple: • •

Reduce Job Stressors Increase Adaptive Capacity

That’s the leverage in this battle and as Archimedes said, “Give me a lever long enough and I can move the world.”

Figure 1

Imagine that you have an illness or injury in your family-how comfortable would you be in entrusting their care to a team of people-half of whom are burned out. How comfortable would you be in doing that? Unfortunately, that unsettling prospect is today’s sad reality, as multiple studies have shown. And while the pandemic did not help the situation, it did not cause our pandemic of burnout, which varies by practice site and specialty, but to which none of us are immune. But I submit that “burnout” and “resiliency” are still terms which are more often used than they are clearly understood and articulated. Let’s fix that through the work of the Santa Clara Medical Society! First, “definitions must drive solutions,” by which I mean simply that defining an entity-particularly a disruptive entity like burnout-should by the very nature of the process make solutions evident to those seeking to make things better, whether a patient or those who care for the patient-all of you and all of your patients. So, here’s my definition, which I think drives pragmatic solutions: Burnout is simply a ratio of 2 things: Job Stressors/ Adaptive Capacity (Figure 1):

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Physician We

Where Are We And W

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www.sccma.org

ell-being 2.0

Where Are We Going? By Tait D. Shanafelt, MD

ABSTRACT Although awareness of the importance of physician well-being has increased in recent years, the research that defined this issue, identified the contributing factors, and provided evidence on effective individual and system-level solutions has been maturing for several decades. During this interval, the field has evolved through several phases, each influenced not only by an expanding research base but also by changes in the demographic characteristics of the physician workforce and the evolution of the health care delivery system. This perspective summarizes the historical phase of this journey (the “era of distress”), the current state (Well-being 1.0), and the early contours of the next phase based on recent research and the experience of vanguard institutions (Well-being 2.0). The key characteristics and mindset of each phase are summarized to provide context for the current state, to illustrate how the field has evolved, and to help organizations and leaders advance from Well-being 1.0 to Well-being 2.0 thinking. Now that many of the lessons of the Well-being 1.0 phase have been internalized, the profession, organizations, leaders, and individual physicians should act to accelerate the transition to Well-being 2.0. www.sccma.org

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wareness of occupational distress among physicians and efforts to cultivate physician well-being have crescendoed in recent years. This awareness was amplified by the COVID-19 pandemic, which emphasized the foundational importance that well-being plays in physicians’ ability to serve patients and for health care organizations to achieve their mission. Although general awareness of the importance of physician well-being has increased during the past several years, the research that defined this challenge, identified the contributing factors, and provided evidence on effective individual and system-level responses has been maturing for several decades. The maturation of this field has evolved through several phases, each influenced not only by an expanding research base but also by changes in the demographic characteristics of the physician workforce and the evolution of the health care delivery system. This perspective summarizes the historical phase of this journey, current state, and insights regarding where we need to go next. The summary of each phase is intended to be descriptive rather than a critique and to illustrate how the field of physician wellbeing has evolved and matured.

The Past: The Era of Distress

The historical era, or what I will coin the “era of distress,” was characterized by a lack of awareness, or even deliberate neglect, of physician distress. This phase largely described the field before 2005. Although early data on physician burnout and evidence of its potential repercussions on quality of care had begun to be chronicled,1,2,3,4,5,6,7,8 the issue of occupational distress was not a meaningful part of the conversation among the profession or society. Evidence from other fields that occupational burnout was a system issue originating from problems in the work environment, rather than a weakness in the worker,9,10,11 was not widely adopted by the field of medicine. Physicians were selected and winnowed through an arduous training process and were, in many ways, expected to be superhuman. Medical school and residency training were characterized by a “rites of passage” mindset that subjected physicians to unlimited work hours, often involving many consecutive days on duty with little sleep, rest, or breaks.12,13,14 The evolving science on sleep and human performance was not applied to physicians, who were expected to perform with equal excellence throughout the arc of extended-duty shifts independent of whether they had slept. Physicians worked regardless of whether they were ill, and there were few if any backup systems to provide coverage.15,16,17 If physicians were unable to report for work, their colleagues “picked up the slack.” For individual physicians, a desire not to shift the burden to colleagues created a powerful disincentive to attend to personal health needs or illness. Individuals who pointed out the inherent problems of this approach were often marginalized as being “uncommitted” or “weak." From the demographic perspective, physicians in this era were predominantly men whose spouses or partners did not have a career of their own. This arrangement allowed the spouses and 24 | The Bulletin | First Quarter 2022

partners of physicians to devote greater time to “keeping things running on the home front” even though the physician was often absent or devoted little time to these activities.18,19,20 The practice environment was less consolidated, with fewer physicians a part of large group practices.21 Electronic health record (EHR) use was not widespread, and measures of patient satisfaction and quality were not routinely assessed. In part because of the different structural characteristics of health care delivery at the time, physicians had greater autonomy, less oversight, and more control over the practice environment.22,23,24 Nonetheless, payers and regulators in this era used a “gotcha” approach to auditing payment and documentation that communicated a lack of trust and questioned the integrity of all physicians on the basis of the unprofessional behavior of a few. At the organizational level, there was limited if any attention to the impact of administrative decisions or regulations on physicians' work life. The concept that quality of care was a system characteristic had only begun to take hold.25 If medical errors occurred, the default was to blame the individual. This typically took the form of accusatory “root cause analyses” and morbidity and mortality conferences that subjected junior physicians to humiliation and shaming by supervisors and peers.26,27 The message conveyed was that the physician should be all-knowing and able to overcome every deficiency of the health care delivery system to ensure optimal care for patients under any circumstance (ie, physicians were supposed to have deity-like qualities).28 There was inattention to the impact of physicians' personal well-being on the quality of care they provided patients. Institutional needs were prioritized above patient and clinician needs, and there was no appreciation of the economic implications of physician distress on the financial health of the organization. During this time, the professional culture of medicine was characterized by a mindset of perfectionism that reinforced the concept of physician as deity.29 This framework discouraged vulnerability with colleagues, encouraged physicians to project that they had everything together (“never let them see you sweat”), and contributed to a sense of isolation.30 To the extent there was dialogue about physician distress, the focus was on individuals rather than the system or practice environment.31 Collectively, all these factors contributed to physicians’ professional identity subsuming their human identity. There were no limits on work, and the concept of boundaries between personal and professional life was considered a lack of commitment. To the extent there was attention to “physician wellness,” it centered on the concept of self-care: healthy diet, exercise, stress reduction, and getting enough sleep when not on duty.32,33,34 The Present: Physician Well-being 1.0

Over time, increasing evidence and research began to change many of these historical paradigms. The “Physician Well-being 1.0” phase, to some extent, began between 2005 and 2010 and largely continues to present day. This phase has been characterized by knowledge and awareness. National studies began to chronicle the prevalence of distress among medical students,35,36 residents,5,37,38,39 and practicing physicians40,41,42,43 as well as trends in distress over time. Publication of these studies in peer-reviewed journals also began to result in headlines in the widely disseminated physician press www.sccma.org

(i.e., “throw-away” journals; Medscape) with occasional pickup by the lay press.44,45 Importantly, the repercussions of physician burnout and other forms of occupational distress (e.g., moral injury, fatigue/ exhaustion) began to be recognized and to have an impact on conversations within the health care delivery system. The personal repercussions of physician distress (e.g., broken relationships, problematic alcohol and substance use,46,47 depression and suicide48,49,50,51) began to establish a moral and ethical case for action. Research also demonstrated the links between physician well-being and quality of care,52,53,54 including medical errors,5,55,56,57,58 patient satisfaction,59,60 and professional behavior.6,61 This evidence began to bring together a broad coalition of stakeholders concerned with clinician well-being and resulted in expansion of the triple aim of health care (improving patient experience, reducing the cost of care, advancing population health) to a quadruple aim that included clinician well-being.62 Other studies established links between physician burnout and clinical productivity63 as well as turnover,59,64 which drew attention to the economic costs of physician burnout for health care organizations and society.65,66,67 The demographic profile of physicians in this era evolved, with gender parity among medical school matriculates and an increasing proportion of women among the practicing physician workforce. More physicians were in 2-career relationships that assumed increased involvement of physicians in home responsibilities.68,69,70 The historical pattern of professional identity subsuming human identity shifted to a dual role and the need to “balance” personal and professional identities (i.e., work-life balance).71,72 In parallel with these demographic changes, tremendous change occurred in the training and practice environment. Residency and fellowship training transitioned to a competencybased framework, and substantial, new limits on work hours were instituted. Consolidation of medical practices occurred, resulting in a majority of physicians working in employed practice models.21 Use of the EHR became widespread with the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, which defined and tied reimbursement to “meaningful use” of EHRs. Although organizations also began to appreciate the administrative impact of the EHR on physicians,73,74,75,76 the response was to provide opportunities for physicians to learn “tips and tricks” to become more efficient in their ability to use suboptimal technology.77,78 In an effort to quantify performance, organizations began to evaluate physicians using a host of new metrics, including measures of patient satisfaction, quality, cost, and productivity.79,80,81,82 Physicians became familiar with terms such as relative value unit generation, visit/billing targets, payer mix, service lines, top-box score, and net operating income.83 This contributed to a perception of misalignment between the professional values of physicians and the motives and priorities of their organizations.84,85,86,87,88,89,90 At the organizational level, awareness of the system nature of the problem began to develop.7,91,92 The response, however, typically remained focused on individual-level solutions93 and centered on providing treatment for physicians in distress (eg, mental health resources, peer support)94 as well as cultivating personal resilience through interventions such as mindfulnesswww.sccma.org

based stress reduction.95,96 Despite these efforts, state licensure questions and stigma about mental health conditions remained a barrier to seeking help.97,98,99 Organizations began to view addressing physician distress as a necessary cost center, but, to the extent they allocated resources to advance physician wellness, they viewed it primarily through a “return on investment” mindset. As they considered addressing defects in the practice environment, organizations viewed the issue as a zero-sum game problem. This mindset suggested that the only way to relieve physicians from excessive workload and administrative burden was to shift this work to others. This framework suggested that system approaches to improve physician well-being would invariably worsen the well-being of other members of the health care team, resulting in inaction. At the professional level, discussions about a “culture of wellness” began to take hold but tended to focus on a message that encouraged physicians to “take care of themselves and become more resilient.” Physicians began to express frustration that this approach failed to address the underlying problems in the practice environment that were the core issue.90,100 Some physicians suggested that health care administrators were the root cause of the problem. That oversimplification was neither accurate nor constructive and led to divisiveness and reciprocal scapegoating (physicians blame administrators; administrators blame physicians)101 that drove a wedge between physicians and the individuals they needed to work with to improve the practice environment.84,102,103 Although physicians argued about what label best described their occupational distress and how to measure it,104,105,106 there was agreement that the problem was pervasive and that the practice environment was the issue.107 Acceptance that distress was widespread created openness for more physicians to discuss occupational challenges. This helped move physicians who were struggling in isolation to realize they were not alone and created greater willingness to discuss distress with colleagues.108,109 The Future: Physician Well-being 2.0

Around 2017, vanguard institutions began to transition to the Well-being 2.0 phase. This transition has been accelerated by the COVID-19 pandemic, which illustrated the foundational importance of clinician well-being to health care delivery systems and the profound impact that work characteristics have on well-being. The Well-being 2.0 phase is characterized by action and system-based interventions to address the root causes of occupational distress.110,111,112,113,114,115 The focus in this phase shifts away from individuals toward systems, processes, teams, and leaders.112,116 The importance of transitioning to the Well-being 2.0 phase was validated by the National Academy of Medicine Action Collaborative on Clinician Well-being and the formal report from the Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-being released in late 2019.116 The scapegoating and finger-pointing that divided physicians and administrators in the Well-being 1.0 phase are replaced with a mindset of physician-administrator partnership to create practical and sustainable solutions. There is acceptance that physicians are subject to the same human limitations that affect all human beings,117 with attention to appropriate staffing, breaks, and rest as a part of performance. This phase builds from a foundation that burnout is codified as an occupational The Bulletin | First Quarter 2022 | 25

The intersection between diversity, equity, and inclusion to wellness is recognized

syndrome by the World Health Organization118; harmonized definitions for burnout have been established106; instruments to assess the syndrome have been developed, validated, and crosswalked9,119,120,121,122; the neurobiology of occupational distress has been recognized123; and the distinction between burnout and depression has been clarified.124,125 At the organizational level, the mindset in this phase centers on cultivating well-being and preventing occupational distress rather than simply reducing burnout.110,111,112,115 Senior leaders, such as Chief Wellness Officers,113,114 are appointed to address system-based drivers, and the infrastructure and resources to enable these leaders to drive organizational change are established.111,126 The principles of human factors engineering and design are embraced.127,128,129 The organizational focus shifts from patient needs to a people focus that attends to the needs of all individuals in the practice environment as both necessary and mutually beneficial to achieve the desired outcomes. This includes caring for the team and creating an organizational environment that attends to leadership, professionalism, teamwork, just culture, voice and input, and flexibility.102,112,127,130 The needs of individual clinicians, including sleep and work-life integration, are acknowledged and supported.117,131 In the Well-being 2.0 phase, the organization transitions from viewing wellness as a necessary cost center to viewing it as a core organizational strategy.65,110,111 The resource allocation mindset shifts from a return on investment framework to value on investment. From a demographic perspective, it is recognized that there is an equal mixture of men and women physicians and that most physicians are in 2-career relationships with shared duty for personal and family responsibilities. To enable people to meet these responsibilities, organizations create flexibility in the practice environment that allows physicians to meet both personal and professional obligations. This provides organizations a competitive advantage in recruitment and retention and allows physicians to work full-time and still accommodate personal needs rather than having to work parttime to do so. At the individual level, physicians have transitioned from a mindset of balancing personal and professional identities 26 | The Bulletin | First Quarter 2022

to one of integrating professional identity and personal identity into a single identity that encompasses human, personal, and professional dimensions.131 The intersection between diversity, equity, and inclusion to wellness is recognized. Although these are distinct domains, promoting antiracism and addressing threats and system factors that undermine diversity, equity, and inclusion are appreciated as foundational to efforts to advance clinician well-being. Consistent with this premise, more authentic conversations about organizational deficits in these domains occur in concert with action. At the professional level, the emphasis shifts from a culture of wellness to a culture of vulnerability132,133 and selfcompassion,134 which acknowledges that physicians are not perfect, that they will make mistakes,30 and that they need to be vulnerable and support one another.135,136 Physicians recognize and acknowledge that they may have an Achilles’ heel as it pertains to perfectionism and self-criticism and dedicate themselves to developing skills to address these mindsets.134,137,138 Supporting colleagues involves creating not only connection but also community involving shared experience, mutual support, and caring for each other.109 Training programs embrace these principles and work to actively develop these qualities as core dimensions of competence as well as holistically cultivating residents’ and fellows’ well-being. Call to Action

We have now internalized the lessons of the Well-being 1.0 phase, and vanguard institutions have begun to move to the Well-being 2.0 phase (Table). The profession, organizations, leaders, and individual physicians should act to accelerate this transition. At the broader professional level, physician leaders and professional societies must embrace the physician as human mindset rather than the physician as hero mindset (Figure 1). This mentality should permeate the values transmitted to the next generation of physicians at the earliest phase of training both cognitively and in the structure, design, and expectations of the clinical training process. This will require promulgating www.sccma.org

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the core values of the profession (commitment to patient needs, service, altruism) along with the realities of human limitations and the concept that healthy boundaries, appropriate limits on work, work-life integration, and attention to personal needs are part of professionalism. These values should be embraced by the established members of the profession and care taken to responsibly impart them, along with other core values, to physicians in training. Deliberate efforts to change the professional culture of perfectionism to a culture of excellence in combination with self-compassion and growth mindset must be pursued. At the organizational level, the transition to Well-being 2.0 requires a shift from awareness to action (Figure 2). It requires organizations to establish the leadership, structure, and process necessary to foster sustained progress toward

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desired outcomes.111,113,126 This involves addressing system factors that drive occupational distress and reduce professional fulfillment. It includes attention to the efficiency of the practice environment and dimensions of organizational culture that can promote or inhibit well-being.84 Organizations must embrace human factors engineering and pursue system redesign that creates sustainable workloads, provides coverage when physicians are ill, and incorporates appropriate breaks and rest.127,128,129 Health care organizations must deepen their commitment to leadership development, increase receptivity to input from health care professionals, make a more authentic commitment to teamwork and optimization of team-based care, and foster an environment built on trust.89 For leaders, accelerating the transition to Well-being 2.0 requires attending to the leadership behaviors that cultivate

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Deliberate efforts to change the professional culture of perfectionism to a culture of excellence in combination with self-compassion and growth mindset must be pursued

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professional fulfillment for individuals and teams.102 This includes caring about people always, cultivating individual and team relationships, and inspiring change.139 It requires both physicians and administrative leaders to foster a collaborative relationship and to engage in partnership to redesign and implement necessary changes. Working together to develop a shared sense of purpose and to create alignment of organizational and professional values is a foundational step. At the individual level, the transition to Well-being 2.0 requires mindfully considering how to incorporate selfcompassion, boundaries, and self-care alongside other professional values. Physicians must acknowledge that they are subject to normal human limitations and attend to rest, breaks, sleep, personal relationships, and individual needs. They must reject the role of victim, stop blaming administrators, and be part of the solution. This requires casting off the narrative that physicians are powerless to effect change in large health care organizations (learned helplessness), which is not true and is a barrier to creating the system change that is needed. Catalyzing such change requires physicians to work in partnership with operational leaders to improve the practice environment and health care delivery system. Physicians must hold fast to the belief that it is a privilege to be a physician and that honor requires dedication to others and responsibilities that involve sacrifice. That duty to patients and society, however, has limits. Times of intense work must be offset with appropriate time

to recharge. Individual physicians are responsible to learn to simultaneously navigate the challenges of their career and attend to personal needs. This includes cultivating self-compassion and attention to self-care (sleep, exercise, rest) and work-life integration. Individual physicians must also preserve a strong commitment to supporting their colleagues. They should strive to create community with one another, including relationships that enable vulnerability and mutual support. Roadmaps to facilitate these changes at the profession,84 organization,110,111,112,113,115,127,140,141,142 leader,139 and individual7,31,93,95,137 level have been developed, studied, and published. Organizations and individuals that have not started their journey should use these roadmaps as a place to begin. All physicians should work to accelerate progress in their sphere of influence. Continued research and organizational discovery will enhance current knowledge and provide new learnings to help the Well-being 2.0 phase flourish. As this phase matures, the contours of a yet to be defined Well-being 3.0 phase will inevitably develop. Article citation: Shanafelt TD. Physician Well-being 2.0: Where Are We and Where Are We Going? Mayo Clin Proc. 2021 Oct;96(10):2682-2693. doi: 10.1016/j.mayocp.2021.06.005. PMID: 34607637. Read the full article, including references at https://mayocl. in/3u8qunc.

Conclusion The last 3 decades have a been a time of tremendous progress for the field of physician wellbeing. We have moved from the era of distress, characterized by ignorance and neglect, to an era of awareness and insight. Leading institutions have now transitioned from knowledge to authentic action. Robust research and application by leading institutions has been the key to the maturation of the field. The profession, organizations, leaders, and individual physicians should commit themselves to accelerating this transition to the Well-being 2.0 era. Now is the time for action.

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www.sccma.org

Pearl E. Grimes, MD

Physician Burnout or Joy: Rediscovering the Rewards of a Life in Medicine

“May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” —excerpted from the Hippocratic Oath

This key passage from the Hippocratic Oath has been sworn to by many of us at the starting gate, as young and enthusiastic medical school graduates, eager to embark on the intriguing and kinetic trajectory of medicine. Yet in today's high-stress world, the avowed “joy of healing” may at times become overshadowed by the quotidian burdens of modern-day medicine. Despite the early years of enthusiasm and idealism among physicians as healers and caregivers, a burgeoning body of data has emerged suggesting pandemic burnout among physicians in multiple specialties (Shanafelt et al., 2012, Shanafelt et al., 2019). The syndrome of burnout undoubtedly affects the ability of physicians to practice medicine with ongoing compassion, empathy, respect, quality of care, and understanding. A closer look at physician burnout The syndrome of burnout encompasses a spectrum of emotions, including feelings of ineffectiveness, emotional exhaustion, loss of meaning at work, depersonalization, loss of motivation, self-doubt, helplessness, and reduced personal accomplishment. Recent reports suggest that major causes of physician burnout include electronic medical records and comprehensive records documentation, excessive clerical burden, excessive workload, too many hours at work, loss of autonomy and control, loss of support from colleagues, loss of work–life balance, and loss of self-accomplishment (Dorrell et al., 2019 Jul, Patel et al., 2018, Shanafelt et al., 2012) (Table 1). The numbers help tell the burnout story Physicians who spend <20% of their time on the activity that they find most meaningful have been reported to be three times more likely to experience burnout versus those who spend at least 20% of their time on a favorite work effort (Shanafelt et al., 2019). Unfortunately, practicing physicians have witnessed their specialties being undermined by the monetary goals of behemoth health systems, which regard them as commodities, and their exemplary skillsets have been profoundly marginalized. Physicians have the highest suicide rate of any profession. It has been reported to be twice that of the general population of 12.3 per 100,000 (Anderson, 2018). Female physicians attempt suicide less often than women in the general population, but their completion rate equals that of male physicians and is estimated at 2.5 to 4 times that of the general population (Dobson, 2007, Frank and Dingle, 1999, Lim, 2003, Schernhammer and Colditz, 2004). Risk factors for suicide include depression, substance or alcohol abuse, as well as knowledge of and access to lethal means. It has been suggested that programs that address wellness and burnout may reduce suicide rates in physicians (Anderson, 2018). The consequences of burnout are myriad, including attrition and loss of physician workforce, increased physician turnover, decreased quality of life and self-care, increased health care costs, medical errors, increased medical malpractice, lower quality of patient care, less patient access, and lower patient satisfaction. www.sccma.org

Recent studies, however, document key difficulties in accurately measuring physician burnout. Rotenstein et al. (2018) assessed the prevalence of burnout in a systematic review of 182 studies involving 109,628 individuals in 45 countries. The authors reported substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. The researchers emphasized the importance of developing a consensus definition for burnout and standardizing measurement tools to assess the effects of chronic occupational stress on physicians. In 2011, Shanafelt et al. assessed burnout and satisfaction with work–life balance among U.S. physicians relative to that among the general U.S. population using the Maslach Burnout Inventory Scale. The researchers surveyed 7288 physicians from medical and surgical specialties nationwide. Physicians had a higher frequency of burnout symptoms (37.9% vs 27.8%) and dissatisfaction with work–life balance (40.2% vs 23.2%) compared with a probability-based sample. Substantial differences in burnout were observed by specialty, with the highest rates noted among physicians at the front line of care. Such specialties included family medicine, internal medicine, and emergency medicine. Physicians practicing dermatology were at one of the lowest risks for burnout. A follow-up study by the authors in 2014 evaluated burnout and work–life balance relative to the reported data from 2011. Of the 6880 physicians who completed the survey, there was a statistically significant increase in burnout compared with 2011, with 54% of physicians reporting at least one symptom of burnout compared with 45.5% in 2011. Interestingly, dermatology had the highest increase in burnout, moving to the top 10 group and ranking ninth highest among medical specialties compared with 23rd of 24 in 2011(Shanafelt et al., 2012). A recent survey explored burnout among U.S. resident physicians in a cohort of 4732 U.S. residents. Subjects completed a baseline questionnaire during the first year of medical school and follow-up questionnaires during the fourth year of medical school and second year of residency. Symptoms of burnout were reported in 45.2% of residents and career choice regrets in 14%. Characteristics that were connected with a higher risk of burnout included female sex and higher reported levels of anxiety during medical school. Additionally, a higher reported level of empathy during medical school was associated with a lower reported risk of burnout (Dyrbye et al., 2018). Dorrell et al. (2019) assessed the most common causes of burnout among practicing academic dermatologists in the United States. Of 518 e-mail reports, 91 attending dermatologists completed the survey. Common causes of burnout in this group included excessive documentation and time spent on electronic medical records (22%), lack of protected time for pursuing academic interests such as teaching and research (17%), and increased administrative demands for productivity. This study suggested that institutions valued finances over proper patient care and academic pursuits (Dorrell et al., 2019). The Bulletin | First Quarter 2022 | 31

Currently, women now represent 50% of residency training positions and 45% of practicing dermatologists. Despite cultural shifts, female physicians still spend more time parenting children and orchestrating household demands compared with male physicians (Wietsma, 2014). Women juggle the demands of family and household with career growth and advancement. Multiple U.S. studies have reported a higher frequency of burnout among female physicians, who have been found to have 20% to 60% increased odds of burnout. Suggested causes include work–life balance, home–work conflicts, sexism, and discrimination (Dyrbye et al., 2011, Dyrbye et al., 2014, Fnais et al., 2014). Raffi et al. (2019) assessed work–life balance among 127 female dermatologists surveyed from the Women’s Dermatologic Society. Eighty-five percent of surveyed women were married and 75% had ≥1 children, suggesting that the surveyed women pursued a career and family development. Interestingly, 40% claimed to have only 1 to 3 hours per week of personal downtime suggesting a profound lack of work–life balance (Raffi et al., 2019). A recent survey reported that burnout and satisfaction with work–life balance improved between 2014 and 2017 compared with 2011 and 2014, with burnout nearing the 2011 level. A 2018 Medscape National Physician Burnout and Depression report identified burnout in 32% of dermatologists compared with 46% in 2017 (Medscape, 2018). However, physicians remained at risk compared with professionals in other fields (Shanafelt et al., 2019). Multiple strategies have been proposed to address burnout at both organizational and personal levels (Table 2). Given the aforementioned statistics, how can we restore personal and professional joy and humanity to the practice of dermatology and medicine? The antidote to burnout: Recapturing joy in medicine Multiple studies have begun to address recapturing joy in medicine. Efforts to recapture or maintain joy incorporate support for physician wellness, self-care, professional satisfaction, and a healthy work environment. Maintaining and/or restoring joy in the practice of medicine is key for optimal health outcomes (Wohlever, 2019, West et al., 2018). Joy is about who you are as a physician, why you are a physician, and how you are as a physician. Joy is an internal barometer of well-being and wellness. However, we must make the distinction between joy and happiness. David Brooks, esteemed New York Times writer and columnist, recently shared his perspectives on the differences between joy and happiness: “Happiness involves a victory for self. Joy involves the transcendence of self. Happiness comes from accomplishments. True joy is the present that life gives you as you give away your gifts” (Brooks, 2019). Sinsky et al. (2013) conducted a site visit analysis of 23 highly functional primary care practices to address effective and efficient models that promote joy in the practice of medicine. The authors’ findings suggested that a shift from a physician-centric model of work distribution and responsibility to a shared-care model including higher levels of clinical support staff for physicians would enhance joy in the workplace. Such changes would ultimately lower health care costs while optimizing quality care for patients (Sinsky et al., 2013). Bohman et al. (2017) suggested that the facilitators of both burnout and high professional fulfillment involve three major domains: the culture of wellness, efficiency of practice, and personal resilience. Each domain reciprocally influences the others. Hence, a balanced approach is necessary to build a stable platform that drives sustained improvements in well-being and op32 | The Bulletin | First Quarter 2022

timal performance of health care systems (Bohman et al., 2017). In reality, these are essential pillars necessary to sustain joy in the practice of medicine. A personal tale of burnout and joy After years of a full-time career in academia and research, I made the decision to enter the private domain by establishing a pigmentation institute for research and patient care. The stark reality is that I work so much harder today than I did in fulltime academia. After the transition, I experienced periods of emotional exhaustion, helplessness, and self-doubt. I also questioned the impact of my work on my local community. These emotions forced me to ask why I do this. Why does it matter? What will my legacy be? My answers to these questions were grounded in my passion for the trajectory of medicine: the trajectory that encompassed my love for healing, science, research, and making an impact among underserved populations. I wear multiple, complex capes on a daily basis. I am a caregiver, researcher, educator, leader, mentor, administrator, and entrepreneur. Additionally, I am the founder and president of a nonprofit organization for foster and at-risk youth serving an urban Los Angeles population. I have practiced dermatology for >30 years and have navigated, negotiated, and defied the shroud of burnout. During these bleak periods, I chose to relinquish the chains of burnout and find the freedom of joy. Despite a heavy workload and flawed work–life balance, I remain joyful and balanced. I actively champion joy no matter what. It is not always easy or readily possible to do this, but my GPS is set to “finding joy” in whatever path I am on. I manage to control my destiny as a solo practitioner while masterminding my successes, mitigating my failures, and having the resilience to stand strong after defeat. After >30 years of practice, I remain as excited when my patient says “Oh, Dr. Grimes, I am so much better, thank you!” as I was 30 years ago. My patients are an endless source of joy! I listen to my patients’ stories of joy, success, heartache, pain and loss. I know their families. Sharing such stories is part of their healing process. I have witnessed and followed the growth of many patients from childhood to adulthood. I treat them with unwavering compassion, empathy, dignity, and respect, and I have learned from them as much—if not more—than they have learned from me. Their resilience through hardship and illness reinforces my passion for change and making a difference. I feel a profound and unwavering joy in knowing that I have changed lives. Despite my heavy workload, I never lose sight of the pressing need to connect at some level with each individual and provide the best possible care based on evidence- and experience-based medicine. Joy lurks in the most obscure places. We can create joy and we can choose joy. We must seek and find joy in our daily practices and lives. Renewing our oath Burnout can destroy us. Joy saves and heals us. Let us be joy's champion, every day. Let us renew the joy clause in our Oath: May I always act so as to preserve the finest traditions of my calling and may I long experience theJOYof healing those who seek my help. Article citation: Grimes PE. Physician burnout or joy: Rediscovering the rewards of a life in medicine. Int J Womens Dermatol. 2019;6(1):34-36. Published 2019 Dec 27. doi:10.1016/j. ijwd.2019.12.001 View full article and references at https://bit.ly/3IqIhuK www.sccma.org

BOOK EXCERPT

Positive Adaptation

By John Chuck, MD

We seek the comfort of stability and sameness, but Heraclitus’ proclamation that “the only constant in life is change” rules the day. Some changes are easily overcome, but others such as the loss of a job, dissolution of a marriage and family, or death of a child are devastating and send victims free falling into a deep and dark crevasse where they come face-to-face with the five stages of grief described by Elisabeth Kubler-Ross: denial, anger, bargaining, depression, and acceptance. Effectively adapting to such turmoil is an essential skill of a life well- lived. In his book Switch: How to Change Things When Change is Hard, Chip Health reminds us that in the wake of change and challenges, there are always individuals and groups who are adapting more favorably than others. He calls these super adaptors “bright spots” and advises that the most effective way for us to deal with change is to either be a bright spot or learn from bright spots. My personal version of this practice is to maintain a “liger” (from the movie Napoleon Dynamite, “It’s pretty much my favorite animal. It’s like a lion and a tiger mixed, bred for its skills in magic”) composed of my favorite role models for positive adaptation. When faced with high stakes stressors, I bring forth my best effort by imitating the habits that these people have used to overcome adversity. Adopting a positive mindset is another powerful tool for maintaining joy and meaning when swimming in a pond of pain. Remarkable examples of the power of mindset were the 29% of women Holocaust survivors, who when interviewed as older adults, said they had lived a good life. How could this be? Sociologist Aaron Antonovsky found that these women had an unflappable sense of coherence—a deeply held belief that despite circumstances that screamed otherwise, life was comprehensible, manageable, and meaningful. And while it is true that no sane person would invite tragedy into their life, cataclysmic change is often the catalyst for positive transformation. Based on her work with terminally ill patients, Kubler-Ross observed that suffering can fill its hosts with newfound empathy, compassion, and a deep loving concern for others. Adds Mark Thibodeaux in God’s Voice Within, “. . . dark times can be breakthrough moments in our own salvation history,” creating opportunities for repentance, fortitude, humility, patience, trust, self-assurance, self-confidence, and wisdom. This principle of goodness emerging from our brokenness finds its artistic home in kintsugi, the Japanese practice of repairing broken pottery by filling its fracture lines with gold. The www.sccma.org

resulting masterpiece is a moving metaphor for our capacity to adapt to suffering and emerge as more beautiful people. Finally, suffering, experienced firsthand or vicariously through the life of another, also gives us a realistic perspective of how full or empty our glass is compared to others, and whether it is filled with wine or urine. Case in point: early in my medical career, I worked with Larry, an upbeat licensed vocational nurse who sported a flat top hairdo and wore a striped Ben Davis work shirt to cover his big belly. Larry had previously seen duty as a helicopter medic in Vietnam where it was his team’s job to swoop down into the jungle to scoop up the victims of war, some of them dead, many so badly injured that they wished they were dead. In the wake of a challenging patient interaction that left me feeling angry and defeated, I found myself venting to Larry about the difficulty of my job. After listening to my story with compassion, he offered this gem of advice based on his harrowing wartime experience: “Young man, if you have a job that only has two bad days a week, you’ve got a great job.” To this day, I rejoice every week I experience two or less bad days.

Editor’s Note This is an excerpt from the book, Pearls From the Practice of Life by John Chuck, MD. We are honored to have Dr. Chuck join us as our special guest for Resilient MD on April 26th. For more information, or to register, visit https://bit.ly/3IfxHXt.

The Bulletin | First Quarter 2022 | 33

Upcoming Events Reflection Rounds with Dr. Gail E. Wright Tuesday, April 5 – 7:00-8:30pm. | Virtual Friday, April 9 – 7:30-9:00am. | Virtual Sunday, April 10 – 4:00-5:30pm. | Virtual Thursday, April 14 – 5:00-6:30pm | Virtual

Restoring Joy to the Practice of Medicine Together: Bay Area Clinician Wellness Collaborative Conference Thursday, April 21, 9:00am-12:00pm | Virtual Thursday, April 28, 9:00am-12:00pm | Virtual

Reflection Rounds provide an opportunity to gather as colleagues to reflect on and explore how encounters in medicine affect us personally. We focus on our inner life experience, spirituality, professional formation, wisdom, and well-being. These are single, 90-minute sessions. Participation is free, however, advance registration is required and is limited to 8-10 physicians for each group.

MICRA Media and Message Training

Resilient MD Series – Go Swine or Go Saint: The Personal Choices That Determine Our Destiny

Monday, April 18, 3:00-5:00pm | Sacramento, CA

Tuesday, April 26, 2022, 6:00-7:00pm | Webinar

The California Medical Association (CMA) is hosting a memberonly training on the upcoming ballot initiative threatening to end California's long-standing liability reform law - the Medical Injury Compensation Reform Act (MICRA). Participants will have the opportunity to receive a comprehensive overview and in-depth media training on the ballot initiative.

Join the SCCMA and the Physician Wellness Committee for our solution-oriented wellness series, Resilient MD. This onehour session will be led by family physician, teacher, author and wellness consultant, Dr. John Chuck. In this presentation, Dr. Chuck reviews common positive and negative adaptive responses to our predicament as human beings (namely, our stressors, suffering, and mortality) and highlights evidence-based habits that empower us to reclaim internal joy and meaning in the midst of external chaos. Registration is free. Attendees will receive a $15 DoorDash gift card and copy of Dr. Chuck’s book, Pearls from the Practice of Life.

CMA’s 48th Annual Legislative Advocacy Day Tuesday, April 19 | Sacramento, CA Register at https://bit.ly/3udYLkU CMA's Legislative Advocacy Day consistently brings together more than 400 of physician and medical student leaders from all specialties and modes of practice. Attendees will have the opportunity to meet with legislators on priority health care issues.

34 | The Bulletin | First Quarter 2022

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Q1 2022 Bulletin: Reconnecting with Your Purpose - Pathways to Physician Resilience and Wellbeing

Articles inside

Upcoming Events

Physician Burnout Or Joy

How My Own Grief Helped Me See My Patients’ Loss

A Path Forward

Physician Well-Being 2.0

Positive Adaption

Battling Burnout And Restoring Resilience

2021 CMA Federal Wrap-Up

President’s Message