COLLEAGUE INTERVIEW

Colleague Interview: A Conversation with Natalia Dorf-Biderman, MD

Dr. Dorf-Biderman is an Internal Medicine practicing hospitalist at Methodist Hospital, Park Nicollet/Health Partners. She received her MD degree from Universidad de la Republica in Montevideo, Uruguay, and completed her internal medicine residency at the University of Minnesota. She is currently the medical director for Clinical Documentation Integrity and chairs the Hospital Wellbeing Committee. While promoting personal wellbeing programs in the workplace, she works to look at practice and documentation inefficiencies that add friction to clinical practice and seeks to find attainable solutions. In partnership with the MMA, she is currently chairing the Physician Wellbeing Advisory committee where leaders and champions from across the state collaborate to develop programs to impact the health and wellbeing of clinicians throughout Minnesota.

How is it you came to Minnesota from Uruguay?

I was born and educated in Uruguay, attending medical school at the Universidad de la Republica, School of Medicine where I received my MD degree. During the 2004 economic recession, I moved to Santiago, Chile, to work and continue training in Internal Medicine. While living there, the Pan-American Maccabiah games, an athletic and cultural event for Jewish people from around the world, was held. I was one of the physicians organizing the medical and health response. Quickly, I was assigned as the physicians’ liaison with all the English-speaking medical directors. That’s where I met my husband, who was the medical director for the American delegation. A year later, we were married and moved to Boston for his fellowship in Palliative care. After completing the recertification process from Step 1-3, I again started an Internal Medicine residency at the University of Minnesota, and we have been here since.

Medical care delivery is organized differently in Uruguay and Chile. Are there practices that Minnesota physicians might apply to their advantage?

There are so many differences in healthcare delivery in South America that it deserves a whole article itself. The biggest one is probably healthcare costs and access both with and without insurance. The public healthcare system is basically free, albeit with different resources than the insured sector, but no one goes without access to medicine for fear of bankruptcy. Additionally, from an access standpoint, communicating with your medical team is so much easier. You might even be able to text with your clinicians and, in most instances, get a same-day or next-day appointment. When you have a long-standing relationship with your physicians, and they know what matters to you as a patient, the care is much more personalized. I can’t recommend specific changes in practice to consider, but broadening their perspective as to how things can be done by either practicing abroad—which I know is hard to accomplish—or going to international conferences and engaging with international teams can spark a myriad of ideas of how to do things differently.

Have you been in touch with the community in Uruguay about Covid-19?

Yes. My whole family still lives in Uruguay, and I have many friends and colleagues still practicing there. I am always paying attention to how my home country and surrounding areas are doing with COVID-19 in terms of transmission and the pandemic response implementation. The pandemic hit Minnesota earlier, and so, especially in the early days, we communicated a lot about what we were seeing at home in terms of numbers or transmission. Now, topics of discussion have mostly switched to vaccine acceptance, hesitancy, and recommendations. Personally, it has been fascinating—I would even go as far as to say—educational—to see the striking differences among communities and countries. Technology and social media have significantly impacted communications and have made the world a smaller place. This is both for the good and bad — unfortunately, misinformation is rampant, so it has been vital for me to share trustworthy and scientific information that is culturally sensitive so people can hear it.

What physician wellness aspects fall or should fall to the organization/administration?

These are challenging times for health care in general and specifically for our profession due to unprecedented changes. Our organizations are experiencing countless external challenges, including changes in reimbursement, increasing regulation, use of healthcare data, hiking clerical burden for staff across the board, changes in contracting practices due to consolidation within the market, and the implementation of new quality metrics and reporting, among others. To navigate this landscape, our organizations would, ideally, count on a committed and productive workforce. Unfortunately, now more than ever, physicians and other healthcare workers are exhausted, disillusioned, and have dropping engagement levels. There is a moral and ethical aspect to address this but, beyond that, studies indicate that physician wellbeing influences medical errors, quality of care, patient safety, patient satisfaction, and ultimately, the fiscal health of our healthcare system. When almost 80% of respondents to a survey by Medical Economics magazine respond YES to the question “Do you feel burned out right now?”, organizations have a vested interest in improving this metric. A host of factors can contribute to burnout or thriving/ engagement, and many models address them. Addressing these factors is a shared responsibility by the individual clinicians and the organizations they work in. Each practice and each organization might struggle with something different. Even each sector within a large organization might have areas that more prevalently affect one practice or another. However, the culture of medicine in which we practice and the leadership behaviors that foster wellbeing are key aspects that all organizations can and should address. Ultimately, what should always fall on the administration is to listen with intention, respect its teams, and empower its leaders to find and implement opportunities for improvement.

The culture of a team can influence the wellbeing of the team members. How should physician leaders emphasize and promote wellbeing on their teams?

The importance of leadership in the success of organizations has been well described. A 2013 study of more than 2,800 physicians at Mayo Clinic found that each 1-point increase in the leadership score (60-point scale) of a physician’s immediate supervisor (was associated with a 3.3% decrease in the probability of burnout (P < .001) and a 9.0% increase in satisfaction (P < .001).1 Additionally, an excellent study on “zero burnout practices” authored among others by two of our local physicians used a measure called “adaptive reserve.”2 This measure evaluated leadership along with five other factors. They called it “facilitative leadership.” The Institute of Health Improvement (IHI), “Joy in work” white paper calls it “participative management.”3 The key learning here is that the culture of a team is directly impacted by their direct leader. This kind of leadership is based on listening and engaging, even when the leader cannot change a significant, for example, regulatory issue. We know that involving staff in understanding problems and even building solutions creates an environment of psychological safety and teamwork and helps us build healthy, effective teams and systems that are ultimately an asset in highly complex settings like health care.

Within the scope of your work with CDI, Wellness, and QI, what tools exist to acknowledge and address individual variation?

Understanding and managing variation is essential to quality improvement and my work with CDI and performance data. These processes require data to understand, provide a common reference point, track our impact with specific actions, and predict future performance. We must realize that every process, especially in complex settings with humans (like health care), has inherent variation. This variation can be intended or unintended, variation from common causes or special causes. And we have many tools to better understand variation of which control charts and run charts are some of them. Frequently, physicians perceive these strategies as a cover to question their ability to provide appropriate care and to question the quality of care they give their patients. In truth, we implement best practices and benchmark performance to improve overall outcomes and value. Ultimately, physicians are critical stakeholders in this process, and the more we understand and get involved, the more partnerships we build, the more our perspective will be taken into account. It is through those partnerships that we can impact the future of health care and build sustainability within our practice.

If a physician is employed in a larger group practice, how can they contribute to improving their wellbeing and the wellbeing of their colleagues?

Reclaiming the agency of one’s professional experience is fundamental to improving our wellbeing. There are several aspects to this, of which I will mention two. Many of us physicians have practiced in a culture in which our own health is not a priority. The Stanford WellMD Center has done significant research in what they have termed “self valuation”4 as a way of constructive prioritization of personal wellbeing and a growth mindset applied to the practice of medicine itself. They have shown that the higher the self-valuation scores, the lower the burnout scores. This study matters because this practice is something we can “take the reins” on; we don’t need any external factors to change to be able to do this work for ourselves. Additionally, we know that we all have unique talents and interests. Evidence shows that physicians who spend 20% of their professional effort focused on dimensions of work they find meaningful are at a dramatically lower risk for burnout. Health care is a diverse, expansive, varied field so finding a unique area is possible. This could be caring for a particular patient population or patients with a given health condition or engaging in other activities such as advocacy, medical writing, patient education,

Colleague Interview (Continued from page 11)

quality improvement work, or involvement in local or national organizations to impact the healthcare environment, and many more. Finding something we feel especially connected with and pursuing it gives us a sense of meaning and purpose that protects us from burnout. Both are hard work; both involve a significant amount of personal development and understanding of oneself, where we currently are, and then, potentially, pursuing change. This is all energy-consuming and sometimes difficult. But the cost of staying exactly where we are personally and professionally might be much higher.

How prevalent is pandemic burnout among various healthcare professionals?

Burnout continues to be a critical problem, and it seems to be getting worse. A Medscape survey showed that about an average of 42% of physicians feel burned out right now, ranging from 29% to 51%. That is a minimum of one in three physicians in the lowest burnout specialty. Interestingly, women comprise 51% and men 36%. While 79% of respondents answered that their burnout started before the pandemic, happiness among physicians took a massive plunge after the COVID-19 pandemic started, and 47% of respondents reported burnout as having a strong or severe impact on their lives. A recent article by Maunder et al. showed that the prevalence of severe burnout in the spring of 2020 was 30%-40%. But by spring 2021, rates of more than 60% were found in Canadian physicians, nurses, and other healthcare professionals.5 Lastly, burnout extends well beyond physicians. A study co-authored by the AMA and the Hennepin Healthcare team, which was published by The Lancet,6 showed that stress scores were highest among nursing assistants, medical assistants, and social workers, inpatient vs. outpatient workers, women vs. men, and in Black and Latinx workers vs. whites. This national cross survey study of 20,947 healthcare workers shows what we anecdotally already knew, stress and burnout affect the gamut of health practitioners across the board.

What wellbeing practices and resources can medical students and residents incorporate now to avoid burnout in their future career?

It is never too early to start practicing how we stay healthy. Sleep, sleep whenever you can. You are young, and sleep seems dispensable instead of studying for tests, but sleep deprivation has been shown to affect mood and productivity. Know your limits, start practicing self-compassion/self-valuation right now. Find your community; they will keep you afloat and walk with you during hard times. You will have challenging moments—many of them throughout your career. Reach out to your team early on and, while a student or a resident, find someone on staff you can trust and look up to. They, too, are trying to figure out how to best care for themselves.

Minnesota is home to a significant number of foreign medical graduates who cannot practice because they can’t get into residency programs. Do you have any advice for them?

The answer here has two, almost opposite takes. On the one hand, if practicing medicine at the bedside has always been your dream, keep trying. Get creative, connect with others who have walked the same path, explore many options. There is no shame in reaching out for help to local people. Many of us International Medical Graduates (IMGs) will be more than happy to help through that journey. On the other hand, bedside medicine is not the only path to being in health care. Your MD degree is invaluable. You might need to get some training in another field, which is usually not as taxing as medical school. But the field of medicine and health is expansive, and you might be as happy working in an adjacent field.

What advice would you give to a 2021 graduate of the Universidad de la Republica, School of Medicine regarding where to practice medicine?

Every place on earth has its pros and cons. That also applies to the practice of medicine. Adam Grant, an organizational psychologist at Wharton School, recently suggested that “for generations, we have organized our lives around work” and that we should consider “reversing that and start planning our work around our lives.” Interestingly, I believe he was basing his recommendation on how Americans organize their lives, not on how the culture in Uruguay works. I would never tell anyone how to live their lives or practice their career. What I hope everyone can see is that health, happiness, and professional fulfillment are available to all of us. We must know ourselves and pursue what matters unapologetically.

References: 1. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432440. 2. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts:

Institute for Healthcare Improvement; 2017. 3. Samuel T. Edwards, Miguel Marino, Leif I. Solberg, Laura Damschroder, Kurt

C. Stange, Thomas E. Kottke, Bijal A. Balasubramanian, Rachel Springer,

Cynthia K. Perry, Deborah J. Cohen. Cultural And Structural Features Of

Zero-Burnout Primary Care Practices, Health Affairs VOL. 40, NO. 6: 4. Mickey T Trockel 1, Maryam S Hamidi 2, Nikitha K Menon 3, Susannah G

Rowe 4, Jessica C Dudley 5, Miriam T Stewart 6, Cory Z Geisler 7, Bryan

D Bohman 3, Tait D Shanafelt 3Self-valuation: Attending to the Most

Important Instrument in the Practice of Medicine. Mayo Clin Proc 2019

Oct;94(10):2022-2031. 5. Maunder RG, Heeney ND, Strudwick G, et al. Burnout in hospital-based healthcare workers during COVID-19. Science Briefs of the Ontario

COVID-19 Science Advisory Table. 2021;2(46). https://doi.org/10.47326/ ocsat.2021.02.46.1.0. 6. Kriti Prasad, Colleen McLoughlin, Martin Stillman, Sara Poplau, Elizabeth

Goelz, et al. Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: A national cross-sectional survey study. https://pubmed.ncbi.nlm.nih.gov/34041456.

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