Ray Spadoni (4:58)

Well, that makes sense, this notion of self identification, but it does seem to me to open the door to a great deal of variability in definition and that your results are always going to be subject to some interpretation. But just quickly. And you mentioned the pandemic. I want to come to the pandemic because I think that that put a bright spotlight on this issue. But I suspect it wasn't the beginning of this as a challenge for us. But let me just back up a bit. I started off by talking about physician burnout. You mentioned healthcare worker burnout. Could you differentiate for us here? I mean, I think in terms of physicians, but of course there are many other key provider categories in the mix here. Can you talk a little bit about that, Erin?

Dr. Erin Sullivan (5:47)

Sure, and thanks for noticing that. So, yes, physician burnout is an issue, but I think what we have learned and seen in the data is this isn't just physicians anymore. This is not a uniquely physician problem. As I think of it. This is a healthcare problem. We have studies, again, a lot of them are coming from COVID when we had people who were willing to take surveys because there wasn't a lot going on in the world. And you know, they, a lot of people were actually looking for outlets, I think, for what they were feeling. But we now have the data that show it. Is everyone across healthcare, from CEOs, CFOs, COOs, to physicians, to nurses, to medical assistants, to patient service reps who are answering phones to the environmental services staff. This is a across the board phenomenon within healthcare. We have data on lots of different groups that work in healthcare that have reported burnout.

Ray Spadoni (6:46)

Okay, wow. So it's, it's broad based. It's not specific tracks per se or types, categories of worker. It is very, very broad based.

Dr. Erin Sullivan (6:57)

It sounds like it's very broad based. And we do have one study in which we saw that it looks a little bit different in different roles, but it is as a phenomenon, burnout has affected everyone in healthcare. How it might look, how a nurse might experience it might be different from how a physician experiences it, but everyone is experiencing burnout.

Ray Spadoni (7:23)

Are you confident based on what you've seen and based on your work that this really is a healthcare industry specific phenomenon and not something that's more societal, cultural, something going on at a broader, you know, kind of anthropological level, or is this the healthcare industry we're talking about?

Dr. Erin Sullivan (7:45)

So I just study healthcare. Right. So for me, this is a major issue within healthcare. I think it's quite possible that this is existing in different pockets of society or other industries. You know, I've done a little bit of work with a health healthcare system that focuses on parental wellness, and while we've done it focused on parental wellness within a healthcare system, I could actually imagine parents in other industries, wherever they're working, might have been experiencing burnout, particularly during COVID with kids at home and school shut down, and that might have caused additional burnout for parents. So I do think this is probably a phenomenon that is crossing industries and different pieces of society. But for me, most of my research is in health care and I see this as a big problem in health care.

Ray Spadoni (8:41)

Gotcha. Okay. So I broadened it out to the, to the larger societal culture. Let's talk intergalactic. No, I'm kidding. We're going to, we're going to hone in on health care. That's, that's, you know, what we aim for on the podcast. That's your area of expertise. What is the research? What does your research suggest? Are the primary causes and are there aspects of work environments that seem to contribute more than others?

Dr. Erin Sullivan (9:12)

Yeah, that's a great question. And my research that I have done on in this space for the last six to Seven years has actually been informed by even earlier research that was done in this space over 10 years ago. One of the seminal studies actually showed that time pressure within the clinical setting, as well as what we call the three Cs, chaos, culture and control, all contribute to burnout and our work environment factors. So a system with excessive work, so high workloads and chaotic environments, without suitable controls or attention to aligned values is associated with lower quality of care and burnout. And that comes from one of the early studies. And health care workers and systems with high workloads, lots of chaos, they have less favorable experiences, they report more errors, and they often have a higher desire to leave. So I really think from an environmental lens, I think around workload, I think about control or that sometimes shows up as lack of autonomy. And I think about individual sense of purpose and meaning in the job. I think that's important. And we've also seen that actually as a protective factor against burnout. The other thing that I like to think about in terms of the work environment factors is the National Academy for Science, Engineering and Medicine have a great framework around burnout that I like to use and teach that divides burnout into individual level factors and system level factors. Right. So there are some individual level factors that contribute, such as personality traits, personal values, ethics, individual ability to cope, and coping mechanisms. Those are all individual level factors that play a role. But then there are these system factors or these work environment factors that come in. And that's where I think organizations have some levers to pull potentially. I think a lot about what a rural CEO explained to me five or six years ago, which is that yoga does not fix a call schedule that is burning out your physicians. Like, that's a structural change that needs to be made by the people in charge of the call schedule. And free pizza is not going to make people feel valued. And that's one of the things we heard a lot like, stop sending us free pizza during COVID That's not making us feel valued. What makes us feel valued is actually expressions of thanks or our leaders showing up in the ICU and talking to us and seeing what's going on. That's going to make us feel valued more than, you know, another free pizza.

Ray Spadoni (12:04)

Well, my plan for this podcast was to develop an inventory of solutions. So yoga and pizza are out, I take it? Yeah, that's too. Sorry, because I was going to lead with pizza now, you know, workload. So let's talk a little bit about the consequence. What's the implication of the burnout? Are you Seeing that people are leaving the profession, they're rethinking whether to come into the profession. And then this becomes somewhat of a self fulfilling prophecy because then you have shortages. The providers who are in the system have to work that much harder. And does this then send us into a cycle that's heading straight downward?

Dr. Erin Sullivan (12:47)

I mean, we are having issues with recruitment intention and retention across healthcare. Since COVID I don't think that has shifted that much. So for those who are, let's talk about the current workforce before we talk about pipeline. I think for current workforce, we continue to see almost a revolving door in terms of retaining your nursing staff, your administrative staff, your physicians. I think that remains a problem. To have attractive, manageable jobs with a manageable workload for healthcare workers, that I think has not shifted dramatically. And so that's, that's an issue because we need people currently practicing medicine. And I think one of the things we've seen that I'm trying to get some data around is fractional quitting, which, you know, during COVID we heard a lot about early retirements and people retiring early and deciding medicine wasn't for them and going to do something else. There's something that has since happened that I'm, like I said, trying to get data around, which is how many physicians are still practicing medicine but might have decreased the amount of medicine they're practicing. Right. How many physicians have gone from seeing patients four days a week to three? Because that still causes, that causes access issues for patients. And that is still having a doctor who's still practicing but is practicing less and figuring out how to track that and track the numbers for that I think is interesting because I think that fractional quitting is contributing to some of the access issues patients are experiencing. And we haven't quite figured out how to measure and account for that in our current workforce.

Ray Spadoni (14:35)

Okay, well, this might be a good time to go to the timeline question. The trend line piece of this, which I think burnout came to the fore. We heard a lot about it during COVID I think we all observed how much pressure was bedside and on those who are caring for patients in ambulatory practices and so forth. I was leading an organization at the time and we certainly saw the impact on our nursing staff of all this. And so I guess the question is, was Covid the culprit? Did that put a spotlight on it? You know, what was happening before the pandemic hit? What happened during the pandemic and then, you know, what's been happening since?

Dr. Erin Sullivan (15:21)

Great question. And I Think if we, like, rewind the tape to 2018, 2019, so to speak. Pre Covid. I'll tell you what I was doing, which was working in primary care specifically, and working on a collaborative to address burnout across the city of Boston and several of the major health systems, specifically in primary care. So, pre Covid, we are actually working hard to decrease burnout in primary care, which was one of the specialties pre Covid that was experiencing high levels of burnout at the time. I believe to be a primary care physician and do everything that you need to do as a primary care physician, it would take you 21.7 hours of working. There's only 24 hours in a day. But to be a primary care physician, pre Covid, it was 21.7 hours of work if you did everything you're supposed to do. And so we were working really hard to decrease burnout across primary care practices in the city of Boston. And we actually found in that collaborative that strengthening team structure within practices and combining that with reducing administrative waste in the practice, actually, we were getting great results in reducing burnout across primary care teams. And that was really exciting. And the health systems were bought in and investing resources in this. And then along comes Covid, and everything that we were doing in that space stops because we have a pandemic. So what I would say is pre pandemic, we knew it was a problem, and we were working on it. Then Covid happens, and we have a whole different phenomenon where I think we initially saw in. In the healthcare workforce, like, incredible feelings of meaning and purpose in fighting the pandemic. And the first, say, six, nine months of the pandemic, everyone sort of, I trained for this. I know how to care for patients in a situation like this. And people are feeling meaning and purpose. And we saw this in national Covid data across the country that I had the privilege of analyzing those first six months. Lots of meaning and purpose, people feeling like they know how to do the job they signed up to do. And then I think what we start to see after that, you know, initial meaning and purpose spike, so to speak, is skyrocketing. Burnout. We start to see burnout skyrocketing in the emergency department, in the icu. It's also in primary care. Primary care wasn't in the headlines, but I'll tell you, they were on the front lines dealing with anxious patients, sending portal messages and making appointments to talk about what happens if they get Covid. And they were experiencing it too. But we see a lot of headlines. Burnout in the emergency room, in the icu. And I think we see a lot of more conversation about it because it's, it's moved out of, you know, the places I was reading about it, like medical and healthcare journals, and it's moved into the front page of the Boston Globe and the New York Times and everyone's talking about burnout and healthcare and what's happening in Covid. So I think Covid was a little bit of a unique situation that accelerated the experience of burnouts in some specialties and then also put a spotlight on what was happening and on a complex system that is not actually always easy as a work environment for healthcare workers. It's a complex system. It's a work environment that is sometimes characterized by high workload chaos, some cultural issues, and it's not where people always want to work and it's. They're feeling burned out.

Ray Spadoni (18:51)

Well, I think one of the challenges, and I'm curious to know if this has been your experience or you've seen this, but one of the challenges when you look at something as being an industry phenomenon is that it takes the pressure off of individual organizations. When an individual organization can think, it's not that they're trying to skirt the responsibility, it's just that it can feel bigger than them. They can say, well, this is happening across the country, this is within an entire professional track. So what can we do? You know, what can we do? But I'm wondering what some organizations actually have been able to do to support the well being of their employees, of their providers. Are there some solutions out there that are gaining traction? And then what does the data show about some of that?

Dr. Erin Sullivan (19:45)

Yeah, I think that's a great question, Ray. And I think one of the things I've started thinking about, fundamentally that's been a little bit of a shift in how I think about this is people are talking about burnout, people are talking about clinician well being. And I do think, especially if you think across industries and beyond healthcare and how this is playing out potentially in other places, I think it fundamentally comes down to, at the organizational level for people who are leading organizations, how do you create environments where people can thrive, where people can show up every day and do their best work and thrive and go home and live their life? Because I think that's what people want to do. So for me, maybe it's about burnout, maybe it's about well being. But I think if I was an organizational leader, I'd very much be thinking, how do I create a workplace and an environment where people can thrive. So that, that's, that's how my organization feels to people when they show up to do their job. Specifically, strategies that have worked, what we have seen work is workflow redesign. So redesigning processes in clinics and inpatient units, communication improvements between within teams and different provider groups, quality improvement initiatives that have worked to share the care among different members on teams have helped reduce burnout. Right. A primary care physician, I was saying 21.7 hours pre pandemic. That number is actually now up to 27.8 hours post pandemic of all the work a primary care physician would need to do. And a lot of my research has been in primary care. So how do you share the care across the team that's supporting you in clinic that can reduce your burnout as a primary care physician. That can also improve your satisfaction as a primary care clinician. If you can come into your appointment with a patient and really focus on those things you're uniquely qualified to do and that you train to do, that improves your satisfaction as a provider and that keeps you in practice longer. I was asked recently what one thing would I do to reduce burnout if I was, you know, in a clinical setting or in a healthcare setting. And one of the things I think is interesting to think about is can you re engineer the beginning and the end of the workday so that people can manage that home life interface, reduce the chaos, reduce the time pressure and feel a sense of control as they come into their day in the morning and exit their day in the afternoon. Do they have time to do that? I actually talked with a practice on a completely different unrelated study, but they were doing a really interesting thing in their design where they were and this is primary care again, but they were giving their primary care clinicians 30 minute, a 30 minute block that they could drop in their day, in their schedule where they needed it. And it was like a just get it done time. Like Maybe that was 30 minutes they needed to call patients back that day. Maybe it was 30 minutes they needed to meet with their advanced practice provider that they work with or their medical assistant. But they were giving people just 30 minute block. They could decide where it goes and it was helping them to just manage some of the things they needed to get done. So that's like another really, that's a concrete suggestion. I don't have data around this last one of re engineering the beginning of the day and the end of the day, but I think it helps with that work. Home interface.

Ray Spadoni (23:27)

Well, that's fascinating. That Makes me think about the fact that there's probably a generational shift that continues to take place where there was a time probably in work life where there was a very significant partition. I think physicians experienced this. You were home or you were at work and that was it. And then we moved to a phase where we were all about finding more balance. And you're suggesting now that this is really about helping to facilitate the transition by virtue of having a managed interface between the two former partitions. I mean, they still need to be somewhat partitioned, obviously, but this is more than just balance. This is actually helping folks as they move in and out of these different components to their lives.

Dr. Erin Sullivan (24:22)

Yeah, I mean, I think it's sort of like that 30 minutes to reduce the chaos, or if you've had a really chaotic day, to have that sort of transitional space, wrap up a few things and to feel like you're in control. Right. I mean, just to sort of ramp up or ramp down and those like work on those chaos and control levers that you might be feeling. So you can go home or enter into the day and be like, okay, I'm on top of the next six patients I'm going to see this morning. Because I had 30 minutes or I had 30 minutes to call back people who needed to hear from me about lab results from the last two days. I think it's giving people some level of control to manage what they might see as high workload load or chaos.

Ray Spadoni (25:06)

Let's maybe shift a bit from what can individual organizations or practices do to something that's a notch above that societal. Maybe from a policy perspective, are there changes that are being looked at or that are likely that could potentially impact this, this issue. Again, some of it's. Some of it may be how the professions are preparing and developing the next generation of folks. Some of it may be the payment mechanisms and the regulatory environment. Some of it may just be a broader policy like what is happening from a top down perspective that suggests that people are recognizing that this is a problem and that we ought to do something about it. Top down?

Dr. Erin Sullivan (25:54)

Oh, goodness gracious. That's a great question. I think. Okay, so from a top down perspective, I'm not going to give you a solution, but I'm going to explain to you more what I think is part of the problem that we haven't talked about, if that's okay. I think what really ramped up during COVID 19 and what continues to be significant in healthcare is the enormous financial pressure that are on these health systems and that are on organizations and it was intense in Covid. And I feel like when I talk to leaders, the intensity of the financial pressure has not let up. And I think we've seen increased consolidation of physician practices into major health systems. And that's also complex for frontline providers when they get absorbed into other systems and I think start to feel potentially a lack of autonomy and a lack of control in their, in their practice. But I think the external environment, the pressures in healthcare around payment and policy are huge. And I think some of what's happening in that space is creating some of the things internally in organizations that are leading to frontline worker burnout that are impacting people at the individual level. So that's one of the external environmental forces that I see as having a part in what's happening. I'm not a policy person, so I don't have a solution for you, but that's absolutely one of the things that I know we have a whole study that we did on burned out leaders and that's one of the things that keeps them up at night. They actually love coming to work. A lot of these healthcare leaders I talk to and working with the humans at their job and making people better and getting barriers out of people's way so they can deliver better care to patients. What's keeping them up at night and what they can't always solve is some of these bigger environmental pressures. So that's one of the top down factors. I think what gives me a little bit of hope from the external environment right now is correctly harnessed. How do we use AI in this space? I have a couple of studies in pilot or at the starting line phase around using AI. And I think what I'm hearing from a lot of the clinicians I do work with on a regular basis is how the incorporation of AI scribes into clinical practice is giving in particular some of my primary care physician colleagues some of the joy back in primary care. Because yeah, yeah, I think that's one of the causes for hope is can we use this new technology to give physicians more time with patients? Because right now, anecdotally what I'm hearing from my colleagues is instead of sitting behind a computer, which they have been complaining about almost since the advent of medical electronic medical records and talking to a patient, they can now walk into an exam room, put down their phone that has their AI scribe technology on it, hit play and have a conversation with a patient for 30 minutes. And that's actually what they went to medical school to do, is to have a conversation with A patient to diagnose and treat what brought them in that day. And for primary care in particular, to have a conversation that's going to build a relationship with a patient over time so they can care for them. And so I think that's one of the really exciting things. And then not only is that returning some of the satisfaction and joy to physicians, but that AI scribe is drafting the note for the physician. So they are not spending as much time after hours working on those notes. They're editing the notes. The notes need to be revised and edited because they're not perfect. AI is not perfect, but it's saving them a lot of time in that medical record and in doing a task that was historically taking a lot of pajama time, which is after 5 and after 5pm and before 9am Interesting.

Ray Spadoni (30:30)

Some interesting points, Aaron. Just in terms of the consolidation, I've been working with a number of organizations that are in various stages of evaluation or implementation of this. And generally speaking, it's financially driven. It's how do we reduce unit cost? And there are market factors and there are other strategic reasons. But generally speaking, it's about the economics and it's about trying to lower cost structure. And this means streamlining, this means centralizing functionality. It means, you know, homogenizing workflows and so forth. The trick is, how do you preserve and enhance clinical autonomy and decision making? And that has, you know, that prove that has proven to be very difficult on the AI front. I mean, I think I had an opportunity to do a podcast on AI. It's the Wild West. We're at the very beginning. There's a lot of upside. There are some concerns and some potential downside. So we have to see how this play plays out, and we have to make sure we manage it well and contend with the ethical considerations and so forth. I'm fascinated by the idea that AI can allow for, as you described, physicians to do the kind of things they would rather be doing and let AI and, you know, technology handle all the rest. I hope not to be pessimistic, but I hope it doesn't become, in some settings, a way of enhancing productivity so that more patients can be in the throughput and we can lower our cost of goods sold. And we don't need as many physicians because we've got, you know, we've got the, you know, the robots that'll handle this. And it's like, you know, I mean, I guess any technology, any solution can be, you know, used for good or it can be, you know, used in the other direction.

Dr. Erin Sullivan (32:34)

Yep. No, 100% agree. And for what I've heard about AI scribes being hugely helpful, I've had equally as many conversations, Ray, about the mistakes and hallucinations AI is having. Some of the ethical concerns we have about AI medicine and also, you know, in particular clinicians saying, I hope that the people upstairs don't decide this is a way to get me to see five more patients a day. Right. This isn't used for productivity. And I think, you know, I was on a panel not long ago where I said, one of the things I worry about with AI and use of AI in healthcare is taking more humanness out of the system. Healthcare has been a very human industry, human facing industry, caring for others and taking those humans out of the system. I, I think there's something that we would lose that we are not even sure what it is until it's gone. Right? It's almost like oxygen. You don't know it's gone until it's not in a room anymore. And I worry about taking the humans out of the system. And I think, you know, thinking about humans, one of the other things we've started to see around data for some of the interventions with burnout is peer coaching interventions and interventions that are connecting people back to each other. Post Covid has been helpful. And so thinking about that and thinking about the power of technology to remove humans is food for thought. How do we keep the humans doing those important jobs and the jobs where we need them and how do we use technology to the benefit of humans so they can do their jobs even better?

Ray Spadoni (34:23)

Hear, hear. I mean, you mentioned earlier, meaning and purpose and you know, connection and community as drivers of sense of meaning and purpose is I think a pretty well documented and you know, as, as workers, ourselves in various environments, the more disconnected we get, the harder it is to feel as though the work we're doing is contributing and valuable. So, yeah, so I mean, AI, ultimately we'll find out it's either part of the solution or it's just the next big problem, you know, or, or maybe some elements of both. But we'll have to, we'll have to see. Aaron, let's talk a little bit about your work and what you're doing and what's on the horizon for you in terms of research. You know, I guess thinking about the work you're doing, what makes you more concerned about burnout and what helps you to feel more optimistic.

Dr. Erin Sullivan (35:25)

That's a great question. So I think in the last two months AI has done both, right? And I just talked about AI, but I think AI makes me concerned for all the reasons we just talked about. And it makes me optimistic because I'm seeing clinicians saying, oh my gosh, I can sit and talk to a patient. And that's what I went to med school for. Right. And I think that helps us keep physicians in practice, specifically because that's why they went to med school. They went to med school to care for people. They didn't go to med school to do excessive documentation and sit behind computer screens and work 27.8 hours, which you can't do in any given day. Right. That's not what they went to school to do. So I think that's a fascinating space to keep watching. I think thinking about, we know burnout's a problem. We have plenty of data. We have so much data about what a problem burnout is in this industry. What we have less data on are solutions that scale. And I think that's exciting to think about and explore and identify more solutions that more organizations and systems can adopt. I think that's where the research agenda for this problem needs to go. So I think a lot about that. I also continue to think about this leader burnout issue and what does it mean? Because generally, specifically in rural America, which is where I've done some of the rural leader burnout work, as I call it, if you lose a hospital leader, your organization is more likely to fail. So it's really important to retain leaders in rural America in critical access hospitals. And so how do we do that? Because it's directly tied to the success of the hospital and we know that from the data. So I think that's interesting to think about moving forward. And I also think more broadly about some of the pieces of integrating healthcare and other sectors at the community level to care for populations is interesting to the continuing question of collaboration and caring at the local level for communities. And how do you do that and how do you train leaders to do that? Is something I'm sort of starting to think about doing some work with a few organizations and so stay tuned on that.

Ray Spadoni (37:47)

Great. Well, the leader turnover, I mean that's, I've got that on my list of, of potential future podcast topics to discuss. But I've certainly seen in the clients where I'm working is it seems as though there's a higher degree of churn is that, you know, folks are coming into and out of high level jobs much more quickly than in the past for a variety of reasons. And it's, you know, it's For a variety of reasons. But it's, you know, for the organizations, we can talk about the impact on people, but certainly from the organizational perspective, it's expensive, it's disruptive, and it hampers forward motion. It prevents longer term plans to take root and become reality when you have to pause to bring in new leaders. And that is probably a good topic for a future discussion.

Dr. Erin Sullivan (38:45)

Yeah, I mean, the, the seed for why I even went down that path was a colleague of mine who was working in Colorado at the time saw two thirds turnover in rural leaders within the year or two at the end of the pandemic. So not in the thick of it. It's almost like a hypothesis we had is, did people hang on until Covid was under control and then they were burned out and they left. But they saw really high numbers of leader turnover post pandemic. And we saw a number of institutions here in Boston actually turnover in a similar timeframe. And so that got me interested in thinking about leader turnover also, because I had read all these comments from the healthcare workforce across the country, like over 50,000 comments, open ended. Is there anything else you'd like to tell us? And some people want to tell you an entire book of things. But the amount of anger and vitriol that healthcare workers had for the administrators, for the leaders of the organization also made me think about, I wonder what's happening with this group, because would you want to be on the receiving end of this and be staying in this job? So that led us down a path to look at the leader turnover and the burnout. And I will say, I think our leader, our first phase of our rural leader burnout study showed that the leaders were actually more burned out than physicians and more burned out than the comparable leader group that we could find in health care, which would be chiefs and chairs of divisions and departments. And they also had a higher intent to leave in the next two years than physicians. Their ability to think about where else they were going to go or what else they were going to do, which we call intent to leave. Like, what's the, what's the chance you're going to leave your organization the next two years? Was very high.

Ray Spadoni (40:44)

Well, that might just be a good, a good place to end the conversation, Aaron, because a fair bit of what I cover on the podcast and in my own consulting and coaching practice relates to emerging leaders, the next generation of leaders. I know that's a big focus for you and as a, as a professor and a graduate program, but, you know, I, I have a number of topics lined up specifically on that. And I I may circle back. I want to have another conversation with you if you'd be willing. But I think this is given the target audience here and given the work that I do, this is a sweet spot topic for sure, 100%.

Dr. Erin Sullivan (41:26)

And thank you for having me and thank you for the conversation. And I'm happy to talk about leaders in healthcare anytime.

Ray Spadoni (41:32)

Awesome. So if folks would love to learn a little bit more about you and your work, how best to find you.

Dr. Erin Sullivan (41:40)

The best place to find me is on LinkedIn and my profile name is very specific because there's more than one Erin Sullivan in the world. It's erin E. Sullivan, PhD on LinkedIn.

Ray Spadoni (41:54)

Aaron E. Sullivan, PhD is your LinkedIn. That's the best place to find you. Fantastic. Again, thanks so much, Aaron.

Dr. Erin Sullivan (42:03)

You're welcome. Thanks Ray.

Ray Spadoni (42:05)

Thanks for listening. Leaving a positive review and letting others know about this podcast will help a great deal. My mission is to help empower organizations that matter by supporting those who lead them. I offer coaching, mentoring and consulting services. You can learn more about me@racetoni.com.