Dr. Jill Jin: Clinician Wellbeing - AMA Perspective

In this episode, I welcome Dr. Jill Jin to discuss clinician wellbeing from the perspective of the American Medical Association (AMA). In our conversation, she reinforces that everyone in the care team needs to be working to the highest level of their license, unnecessary work should be eliminated, and necessary work is shared across the team to improve the culture in each practice. Dr. Jin has worked with the AMA in combating physician burnout, particularly in developing the comprehensive collection of STEPS Forward® resources, which we will  discuss in this episode. 

Dr. Jin is a practicing internist and Clinical Assistant Professor of Medicine at the Northwestern University Feinberg School of Medicine. She is a Senior Physician Advisor for Professional Satisfaction & Practice Sustainability at the AMA, and an associate editor for JAMA. 

For more information, please visit stepsforward.org. All of the resources including playbooks, toolkits, webinars, podcasts, and mentoring services are open-access and provided FREE of charge.

Here are links to resources mentioned in the discussion: 

StepsForward Program: stepsforward.org

Saving Time Playbook: https://www.ama-assn.org/system/files/ama-steps-forward-saving-time-playbook.pdf 

Taming the EHR Playbook: https://www.ama-assn.org/system/files/steps-forward-taming-ehr-playbook.pdf

Advanced Team-Based Care Podcast (Heartland Health): https://www.ama-assn.org/delivering-care/physician-patient-relationship/improve-patient-care-collaborative-care-team-models

Advanced Team-Based Care Podcast (TexomaCare): https://www.ama-assn.org/practice-management/scope-practice/one-practice-s-success-implementing-advanced-team-based-care

Check out the book: "Healing and Cancer: A Guide to Whole Person Care"
Visit https://www.healingandcancerbook.com/ for more information.

Connect:
Twitter: @DrWayneJonas
Facebook: Dr. Wayne Jonas
Instagram: @drwaynejonas
LinkedIn: Dr. Wayne Jonas
LinkedIn: Alyssa McManamon

Visit Healing Works Foundation www.healingworksfoundation.org for more information.

Dr. Wayne Jonas is a board-certified physician and Dr. Alyssa McManamon is a triple-board certified hematologist/oncologist. The opinions expressed on this show are those of the hosts and guests and do not necessarily represent the views and opinions of their places of employment, the Department of Veterans Affairs, or the United States government. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Wayne Jonas and Dr. Alyssa McManamon have no relevant financial disclosures.

Transcript

Please note that this transcript is produced electronically and may not be an accurate representation of what was said. It may not be reproduced, edited, altered or modified in any way without prior written permission. Any use of quotes or excerpts from this interview requires explicit permission from Healing Works Foundation. Please contact us at healing@healingworksfoundation.org if you would like to use any part of this transcript for quotes or other purposes.

“How Healing Works with Dr. Wayne Jonas”

Interview with Dr. Jill Jin - Clinician Wellbeing - AMA Perspective

Dr. Wayne Jonas (00:05):

Hello, everyone. Welcome to our next installment of How Healing Works. It's a great pleasure, and I would like to introduce my guest, Dr. Jill Jin, to the program. Dr. Jin is a practicing internist, clinical assistant professor of medicine at the Northwestern University Feinberg School of Medicine. She's also a senior physician advisor for the Professional Satisfaction and Practice Sustainability at the American Medical Association and an associate editor at the Journal of the American Medical Association. Dr. Jin has worked with the AMA in combating physician burnout and wellbeing, something that is important I think to many of our listeners, whether they be physicians, non physicians or even patients. She has been particularly instrumental in developing a comprehensive collection of tools and resources to help this called the STEPS Forward Program and Resources. And we'll discuss this in the interview today. I'm happy that we have her with us today to discuss clinician wellbeing and especially from the perspective and input of the AMA. So welcome, Dr. Jin.

Dr. Jill Jin (01:21):

Thank you, Dr. Jonas. It's an honor to be here.

Dr. Wayne Jonas (01:24):

So I'd like to start off all the interviews just to get to know our person that we have talking and let listeners know a little bit about her. And you have an unusual journey. I mean the journey first of all to become a physician, then to get into health education and to become part of what the AMA is doing and then to get into the area of clinician wellbeing and burnout in those areas. Can you tell us a little bit about your story? What led you to get an interest to move into that area, to do what you're doing now?

Dr. Jill Jin (02:02):

Yeah, of course. So my journey to become a physician, I would say is pretty typical, nothing too exciting there. I feel like from a young age, that's something I always wanted to do. Both my parents were trained as physicians and I just loved everything that I knew about that and learned from them. So that was kind of always my default of what I wanted to do, and I continued to enjoy every step of the way of the process. I went into internal medicine and into primary care specifically because I loved the patient connection component of that, and I still do. And that is still my favorite part of my job. In terms of how I got into the field of physician burnout and wellbeing, that I do agree with you is a little bit atypical.
(02:54)
Probably most physicians who are at the forefront of this field entered it because they had their own personal burnout crisis of sorts. And that kind of caused them to step back, reevaluate their practice and reemerge with this passion and leading change in this field. I, on the other hand, entered it early in my practice, so within my first few years of starting practice through my writing and editing experience. So that's how I was brought into this field. As you mentioned, I do some editing work. I am an associate editor at JAMA and I did a editorial fellowship there before I started practice and then stayed on as associate editor. And through that work I was connected with the AMA folks who were creating this library of resources at the time. So this was back in 2015, physician burnout was still kind of new to people and there were very few resources.
(04:00)
There was a sparse library out there of resources on how to combat this problem. So essentially I met with Dr. Marie Brown and Dr. Christine Sinsky, who are both at the AMA, leading this work and started with my writing and editing experience, helping them develop all the STEPS Forward resources that we now have online. We now have, I believe, 1.8 million users. So we've grown significantly since those days. And through my work in research and interviewing physicians and leaders from all over the country, I naturally became very passionate about the work and realized just how essential it is now in this day and age. And I have also been able to apply much of what I've learned to my own practice and to my own professional work life throughout the years. Now I've been in practice almost 10 years, and I am happy to say I've been pretty successful at preventing my own burnout through some of those strategies.
(05:08)
So I think that it makes me more motivated to continue this work and sharing it and spreading it. And I see other physicians, some newly out of training, they've been in practice, they spent over 10 years in training, and then they've been in practice one to three years, and they are already looking for an exit strategy because they have reached that point of burnout. And I just think it doesn't have to be this way and it shouldn't be this way. So that's what motivates me to keep doing this, and it's kind of how my personal journey has led me to this point.

Dr. Wayne Jonas (05:48):

That's great. I think key thing that you said there in my mind is preventing burnout is being proactive in designing both practice and the system that you work in and helping to influence that in a way that allows sustainability. That's the one of the words in your title, isn't it, is sustainability. It's sort of healing the healer. And I think it's fascinating, despite all the reports that have come out, and you started this even before the pandemic, but since the pandemic, it's been exacerbated and gotten worse. And the data that I've seen, and correct me if I'm wrong, is that for frontline physicians, we're talking about over 50% of them meet many of the criteria, if not the full criteria for burnout. That 20% of people in healthcare, not just physicians, have left during the pandemic because they just don't want to be there anymore. So there's getting to be a shortage now of clinicians, nurses, other health practitioners and providers on the team.
(06:59)
And the suicide rates are also not pretty. I mean, they are higher than in the average population. And certainly the mental health issues contribute to that both from the time issues, from the mental health issues, but also from the moral injury that goes on when you go into a profession to be a healer and you find out it's hard to do or you can't do it, and you see people suffer in that. So can you talk us through a little bit about what is this thing called burnout and how does it relate to wellbeing. Clinician wellbeing, is it just the flip side of burnout? Is it the positive part of it? Or tell us a little bit about this entity that you're trying to improve here.

Dr. Jill Jin (07:51):

Yeah, yeah, absolutely. So there are various definitions of burnout. The one that we use is the triad of emotional exhaustion, depersonalization, and a low sense of personal accomplishment. But I think when I talk to people, I just tell them, if you feel like you're burnt out, you're probably burnt out. It's just you know what that is, what the sense of professional burnout is. And you are absolutely right on the statistics, it's a huge problem. It's a epidemic and it's growing and it has grown since the COVID pandemic. And in terms of wellbeing, it certainly is in one sense the flip side of burnout, but to me it is also more of a culture. So when we're talking about from a practice level or an organization level, we sometimes use the term culture of wellness. And that to me is more the goal state that we're hoping to achieve.
(08:54)
So it's not just personal wellness, it's not self-care and what you feel like when you go to a day at the spa. And that kind of wellness is great, but that's not really the ultimate goal. Our goal is to create organizations that have leaders who are focused on wellbeing as a core objective and priority of theirs. And through that create a culture of wellness in the organization that's centered around clear and transparent communication, trust between their providers and themselves, and support for the individual clinician. And then of course, what we'll talk about a little bit more, changes in workflows and the EHR and all those kind of things that can be either implemented or de-implemented to make the daily lives of clinicians easier and to save them time. At the end of the day, that's what we're all looking for is time.

Dr. Wayne Jonas (10:01):

Is time, right. So you've already dipped into what my next question was going to be, which is what's driving this, and not just what's driving the burnout, but what drives wellbeing. And you talked about culture and culture is a sort of a slippery thing, isn't it? It's a lot of different things, systems, leadership, team care. In many ways it's a selection of people having a shared set of values and mindsets that they agree that something is high priority and they're going to pay attention to it in those areas. Trust, fascinating that that comes up. I would assume that good teams have to have trust and have to be, that the operations have to somehow be based on that. But even trust is a little hard to get your fingers around. Isn't it? I mean, what's driving both the burnout start and what drives wellbeing? What are the core factors that need to be looked at and changed in the system that leaders and clinicians need to pay attention to?

Dr. Jill Jin (11:07):

Yes, you're absolutely right. These are tricky things to get the root at. So I think communication is a key part of it is frequent, clear and transparent communication. And then beyond that, the sense that when you do communicate something, if you're a frontline physician and you communicate some, that you feel like the leaders are communicating with you, but then when you give them some feedback or tell them something that can and should be changed, that they're actually acting upon that and that there's actually tangible change happening as a result of that. So I think that kind of cycle of feedback and action and communication is essential. And of course, it's all centered on trust. You have to trust your leaders, and the leaders have to trust their clinicians. And it's not easy. I mean, in healthcare and in other organizations, leadership is, there's a lot to that in what makes a good leader, but that is one thing that is at the core of this of what's driving burnout versus wellbeing.

Dr. Wayne Jonas (12:20):

Yeah. Well, let's talk a little bit about this. I mean, you've laid out in the STEPS Forward program that the AMA has and the tools and resources, a lot of different things in those areas. We've actually talked about the first one on what is wellbeing and burnout and core components of that. I know there's an introductory guide to that. Let's drill down to some of the others. I mean technology, the organizational culture, the relationship issues, the team and communication and practice flow. Can you talk about some of these that are the most important and the most prominent that if listeners want to say, "Hey, I need to address and create a culture of wellbeing where I practice, what are some of the key things I need to address?"

Dr. Jill Jin (13:10):

Yes. So I would say that our three key messages to organizations on tangible, practical things they can do is, number one, is stop the unnecessary work. So this is centered on de-implementing things that physicians have to do in their day-to-day lives that are not really necessary. So they're administrative burdens. They're things that we have to do due to perceived regulatory compliance that may or may not be true. So any of the filling out the forms, the EHR clicks, all those that, or even some of those mandatory trainings that we have to do every year, how much of that is really necessary? So that's one bucket, stopping the unnecessary work. The second is sharing the necessary work. So of course at the end of the day, there's lots of value adding needed work that needs to be done. But the idea here is that the whole healthcare team, both clinical and nonclinical, needs to be involved in that effort and the physician cannot do it alone.
(14:24)
So this is team-based care essentially where all members of the team, which includes nurses, medical assistants, respiratory therapists, physical therapists, pharmacists, social workers, clerical staff, the front desk staff, all of these people, and of course speaking from my primary care perspective, but all of these people are an essential part of the team and need to be, and should be working at the top of their license to the highest level of their training to take part in the patient care for the sake of efficiency and for the sake of reducing burnout.
(15:05)
So that's kind of the second bucket, share the necessary value adding work. And then the third bucket, which we talked, which we touched on already a little bit, is supporting the individual clinician. And this from an organizational perspective, and that is not just referring to giving them free food or a yoga classes and not that kind of self-care support, but the support as in giving them autonomy, flexibility over their own schedules, providing them with opportunities for CME classes for leadership training, for teaching, for research, for camaraderie. So having events either during or outside of work, providing them opportunities for professional growth, peer support or peer mentoring is another component of that. So all of that, the organizational structure to give individual physicians the personal support they need is another thing that organizations should be striving for.

Dr. Wayne Jonas (16:20):

Yeah, that's fantastic. I love that. Do less.

Dr. Jill Jin (16:25):

Yes, do less.

Dr. Wayne Jonas (16:26):

Especially those things that aren't actually helping people to get better or cultivating what you've been trained to do in terms of the relationships with patients and in terms of helping to make the complex decisions. And this doesn't, a lot of these principles have been embedded or important in primary care, but they're not isolated by any means to primary care. I mean, this goes well beyond that. So do less of the administrative and of the practices that just keep getting added on all the time and other things aren't taken away. Focus on and spread the essential components, spread it to your teams, I love that. Also, I know we train some of our medical assistants in my practice in some basic skills of health coaching, just how to work with patients, how to help them move along through smart goals and be successful at it and that kind of thing.
(17:24)
From whatever came out of our visit, we do something called the hope note, which gets at behavioral components with physicians, with patients that ask them what matters to them in their life and what do they want, and then helping them move forward, establish in those areas. But the teams are absolutely essential to do that. And the medical assistants love that. They say, "oh, now I can actually interact on something that is helping the entire patient get better in those areas and support the individual. Boy, that's fantastic." And it isn't just more yoga, please. It's actually real realtime support with time and time is often one of the assistance in the things that have to be done. Electronic medical records are not going away. And in fact, in my practice, we just implemented a brand new comprehensive electronic medical record.
(18:27)
And if I may tell a brief story quickly, I was, what's the word? I was afraid of doing it, again, I mean, I was used to the old one. I didn't like it particularly very much, but a brand new one that came in and in my first patient where I had to use it, I came in and there was actually a super user clinician who said, I know what physicians need for this. And he came in on those first few patients that I had and he helped me set the whole thing up and it was like, "wow, this is easy. I can actually do this." That kind of support is what you're talking about, I think in those areas-

Dr. Jill Jin (19:07):

Actual practical support.

Dr. Wayne Jonas (19:11):

So that's great. Take the handcuffs off sometimes I call it. Okay? So that people can do that. That's great. Can you talk a little bit about technology? I mean, in the reports that come out on this and the surveys that come out on this, the administrative and management of the technology, the EHR, which originally wasn't built to help with the doctor patient relationship, it was built for billing, right? I mean, can you talk about some of the innovations and the ways in which technology can be made more of an assist and really make a joy to use? Are there any practices where it's a joy to use in those areas that you've come across?

Dr. Jill Jin (19:54):

Well, yeah, the EHR is a tricky one because of course in this day and age, no one wants to go back to paper charts. But at the same time, I think it's a key reason why burnout has just steadily increased over the past few decades is because the demands and the work that has to be done via the EHR has grown exponentially, the clicks, the documentation, all those things. So we do, again, we have a playbook in AMA STEPS Foward playbook on how to tame the EHR. It's called Taming the EHR, but the principles are the same. It's remove, stop the unnecessary work, do less, get rid of those unnecessary clicks. If you have a hard stop, evaluate why you have that hard stop. And sometimes more often than not, it's not really necessary. And then the second part of it, share the work, team documentation, that's a big one is physicians right now, most of them are fully doing our own documentation, and it doesn't have to be that way.
(20:54)
There's documentation assistance that can be either clinical, so the medical assistants or nonclinical scribes, they can be even patients themselves. Some newer EHR functionalities allow the patient to start typing in their own HPI. Of course there's new things coming out with AI and things like that [inaudible 00:21:13] I'm not too familiar with. But those are all solutions down the horizon. And I think that that's going to be a big part of it is offloading the documentation off of the physicians, and of course getting more personally proficient with the technology is also helpful as well. As you just mentioned, meeting with those super users and getting at the elbow support, taking 30 minutes out of your schedule every month or so to clean up your note templates, build your smart sets and your preference lists and all the stuff that feels like we're wasting time. So doctors hate to do it because it's just we don't have the time, but saves time in the long run. So little tricks like that can help as well.

Dr. Wayne Jonas (21:56):

Especially the things that are routine you do every day. If those can be automated, made simpler, et cetera, then that takes off a burden throughout the entire interaction and the flow in those areas. I don't think AI is there yet to do this very well, but it's getting there. It'd be interesting to see. So keep, stay tuned on this area. You talked about a lot about the team care and the clinical flow. Are there some good examples, and you don't have to name any specific practices, but what are some of the top examples of redesigning your practice in a way that allows for this kind of a team care and flow and communication to occur more automatically and in a way that facilitates what matters?

Dr. Jill Jin (22:48):

Yes, absolutely. So yeah, outside of the EHR, I would say that's the next big thing is the team-based patient care workflows, so that, we call that advanced team-based care. And that is where the entire team, as I was kind of mentioning before, is just fully engaged and very active and fully participatory in all parts of the patient visit. So that kind of starts with the pre-visit planning, pre-visit laboratory testing, the advanced rooming and discharge where it's not just getting vitals, but getting, setting an agenda, doing medication reconciliation, pending orders, sending in prescription or pending prescriptions that are ready that need to be refilled. And even doing some patient education as you're saying. So kind of taking it up to the next level of rooming. Team documentation, staying in the room with the patient while the physician is in there. So it's not a physician visit, but a team visit.
(23:51)
So the medical assistant is fully part of that care team as one of the clinicians taking care of the patient and going all the way through discharge and at the time of discharge, doing patient education, doing planning for the next visit. So making that next follow-up visit at the time of your current visit. And so that there's no gaps in between minimizing the chance of care gaps happening. So all that workflow is what we're aiming to spread to other practices around the country is because this advanced team-based care and yes, there are several practices that have kind of reached this ideal stage.
(24:37)
And we have a few podcasts about those practices. And it is, when you talk to these medical directors or these physicians who have fully embraced this, it's phenomenal. They're just like this is how it was meant to be. This is what I envisioned when I went into medicine and before they were only able to see X number of patients and that since then has increased by 50% because of this. They're more efficient because of that, even though they feel like they're actually getting more time to spend giving undivided attention to patients because they're focused and they're not doing this extraneous administrative work, they're actually more efficient at the end of the day and patients get more access. They're not having to send messages after hours. So it ends up being a win, win, win. And I think it is hard to kind of believe when you're not there that that can happen. But again, we've talked to practices where it happens.

Dr. Wayne Jonas (25:36):

Yeah. Yeah, this takes some practice improvement processes. I mean, you got to stick it in your practice. You got to apply the principles of this. And I know that in your resources, the STEPS Forward program where all these resources are, and I'm going to ask that we stream this along the bottom here so that people know where to go to get it. And it sounds like it's getting a lot of traction, which is fantastic, but you got to do the hard work to actually get it into the practice. So you got to kind of unfreeze stuff and reestablished, get the culture established, try it, refreeze it, get it sort of embedded in it. That in itself is a skill and an art and even a science on how to do that. And are there resources on your website within the STEPS program showing how that happens?

Dr. Jill Jin (26:25):

Yes. I mean, there are some kind of training guides that we have as downloadables that other practices have used because yes, there is a process where you have to train the team and tell them what to expect, and then it's iterative and it takes probably at least three to six months to get people just starting to get used to this idea and then years to optimize. But yes, we have resources on how to, a general approach, and then we also do one-on-one mentoring as well for practices. If they have specific questions about how do I do this for my patient population and my clinician population, we do offer that as well.

Dr. Wayne Jonas (27:04):

That's wonderful to hear. And so I think going and getting those resources, listening to the examples of how people have done it can really help encourage people to do that. I'm going to do one little plug for a CME program that our Healing Works Foundation worked with at Tufts, that is now free and available for putting in something we call the whole person care model or the HOPE note. And it's some of the tools were derived from the Veterans Administration, and then we ran a learning collaborative that was just published in the Annals of Family Medicine on this. And the tools are all available, the CME is free in that area, and the practices implementing this have found that it helps with behavioral change, very important area, in practice, helping develop relationships by setting some time to talk to the patients about what matters to them in life, and then embedding it in things like annual practice visits, team care, and that type of thing in those areas.
(28:09)
So I'll ask us to stream that link to that CME program also that's on that. It also then instructs specifically about practice improvement and how you do that in those areas. And I think the experience we've had with those practices is this has also helped improve clinician wellbeing. I mean, if you could get 50% more time in your day-to-day practice, that is huge. I mean, that is huge. That's worth investing some improvement [inaudible 00:28:44] to do so, and that's great.
(28:47)
Well, there is a summit that we're doing with AMA and with ACGME that's going to happen at the fall at Princeton. And it's going to be looking at really what are the system issues, what are the system changes that are needing for clinical wellbeing? And so thanks to the AMA for participating in that, working for that and others. And so want to ask our listeners to stay tuned for that. Hopefully that will enhance a lot of the information that you're doing. What's next for you and the effort? What would you like to see happen with this program and with clinical wellbeing in general? Where are you going with it? What do you want to end up with here?

Dr. Jill Jin (29:40):

Well, I mean it's, yeah, ultimately of course we want to keep physicians taking care of patients and we want to keep them from leaving the workforce, and we want to serve the patients in our communities to the best that we can. I think that the goal, it STEPS Forward, it's a work in progress. I mean, I think we're continuously developing new resources, new playbooks and toolkits and webinars and podcasts and welcome any ideas from anyone, from listeners about new content they need. And we are happy to explore that because we do want to meet the clinicians and the leaders where they are at, and we want to provide them with what they need. I think that, I guess, yeah, it all goes back to this culture. I think the culture of healthcare has, it's just been different than other professional fields for a long time. And I would just like to see that shift to one where wellbeing is supported and physicians are supported and patients are happy and feel well taken care of.

Dr. Wayne Jonas (31:00):

Yeah, that's wonderful. Thank you. The culture is the wider culture, not just the clinician and the clinical system culture too. So there need to be some changes in that. And hopefully we'll talk about some of those things at the summit. We won't have time and won't go into that now, but that includes new policies that need to take the handcuffs off and facilitate this kind of change. Payers need to start paying for things that make this happen, and patients are keys into this, right? Patients have to realize that they're an integral part of making sure that the folks that are helping them to get the proper treatment and to heal themselves have engaged in those kind of wellbeing practices too.
(31:45)
And so shout out to all patients who are proactive in that area, and I know you have, for example, patient engagement councils as an example to help bring that into practice in those areas. Thank you very much. I really appreciate this discussion. I really appreciate what you're doing. It's a tremendous amount of, number of resources that are really helpful, and I look forward to continuing to have the discussion about how to move this culture of health forward for everybody involved in healthcare and in the nation.

Dr. Jill Jin (32:19):

Thank you so much. It was a pleasure to speak with you.

Dr. Wayne Jonas (32:22):

Okay, take care.

Dr. Jill Jin (32:23):

Take care.