Tending the Flame: Supporting clinician wellbeing

Guest Background
Evangeline C. Andarsio, MD is a Clinical Professor of Medical Education and Obstetrics & Gynecology at Wright State University Boonshoft School of Medicine (WSU-BSOM). Dr. Andarsio is the Director of the Remen Institute for the Study of Health and Illness (RISHI) at Pure Healthcare and Director of the National Healer’s Art Program and Tending the Flame Program.

Summary
Dr. Vange Endarsio,  discusses the concept of clinical wellbeing and the importance of addressing burnout in healthcare professionals. She shares her personal journey of becoming a doctor and how she transitioned from practicing medicine to focusing on burnout and wellbeing. Dr. Endarsio explains the Tending the Flame workshop, which is designed to help clinicians restore their passion for their profession and find a sense of community and purpose. She emphasizes the need for self-care and the integration of meaning, medicine, and resiliency in healthcare. The workshop teaches mindful practices, rituals, and storytelling as tools for maintaining meaning and promoting self-care.

Takeaways

• Clinical wellbeing is essential for healthcare professionals to provide quality care and prevent burnout.
• The Tending the Flame workshop helps clinicians restore their passion for their profession and find a sense of community and purpose.
• Self-care, including mindful practices, rituals, and storytelling, is crucial for maintaining meaning and promoting resilience in healthcare.
• Addressing burnout requires systemic changes in the healthcare system and social support from peers.

Chapters
00:00 Introduction and Background
04:08 The Importance of Meaning and Relationships in Medicine
09:14 Addressing Burnout: Systemic Changes and Social Support
14:02 The Three S's: System Issues, Social Support, and Simple Techniques
28:00 Professional Identity Formation Continues After Medical School
30:00 Conclusion and Appreciation

Resources

• RISHI’s Tending the Flame Retreat Workshop
• ASCO/SIO Guidelines Summary
• USSG's report on Health Worker Burnout

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 & Dr. Alyssa McManamon”

Tending the Flame: supporting clinician wellbeing

Wayne Jonas, MD (00:01.843)

Hello and welcome to How Healing Works. I am Dr. Wayne Jonas. Today I have the great pleasure to discuss the topic of clinical wellbeing with my guest, Dr. Vange Andarsio. Dr. Andarsio is a colleague of a friend of mine and who is also a co-author of our recent book that we've come out with, Dr. Alyssa McManamon. And she works closely with an organization called

Wayne Jonas, MD (00:30.623)

the Reman Institute for the Study of Health and Illness, teaching a course called Tending the Flame, which we're gonna talk about, designed for helping clinicians and team members reset themselves if they find themselves in burnout or tending to burnout. Tending the Flame is a two and a half day workshop for all members of the care team who are seeking to restore their passion for the profession and are looking for a sense of community and purpose.

Wayne Jonas, MD (01:00.159)

Dr. Andarsio has also been a major leader in medicine and medical education for many, many years. I urge you to look in the show notes here about all that she has done to bring the concept of wellbeing and addressing burnout out to the medical profession and others, way before it was popular to talk about. A long time before that. And now we're coming back around to see how important that is.

Wayne Jonas, MD (01:28.991)

Dr. Andarsio, thank you for joining me. I really appreciate your time.

Evangeline Andarsio, MD (01:29.526)

Thank you, Wayne, for inviting me to share about our programs here at RISHI. 

Wayne Jonas, MD (01:41.311)

So I like to start by just having my listeners get to know a little bit about you and how you got to where you are. The personal stories are often so interesting and so important. How did you end up being a doctor? And then once you became a doctor, how come you're not just, you know, in the ICU somewhere doing something, but you're actually focused on this concept of burnout and wellbeing and are now actually helping people address those issues. Tell me how you got where you're at now.

Evangeline Andarsio, MD (02:28.494)

Well, I guess it all began when my parents came from Cuba in 1957. My father was at the University of Havana Medical School and actually obtained a residency position in Columbus, Ohio at Mount Carmel Hospital. So coming from a background of immigrants, we always strive for excellence in whatever we tried to do. So I would follow my father in rounds as he was practicing then full-time in Springfield, Ohio.

And I just was so enthralled by the atmosphere of the hospital, all the hustle and bustle, and the interactions that he had with patients. And back in those days, I actually would go into the room with him and make rounds. Then I also had an experience where I fell off a slide at a very young age.

And my mother just picked me up, swooped me in her arms, and carried me home and tended to my wounds. And I experienced that deep sense of compassionate care. And those two combinations led me to medicine. So in my journey of becoming a physician, I initially went into family medicine.

And then I decided to do a second residency in OB-GYN because I fell in love with delivery of patients and their babies and that whole journey of assisting women with their healthcare needs.

Wayne Jonas, MD (04:08.703)

Yeah, wonderful. So you got the love and the caring component of it and the professional component of it simultaneously in your families.

Evangeline Andarsio, MD (04:19.546)

Yes. And then 10 years into my practice of obstetrics and gynecology, I felt a change happening within me and where I started becoming very cynical. There was a lot of administrative burdens, things in running a practice, and I said to myself, whoa, that's not who I am. That is not really what I intended medicine to be for me and for my patients.

And I really came to learn that I didn't quite know how to word it, but it was some symptoms of near burnout. So I considered making a big change in my practice and actually even considered doing something different. And I remember one of my colleagues saying, Vange, you can't leave medicine. And she recommended that I read Kitchen Table Wisdom, by Rachel Naomi Remen, MD. And she said, you know, Rachel thinks like you do, being of compassionate presence, listening and healing, not always curing. And so I read the book and I said, boy, she does think like I do. She's framing medicine in the way that I've always loved medicine and had joy in medicine.

So I remember reading in the book that there were workshops for physicians and I had no idea how I would learn about going to one of these workshops. And at that time I had a GYN clinic in the homeless shelter and I remember sitting down and writing a prescription and there was a journal from Harvard called Hippocrates and on the cover it said physicians dealing with grief and loss.

I said, gee, that sounds like some of Dr. Reman's work. Well, I go to the article and it's all about her work and her address and phone number of where to reach her institute. So if that wasn't just an incredible synchronicity and I went ahead and I contacted them and they said, oh, Dr. Andarsio, you've got to apply well in advance for these workshops. Well, I did apply and fortunately I was accepted.

Evangeline Andarsio, MD (06:39.338)

And it was a life-changing experience in the sense of I reconnected to the calling of my work, the passion and the joy of my work. And I left there thinking, how can I bring this back to my colleagues in Dayton, Ohio, because the workshops back then were in California. And so from there began my journey of really promoting my care of my patients and self care, so I could care for my patients, and led me to a lot of experiences that I'll share with you throughout our interview.

Wayne Jonas, MD (07:20.683)

That's fantastic. Well, you were, you were, Dr. Remen was a pioneer in this. I remember reading some of her books also when I was early on in my career. And then remembering them later on, when I, you know, began to wonder myself, okay, where's the healing in this process? That's not what I, what I, you know, I thought I had it and then, and here it is. So she really was a pioneer, but you went beyond that. You actually not only took the course, but you took over the course. You took over her institute, right? And you're the director of RISHI, and have been leading these kinds of workshops. And it's fascinating that, you know, back then we thought, oh, well, you know, there isn't, this is only happening to a few people. But now we know that actually it's the majority of people even in general who also took one of her early courses and mentions that in his health worker burnout report.

Wayne Jonas, MD (08:19.475)

Vivek Murthy that just recently came out highlights the fact that the majority, more than 50 percent of clinicians now are suffering from the symptoms of burnout. And our system as a whole is set up in a way that actually helps drive that, that the way it's designed of volume-based, pill and procedure type of process rather than the relationships

Wayne Jonas, MD (08:47.347)

which she was emphasizing as the core. And I don't know how many folks, and you have had more than me, because you've listened to them and you've talked and you've trained with them, have said to me towards the end of their career, boy, what was the most important thing in your practice? And it wasn't how many prescriptions or procedures. It was the relationships, the deep relationships that you mentioned. So talk to us a little bit about that. We recently held a summit on

Wayne Jonas, MD (09:14.955)

clinical wellbeing at Princeton, along with the American Medical Association. And I interviewed on this podcast, Jill Jinn from AMA, who is one of the leaders in their Steps Forward program. And it sounds like this kind of effort should be part of the AMA Steps Forward program, you know, to help address burnout and clinical well-being in those areas. Can you talk a little bit about what you've done to bring this to clinicians, to their teams, and what actually is the Tending the Flame workshop and does it work? And who should be thinking about it and attending it? 

Evangeline Andarsio, MD (10:08.234)

Well, Tending the Flame is a two and a half day retreat workshop that we offer for clinicians and residents. And the premise is it's trusting that as clinicians,

we were drawn to medicine, nursing, or other healthcare professions because we desire to alleviate suffering in others. And so there's a deep meaning and purpose in what we do in healthcare. And some would call it a calling. And so unfortunately, the healthcare system and all its challenges can derail us from our calling

from our deep meaning and purpose in medicine and other healthcare professions. So what Tending the Flame does through utilizing the discovery model of learning, which is a self-discovery process, is that it creates a safe space amongst supportive community for reflection to really tend that flame, to reignite it in meaning and purpose in what we do.

So we connect meaning, medicine, and resiliency and service, all those aspects with resiliency. It's very, very important. So connecting meaning, medicine, and service with resiliency is so key. And by doing this, we allow a space for physicians, nurses, and other clinicians in the healthcare team

to really reflect on the deep meaning of their work and that actually can assist them in the care of alleviating burnout or prevention of burnout. What I say is, can we really prevent it? In many ways, we're trying to mitigate it by doing these things, because ultimately it is the healthcare system, this workforce environment with increased workloads, 

trying to deal with staffing shortages, the issues that we have with workplace inefficiency. All these things, these layer administrative burdens, regulatory burdens, all contribute to this aspect of, to the syndrome of burnout. And physicians could have, and other healthcare professionals could just have one symptom of burnout, or all three. And so,

Evangeline Andarsio, MD (12:30.966)

This is important for us to care for ourselves so we can care for others. That's a key component to this. This workshop deals with three modules. Module one is a workshop on the connection of meaning, medicine, and resiliency. Module two is teaching and allowing people to experience finding meaning groups.

where narrative and storytelling is a source of healing for healthcare professionals. And how do you run those groups? And then the third module is on service and commitment. How this is a way of life. We have entered into a profession of service. So how do we balance that with our personal life and find ways in which our work is not a burden, but it actually is a source of vitality for us. 

And so we integrate our work in life and understanding that deep down, it is a profession of service. So those are some of the things that we do with Tending to Flame. If you go to the retreat and you feel that this is a program that you would like to ask your institution or residency program to start, then you would have additional training to bring this program to your institution or residency program.

Wayne Jonas, MD (14:02.059)

That's great. And so those that are looking to improve clinical wellbeing, I mean, they can actually bring this and do it at their institution so multiple people can participate in that area. I'm so glad that you pointed to the core of healthcare and meaning as a purpose. So often, and with COVID, we did see this, that overwork can exacerbate these types of things. 

Wayne Jonas, MD (14:30.847)

But in discussions with clinicians, it's not that overwork is the cause. In fact, many of them are used to working a lot. I mean, that's how we got into medical school and what we did in our medical training. The goal of alleviating suffering, which one of my favorite authors, Eric Castle, wrote a whole book about the goals of suffering.

We immerse ourselves in it. We jump into the middle of the fire and then we think that it's not gonna affect us, right? We think we don't have to process the trauma that is part of what we have volunteered to go in and help relieve. And so processing that trauma requires self-care. It requires connecting to that meaning and not simply next, who else is gonna come in those areas. 

Wayne Jonas, MD (15:26.899)

So this is really in many ways, you call it a calling, which is really, that's a spiritual term really, in many ways. And so many people come into that, but then the forces force them out. And I hear for some, so many young people saying, well, gee, I would like to do this, but I've got $200,000 worth of debt and I gotta make money. So I'm gonna go into something where, you know, I can just, you know, look at a test, do something on the wall, do a procedure in those areas.

Wayne Jonas, MD (15:56.811)

And it's difficult then you can still connect to the meaning in those procedures and to the people in those procedures. And you're alleviating suffering in those areas, but you've got to make extra effort, don't you? And you've got to have the time to do it. You've got to get to know the individual in those areas, which you're not being paid for in those areas.

Evangeline Andarsio, MD (16:08.874)

Yeah, and just a comment on resiliency, because I think sometimes what we forget is that resiliency meets facing our challenges, and yet, and we learn from those challenges, and we are able to move forward. But an important piece of resiliency is that we have time for recovery.

And we didn't get that in COVID. The COVID pandemic was very just traumatic in that way. It was one patient after other, you were constantly working. It was difficult to take any kind of a break or recovery. And so that's a key piece of resiliency. So I know with the AMA, you know, the system broken is one of their slogans is,

“The system is broken, not the physician.” But what I would say is in the midst of this broken system, we as physicians need to care for ourselves so we can care for others. So we need to have time for recovery. And wellness is not a one size fits all. People have different ways of their recovery. So that includes a lot of the things in the book that you talk about.

The importance of rest, nutrition, exercise, finding time for family and for relationships. All these things are so important because it's not just whole care for the patient, it's whole care for the person. So that includes the provider who's providing that care to the patient.

Wayne Jonas, MD (18:01.299)

Yeah, now that's wonderful. I think what's ironic about this too, is that we know that many of those same wellness practices are underlying risks for the development of chronic illness. 

Many of the chronic diseases that we're facing now are because our patients actually don't engage in self-care that keeps you healthy, right? Or sometimes it even reduces risk and maybe even reverses sometimes these chronic illnesses in those areas. So self-care is not simply convenience. It's not simply just nice to have. It's fundamentally getting at the root of addressing the chronic illnesses that come into our office day in and day out.

And how can we do that if we don't know how it's done? We don't know how it's done. I often say to my residents, well, you can't do brain surgery, you can't learn brain surgery by doing it on yourself, but you can learn chronic disease management by doing it on yourself, prevention and health promotion by doing it. You have to do it on yourself to really understand it and know how to do it. Does your workshop end up, I mean, I assume there are some very specific skills that come out, so.

The book Healing and Cancer that Dr. McManamon and I just wrote, we talked about some of the evidence for self-care in the care of patients with cancer. And one of the guidelines that just came out from the American Society of Clinical Oncology (ASCO) and the Society of Integrative Oncology (SIO), summarized the evidence about mindfulness and mindfulness-based practices as a key part of high-level evidence now for the management of anxiety, depression in patients. They didn't really talk about the importance of it for clinicians, but...is that something that you all teach in Tending the Flame? 

Do you learn some of those mind-body skills? 

Evangeline Andarsio, MD (20:11.106)

Yes, definitely. We teach mindful practices at the Institute and simple things that you can connect with that can assist you in maintaining meaning in your work and promoting self-care. Things such as the breath. The importance of the breath, journeying and reflection, use of poetry, narrative and storytelling. All these things assist in your care so you can care best for your patients and your colleagues. Because that is a key piece. You don't have to do a six to eight week course on mindfulness. You can tap into it very quickly. Also the importance of ritual, the different things that we do that can assist us in caring for our patients. I remember, you know, as an obstetrician gynecologist, I was juggling patients and labor and delivery, surgery after being involved in surgery. Then also I'm in my office seeing patients when I had someone in labor. And so before I would walk into a patient's room, if I knew I had all these different things going on.

I would always take time to do a ritual of putting my hand to my heart, looking at the chart and trusting I was about to walk into a room, a sacred space where someone was going to share their journey with me, their story, their vulnerability. And so my presence, my absolute presence, listening skills and compassion needed to be in that room for that patient.

So that little ritual helped to center me walking in. And so there's different things that physicians can come up with or other health care professionals to give them that sense of reconnection, of being totally present to that patient, being aware of the present moment and allowing you to assist them in...

in treating their whole self. So it's, you know, I remember patients that come with a gynecological issue and just the way that I saw them or their physical presence, I could tell that something else was bothering them. And asking that question was so important because in many ways, that's the real reason they came. It wasn't just because of one symptom.

Evangeline Andarsio, MD (22:37.714)

I feel that's a very important aspect of what we do as physicians, but that requires time. And we realize that. We are under time constraints. And can you tap into these things quickly so you can be totally present and be there for them? So these are just some of the things that we talk about. And we learn from each other. And that's the beauty of this setting of being in a supportive community.

Because everyone has their own ritual that they may use. And they may share that in the community setting. And we learn from the collective wisdom in that room. And it is very powerful to see what healthcare professionals are doing to assist them to being present to their patients.

Wayne Jonas, MD (23:27.315)

Well, that's a great lead in. I'd like you to think about an example in a minute, if you can give us someone that has taken the course and the impact it's had. But what you've just described, I think, and what we've described in this discussion is the S's, I would call them the three S's, the big system issues, and yes, the system is broken, the social support that's necessary to connect to others of our peers to help support the process so that we know we're not alone. And then the very simple techniques that you have, that you just describe in day to day and moment to moment practice that then can reinforce that even in a broken system, to build resilience. 

Can you give us an example of someone that sort of came to Tending the Flame Workshop? Maybe went through the fire, where there's flame, there's fire, and came out on the other side more resilient? 

Evangeline Andarsio, MD (24:39.106)

Yes. I remember one physician, and of course, all our settings are confidential, so I did receive permission to share this story.

During COVID, it just felt like they were in a, like an airport where a plane would come, crash, another plane would take off, land and crash, and it was just continued. And in that process, this physician came to learn, you know, it's time I have to care for myself so I can be there for my patients. This pandemic was very difficult. And then they decided to start the programming in the area where they're at, so they can help other physicians and other healthcare professionals. So those are just some of the stories. I mean, it's endless of people that come to the program and make not only changes within themselves, but also systemic change in their institutions. 

But we have to begin with ourselves and start small. People can get so overwhelmed, well, I'm going to do this and do that, and then they lose themselves again. It's so important to start small and then find like-minded partners in your journey to bring good holistic care to patients and also ourselves.

Wayne Jonas, MD (26:01.931)

I think that's just well said. Thank you very much. And when you find like-minded partners like that in your own system, you can begin some change in your local system to actually make it better for everybody in those areas..

Evangeline Andarsio, MD (26:17.074)

Yeah, and I speak from a place of deep humility because when I came back from Dr. Remen’s and I went back four other times because I wanted to train on how to bring the Healer's Art to my medical school at Wright State University Boonshoft School of Medicine. And I also started a finding meaning program for the physicians in my medical community. Well, from that, I started an annual medicine spirituality conference.

And then I wanted to really change some policy to improve the healthcare work environment. So I became involved with my medical society, ultimately became president of Montgomery County, and then onto president of the Ohio State Medical Association, where we could actually enact some policies to try to improve the workforce environment for healthcare professionals. And I could not do it without all these other stakeholders. And we all have different gifts and strengths that we can contribute to this. And so I feel like things will present themselves to you and just know if it's something you're interested in and you have passion for to follow that. And we can improve the healthcare environment, all of us if we work together. 

Wayne Jonas, MD (27:44.459)

Well, just because the pandemic is over doesn't mean this problem is over. In fact, it's a continuous problem in healthcare. 

Wayne Jonas, MD (27:50.775)

Vange, this has been a great discussion. Thank you so much for your efforts. Any final comments that you'd like to make for our listeners about this area and lessons for them?

Evangeline Andarsio, MD (27:58.05)

Yes, Wayne, I did wanna touch upon that. In medical education, we hear a lot about professional identity of formation. And what that is, is it's a process that allows expression of a deeper truth, a meaning, purpose and spirituality actually, of your work. So you align your values with your work. And what happens is when there's a disconnect there, that's where burnout can occur. And so we want to encourage physicians and other healthcare professionals that professional identity formation doesn't end at medical school. It is just a lifelong learning process.

Evangeline Andarsio, MD (028:58:66)

And events like COVID really stressed us and exacerbated issues with moral distress that led to moral injury. And so we do need to really understand that lifelong learning in professional identity formation is very important.

Wayne Jonas, MD (30:19.303)

That's fantastic. So ongoing professional and personal development is essential, and this is both. 

Evangeline Andarsio, MD (31:00.366)

Yes. And it's a legitimate aspect of medicine.

Wayne Jonas, MD (32:32.987)

Absolutely, this is important for your own practice and for yourself. 

And so I wanna thank you so much for your leadership in these areas, the workshop and the activities and the system change efforts that you've just described, the self-change efforts that you've just described are even more essential now than they've ever been to help in the alleviation of suffering for all.

And so thank you so much for taking the time. Thank you for what you do in these areas. And I hope you get many more people flocking to these courses, Tending the Flame. And we'll make sure the information about how to do that is on our notes. So thank you so much.

Evangeline Andarsio, MD

And I also want to thank you for all the work that you and Alyssa are doing in whole person care. Thank you for all your work.

Wayne Jonas, MD (34:38.591)

Thank you, it's good to talk to you.

Evangeline Andarsio, MD (34:45.29)

Great to talk to you, Wayne.