Physicians’ sense of powerlessness and being a cog in a wheel [PODCAST]

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“Toward the end of my clinical career, I didn’t feel like I had control over much at all. The patient safety issues loomed large. We used ridiculous workarounds for broken processes. The constant vigilance to provide excellent care in a suboptimal environment was exhausting. I didn’t see anything I could change. Based on my work with physicians as a coach, I think that the sense of powerlessness and being a “cog in a wheel” is now at an all-time high.

While on an uninspiring stretch of road on a recent family trip, a realization came to me: There are many, many system issues over which physicians have little control. But physicians do have control over three things:

• How they lead in both formal and informal leadership roles
• How effectively they advocate for change
• Who they show up as every day”

Diane W. Shannon is an internal medicine physician and physician coach and can be reached at her self-titled site, Diane W. Shannon.

She shares her story and discusses her KevinMD article, “The sense of powerlessness and being a cog in a wheel is now at an all-time high.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back to the show Diane Shannon. She is an internal medicine physician and a physician coach. She wrote the KevinMD article “The sense of powerlessness and being a cog in a wheel is now at an all-time high.” Diane, welcome back to the show.

Diane W. Shannon: Thank you, Kevin. It’s great to be here.

Kevin Pho: We’ll get into your article in a little bit, but for those who didn’t listen to our first episode together, can you share a little bit about yourself?

Diane W. Shannon: Sure. I am an internal medicine physician. I trained and then worked in primary care for just a few years, because I burned out. At the time, I really didn’t know what was going on; I just knew I had to do something different. It was a really difficult time, but I managed to kind of land on my feet and became a freelance health care writer, and I have done that for more than 20 years.

That led me to understand that I had experienced burnout, and to really want to change the situation for my physician colleagues. So I wrote a book with another physician about how to prevent physician burnout that really looked at the system issues that are driving burnout. Then I also decided to become a certified coach, and now I work with physicians to work through some of the work-life balance and time and energy management, and sometimes just to strategize about how to deal with health care today.

Kevin Pho: You mentioned that you’ve been a writer for the last 20 years or so. Burnout, of course, has been in the news, and we’ve been talking about it on KevinMD for the last few years now. But tell me about burnout 20 years ago, and the evolution, and the awareness of burnout since then.

Diane W. Shannon: Oh, there’s been a huge change, which is fabulous. Back when I was considering leaving, I really didn’t share that very widely, even just that I was considering it, and I considered it for several years before deciding to leave practice. There was more of the guilt. There was, you know, pushing it back, like, “How can you even think about doing that?” There really wasn’t much understanding, and I think that’s part of the reason why I didn’t recognize it in myself until years later, when I was writing about burnout, and actually about the connection between physician well-being and patient experience. That’s what led me to understand more about burnout.

So today there’s so much more awareness. I think that began, you know, five to 10 years ago. That’s not to say the problem is solved; I’d say, if anything, it’s worse. There are different factors driving it now. A big piece of it is the inefficiency and difficulty with all the coding and the documentation in the electronic health record. When I was practicing, we were dealing with paper charts, which have their whole other set of issues, but not the kind of workload around documentation just for billing and coding, which is, you know, a big problem now.

Kevin Pho: One of the things that struck me is that you mentioned guilt when you transitioned from clinical practice. Where did that guilt come from? Was it from yourself? Was it from colleagues? Was it from patients? And how did you overcome that guilt?

Diane W. Shannon: Yeah, I’d say it was both. I actually had someone say to me, “You can’t leave, because society put investment into your training, so you can’t leave.” That was really kind of shaming. And what I thought about later was, well, wouldn’t it have been worse if I’d continued in something that wasn’t working for 10 or 20 years? My career was really not working for me. I was not happy, not able to have any work-life balance that I could see, and so really not thriving.

I think the goal for everyone is not just to not burn out; it’s actually to thrive in what you’re doing. So I felt like, well, that would be a bigger tragedy. And today I’m not encouraging physicians to leave practice. I think it was a tragedy that I left. I’m helping them to see: Are there places where they can make different decisions, or maybe prioritize their well-being in a way, or change their mindset in a way that helps to mitigate some of the stresses that are definitely there in the health care system?

Kevin Pho: I’m sure we’ll talk a little bit more about that going forward, but let’s talk about the KevinMD article that you wrote. It’s titled “The sense of powerlessness and being a cog in a wheel is now at an all-time high.” For those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Diane W. Shannon: With the physicians I work with as a coach, what I’ve been seeing over the past, let’s say, six months is that more and more, when they describe what their day or their week is like, it is more about productivity, more about doing more with less, being understaffed in terms of medical assistants or other clinicians to do the workload. It’s really, you know, causing all sorts of additional stresses that I don’t think were there as much six months or even a year ago.

So I feel like the reflection back that I’m seeing and hearing is so much about, you know, “My time, the thing that brought me to medicine, connecting with patients and doing really great care, is being compromised or is being squished.” There’s just that feeling of, you know, “10 minutes is not enough, or 15 minutes is not enough, to establish a relationship and make sure I’ve done what I need to do.” And then there’s all of the in-basket and all of the documentation that comes after that. So I think that the heat has really been turned up. You know, some physicians will say, “I feel like I’m a data entry clerk. That’s what I do.” It’s really eroding the purpose and the meaning and all of the wonderful things about being a physician.

I was thinking about this, thinking, you know, there’s so much about the health care system that could be changed, could be improved, but where we are now, what can individuals do to try to mitigate some of that stress? So with the article, I was thinking about this, and I thought there are really three places. It’s how you lead, how you advocate for change, and who you show up as every day. I think the last, who you show up as every day, is so important to the other two, so that’s foundational.

I think in training, and as part of the profession, we are given the message: Put the patient first, put other people first, self-care is selfish. This is really turning that on its head to say, if we don’t have some level of well-being ourselves, we’re not going to be able to sustain what we need to do for patients and to support our colleagues.

Kevin Pho: Before they come to you for coaching and guidance, you obviously see a spectrum of physicians who deal with what you’re describing. How are they themselves trying to manage that situation before they come to you?

Diane W. Shannon: Right. So some of them are doing things like trying to write shorter notes, trying to make them more concise, trying to set some limits in terms of their accessibility. You know, when they’re not on call, are they still taking pages and texts and things like that? So they’re making some of those sorts of logistical changes to try to capture, or recapture, some of that time. But often it’s things like, “Oh, I’m going to now come in at six o’clock, two hours before my clinic starts, so that I can have two hours to do my pre-charting or the documentation I didn’t finish yesterday.” So in a way, they’re stretching themselves even thinner to try to keep up with the work.

Kevin Pho: And then they’re coming to you for guidance, so it doesn’t sound like that’s a successful tack in a lot of cases. Now, they come to you, and I think what you’re describing is a very familiar scenario to what I see in primary care. You did mention a framework in terms of making that change, so go into a little more detail. Take me through a sample case study of how you would guide someone to implement some of your ideas.

Diane W. Shannon: I kind of start with: Well, where are things now? What is really getting to you? What are the key challenges? Then I have the person walk me through their week. How many hours are they working? What are those hours? What does call look like? That way I have a sense of, you know, what we are working with. And then, what are the other responsibilities they have outside of work? So I’m trying to better understand what the current state is.

Then there’s a series of assessments I do. One of them that’s been really helpful is called the life wheel, where we look at all the components of your life, you know, health, your relationship with your significant other, family, home environment, things like that. How satisfied are you with each component? And then which three of those are the ones that absolutely have to be in a good place for you to be in a good place? Then we begin by just picking one area and one change to start with, so really breaking it down to something that’s manageable.

So for instance, if it was, “You know, I can see I’m not that satisfied right now with my relationship with my significant other,” well, maybe it’s, “Today I’m going to communicate with him or her and say, ‘OK, let’s schedule a date night next week,'” and do whatever we need, you know, child care, whatever we need to do. So it’s just one small action, but what I’ve seen is that it then helps people to feel more empowered when they’ve done something to move in that direction.

Now, what I’m talking about right now is a lot about home life, like personal life, but I do think that comes first, because, you know, it’s however you come into work, right? I use the analogy in the article about trying to climb a mountain without eating breakfast. You’re not going to be as successful. You’re going to be irritable. You’re not going to want to talk with people or enjoy the scenery. It’s the same thing if you come to work and you’re exhausted, or you’re feeling stressed about, you know, things going on at home, or you just haven’t been able to exercise or sleep enough. It’s going to put you at a deficit to then start a stressful, busy day.

So that’s the beginning of what we do, and then really it’s a lot of brainstorming and helping, you know, the physicians I work with. It’s not so much that I tell them what to do, as help them to have some insight and to set goals for themselves, and then have that accountability to move toward them. And sometimes, just with my experience in burnout, I will stop and say, “OK, this is what I know about burnout and the burnout drivers,” but I really separate that out from the coaching work that I’m doing.

Kevin Pho: So in terms of taking next steps, implementing some of these ideas, say, on a daily, busy primary care workflow, what are some actionable scenarios where you could implement some of the things that you’re talking about?

Diane W. Shannon: One of them I’ve found really helpful most recently is mini mindfulness breaks. You know, I’m not someone who meditates for 60 minutes every morning. Not at all; that never worked for me. But I’m able to do, you know, three minutes in the morning and then a minute or two throughout the day. It’s mindfulness as in focusing with a lot of attention on a physical sensation. That might be tactile, like rubbing your fingers together. It might be listening to a sound. It might be looking with a lot of attention at an object.

Just doing that is kind of a reset, and it pulls us out of that stressful, paced mindset, just for a moment, to reset during the day. And because it’s short, it might be 20 seconds before walking into a patient room, you know, spread out over the day. I’ve seen that, and some of the physicians I work with have found that to be really helpful. I think the hardest part is remembering to do it, right?

Kevin Pho: One of the things that you did mention in your article was being a voice for change, and I certainly agree with that. Sometimes the biggest way physicians can change the system is that they can change a system from within, and hopefully help the surroundings around them. So what are some techniques so that physicians can be that voice of change within their own organizations?

Diane W. Shannon: Right. Well, I think the first step is that they’re in a place where they can do that. I think so many right now are in survival mode and just trying to get through the day, and that’s a really hard place to try to advocate for change. So I think some of it is shoring yourself up with whatever that means in terms of self-care, or some of the other things we talked about.

But then I think it’s a matter of how you can most effectively have those conversations, to understand, you know, what the big pebbles in the shoe are for your group or clinic, and then being able to advocate effectively for change. So some of that is using “I” statements instead of “you” when approaching and making a request: “I see this,” or “I observe this,” not “You did this,” or “You should have done that.”

The other one is what I call leading with curiosity, so really trying to be in that curious place about what’s not working and why. And also, when going to make a request of leadership or the decision-makers, being curious if you get negative feedback or pushback or whatever, trying to be in a neutral but curious place about why. That sometimes leads to more fruitful conversations and some kind of negotiation for something that is a move in the right direction.

Kevin Pho: We’re talking to Diane Shannon. She is an internal medicine physician and a physician coach. She wrote the KevinMD article “The sense of powerlessness and being a cog in a wheel is now at an all-time high.” Diane, can you take us through a successful case study, certainly without going into too many details? Maybe a before and after of a typical client that you would see, and then implementing some of the ideas, and the aftermath.

Diane W. Shannon: There are a number of different clients I could pick. There’s a physician who comes in, and they’re feeling completely stressed, and by their own admission feel burned out, and really don’t think they can stay, like at the point of, “I can’t do this anymore.” Some of them have taken, I’ll speak about one in particular, have taken medical leave already during the pandemic, because of the stress and a bout of depression. So now they’re back at work, realizing, “The current situation is not working,” right?

So we work through some of the tools that I mentioned to you. I also do some personality assessments, really getting an idea of what is going on, and then brainstorming with them about what might change, what they could do differently, and really focusing on where they have agency. There are a whole bunch of things driving burnout that an individual does not have control over, and that’s really frustrating. So we acknowledge that, and then also say, “OK, what if, by focusing in these areas where you do have control, you could make a change that would affect how you felt?”

So some of that has been, you know, more effective communication with others, like a partner that you’re not getting along with, and that is causing your day to feel incredibly stressful. Or with another physician I worked with, it was impostor syndrome, and just carrying that around all the time was a huge burden. So it’s by working through these things and trying something. I always look at it as an experiment. So it’s not, “Oh, this is what’s going to work, and if it doesn’t, forget it ever, you know, there’s no hope at all.” It’s, “Let’s try this. Why don’t you try something, and then let’s see how that went?”

So that might be trying to write shorter notes, or be more concise in your documentation, or trying, for example, at home, to leave your phone outside the bedroom if you’re not on call, right? Try something small that gives you back some of what you’re needing in terms of time, protected time, rest. It might be trying something around communication with others. You know, if you get very stressed in terms of communication, well, let’s look at that and try a different way.

I’m thinking also about new leaders that I’ve worked with, where it’s just, “How am I doing, right, as a new leader? What should I be doing differently?” I help them to, again, try something that fits with their strengths. You know, based on some of the personality assessments, what are your personal strengths? Then building on that, using that, knowing that that does differentiate you from the next person.

So there are all these different ways that I work with folks, and generally, by the end, you know, they’ll say, “Wow.” We do a mini, kind of informal set of metrics: “My burnout has gone from a seven to a three. I feel more excited about going to work. I’ve decided to stay at my organization, where I was about to be out the door. Now I’ve decided to stay, and I’m happy here.” So it is possible to make those changes that really do affect what your daily experience of your work is.

Kevin Pho: My final question, Diane: What’s your take-home message that you want to leave with the KevinMD audience?

Diane W. Shannon: I think it’s really about, you know, self-care is not selfish. It really is the foundation for being able to show up as your best self, which then has this ripple effect on everyone around you, your colleagues, your patients, and others. So that’s my primary message, that it’s not something we learned in medical school: how important self-care is.

Kevin Pho: Diane, thank you so much for coming back on the show and sharing your time and insight.

Diane W. Shannon: Thanks, Kevin.

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