EP. 7: COACHING PHYSICIANS TO ADDRESS THE BURNOUT CRISIS

Apr 19

WITH REBECCA MERRILL

A leadership coach shares how she helps doctors rediscover their passion for medicine.

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Episode Summary

A crisis of burnout is rippling through the medical community; physicians are experiencing ever-increasing mental, physical, and social strain while the healthcare system offers little assistance with that burden. For leadership coach Rebecca Merrill, this crisis is a calling. For years, she has been coaching senior leaders in healthcare to help them reconnect with what brought them to medicine in the first place. In this episode, we speak with Merrill about how she helps clinicians lead a purposeful life and how healthcare institutions can better safeguard against workforce attrition.

Rebecca Merrill coaches top-level leaders to enhance the effectiveness of their personal and professional leadership by seeking first to understand the fundamentals of personality preferences and historical patterns of relating and communication styles, and then assessing how these fundamentals affect interpersonal relationships and leadership performance. She primarily works with physician leaders, either individually or in groups, at institutions including Stanford, Yale and Duke Universities.
Prior to her work with doctors, Merrill worked with the senior leadership of entrepreneurial and established companies in various industries including banking, clinical research, commercial real estate, education, manufacturing, on-line retail and private wealth management.
Merrill earned a bachelor’s degree from Wellesley College with a double major in Psychology and Religion, graduating magna cum laude with special honors in Religion. She received a master’s degree in Education from Harvard University and a second master’s degree in Clinical Social Work from Smith College, followed by four years of clinical training at Duke University.
In this episode, you will hear about:
• What coaching is, how it compares to therapy, and how it can help doctors - 2:20
• What makes physicians unique when it comes to coaching them - 10:40
• How Merrill responds to skepticism of coaching - 14:44
• The primary causes causes of physician burnout - 16:32
• How healthcare administrators can balance patient satisfaction with physician well-being - 24:32
• Merrill’s advice to medical professionals around self-care 38:06
• Merrill’s advice to healthcare leaders and administrators who want to better support and protect their staff from burnout - 40:28
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Tyler Johnson: [00:01:03] All right. This is Dr. Tyler Johnson, and I'm here with Henry. And our special guest today is Rebecca Merrill. Rebecca earned a bachelor's degree with a double major in psychology and religion from Wellesley College in 1985. She also received a master's degree in education from Harvard in 1989 and a second master's degree in clinical social work from Smith in 1993, followed by four years of clinical training at Duke University. She is going to be unique among our guests, probably ever because of the unusual role that she plays in the health care system. In a sense, she's kind of like a ethical or spiritual or metaphysical doctor to a lot of the leading doctors that you might hear about.

Tyler Johnson: [00:01:47] So she helps physicians, particularly physicians who may be feeling burnt out or directionless to help them figure out how to connect back to the meaning that brought them into medicine in the first place. So in that work, she does personal coaching for academic physicians and leaders, and she also teaches classes, particularly here at Stanford University, helping doctors specifically to reconnect with that deeper meaning. So first of all, we want to welcome you to the program, and we really appreciate you being here. Can you explain what does coaching mean and specifically when you're when you're working as a coach with academic physicians, you also teach some classes which maybe we can talk a little bit more about that later. But first, in terms of the one on one coaching relationship, maybe not necessarily with Dr. Harrington, but if you're working with any academic physician and they come to you for coaching help, what does that relationship look like and what is it that you're really trying to do?

Rebecca Merrill: [00:02:46] That's a very good question. And the answer to that is really dependent upon the physician in question. But essentially coaching is a transformational conversation. I start out getting to know the physician in question with some basic background questions about where they came from, how they got into medicine, what's driving them, what their personality type is, what their history is, family of origin. I get some sort of basic sketch of who they are, and then I start into questions about why in particular they would want to do coaching because time is so scarce. And that starts the conversation into sort of the when, where, why, how? What questions of what they're doing. And eventually, not too long into that conversation, we stumble onto some challenges that they haven't figured out yet. And I'm always very attentive to not wanting to be preachy or tell them what they already know. So what I try and do is I try and in the conversation, which I often is done in a walking format because it's I find it's conducive, I basically explore the edges of their current life experience to find out where they're getting hot spots, where they're coming up against questions, conundrums, challenges, frustrations. And in that place, I then start to query and explore more deeply. I have an instinct at this point from many years of doing this what's pay dirt and what's not. And I'll sort of start pulling a thread and if it resonates, they tend to pile on. And if they if it doesn't resonate, then they will say that's really not terribly relevant or interesting and we'll go on to the next thing. But essentially coaching is a lot like psychotherapy in that it's an it's a transformational, trusting conversation that leads the people being coached into a new way of thinking about their lives and their work and their paradigms and their narratives and all the things that make up their world.

Henry Bair: [00:05:11] Is there anything unique or different about physicians in particular that affects the way you approach coaching them versus coaching other types of executives and leaders?

Rebecca Merrill: [00:05:26] Absolutely. Absolutely. So I've worked with leaders in all kinds of vertical industries, banking and commercial real estate and insurance, and you name it, manufacturing, online, retail, the physician. The phenotype of the physician is extremely unique. You all self-select into this profession because of a perfect storm in a good way of experiences, personality, family of origin, early life challenges, high, high level of intellect, conscientiousness. There's this whole phenotype. So that personality and all of the constellation of attributes around that personality is very different, I find, from any other kind of person that I've coached, and it requires a certain kind of finesse and insight that isn't easily gained by somebody who just wants to hang up a shingle and and coach. You have to have a deftness and a certain kind of emotional perspective to really reach into the lives of physicians, because physicians are typically very self contained, very independent, often bulletproof, got a good game face. They can hang in there through the tough and the tougher and the toughest. You all have been trained since early, early, early on to just suck it up and keep going. You've got incredible levels of stoicism and as I mentioned before, the ability to delay gratification ad nauseam. And so it's a very, very different kind of coaching that requires an understanding of the humanity of the physician, which is, in my experience and again, I've I've coached across many, many different industries, is absolutely unique.

Rebecca Merrill: [00:07:28] I also happen to believe firmly that being a physician is probably the hardest profession there is. First of all, you have to have enormous intellectual capacity, but you also have to be able to tolerate, as you know, Henri death and dying. You have to tolerate incredible high urgency situations. You have to tolerate. Questions and problems that have not been solved for yet, like in oncology. Tyler You have to be able to manage family systems and family members who are sometimes more distraught than the patient. You have to you have to manage the entire industry of health care. I have coached several people in Stanford health care. And it's a completely different industry than. Being a doctor. I mean, it's just it's not the same the same beast at all. So you have you have a lot of different things that are going on. And and particularly let's just look at COVID. During COVID, you were at ground zero, you were having to solve for an enormous world pandemic and keep your family safe and keep your wits about you and have equanimity and not lose sight of the ultimate goal and not try to be God a hero. There's so many things that you have to do as physicians that I don't think any other profession comes even close to the level of challenge and emotional stress and strain. That said, it's incredibly rewarding as a profession.

Henry Bair: [00:09:15] Earlier, you did mention that physicians are trained or self selected to be stoic, to be bulletproof in the face of stress and challenges. And so along with that, I'm wondering if you've ever encountered skepticism about the need for coaching with with physicians who you would like to help. And if you've encountered that, how do you turn their mind around? How do you get them to see that there is a value in what you have to offer?

Rebecca Merrill: [00:09:49] So I have been lucky because I started coaching the chair of the Department of Medicine at Stanford, Bob Harrington, that I have like the biggest proponent that the world has ever seen in terms of coaching and medicine. So by and large, one of the premises that I have for coaching is I only work with the willing, so I'm not trying to sell people who aren't sold on it. And the second thing is doctors talk to doctors. And so when somebody has worked with me and gotten some benefit from it, they tell somebody else about it. And so the most powerful way to promote coaching is to just have physicians share what they've gained from the experience. One of the most important things is that physicians see that it's okay to get coaching, it's okay to be exhausted, it's okay to have needs, it's okay to be frustrated or angry, and it normalizes it. And so when you get a group of physicians who've traveled together through this curriculum for nine months, they go out and talk. So I have never actually approached coaching that way as if I have to convince somebody. It's sort of the convincing is usually been handled by somebody else before I meet with somebody. So.

Tyler Johnson: [00:11:06] So one of the central ideas behind this podcast is that I think most people, particularly health care professionals, but even those who are not intuitively understand, as you were just getting at that medicine can and probably should be the most meaningful of professions. Right? It used to be almost universally known as the most noble profession, and yet it's well known that doctors themselves are suffering from an epidemic of burnout. And there are many doctors I just heard again from an undergraduate I'm advising the other day who said that he went to shadow a doctor and that the speech he got from the doctor at the end of the day of shadowing was you really shouldn't go into medicine because it's fill in the blank, x, y, z. So as the person who is talking to doctors in their vulnerable moments and who is likely hearing from them about the very things that are underlying that sense of disconnection and burnout, what can you tell us about your diagnosis of what the problem is? What do you think is making it so that so many physicians, even in many cases, those who are perhaps world leaders in their fields, feel increasingly disconnected from the meaning that brought them into medicine in the first place and increasingly burnt out.

Rebecca Merrill: [00:12:33] So it's a it's a huge, huge, multifactorial answer. However, let me start with the very first thing, which is that physicians through the training process are essentially taught that work comes first. If you got extra time, family comes second and then when you get around to it, you come third. The capacity and the and the habituation of self care has diminished to like almost nothing. And you've been trained to push through your own emotional exhaustion, physical exhaustion, spiritual exhaustion, and keep on keeping on. And there has been this mystique that physicians you know, I think Shana Felt said this physicians used to be deities. They dropped down to heroes. And now they're just human beings. When you're when you're being trained to be a deity or a hero, you're not allowed to have literally human needs, which means you learn the neural pathways in your brain, basically get tracked to I can push through this no matter what this is. The problem with that is that human beings are they're physical creatures who need physical care. And I think the very first reason that in this very big Venn diagram of reasons, but I think the very first reason is that all of you essentially are trained, taught a lot like in the military to just disregard exhaustion, pain and keep going. And that tends to when you're young and you're agile and you're excited, you can go on fumes when you're getting closer to late thirties, early forties.

Rebecca Merrill: [00:14:22] It's really hard to run on fumes when you've got a family that you're trying to take care of and a spouse you're trying to stay connected to. It's really hard to run on fumes. And so what happens is you get this person who is very, very, very intellectually well trained and physically tapping out. So I think exhaustion is the first reason that burnout is happening. Second, I really believe that physicians have been commoditized. You're essentially little widgets that make money for a health care system. You can edit that out if you want to. But I really do believe that the the nobility of the profession has been overtaken by the business of the profession and in such a way that relative value units, RV use and all of the things that press ganey scores, all the things that are sort of required to metric size your performance have drained it of the kind of joy and the privilege of healing broken humans. And now it's just, you know, what's your performance like? Are you checking the boxes? What kind of money are you bringing in? If you're a researcher, how many clinical hours can you carry? Because we need you? I mean, there's been recently enormous pressure because of surge in patient surge. And it's it's wearing you out. And yet we've got to get more and more and more out of a limited number of physicians. And the math doesn't work.

Rebecca Merrill: [00:16:01] It just doesn't work. So you've got that on top of you don't do a lot of self care. And then I think the third thing, if we're just to simplify the model, is that when when you're exhausted, you you basically go to ground, you go to the absolute fundamental bare bones, self care that you can get through with, and you leave the existential and the meaning issues behind because you don't have energy to think about them. The group that I designed, the curriculum I designed is called Making Space for What Matters Most. And I was stunned when I started leading these groups to find out that people literally, when confronted with the question, so what matters most? They stalled out like they couldn't come up with it. That's a function of not spending a lot of time thinking about it because you're too busy getting your press ganey scores up. And also it's a it's an avoidance mechanism because if you actually stop and pause and think this profession is so rough, what is the meaning? And if you can't find it, then you're kind of up a big creek without a paddle. So I find that a lot of times people go into a state of avoidance and denial, i.e., I don't want to think about it, I don't want it to be a problem. I'll just become somewhat robotic so that those larger existential questions which used to fuel the purpose and the meaning, have essentially been shelved because it takes too much psychic energy to even go there.

Rebecca Merrill: [00:17:39] You know, when I brought this conversation into the middle of doctors, you know, it was sort of you could hear these sighs of relief because people could finally open the kimono. Let down their guard. Stop having the game face. Start asking the hard questions. But most of the time, you don't have time to sit around and drink coffee and talk about the meaning and purpose of medicine. You're too busy working. So I find that it's essentially the context in which medicine is practiced has become untenable. And I know I'm very revolutionary here and probably will get some hate mail for this, but I don't think the context is conducive to the kind of beauty, you know, the sort of. Atul Gawande beauty or the Abraham. Abraham Verghese Beauty of healing and medicine and suffering and and meaning and purpose. All of those things are just put on the back burner because you've got to get your reviews and you got to get your press ganey scores up. So I think I think to me it's this perfect storm of those things that has created an environment in which becoming cynical, becoming exhausted and turning this into sort of a robotic process is absolutely expected. I mean, it's hard to think you could do anything else given the kind of pressures that you're under.

Henry Bair: [00:19:06] So thank you for your diagnosis. Rebecca. Even as a medical student, I see many of the issues you raised when I'm on my clinical rotations I'd like to address in particular the second point you mentioned regarding the commodification of the work that physicians do. You mentioned Press Ganey surveys, which for those of our listeners who might not know, are surveys that measure patient satisfaction with regard to things like the friendliness of the care provider, the amount of time a provider spends with the patient and the level of confidence the patient feels in their provider. In some cases, physician compensation is, at least in part, tied to their press gaining survey results. I can easily imagine a health care executive saying that they use press ganey surveys in order to make their institution more patient centered or that they track the procedures physicians perform and measure all those objective patient outcomes not to make doctors lives more difficult, but to make sure that the hospital is providing high value care, meaning care that is high quality and cost effective at the same time. So given those arguments, have you thought about where and how we can strike the right balance? Where do we go from here?

Rebecca Merrill: [00:20:25] I do. I have thought about that. I have some pretty strong feelings about it. I think that that the press ganey score is really tyrannical. I think its intention. Is good. However, you have to understand, when you're when you're getting a basically a customer satisfaction score from a patient, they're suffering. They're in a place they don't want to be. And who's the easiest proximate target for their upset? The doctor and doctors are viewed in our culture as omnipotent. And why isn't the doctor fixing me faster becomes an issue. And so you can you you essentially, when you give the patient this kind of power to wield over the doctor and they want it, they I mean, this is a suffering person. This is a person who feels somewhat helpless, who doesn't have any sort of who feels like they're being swept along in some process or procedure. It's human nature they want to strike out. Well, I think the problem with this whole system is that the way the press ganey scores is built is that a patient can vent via the press ganey score. And you might have a doctor doing a brilliant job in a very upset patient. Maybe they didn't even find a parking space until they were 20 minutes late for their meeting. Who knows? But they can bring every single piece of frustration in and spew it into a press ganey score. And you can have a very, very good doctor who gets rated very poorly because of that patient's experience.

Rebecca Merrill: [00:22:02] So I think that it's given way too much weight. If anything, maybe aggregating across divisions, I don't know, flaws or whatever. But I think it's a really it's I don't think it's fair at all to the physician. The other thing that I think is important is and this is fundamental if you've got caregivers. Who were supposed to be, quote unquote, healing and saving. You can't beat them up. It's like saying, you know, in the airplane, don't put your mask on first, just suffocate and then help your neighbor. Right. It's like we have to take care of the physicians first because they're the ones who are taking care of everybody else. And so if you make the entire system patient centric, you forget that the people doing the healing are being left in the dust or criticized or cut down or stressed out about one more metric. And you've got to understand that you cannot take this much out of the hide of a physician and have them still show up bubbly and effervescent and kind and patient and economists and all the other things we want doctors to be. It's just not humanly possible. So if I had my way, I'd do away with press ganey altogether. I also think the relative value units are problematic because they feed the whole hierarchy and status of the academic medical institution. And so if you're a nephrologist or rheumatologist or endocrinologist, you're making less per hour per treatment than somebody who's Tyler's got Tyler's specialty of oncology or cardiology or orthopedic surgery.

Rebecca Merrill: [00:23:45] And all of you went through medical school, all of you did residency training. You you really worked hard. And so this relative izing of the value of medical care, I think, is really demoralizing, particularly for some of the subspecialties that are not as well endowed. It's just everywhere. So you get that demoralization going on. You also get the primary care physicians who are supposed to be the gatekeepers who are really used by the hospital system to basically keep people out of the expensive stuff and keep them in the cheap stuff. And then they feel like they're not valued for anything other than just gatekeeping. And so there's there's an enormous number of things wrong with the way the system is set up. But in general, I think that it's completely out of whack. And I don't think we need to go back to doctor as deity. I do think we need to go to a place where doctors are human and they are doing an enormous amount of servant leadership, very servant leadership, and that we should treat them with kindness and love and compassion and deep respect for the amount of just. Challenging, difficult, incredibly difficult work that you all do. I mean, there just isn't anything as hard as being a physician.

Tyler Johnson: [00:25:08] So let me let me cut in there. Rebecca, I want to ask your comments about although, of course, it sounds wonderful to have patient centric care. If it is exclusively patient centric care, that can actually become a problem. Right. I I'm brought to think when when you mentioned that. So Stanford recently built a few years ago now, but they spent like ten years building this gorgeous new hospital. Right. It is just beautiful. Stunning, almost. And the single most stunning feature is that the way the hospital is laid out, there are four patient towers that stick out, kind of like the points of a four leaf clover or the points of a plus sign. And then the hospital rooms are arrayed in such a way that every single hospital room is a window room. It's on the edge of one of the walls of the hospital. And so every single patient room has floor to ceiling bay windows where the patient can look out literally on the bay and see these gorgeous vistas. And it was so interesting because the first time I toured it, I thought, wow, what a what a fantastic, healing, inspiring space to be in. And so then I asked to see the doctors rooms and it turns out that every single one of the doctors rooms is hidden in the central tower of the hospital such that it is antiseptic white walls. There are no windows anywhere, and they're frankly ugly and cramped and they just feel claustrophobic. They just feel terrible.

Tyler Johnson: [00:26:51] Right. And anybody who has been through hospital training knows that if you're a poor intern or whatever you might be spending, I guess not anymore. But 16 hours used to be 30 hours. And if you're a second or third year resident, you might be spending 30 hours at the drop of a hat in one of these rooms. And there's no natural sunlight. There's no space to move around. Right. It's like being cramped in a closet. And of course, you know, it's not that anybody doesn't want the patients to have access to the beautiful windows, but it does seem to really say something. It's it seems to be a tell about the way that the medical system prioritizes the wellness of the doctors and the rest of the health care practitioners that work in the hospital. By the same token, I'm proud to think about my own clinic. You know, sometimes I have as many as 25 or 30 patients in a clinic day. This is as an oncologist. Right. And just by nature of the work that I do, sometimes we have to talk to people about approaching their death or we have to talk to people about these incredibly complex, high stakes decisions about whether to have surgery or whether to have heavy duty, chemotherapy or whatever. And unavoidably, those conversations can take 30, 45, even 60 Minutes. But if I have 15 patients that I'm supposed to see in the morning and the first visit takes 45 minutes, unavoidably I'm behind. And then the rest of the patients are left frustrated that I'm running behind when I'm trying to do my due diligence in approaching a conversation the appropriate way.

Tyler Johnson: [00:28:20] And so then I end up feeling this sort of moral hazard for the rest of the day, because I feel guilty, unavoidably guilty for being late with people when I'm only that way because I was trying to do due service to the first patient. So all of that is backdrop. It's recognition of what you're saying, but it's also a backdrop to what I imagine many of our listeners will consider to be the most important question. Most doctors would probably love it if they had a magic wand and they could just reform the system, right, and put the doctor's rooms on the outside with the windows and make it so they don't have to see as many patients and all those things. But most doctors don't have that magic wand right. To some degree. They are now employees. Most doctors don't hang up their shingle anymore. They go and work for UnitedHealthcare or whatever. So if you're a doctor who is to some degree feeling like a cog in the system and you don't feel like you have the power or even the know how to enact huge systemic change, what would you as a coach tell that person? What can that person do to try to reconnect with with some of the meaning that brought them into medicine, even recognizing the very steep challenges that we've been outlining?

Rebecca Merrill: [00:29:32] Well, that's I mean, that's exactly what I have to do with all the doctors I coach, because the system is not changing any time soon. And if and when it does, it's going to be like turning the Titanic. It's going to be a very slow turn. It's very unwieldy. So I immediately and always start with something I call Tending Your Nest. Nest is an acronym for Nutrition, Exercise, Sleep and Time Management. And I start. Building up the stamina. And I know this is I'm probably going to get some hate mail for this, but stamina and resilience for physicians, because we can't change the system immediately. Like, I know it needs changing, but it's more nimble to try and get each physician to spend time on setting boundaries, unloading things, not loading the back on, but taking them off, making sure that they're not living on coffee and donuts, making sure that they're actually not cutting into sleep, which is the first thing to go for physicians is sleep. And there's a wonderful book called Why We Sleep that explains why that's a really bad thing for physicians, like not a good thing to cut. So I really start with self care. I have something called the Six Circles first, three of which are self care, first closest family and closest friends second and work third. And that is almost unheard of in medicine. You just don't do it that in that way. So I try and rightsize the self care as the very first thing that has to happen in order for doctors to be able to continue to heal and to continue to find some joy in the process of healing.

Rebecca Merrill: [00:31:16] I know that they're absolutely untenable parameters for the way that you all work. You can't possibly see 30 people in a day and actually spend time with all of them and give them their due. You just can't. At which point, of course, they're irritated and they've been waiting for 2 hours. So you press ganey score, it goes down, right? I mean, it's a catch 22 every way you look at it. But I think I think that the most important thing is to get and I take this this message all the way up to the division chiefs and to Bob, and that is you have to start saying no, you have to start spending time with your family. You have to take care of your physical well-being. I mean, I find it incredibly ironic that doctors take care of everybody but themselves. You know, it's sort of like my goal is to get doctors modeling the most amazing health and well-being to their patients that they can. And in order to get the load off the system, we're going to have to work more on prevention and well being. And that's just not a focus for medicine right now. It's not. So the system's overloaded, no question. And it's, in my opinion, falling on the doctors. And and that is not a tenable situation. So the answer to that is we start with self care always, and then we work out from there.

Henry Bair: [00:32:40] And for those who are still in medical training or those who are still early in their medical careers, what advice do you have for them besides appropriate and adequate self care?

Rebecca Merrill: [00:32:54] It's a great question, Henry. And what I would say is find something you love, whether it's writing or reading or music or soccer or dance or yoga, and don't let it go. Find something you love. That's that's an avocation that is not work related and carry it along with you. Because what happens is as you move through the training process, your entire life starts to exclude everything that makes life rich and meaningful and wonderful and sweet and lovely. And all you're doing is working. And it is not that's not sustainable. So I would encourage every person who's training to become a medical student, who's in medical school, who's doing residency, fellowship, junior faculty, find that thing that creates joy in your heart and keep doing it because it is a leavening agent. When things get really heavy, when you can go home and put on some Beethoven or you can go home and go for a run, or you can go home and read a really good historical novel. Or you can write a historical novel, or you can do something that gives you meaning outside of work. Then it's it starts to create a bit of a better balance. Because of my undergraduate training was psychology and religion. I have always been interested in the intersection of suffering and meaning how we make meaning out of suffering. And so to do that, the arts really help. This is why I, I weave poetry and quotes and, and other things into the work that I do, because I think that it's really easy to become tunnel visioned, super easy, just just to kind of put the blinders on and just do what needs doing. The problem is that you become literally a robot and that is not sustainable. So I would say to everybody starting out, find your passion, find your love, find the thing that you've loved since you were 12 or 15 or 20 and keep doing it.

Tyler Johnson: [00:35:02] So if we can go to sort of the other side of the spectrum, Rebecca, you know, one of the nice and strange things about hosting a podcast is we never know who will be listening, right? So maybe a couple of months down the road, the CEO of some major health care corporation or the chair of some department or the chief of some division, we could flatter ourselves into thinking that that person might be listening to the podcast. But here's the question that I have. If you had that person in front of you and that person said, okay, I'm totally sold, burnout is a huge problem. I see it all over my health care workforce. There's huge attrition, there's lack of engagement. Even in the physicians who are still here, morale is down. I'm a leader and I want to fix this. Give me your number one or your top two or whatever things that I as a leader can do to help ameliorate this problem within my physician workforce. What are one or two ideas that you could give to health care leaders that you think are surefire bets for helping to make this problem better?

Rebecca Merrill: [00:36:04] Okay. So the number one thing that I tell department chairs, division chiefs is that that they have to model good self care because it doesn't help to say to your to your workforce, take care of yourselves. And then the modeling is, I'm going to work myself to the bone because I can you guys, I'll just go home. But no, I'm going to work myself to the bone and I tell the chiefs and the chairs, tell your people when you're going on vacation. Tell your people when you're turning off your phone and putting it on. Do not disturb. Tell your people that it's okay to take time off. Tell your people to go home and spend time with their families. Tell them you're going home to spend time with your family. The leadership has to model this because what happens when you say one thing and you do another always is that people look at what you do and they disregard what you say. So whenever there's a there's a disconnect between doing and saying you, you're going to have everybody following what you're doing. So if leaders are are on the one hand telling their people to take better self care and they're not doing it themselves, the message falls flat. So my very first number one memo to the leadership is you have to do your own self care and you've got to tell your people about it. And I've actually got a group of division chiefs who I coach and I am always telling them, You, you need to show up and show your faculty what it looks like, show your trainees what it looks like to take good self care because physicians are so driven that they'll say, Oh yeah, yeah, it's a trick.

Rebecca Merrill: [00:37:53] He just wants me to like, you know, let go of that extra paper that I could be doing. But he didn't let go of it. And I want to be where he is or she is. So I'm going to keep driving myself into into the sand until I can't move any further. So I think the very first thing is, is practice. Is what you preach model walk the talk model the way that is good leadership always models the way. And the second thing that I would say is I said this during COVID. I told everybody this, I said, I want you to tell your people that 75% of what they can think they can do is good enough. Because right now there's this enormous load on everyone. And if you keep trying to do 100% of what you've done during during something like COVID, you are going to destroy yourself. You know, sometimes I drop it as far down as 50%. I'll say just try and do 50%. Just show up for the bare minimum because it's just not going to work. If you burn out, there will be nobody left. And so I tell the chiefs to make sure that they're de pathologizing time off. I mean, it's almost considered weak to take time off. And so we have to change that culture. We have to make it normative to take time off, to turn the phone off, to rest, to be with your family, to go for a hike, to have a picnic, to hang out and play.

Rebecca Merrill: [00:39:19] I encourage my chiefs to come to group and and to share that they've been on vacation, because I want everybody to know that people do go on vacation when they're physicians and that it's not noble to wear yourself down to a nub. It's not noble. It's a bad idea. So those are essentially the two top things I would say to any chief, any chair, any dean. I would have no problem saying this to the dean. I am sort of revolutionary. I mean, I'm probably not going to get points from everybody, but I think that there needs to be a shift in the culture that starts with making sure the physicians are healthy. Everything else follows from that. Brilliant research follows from that low liability, high competency medicine follows from that. You just can't do it well when you're exhausted, worn out, and your life feels like you don't have anything else going on except medicine. It just doesn't work. And it's so interesting because I've seen dramatic, dramatic change in the entire sort of emotional and physical self presentation of physicians. When they've had a vacation, they've got more energy in their in their voice. They're more spring in their step. They're feeling a little more hopeful. There's there's energy there. And we want to get high press ganey scores. The best thing we can do is get rid of the press Ganey scores. Second thing is to make sure people take their vacations. And the third is to see if we can start to kind of work on the the caste system in medicine, which I don't think is very helpful. I think it's demoralizing for physicians.

Henry Bair: [00:40:58] Thank you very much for for all that.

Tyler Johnson: [00:41:00] Well, I think that we've kept you over our allotted time. We want to thank you, Rebecca, so much for coming on the podcast. We also want to let people know that if they're interested in learning more about what she does, they can go to Merrill leadership, where they can find more information about Rebecca's training and her current programs. And again, we thank you so much for being with us.

Rebecca Merrill: [00:41:24] You are so welcome, Tyler and Henry, it's been a great pleasure and I appreciate what you're doing.

Henry Bair: [00:41:31] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:41:50] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

Henry Bair: [00:42:04] I'm Henry Bayer.

Tyler Johnson: [00:42:05] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.