Steven Reames has been the executive director of Ada County Medical Society since 2014. He has served in a variety of non-profit leadership roles in Boise since 2000. In his monthly blog for ACMS, he writes about personal reflections as he sees it from his chair in the Boise area medical community.
Remember two, three, four years ago when all the construction along Myrtle Street was going on? The JUMP building was finally being finished, two new hotels were going up at Capitol Blvd, followed quickly by the Fowler Street apartments. And as soon as that was done, lanes were shut off on Front Street to host the new parking garage and hotel across from Simplot. It was like a vaso-construction of major arterials. Is it possible for a city to have a myocardial infarction in the heart of downtown?
By the end of 2017 it seemed that quality of life in Boise had been noticeably reduced for the first time in the 18 years I’d lived here. I had convinced myself that “someday we will get our lanes back that have been used for construction.” Perhaps I could recoup a third of my commute time that had been added. Eventually, I came to grips that there was probably never going to be any going backwards unless I wanted to move to Twin Falls, Pocatello or Moscow. This was the new normal.
I sometimes wonder if doctors feel the same way about their practice of medicine. Everyday it seems like there is more traffic added to your work: more boxes to check, more questions to ask, more paperwork to fill out. Suddenly, new lane restrictions arise that don’t allow you to use all the space or time or energy previously available to you when things seemed to flow so smoothly. Where there used to be a good “stopping distance” between patients, everything is crammed a little tighter now and patients expect more out of you in less time you’re provided to give it. Collisions between patient time blocks occur more frequently.
You tell yourself that someday EHRs, and AI, and ACOs you help you recoup your lost bandwidth and you’ll get your hands off the keyboards and onto patients during exams.
I have shifted my expectations and come to accept the reality that our streets will be as crowded as they are for a long time to come (or at least until artificial driving intelligence takes over and radically affects the number of cars on the road). In the meantime, here’s a few ways I’m responding that help me on my drive home:
Gratitude - First, my commute is only between 15 and 30 minutes, at worst. Compare this with our peers in Seattle or Portland or anywhere in urban California, let alone a third-world county. When I was driving a pastor from Kenya around Boise some time he said, “You have the most beautiful roads. I pray that someday my own people will have access to roads such as these.” Hearing that perspective made me appreciate all we do have.
Be Creative - it is too easy to always use the same proven paths over and over, and if you’re commuting from Boise to Meridian every day, you don’t have that many options. But there is something to be said about taking an entirely different way from time to time. It may be faster or slower or about the same, but seeing some different scenery can help a lot.
Travel as a Team - I have the privilege of carpooling with at least two of my kids during the school year. This summer, it’s been a real privilege to carpool with my college-age son, commenting about news stories with each other or just debriefing each others’ days.
Speak up when you see something wrong - over the years, I have provided DOZENS of suggestions to the very responsive Ada County Highway District, several of them being addressed and implemented. I am positive they roll their eyes every time they see another email. But they are responsive and I can take credit for the Federal Way speed limit south of Amity going up to 45 after they introduced five lanes there years ago. (My kids also credit me with the introduction of flashing yellow left-turn signals to the city, but it was probably coming anyway.)
I don’t know how my driving lessons might translate for you in regards to medical practice; that’s a journey for you to take on your own. I do know that by the time I get home I am ready to greet my family with a little more peace and understanding then if I bellyache the entire way.
I recently had the privilege of meeting over lunch with a handful of independent physicians to talk about fostering a trustworthy and supportive culture in their practice. Everybody was very friendly with each other, talking about plans to see the New Kids on the Block concert together, bragging about their latest mountain bike rides, and even one getting ready to begin a several week sabbatical.
I started my talk by posing the rhetorical question, “Have I ever shared my burnout story with any of you?” I knew the answer was “no” since I had not met most of them before and especially since I am not a physician (though I have played one on TV).
My own burnout story specifically involves being a director of a charitable, not-for-profit medical clinic, leading the organization through six or seven years of strong growth. As grants and other secure sources of income began to dry up, the organization began to take a financial nosedive. I had to start slowly letting staff go, picking up some of the slack, and became increasingly overwhelmed. I was coming home so vacant looking that my wife thought I was having an affair. I started questioning my own effectiveness out loud to the board of directors. After giving them three scenarios of restructuring and then disagreeing on which was the best, I was graciously relieved of duty. And I was relieved.
After I shared this, I turned the tables on the physicians and asked them to share their own burnout stories with each other. It started out a little quiet, but as they became comfortable with the process, I heard bits and snatches that made my heart ache for situations which many physicians find themselves in: “I lost three patients last year and started wondering if I was a good enough doctor anymore….” “My daughter told me I was a bad mommy because I always came home late….” Afterward, one doctor told me he learned things about people he had worked with for years he had not known and felt like it deepened everyone’s respect for each other.
Interactions like these in a safe environment allows people to thrive and grow together, in spite of their woes and distress. Unfortunately, many doctors are rightly afraid to share the messy middle of their stories for a multitude of reasons (see last month’s post). As a person who has also been involved in pastoral ministry, I completely understand this feeling: some people we serve or serve with want us to be flawless and many cannot handle it when we are not. In some congregations, those leaders that are honest about their failings are excised from the very communities of faith that would allow for a place of healing and restoration. Sound familiar?
To force somebody into emotional isolation like this is a wrong that cannot be endured anymore in the medical profession. As Brené Brown writes in her book Rising Strong, “The irony is that we attempt to disown our difficult stories to appear more whole or more acceptable, but our wholeness, even our wholeheartedness, actually depends on the integration of all our experiences, including the falls.” Unfortunately, to be wholehearted is not a value embedded in the medical culture yet.
I strongly contend that physicians must be allowed to be human beings at work, full of strength and weakness at the same time. When artificial intelligence is finally strong enough to take over most clinical decision making, the one thing that might prevent physicians from becoming just medical algorithm programmers is their humanity. Already, physicians are at risk of becoming automatons on a robotic assembly line of health care, dutifully playing their niche role to “practice at the top of their license.”
To create workplace cultures that are trustworthy and supportive, I suggest two definitions on this topic:
Leaders and workplace veterans must lead by example, willing to share their screw-ups and foibles, and to not always wait until perfect resolution to do so. We can gain more strength by sharing our stories while we are still in the middle of them rather than after gloriously overcoming obstacles. By modeling this and changing polices to support it, we empower people in the workplace to reach out to each other and build greater resilience in each other’s lives. Whether you serve in a non-profit healthcare setting or have shareholders, that is good for the mission and the bottom line.
Steven Reames, Executive Director
Related Previous Blog Articles
Suicide, Confidentiality and Getting Help (June 2019)
Reshaping Burnout River (July 2018)
Resolved: Physicians Should Be Free to Seek Help (July 2017)
Nobody really wants to have to talk about it because it is uncomfortable, but the facts remain: physicians kill themselves at higher rates than the average population. This has been proven through studies in the US that date back 4 decades and was even cited in the mid 1800’s in the UK. Many people recite the generally accepted estimate that about 300-400 physicians die by suicide each year – “an average medical school size” – but most do not know that the figure comes from a 1977 study published in JAMA.
Idaho is not immune to this, which is why ACMS Foundation applied for and received a grant from the St. Luke’s Community Health Improvement fund this year. With these funds, we will be able to train upwards of 400 local physicians, NPs, PAs, residents, administrators and medical students through a series of QPR trainings.
We are contracting with The Speedy Foundation to provide the Question, Persuade, Refer gatekeeper training. Like CPR, the material can be taught to anybody in a relatively short period of time to know how to look for warning signs of suicidality, ask the difficult question directly, offer hope, and where to refer people. The Speedy Foundation is named after Boise Olympic medalist Jeret Petersen, who battled depression and substance abuse and took his life in 2011 at the age of 29.
This month, ACMS brought the first training to St. Luke’s Elmore with about 14 in attendance, covering a huge swath of their medical staff. We plan to have at least four more sessions, with two already scheduled for first and second year classes of the Idaho College of Osteopathic Medicine. The training is useful for opening conversations with colleagues, patients, family members and friends. We are working to make at least one of these open to independent ACMS members.
As we have planned and implemented this training, some of the discussions I’ve been part of highlight the difficulty in asking this question of medical colleagues, knowing where to refer them appropriately, and some of the real reasons why physicians are reluctant seek help. Among many physicians, there is still some very deep skepticism and cynicism when it comes to looking for help. They still feel that their privacy, reputation, licensure, and means of making a living might be at stake should somebody find out the level of their pain.
These are tough issues to address, tender points among high performers who have seen some well-intentioned efforts go awry. But avoiding them doesn’t make them go away and our hope is that by talking about it more and more, we can foster a more trustworthy and supportive culture in medicine so that physicians can tend to the inherent emotional challenges of their work.
This sensitivity around confidentiality is part of the reason why ACMS chose, when starting its Physician Vitality Program (PVP), not to have any record or knowledge of the members who participate. We built the counseling program around maximum confidentiality whereby:
The only thing ACMS ever gets back is billing with demographic reporting (member type, career stage, gender, employment status, specialty, and types of challenges presented). If participants are concerned that the unique combination of these data points would identify them, they can say “other” to mask themselves. We're glad to have added a couple more contractors in Boise this month to our pool and intend to get one in Elmore County, which is part of our membership territory.
More information about Physician Vitality Program
If you are interested in hosting a QPR training at your practice or facility, please let me know.
The High Rate of Physician Suicide
Preventing Physician Suicide (1977)
Medscape's 2018 Article on Suicide
As we prepare to publish our membership directory, we have finalized our 2019 membership numbers and I felt it would be a good time to reflect on the trends.
Total ACMS membership climbed to just over 2000 for the first time in our history and this was due in large part to the addition of the first medical student class of the Idaho College of Osteopathic Medicine. ACMS represents 60% of the Idaho Medical Association’s total membership and 55% of its physician members.
Exactly half of the 1091 actively practicing member physicians (not retirees or residents) are connected to a hospital system as employer or clinic owner. This represents virtually no change from the prior year in real numbers or percentage.
In keeping with nationwide trends, the ranks of female physicians continue to grow, up a couple points over the prior year, and now representing 34% of member doctors.
The percent of ACMS’ actively practicing members in various specialties is closely representative of the 2017 AMA Master File. The only specialties locally that show more than a percentage point variance is Family Medicine (+6% in Boise), Emergency Medicine (+4%), Pediatrics (+3%) and Psychiatry (-2%).
As I reflect very briefly on these trends, my thoughts are:
Thank you for your membership this year and being part of a vibrant local medical society.
Whenever I have gotten the opportunity to eat a gourmet meal and the $35 dish is brought to me with only 50% of it covered in food, I start to feel ripped off. “Where is my $12, overloaded all-you-can-eat, Chuck-a-Rama filled-up plate?”
And then I taste what is artfully prepared and presented and remember the meaning of “less is more.”
I was sharing with a friend recently about the similar temptation to fill my life up to the brim, where I leave no margins for rest and replenishment. I cut out the white space of my schedule, always thinking that more is better and I want to have options, a little bit of this, a little bit of that. Invariably I get to the overfull, post-buffet feeling of, “I regret that I ate everything I put on my plate.”
Moreover, even though my job is entirely about serving our members, sometimes I feel like I am wasting time when I spend effort being relational rather than punching off tasks. I flashback to what my college pastor and mentor told me, “Steve, you are already efficient with tasks, but you need to become more effective with people.”
Ouch. It still hurts.
I know this is not just a personal problem. All too often, our very national culture of productivity and high-output becomes a gluttony for activity and turns towards an addiction to stimulation. Never is this truer than in medicine, where the trend is to try and squeeze every ounce of value out of increasing healthcare costs. But Princess Leia’s defiance certainly applies here: “The more you tighten your grip, the more star systems will sleep through your fingers.” We are becoming less effective with patients and struggle to remain efficient with tasks because there are just too many to hold on to.
Somehow, we must learn to build margins and rest both into our personal and corporate lives, even if it makes us feel guilty for being unproductive and inefficient. As they attempt to move towards “zero-harm,” healthcare employers and leaders must stop thinking about their organizations as 99.9999% uptime machines and start thinking of them as living systems built of human beings which cannot operate effectively OR efficiently 99% of the time.
I believe as we recover this flavor of our humanity, the quality of what and how we serve patients will leave them more satisfied and healthier than trying to offer everything imaginable.
For me, Winter Clinics is a mixture of extreme logistical output and a cathartic soaking up of gratitude. It is the culmination of many months of work, putting together speakers, travel arrangements, food choices, graphics and design work, securing sponsors and exhibitors, CME paperwork, videoconferencing arrangements, registering attendees…and making it all look like a well-oiled machine.
So as the event begins and wears on and there are inevitably things I want to fix or change, overall it is a weekend filled with various people being quite grateful. This is a moment that I purposefully slow down, listen to what is working and appreciated, and glow in the bask, sucking it in as potential energy for future event planning. When recognized amidst a crowd, I will sometimes even do a small bow, tipping my imaginary hat as if to say, "You're welcome. It has been my pleasure."
And it really is. For those of us gifted in hospitality and event planning, it turns our crank to put the gift of a conference, a dinner or a social all together and watch others unwrap it. I won't apologize for the satisfaction that comes from performing my job well.
And neither should you.
When Dr. Dike Drummond, author of thehappymd.com blog, spoke to us in Boise last May, he talked about moments like these in the exam room. He emphasized how important it is when a patient or their family members begins to thank you for your care that doctors need to stop, turn and give them your full attention, listen closely, and breathe the affirmation in deeply. It's like sitting in the warmth of the sun.
This is why you went to medical school, muddled half-awake through residency, and sometimes skip your kids' soccer games. It was to care for people and be a healing presence in their lives. If you aren't paying attention amidst everything you have to do, it is too easy to let those thank yous go to waste. In fact, some of us have the awful habit of blushing in self-deprecation and saying, "Oh, it was nothing (de nada)" when it really was something huge for them.
In fact, when we slow down, we might actually create more relational space to allow for more gratitude from others. My bad habit is wandering through a room of people with an "I'm too busy to engage with you" look on my face (and sometimes I am.) But when I slow down to prioritize relationships over tasks, it makes my job so much more meaningful than just punching things down. I know this is difficult when you still have to punch those things down, but it can make the extra time spent later so much more worth it.
Having interacted with many of you, I can see how much effort you put into your work so may I be the first (but not the last) to say, "Well done. Thank you for all you do."
At our annual R2 Unit training yesterday, our keynote speaker shared about Practicing Courageous Leadership. Erica Davis is Program Manager for Organizational Design and Provider Engagement for St. Luke's Health System. During this half-day occupational readiness training for about 30 program year two residents (drawn from three local and two East Idaho residencies), Erica talked about some of the core competencies of what leaders do and how they behave.
It is a talk I wish all of our members could hear. She started by asking how many of the residents thought of themselves as leaders and was happily surprised by about ¾ of the room indicating yes. She said this was unusually high and that most physicians she talks with don't see themselves that way unless they hold an official leadership post.
She said, one of the things that are true about all leaders is that they help navigate change. To understand this, we might think of this breaking down into at least three skills:
1) Can you envision a future that is different than the present? Many doctors – read 'scientists trained in science and evidence-based medicine' - have given up on honing their creative and imagination skills, so this is often an area where they get stuck.
2) Can you paint a picture of that future in terms that captures the hearts and minds of others, or at the very least, your own? It is not enough to complain about the present: leadership requires the ability to put some specifics about where you want to go into words or pictures that motivate
3) Can you help people identify and get over obstacles moving towards that future? These obstacles might include internal and external objections to change and you may need to help redesign systems and environments to support attitudinal and behavioral change.
As a physician, you could find yourself leading in one or more of these realms beginning with:
1) Yourself! Internal motivation, setting goals, and self-discipline – you all have this in you if you made it through medical school and residency. Although Erica has the official title of "program manager" for provider engagement, the fact is all physicians need to take on this title as it relates to themselves.
2) Patients. Is not enough to have the medical knowledge of what is wrong with a person's health or even what the solution is. You also must learn the skills of empathy, motivational interviewing, and behavioral change management.
3) Teams. Unless you are the only individual in your office, you have a team to lead. This means growing in your knowledge of group dynamics, conflict resolution, encouraging people, and measuring progress.
4) Organization. Whether it is your own small business or you are responsible for an entire department, you have to get stronger in communication, quality control, budgeting, environmental scanning and systems change management.
5) Culture. This is by far the hardest to bring leadership to because it involves helping shape the way people think before they change their behavior. But it also has the greatest potential for long-term transformation and something that physicians should not shrink back from.
Although some are born with a greater leadership inclination than others, these are skills you can learn. Erica's talk leaned heavily on social scientist, Brené Brown, who pretty much owns the global market on the topic of vulnerability. Any of her books are a great start in "Daring to Lead" and I hope you will dare yourself to do just that.
I have often been identified by people as being a physician, to which I generally respond saying, "Well, I'm not a physician, but I've played one on TV." At that point, I can tell if they grew up watching Marcus Welby MD or not. Regardless, I am like many physicians who are often prone to jumping very quickly into diagnostician mode whenever they see a problem: mentally you run through symptoms and observations, identifying potential solutions and make your assessment. Then you define a treatment that has the best chance at success. Take two and call me in the morning, right?
But, in recent years many physicians are learning how to more fully involve their patients in decision making and finding it is a more powerful form of practicing medicine. This is especially true when a patient needs to make lifestyle changes that will enhance their health. Setting aside your differential diagnostician and voice of authority and eliciting their personal motivations and goals can be a challenge for many physicians (and certainly isn't appropriate for every situation.)
So you might understand ACMS' challenge in facilitating a collaborative process that has many stakeholders and interested parties affected. Right now, I am just getting started on building a "Capital Coalition for Physician Well-being." We are at a place in our medical community where the collaborative intent around shaping a better healthcare culture is very high.
But this isn't just as easy as saying, "What's the problem? What are potential solutions? Let's get to work." Collaborative problem solving is much more complicated, needing a high degree of trust and patience as each party shares their perspectives, negotiates towards agreed upon solutions, and then gets to work, each on their own and in parallel with the others.
In our situation, this is further complicated by the fact that ACMS has no control over what participating physician groups or health systems may choose to accept or reject as potential solutions. I am not the fallback CEO who says "you all will do this if we can't agree to a plan of action." It is either completely collaborative, or nothing moves forward.
I do have high hopes, however, mostly because of what I've seen emerge out of partnerships over the past 3 years as well as who I've seen emerge. Physician leaders from many different levels of health systems, educational institutions and solo practices are ready to roll up their sleeves and say, "Not just for my workplace, but for the good of all the doctors in town we're ready to get to work, together!"
With that, we start 2019 with great anticipation of what is possible, not because it is easy, but because of the hearts of those who care for their colleagues in this noble profession.
I know some doctors who have never learned to establish good boundaries in their lives. By that I mean, they really don't know how to say "no." This is not entirely their fault: the medical education process teaches not only the applied practice of medicine but also the fortitude to be able to go beyond what is comfortable. And that involves a lot of boundary violations.
So, it is no surprise that after residency, many physicians never really learn how to take back control of their life and save some white space for themselves. It can be a mental, and even spiritual, exercise to work through the difference of "the patient always comes first" and the need for your own rest, rejuvenation, and personal life away from medicine.
Here are a few thoughts on creating some healthy borders in your life for your own longevity's sake:
1. Give yourself permission to set boundaries. The practice of medicine will consume every inch of ground in your life that you don't reserve for other purposes. It does not help that your education and enculturation will tell you that is normal. But it is your right to decide how much you’re going to give. You must choose when you are going to be generous, otherwise, it is too easy to feel resentful for giving more than you wanted to.
2. Know your values. It is crucial for you to know in your life what is inviolable except under the most extreme circumstances. Is it your running therapy? Weekend worship? Family vacations? Personal space? Only you can say what you need to protect and what you can afford to be squishy on.
3. Create structure. Sloppy boundaries invite incursion. I remember a time when my wife was pregnant before we had a fence built and the neighbor boy would practice his ball bouncing skills against the outside wall of our bedroom. Not only did we tell him not to do this, eventually we built a fence. Structure in your work and family life helps reinforce boundaries you have established.
4. Communicate your limits clearly and proactively. The Great Wall of China was a pretty effective sign saying, "thus far and no more." Same thing with razor-topped fences around U.S. military facilities. If you have not yet communicated to others what your boundaries are, then you cannot assume they are going to respect them.
5. Prepare for violations. You can bet that every civilized nation has a plan for what happens if their neighbor crosses into their territory, be it land, air or sea space. People will push your limits, intentionally or otherwise, and you need to become adept as a physician at how you will respond. It does not have to be harsh, rude, or violent – it just needs to be clear and firm.
6. Pay attention to your feelings. Guilt, resentment, anger, lashing out at others: these are all red flags that something has been violated, sometimes unspoken or unarticulated even to yourself. What kind of warning signs tell you when somebody has crossed a perimeter that you have established?
7. Bring up boundary violations quickly. It is not effective to tell somebody that they violated your boundary six months ago. A perfectly acceptable response in the moment – and an example of training others what your limits are – might sound like, "No, I am sorry. I will not call in that prescription because I am not the doctor on call. Please call Dr. Jones instead." The problem with saying, "just this once" is that it never seems to end that way.
8. Practice saying "no." It is so difficult for most of us to feel like we are letting others down and there are certainly times in your calling when you will have to say "yes" even though you don't want to. That is fine and none of us get this perfect. This is more reason why you must practice saying "no" to things you really can deny.
When doctors unlearn some of the "brainwashing" they underwent early on, it helps create a more sustainable life of service to others.
St. Luke's Treasure Valley VP Medical Affairs Dr. Frank Johnson and Saint Alphonsus Physician Resilience Medical Director Dr. Sheila Giffen, during a joint Peer-to-Peer training session.
by Steven Reames
Let's look at some of our local health institutions' mission and purpose statements starting with the shortest:
Director: Steven Reames, email@example.com (208) 336-2930Membership Assistant: Jennifer Hawkins, firstname.lastname@example.org (208) 344-7888305 W Jefferson Street Ste 101, Boise ID 83702 FAX (208) 336-3294
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