Steve Swensen, MD, Medical Director for Professionalism and Peer Support at Intermountain Healthcare, sat down with Taylor Davis with the KLAS Arch Collaborative to discuss professional burnout in healthcare. Listen to understand what burnout means for our caregivers, but most importantly, what it means for our patients. We like the conversation so much we wanted to share the full dialogue, enjoy! 

Steve Swensen: If you look at esprit de corps, esprit de corps is the spirit of the body, of the team. It's camaraderie. It's joy, satisfaction, and it's resilience with no burnout. Esprit de corps is the most important and impactful leading indicator, and we don't have a lot of leading indicators in healthcare, leading indicator of patient experience, patient outcomes, and patient safety, and organizational effectiveness. 

Taylor Davis: Unsurprisingly.

Steve Swensen: Yeah, so why shouldn't every organization focus on the well-being of their caregivers, so that we can all give better care for our patients? I think that's the opportunity we have in the whole developed world, where we have numbers that show that the profession that probably should have the most meaning and purpose and the lowest levels of burnout, by the nations that work, have the highest levels of burnout.

Taylor Davis: I think that is a really critical question to be asking, which is, why are we all not focused on this? As you think about different things that you focus on in your life, some things you focus on because you feel like that they're not important. That can't be the case when it comes to caregiver wellness. The other reason why an organization maybe wouldn't focus on this is because they don't believe that they can fix it.

Steve Swensen: Yeah. I think that's part of it, that some organizational leaders just say, "It's the nature of the beast, and I'm not sure it's evidence-based with the approach, and I'm not sure there's a business case." In fact, we know there's a business case. There's a rock-solid return investment, very similar to the era we went through with quality in healthcare, where in the early days, many leaders looked at healthcare quality, variation of waste defect through the eyes of the patient, as being an important expense. Then they grew to understand, like all the other business sectors, there is actually a business strategy that had a rock-solid return on investment, like manufacturing or like oil and gas, or like any other industry saying, "If we improve the care of patients, we get better results for them, and our finances are better as well."

Taylor Davis: Healthcare is different than any other industry in that the options that leadership can walk down, the roads that they can walk down, are just staggering. There are so many different things that they can go focus on. In an organization that's not focusing on clinician well-being, it's not that they're a bad organization or bad people, because there are so many different other areas that they can put their effort. There are so many things that are new in modern healthcare that we don't always know exactly where we can put our efforts. It's interesting in the collaborative efforts that we've been doing at KLAS is we meet with an organization and share with them that their EMR is contributing to a very negative experience at their organization. Not always, but for some organizations, we'll share that with them.

It is more common than not that we almost are acting as cheerleaders to the leadership of that organization and helping them believe that they really can make some changes. It is very, very common to be on the phone with a CIO, a CMIO, or even a CEO where they look at the results, and we offer suggestions of where they can make some changes. They say, "We need to think about whether this is something that we want to do or not." There is a slight despondency. These are individuals who've tried things in the past, and it hasn't worked for them. We need to put a science to this in order to really learn what can actually make a difference as we move forward on this.

Steve Swensen: The best leaders do this because they care about their doctors and nurses and NPs and PAs and so forth. They care about the caregivers, and they understand in their peripheral vision that it's the right thing to do for the business as well. If you look at professional burnout in America and in the OECD countries, about half of physicians, about half of nurses are experiencing burnout, emotional exhaustion, cynicism, depersonalization, a feeling that you've lost confidence in your ability to do the best care for patients.

What that leads to for the caregivers is higher rates of turnover. It leads to more medical errors. It lowers productivity. There are more thoughts of suicide. The suicide rates of physicians and nurses are about twice that of the general population. Then what does that mean for patients? For patients, it means they have poorer outcomes. They have less satisfaction. Their costs go up. There are more tests and procedures ordered on them. It's bad for everyone involved, most importantly the patient, of course the caregiver, and of course the organization.

Taylor Davis: Absolutely. It really hits home. Just recently, I had a close family member that spent a couple weeks in the hospital. I think for all of us, healthcare is an industry that we can relate to, because we've all had experiences like that. We all realize how critical it is in those moments, and how helpless we feel sometimes when we have a family member in the hospital. We really need a whole team. You could even have a relative. My father is a physician, and he can help in situations like that, but you need a full care team and you need a care team that is working like a care team. Physician burnout kicks the knees out from a team mentality in healthcare.

Steve Swensen: It does. I worked with a large system a few years ago. The woman that headed up this system of hospitals had ... Her son needed a kidney transplant after years of dialysis. He had the procedure done in one of her hospitals. Technically, everything went well. There was no infection. There was no remission. There was no medication errors, and the kidney worked. But she described her son's and her family's experience in her own hospital with seven words. She said, "There was no love in the system."

What that means from the research in this area is that means that patients have a poorer experience, and they don't heal as fast. Their physical wounds don't heal as fast if they don't feel empathy and feel love from the care team. If you look at the population health piece of it, caregivers who feel empathy with their care team are more likely to follow through on their health plan that saves them money, improves their health, and saves the system money. If we lose the love from this care team to the patient and family, there are many more consequences than more medical errors and longer length of stay.

Taylor Davis: We're learning more and more in medicine as we move forward about the importance of not just treating the body, but the whole emotional and the whole being of patients and those who come into healthcare. It reminds me, as you mentioned, of some of the recent research that, several years of research that's been out there about the effects of loneliness and how dangerous that is for any population, but especially for a baby boomer generation, and how critical it is that we get ahead of that. Frankly as you speak about that, a hospital or healthcare system without love is a very lonely place. We're learning that loneliness is dangerous. It's not only doesn't help healing, but it's actually dangerous to healing. How do we create inviting environments where a team can be a team, and everyone is focused on creating a great holistic experience for these patients?

Steve Swensen: The research that we've done and experience we have with now over tens of thousands of healthcare professionals in different organizations, one of the tactics is to do just that, is to build camaraderie, because we know it makes a difference to combat burnout and bring joy in work. One of the tactics there is a fancy word called commensality. Commensality is a word that means sharing a meal together. The original research was done with firefighters who eat a lot of meals together, make a lot of meals together. Basically, commensality improves team dynamics, team performance, and camaraderie, and outcomes. At Mayo Clinic, there are some physician leaders that ran two randomized control trials with doctors in commensality. Guess what? It improved all the dynamics of professional burnout in the doctors that had a meal together and talked about something in their lives, patients and mentors and coaches and good cases. It decreased emotional exhaustion. It decreased social isolation, increased positive feelings about the organization. This camaraderie, whether it's over a meal or not, is part of one of those human needs that, if we lose that in any parts of our lives, and our work life is the biggest part of our life, then we're vulnerable to bad things, including professional burnout.

Taylor Davis: Yup. It's interesting how you say that, the importance of having a team environment. Healthcare is moving much more towards a team, and one of the areas that has created a significant stress for healthcare providers and clinicians has been moving from a paper chart to an electronic chart. I think of these almost as two different sports. You have a solo sport with a paper chart, and you have a team sport with an electronic chart. Right now, we're watching in the Olympics. We're watching a number of team sports and a number of solo sports, and there's a very different mentality as to how you approach those. When I was working in a paper chart as a physician, I could write what I wanted to write. I could write it where I wanted to write. I could own that chart in many cases for the patients that I worked on. Sure, others could get in, and they could look at that. Charting is in order to enable a care team to work together, but in an electronic medical record, I can't just write anything that I want to write anywhere that I want to write. I don't have control over how that electronic medical record works, and frankly I have to work with a large team that doesn't just include other clinicians, but includes healthcare administration, includes IT, can include an EMR vendor.

All of a sudden, I have to work with a much broader team than I've ever had to work with. If I am used to being a solo sport type of caregiver, and now I need to work in a team environment, I have to fundamentally change the way that I approach healthcare. That's one example that if we can't make that change, then you took a solo sport individual playing a team sport, and they just are frustrated. It can create significant challenges for them.

Steve Swensen: A couple things. Today with all of the expertise and knowledge needed for the best care for patients, it has to be a team sport. The EHR used correctly can facilitate that. If there are physicians that think that it's still a heroic solo sport, they're not safe. They need to understand that. It has to be a collective effort with a team of physicians and nurse practitioners and physician's assistants and nurses and social workers and pharmacists in a psychologically safe environment where collectively they get the best care. The goal then is to facilitate teamwork, and technology can help with that. We should be training and selecting physicians for ... IQ isn't that important. It's the EQ and their ability to work at a team empathetically and with more of a participatory management, instead of I know all the answers and we're turning left here.

Taylor Davis: I think one really good thing that healthcare has that is not common to every industry is is that we have some of the most insightful, kind, and educated workforce that any industry has. Actually, I would put this workforce up against any other workforce in any other industry. As we look to face some of these challenges, we could have really strong optimism that we're going to get to a good place, because of the wonderful people that make up healthcare. But we need to listen to them.

One thing that we've learned, and if I could give a little bit of background as to some of the work that we've done, KLAS is an organization that does research by gaining perspectives from healthcare leadership about their IT decisions and how well those have worked. We have been hearing for so many years frustration around the electronic medical record being a hindrance, really strong comments about that. We started asking healthcare organizations, "Are you systematically collecting the feedback of your clinicians regarding your EMR, because it's a huge pain point that's being reported?" After surveying roughly 100 organizations, we only found seven that had surveyed the feedback of their clinicians, that were actively putting out a microphone and saying, "Please tell us your feedback." Only seven had done that in the last three to four years.

As we've walked down the road with this collaborative, we've only been doing it for 14 or 15 months now. Just with a simple idea of healthcare is full of the smartest people in the world, let's have them come in and help us all solve this problem. Here's the amazing thing is that the insights that they've given us are different than what we all assumed. As we walk towards these challenges, if we make assumptions about some of what's going on here, and we don't take the time to listen to this amazingly bright workforce and some of the challenges that they're giving us, we might be solving the wrong challenges and might be chasing our tail. It's really critical as we speak about teamwork that we also, and when I say we, anyone who is working to improve this, that nobody goes out on their own with their own agenda, but that we really listen to the feedback from this amazing workforce.

Steve Swensen: Yeah. You're exactly right. I think the opportunity here to address professional burnout is real exciting, because it'll make a difference for patients. We know that we can flip numbers with certain interventions from leadership to commensality to participate in management to looking at workflow issues. One of the opportunities is the EHR. There are several mistakes that organizations make in that space. One is to say it's only the EHR.

Steve Swensen: In fact, in our experience over looking at hundreds of work units, EHR is absolutely an issue but it's not often ... More often than not, it's their other frustrations and inefficiencies that sap the joy. It's easier for people to talk about the EHR because that's front of mind. It's an issue. It may not be the dominant issue. The first mistake that organizations make is to say, "It's only about the EHR. Either we're a victim, we can't do anything about it. It's all these technology companies' problem, and we're stuck." Big mistake. The second mistake organizations make is say, "It's only about the EHR," and address it successfully, but then they ignore all of the other issues with meaning and purpose, and flexibility and control, and camaraderie and respect and teamwork, and psychological safety, et cetera. That's another mistake.

I think it's healthier to actually not target the EHR and just talk about the electronic environment. Much of what the EHR is a surrogate for is all the clerical work that either externally regulatory agencies, CMS, whatever have put in place for the public reporting. With meaningful use, that's changed in the last generation that we'd have to be doing with a paper and pencil if we didn't have electronic health records. There are workflow and efficiency issues with electronic health record that we should address, but look at the whole environment from iPhones and alarms and email. All of that together has changed the cortisol levels of physicians and nurses in a bad way.

Taylor Davis: We have been really surprised as we've walked down this road. We've collected the feedback of over 30,000 clinicians from almost 90 organizations regarding their experience with the EHR and with their technology. We have one question right now. We're going to be expanding this. We're in discussions about adding a physician wellness component to this survey overall, but we have one question regarding clinician fulfillment. The correlation between EMR satisfaction and clinician fulfillment is very low. It's a fairly weak correlation. At first, we were very surprised by that.

However, as we've gotten more and more into this, we realize that where maybe 12 months ago, we assumed that as part of this collaborative we were going to be having lots of technology discussions, we're realizing that now we're having lots of change management and culture discussions. In a lot of ways, just to focus on the EHR is a misnomer. However, organizations who are trying to create a great experience for their clinicians look at everything holistically. They look at the team environment. They look at what's going on, and they also ensure that the technology is enabling and accelerating great care.

As we have started to get into this, we realized that the keys to successful EHR deployment are three-fold. One is is that clinicians who use the EHR can't feel stupid. Roughly over half of physicians we find express frustrations that they feel stupid when they use the technology, when they use the EHR. No one likes going to work and feeling stupid. Nobody likes to do things and feel stupid, especially a workforce that's gone to school for over 12 years after high school in order to get to the place where they are. This is especially a group that doesn't like to do that. We're not giving enough education to some of the technology that we're doing. There's other areas in the hospital where we're also not giving enough education. To work as a team, you need to have the skills that you need to have. It's not just the EHR. We need to holistically look at, are we empowering people with the skills that they need and not just only relying on medical school to do that?

Secondly, we're finding that individuals who are using the EHR feel like they're using a one size fits all EHR, and it's not configured to their needs. That's extremely frustrating if we don't take the time to help configure it to make it work for them. You talked about depersonalization of being a challenge with physician burnout. Asking everyone to use the exact same EHR, not that we should be using different products, but not configuring it to my needs, not taking the time to configure it to my needs as a caregiver, that's depersonalization. That means that I as an orthopedic surgeon should be using it the same, which I'm not. If I were an orthopedic surgeon, I have to be using it the same as a podiatrist, the same as a urologist. Well, we have very different workflows. To be expecting us all to use it the same way is not fair.

The third piece that we're finding is is that the organizations who are highly successful, the end users report a high level of trust with leadership, administration, IT. Again, speaking to the team environment, they feel like that these others care about their patients as much as they care about, and their efforts to give care, they care about it as much as they do. As we step back and look at some of those drivers of EHR satisfaction, they're absolutely in line with drivers of success in reducing burnout and strong clinician and physician wellness. These two efforts overlap. If you're effectively working on the EHR, you're effectively working on burnout, and vice-a-versa. You really can't touch one without the other, because they're so tied into the culture of an organization and where the organization is going.

Steve Swensen: You're exactly right. They're inextricably linked and intertwined, and there are dividends for workflow and organizational efficiency and the well-being of the caregivers. One of the first steps is, if you look at the workflow in urology or orthopedic surgery, is to track it. A couple big landmark studies, Sinsky looked at the ambulatory settings, hour of doc time with patient, two hours of clerical work. Hill in the emergency department, 10-hour shift docs 4,000 mouse clicks. That's out of hand.

The first thing you ask is, well, are these most clicks necessary? Is this process or documentation there because of a regulatory reason or patient safety reason? If not, stop doing it. If it's necessary, then make it as efficient as possible. Squeeze out the most clicks. The third is then, if it's necessary, you've made it as efficient as possible, then find the right person on the team to do it. Can be a clerk or a scribe or an NP, PA, RN, or a physician, and then you've got the team working together in an optimal work environment.

Taylor Davis: If you don't mind, this may be an area where I might disagree a little bit if that's all right.

Steve Swensen: Yeah, please, yeah.

Taylor Davis: 12 months ago, I would have absolutely agreed with what you just described, and I do mostly agree. What we're finding though is is that if we treat the EMR like a paper chart, then our expectations also are not higher. We're finding that the most successful clinicians, it's not that they've found dramatically better ways and that they've reduced the burden of getting data into the EMR, which we should always be focusing on. However, we're worried that that's a little bit of a red herring to making the EMR successful. Where organizations that are helping clinicians be very grateful for the EMR and the work that they have to do clerically, they're helping them get data out of the EMR really, really well.

What are some of the things that they're doing? Less than a third of organizations create any sort of enablement for clinicians to have any sort of reporting on all of this data that they're putting in. The clinicians are putting lots and lots of data in, and there are incredible analytics that I should be able to have, just as a single caregiver, around how I'm doing, around how my patients are progressing, around hot spots I need to look at. Less than a third of organizations are enabling those for clinicians.

Also, if we look at some of the education and the training ... I don't love that term with the EHR. It feels like something you do with a dog. The education around an EMR, organizations typically spend over 90% of their time in that education talking about how to get data into the EMR. We've only made the EMR a burden. The point where clinicians start to say, "Hey, I'm grateful for this," is when we work really hard to get data out of the EMR, really crispy and cleanly.

There are some other efforts with interoperability, with reducing note bloat, some things like that that could make a huge difference, so that as a clinician, yes, I have to continue to do this, and there are some efforts that can decrease the burden of getting things in. We should be looking at clicks. We should be looking at the overall user experience. But let's make sure that we also bring the value and the benefits to clinicians, because those are so under-accessed by clinicians. They're living so far below their privileges when it comes to actually seeing the benefits of technology, of everything that we've been working on.

Steve Swensen: Yeah, so that makes sense. I agree with that. The first thing we have to do is help the doc though, because they're suffering. They're hurting. The organization needs to be authentically interested in their well-being.

Taylor Davis: Yes, I agree.

Steve Swensen: What Intermountain Healthcare does, it's kind of interesting. They have 5,500 docs. They monitor the use of the EHR across the whole enterprise of 39,000 caregivers to see who's working nights and weekends, who is less efficient at charting. They find the outliers. It's a very caring super-user clinician helping clinician experience. Tap you on the shoulder and say, "Taylor, we can help you." The first thing they do is they say, "You're taking 67 mouse clicks to chart otitis media. It only takes 18, so here's how we can help you with that, including extracting information about this patient." The second is workflow. It has made a huge impact on after-hours use of EHR for the docs that are burning out. When is the best time to chart? How do you workflow in urology and orthopedic surgery? That dramatically reduces their wasted effort during the day.

The third thing is multitasking and interruptions. The team at Intermountain Healthcare teaches physicians that multitasking is a myth for efficiency gains. It actually decreases efficiency. To the extent that you can control the interruptions in your workflow, you can make a huge difference in your stress levels and in the amount of time that you spend wasted on clerical work or reengaging. Those three tactics have dramatically reduced, 30 to 40%, in this most vulnerable group of physicians, helping with their interface with an electronic environment, to the point where they now can come home for dinner and stay home mentally because they're done with their work by the time they get home.

Taylor Davis: Yup. I think one of the critical things is is that as we've been out, and as I've been out at organizations and have talked to physicians, as we've collected the perspectives of these 10,000+ clinicians, and we look at some of the correlations, so we ask how much after ... Self-reported, how much after-hours charting do you do? We look at some of these trends. It's interesting. There's different cultures for different organizations regarding after-hours charting, and there's different cultures for different people.

As we approach this, and I'm sure that this is something that you're seeing, asking people what matters to them and then helping to make that successful for them is really critical. Different things matter to different people, and for one individual, doing some charting at night is beautiful flexibility and something that we hear a good amount. "Don't worry about me doing charting at night. I don't mind it. I'm grateful that I'm home by 5:00 every night in order to have dinner with my family. That's what matters the most to me." Some others care a lot about and are happy to stay until 6:00 or 6:30, finish their charting, and then want to be home and be all the way disconnected.

We all have different preferences, and I think that what you said when you started, which is the most critical piece, it really starts with true caring. As caregivers know, you don't just treat the symptoms. You ask what matters the most to the patient. If we're going to help the wellness of our physicians and clinicians, we have to really ask them, and we have to understand them. Somebody has to really understand what matters to you as a clinician and enable you to be successful with that. Whether that's reducing your mouse clicks, whether that's helping you get home on time, whether that's increasing the flexibility of what you're able to do or getting to the insights of what you need to get to, I need to understand what's important to you, and I need to help enable that.

Steve Swensen: I think that if you look at the holistic approach to addressing professional burnout, specifically physician burnout, that's the right approach. Then the EHR is just a small part of it. When we did this at Mayo Clinic over the last decade, we looked at the 20 departments and divisions that had the highest rate of professional burnout. Every one of them had dramatic improvements in their esprit de corps over the next two years of work. To some of them, three of them went from the highest rates of burnout at Mayo Clinic to the lowest rates of burnout at Mayo Clinic. That was already below the national average.

It basically started with this. We would go in in support of the division or department chair, focus group six to eight docs, and say, "What brings you joy in work? What saps your joy at work? What are the pebbles in your shoes? What doesn't work well in this unit? What are the inefficiencies at work?" Then we together would take notes, and we'd have a list of a couple dozen things. We'd prioritize them, and then not for them but with them, address those issues.

EHR came up occasionally. The vast majority of the time, it was workflow issues. It was team dynamics. It was communication and handoff things. Over half of the issues that were brought up by physicians as frustrations could be addressed locally without a capital budget, just the time and attention of workflow, fixing broken processes, clarifying communication, or putting the process in place where there wasn't one. It takes time and attention for the vast majority of this, not a big budget.

Taylor Davis: You mentioned earlier being a victim. We can't allow any healthcare organization to be a victim as far as this goes. One organization that we've worked with that's been wonderful, and I have their permission to share this, JPS Health System, probably not a group that almost anybody knows unless you're from the Texas area, a public health system. They reported and have shared with us some of their clinician satisfaction surveys going back five years, an incredibly low clinician satisfaction.

A new leadership team came in. A new CEO came in. One of the rules that they put in place, this was word for word, we don't work with jerks. They have asked jerks to leave their organization, and there is an expectation that you be kind to everyone that you work with. What happened? Out of the fulfillment question that we've asked over 50 organizations, they're a delta ahead of every other organization. What's fun is just to talk to them about what they've done. They said, "Look, there's two things that really matter here in this story."

I'm paraphrasing. They're actually a fairly humble group, so they don't say it as strong as I'm about to say it. "One thing is that we've moved from horrible to great. If we can do it, then other organizations can do it. If there's a feeling that just some organizations are great to work for and some are not, and if I never have the beautiful lobby of Northwestern Medicine or some of these well-known organizations, or if I don't have their strong name, then I can never be successful with that, that's just false."

Steve Swensen: That's right.

Taylor Davis: They also talked about, "We're a public health system. Look, we don't have a lot of money. We don't have a lot of clout. There are not big reasons as to why you should absolutely love working here." However, as we worked with some of those leaders at that organization, they expressed over and over again that this is the best place that they've ever worked.

Steve Swensen: You touch on something that's really fundamentally important, Taylor, and that is leadership. If I were to pick one thing that was the most impactful for esprit de corps and eradicating burnout, it would be point-of-care leadership. The senior leadership needs to be supportive of all, but we studied this at Mayo and we managed to it at Mayo. Basically, there are five leadership behaviors of the nurse manager, the head of nephrology, whoever the urology or the orthopedic chair or unit leader or practice leader, there are five behaviors that in a statistically significant manner correlate with higher rates of satisfaction and engagement. For every point on a 60-point scale up, there is 9% increase in satisfaction. For every point upwards, there's a 3.3% decrease in professional burnout.

The five behaviors are common sense. They're just not common practice. I appreciate your work. Thank you. I'm really interested in your ideas. Let's figure this out together. Let's communicate transparently. Here's everything we know about this work unit. That's all the data that's not confidential. We're going to figure this out together. Four, I'm interested in your career. What do you want to do at JPS, at Northwestern, at Intermountain? Let's work together so your dream comes through as a professional in healthcare. The fifth is everybody on the team, regardless of genome or phenome, what kind of scarf they wear or not, feels respected and trusted and included.

Those five behaviors that you can measure with a leader index. When I was head of leadership development at Mayo, we had 242 point-of-care physician leaders. Every one of them had a leader index that we got from annual surveys of the people that they served. Big bell curve. We worked with the doctors, leaders at the bottom, to make them better. Guess what? Burnout went down. Engagement went up. Esprit de corps went up. Leaders matter, and the cost of that? Time and attention.

Taylor Davis: As you talk about, I want to circle around a little bit to the EMR, because one of the challenges is is that the EMR can exaggerate, can amplify challenges when there's not listening, when there's not respect, and when there's not communication and teamwork within an organization. The challenge is is that an EMR creates a situation where, as a clinician, I sit down and I start using it. Something looks clinically ridiculous to me. I say to myself, as a clinician I say, "I can't believe that they want me to do this." I quickly make some assumptions about the ridiculousness of the leadership and the teamwork, and what a poor organization this is.

Then if I amplify this, and we have gone and had some webinars, and had some of the leading organizations share what do they do in order to be successful with EHR, and the highest satisfaction organization that has participated in the collaborative is Kaiser Permanente's Northwest region. Mike McNamara, a good friend and the CMIO of that region, said one of the most critical things is is that when a clinician walks in the door with a challenge with EMR, that they really feel listened to. He said that, "We have a common practice of how we work with them so that we don't give them a no." They walk out. They always have to walk out with options of how they can fix the challenge that they're facing.

I just did a webinar this past Monday, so this is a worldwide challenge. I just did a webinar this past Monday with Rachel Dunscombe, the Director of Technology for Salford Royal Group in the UK. What's interesting is they're in northeast England. That's a group that, if you know and she'll say this, that's not always a group that's super positive, but they're incredibly positive about their teamwork and their EMR. They have a place where anyone can come, sort of a home base for their EMR, a large room. She said, "Our team's goal is is that any time that anyone walks in angered, they walk out empowered."

One of the key things to remember is is that the EMR is a mirror of our organization, and even an amplification of how we look. It's going to amplify, so it does create additional challenges in the world in healthcare as we move into a more digitized and higher technology world, because it can increase depersonalization. It can increase frustration. It can increase a feeling of a lack of teamwork. But it won't increase anything that doesn't already exist.

Steve Swensen: I think that's really well-said, Taylor. I think that maybe crystallizes this whole conversation. If you look at the single most important thing that we can do to help improve patient care, their experience, their outcomes, their safety, and organizational effectiveness, it's leadership working with the people doing the real work in an organization, caring for patients, in a participative way. We ask them what matters to them, what are the pebbles in their shoes, and how can we work together? If it's the EHR, we deal with that. If it's a relationship with another group of doctors or nurses or administrators, we work with that. We always try to get to yes, and we do that by listening authentically and empathetically so that we can find out how to make the care of patients better by caring for each other.

Taylor Davis: Well, I think as you ask about age and different folks working together of different age groups, and there's a lot especially recently in the media about different generations out there and categorization of those different generations, I'm reminded, and I hope it's okay to bring in a reference, I'm reminded of the great book, Boys in the Boat. They talk about putting together a world-class rowing team and how it's not ... You don't just need a whole bunch of really strong individuals that are all the same. You need to have differences between the group in order to work out.

The same is true. Different generations and different age groups is one type of stratification of your caregivers, and if we're working together as a team, we're appreciating the differences of what people can bring. An example of that that we find is is that there's a common myth that the older clinicians are always the ones who are the least happy with technology. That's a myth. It is true in some organizations. It is not true in other organizations. We could go deeper into why that is, but you can work together and help each other.

However, if your training and education is being done by somebody who doesn't understand that part of your workforce may not be as digitally ready as the rest of your workforce, then you can alienate that group. You can make them feel really, really stupid when they come to work every day, or vice-a-versa. You could have a situation where the culture is driving against some of the younger clinicians and making them feel foolish. As you talk about some of these critical components of success, respect is one of those. We need to respect and appreciate the differences that we all bring based on our backgrounds, whether we're a younger caregiver or an older caregiver.

Steve Swensen: Exactly right. It's that basic respect that engenders trust and camaraderie and teamwork. The millennials have the same basic human needs as the Greatest Generation. It's manifest itself in a little bit different work-life balance and that sort of thing, but they basically want to be respected. They want camaraderie. They want meaning and purpose. They want some control over their lives. Instead of having five different tracks for five different generations, it's better, getting back to what we were talking about earlier, is saying we just ask them what matters to them, and then have an organization or work unit or team or department or practice, whatever type of organization you're in, that has some flexibility built into the organizational design.

For instance, the teams at Mayo have done research on two different areas that relate to this. One is that if doctors have at least 20% of their time where they're doing something that's particularly meaningful to them. You love polycystic kidney disease. You like improvement work. You like teaching medical students. Whatever it is that's meaningful to you, if you do it at least a day a week on that on average, you have half the rate of burnout of someone who isn't. There's some flexibility. You're doing something that's particularly meaningful for you. It builds immunity to burnout. That's different for a baby boomer than it is for a millennial, but they both have the option to do that, and they'll be more joyful in their work.

The other is having some control over your work life. Organizations that say, "Taylor, if there's a time in your life when you want to work 80% or 60%, and then come back up higher, or take more calls and work 110% to pay for whatever mortgage," that when people, human beings including doctors, have control over that flexibility of their life about how much control they have over their time and functions. We found in our research, it mitigates burnout to have that flexibility. It could be millennials want to do more than the Greatest Generation, or maybe the Greatest Generation or baby boomers have paid off their mortgage and now they want to spend ... Whatever. Let them decide.

Taylor Davis: Dr. Swensen, I think something that's really critical that you mentioned is is that in order to understand all the things that you just described, and we keep coming back to this as a common theme, you have to listen. As we're looking at some of the feedback that we're getting, different areas, whether they're metropolitan or they're urban or rural, or different areas of the country have different expectations in terms of what they do. Different age groups have different expectations, if we don't take time to listen. Something that we can urge anybody who's listening right now, if you're listening to even what we're saying or this feedback, and you're not taking time to listen to your clinicians, stop listening to us and go take the time to listen to them. I mean, do both. Listen to the best research that's out there, and go listen to your clinicians, but if you only have time to do one, go listen to your group.

Let me share something that I think is really interesting is we go meet with organizations. There's almost a great reveal. They do a survey. They send it out to all their clinicians. We give them the feedback of how their feedback compares to other organizations. Almost every organization that has had really high positive feedback, as we've told them that they have really high positive feedback, they tell us ... There's two things that I notice. The first is is they almost don't believe us. They say, "Really? We're that high? I didn't know that." I've had two this week that I've talked to. One yesterday was an academic health system. I said, "You guys have the highest-rated training of anyone." They said, "Oh my gosh, I can't believe that."

Steve Swensen: The rest of the world must be terrible.

Taylor Davis: That's a really common phrase that they'll say. They'll say, "We have so many areas that we still want to get it better, because I know we're hearing a lot of negative things." The challenge is is that the other group isn't always listening. Then the other piece is is that we never tell them, other than that they're doing well, we never tell them anything that surprises them.

We had low satisfaction organizations with a big health system that we met with, and we said, "Your training is one of the worst that we've seen." They said, "Really?" We said, "Yeah, you probably already know that, and you're probably already working on that." They said, "You know, in all honesty, no. We had no idea." They said, "We actually met with our training team today, and they said everything was good. It was this positive meeting. We all walked out, so we had no idea that it was going poorly." The blind spot that we have to fix is we have to listen. You have to find ways to listen. You can do those in different ways, but if anything that we take away from today's discussion, listen to your clinicians.

Steve Swensen: There's one thing that we haven't talked about, and it's good that we left this towards the end. That's this shared responsibility. The most common mistake that organizations make when addressing professional burnout of nurses or doctors is to put on a mindfulness class and teach them yoga. The message there is, "You're burned out because you're not taking care of yourself. We have no responsibility," when in fact, pre-med students have above average mental health. We systematically squeeze out that vitality and idealism over the next half dozen years, and 54% are burned out.

Taylor Davis: Resiliency.

Steve Swensen: Resiliency.

Taylor Davis: Absolutely.

Steve Swensen: Mindfulness and yoga and diet and exercise and forgiveness and gratitude and friends and family are evidence. The Mediterranean diets, exercise, they all make a difference, done properly. We need to help make the right thing to do the easy thing to do for those caregivers, but don't stop there.

Taylor Davis: Let's put it in caregiver's terms. The equivalent of telling a physician that they just need to work on resiliency, and the word just is key there, is the same as telling a patient who's in the emergency room, "Well, why weren't you exercising more?" "Well, I have a kidney stone, right? You're right. I should be drinking less soda, but right now, can you treat the kidney stone? Work with me. Care about me. Listen to me, and at the same time, give me recommendations that can help me help myself. But I need help right now."

Just realizing that you could be putting fuel on a fire by sending some of those wrong messages, that can be really, really detrimental to tell somebody who has a kidney stone, "Well, you should be drinking less soda." That's great, but there's a time and a place to say that. Just as with any caring effort, lead first with the things that you can do to help them. Then help them help themselves. They'll be at a better mental place to be able to help themselves after you've made an effort to lead out. There's an order to these things.