[MUSIC PLAYING]

ANDREA TOOLEY: Welcome to the Mayo Clinic Ophthalmology podcast, brought to you by Mayo Clinic. I'm your host, Dr. Andrea Tooley.

ERICK BOTHUN: And I'm Dr. Erick Bothun. We're here to bring you the latest and greatest in ophthalmology medicine and more. Today, we get to sit down with Dr. Colin West. He is a Professor of Medicine and Director of the Mayo Clinic program on Physician well-being. We will have the opportunity to discuss the hot topics of physician burnout, mental health, and well-being solutions for physicians.

ANDREA TOOLEY: This is part one of a two-part podcast series with Dr. Colin West. We talk extensively and have a fantastic discussion about physician well-being, burnout, methodology for research, solutions, and the future. So thank you for joining us. This is part 1, and make sure to come back for part 2.

Dr. Colin West is Professor of Medicine, Medical Education, and Biostatistics at Mayo Clinic, as well as Assistant Dean for Graduate Medical Education Scholarship, and Director of the Evidence-Based Medicine Curriculum for the Mayo Clinic Alix School of Medicine. Dr. West received his MD and PhD in Biostatistics from the University of Iowa, completed residency in Internal Medicine here at Mayo Clinic. He is a recipient of the Mayo Clinic Clinician Education Investigator Award, a legacy member of the Academy of Educational Excellence, and a Mayo Clinic Distinguished Educator.

He is the Director of the Mayo Clinic program on Physician Well-Being and was recently named the first Medical Director of Employee Well-Being for Mayo Clinic. Dr. West's research has focused on medical education and physician well-being and has been widely published in prominent journals, including Lancet, JAMA, Annals of Internal Medicine, and JAMA Internal Medicine. Welcome, Dr. West.

COLIN WEST: Thank you so much. Delighted to be here.

ERICK BOTHUN: We're happy to host you. Why don't we start out and just ask you to share a little bit about your history in this field of well-being at work at Mayo that has led to your current roles. What brought you into this field? And how do you look back in your journey to understand this is a passion and skill?

COLIN WEST: I'll try to keep it brief because it's been nearly two decades. But unlike some folks, I did not come to this with an origin story in a history of personal distress, or challenges, or things that a lot of people have dealt with. As Dr. Tooley mentioned, my PhD is in biostatistics. When I was a chief medical resident in internal medicine at Mayo, Tate Shanafelt came to Mayo to do his hem/onc fellowship.

And he was interested in healthcare professional well-being, particularly in learning more about residents and fellows and their experiences. And Mayo has such a huge GME community that he approached our program director at the time with a question of, well, is there any interest at Mayo in exploring this? And our program director, Joe Kolars, said, well, I don't really know what you want to do. But if you're talking about doing this in a rigorous way and studying it, I've got a chief medical resident who has a methodology background.

ANDREA TOOLEY: Perfect.

COLIN WEST: And honestly, up to that point, I was someone who basically just put my head down to get through training, and I tried to be observant about things around me. And certainly, there were experiences, as I think anyone in medical training has, that are stressful and not ideal. But I tried to get through them, learn from them, take lessons of, ooh, I don't want to interact with learners in that way, or that was amazing, really liked how that team worked. But I hadn't really thought that much about distress or well-being beyond that.

So we started a study. We met. I was a busy chief medical resident, so it was a little bit annoying initially, like, oh, you're making me add a meeting to my calendar. I don't have time for this.

We sat down somewhat against my initial will. And two hours later, we were still designing the first study. It was a click of, this is an important question. This is something we haven't thought enough about, and it aligns passion and skill set together.

And that study turned into a longitudinal resident well-being study that led to a JAMA publication. That led to interest from departmental leadership in medicine asking the question-- Nick Russo asked the question, if this is going on in residence, we have burnout leading to experiences with major medical errors, what's going on in our staff? Because I have to believe that they've got similar challenges.

And the honest answer then was, we have no idea, and we don't have the bandwidth to study this. So if you want us to study this, you're going to have to give us some resources. And that's how the program on physician well-being got started, because Dr. LaRusso said, OK, at that point, Tate, also Lottie Derby, and myself, I want you guys to work together to keep doing studies like this to advance our knowledge on these issues because this will make patient care better. It'll make our work climate better.

From there, we went from Mayo-focused studies, where we're building some advocacy, to partnering with the American Medical Association on some national studies for prevalence and epidemiology. The first one of those was published in 2012. That was a major inflection point because, up to that point, there was a bit of pushback across the medical profession with a mindset that physicians that struggled with well-being-- well, maybe they just didn't appreciate the rigors of the field. Maybe they weren't cut out for the profession and made a bad career choice.

ANDREA TOOLEY: Sure.

COLIN WEST: The prevalence data came out. That first study documented a prevalence of burnout 44%. Suddenly, the conversation shifts. You can't say that 44% of your healthcare professionals weren't cut out for the career they chose. Now you've got to start thinking about what's going on in their learning and working environments that this is so common.

And almost overnight, we went from having to defend whether this is even an issue worth talking about to, why haven't you fixed it? Where are the solutions? And so for most of the 2000-teens, there was a shift to continuing to understand the epidemiology, but also trying to work toward frameworks for solutions, national advocacy efforts. And that's continued.

Mayo has had an absolutely central role, for example, in the National Academy of Medicine Consensus Report that came out. That report was a foundation for the recent Surgeon General's reports-- advisories on employee well-being, healthcare, worker well-being. Much of that work has its genesis, really, in going back nearly 20 years to a meeting that I didn't want to take.

ERICK BOTHUN: So when you started to unpack this and realize the multifaceted opportunities that were there to look at different levels of training and then career steps, and people started to appreciate how prevalent this was, or this is, do you think-- is the discussion been more and more in the evolution of this, that it's always been there, and we are understanding it more? Or is there a sense of greater surge in this research that's unique to current age of medicine?

COLIN WEST: It's a great question. It's one I don't know that we have a great answer to. I don't think this is a completely new phenomenon. But my own opinion here is that historically in medicine, it might not have come forward in training, for example, before we had duty hour regulations, when it was common for people to have every other night or every third night call and work 110 hours a week. Who's going to talk about burnout when what you really have is overwhelming fatigue? And you can't talk about any other condition because the fatigue is what drowns everything out.

Now, you've got to balance that with other things that have shifted as well. So societally, if you go back several decades, maybe even longer, this stereotypical role where often, the resident was male, they had a support structure at home that often didn't work outside of the home. And even in practice, that stereotype was fairly common.

You have a situation where, OK, I'm going to work really hard at work, but I don't have other responsibilities to the same degree. I'm not engaged as much to the same degree in other dimensions of my life. Maybe I can compartmentalize these things. That, I think, is less acceptable to almost everybody in medicine now.

It doesn't matter what your gender role is, what your structure is in your family, whatever your identity formation is, people want to be in touch with more dimensions of their lives. And I think that has caused tensions with medicine as a demanding taskmaster. And medicine doesn't like boundaries being placed on your commitment to it as a profession. And sometimes, we engage with that because it's fulfilling, and we see that as purpose-driven.

But I think more recently, those boundaries have become a little bit more visible. They've risen into people's awareness. And I think that's where we start talking about as fatigue lessens a bit-- because we have things like duty hour regulation-- that some of these other issues of distress, not just burnout, but other dimensions suddenly become visible.

They emerge a little bit. And people realize, wait a minute, I'm not as fatigued, maybe, generationally. But I've got lots of other obligations that are important to me being a complete human being. And this profession is in conflict with those at times, and burnout can result from part of that too.

ANDREA TOOLEY: There's so much to unpack here. I really resonate with so many things that you've said. Reading about burnout-- we all hear about burnout. It's been such a hot topic. It's such a trendy thing to talk about-- physician well-being, work-life balance.

It's something I'm asked about all the time. And I should disclose, if you can hear little cries in the background, I have my newborn here right beside us because that's the stage of life that I'm in. And you talk about different roles in medicine. And so I have my mom role wrapped up in my doctor role here--

ERICK BOTHUN: It's wonderful.

ANDREA TOOLEY: --altogether. No, but it's challenging, for sure. One thing that was interesting to me reading more about burnout that I didn't completely realize is that-- and this is partly from your research-- is there's a big component of medical errors, actual patient safety, and that's separate from fatigue.

COLIN WEST: Right.

ANDREA TOOLEY: And so that's fascinating to me because, just like you said, we've tried to address some of the fatigue with duty hours, and there's still a lot of work to do there. But even separate from that, burnout still contributes to medical errors. So I'm really interested in the patient safety aspect. And then I want to talk-- I want to talk about a lot of stuff, but can you tell us a little bit about that, separating the fatigue from the other burnout component?

COLIN WEST: Yeah. I think we don't fully understand why these different dimensions contribute separately and in an overlapping way, really. But I think one of the key findings across a lot of dimensions is that burnout and fatigue do have their own independent contributions to a host of outcomes.

It's not just errors, patient satisfaction concerns, professionalism concerns. We even did a study at Mayo looking at motor vehicle crashes and near misses. And after adjusting for fatigue, burnout was independently associated with public safety issues, like motor vehicle incidents.

I don't have a great physiological or psychological explanation for that, but I think it's important to recognize that complex issues, like distress or a holistic sense of, how do we meet our fullest potential, which is, to me, what well-being is really about-- they don't lend themselves to simple answers like, if we simply fix fatigue, these other problems are turned off. We have to recognize that there is complexity in these discussions. And this is part of the evolution of our understanding of these issues. When duty hour regulation and other work hour reforms were put in place, they were primarily designed around fatigue mitigation.

What we have to understand, I think, as a lesson to take from the burnout literature is the fatigue mitigation efforts are important, but burnout is much more than just workload. There are other drivers, sense of community, being treated fairly at work, connection with meaning and values-- all of these things that aren't directly connected with fatigue alone, but really stress the importance of not just having policies in place around things like duty hours, but thinking, taking a step back to, what is it about the learning and working environment that allows people to thrive and flourish? It's a 30,000-foot view, really, which is intimidating to some people, honestly, because it's vague and squishy.

And I get asked this question a lot. If you're going to implement a well-being program, how do you measure whether it's successful or not? And this is actually a great segue with your baby here because one of the ways I've started answering that question is, well, it's a complex issue, and there are some measurements and some milestones that we can use.

But let me flip that around. What's your measurement to determine whether you're a good parent? There's not a simple number. And for different people, they're going to look at that, and they're going to say, well, I want my kids to meet their education milestones. I want my kids to be polite. I want my kids to stay out of jail, or whatever it happens to be.

But you can't distill it down into a test score. There's a vibe around it, and that's how I view the burnout fatigue discussion, is that burnout is this larger issue as part of this deeper menu around well-being, and fatigue is a partner in that. And they overlap--

ERICK BOTHUN: It's a subset, almost.

COLIN WEST: Almost a subset, although fatigue can have its own impact on things as well. I think it deserves its own sovereign state as well. But they share borders and overlap. And the whole-- all of this is about if you're trying to meet your fullest human potential, if that's what we mean by well-being, all of these are contributing factors.

And there's room for all of us. I don't just study burnout, and I don't need to rag on people who study fatigue, for example. There's a huge literature around fatigue in medicine and errors that other institutions have been leaders in as well. And all of that needs to come together with the goal of having the best possible environments for our healthcare professionals, both for themselves and, as you alluded to, for our patients.

ANDREA TOOLEY: What do you think about the term "moral injury?" And is that a reasonable way to quantify burnout or to characterize burnout, I guess? That was a real trendy, and now it's fallen out of favor.

COLIN WEST: Yeah. I think-- so the challenge with moral injury is that people who have tried to elevate that to our awareness-- and it's a real issue-- but people who have tried to elevate to our awareness have sometimes, I think, tried to shine the light on it and say, no, it's not burnout, it's moral injury, as if it's a "one or the other" kind of thing. And my general view on it is moral injury, which is often cast as this idea that, well, I know what I want to be able to do for my patients, for myself, but my practice, my personal limitations, my environmental healthcare system limitations don't allow me to do that.

And so I feel conflicted. I have an internal tension. I experience moral distress. And, oh, by the way, I'm getting paid to be part of a system that doesn't deliver the best possible outcomes for my patients. So there's all of these layers that cause us to ask hard questions of ourselves.

Am I doing enough myself? Which plays into other aspects of the physician personality, often, this tendency towards perfectionism and almost a narcissistic characteristic in the psychological sense of that word, not necessarily pathologically projected towards other people, but a sense that what we do must be so important and critical that we really hold that to such a high standard, which is both adaptive because it contributes to dutifulness and not being late for work and going the extra mile for your patients, but is also maladaptive because it contributes to not setting boundaries. And there's data that physicians, on average, don't use all of their vacation every year, for example.

Why is that? Well, it's not because they don't want to take vacations. I've never met a physician who doesn't actually want to take time off when it's appropriate, but they feel like the workload and the obligations, the professional duty, doesn't allow them to always tap into those things. So I think moral injury is all part of those distress and tension aspects.

And I think moral injury can certainly contribute to burnout because it's a values problem. And we've just talked about that values, and meaning, and purpose-filled work is crucial to well-being. And where those aren't present can trigger burnout.

I think it's also possible that burnout may contribute to feelings of moral injury. I think they can live together. We don't have to suppress one at the expense of the other. And that's really where I think the conversation has gotten a little bit confusing, is in the push to elevate moral injury to people's awareness, at least to my perception, there was a sense of, look at me, look at this, stop talking about these other things. And you will see, whether it's on social media or even in some published reports-- there was one recently, for example, I think the title was something like, "It was never burnout, it's always been moral injury."

And I think that's reductionist, and I don't think it's actually helpful. I've written about this. I've tweeted about this, actually, that there's room in the sand box for all of us. We're all interested in elevating our collective experiences to be more positive.

Some of that's moral injury, some of that's burnout, some of that's formal diagnosable mental illness. There's room for all of it, and we actually probably need experts in all of it. And we don't need to talk each other down. We actually need to support each other and keep an eye on the ultimate goals.

ERICK BOTHUN: You shared a little bit about just now about how, as physicians, we commonly are wired in a way to feed into this work balance with stress. When you look across the house of medicine and you look at different types of medical professional niches, whether it's mid-level providers, nursing, physicians, are physicians a little more uniquely geared to make us more vulnerable?

And also, when you look across the house of medicine and look at different types of physicians, whether subspecialty, or private practice, or academia, do you see this current-- or I mean, how broad is the problem? And is a physician at an academic institution uniquely positioned to experience this rather than a different role, either in the same academic setting in a different role or a physician in a different setting?

COLIN WEST: Yeah. So the short answer is, it's complicated. Every study that we've done that's looked at academic versus non-academic practices actually finds lower burnout rates in the academic setting.

ANDREA TOOLEY: Really?

ERICK BOTHUN: I'm surprised.

ANDREA TOOLEY: That shocks me.

COLIN WEST: And the idea behind that-- it's not fully understood, but the idea behind that is that people that work in academic practices often have the ability to have more variety in their work, and they can pursue things that are deeply meaningful to them in multiple domains.

So I think about my own career at Mayo. I have the opportunity to pursue research interests. I also have the opportunity to have deeply meaningful relationships with patients, either in a consultative role or working with residents in a primary care environment. That variety can be really rewarding, and it can be beneficial if it's something someone wants.

The challenge that we see in private practice, conversely, is not that the work is less meaningful, but it can often feel like a treadmill. And if you don't have diversifying roles-- this is at least what some physicians in private practice have shared with us. If you don't have those diversifying roles, I use the treadmill analogy intentionally because it can feel like, well, there's no reason for me to ever paint a boundary because my revenue keeps going up.

The more patients I see, the longer my hours are, the more days of the week I see patients. And having the, for lack of a better word, the self-discipline to recognize where your boundary is is not something we're trained on. And so you get out into the private practice world, and, yes, there are financial rewards for being super busy. There are also costs to that.

I back to the treadmill analogy, and I use that intentionally because I gave a talk a number of years ago where a cardiologist came up after the talk and said, you know, I felt like you were describing my life in your description of the drivers of burnout. And he said, I'm in a practice where, at the end of every day, we have orders for cardiac stress tests that have come in over the course of the day. And they aren't urgent, but it's convenient for the patients if we can get them done the same day because they can make plans, we can know what the next steps are going to be.

It's good patient care, but we don't know what's going to be on the menu until after 4 o'clock every afternoon. I get paid a bonus for every one I do after my afternoon clinic. And I have been doing these until 7:00 PM for the last several years.

And I justified it with my family by saying, this is the Disney World fund. All of this extra money is going to go. We're going to have a glorious family vacation and go to Disney World.

But he said, I'm listening to you discuss the physician experience, and I'm realizing I haven't been home for dinner in three years. I've never been to one of my daughter's soccer practices and all of these other things that he was missing out on. And it's always been because the carrot's been dangled out in front of him, like, hey, the family's got the Disney World fund.

ERICK BOTHUN: Turn up the treadmill faster.

COLIN WEST: Turn up the treadmill. Keep doing them, keep doing them. And so I knew what the answer to this question was going to be, but I couldn't help but poke at it a little bit. And so I said, well, at least, how was the trip to Disney World? And I knew what the answer was going to be. He said, we've never been.

And I just said, I'm just going to leave you with that. You already know what you need to be doing here. By even thinking about this, you recognize that you're out of balance on this treadmill. Your obligations to your work sphere and your non-work sphere are out of balance, and you owe home something pretty dramatic, and you know that. You don't need to be talking to me about that.

So private practice, I think there are different stressors. It also depends on what your objectives are, that values alignment's really important. For me, diversity in my roles is critically important. For other people, if that's not what they want, they might be more burned out in an academic practice because there's a disconnect. So it's individual.

Now, you also asked about job roles and other functions within the house of medicine. Historically, physicians have always had the highest burnout levels. We don't know exactly why. But when you think about the drivers, physicians generally work the longest hours. We generally have the highest level of responsibility.

The buck stops with the physician on a team. We recognize we can't do what we do without a great team, but we're where everything comes to rest at the end of the day. And that level of responsibility, it does wear on many physicians. And there's something called the physician triad that was coined in the mid '80s in a JAMA article, this idea that physicians feel guilty when things don't go great for their patients. They also have this drive to deliver outcomes, and they have an exaggerated sense of responsibility for the outcomes that aren't just their responsibility actually are dispersed across the team.

And again, as I mentioned earlier, it's both adaptive and maladaptive. All of this is great for staying patient-centered and focused. It's terrible for setting boundaries.

When you look at other healthcare professionals historically, their job roles either allow them or they're simply more skilled at maintaining some of those boundaries. What we've seen during the pandemic, however, is that those differences have started to boil away. And in fact, at Mayo, when we did studies about a year ago now, actually, what we found was that a couple of groups had now risen to challenge physicians for the lead in terms of highest burnout levels-- to no one's surprise, inpatient nurses and, to some people's surprise, work unit supervisors and other mid-level leaders. So when you mention moral injury--

ERICK BOTHUN: Trying to keep the place running.

COLIN WEST: They're trying to keep the place running. But at the same time, they also feel obligated to the people they're leading. And we sometimes like to think of our leaders as, well, that's them.

We're us, they're them. They are us. And they're human beings, and they actually don't want other people to suffer as a general rule. And so we're starting to see with the stresses of the pandemic that their support structures have broken down to where they're experiencing a lot of distress as well.

So historically, yeah, physicians led the pack. As I like to say, they were in the gold medal position for the suffering Olympics within the house of medicine. But that's not a games that any of us want to win. Other groups are now challenging this. And what that really tells us is we need attention across the entire structure of medicine to improve this for everybody because we really haven't given that the attention that it needs, in part because we've been just trying to think about keeping the lights on for tomorrow, not thinking about, well, is this a sustainable future?

ERICK BOTHUN: One of the questions about it just in the work day and even vacations, across globally, internationally, healthcare is provided and delivered in different ways. Some locations, they take nice siestas or tea breaks. In other locations, it's a 7:00 AM to 9 o'clock at night endeavor six days a week.

How is this research advancing globally across the world? Is it going to shape how we affect our work day or how we're allowed to take our vacations? Because certain habits probably aren't as fruitful, saving up everything for a Disney World vacation. But just so first, talk about just across the House of or the cross varieties of international locations, what's being discovered? And how might it affect our lives here?

COLIN WEST: Yeah. The comparisons-- also on my theme of complexity, the comparisons end up being really tough because healthcare systems are so different. There have been some comparative studies, for example, looking at the Netherlands. And burnout rates for physicians in the Netherlands were about 10%, absolute rates lower than in the United States.

On the other hand, work hours were much less. And then on the other hand again, salaries were much less. That's complicated by a completely different social structure, however.

So your salary is lower, taxes are higher, but you can count on an infrastructure and a social contract, if you will, that contradicts a lot of our-- if you'll forgive my editorializing-- almost extreme capitalist approach to what I think contributes to some sense of moral injury for many physicians with a conflict between our professional ideals and the business of medicine. And I think in a lot of other countries, the business of medicine is a more foreign concept. In the United States, we've struggled to reconcile that.

So does that mean that the system in the Netherlands is better? I don't think so. It means that they have different drivers of stressors, and they have different elements of their social contract that they are comfortable with that, in the United States, I don't see a path to get there right away with the idea that we would have a universal healthcare model that might take away some of the moral injury about underserved populations and things like that, but would also require that physicians, especially physicians in subspecialties, not have the salaries that they have, especially when, in the United States, you're dealing with massive amounts of student loan debt, and other expenses, and malpractice premiums for some subspecialties that are all beneath the surface and not visible when people talk about just their absolute reimbursements.

Then, you take it a step further, and you start thinking about, well, let's not talk about Europe or North America. Let's talk about physicians in countries with what we would consider in a negative connotation as less developed medical structures or social structures, where, as you mentioned, the work day might be 14 hours long and maybe 120 patients. What are the burnout levels in those countries? And are they even aware? Or is it just, this is how it is. And we don't really know because those studies have not been done using rigorous methodologies, good metrics, and the ability to compare apples to apples.

I don't think we're ever going to go the other direction. I don't see the United States at this point moving to 14 hours a day, six days a week, see 100 patients a day in clinic. I don't think our training pipeline will accept that, nor should it. I think we recognize-- the duty hour conversation's a great example. We recognize this is not aligned with great patient care outcomes.

But I think we're still grappling with this notion of, how do we train people rigorously in a reasonable amount of time and meet the demands of a population that has healthcare needs without overwhelming the healthcare workforce-- at the same time, staying affordable? And that's a pretty tough knot to try and untangle. If it were an easy thing to solve, it would be solved already. And then you layer on top of that all sorts of political differences and viewpoints that are almost irreconcilable, and the solution set becomes really, really difficult.

That's a little discouraging, I guess, in terms of where we're going, but there has been such a massive change in at least awareness that our current state isn't healthy. And I think, importantly, it's not just that it's not healthy for physicians and other healthcare professionals. There is this medical ideal that we're not doing this for ourselves.

I've spoken with Mayo leadership in explaining Mayo well-being initiatives. This isn't about Friday spa day. This is about helping us be our best selves so that we can meet the ideal goals for our patients. If the needs of the patient come first, that can't be, in a sustained fashion, at the expense of the healthcare professional because, in the short term, one patient may benefit. And then 100 patients suffer because that healthcare professional has been depleted.

So we need to think about this as a system. How do we help each of you, me, all of our colleagues see every patient at the best of their abilities, but not necessarily see every patient personally? We represent as a team so that when I need to tap out and have someone else come in who's at their best, we have that kind of redundancy in our system. And that's where we need to go with a lot of our solutions.

ANDREA TOOLEY: That's an interesting solution. I like that. We hear a lot about this in the discussions of burnout. And people joke, and there's memes and all kinds of things about how we don't need another module on yoga or meditation, or we don't need free pizza on Fridays-- everything you've alluded to in terms of these big solutions. So I want to talk more about meaningful solutions.

And then the other thing I'm really curious about is, how do we turn this into hard data with, what you said, rigorous methodology to actually study this? And what metrics do we use when you talk about burnout rates? And there's different scores of physician satisfaction. How do you make those actually meaningful? And how do you study it?

COLIN WEST: Yeah. I'll maybe take the study part first because that's been what we've been doing for the last 20 years. I think one of the keys for these constructs is it's really important to use metrics that have been developed in a rigorous psychometric fashion. And I'm not going to get too wonky about these things, but there are well-established instruments for burnout, and then there's the colloquial understanding of burnout.

And the analogy that I use for this is many of us have walked around or as younger people like, oh, I'm so depressed today. Something you saw made you a little sad. Oh, I'm so depressed today. The Vikings lost. That's not depression.

ERICK BOTHUN: You'll be depressed often.

ANDREA TOOLEY: [LAUGHS] Oh, it's sad. No, it's true though. I have days where I just am more down.

COLIN WEST: But it's not depression.

ANDREA TOOLEY: No

COLIN WEST: Right? We've colloquialized the term. But from a psychiatrist's standpoint, it's a very different thing. Well, burnout, as it's become more in the public domain, has suffered a little bit from the same kind of deal.

ANDREA TOOLEY: It has.

COLIN WEST: It's not just fatigue. And sometimes, people use it as a synonym. It's not just moral injury. It's not I'm angry at the system today. I'm so burned out. I got up this morning, and I didn't want to come into work. I'm so burned out.

Well, maybe. Or maybe you're just having a bad day. Or maybe you're just tired today. Or maybe you actually are depressed.

And so using the right instruments is really important to be able to tease those things out. One of the things that we've really pushed-- and this is part of the National Academy of Medicine framework around well-being-- is using measurement instruments that have that kind of supporting evidence for them. That's the basis for having good information. So when we're talking about, what is the national prevalence, and what does it look like in a neurosurgeon versus a radiologist versus a family physician, they all need to be using the same measure so that we have comparability. And there are people working on crosswalks across measures to be able to compare them, but that's always going to be an imperfect science.

There are a lot of instruments out there that have not been through that kind of rigorous review, and I don't know what to make of them. And so when you see a report online, there will be these magazines-- I'll call them magazines because they're not science journals, really. they're well-intentioned, but they'll say, the 2022 Physician Burnout Report. I have no idea what measure they used.

And they'll say, burnout, 60% of physicians. Well, maybe. But if I don't know what tool you used, I don't really know whether I can trust that number. And those are the things that often pick up the headlines. And that's one of our challenges.

ANDREA TOOLEY: OK. I think that's really helpful to know, though, that there are specific ways that we can have data that are real and not just these big claims where we don't actually know what it means.

COLIN WEST: Right, and exactly right. And I think, to that end, one of the things that we've advocated for for more than a decade is that, at Mayo, for example, when we have things like the all-staff survey, where we're looking at, what's the picture across all of our employees, and we have this amazing opportunity that our employees gift us with engagement in that survey-- 75,000 employees with a 75% response rate. No healthcare organization in the world can claim that level of engagement.

That's a ton of information that really is a gift to all of us. Here's what we're experiencing. We need to honor that by using the right measures. And so we advocate for-- right now, there's one question on the all-staff survey, but it is a well-validated, studied question that we have endorsed that gets at the emotional exhaustion domain of burnout.

Now, there are some other dimensions to burnout that I would love to see added so that we could get more information about, for example, depersonalization, which is this domain of, I've become callous toward my patients' experiences-- antithetical to all medical professional ideals, especially Mayo's values. And I think that can be a canary in the coal mine for other concerns. I would love to see that question, if we had the real estate, included. But we need to be intentional about what those items are.

In other work, if we're talking about depression or other things like that, there are measures. There are well-established tools. And it's usually not good enough to just make up a question.

Well, I wonder how burned-out people are feeling in my division. Well, I'm just going to ask them, on a scale of 1 to 10, what's your burnout today? That's not a question that we can interpret. We don't know what that means.

But as you mentioned, there are instruments that allow us to do that. And I think contributions to the broader knowledge to answer a host of questions, such as have already been mentioned, requires that we have that common language using common instruments. We wouldn't measure distances using rulers of different length and saying, each of them is a foot or a meter.

They're completely different. We have to have a standardized process. And measurement of human experiences really isn't any different.

ERICK BOTHUN: I fully agree and find in healthcare across the board, our survey data is just flawed with non-rationalist-studied surveys that are created in good intention that are meant to ask people questions that we want to know the answers to, but they're just fraught with challenges and interpretation. And I think whether it's in measuring quality-of-life and vision outcomes or, in this case, quality-of-life and physician well-being, really, we appreciate your work because you have to have those sort of metrics to be able to compare apples to apples and make a difference in terms of quality outcomes in the life of our physicians and teams.

COLIN WEST: Yeah. And I think, also, an emphasis point at Mayo recently, which I think is a good move, is recognizing that we are all over-surveyed. We get questionnaires all the time. And so you need to be able to trust that if you are going to-- and again, I'll say, a gift-- if you're going to give your time to provide that input to your organization or to whoever's doing the survey, they owe it to you to have that information be trustworthy, and sound, and collected in a rigorous fashion.

I think that's an organizational obligation. And it's something Mayo is uniquely positioned to deliver if we pay attention to it, which we're starting to do much, much more. But it makes it difficult when we get things dropped into our inbox all the time from all sorts of sources. And the question is, as you said, well-intentioned usually, but you may not know enough about the area to know, is this a valid way of asking this question or not?

And why give 10 minutes of your time, which is a paper cut-- oh, it's only 10 minutes of my time. Well, 10 minutes adds up when it's 10 minutes, seven times a day, six days a week because of all the emails that we're getting with all these sources that want our input on various things. So that attention to rigor is really important.

ERICK BOTHUN: Well, I just want to thank you, Dr. West, for sharing. I think we could continue to go on, but it's certainly exciting that we were able to learn and understand the dimensions of this, as it's complex, but also give hope for not just what we're doing as an organization, but what people can do individually. I celebrate that we've been able to do this and over a couple of podcasts here to enjoy learning from you as we help our listeners. Thank you again. And I want to--

ANDREA TOOLEY: Yeah, thank you so much.

ERICK BOTHUN: --also just come in. You know, as we talk about these different dimensions of life, celebrate, Andrea, your leadership of COD podcast, but in this way, coming in during your maternity time with your infant here to celebrate being multi-dimensional and succeeding in what we do in all aspects of life. So thank you for being a leader that way.

ANDREA TOOLEY: Thank you. Thanks for letting me bring the little one here. And I feel very rejuvenated and hopeful, truly, that there's really good work from leaders, mainly like you-- I mean, you in this field. I feel very optimistic about the future, so thank you so much. We've learned a ton.

COLIN WEST: You're very welcome. And this is an incredible profession. None of us should ever forget that. And we can be each other stewards in delivering everything that this profession has to offer.

And that's what's on the horizon. So I share that optimism. That's why I work in this field, is to be able to deliver on that vision.

ERICK BOTHUN: It's appreciated. Thank you.

ANDREA TOOLEY: Thanks so much.

COLIN WEST: Thank you.

[MUSIC PLAYING]