Episode #65 Clinician Safety, To Care is Human, Part 1

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. We have a special series that we are starting for you today. If you attended the 2021 APSF Stoelting Conference in person or on zoom, then you already had a sneak-peak because this series will cover the 2021 APSF Stoelting conference, “Clinician Safety, To Care is Human.” The conference was directed by Patty Riley, Brian Thomas, and Matthew Weinger. Today, we will be talking about highlights from the first conference panel and we have a special guest on the show!

Before we dive into today’s episode, we’d like to recognize Edwards Lifesciences, a major corporate supporter of APSF. Edwards Lifesciences has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Edwards Lifesciences – we wouldn’t be able to do all that we do without you!”

To kick off the show today, we are going to hear from Jina Sinskey. I am going to let her introduce herself now.

[Sinskey] Hi, my name is Jina Sinskey and I am an assistant professor of anesthesia at the University of California San Francisco. I am the Associate Chair of wellbeing for my department and the vice chair of the ASA committee on physician wellbeing.”

[Bechtel] Later in the show, we will be hearing more from Sinskey with her takeaways from the Stoelting Conference. Keep listening because she provides some great insight.

The conference opened with an overview by Mark Warner who read this quote by Ellison C. Pierce, the founding president of the APSF, “Patient safety is not a fad. It is not a preoccupation of the past. It is not an objective that has been fulfilled or a reflection of a problem that has been solved. It is an ongoing necessity. It must be sustained by research, training and daily application in the workplace.”

And with that, let’s talk about some of the highlights from this years, Stoelting conference. The goals for the conference included the following:

• Identify the importance of clinician wellbeing in relation to patient safety issues.
• Evaluate the impact of clinician burnout as it relates to patient care.
• Define and discuss burnout, professional wellbeing and resilience as it may relate to patient safety
• Describe a systems level approach to clinician wellbeing

Over the course of several shows we will be hearing from speakers and attendees and discussing all of these topics.

The first panel kicks off to discuss “Defining the Problem” with a talk by Matthew Weinger who defined clinician wellbeing as the integration of work and life including mental, emotional, and physical health as well as personal life issues. Next up, he defined burnout which may occur when there is a persistent imbalance between job demands and professional stress and professional resources and personal resilience. Have you every experienced this imbalance? The result may be developing a syndrome of emotional exhaustion, cynicism, and diminished sense of personal accomplishment, which is burnout. He wraps up his talk with the reminders that when clinicians have degraded wellbeing, which is a symptom of burnout, then that is a very real threat to patient safety. He also includes a call to action that this is a systemic issue which needs to be recognized because trying to fix the un-well clinicians with yoga classes or mindfulness may make the problem of burnout worse and does not address the systemic issue.

The next speaker is Tait Shanafelt on “Burnout and its Consequences.” He highlights the personal and professional threats to clinicians which include depression, suicide, alcohol and substance abuse, medical errors, turnover, and decreased professional effort. There are important clinical consequences as well. So, what can be done to mitigate burnout? It may not be that we need to lessen job demands, but we do need to provide the right resources to help meet these demands, and Shanafelt goes one step further with an analogy to a construction worker who wears a hard hat and protective gear when he shows up to the job site and what protective gear do institutions need to provide to protect the healthcare professionals from burnout. The solutions are likely multifaceted and include a culture of wellbeing, efficiency of practice, and personal resilience surrounding a core of professional fulfillment.

To continue to define the problem, our next speaker is Meghan Lane-Fall who we have heard from before on this podcast. Check out episode #46.  Her conference talk advanced the discussion on the importance of diversity, equity, and inclusion on patient safety and clinician safety. She started with some definitions as well. For diversity, she states that this is a property of groups and is related to the characteristics that shape one’s perspectives on the world, work, problem solving, and relationships to other people. Equity has to do with fairness and how we treat the people that we interact with in order to give people the support that they need to get where they need to go. For inclusion, Lane-fall highlights that this is a sense of belonging and this may be the most important step.

So, how does diversity, equity, and inclusion relate to patient safety? This relationship revolves around psychological safety as it relates to how a team functions and in the healthcare setting, healthcare teams need to function in order to keep patients safe. Let’s take a moment to also define psychological safety which is the ability to take interpersonal risks in an environment that is supportive of organizational learning and performance. These interpersonal risks may include speaking up or asking for help or being able to say, “I don’t know.” She concludes with the takeaway that diversity is related to safety through lived experiences, physical and cognitive capabilities, and psychological safety and that different people may need different support in order to be able to function well on a diverse team.

Doug Yoshida spoke next on the Medicolegal implications and asks the question: Chicken and egg? This is an important question since burnout and impairment issues can lead to legal issues and legal issues and impairment can lead to burnout. So, what are these legal issues? These may include loss of medical license or disciplinary action of the board of medicine, malpractice claims, criminal charges, employment issues, restriction or loss of privileges, insurance reimbursement issues, antitrust claims, HIPAA violations, and residency/training suspension. These complications can have a major personal, professional, and financial impact and can have an impact on patient safety as well.

Back to the chicken and egg question, from a legal perspective, the goal should be to minimize the downstream legal implications and stigma so that healthcare professionals can get the help they need which may include enrollment in a physician health program. The goal is for physicans to practice safely or return to practice safely and continue to keep patients safe. This will require improved privacy and legal protections for clinicians who seek help and successfully complete treatment and are deemed safe to return to practice. There is a call to action here to remove the stigma from clinicians getting treatment. This is in the best interest of patient safety because clinicians need to be healthy in order to provide safe anesthesia care.

The final talk for this panel is brought to us by Della Lin and it is called, “Incivility, rudeness, violence: Toxicity in the Workplace.” She opened with voices from our peers in the workplace with shocking clips of verbal and physical abuse in different toxic environments that was from respondents to the APSF workplace violence survey. Then, she asks some questions.

• How prevalent is workplace violence in healthcare?
• Does workplace violence affect performance?
• How common is workplace violence in the perioperative environment?

Well, there is a myth in healthcare that violence is part of the job due to the stress of the job. In reality, rates of violence in healthcare exceeds that of other industries. There are about 24,000 reported assaults in the workplace each year and 75% of these are in healthcare. It appears that workplace incivility, rudeness, and violence are on the rise. This is a big threat to patient safety because it affects how the clinical team functions, but also affects knowledge gathering and knowledge transfer as well as a creating a diagnostic bias. What happens in the OR? Well, there is evidence that rude surgeons can negatively affect the performance of the anesthesia professional while at the same time, the anesthesia teams were not aware of the impact of the rude surgeon on their performance. This was a simulation study, but even looking at surgeons who were reported for rude behavior, they had an increased rate of surgical complications as well compared to surgeons who did not have any behavior reports. A recent APSF workplace survey revealed some of the following results.

For anesthesiologists, about 20% of those surveyed experienced or witnessed workplace violence with 40% of the incidents being reported, less than 5% of these incidents resulting in time away from work, and about 40% of respondents feeling like the situation was adequately addressed. Nonphysical workplace violence was more common with about 65% of respondents experiencing or witnessing these incidents. Reporting occurred less than 40% of the time and only about 30% of the respondents feeling like the situation was addressed appropriately.

Workplace violence is also common for other members of the perioperative team and it occurs frequently. This is a big threat to patient safety because it is a distraction from patient care and negatively affects performance. Lin leaves us with a call to action to eliminate workplace violence and incivility.

The panel wrapped up with some of the following thoughts: The solution to burnout depends on this problem being tackled by leadership and there must be must be a dollars and cents case to address this systemic issue. The mindset will likely to need to shift to a value return on investment for improved clinician well-being. There is not one single solution. Going forward, treating all people with respect in the workplace is vital to maintain clinician well-being who will then be able to provide safe care for patients.

One of the conference members asked the following question, “Is there a better metric to use rather than just adherence to policy that mid-level leaders can use?” This is such an important question since leadership behaviors are associated with burnout on teams and professional fulfillment. This is an area for further investigation and for leadership development going forward. Listening to team members is one of the foundations here.

Another question related to what about healthcare professionals who are not part of big organizations who have either left large institutions for smaller private practice groups or those who have left clinical medicine. What we know about this is that almost 100% of healthcare professionals who leave clinical practice early, prior to retirement, are burned out. For those that remain in clinical practice, there are advantages and disadvantages to different practice structures from large institutions to smaller private practice. It is likely that psychological safety, that feeling of belonging, in teams is one of the most important factors related to clinician well-being and burnout and this is no matter what the size of the practice.

The session wrapped up with a question about medical students and residents who participate in physician wellness programs and the financial burden that this necessary care places on those in training. Physician wellness programs are associated with a high cost in terms of money and time and at this point, little has been done to mitigate these costs. Going forward, institutions may be able to help offset this barrier to care to make sure that medical students, residents, and physicians are able to get the care they need.

Before we wrap up for today, we are going to hear from Sinskey again. I asked her, “What are your most important takeaways from the conference?” Let’s take a listen to what she had to say.

[Sinskey] “This was my first time attending the APSF Stoelting conference and it was one of the best conferences I attened. A key takeaway for me is that clinicians must be well to be able to fully contribute to patient safety. For example, both Dr. Meghan Lane-Fall’s talk on diversity, equity, and inclusion and Dr. Della Lin’s talk on toxicity in the workplace made me think about the concept of cognitive load. When we spend our mental capacity hiding our authentic selves at work due to a lack of psychological safety or dealing with interpersonal conflicts due to incivility in the workplace, it takes away from our ability to concentrate on patient care. Clinican wellbeing is essential for patient safety.”

[Bechtel] What a fantastic takeaway! I also asked Sinskey about her future research and projects and we are going to hear from her again now.

[Sinskey] “At the Stoelting conference, Dr. Tait Shanafelt said that we have enough data and it is now time for us to translate and transition to action. I whole heartedly agree. My team is interested in how we can bring wellbeing theory into practice. Since clinician wellbeing is affected by the workplace culture and environment, we will be partnering with our surgeons and nurses at UCSF to design and implement perioperative wellbeing initiatives. We view our efforts to improve clinician wellbeing as clinician quality of life improvement. We have developed an approach that incorporates principles of human-centered design, quality improvement, and implementation science to facilitate a systems approach to this issue.”

Thank you so much to Sinskey for providing such incredible insight and we cannot wait to hear more about the quality of life improvement projects at your institution going forward.

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Are you attending the ASA this year?! If so, we invite you to join the #ASPFCrowd. Run, don’t walk over to booth 2117 and sign the wall. With your signature, Fresenius Kabi will donate $15 to APSF. Fresenius Kabi is proud to support the Anesthesia Patient Safety Foundation in important initiatives to support the APSF vision that “no one shall be harmed by anesthesia care.” Your signature on the APSF signing wall boosts global support and provides a crowdfunding contribution to APSF. Your action and a donation made on your behalf helps to provide for the following enduring programs, the APSF website with over 1 million visitors each year, safety research and education, the APSF Newsletter translations, and the APSF Consensus Conferences. Your signature can have a big impact and we can’t wait to meet you at booth 2117 at the ASA Annual Meeting in San Diego!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation