Physician Wellness: Dr. Christine Hein

And today it is my great pleasure to have in the studio Dr. Christine Hein, also known as Chris to those who are her friends. She is an emergency physician and also the Chief Wellness Officer. She works with Maine Health Medical Group and Maine Medical Center. And I'm really here to champion something that I similarly have a great passion for. So I feel like we're a little bit two peas in a pod today, Yes, we are. Yes, It's wonderful. Thanks for taking the time to come and talk. You have a very busy life. Yeah, it's good. It's full, very happy and kind of a circuitous route to get here as you can imagine. And this is something that's really near and dear to my heart and I think more than anything important for us to figure out in healthcare so that people will stay in healthcare and have long productive careers. So this idea of a Chief Wellness Officer, that's a relatively new concept. Talk to me about that. It's interesting because as kids often do, when I was named the Chief Wellness Officer, it was originally for Maine Medical Center and a few years ago it expanded to encompass the entire medical group and I kind of knew what that meant, obviously taking it on, but it was hardest to explain it to my then 12-year-old daughter who said, "what does that mean?" The way I see it is it touches all realms of professional satisfaction and fulfillment, which might be difficult for people outside of medicine to kind of conceptualize why would it be challenging to feel fulfillment and satisfaction in a profession that is based on helping others because right at its core is this incredibly intrinsic motivation to help others and do good. But as healthcare has evolved and the system has become more complex, there's been a lot of things that have pulled physicians and apps and really all care team members away from taking care of patients, which is what drew most everybody to the profession to begin with. So it's kind of dealing with those things and trying to minimize the collateral damage of the complex system on providers overall happiness, trying to do what they love. It is true that the patient care can be stressful but also very rewarding and the people working with the human beings and often the things that really injure us are things like processes that don't work correctly or the electronic health record, which even if you have the best one in the world, it's only going to be so good. And I think that for me has become the thing that it had such promise when we started out and now fast forward a couple of decades, it's really ended up causing problems that maybe we didn't understand were going to occur. I think that that probably accounts for 75% of what is driving dissatisfaction and distress amongst healthcare providers is the impediments to being able to do your job efficiently and things that get in the way of face time with patients because those are the joyful moments. And as you noted, it can be stressful taking care of sick people and making those decisions, but we are trained to do that. That isn't usually what is bringing people to this spot in their career where they're questioning, "Why am I doing this?" It's all the other stuff. If you look at the Stanford model of professional satisfaction, there's culture of wellbeing, there's efficiency of practice and then individual factors and the first two are really probably 75% of the drivers of dissatisfaction. And that's where we have to focus our efforts. People are resilient and they're prepared to manage the stressors that come along with taking care of patients in times of health and illness. But we didn't understand that when we kind of wade into this world of the EHR that we would be spending twice as much time on the EHR as we are in face time with patients and patients feel it too. So it's not just about the healthcare team, it's about how is this perceived by the patients that we're trying to sit and have compassionate interactions and develop therapeutic relationships and build trust and rapport so that we can really take care of 'em with the best outcomes. That's a great point because I know that when I first started in medicine and we had paper charts so long ago and people are going to be like, how old are you now? Okay. I don't remember what those were. So you have your paper chart, it may not have had everything in it, but it was out in front of you and you looked at the patient and now the patient is maybe here and you're spending all your time over here looking in a completely different direction. And I think that absolutely patients feel it and they want you to know them and certainly they want you to know the information in the chart, but they really want you to know them. And how do you, even if you're an emergency room physician and maybe your interactions are kind of more brief, how do you get to know somebody without actually looking at them? Right. You don't because you miss all of those cues when you're taking a history and trying to obtain the critical piece of information that you need to make the correct diagnosis and help them. If you're missing the nonverbal cues, that's probably at least 50% of the history. And if you're not seeing what their family member or friend who often people are accompanied by someone what their face says when you ask a specific question, you're missing additional information. And it's really critical to taking care of patients. They're not trying to withhold information, but we communicate in lots of ways other than verbal and we need to be making eye contact and looking at each other to really establish that relationship. I agree. And I think the other thing that has happened, and I'm not dinging technology, I actually like technology when it works well, when it enables us to do our job well, and I think there is a lot of opportunity there, but the other thing that happens is the way it parses information, it takes kind of the story and the narrative away from the patient and it ends up kind of boxing them into where the check marks land. And that is not the way people think. It's not the way patients think, it's not the way practitioners think. I saw this really interesting study recently, and I'll totally get the numbers wrong, but the point of it was really impactful for me and it was specific to emergency medicine and how long and large the electronic charts have gotten. So I will say this number, and it's probably wrong, but at least 40% of patients' charts are now over 80,000 words in them. How are you supposed to really digest 80,000 words in a brief? You have a couple minutes to do a chart review before you go to see someone, right? So we are at this inflection point where as you mentioned, technology can be really helpful, but we're at this inflection point where we have to develop the systems to make it work for us and for the patients so that we can distill out the important information that will help us take care of them, but not be completely overwhelmed by information that is not relevant or duplicative. And we simply don't have the time to review that on every patient that we see. I have a lot of hope that we'll do that because I think there's a lot of attention on this now. We're just not there yet. But this is something that is being widely discussed at the national level. The US Surgeon General put out a public health advisory about healthcare worker burnout, and this idea about making technology work for us was a large piece of that. The National Academy of Medicine is looking at this and has brought together really a broad group of experts in the area of wellbeing. So I think we're going to get there, but in the meantime, we have to have something to offer people because we're still several years away from that. So we need programs and initiatives and creative solutions to the problems that are facing people right now so that we don't lose them before we get to a better point organizationally, systematically. So tell me about some of the programs that you are currently involved in. When we started our program at Maine Medical Center was about 11 years ago. We actually started with an initiative from our medical staff and the Medical Executive Committee, our med staff president at the time, Dr. Jamie Zeitlin, was really passionate about the idea of peer support. And so we partnered with Dr. Joe Shapiro from Brigham and Women's and created a peer support program for the medical staff and house staff at Maine Medical Center. We took about 12 to 15 months to actually develop that program, do trainings of 25, 30 individuals that we tried to have representation across different specialties and different levels of training and different roles as well. And we also started a nursing peer support program at the same time understanding that we really need to focus on the whole team. And that morphed over the course of the last 10 years into many other initiatives and programs. So we had partnered with Doc Executive and it's an external organization in Maine Medical Center, which has been a great partnership and I would say an extension of peer support when one or two interactions with your colleagues enough, you need something more and a way to address a challenge in your professional life. So we've had a really great partnership with Doc Executive. We've also secured some grant funding and developed, we call it our "code". Well, it's a council and departmental engagement and wellbeing with representation across the organization to really support ideas that frontline staff come up with themselves for things that will help them in their own work units. And I think that's a big piece of what we are trying to communicate with our colleagues, with our administrative team and the executive team, is that we can't say we know what the answers are within an individual practice or work unit. And so we have to really give them the tools to help prioritize what are some of their driving impediments to efficient practice and wellbeing and then help support them as they create solutions to it instead of having this kind of oppressive top-down approach like, oh, we know what all the solutions are. That's just not possible. We're supporting like 3000 individuals across the medical group at this point in the MaineHealth system. So it's been really interesting to see what people have come up with and we love being able to support that. So we have some grant funds and they can apply if they need a little bit of seed money to get a project going. Also, I know that across the system, the MaineHealth system, you've been able to get some leadership time allotted to have more regional chief, well, I guess they're not chief but wellness officers, which I think it speaks to your point of really engaging people locally and having it be recognized that it actually does take time to create programs. There's so much, I could talk about this all day long, I think a wonderful demonstration of the commitment to actually supporting frontline staff that MaineHealth has been able to develop these programs and positions. So when I started out, I started out with the peer support program and it was really nominal amount of time, but a lot of interest, like sort of a project of passion and then it's developed into the majority of my time. I still practice clinically several days a week, and that's really important for this position so that you understand what people are actually experiencing. But then we've also been able to develop two regional positions. Well, we already had a lot of infrastructure in the southern region and MaineHealth is organized into three different regions, southern, coastal and mountain. And so now we've been able to develop a Coastal Regional Wellbeing Medical Director and a Mountain Regional Wellbeing Medical And the idea is that when you put a face with something, people will start to trust that individual and go to them with their challenges. We know actually there's been a ton of research on how to solve these problems. None of the problems we're experiencing in Maine are different than anywhere else in the country. There are tried and true solutions, we just need someone to do it. I would say that wellbeing is very similar to the quality movement of the early two thousands, right? There were no quality directors within every department in two, 2000, 2001. And then we realized this is really important, we need to pay attention to it. Well, wellbeing is kind of in that stage now, this stage of early development and starting to take off. I'm part of a national network of Chief Wellness Officers, and when I joined it, I guess four or five years ago, there was probably less than 30 members and now there's several hundred at this point. And so it's really something that seems to be supported and increasingly implemented for organizations. You and I share a similar early childhood path. You graduated locally from Greeley High School and then you went on to Colby College. I graduated Yarmouth High School, one town over. We were sports team rivals, but in a friendly way. And then I went to Bowdoin College. Again, sports team rivals very similar. Very similar. And we've both come back to our homes essentially to raise our kids. And I know that we have similarly some children who are now adults, and so I can't speak for you, but I can say for me the need to have great healthy healthcare practitioners in this area is very important because this is where I came from. This is where I live now. This is where I suspect at least some of my children will live in the future. So we really need to have people feeling good about practicing in healthcare. But tell me how you feel about this. Well, I can encapsulate it in a story. So I have been at Maine Medical Center, I did my residency there and I've completed it in 2004. And I've been practicing as an attending in the emergency department since then. And I love it. I absolutely love my colleagues. It's the reason I wanted to stay there as well as my families here and many of my friends, but I love my colleagues and they mean so much to me. But I was sitting in my office probably 15 years ago and my mother came to visit me and she walked in. She didn't realize where my office was at Maine Medical Center, and she walked in and she said, this is the building and the floor where I came when I was pregnant with you. So when she was pregnant with me was like one door down in my colleague's office having her prenatal evaluation. Then I thought, that's incredible that it's this kind of full circle moment and it means so much to me to try and sustain people wanting to go into this profession so that we can take care of our communities. I suspect you probably have a similar experience, but your friends and your family ask you questions right about their health and what do you think I should do about this or that? And I see it as a form of giving back, not to be providing medical advice, I shouldn't be doing that, but to help them navigate the system and think about, yeah, that sounds like something you should definitely speak with your doctor about or yeah, I think that you have a valid concern, and this is what I would do if I was in your situation or ask for or whatever and is why I went into medicine. I want to help people be healthy and I'm worried about it because I have three children in college. All of their friends are obviously going out seeking out professions that are interesting and inspiring to 'em and not that many are interested in medicine anymore. And that's a problem and we need to change it. So when I decided to be a physician, I was really young when I realized I wanted to do this, but I thought it was the best possible profession I could ever aspire to be a part of, and I want to return that feeling to it. If there's any way I can help, I feel the same way. And I mean my father who recently passed away, he was a physician for half a century. He was incredible, most of it in Maine, and he was from Maine. And to him it was such an honorable thing to be able to care for the community. And then my son finished his emergency medicine residency actually just before my father passed away and returned to New England. And I think that there was such, my father had such pride in the fact that there was another generation that was going to be helping to care for the community, not out of a sense of personal like, oh, look what I did, but more look at this person that's going to come back to the community and offer this care. So for me, this is an urgency. It's all the practitioners and also there's my son. I want my son to have the joy in medicine that I know that I have often felt myself and try to figure out a way that that joy then gets transmitted to the people that we are trying to establish relationships with, who we are attempting to care for. It's so important. Some of the most satisfying times outside of patient care that I have had are asking a group of people, why are you doing this? What brought you to this work? When was the last moment that you experienced joy with a patient and hearing all of the experiences that brought people joy, and then how do you think we can help protect that joy? What are the things we can do so that isn't taken away? And we do that sometimes with groups when we're working with 'em. It's incredibly uplifting to hear how people's paths brought them to healthcare and then what were the things that brought them joy. And the answer is never, well, when I figured out how to make the EHR finally work so I could do whatever, it's always about this really inspiring moment of connection with a patient or their family or some way that they experienced that core value of why we're here. And I'm kind of distracted because thinking about all of those moments that I've had, they're very different. But there's many that go through your mind. And I think that mean there are those many moments. And also it is so interesting that, I mean, being human has challenges and most people don't come to see, well, they almost never come to see you when they're in the middle of the happiest day of their life. No, they do not. And so at least in family medicine, there's more of a wellness component and people will come and they'll do preventive care, and I get to update like, oh, what are you doing now and where did you travel to? And it's not because trying to find out what kind of infection they have, right? In your case, you are dealing with people who they might leave feeling much better and that's the hope, but they're coming in and it is what some people would say would be one of the harder days of their lives, which as valuable and rewarding as that can end up being, it's still stressful. And when I would talk to my son about doing his residency out in California, he would talk about people who had come in and would pass, and whether it was a long-term chronic issue or something really sudden, and that's really hard. It's really hard. So then knowing that just on its own is so hard. And then you add on the layers of complexity and process somehow being able to at least move away the things that we really should not have to deal with and just the stress that's always going to be there because we're human. So I think about it a lot because I practice as you do in the community that you live in. And so I think what kind of care would I want for my mom and dad and my children and my friends? And that's the kind of care I aspire to give all of my patients. And I sometimes succeed and I sometimes fall short on that. But really those other things that are adding stress are often why somebody can't give that kind of care to someone. And we have to take that away. I had two patients this week who were separate. It wasn't a related encounter, but who both had just lost, one had lost their spouse like five days prior and one had lost their father. And that's not why they were in the Emergency Department, but it was probably the most important piece of information I got in taking care of 'em because then I could understand why it was so upsetting to be back in the hospital because they've been in and out of the hospital so frequently with their family members. And if you don't get that information because you're too busy with whatever or you're not looking at 'em and so they don't feel like they can share that, then you're really missing an opportunity to make a human connection and make that experience less traumatic for them in the moment. I absolutely agree with that. And sometimes the things that you learn by listening, not necessarily by filling in the blanks on your EHR, can be the linchpin moments and they're incredibly important. And I also think that if we can improve processes kind of across the board, then the things that in the emergency room you are currently dealing with, I suspect, because I think we're all dealing with them everywhere. People who don't have a place to live out their final days, they need to be boarded in the emergency room, they can't even get into the hospital, they can't get into their primary care physician, so now they have to come to the emergency department. If we can fix little pockets of processes in all the places, then people can show up and do their jobs in the right place at the right time, in the right way, and we're not always constantly picking up the pieces. Right? Absolutely. And that is back to kind of where we started about what's the intrinsic motivator for being in medicine. When you have the opportunity to ask people almost universally the sentence, "because I wanted to help" is in that answer. I hesitate to even go down this path. I have feelings on this probably because of who my father was, who tended to be someone who was always looking toward the possibilities and with optimism. And I tend to be thinking, okay, I'm a realistic optimist. I understand that these are very difficult things, but I think that the future looks positive. And on the flip side, I know that there's been a lot of conversations around terms like moral injury, and I don't discount that that is a thing, and I believe that it's something that we need to be paying attention to, but I tend to focus more on things like resilience and wellness, and I think words do matter. Do you have thoughts on how to navigate the murky waters of where we are currently? I think you and your father, I am an optimist. I think you have to be, if you're going to be doing this work to believe that there is something better in the future. There are so many terms that are thrown around, and the term burnout is obviously ubiquitous in medicine right now. I think what's more important is that there's been a shift in all of the research that's been done was originally about how to even describe what is being felt and why it's there. And that was almost like research that could help you make a case for supporting people. Well, in the last five-ish years, the focus of the research and conversation nationally and regionally has really shifted to how do we make it better? Which to me has been an incredible relief for probably the first five years in this work. I lost sleep at night thinking about we know the problem, how do we even begin to fix it? There are clear strategies that we can use now, and I find that we are not in the position where we have to convince anybody anymore that there is opportunity for something better. And unfortunately, probably the pandemic is what really brought that to light. When you think about what is the most important resource in healthcare, and there's so many things that support a healthcare system, it is undoubtedly the people within the system that are the most important resource. And we lost a lot of them through the pandemic. We can use terms, and I think they're all kind of subcategories of things that are distressing for one individual or a group of individuals versus others. And some of it depends on your specialty. Access is obviously so important in primary care, it doesn't even really matter because we need to bring this conversation to the front line and help empower people to come up with solutions that we are willing to implement. So I'm hearing lots of things that make me really hopeful and not just hearing but being part of. So we are developing processes that are focused on, wow, we have all of this data from the EHR on how people are using it and seeing does it appear to be efficient use or does it appear that somebody's struggling? And instead of just watching that and then watching that person walk out the door two years later because they're on the EHR every night at midnight, we are now saying, we're going to help those people. We're going to help figure out what the impediment is to being able to complete your work in a workday. And that's important that we do that. We don't want to lose someone. So to me, that's really different than where we started, which was a great place to start. We're going to support people, but then you hear about all these things and you're like, we should be preventing this. We shouldn't just be supporting you as you're kind of on your way out the door. Yes, that's so important. I mean, just the visual as you're describing it of, oh, we know that this person's spending too much time doing this because there's whatever the reason they don't have the skills or there's some other reason, but we're just going to watch them and we're just going to assume that it's okay for you to work beginning at 7:00 AM and you're going to just keep working until 11 o'clock at night and also take care of your family and your community and your aging parents for five to seven days a week, as opposed to, oh wait, actually there are ways that we can actually join with people and create solutions. And I think it is interesting because we've talked so much about inclusivity and about really bringing all the people to the table, and I think sometimes what doesn't happen is remembering that being inclusive also means you're going to have people at every stage in the profession. So you're going to have new learners, you're going to have people who are closer to retirement, you're going to have people who are great with digital technology. You're going to have people who it's not intuitive to them. And how do you meet them? How do you be inclusive with them and not make them feel like they have to fit into whatever digital structure currently exists in order to even practice medicine? Right. It's interesting. I've been asked to talk to groups about not just what is burnout and here tell people how to make themselves more resilient so that they can withstand all of these pressures from the system, but actually can you come talk to us about how we can change our unit, our practice group, whatever we're talking about, and how do we recognize risk factors for burnout? How can we get out in front of it before it even happens? And there are definite risk factors, and many of us in medicine have personality characteristics that drive us to constantly be going to the nth degree of completing a task and feeling like we've done it as well as we possibly can. So those things put us at risk and then our system just absolutely implodes that. And so I really like it when I think about leaders who are asking, can you help me understand what might be things I should be looking for in my team that I can understand now would be a precursor to this distress developing? And then how can I change our team dynamics or our practice environment so that we can minimize that? And it's real things, it's understanding when people are doing their work, understanding if there's a persistent barrier that everybody's kind of experiencing, then we probably have to develop a new workflow for us in emergency medicine, it's the waiting room, and I'm sure for the community it's a similar driver of distress knowing that you go to the emergency department anywhere and you're likely to be waiting for a long time, that doesn't feel good at all. It's not what any of us want for our families or friends or community members. And so we've developed very significant workflow redesigns to bring our team out to the waiting room and take care of people out there as well. What would be wonderful is if we had all of the resources in the community and around that we didn't have this problem of a bottleneck and people getting stuck out there. But that's one example specific to emergency medicine that's like we can't wait for there to be enough skilled rehab facilities to accept patients too, so that we can admit our patients and they don't have to stay in the waiting in emergency department while they're waiting for an inpatient bed. That's years from now. So we have to get creative and it's for the good of our patients as well as our team members, The sense of empowerment and the ability to engage in the problem solving. And I think that that creates its own positive momentum so that instead of just sitting and kind of quietly quitting and being like, well never change. I totally understand. You feel burned out, you feel upset, you feel not listened to. Okay, I'm going to absolutely validate that those are very real experiences for you, and here we are. So how can we work together and how can we all participate in solving this problem? And you're right, I think it does take leaders who understand the importance of that and understand the importance of drawing people together. Right, absolutely. And one of the things that's interesting to me is that when you ask healthcare professionals where their confidence lies, it's in their teams for the most part. People feel really good about who's in their immediate environment and who they're working with. So if you can make that environment as positive as it can be, you can often withstand the inevitable stressors that the system as a whole is experiencing and accept that there are some things you can't change, but knowing that you're changing, the things that you have are within your scope of control to actually influence. As you said earlier, I know you could talk about this all day, I could talk about this all day. I feel like this is such an important topic, but I really give you so much credit for kind of dedicating yourself to this. You said you've been doing this particular thing for 11 years working on this thing. I can't imagine that when you first started, it was the easiest path to take. No, it was not. And I kind of went into it with optimism and hope. I actually remember talking to my husband seven or eight years ago about what my vision was and we were on vacation. I was not stressed out, we were just walking along and I was kind of saying, if I could create this program within Maine that would help people, that would probably be one of the most important things I can do in my nonclinical professional life. I didn't really know what it looked like at that time, but I knew it would take a lot of support from the leadership team that I've been fortunate to work with. And now that's sort of where we're at. We're still building and still working, and we have so many opportunities in front of us to approach. We have not e