address this, Stanford has created new metrics—including time spent charting in EHRs during personal time—and is working with administrative leaders to track and improve them by providing physicians additional assistance in the clinic, redesign of work flows, and better team‐based care. Another important intervention has been for every department chair to appoint a director who works with WellMD to improve professional fulfillment for physicians in the department. In collaboration with the clinical and improvement leaders in their departments, these individuals are tasked with addressing the local irritation and friction points unique to their department/specialty or local practice. Larger‐scale efforts with operations and improvement leaders are designed to improve operational metrics on the efficiency of the practice environment (time spent on clinical documentation at home, operating room turnaround time, time per week more broadly).
The center has also been working on organization‐wide efforts to improve dimensions with broad relevance independent of specialty, such as the following:
Cultivation of community and connection between colleagues by helping physicians connect with a small group of colleagues regularly to provide support for the unique personal and professional challenges of a career in medicine—a strategy found effective in two randomized controlled trials that Shanafelt helped lead at the Mayo Clinic [34].
Development and testing of strategies to improve self‐valuation (studies demonstrate that low self‐valuation is a critical driver of burnout in physicians).
Development and testing of strategies to encourage leadership behaviors among division chiefs that cultivate professional fulfillment among those they lead.
Creation of a formal peer support program to serve as a safety net for physicians experiencing distress related to the professional (medical error, friction with a supervisor or coworker, dealing with a malpractice suit) or the personal (relationship issues, problems with work‐life integration).
Stanford has also been at the forefront of developing an organizational model that illustrates how the quest to cultivate professional fulfillment among physicians is about far more than personal resilience and requires structural, system‐level changes in the organization and practice environment. This model has now been used around the country to heighten awareness of physician burnout among those who are able to do something about it, such as administrative leaders and people who serve on hospital boards. A 2018 paper coauthored by several Stanford officials highlighted seven ideas that should motivate board members around the country to focus on making this issue a priority for their organization:
Burnout is prevalent among physicians and other health care professionals.
The well‐being of health care professionals affects the quality of care.
Distress among health care professionals has a tangible fiscal cost to organizations.
Greater personal resilience is not the solution.
Different occupations and disciplines have different needs.
Approaches to remedy the problem have been developed.
Interventions have been shown to work [35].
I’ve been encouraged by other institutions joining our efforts. As of January 2019, 16 academic or academic‐affiliated medical center members (including Stanford Medicine) had become part of a Physician Wellness Academic Consortium (PWAC), which is focused on driving innovative advancement of physician well‐being. The consortium is taking the following steps:
Applying common measures for longitudinal assessment of physician well‐being and the primary drivers of well‐being.
Developing and testing innovative strategies to improve physician well‐being.
Meeting at regular intervals to share innovative best practices to improve physician well‐being.
Implementing evidence‐based/best‐practice strategies to improve physician well‐being.
We’re also seeing interest by leaders of the medical establishment. In the fall of 2018, Shanafelt and I were among the authors of a Health Affairs blog posting that made the case for health systems to hire a chief wellness officer (CWO) to support the well‐being of clinicians [36]. The other coauthors included the president and CEO of the Association of American Medical Colleges, the presidents of the National Academy of Medicine and the American Nurses Association, and the CEO of the Accreditation Council of Graduate Medical Education. The role of a CWO is to help lead all aspects of organizational change necessary to reduce burnout and cultivate professional fulfillment. The CWO is a senior leader who plays a role analogous to that of the chief medical officer or chief quality officer. The key responsibilities of the CWO include evaluating the scope of the problem within the organization, reporting the results to senior leaders (e.g., the hospital board, dean, department chairs, operational leaders), developing an organization‐wide strategy to drive improvement, and overseeing broad system‐level efforts to make progress in the dimensions most relevant to the local organization.
Once again, these efforts primarily focus on system‐level improvements addressing dimensions of organizational culture and inefficiency in the practice environment. CWOs should also have expertise in tactics and strategies to support local unit‐level efforts to address unit‐specific issues. They must be effective in engaging other leaders (chief quality officer, chief medical officer, chief medical information officer, and human resources officer), partnering with them to drive necessary change and measuring the progress.
While change comes slowly in medicine and health care, as I will explain in more detail later, I am encouraged by the speed with which this issue has become a priority for many individuals and institutions. A lot more still needs to happen, and when it does, physicians and their patients will see the benefits.
* * *
One incontrovertible fact applies to U.S. health and the U.S. health care system: there’s a clear need for improvements to both. Declining life expectancy, coupled with large life‐expectancy gaps based on geography and income, is a tragedy at a moment when there are extraordinary new tools to enable healthy living. Similarly, the multiple flaws embedded in the U.S. health care system are imposing great costs on the United States—in outright spending (with low returns on that spending) and the care and treatment of patients.
I am confident that changes inspired by Precision Health approaches could help reverse the gloomy state of affairs I’ve just described. But first, I will explore the determinants of health that are largely overlooked by the U.S. health care system.
CHAPTER 2 THERE’S MORE TO “HEALTH” THAN HEALTH CARE
One of the essential ideas underpinning Precision Health is that medical care plays only a small role in determining our health outcomes. For too long, “health” has been equated with the amount and quality of medical care that’s delivered. Doctors have focused their work primarily on treating disease. That’s how they’ve been trained, how they’ve practiced, and how they’ve thought for as long as the medical profession has existed. The gold standard of medicine has always been to find treatments that work for large numbers of people and match them appropriately to the conditions facing their patients.
But this is an incomplete and flawed approach, in a few different ways. It’s reactive—it focuses on people only after they’re sick. More fundamentally, it doesn’t take account of the factors outside medical care and genetics that drive human health. While every individual is different, the key areas below show approximations of what are typically the key drivers of health outcomes, and the importance of each one relative to the others:
Environmental and social factors: 40 percent
Behavioral factors: 30 percent
Genetics