A: Hey guys. Welcome back to the podcast. I'm Amanda.
L: I'm Laura.
K: And I'm Kendra.
A: And before we get started, another one of you took the time to write us a review on our podcast, and that means so much to us. So I'm gonna share it. It's from mamaof3pediMD and she says, “Fellow physicians take the time to listen to this podcast. Concise, eye opening and encouraging. We could all use the tools these women describe. To each of you, Kendra, Laura, and Amanda, thank you for investing the time to help us care for ourselves and continue to care for others. Cheers ladies.” Cheers mamaof3pediMD. That helps us so much for other physicians to find this podcast, and it just, to be honest, it feels good.Thank you.
L: Thank you.
A: So, I am super excited today because we have Dr. Hani Chaabo, who is joining us today to talk about ORGANIZATIONAL WELLBEING. In preparing for this interview, a quick Google search reveals how amazing he is. I personally met Hani during our Fellowship in Integrative Medicine through the Andrew Weil Center at the University of Arizona, and we were lucky enough to have one residential week in Tucson, Arizona before COVID turned everything virtual. And I'm just telling you, when you walk in the room, when he's there, he just has the best energy. Like, and everyone can feel it. So I'm so excited to have him on today so that you guys can meet him too.
L: Yeah. Thanks so much for being here with us, Hani. Can you tell our audience a little bit about your backstory, kind of who you are, your training, what you do now, et cetera?
H: Absolutely. Thank you so much for having me, seriously. I'm really honored to be here with you guys. You guys are doing amazing work, and I'm just really proud of what you guys are doing. Amanda, just watching what you've done after the fellowship and finding you guys as well, Laura and Kendra, and putting this together. And I've been, like, just talking to you know, all our providers about you guys. You're in our mental health resources brochure. And it’s just, I'm really proud of you guys. So thank you so much for all the wonderful words you said to me. I wanna just echo that back at you. And to answer
A: No, no, go on. No, really go on
H: I could go on forever, for the whole 30 minutes
A: But back at you- like in this Google search, you guys. Like during his med school in Lebanon, right? He's doing all this work with refugees and universal healthcare for underprivileged people, all this sort of stuff. I was drinking beer and playing darts with my spare time in medical school. So Hani is a special kind of person.
H: Oh, thank you so much. I am definitely, I've been very lucky, I would say, along my journey. Really, very lucky. And you know, you said all these wonderful things about me, and I want to acknowledge that a lot of those wonderful things I picked up along the way from people who just showered me with a lot of kindness and mentored me. And I've definitely had a lot of experience with working with different kinds of people from all over the world, and I really feel like that's really what led to who I am today and what I do today. You know, like all of us, we've all probably been through a lot of suffering in our lives. And I know that anyone who's a coach, especially you three, you've been through your own darkness, and now you've found your light. And you're helping others find their light. And in many ways, that's what I went through and what led me to become a doctor.
I used to be obese and depressed and anxious. I still struggle with anxiety. I still find my trauma responses coming up to the surface and my challenges. And I think my journey towards healing started about 10 years ago. It started with yoga and meditation and lifestyle change, and it led me to becoming a doctor, and then becoming a family doctor, and becoming an integrative medicine specialist. And what I do today is a mix of traditional primary care as well as integrative medicine, and a lot of, I would say, also coaching and therapy. So I function as a coach and a therapist, and I run a stress reduction clinic in Ridgecrest California where we deliver a eight week mindfulness based lifestyle change program that I developed.
And all of that started with my therapy journey 10 years ago, but also I was lucky enough to be charged with developing wellbeing education when I was a resident in West Virginia. So I completed my medical school in Lebanon, and I moved to West Virginia to do my residency. And that was a really big cultural shock, I would say. I was thinking, “I'm coming to America. First world.” I thought America was New York and LA and San Diego and San Francisco and all these wonderful places. And Pittsburgh and all these wonderful places. And you know, I landed in, I would say, one of the most struggling states in America.
And through that I was able to get really high quality training. And also, there was a role for a lot of wellbeing education in our residency. And then when the ACGME mandated that all residency programs start addressing wellbeing as a core educational pillar for residents, I was charged with developing a wellbeing program. And from there I just learned a lot about what wellbeing means in healthcare. And now I'm actually medical director of wellbeing in our hospital, and I've completed training from Stanford for that role. And I'm currently enrolled in a one year leading physician wellbeing certification with the American Academy of Family Physicians. And I'm also now a faculty with them developing wellbeing education for learners.
L: That is amazing, and I bet you just said a lot of things that most of our listeners have never even heard of or knew were happening. So that is all so super exciting. So you, what can you tell us about, when we're talking about organizational wellbeing. What does organizational wellbeing mean and what does it look like?
H: So it's really important that we're actually watching, now. healthcare organizations acknowledge burnout and want to invest in wellbeing. Organizational wellbeing is, really, it starts with recognizing that wellbeing is something that needs to be valued at an organizational level. So prioritized, you know, resources are allocated towards it in terms of time, leadership, goals. Even we're watching organizations incorporate wellbeing into their purpose statements and their missions and their values, et cetera. But what it really means in healthcare is optimizing the clinical environment so that people who function in that environment, whether they're physicians or nurses or managers, or any kind of people in admin, those people are able to be their best, to do their best. So we watched our care go from patient-centered care, where the priority was lowering cost, having better outcomes, and improving care, towards person-centered care where now wellbeing is part of that. We went from the triple aim to the quadruple aim where we incorporated wellbeing. Because realized that yes, lowering costs, improving outcomes, and improving care is great for patients, but it was coming at the expense of the people delivering care to patients.
And so prioritizing wellbeing now allows us to not just prioritize our patients, but also prioritize those people that deliver care. So that's really what it means at an organizational level.
L: Oh, I love that. That's great. And sounds like something that most hospital systems are probably falling short on, so.
H: Yeah, absolutely. Yeah.
L: So we've heard you mention that 70 to 80% of burnout is actually institutional. We work a lot, maximizing the remaining 20 to 30%, but tell us the latest stats that we should know about.
H: Absolutely. So, Yeah. So I think now it's become common knowledge that about 50% of clinicians in the US are burned out. That number is a little bit higher in nurses. And that number varies by type of clinicians. So actually in ED Docs now, it's about closer to 60%. Yeah. Kudos to you guys for doing what you do. And, it's highest of all in healthcare, highest of any helping professional. So higher than being a police officer or a firefighter or a teacher. So it's a really big problem in healthcare. In fact, suicidality is highest in healthcare. So the estimate is that one clinician is committing suicide every day in the US. So that's about a whole medical school class away because of burnout. And we know that burnout affects us on a personal and a professional level.
So on a personal level, it leads to broken relationships. In fact, in the Medscape survey from 2022, 68% of respondents said that burnout was affecting their relationships negatively. It also makes people more prone towards substance use, escapism (where we wanna stop this awful feeling), and therefore depression, suicidality, et cetera. And on a professional and also organizational level, we know that burnout leads to decreased quality of care. And therefore more medical errors, less satisfied patients, less productivity, because clinicians are more likely to reduce their work hours and more turnover. So you know more physicians leaving the workforce, and that's very costly. In fact, the estimate is for every hundred physicians, it costs about $1 million. And that doesn't take into account things like lost revenue because of gaps in patient care or loss of revenue due to reputation being affected because of turnover, et cetera. So that number is pretty much higher than $1 million for every a hundred physicians.
And because burnout is mostly related to the institution, it's related to high workload and job demand that are disproportionate to the available resources to the clinician. So now we know that in systems that have low physician satisfaction, it's also an indicator of the quality of care. Because clinicians, what they want, what is most conducive to their wellbeing is being able to provide a high quality of care. But as soon as that quality of care starts to become degraded, burnout increases. So now we're starting to also realize that in systems that have low satisfaction, it's also an indicator of the quality of care that's being given in those systems. So it's really important to link those two together and tackle those two together.
And some really interesting statistics I found. The administrative burden that we have as clinicians. So the estimate is that for every one hour spent in direct patient care, which is what gives us meaning and purpose, as clinicians, we spent two hours in bureaucratic work like the EHR and documentation, et cetera. And this admin burden is also very much a US phenomenon. If you compare our admin burden to those colleagues across the world, we have three times more inbox messages, for example. And we know that inbox messages went up by two times during the pandemic and still haven't come down because of the bureaucratic effort. And we know that we spend double the amount of time in the EHR than our colleagues across the world. And also our notes are four times longer because of that bureaucratic load. Crazy. So, yeah, so crazy. So, you know, all of those are organizational level factors. How do we address those things to create more efficiency, et cetera?
And then the 20% that's related to resilience. How do we manage our stress, lifestyle, et cetera? That 20% is where we come in here as coaches and stuff like that to help. But really if we want to tackle burnout, we have to tackle it at the organizational level.
A: Yeah, I like that. And we've discussed it too. I don't even like the term resilience because I don't think there are more resilient people than physicians. I almost prefer the term moral injury because we're not able to do the things that we want to do, but yeah. But we all know what we're talking about when we talk about resiliency.
L: I have another question, since so much of what we're calling burnout is institutional. Do you have something that you would say to maybe hospital administrators who are dealing with an organization where they're having lots of turnover of…nurses seem to turn over a lot more quickly than physicians, but turnover of nurses and physicians.
H: Yeah. So, you know, there is a structure now that the American Medical Association rolled out. It's called the Joy in Medicine Framework, which I absolutely love. In fact, our organization is trying to become awarded for that work, and they award organizations for incorporating that structure. But I would say if, for organizations to become much more competitive and to retain employees, we should all be moving towards what's called the Wellbeing 2.0 Framework. So it's an evidence-based framework, that incorporates much of the structure of the Joy In Medicine, that allows organizations to become more competitive and retain employees. In fact, it's been proven, there's now multiple research studies from national collaboratives. There's one research study that incorporates 200 organizations incorporating the Wellbeing 2.0 framework that showed that they've actually had less turn turnover, better wellbeing, reduced burnout, better attention, and it also reduced costs. And they found that it has actually increased revenue. So we know that prioritizing wellbeing and incorporating the structure and really making wellbeing an organizational goal is actually lucrative to the organization in many ways. So I would say, for organizations to start looking at what that structure means for them and how to start prioritizing it today.
K: Wow, That's impressive. Especially since it's a national collaborative and trying to get some sort of initiative pushed through that is reproducible, in no matter what type of hospital or community that you work in, whether it's a large institution versus a small community hospital. So speaking of that, what have you found are some of the things that organizations do that don't work?
H: So, we touched on this a little earlier, and we said many hospitals are still kind of in a place where they're focusing on things that don't work. And that's called the Era of Distress. We've actually characterized the Era of Distress in healthcare where mainly the headline is that organizations scapegoat physicians for not being resilient enough. And you know, Amanda, you said we are definitely more resilient than- the Department of Labor has released actually data that shows how resilient you are. We are the most resilient out of any profession. However, even the most resilient of us experience about 30% burnout. So there is a pattern of scapegoating that happens between organizations and clinicians where the clinicians blame the organizations for not providing an optimal work environment. And the organizations blame the clinicians for not being able to function in a non-optimal work environment. And that's called the Era of Distress. Many organizations are still there. It's been happening since 1980. And it's only been since 2005 that we've been going towards the Era of Wellbeing 1.0, where we're starting to touch on things to improve burnout and wellbeing. And a very small, I would say, population of organizations in the US is in Wellbeing 2.0, where now we are really looking at system level factors, and we're improving them. But I would say, you know, the biggest thing that many organizations are still doing is the scapegoating and focusing on resilience initiatives, and that just doesn't work.
A: So the devious part of me wants to like put all of that on flyer and like secretly put it mailboxes.
H: Great idea. I love it.
K: Definitely we would put it in there anonymously. Not that our podcast doesn't reach almost 3000 listeners right now, but…
H: Amazing. Like maybe all 3000 listeners will help us do that.
K: Yeah, maybe. So what, on the flip side, so we just talked about some things that organizations do that don't work. How about you elaborate on some of the things that organizations do that do work.
H: Absolutely. So again, I want to highlight this Wellbeing 2.0, Joy in Medicine Framework, because it's really accessible. You can find it online on the AMA website. And you can actually read the article entitled Wellbeing 2.0 by Dr. Shanafelt, who really is the guru of wellbeing in healthcare right now. But basically, if I was to frame this very simply, the opposite of burnout is engagement. So when you engage people in their workplaces to improve their local environments, and when you allow them to take ownership of their workplaces, that reduces burnout, and also it helps them improve their local environments. And that's basically the main headline behind Wellbeing 2.0. And this incorporates what's called Intrinsic Motivators. So intrinsic motivators come from a discipline called Human Factors Engineering, where now we're looking at professional systems, and we're looking at, okay, what are human capabilities? What are things that motivate us? And also what are things that take us away from being our best selves at work? And those are called intrinsic motivators. And this is a list of intrinsic motivators. I mean, just reading them out is probably gonna be self explanatory. But there are things like incorporating people's voice and input into their work environments. Allowing people to have more autonomy, more control in their work environments. Allowing people to have a sense of meaning and purpose, and also developing our workforce, allowing them to feel like they're growing in their work environment. So , really beautiful words, right? Like these beautiful intrinsic motivators. And that's also part of what organizations are doing now that works. They're, you're, they're looking at these intrinsic motivators and saying, “Okay, how do we build these into how our leadership is functioning? How do we build these into how our teams are working together? How do we build these into how we improve our local environments?”
So I would think, one thing that organizations are doing that's working is looking at this from this kind of lens, allowing the integration of this philosophy. And it starts first at the level of the leadership, because what makes or breaks the transition towards wellbeing to 2.0 is if leadership is on board or not. It often is the reason that Wellbeing 2.0 doesn't happen, and there's all kinds of statistics right now about leadership and the transition. And also about physicians’ immediate supervisors and how they are leading those units and how that affects their burnout. It affects their burnout considerably. In fact, every one point increase in leadership score for a physician's immediate supervisor is associated with a 10% increase in satisfaction for that physician.
So leadership is very much linked to work satisfaction. And so one thing that organizations are doing that works is optimizing leadership, training their leadership in things like participative management, where leaders are being led by the changes the team wants to see. Not by not directive, not by the changes they think should be seen or a top down approach, just the changes that the upper level wants to see.
And also, things like compassionate communication and culture, you know, kindness, vulnerability, et cetera. And then also optimizing teamwork. So a lot of organizations are now dedicating resources towards helping teams understand their relational health. We are not all supposed to work well together. We're not all cookie cutter people. We're all universes, and we work differently with each other. But there is a role for us to understand how to work better with each other. If I understand, you know, what my personality is and what your personality is, then I can help myself communicate with you better, and I can help you understand how to communicate with me better. So organizations that are dedicating resources towards relational health are improving team dynamics and then also empowering that team to improve their own workflow and processes, which is the most important part here is- okay, now you're empowering leaders. You're empowering teams, and now they can be the people that are improving their local environments. And now we have a bottom up approach for improvement. And I think this is one of the most important ways that organizations have improved their functioning and one of the things that work the most.
And then of course also there's increasing access to resilience tools. I know we are kind of putting resilience on the back burner here a little bit, but organizations definitely have a role in increasing access towards mental health. You know, even in our organization, we've increased access towards therapists and coaches like you guys, and also increased access towards things that improve lifestyle. So our cafeteria has healthier foods, et cetera. So all of those together, when organizations start to prioritize wellbeing first and foremost at the organizational level, and then also at- caring about their workforce, allowing access to resilience tools, those are all things that work.
A: It feels good to be treated like a human sometimes.
H: Oh yeah.
L: Imagine that.
H: Oh yeah. Imagine that.
K: So, Dr. Hani, for our listeners, if they're interested in getting the ball rolling with their institutions, where can they get started?
H: So, I mentioned the ama steps forward modules- or I mentioned the AMA. But the AMA has the steps forward modules. It's a website that you can access, and it's got all kinds of training modules on there. A lot of my education came from there. There's modules on wellbeing, on burnout. There's also one of my favorite modules. It's called the Listen-Sort-Emower module, which is basically an initiative to incorporate continuous quality improvement at the unit level. So it trains leaders to have productive conversations with their workforce to be able to mine quality improvement initiatives out of their workforce. And then in that way, they can affect improvements within three to six months. And that way they're in a continuous improvement cycle where they're improving their local environments. And then anything that can’t be improved locally can be escalated in the organization so that it can be improved at the systems level. And that way there's a bottom up and top down approach to improvement.
And one thing I really love that I read recently is a Harvard Business Review article about how workers attribute positive feelings at the end of the day, at the end of their work day. And to sum a long article short, basically when workers are feeling like they're having forward movement in their work days, they attribute more positive feelings at the end of their workday to forward movement than if they have a negative experience or a positive experience in their workday. So we all want to feel that forward movement. So the Listen-Sort-Epower training module allows us to start that movement today.
And I think that's a really important place to start. But also a really important place to start is to appoint wellbeing leaders. You know, find people that are passionate about this. That's how it started for me. My program director approached me and said, “Hey, you like to teach about meditation. You like all these things. Why don't you, you know, become a wellbeing champion and start helping us educate people about wellbeing.” So appoint wellbeing leaders, it's really important for a step. And then, once you appoint leaders and you train them, then you can start the conversation about what wellbeing means at our organization and what kind of actions need to be taken.
A: I love it. So now we get to talk about your eight week mindfulness lifestyle change program. Tell us all of it.
H: Yay! Yeah, it's really one of my favorite things that I do in my life. It came out of six years of research and development, and it's- I consider it my passion project. It's basically, the stem cell of any mindfulness program in healthcare is MBST, so Mindfulness Based Stress Reduction, which was developed in the 1980s by Dr. Jon Kabat-Zinn. And that's really the stem cell. Now every single mindfulness intervention in healthcare is basically fashioned after the MBSR program, and so is mine. However, mine is a little bit different. So in our first four weeks we focus on mental health. It's really important for us to understand, you know, our negative patterns, how we function, our stress responses, our trauma responses. And what we try to teach people is that because of neuroscience, now we understand we can rewire ourselves, we can rewire our brain. And the first step is awareness. And so we help people understand patterns in themselves, and then we teach them tools based on the evidence that help us rewire into this “best version” of ourselves.
And then the second four weeks is about lifestyle. So we go into nutrition, into movement, as not just exercise, but as a practice in our lives. And also biohacking sleep. And then it culminates in a silent retreat. And for me, it's one of the most transformative things. Not just, for my patients, but also for me. Watching people, how they incorporate these tools and, the sharing, the group, just the group healing that happens. And then what we start with in the first session and then where we are by the end of those eight sessions and the community that develops. And it's just, it's something that brings me a lot of joy. When I'm having difficult days in my life, I think about my group patients, and it really, it helps me recenter myself. So that's my eight week program. Thank you for asking about that.
A: Oh my God, yes. Sign me up. So speaking of that, how do people get in contact with you? How do they sign up for something like this? What's the best way?
H: So right now we're actually just delivering it through our hospital here in Ridgecrest. So, we're looking into creating virtual groups so that we can increase access, at least in California. But we did, so me and my partner created Mindfulous. It's an online platform to make mental health and lifestyle change fun and more accessible because it can be really dry and difficult. So mindfulous.com is where you can go. Our first program is a burnout prevention course for healthcare workers. But really anybody can do that course. It's just a mindfulness based course for burnout. So you can start there. It's free. It's got a lot of tools that I teach in our program, and we're going to be rolling out more programs on that website. And you can also contact us through that website. That email is [email protected], and I'm always happy to speak to anyone who wants to reach out to me for any reason. So please do reach out.
And I will say, also, with you guys, I know you guys just released a CME also for burnout. And I wanted to say, online self-directed programs are effective for wellbeing and burnout. So, just talking about contacting me, I wanted to put a little plug in there that these kinds of programs do work as well.
A: I love it. Well, any closing thoughts before we wrap up?
H: I started this interview by saying that we've all traveled through our suffering to find our light. And I want to remind everyone, and this is gonna sound a little morbid, but you know, we're all suffering on some level, and suffering is a fact of life. But pain doesn't necessarily have to be a fact of life. And what I found in my life, and I'm sure you guys would also kind of echo this, is everybody who traveled through their suffering and found healing was able to change the world somehow. And, to find healing, you have to travel through your suffering.
And the body wants to heal. As soon as we cut ourselves, the first thing that happens is healing. So you don't be afraid to face the suffering in your life. And here's the thing, we're all wired to focus on the negative. It's called negatively bias. It's so reflexual. We hook onto negative news and negative feedback way more than we hook onto positive news and positive feedback. And that's because we're wired to do that. So if we don't become more intentional about accessing our joy, accessing compassion towards ourselves, just being more present.
From neuroscience we learned that being present allows us to access spontaneous joy. So if I'm looking at a sunset and I'm thinking about all my stresses, I'm not going to enjoy the sunset. But when I tell myself, “Okay, hold on. My situation is the same. Nothing's changed, but let me, let me enjoy the colors. Let me enjoy this breeze on my face. Let me enjoy these kids around.” Suddenly spontaneous joy arises. So being present, we have to be intentional about that because we are so reflectional in being negative.
So I just wanted to leave our listeners with that is, we all have our own blind spots. And we all, you know, need to seek our healing. And we need to start this journey somewhere. And often, it's helpful to find a guide along that way. So, don't be afraid to travel through your suffering. It's probably one of the best things you can do for yourself. And don't be afraid to ask for help. You know, especially with people who want to help, like you awesome people. And thank you so much for having me. This was a joy. Seriously. I really appreciated being with you guys.
K: Thank you so much, Dr. Hani. You enjoyed us, but let me tell you, Amanda was not joking. This whole time you have just emitted such positive and amazingly insightful things. Not only just the business of organizational wellbeing, but just reminding us of the most important things as we go throughout our days. And so thank you so much, and I'm sure our listeners are feeling this emitted positivity- even through the airlines as they- air, airwaves as they listen.
So we are so grateful to our listeners too for joining us today. So until next time, you are whole. You are a gift to medicine, and the work you do matters.
AMA Steps Forward Modules
Joy In Medicine Framework
Wellbeing 2.0 Framework
Hani Chaabo - Mindfulous