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    Transcript for Caring for Caregivers: Tackling Burnout, Costs, and Shortages in Health Care


    AARON DILLARD: Hello, and welcome to the “Beyond the White Coat” Podcast. On today's episode, David gets the opportunity to delve into a topic that impacts all walks of life, especially those within our health care system, in the attempt to meet the demands of society: burnout. To help better understand the calamity and consequences of burnout within the health care workforce, we have two awesome guests. First, Dr. Susan Huang, CEO of Providence Health Network, encompassing 38 hospitals and 18,000 primary care and specialized physicians in California. Alongside Dr. Huang, we have Dr. LaTanya Trotter, associate professor of bioethics and humanities at the University of Washington School of Medicine. In 2021, the British Sociological Association awarded Dr. Trotter the Foundation for the Sociology of Health and Illness Book Prize for her title “More Than Medicine, Nurse Practitioners and the Problems They Solve for Patients, Healthcare Organizations and the State.” David, over to you.

    DAVID J. SKORTON: Well, Dr. Trotter and Dr. Huang, it's such a pleasure and honor to have you with us today. I really appreciate this. Thank you for all that you do in many, many areas. And right now, it's really hard to imagine a topic of more concern and of greater relevance than some of the things that we're going to learn from you today, talking about staff burnout. And the issues with prescription, prescription drugs and prescription drug costs and staff shortages. Those of you who are on the front lines are living this every single day, and we're hearing about it a lot through the AAMC. So, it's great to have you here and wonder if we could kick it off by just understanding a little bit about burnout. You know, the, the word is sort of bandied around a lot. Love to hear, starting with you, Dr. Huang, if you don't mind, what does it, what does it mean when you use the term or someone uses the term burnout to tell us about that? And then I very much like to hear your, your take on that as well, Dr. Trotter. So, Dr. Huang, over to you.

    SUSAN HUANG: Yeah, absolutely. And, David, burnout is just such an important issue. It's really kind of been magnified since COVID. You know, we think of it as the exhaustion — physical, emotional, psychological —that really affects the state of our workforce, our caregivers, our physicians, our providers. It's often accompanied by a sense of decreased accomplishments, a loss of engagements a depersonalization as well. And these are really just important trends that we're seeing, really impactful to our workforce right now.

    SKORTON: Dr. Trotter, your take on it, including if you would from the ethical perspective.

    LATONYA TROTTER: Yes. Well, thank you, David. You know, it's interesting when you sort of think about burnout and what it is, because I think it's actually really important for your listeners to sort of understand that it kind of works at two levels. There is this sort of diagnostic quality, right, of burnout, which I think really is embedded in the sort of psychological roots of the concept. But, it's technically not actually a diagnosis. You know, it's not something that a psychologist would necessarily diagnose you with, but it does sort of have this sort of life, right, as a sort of pseudo diagnostic category, which I think really has shaped the way that we deal with burnout, which is often in thinking about it as an as an individual level problem that we have to come up with individual level solutions about. But one of the things that I think is really interesting is really thinking about this other level around which burnout exists, which is really sort of coming up from the experience of health care workers, not as an individual-level experience having to do just with their individual level exhaustion, but really this sort of groundswell sort of, you know, from the grassroots up feeling of dissatisfaction with working conditions, and that really is often the way in which health care workers talk about and think about what burnout is. And I think, you know, for that, I think, you know, it's really interesting that you asked me to speak about this from the, from the ethical perspective, because I think from the psychological sort of diagnostic perspective, we've known for a long time that, as Dr. Huang noted, the sort of feelings of depersonalization, dissatisfaction can impact the ways in which providers think about how they make decisions about patients. If you are having difficulty feeling empathy, if you're having difficulty feeling compassion, you may not make the kinds of decisions that you ordinarily would make. But I also think that health care providers see that really as a, as a problem for themselves, because they want to be ethical providers, they want to be compassionate providers, and that distance, burnout sort of erases, you know, that, that distance, or rather increases that distance between how they want to provide care and what they actually feel that they're able to give their patients.

    SKORTON: Could, could both of you give just one example each of burnout that would help our listeners, especially those who are new to the niceties of the term, understand it? Dr. Huang?

    HUANG: Yeah, and I can really think of many and there's so many, it's just so prevalent right now. You know, one thing I can think of is, you know, our doctors are saddled with more and more tasks now, and it's not just delivery of patient care. It's not just the one-on-one interaction, which I think is why doctors go into the health care field, right? To help patients. There's a lot of administrative tasks now. And when we look to see how doctors are spending their time, we see that many of them are spending hours and hours, at the nighttime after their clinics or their workday in the hospital, in the electronic health records, and we call this pajama time within our organization. And we've seen that these types of tasks where the doctors are not reimbursed for are increasing and as a result, in order to make this sustainable, we're also seeing doctors fractionally quitting. So they're decreasing the amount of time they're spending their face to face with clinical time with patients, or they're retiring early, or they're leaving medicine altogether. So, you know. When we think about the workforce shortage and people have really projected out, we're going to be really short — doctors, providers, health care workers — this only compounds the issue, but, you know, that's the way that our doctors, some doctors, are making a sustainable for themselves. They have to do that to make it workable.

    TROTTER: It's really, it was really lovely to listen to Dr. Huang talk about what burnout looks like from the physician's perspective. I spend most of my time looking sort of at the other end, right? Thinking about nursing staff, particularly bedside nursing staff. And do you see something actually quite similar, just in a very, very different kind of context, which is the sort of patient facing context. So, when we think, for example, about the ways in which burnout has impacted nonclinical staff, right? So, nursing assistants, front desk workers, for example. These are the kinds of folks for whom the entry into health care that is not quite so steep in terms of training.

    So, those folks are leaving health care because they can go off and do other kind of work that pays really quite similar. They sort of move in and out of health care. So, when conditions in health care are not great, these kinds of workers are leaving in droves. Well, who's left doing the patient facing care, right? When there are no CNAs doing that work, it's the registered nurses who end up doing both the work that they were hired to do, but also the work of other kinds of staff who have left. Because when you are the person standing before the patient. You can't say, I'm sorry that your trash hasn't been emptied because the environmental staff workers are short staffed. You can't say, I'm sorry, you know, I can't take you to the bathroom because we don't have enough CNA. So, nurses find themselves doing things like environmental services or janitorial work.

    They find themselves doing certified nursing assistant work in addition to doing their nursing work. And so there really is a sense of burnout because, you know, on twofold: One is that they're really being overworked, but also they're not actually doing the work that they've been hired to do or that they've been called to do. And that is a really significant issue for nurses.

    And something similar is happening, as Dr. Huang noted, which is that nurses are reformulating their work in order to be able to stay. I like to think about, you know, the kinds of choices that people making as really being an expression of hope against despair, right? They're trying to figure out how to stay when, when somebody lowers the number of hours, if they change jobs, if they move work locations, that's really in some ways a problem for employers, but you can also think of it as an expression of hope. They're trying desperately not to leave the bedside. They're trying desperately not to leave health care and they're doing everything that they can to figure out how to make it work so that they can stay, but they're really having a very difficult time figuring out how to stay.

    SKORTON: Yeah, it's frightening to hear these things. It's eye opening and it's so much in the headlines now in terms of labor organization, for example, that leads me to want to move our conversation a little bit towards staff shortages, which is perhaps part of the cause of burnout, but also part of the result of people fractionally walking away.

    So, love to hear from both of you about the issue of staff shortages and how it intersects with this problem we just talked about and the ethical aspects. Dr. Trotter, would you kick us off on this one, please?

    TROTTER: Sure, David. So, in terms of thinking about staff shortages, I think that there's a number of different dimensions upon which this works. So as I had mentioned before in talking sort of more generally about the way in which staff shortages have impacted the experiences that people have with burnout, as you noted, right, there really is a sense in which it can be seen as its own right cause of burnout. So, when talking to health care workers, particularly nurses in thinking about what staff shortages mean, I think in some ways the pandemic really was a moment in time when nurses realized that staffing shortages were never going to get better, right?

    So, when I talked to nurses who had worked during the pandemic, and I asked them about, you know, increased patient acuity, higher patient loads, they said, yes, you know, the pandemic was difficult. We had a hard time getting through it. But you know, Dr. Trotter, we had shortages before the pandemic. They were just exacerbated by the pandemic. And now that we're not really seeing the same kinds of pressures on the health care system because of the pandemic, we still see staff shortages. And I think that the pandemic in some ways was really a window for nurses to sort of see that A.) shortages were never going to be dealt with by their employing organizations without some kind of outside pressure, like organized strikes and workplace stoppages and advocacy on behalf of patients. But I think the other thing that the pandemic really opened their eyes to was what we could do if we were really interested in solving this problem, right?

    So nurses watched health care organizations find the money to hire the staff that hitherto, previous to, they supposedly could never find the money for. They saw them figure out how to make these dramatic changes about the way in which health care unfolded — the things that they were told could never happen. It was simply impossible. So, in some ways, the pandemic was a horrible moment, but it also was, I think, a moment of clarity for health care workers to see what we could do when we all worked together and brought all of these kinds of resources and all of this kind of expertise to bear. And so, you know, and thinking then about the sort of ethical issues and how that impacts it, I think that often health care workers have felt conflicted about the tension between advocating for themselves and being there for their patients, right? There is often an ethical conflict. You know that when you strike, right, that that's going to have an impact on patient care. And that's often a very, very difficult tension for health care providers to sort of adjudicate and work out for themselves.

    But I think one of the things that happened during the pandemic is that they realized that in order to sort of really sort of adjudicate that tension, they had to do something different than what they had done before. And I think that you were seeing a lot of organized advocacy, a lot of organized labor movements happening among health care workers in part because there is this growing realization that the most ethical thing they could do is to advocate for better working conditions for themselves and for their colleagues, because that is the only way that they are going to be able to provide better patient care.

    SKORTON: Such an important set of points. And the other issue that came early in COVID, which was isolated to COVID, but I think perhaps made all these things a little more acute, Is the inability to do anything for a lot of the patients early on where we had no pharmaceuticals, no vaccines, not enough personal protective equipment, many, many, many deaths and deaths where we couldn't even allow the family in for a final moment with a loved one. So, all of these things added up.

    Dr. Huang, your experience related to these staff shortages?

    HUANG: Yeah, absolutely. And it's a vicious cycle, David, as, as you alluded to, you know, the shortages lead to more burnout, which then internally to more shortages as well. And there's certainly just this complex interconnectedness of health care. COVID, I think definitely was something that unveiled or unmasked probably trends that were already happening. There already were great rates of burnouts, within all of our rings of health care workers. But it kind of unmasked those symptoms and really, you know, the shortages and the burnout then really were much greater afterwards.

    You know, we saw all sorts of shifts too. During COVID, there was a need for a lot of health care workers. People did pay a lot for traveling nurses, for travelers in all different segments of health care. And so, you know, sometimes these things need to reach an equilibrium. We also saw great inflationary pressures as well. Unlike other industries where you go to a fast food chain, for instance, they can pass on those costs to the consumer. But in health care, we largely cannot because we are locked into certain rates. Right? So I think that when one part of the, of the health care system shifts, another part will shift in reaction. So, I think we have to really just think about that.

    We saw a lot of care model transformation, which was rapidly implemented during COVID — things like telehealth. And I think that now that we're out of that pandemic zone, really thinking about, how can we still leverage those new care models? Because that has to be part of the, the solution. Patients are sicker. So that's kind of another aftershock of COVID too, right? There was a lot of care that was deferred, and we're starting to see that increased utilization of health care. We're seeing higher acuity at all levels in our hospitals, in the SNFs, in the care that's provided at home with home health. So, it's really kind of trickling throughout the entire continuum of health care. There's more chronic diseases, more polychronic patients who have hypertension, diabetes, kidney disease.

    So, you know, these things sometimes take time. You know, COVID was kind of an instigator, but now we're seeing all the symptoms of what happened during COVID. So, you know, I, I think the bright side though, is we saw what was possible during COVID. We were able to really launch new care models. I think there's also a lot of talk around payment transformation. So maybe if we can really think about care model transformation along with payment transformation. And then what are the cultural transformations that have to happen in our delivery systems to? Then I think we can be on our way to figuring out how to make health care more sustainable.

    SKORTON: It's so interesting that both of you have pointed out in bold relief the severity of the problem and the connection between staff shortages and burnout. And yet, you both made the points in different ways that there are ways forward. Some ways, as you mentioned, Dr Trotter, that were said to be impossible, off the table, that somehow came. And your point, Dr. Huang, and this is in a situation, in a continuum where we no longer think about the paradigm is in patient care. It's such a broad spectrum, telehealth, as you mentioned, a hospital at home and all these different areas. So, what's the what's the way forward? I mean, we have to find a way to solve this. We can't just roll over and figure this is how it's going to be forever. It's not fair to the patients, as you mentioned. It's not fair to the workers themselves. And those things are tightly interacting. So, what's the way forward in terms of these intersecting problems of burnout and staff shortages. Dr. Huang?

    HUANG: Well, I think it's going to take many different types of efforts and those efforts are all interconnected. So, I mentioned care model transformation. I think that's part of it. We really have to rethink how we do work. The old ways of delivering work, it just doesn't work, right? But we also have new technologies on the front. So, let's think about what are those models? And then what are also things that are not necessarily human dependent, but can assist or augment our work to? And I think along with this, we'll need people on the policy front to help us as well, right? Because I think there's a role to play for those who are in the provider or health care systems. There's a role for our policymakers. There's a role for our payers as well to come together and to really be able to enable this because you really can't do one without the other.

    I think payment transformation as well. I think we really think about the financial sustainability of delivering care, particularly in communities which might be underserved, rural communities — we're seeing hospitals shut down. So, I think we need some very specific solutions for areas where already access to health care is challenged. So, how can we make it sustainable and create new models in these communities too?

    SKORTON: Dr. Trotter?

    TROTTER: So, You know, in thinking about the ways forward, you know, there's really a couple of things that I’d like to say. one of them is, I really think that we have to really focus on what happens outside of the health care system, right? So I think that, you know, in terms of thinking about, you know, payment transformation — there's a lot of people who argue for single payer, as if that is going to sort of, you know, radically reshape things. And, you know, I am a bit of a fan of single payer, if we wanted to have that conversation. But I also am a fan of it with caution, because I study long-term care, and long-term care is one arena of the health care system that comes closest to single payer, right? 75% roughly of long-term care is provided by and paid for right through state funding. And we still have rampant health disparities, rampant difficulties with staff shortages, rampant problems with burnout. So that in and of itself is not really a panacea, right, for this issue.

    And I think partly we really have to sort of think about prevention, right? I'm not a medical doctor, so that's, I'm not going to say too much about that because that's a little out of my wheelhouse. But I do think that as a society, we really have to think about all of the kinds of problems that end up appearing in the health care exam room that actually could have been best addressed outside the health care exam room, right? Problems of poverty show up in the health care exam room. And if we were able to find a payer for poverty problems and not just for health problems, right, they wouldn't actually be impacting our health care system in the way that they are now, right?

    Thinking about prevention, getting people before they're ill. I mean, this is one of those things where I think that, as Dr. Huang noted, it's really an integrated system. We really have to begin thinking about health care as sort of being the sort of one piece of a variety of different kinds of social policy levers for dealing with health.

    The other thing that I think is really important is really thinking about this question of burnout as being a labor problem, right? I think that, you know, it's been amazing to me to sort of see the kind of, you know, in the street action that health care workers are taking in the post-pandemic era. Because I think it's really unheralded in the U.S. context is that health care workers, I think for probably, you know, if not the first time, you know, one of the few times in our country's history where they really began thinking about that, not as just about a relationship with their individual employer or about, you know, their own suitability to do the kind of work that they're doing. But I'm really thinking about this as a labor care problem, right? And because they've begun thinking about it as a labor problem, they've begun banding together in ways that I don't think that we have seen, you know, we're in, you know, the third day of one of the largest health care worker strikes of the Kaiser folks — the union that represents the folks at Kaiser. And one of the things that's been really exciting to me is not just the size of that particular labor action, but who's included, right? It is nurses. But it is also technicians. It is LPNs, right? It is nursing assistants. it's a whole range of folks who previously to this moment have never thought of themselves as being, right, working in common cause with one another, right? So, I want our listeners to really think about the fact that, you know, if you look at any particular health care occupation, you may have 200 or 300,000 folks. But if you're looking at health care workers writ large in the U.S. context it’s 14. 7 million of them, which represents 9. 3% of the total workforce. That's a lot of people, right? Who, if they all bandied together, right, it's astounding what that force of people could do as a voting block or using a number of other political tools, right, to sort of make change.

    And the other is really thinking about the ways in which health care workers can appeal to patients, because that pretty much is all of us, right? Again, once we, I think, begin making this, right, you know, rethinking about these problems as labor problems, but also as questions having to do with justice, I think that some different ways forward, right, that maybe we haven't even thought of can begin coming to the fore.

    SKORTON: I thank both of you for bringing our focus back to an equity lens. Because my generation, and I, next year is my 50th med school reunion if you can imagine such a thing. You know, we did not do a great job of doing anything much about these health inequities, because we weren't looking through an equity lens at everything. And I think it's so important to follow both of your guidance, that if we don't look at things through an equity lens, and if we don't think about those upstream factors, like racism and poverty, that do produce social determinants of health, then we're going to fall short in my view.

    Now I'm going to ask that we shift gears a little bit and think about the world of biomedical research over these 50 years of my medical career has been astounding. And one of the astounding things has been pharmaceuticals. Later on today, I'm lined up to get my latest COVID booster. And I was thinking about the 20-ish years of basic research that went into developing the mRNA platform so that I can walk in and get a, you know, fabulously effective and safe booster and so on. And that's true for pharmaceuticals in general.

    And yet we're facing this problem of prescription drug costs that are a very, very important problem and can put some of these miraculous changes, you know, beyond the reach of health care organizations and most importantly of patients. So, Dr. Huang, thoughts about that major issue of prescription drug costs and how that may intersect with some of the things that we're talking about.

    HUANG: Yeah, absolutely. And it comes back to that interconnectedness of health care. Uou know, prescription drug costs has impact on both the patients and also our health care workers as well. So, you know, we certainly hear a lot of anecdotes where a patient is prescribed a medication, you know, leaves the clinic or post-discharge from the hospital and then sometime later comes back and hasn't, you know, the disease state — whether it’s hypertension, diabetes, or something else — isn't controlled, right? And then in conversation, you know, the doctor finds out the copay was too high. Couldn't fill the medication. Or people, you know, we'll split the medication and, you know, so we need to figure out what is that way that we can make it affordable for patients to be able to get these therapies.

    I think it's been really amazing the types of new therapies and targeted therapies that are available as, as well, today. But how do we make sure A.) that it’s getting to the right patients who need it and B.) that it's affordable as well and sustainable. What happens is when it's not affordable, our health care staff, our pharmacists, our clinicians are spending a lot of time on workarounds trying to figure out how to make this affordable through prior authorizations, through other drug alternatives, by compounding medications.

    So, you know, this really all adds to the additional workload that they already have, right? So, I think we can't discount that as well. So, I think while I'm very excited about these new advances, I think we really need to be cognizant of how we can make it accessible to everyone. I do think that CMS is doing some great work on this front, really kind of tackling drug prices and how they can negotiate directly for the pricing as well. And then other peers can follow too. So, I think it will also take the help of our agencies and policymakers too.

    SKORTON: Dr. Huang, does it also add pressure to those who are leading the hospitals and health systems to deal with the cost factor of these drugs? Of course, the effect on the patient is the primary issue for sure, but does it also affect the ability to manage the finances of the hospital or health system?

    HUANG: Absolutely, I mean, the total cost of care gets transferred somewhere, Right? So, it's just all within the same ecosystem. It's just where it's transferred to. So we really think through kind of where do we acquire these drugs. Also compounding when, you know, we take that work in-house to compound alternatives as well. We look for other alternatives. So we do shoulder a lot of that burden too. We also have a number of 340B programs. So we're grateful for that program, which allows us to fund other programs that can really serve underserved communities.

    SKORTON: over to you, Dr. Trotter.

    TROTTER: Well, thank you, David. So, when I think about the sort of question of rising drug costs, I really think that it's important to really think about it representing a very fundamental tension in our health care system, which is that we structured our health care system as if it is for profit. And yet, the state pays for a good proportion of that of that care, right? And I think that that noticing that tension is really quite important because when we're thinking about the high cost of drugs, right, partly it's because all of our lever levers on drug pricing always are five, six, seven, 10 years behind, right, the sort of initial production of those drugs because we've made an a priori decision that this is a question and a concern really for the for-profit sector, right, to sort of continue innovating and then we’ll figure out the cost later, right? But I would really think that, you know, in terms of thinking about how to have a more sort of equitable sort of sensibility going forward, I think it's important to really have the conversation around that tension. And if we actually want, right, to sort of continue sustaining that tension, right? So that we're not constantly playing whack a mole, right?

    New drug goes on the market. It's really expensive. And now we're trying to figure out how we can help patients pay for this important medication and really thinking about ways in which we could be doing that from the front end because we reconceptualize health care as something that is not just something that sort of sits right in the sort of private market, but that it’s something that is always going to be paid for by states. And therefore, the state should have, be a part of the original conversation about some of that original pricing and, and how it is that it's going to sort of unfold, because otherwise we just continue sort of, you know, playing whack a mole, right? And we're always going to be five, six, seven, ten years behind the times when it comes to new drugs on the market.

    SKORTON: You both have made such an eloquent plea for thinking forward, for thinking upstream, for not only dealing with things that are right in your face right now that have to be solved, but for thinking upstream. I don't know any other way to put it. And what are the kinds of solutions, either through that upstream point of view or — help our listeners to understand the way forward, linking any of these factors, any and all of these factors, the staff shortages, the burnout that results, and also causes more that feeds back on staff shortages, and then the particular frustration and danger of the drugs being priced out of reach. Help us with more proactive ideas for how to go forward because you're already helping us to look forward and upstream at the same time. What other ideas can you share with our listeners? Cause they're on the front lines and they're trying to get good ideas and love to hear more about what you think. Dr. Huang?

    HUANG: Well, I think there's many, many things that we can do. I think first, it's, you know, what is that type of approach we need to take? And it has to be really collaborative, right? We traditionally have thought of, you know, the health care delivery system as the deliverer of health care. Right? But, it's not just when someone gets sick and acutely needs a hospital, or, you know, they have some symptom, they go to a clinic, right? It's really how do we think about that person, that patient, in a whole. And that person is not just characterized by their illnesses or diseases, but those social determinants of health factors. And that to address these things, it's not just the delivery system, right? It's also the payers because there's a payment aspect to this. There's governments — Medicare and Medicaid as well. There's community health partners. I think we really need to tap into their communities. Sometimes we talk about care and the communities that we serve, but how about the communities that we're not serving? We know that areas that are underserved have decreased access to health care, right? So how do we get into those areas? And then also, if there are staff shortages, how do we rethink the different types of roles of health care workers? And it might not be the traditional roles that we always think about.

    I think there's also this need to really think about populations and subpopulations, too. Because I think how people interact with their health and health care is changing. And how our workforce interacts with us is changing, too. So, we know that there's different preferences. We know there have been trends since COVID, as well with hybrid work. So really, how do we embrace those trends and make things viable for people? We also know that people are looking for that mission connection now, especially post-pandemic. So, how do we ensure that that is a part where we can really align the values that people are looking for in their workplace with the values of our workplace too.

    And at Providence, were over 160 years old. It was started by a group of sisters, the Sisters of Providence and Sisters of Saint Joseph. And there was a Providence promise, which was know me, care for me, ease my way. And we often apply this to patients. And we need to apply it to our workforce, too, right? There are patients. They're also part of our family, too. So, how do we really know them, care for them, and ease their way? How do we not only just think of patients across the care continuum, but also, our workforce as individuals across their different aspects of life too. So, I think those, these are many of those different nodes that need to be connected. It's not going to be — it's not going to happen in silos. So, there's that interconnectedness where we need the public sector, the private sector, we need tech, we need startups, we need all of that together working on these issues.

    SKORTON: Thank you. Dr. Trotter?

    TROTTER: Yeah. I mean, whenever somebody asked me to sort of, you know, to talk to them about ways forward, I always sort of say that, you know, I think the way forward really lies with people and not with experts. Right? and so in some ways, I think the way forward really is the sort of question of solidarity and Crafting and creating solidarity across many, many different kinds of lines of — echoing Dr. Huang’s focus on the sort of collaborative effort, right? So, you know, I think that one of them is really thinking about the ways in which health care workers can build solidarity with patient communities. When we're thinking about what it is that we think can be most helpful for patients. There are ways in which patients actually know, right? They're the ones, right, receiving the care. They're the ones who can give a really, really wonderful diagnosis of the problem. They're also the site of a lot of ingenuity and a lot of knowledge about what they actually want to see going forward.

    I think you can also think about building solidarity across the health care system. And so I think one of the things that we saw during the pandemic was both the power of the public health system, for example, but also the kinds of problems that can arise when the public health system kind of, you know, crumbles to the ground, right? We sort of saw both things happen during the pandemic. And I think that there is ways in which we talk — when we talk about health care, we often don't include all of health care, which includes public health initiatives, right? So, I think, you know, one of the most important things that happened in the 20th century was not just, you know, particular advances in curative medicine, but also, you know radical transformations and public health initiatives, right?

    That is one of the things that greatly improved our population health was really this focus on vaccinations, really this focus on clean water, clean air, right? And I really think that it's important as we are in the 21st century to really reinvigorate and make connections between our health care delivery system and our public health delivery system in realizing that they really are both. trying to impact patient wellness just with different tools and from a different perspective.

    And I think the other thing too, is thinking about building solidarity across the range of health care workers, which includes trainees and students. I think that, you know, one of the things that we didn't talk about in the in our broader conversation having to do with burnout is really thinking about the way that it's impacting our future health care workers. If people who've been doing this work for 10, 15 years are burned out, just imagine what that looks like for them to be the people in charge of training the next generation.

    We have trainees and students who are learning to work under burnout conditions, right? When 50 percent of all health care workers are burnt out, right? That's the context in which students and trainees are being trained, right? And I think that that is, you know, radically transforming the next, you know, two or three generations of health care workers in ways that I don't think we've even begun to grapple with. So I really think there has to be solidarity too, right, with students and trainees pulling them in to these kinds of efforts to think about and talk about, not just the problems, but what we can do as a group of people connected in solidarity with one another to change our health care system for the better.

    SKORTON: Yeah, thank you so much, both of you for pointing out, these things. We have to keep our eye on the ball. Dr. Trotter, thank you for bringing up the future generations. That's, you know, obviously a big, big focus for the AAMC and our member medical schools — and the hospitals and health systems because of graduate medical education. So, it's critically, critically important that the baseline that they're seeing is a baseline that's not good. That's not good. And I also want to thank you for bringing up what we call community collaboration. We, about three years ago, added to the, at the AAMC, added to the traditional so-called tripartite mission of academic medicine, of education, patient care, and research. A fourth one, community collaboration, by which we don't mean us educating the community. It's the other way around. It's working together to figure out solutions, or to put it a different way, to paraphrase what you said, Dr. Trotter and Dr. Huong, if you want to know something about a problem, ask the people who are, who are you know, suffering it. If you want to know something about solutions, ask them. And our Center for Health Justice, by listening to community voices nationally, have developed a series of so-called principles of trustworthiness. And one of them, Dr. Trotter, paraphrases one of the things you said, and that was, you're not the only experts. That's the community voices speaking with us.

    If the producer was with us, he would end by asking you for something on a lighter note that he calls the Prescription for Relaxation. So, this is just like off the top of your head. What do you prescribe, you know, to sort of kick back a little bit? And I'll tell you what, what mine is for today, just so that you can, you know, can think about what yours might be. And then Arron will make sure before we lose you that nothing else needs to be done.

    So, I'm a constant student of the multiple instruments that I'm trying to learn how to play since I was nine years old. And I mentioned in one of our recent podcasts that I'm studying a Japanese flute called the shakuhachi and I wanted to report that I finally was able to get a sound out of it.

    And so one of my prescriptions for relaxation is to push a new skill, a new hobby, and enjoy the fact that you make a little tiny progress, even though my progress on that flute brings me In terms of development, maybe to the level of like a two year old, I'm sure glad I'm a two year old. So Dr. Huang, Dr. Trotter, put you on the spot. What's your prescription to our listeners for relaxation? Dr. Huang?

    HUANG: Yeah. So, I'm a musician myself. I'm a pianist and violinist. So, it's music. And for me, it's not playing music. It's listening to music. So just unplugging, but allowing myself to immerse in the sounds and the different engagement of the senses. So, I would say that's probably my go to for prescription for relaxation.

    SKORTON: Dr. Trotter?

    TROTTER: I think there's a theme going on here because mine also has to do with music. I am actually not a musician, but in following David's lead, many years ago, I was working in Nashville, Tennessee, Music City, and I thought to myself, Well, how do I tap into what this place has to offer? And so I began taking lessons in the traditional Irish fiddle. And I play badly. I'm not a very good student. I don't practice very often. But I do really enjoy playing. And it's a kind of social music. Whenever you, whenever I meet other folks who play any kind of traditional fiddle music, immediately their eyes light up when they hear that I do it and they don't care that I don't play very well. They want to know what tunes I'm playing, right? And do I know this person and that person? So, it's both a way for me to de stress, but it's also a way for me to connect with other people.

    SKORTON: You know, this, this is not a contest for who's doing worse, but I just have to move my camera. This is my recording studio I'm sitting in. And so the fact that I've been composing for 15 years, and you never heard of it, and you never listened to one of my things recorded because it's never been recorded. I think I have the record for swings and misses at the plate.

    DILLARD: Thank you, David, Dr. Huang, and Dr. Trotter for such an amazing conversation on the subject of burnout and the share of your love of music.

    We'll see all of you next time on the “Beyond the White Coat” podcast.

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