Healthcare Leadership (pt. 1)
Dr. Andrew Agwunobi, a BRG special advisor and former co-chair of the firm’s Healthcare Performance Improvement practice, joins host Eddie Newland. Andy is a board-certified pediatrician who now serves as chief executive officer and executive vice president for Health Affairs at UConn Health. In the first of a two-part episode, he discusses issues facing today’s hospitals, the tools available to health system leaders to address financial challenges and his views on doctor satisfaction.
TRANSCRIPT
S1: 00:01 Hi, ThinkSet listeners, Eddie Newland here. As you might know, Phil Rowley, BRG's executive director and chief revenue officer, is getting into the podcast game. Check out his conversation with Jaime Diaz at the Golf Channel and other experts on leadership. Phil's podcast is called Intelligence That Works, and it's available in this feed and wherever you get your podcasts. [music]
Welcome to BRG's ThinkSet podcast. I'm your host, Eddie Newland. BRG is a global consulting firm that helps leading organizations advance in three key areas: disputes and investigations, corporate finance, and strategy and operations. Headquartered in California, with offices around the world, we are an integrated group of experts, industry leaders, academics, data scientists, and professionals working beyond borders and disciplines. We harness our collective expertise to deliver the inspired insights and practical strategies our clients need to stay ahead of what's next. For more information, please visit thinkbrg.com.
On this episode of the ThinkSet podcast, we'll be speaking with BRG Special Advisor Dr. Andrew Agwunobi. Andy is a board-certified pediatrician and a former co-chair of the Healthcare Performance Improvement practice here at BRG. Andy is now the chief executive officer and executive vice president for Health Affairs at UConn Health. With more than 25 years of experience as a practitioner, consultant, and executive in healthcare, Andy brings a unique and important perspective on the challenges faced by hospitals and other healthcare organizations.
In this, the first of two episodes with Andy, we'll focus on critical issues facing leadership in the healthcare sector, including physician burnout. And with that, let's get started. Andy, thank you for joining us on the ThinkSet podcast today. How are you?
S2: 02:03 I'm well. Thank you. Thanks for having me.
S1: 02:05 So to give our listeners a little bit of a background, can you kind of walk us through the last few stages of your career and how you ended up in your current role as CEO of the UConn Health system?
S2: 02:16 So I'm a pediatrician by training. I trained at Howard University Hospital, and then I went straight into practice as a general pediatrician and went to business school from there, ended up running hospital and health systems for my whole career, about 18 years now. I've run for-profits, not-for-profits, faith-based health systems, and I ended up at UConn Health, actually, as a consultant. I had joined the consulting industry for about four-and-a-half years, and in that role, I ended up running a consulting engagement at UConn Health. And my wife and I decided it was time for me to get off the road, and I ended up being the CEO at UConn Health.
But one of the things I'd like to point out is that my background really is as a physician. Not only am I a pediatrician, but my father was a surgeon. My grandfather was a physician. My brother's a physician. My wife's a physician. Even though I consider myself a card-carrying, so to speak, CEO—I've been to business school, I've run all sorts of hospitals, as I said—at my heart, I think I'm still a physician. It's something that I've really brought to this work regarding physician engagement and physician burnout.
S1: 03:30 So when it comes to the Thanksgiving dinner, do you get a hard time for not being a real doctor anymore?
S2: 03:36 Yes. My wife does give me a hard time, but actually, you're talking about Thanksgiving dinners. I grew up in Britain, so we didn't have Thanksgiving dinners. When I was younger, we had Christmas dinners, but I always remember my father dissecting the turkey and explaining all the different joints, and you had to sit through that before you could eat. So I have a fond memory of dinners like that, and part of it led to my becoming a physician.
S1: 04:00 That, actually, really informs the next question I want to talk about. In your book, you write about how physicians are demoralized. And given your background and all the physicians that you know, I think you're uniquely suited to make that comment. So what's behind that? What has changed in recent years, say, from when your father got into the profession till now?
S2: 04:18 It's a bit of a complicated answer, because we talk about physicians being demoralized or physicians being burned out, and I think to answer that question, you first have to realize what we mean by that. Burnout is the end result of chronic dissatisfaction with work. There are two authors, Maslach and Leiter, who wrote a book called The Truth About Burnout, and in that book, they defined burnout as an erosion of the soul caused by a deterioration of one's values, dignity, spirit, and will.
So it's deeper than just a superficial, long-term dissatisfaction. This is a deep dissatisfaction with work. In some ways, it is people, physicians, not feeling that their work is valued, not feeling that it's meaningful and feeling that it is too hard to do.
So what's changed in recent years? There's a survey from Medscape and many others that really highlight the fact that it's multifactorial. It's issues like too many bureaucratic tasks, too much charting, too much paperwork, the difficulty of electronic health records, the amount of time that physicians have to spend putting in information into computers that are difficult to navigate and difficult to use. It's more regulation. It's more work. Because of reimbursement declines, physicians are having to work a lot harder. You hear about health systems incentivizing physicians based on work units, relative value units—so, how productive you are based on the bills that go out the door.
In summary, I would just say that the work that physicians, particularly the older physicians, thought they were getting into, the world they thought they were getting into, has turned out to be different. They thought, many of them and many physicians today—when you watch TV or you talk to physicians who started practicing years ago, these physicians were relatively autonomous. They got to decide what happens with the patient. They got to decide how the care team behaves. They got to decide whether they use a paper chart or whether they use a computerized electronic record. They got to decide whether the outcome of a treatment was good or whether the outcome of the treatment didn't meet the standards that they thought it [should meet].
And in those days, they got their satisfaction from that. Doctors typically are not bonused, for example, on whether or not the health system does well, or bonused on whether or not the health system or the hospital expands or grows, or the bottom line of the hospital or the health system. They're not bonused or given payments based on that. They're basically paid a salary most of the time, and they see patients.
So their satisfaction doesn't come, typically, from the monetary rewards. It comes from patients being satisfied with the care, and it comes from the doctor themselves or the doctors themselves feeling that the standard of care they provided met their own personal bar of excellence. And they did it the way that they felt they needed to do it. So a lot of that has changed.
S1: 07:37 And I've read a few studies, and I think it might have actually been in your book too, but some reports have physician-burnout rates as high as 50 percent. If we take that number of 50 percent and you were going to break it out into all the different factors that you laid out just there, is there one to you that seems to be the leader in the clubhouse of, "I hear this complaint more often than not," and does it break out?
S2: 08:00 One of the factors that comes up often in surveys that are done across the country is the difficulty of use of electronic health records, or some people call them electronic medical records. These are big records that hospitals have where the doctors and the nurses input their documentation, their lab tests, and everything else to do with the patient, so that when the patient comes for another visit, or they need to look back at what happened, then it's there in the record.
The challenge is that these records are often very difficult to use, number one. Number two, because of regulations, it's required in many instances that the doctor inputs certain information that before, when using paper charts, the doctor might have delegated to a medical assistant or to a nurse. But regulations require that only the doctor can access the records for certain inputs. So there's a lot more work associated with it. Regulatory authorities require more inputs. You have to put in certain information if you want to get paid by Medicare or by commercial insurance. It has to be in the record. So there's a lot of time that doctors have to spend charting. So you can imagine a doctor, who has to see a certain number of patients every day, seeing all those patients but not having the time to put the information into the electronic record until the doctor gets home from work and then spends two to three hours doing that. So one answer to your question is that electronic health records are a big factor.
When it comes to things like age, there was a 2018 study that reported, yes, that 50 percent of practitioners suffer symptoms of burnout, and they noted—now, it won't be the same for every organization. For example, we've done a survey at University of Connecticut that did not show this exactly the same way, but 50 percent suffer symptoms of burnout and that this increased with age. So 35 percent at age 28 to 34 reported symptoms of burnout, 50 percent at age 45 to 54. And probably part of that—and again, this is my speculation—is because younger doctors tend to be more facile with computers.
But all the same, we hear it across all age groups. Physicians want to see the patient. They want to spend time with the patient. They don't want to spend time in front of a computer.
One of the things I would like to add is that even though there are specific issues like electronic health records that contribute to physician disengagement and burnout, what I've sort of pointed out in my book is that it's a broader issue. For physicians, it is actually more about them having input and involvement in decision-making at health systems and hospitals, what I call co-leadership. Because if you involve physicians in the co-leadership of decisions in hospitals and health systems, you would involve them in the choice of the electronic medical record. You would involve them in making sure that the work processes when you implement a new electronic medical record match the work processes in the clinic. You would involve them in other decisions that take away some of their autonomy.
So I think it's a broader issue of promoting co-leadership with administrators, with executives in health systems, and that will address the many different issues that contribute to physicians' dissatisfaction.
S1: 11:44 One concept that you mentioned earlier that we've talked about is physician autonomy and how that's really diminished, and in your opinion, that the pendulum may have swung too far away from physicians being able to make decisions about things like the medical record systems that they'll use and how they're going to use their own time. If you go back in the day, if you will, somebody was able to build their own schedule, and they were able to do things on their time. That was one of the biggest benefits of being a doctor that has now become kind of eliminated as more people are working for bigger health systems and not putting out their own shingle.
Do you see that swinging back in any way with this co-leadership idea that you have of more organizations maybe consulting with their physicians on bigger decisions?
S2: 12:26 Yes. I do see it swinging back. I mean, I think that this issue of physician disengagement and physician burnout has gotten the attention of us, of hospital executives, health-system executives, so you definitely see some efforts in that direction. My concern at this point is that we're not going far enough. And I think it's because it's a very difficult problem to address. And it takes executives and the people that run and manage health systems admitting that we are part of the problem. We have to start with that, that we are part of the problem.
And we also have to start with the basics, that we improve our communication bidirectional with physicians so that we are truly listening to physicians, listening to the pain that they're going through. Then we share decision-making with them. And that is hard, because that's like saying that you're taking an executive who maybe is responsible for a business unit in a health system and saying, "Look, you're not going to make all the decisions here. You're going to sit with the physicians, and they're going to work with you to make those decisions, even though you're going to be held responsible, just as the physicians are, for the outcome."
So giving up some of that power, so to speak, and letting the physicians be involved in that, that will lead you from engagement of physicians to them feeling empowered and then to them having ownership. That's how we get the pendulum swinging in the right direction. And then, in addition, what we then have to do is we have to implement various specific initiatives that will help to address the symptoms of burnout, but also the path that got us to that position.
S1: 14:10 So if we flip it then and think of it more from a consumer side, I'm not in the healthcare field. I work at BRG, and we do a tremendous amount of great healthcare work. I'm probably one of the few people here that doesn't have some sort of tie into healthcare. I'm just a person who occasionally needs medical services. Today I had to go to the chiropractor. Why should I personally care about the internal dynamics of a healthcare organization in the issues like physician burnout? How does that affect me, in your opinion?
S2: 14:38 I think a good analogy would be asking a person who's at the airport about to board a plane whether or not they should be concerned that the pilots in the cockpit are burned out? And I think the answer would be, they would be very concerned, and they might not get on the plane.
Surveys have shown that physicians who are burned out are not as good as physicians who are satisfied with their job when it comes to the results that they get for patients. There is evidence that shows that there is less of a relationship between those physicians and their patients, that there is lower patient satisfaction, potentially, because of that. There's lower quality of care with increased medical errors, and with that, a higher malpractice risk.
And you can understand how that would occur because if you think about the symptoms of burnout—again, I always hesitate to use the term burnout, because I don't actually use it in my book. But I hesitate to use it for two reasons. One is: it's at the end of the process. Really, the damage is being done before a physician gets burned out. Once they're burned out, then it's not too late, but you're at a very bad situation once a physician becomes burned out. So we really have to focus upstream of that. And the second reason I don't like to use burnout that much is because nowadays, it's getting the connotation that it's the physician's fault that the physicians are burning out, as opposed to the factors around them that are causing them to be dissatisfied.
But having said that, the symptoms of burnout are emotional exhaustion. So physicians have less emotional resources to cope with the difficult issues that might arise around caring for a patient and interacting with a patient. Also, they just are tired. They're less able to handle the amount of work that being a physician requires. There's a depersonalization.
So for example, they might go to work feeling like it's a war zone, and therefore start thinking of patients less as human beings and more as a number, or a condition—a room number, or a condition, or a disease, or something like that. They're just more disengaged from the work, so sort of on autopilot because it's so hard. It's so difficult. It does affect the care that they deliver. They might not realize that.
But it's just like someone who does a desk job, waking up, opening their eyes in the morning and saying, "I don't want to go in to work. I hate my job." You're not going to be as good as the person that jumps out of bed and says, "You know what? I love my job. I love what I'm doing. It's a calling, and I want to continue to do that." And the sad thing is that I would say every physician or most physicians that got into the field of medicine did it because they love it. They love the idea of taking care of patients, and they want to do their best. But really, the ones who are dissatisfied have gotten to the point where it's overwhelming, and they're second-guessing whether or not they should even be in that field, and that does lead to problems.
Someone could say, "Well, oh, they should get over it. It's a hard job, and if you choose it, that's the way it is. Life has changed for everybody," etc. But it's very serious. The job of a physician is more than just a job. Most physicians get into it as a calling. And when they realize, or when physicians feel, that they're no longer valued—their input is meaningless; they are helpless at work—it can have some very bad ramifications not just for patients, but for the physicians themselves. So for example, it does lead to depression, alcohol, substance abuse. I know running health systems that it can cause a lot of physician turnover, where physicians actually leave work and decide that they're going to either retire from the profession or just leave the current work environment and try to seek a better work environment. And that's very expensive, but it's also disruptive for patients.
I don't want to overstate the situation, but the worst problem, of course, is suicide. And studies have shown that a doctor commits suicide in the US every day. And in fact, the information I've received about this shows that it's the highest suicide rate of any profession. It's about 28 to 40 per 100,000 doctors, which is more than twice that of the general population. So these are very serious issues not just for the patient, but for the providers, for the physicians themselves.
S1: 19:13 [music] This ThinkSet podcast is brought to you by BRG. You can subscribe to the podcast and access other content from ThinkSet magazine by going to thinksetmag.com. Don't forget to rate and review on iTunes, as well. I'm Eddie Newland and thanks for listening.
The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the opinions, position, or policy of Berkeley Research Group or its other employees and affiliates.