[SPEAKER_02]: Hello and welcome back to ACRAC.

[SPEAKER_02]: I'm Jed Wolpa and I am thrilled to have an incredible show today.

[SPEAKER_02]: This is something that actually though I didn't know about it until recently, I've kind of been wanting to have somebody come up with forever because and people will know I've talked about this before that you know, it doesn't make any sense to me that like the joint commission comes around and they judge hospitals on things like whether or not you have boot covers on in the OR, but they don't for which by the way there's no evidence at all, but they don't [SPEAKER_02]: judge institutions based on how well they take care of the well being of their workers.

[SPEAKER_02]: And part of that problem, of course, was there was not a necessarily a good way to measure it or to do it.

[SPEAKER_02]: And now we've got some people who are doing it.

[SPEAKER_02]: And so I'm thrilled to have with me two guests who are going to talk to us about what they've come up with in the way it's being used.

[SPEAKER_02]: And I just think this is going to be a real game changer for all of us.

[SPEAKER_02]: So I have Dr.

Elliott Higgins.

[SPEAKER_02]: who's a regional anesthesiologist and director of well-being at UCLA anesthesiology, and he's the leader of the wish, research, and development efforts, and wishes the tool that we're going to talk about.

[SPEAKER_02]: And then, of course, Dr.

Amy Vincent comes back to the show.

[SPEAKER_02]: She's a pediatric anesthesiologist at Boston Children's, where she's the departmental chief wellness officer.

[SPEAKER_02]: And they both hold leadership roles within the American Society of anesthesiologists well-being efforts.

[SPEAKER_02]: Dr.

Vincent was the immediate past chair of the committee, as well as with organizations like the National Academy of Medicine, very, very excited to have you both on the show.

[SPEAKER_01]: Thank you very much, Judd.

[SPEAKER_01]: Thank you, Judd.

[SPEAKER_02]: So, let's start by talking about how each of you came to be interested in this work.

[SPEAKER_02]: What sparked your interest in well-being and improving well-being?

[SPEAKER_00]: I mean, I'll go ahead.

[SPEAKER_01]: For me personally, it was an interesting path.

[SPEAKER_01]: I've always been interested in science.

[SPEAKER_01]: And actually, when I was in undergrad, I wasn't even sure if medicine was right for me.

[SPEAKER_01]: My interest honestly laid at sort of this funny intersection of biology, communication, and human behavior.

[SPEAKER_01]: And so I was actually studying communication sciences and disorders at Northwestern University.

[SPEAKER_01]: And that led me to explore all of those things while kind of keeping the door open to medicine.

[SPEAKER_01]: But it's interesting.

[SPEAKER_01]: While I was studying that, I joined a simulation lab that was studying how anesthesiologists actually respond to crises.

[SPEAKER_01]: And specifically we were studying how anesthesiologists respond to stress, how they perform wonders for us human behavior, all these things that I personally have always found quite interesting.

[SPEAKER_01]: And that led me to understand, like, wow, the field of medicine has quite a lot of breath to it in terms of what you can pursue as a career.

[SPEAKER_01]: And so that led me to medical school and that led me to anesthesiology.

[SPEAKER_01]: And for me, the why well-being question is really much wrapped in all of that is, as I've always had, a really very strong interest in that intersection of human behavior and teamwork and performance.

[SPEAKER_01]: And kind of a funny one quick anecdote, [SPEAKER_01]: It's that journey for me shows a great example of mentorship, that's similar that I worked in.

[SPEAKER_01]: That was Dr.

Christine Park at Northwestern University.

[SPEAKER_01]: She's the senior author on the Wish Effort.

[SPEAKER_01]: And it was kind of a full circle moment for me to work with her on this.

[SPEAKER_01]: But just like a nice example of some really good mentorship there.

[SPEAKER_02]: That's awesome.

[SPEAKER_02]: How about you, Amy?

[SPEAKER_00]: Yes, so when I transitioned from pediatric residency to residency number two, and as these are residency, I was struck both personally and in my colleagues.

[SPEAKER_00]: I'm differently.

[SPEAKER_00]: We cognitively analyze and works through adverse events, going from a very team-based to a very self-laiming culture.

[SPEAKER_00]: And I noticed that anesthesiologist take a really out-sized [SPEAKER_00]: degree of responsibility for adverse events even when it's nothing they could have done.

[SPEAKER_00]: And it was really devastating because you combined that with sort of the loneliness and the isolation of the job.

[SPEAKER_00]: And it's a real setup for [SPEAKER_00]: in massive psychological trauma occurring over and over when bad things happen.

[SPEAKER_00]: So I got interested in your support and creating peer support, constructs and did some research in that and that was sort of my gateway drug into the well-being realm.

[SPEAKER_00]: And then after a series of key mentors and opportunities, I have had the privilege of getting [SPEAKER_00]: of individuals in the well-being space who really critically and rigorously wants to study and improve this from a very pragmatic standpoint.

[SPEAKER_00]: In addition to the mentorship, I really had an unwavering fascination with organizational psychology and how people handle these sorts of stressors and what's unique about anesthesia.

[SPEAKER_00]: And so, it's been very easy to maintain an interest in this and a dedication that is even when being made fun of as studying where you're in Bozanyan records and whatnot.

[SPEAKER_00]: You know, I never really bothered me because it just endlessly fascinating over the years.

[SPEAKER_02]: Yeah, well I'm so glad you both have developed this interest.

[SPEAKER_02]: It's so important and you're doing incredible work.

[SPEAKER_02]: So let's talk about where we are right now in anesthesiology with well being, how are we doing, what's the current status?

[SPEAKER_00]: We know it's really interesting.

[SPEAKER_00]: I started studying well-being before it was cool.

[SPEAKER_00]: And shortly after I started doing that, the first major study of burnout and physicians was released in 2012.

[SPEAKER_00]: And it was groundbreaking.

[SPEAKER_00]: And it started real national dialogue about well-being.

[SPEAKER_00]: And the group that published this continued to do work and continued in this field to gain data and ideas about solutions and ideas about reframing [SPEAKER_00]: And all of that is very, very well and good.

[SPEAKER_00]: The problem is, and what we've really come to recognize is that the modern well-being [SPEAKER_00]: movement in medicine has been driven by, and I would say, four, primarily internal medicine and primary care physicians, and psychiatrists to some degree.

[SPEAKER_00]: And these are a very distinct group in medicine to what we call perioperative and acute setting clinicians.

[SPEAKER_00]: who have very different stressors and strains.

[SPEAKER_00]: The stressors and strains of the group that has been studied over the last 10, 12, 15 years, it's primarily based around [SPEAKER_00]: Administrative frustrations, EHR, inefficiencies, more frustration-based, even some moral distrust thrown in there, but mostly frustration-based, you and I know that perioperinvacute setting of clinicians that includes anesthesiologists, critical care physicians, ER docs, obese, whom I'm forgetting, surgeons, of course.

[SPEAKER_00]: Our stressors and strains are more acute stress, work intensity, and more akin to PTSD.

[SPEAKER_00]: These are traumatic events that we're experiencing and needing to recover from.

[SPEAKER_00]: And so the solution is going to be different.

[SPEAKER_00]: The interesting thing about this group is they are primarily clinical.

[SPEAKER_00]: They have a lot less non-clinical time, which is probably the reason why they haven't led this discussion up till now.

[SPEAKER_00]: But these clinicians are the ones that drive depending on what you look at 70 to 80% of a hospital's revenue.

[SPEAKER_00]: They're the ones with the highest intention to leave.

[SPEAKER_00]: They're the ones with the highest, more morbidity and mortality from suicide,ality, and substance use disorder.

[SPEAKER_00]: So really, this is the group that needs to be addressed.

[SPEAKER_00]: And [SPEAKER_00]: We didn't really have a great path forward for that until we had established a real working network of serious, pragmatic researchers from a whole bunch of different areas and a way to study it, and that's where the wish metric comes in.

[SPEAKER_01]: Yeah, I just want to piggyback off a couple of things that Amy mentioned, it's pretty clear I think right now that anesthesiology, despite being incredibly popular for residency applicants in a very hot field, we have a really remarkable profile of strain.

[SPEAKER_01]: If you look at the data in kind of zoom out, whether it's burnout data, fulfillment data, intention to leave, attrition risk, [SPEAKER_01]: Suicideality.

[SPEAKER_01]: We have a remarkable profile and I just wanted to underscore that from what Dr.

Vincent was just saying and for me what it comes down to is You know everything that Amy said it come our field we have a very little margin for error It's very high stakes.

[SPEAKER_01]: We're constantly needing to be available for rapid decision making [SPEAKER_01]: in an unpredictable way.

[SPEAKER_01]: So the cognitive workload is high, the care-cueity is high, the physical and emotional burdens are high, and then the production pressure, because of that centrality of us to the profits and the operational sustainability, I think it all compounds to create this milieu.

[SPEAKER_01]: We have a lot of strength and it manifests in these various ways.

[SPEAKER_01]: It doesn't matter which metric you're choosing to look at the occupation of wellbeing, whether it's a burnout lens or a fulfillment lens, [SPEAKER_01]: even things that are much more distal on my opinion, like intention to leave.

[SPEAKER_01]: You're seeing the strain manifest in remarkable ways.

[SPEAKER_01]: And so I think right now, to summarize where anesthesiology is, it's kind of an alarming profile of strain.

[SPEAKER_01]: And I think the reasons are all those and probably some more.

[SPEAKER_00]: I want to piggyback on something both of you have now said, and that has to do with sustainability.

[SPEAKER_00]: You talked about how, when you introduce this topic, how [SPEAKER_00]: we're looking at it from a sustainability lens.

[SPEAKER_00]: And one of the major things that's happened and I don't even wanna start this whole conversation today without acknowledging this.

[SPEAKER_00]: One of the major things that's happened in the past 20, 30 years in health care is we have moved from a sustainability model to a for-profit model in health care.

[SPEAKER_00]: And part of that is due to the Encouragement Private Equity and to health care sector.

[SPEAKER_00]: Part of that is due to changes in leadership structure and in hospitals and community hospitals, [SPEAKER_00]: Part of that is due to us a little bit being asleep at the wheel in medicine and not recognizing when these dangers have presented themselves over the years, but right now we're in a mode of healthcare where the sustainability of the workforce is very clearly not the objective for those who lead our healthcare systems writ large and that has to change.

[SPEAKER_02]: Yeah, and I feel like we've gone from what once was a time where well being was just not talked about it all to a time when it was talked about as like well, this is, you know, just like do some yoga and you'll be better right and I feel like now over the past few years we have hopefully now started talking about it a little differently.

[SPEAKER_02]: So what has changed and and what change are you pushing for even more.

[SPEAKER_01]: Yeah, there's been a dramatic change in focus in your exactly right.

[SPEAKER_01]: Um, I think of this in sort of two big errors, error number one, and then this current area that we're arguably just untrained.

[SPEAKER_01]: We can call it error number two.

[SPEAKER_01]: Early era was very much focused on burnout.

[SPEAKER_01]: Dr.

Vincent mentioned that early 2012 study.

[SPEAKER_01]: That was T-Shanniff Lz team, and that was a very important landmark study.

[SPEAKER_01]: Burnout has been studied outside of medicine for quite some time, but that was when we first started to look at it within medicine.

[SPEAKER_01]: And this big error number one was this explosion of attention on Burnout.

[SPEAKER_01]: How prevalent is it?

[SPEAKER_01]: What are its consequences?

[SPEAKER_01]: And then some early dialogue on what we should maybe be doing about it.

[SPEAKER_01]: The thing with this early era, in my opinion, was unintentionally, we talked about burnout mostly in a way where our language sort of put the accountability on to the health workers themselves.

[SPEAKER_01]: We unintentionally implied, like, oh, if you're struggling, you need to do more yoga, like you said, or you need to take this resilient training class.

[SPEAKER_01]: Essentially, if you're burned out or you're struggling, you are somehow flawed, or you're not enough.

[SPEAKER_01]: Again, was I think the unintentional message that we got across.

[SPEAKER_01]: It's interesting.

[SPEAKER_01]: During that same period, we also learned some really important findings in addition to burnout.

[SPEAKER_01]: We learned that despite having more burnout than the general population, physicians actually have more resilience.

[SPEAKER_01]: and so something that became really critically in focus towards the end of this first era is that actually it's it's definitely not a flaw within individuals you are not weakened some way the conversation started to shift towards one where we said oh this isn't about why are you burned out the question probably should be more what kind of system are we asking you to work in and that's where we're entering now which is this sort of [SPEAKER_01]: well-being 2.0 error.

[SPEAKER_01]: It's been coined, which is very much about taking a systems improvement approach to health worker well-being.

[SPEAKER_01]: In my opinion, it mirrors a change that happened, you know, decade or two ago with patient safety and quality.

[SPEAKER_01]: So yeah, it's been a very huge change.

[SPEAKER_01]: It's in some ways a more focused question, but it's in some ways a hard question because [SPEAKER_01]: The honest headwinds that were up against in healthcare are large, staffing issues, infrastructure policy culture.

[SPEAKER_01]: These are very nebulous topics, but they're the right topics, and we're starting to focus our lens much more on that.

[SPEAKER_01]: Another thing that I'll point out with this shift from [SPEAKER_01]: individual focus, well being ethos to this more system oriented, well being ethos is that the consensus is like strong, you know, there's major societal consensus and that's all on a foundation of very strong evidence and that's the body of work that I think wish contributes to in showing that, you know, empirically taking this systems oriented approaches is frankly critical.

[SPEAKER_01]: So yeah, really air up burnout.

[SPEAKER_01]: How much do we have?

[SPEAKER_01]: Yes, it's a big deal.

[SPEAKER_01]: Okay, it's epidemic.

[SPEAKER_01]: Wow, the consequences are profound in terms of finances and all of these things in patient care.

[SPEAKER_01]: And now we're on this two-point-o focus where it's like, oh, okay, this is it's the system.

[SPEAKER_01]: And we need to be thinking more about how do we support the demands of clinical care?

[SPEAKER_02]: yeah and so first let's talk about tell us what wishes but also why was it necessary like why not just give everyone the mass lock burn out in the story and then say like oh well if you have lots of people who score poorly on that then that's bad if you have people who score well that's good why why did we need a new assessment [SPEAKER_01]: Yeah.

[SPEAKER_01]: So, which is the well-being influencers survey for healthcare?

[SPEAKER_01]: And which came about during this change in focus?

[SPEAKER_01]: And I think in some ways it reflects that change in focus.

[SPEAKER_01]: Around when I started as director of well-being in my department, I was personally diving deeper into the science of well-being.

[SPEAKER_01]: improvement in a particular measurement insights analytics.

[SPEAKER_01]: I have these two posts on my desk.

[SPEAKER_01]: Number one is if you can't manage it, you know, if you can't measure it, you can't manage it.

[SPEAKER_01]: And the number two is, is don't get angry get data.

[SPEAKER_01]: And that's just like a personal ethos that I take with me, but as I got deeper into assessment and measurement I did realize that there was this mismatch in terms of what we were saying mattered being the system level determinants.

[SPEAKER_01]: And what we were focusing are insights on which were these individual level manifestations, right, and that gap really stood out to me.

[SPEAKER_01]: In my mind, these lenses, like burnout, fulfillment, and tension to leave, they're lagging indicators.

[SPEAKER_01]: They're demonstrating how bad a problem is, but they're not telling us how to fix the problem.

[SPEAKER_01]: And if you think about all of the established tools, like he mentioned burnout tools, the Mazlec burrow inventory, another key one, it's the professional fulfillment index.

[SPEAKER_01]: They're incredibly important tools, but they're all asking you, are you burned out?

[SPEAKER_01]: Are you fulfilled?

[SPEAKER_01]: Are you going to leave?

[SPEAKER_01]: And it's not asking you instead on well in your work environment, what are the facets that are shaping these outcomes within you and your team, your work unit, and et cetera?

[SPEAKER_01]: And so that's why we developed wish, which is asking health workers to reflect on their experiences across eight influencers of well-being, psychological safety, perceived social support, leadership support, work meaning, inclusion and belonging, justice or organizational fairness, work life integration and working conditions.

[SPEAKER_01]: And so the hope when we made Wish was to more appropriately ask people about those things in this system so we can have a road map for change, a kind of a compass.

[SPEAKER_01]: Also, change the language on where the accountability is.

[SPEAKER_01]: Instead of saying, hey, you burned out, maybe say more, are you invited to participate in decision making, which is a completely different conversation.

[SPEAKER_01]: So the goal where the goals are multiple, but that's why we developed Wish.

[SPEAKER_02]: Yeah, so like in other words, we could give everyone the best lock.

[SPEAKER_02]: Tell me if I'm right here.

[SPEAKER_02]: And if everyone in an organization, you know, scored horribly, well, okay, but now what, right?

[SPEAKER_02]: And so wish would tell us that now what, right?

[SPEAKER_02]: It would say like, here's why, and here's where you can take action.

[SPEAKER_00]: But here's where it's also really, really helpful.

[SPEAKER_00]: And we, in the committee on well-being, we were trying to develop something like this sort of parallel to what, what, Elliot, his group are doing.

[SPEAKER_00]: When I saw his approach to it, I immediately knew this is exactly what we've been wanting to do.

[SPEAKER_00]: Let's go with this.

[SPEAKER_00]: And the reason why it's important is you talk about that middle step of burnout, professional fulfillment, depression, whatever these sort of intermediary states are.

[SPEAKER_00]: prior to the negative outcomes which are intended to leave or substitute this order or to a side, right?

[SPEAKER_00]: Before we get to that, we have the things that are that are driving it, right?

[SPEAKER_00]: So the reason this is important is with it being downstream in intervention you make.

[SPEAKER_00]: It's going to take a lot longer and it's going to take a lot bigger impact to change one of those metrics of state like burnout or professional fulfillment.

[SPEAKER_00]: So when you're trying to design research studies to improve well-being and to improve workplace cultures, when all you're studying is the impact.

[SPEAKER_00]: You're not understanding the mechanism of action, right?

[SPEAKER_00]: You have to have something profoundly impactful to bunch the needle at all on these really far downstream impacts.

[SPEAKER_00]: To even know if you're making a difference.

[SPEAKER_00]: Now with wish, you could easily design an organizational systemic study of some intervention.

[SPEAKER_00]: and then show an impact in, say, justice, or an impact in resource availability, or, you know, support and resource availability.

[SPEAKER_00]: So you could show that this intervention makes an impact in this domain out of eight.

[SPEAKER_00]: much more easily than you can say this intervention impacted burnout, which could be impacted by so many other external factors and the confounders are unbelievable when you're looking at such a downstream impact.

[SPEAKER_00]: And so I think what we're going to see is that one of the primary benefits of something like wish is that we're going to be able to design interventions that we [SPEAKER_00]: target two certain domains, or we discover impact certain domains.

[SPEAKER_00]: And then when we study groups or departments or what have you going down the line, and they show a certain phenotype of dysfunction in certain areas, we can say, hey, look, look what we have in our toolbox for you, you're having a problem with justice.

[SPEAKER_00]: This intervention has been shown to work on this domain of justice.

[SPEAKER_00]: Right.

[SPEAKER_00]: And so the impact of well-being research, which is inherently, incredibly difficult, is going to be made much smoother, much more effective.

[SPEAKER_02]: Yeah, I mean, it sounds to me like comparing it to like clinical work right if you if you decided we're going to have we're going to measure mortality and then we're going to make a change and then wait and see how that affects mortality right I mean that would not be a vision, but if you could show that there were eight things that you know all independently predicted mortality and you could change one of those eight things then that [SPEAKER_02]: would be a good intervention.

[SPEAKER_02]: So how did you know these eight things were valid predictors of downstream effects of like burnout?

[SPEAKER_02]: I mean, how did you validate this?

[SPEAKER_01]: Yeah.

[SPEAKER_01]: So validity is a huge topic and the story of wishes development and validation has unfolded over several years.

[SPEAKER_01]: One thing I like to point out when we're talking about validity and I'm going to nerd out for a second here.

[SPEAKER_01]: So forgive me.

[SPEAKER_01]: But validity is not like a black or white thing.

[SPEAKER_01]: It's not like something.

[SPEAKER_01]: Oh my gosh.

[SPEAKER_01]: It's now valid.

[SPEAKER_01]: Let's celebrate.

[SPEAKER_01]: It's something you're always [SPEAKER_01]: striving toward and working toward and your gathering evidence over time, and each layer of investigation when you're evaluating a metrics performance is adding a new layer of understanding.

[SPEAKER_01]: Is this measure doing what it's supposed to theoretically and then does it behave as expected?

[SPEAKER_01]: And then if it's not, that actually tells us information that feeds back into our understanding of the overall construct in this case, like well-being.

[SPEAKER_01]: So [SPEAKER_01]: The first step is building the team like any project.

[SPEAKER_01]: So we put together a multidisciplinary team.

[SPEAKER_01]: We deliberately made sure we had expertise from informatics, organizational psychology, psychometrics, medical education, and clinician moving.

[SPEAKER_01]: I want to give shoutouts to doctors, Theo Winger, Beth Duggen, Max Nansulf, Max is a psychometrician at Northwestern University.

[SPEAKER_01]: He's part of their department of medical social sciences.

[SPEAKER_01]: If this whole department, [SPEAKER_01]: of people who spend like all of their time working on stuff like this.

[SPEAKER_01]: And then Dr.

Christine Park and Jose Hernandez Carcamo from our well-being program at UCLA.

[SPEAKER_01]: These were the, you know, the original core contributors.

[SPEAKER_01]: And that that's expanded to dozens of people at this point.

[SPEAKER_01]: But the early focus was we need to align on exactly what gap we're trying to fill.

[SPEAKER_01]: because this early work where you're converging on exactly what you're trying to measure is how you avoid metric proliferation.

[SPEAKER_01]: We're all of a sudden, yeah, you made a new mouse trap, but it's kind of the same mouse trap you've already had.

[SPEAKER_01]: And that early step is a lot of work, but it's the first foundational step.

[SPEAKER_01]: The next phase is a largely qualitative phase that we call content validation.

[SPEAKER_01]: And that's where you're asking, [SPEAKER_01]: specifically in the eyes of experts.

[SPEAKER_01]: So this is subjective, qualitative.

[SPEAKER_01]: We assembled an external team, Dr.

Vincent was part of that team and you go through iterative feedback cycles where you refine items and you reject items and back-and-forth and back-and-forth.

[SPEAKER_01]: and tell this consensus that you know what, in the eyes of experts, this thing is measuring what it should.

[SPEAKER_01]: And that external team is health workers, it is non-health workers, it's experts in the science of human happiness, it's medical anthropologists, it's all of these people kind of giving their unique lens onto this.

[SPEAKER_01]: The next phase is where we get into the psychometrics, and this is where we start to get a little heavy with the statistical evidence to support that theoretical framework.

[SPEAKER_01]: We're asking various questions.

[SPEAKER_01]: A big question is, okay, well, what's the dimensionality of this measure?

[SPEAKER_01]: Right, so we're talking about well being right now as an overarching construct.

[SPEAKER_01]: We're hypothesizing in early days that there's an overall strength of well-being culture and then that culture patterns out into these sub-drivers that we call influencers these eight buckets.

[SPEAKER_01]: You have to prove that and you can do various statistical techniques factor analysis item response theory to do that.

[SPEAKER_01]: But that's a very critical step.

[SPEAKER_01]: That was one of the biggest hurdles that we had to clear to make sure, does this, does a theoretical basis align with empirical support in terms of how this construct behaves in terms of how people's responses vary in how patterns emerge in the data?

[SPEAKER_01]: The next big quantitative, very heavy step is what we call criterion related validity.

[SPEAKER_01]: which is where you you ask can this measure predict an outcome or a behavior as it relates to established measures and that's where you have health workers take wish alongside other measures like burnout measures or fulfillment measures but broader measures too like measures not just speaking to occupational well-being like burnout or fulfillment measures that speak to general life well-being perceived stress, life satisfaction, meaning and purpose.

[SPEAKER_01]: What we find is that wish correlates with these metrics in predictable directions and magnitudes, it's kind of in that Goldilocks zone where it's strong correlations, but it's not so strong as to indicate redundancy.

[SPEAKER_01]: It's still like a novel lens.

[SPEAKER_01]: And in the end, what this initial chapter shows in terms of scoring wish, interpreting wish, is that yes, it's a measure of the strength of well-being culture, and then it's going to give information and feedback in terms of interpretability as to how that culture patterns across the influencers of well-being.

[SPEAKER_01]: So yes, it's a mouse trap.

[SPEAKER_01]: Yes, it's a good mess trap.

[SPEAKER_01]: Yes, it's a new mouse trap.

[SPEAKER_01]: And then the validation science gets into the stuff that I actually think is much more interesting, which is, okay, what is this new tool teaching us about the behavior of the needs in this rounding environment?

[SPEAKER_01]: Can it start to fill in a picture of this overarching construct?

[SPEAKER_01]: So how do these metrics relate to each other?

[SPEAKER_01]: Can we prove that burnout's downstream [SPEAKER_01]: these influencers are well-being.

[SPEAKER_01]: Can we prove that attrition risk is even more distilled of that?

[SPEAKER_01]: And that's sort of the new frontier of the validation science that we're getting into these days.

[SPEAKER_02]: Stay with us.

[SPEAKER_02]: We'll be right back.

[SPEAKER_02]: all right, and we're back.

[SPEAKER_02]: So great quick question.

[SPEAKER_02]: So this is eight, eight factors, right?

[SPEAKER_02]: Eight measures.

[SPEAKER_02]: How do we know?

[SPEAKER_02]: I'm sure you do, but you know, let's say that seven of them are all independently predictive of or influence downstream burnout.

[SPEAKER_02]: But one of them is not but you're measuring all eight.

[SPEAKER_02]: So you know, how do you know that each of them [SPEAKER_02]: What I'm thinking about is like the central line bundle right where we know that when you do it all, you get better outcomes, but maybe actually the full body drape is not that important.

[SPEAKER_02]: Like if the toes are not covered by the drape, it's probably not going to increase the central line infection rate, but we didn't do with and without toes to see whether or not that bad.

[SPEAKER_02]: So how do we know that each of these eight is in fact important?

[SPEAKER_01]: I love that question.

[SPEAKER_01]: And I need to give a shout out to Max Mansoff, he gets the credit for what I'm about to describe.

[SPEAKER_01]: But when you're evaluating a metric like this, you have to do those steps.

[SPEAKER_01]: And that requires a very complicated custom code.

[SPEAKER_01]: And so Max Mansoff made this program in R.

So whenever we're evaluating, let's just take one influencer of all being, [SPEAKER_01]: thousands of statistical tests that run simultaneously to demonstrate each form of that validity evidence at the whole construct level, but then at the sub construct level at the individual influencer level.

[SPEAKER_01]: And so part of this is you actually put each influencer in a bit of a horse race where you see can these influencers alone account for these outcomes?

[SPEAKER_01]: And if they can, can they outperform others or can they outperform the metric as a whole and you start to get understanding of each influencers contribution and to make a long story short what we see is that these eight influencers [SPEAKER_01]: Yeah, they're related.

[SPEAKER_01]: Of course, they're related.

[SPEAKER_01]: Of course, psychological safety is related to leadership support.

[SPEAKER_01]: Of course, work meaning is associated with perceived social support.

[SPEAKER_01]: But what we're seeing is that each of these things make unique contributions to these outcomes.

[SPEAKER_01]: And that's how we largely define how they account for impact in terms of the big construct of wellbeing.

[SPEAKER_01]: Can they predict effective commitment, which is a measure of one's emotional attachment to the department?

[SPEAKER_01]: That's really important for residents and anesthesiology and trainees, honestly.

[SPEAKER_01]: For faculty, can these things in how do they predict attrition risk and intention to leave?

[SPEAKER_01]: And by taking this very wide lens, you start to see how each of these things moves in needle.

[SPEAKER_01]: And we don't, honestly, we don't just do it for the influencers, we also do it at the item level.

[SPEAKER_01]: So the number of statistical tests gets to be many.

[SPEAKER_02]: Yeah, I'm sure it was an incredible amount of work.

[SPEAKER_02]: Take us a little bit through the research.

[SPEAKER_02]: What research is being done and where are you going to go with it?

[SPEAKER_01]: Yeah, so we just walked through a lot of the validation science.

[SPEAKER_01]: So what we've established so far is that wish is like a metric we robust.

[SPEAKER_01]: It's a reliable tool.

[SPEAKER_01]: It's an effective tool for measuring the strength and patterning of well-being culture in anesthesiology and beyond.

[SPEAKER_01]: Wish was designed to be probably applicable.

[SPEAKER_01]: Dr.

Vincent mentioned earlier that a lot of the conversation, the early conversation, on well-being focused on drivers of well-being that may not be broadly applicable across the whole field.

[SPEAKER_01]: So, administrative burden, inbox management, for example, does not translate to our work lives in the OR readily at all.

[SPEAKER_01]: We designed wish to be broadly applicable across all of healthcare, so a lot of the coming work that we're actively engaged right now is looking at how wish performs outside of anesthesiology to prove at hypothesis.

[SPEAKER_01]: Our first data set was from my home department and it was a single center study and that was quite intentional.

[SPEAKER_01]: We know that single center studies get high response rates, and that's really, really important for benchmarks, like a metrics.

[SPEAKER_01]: We're now wrapping up a multi-center trial in anesthesiology.

[SPEAKER_01]: It's over a dozen anesthesiology departments representing every U.S.

census region and one department from Canada.

[SPEAKER_01]: This is the consortium that's sort of galvanizing around which, and those findings which are soon to be submitted for publication are incredibly exciting.

[SPEAKER_01]: They're not just showing, yeah, we're just solid.

[SPEAKER_01]: But it's kind of unpacking that construct of well-being itself.

[SPEAKER_01]: I was willing to this earlier in some very meaningful ways.

[SPEAKER_01]: So the science is really shifting away from, is this a good tool to what are we learning about well-being as a construct in anesthesiology?

[SPEAKER_01]: One of my favorite parts of this, this is a ridiculous word, is getting to look at what we call nomological relationships, which is in an insane word, but basically what you're asking is, how do these measures fit together in theory and in the data?

[SPEAKER_01]: And so we're starting to see, okay, yeah, actually these upstream influencers, [SPEAKER_01]: They are actually upstream.

[SPEAKER_01]: And midstream are states like burnout and then way downstream are indicators like intention to leave.

[SPEAKER_01]: And those types of relationships while they sound obvious have never been empirically supported.

[SPEAKER_01]: And that's where we're going with with the work is trying to really unpack this construct a little bit more rigorously.

[SPEAKER_02]: Yeah.

[SPEAKER_02]: Awesome.

[SPEAKER_02]: All right.

[SPEAKER_02]: Well, let's talk about, you know, we said earlier, we're trying to get to this well being 2.0, right?

[SPEAKER_02]: Where we're talking about system change and not individual change.

[SPEAKER_02]: And so let's talk about how wish is going to help us do that.

[SPEAKER_02]: It's free and available to anyone.

[SPEAKER_02]: Is that true?

[SPEAKER_02]: Yeah.

[SPEAKER_02]: And so that means any institution can use it.

[SPEAKER_02]: And so Amy, have you used wish for any improvement efforts?

[SPEAKER_02]: What can you tell us about?

[UNKNOWN]: Yeah.

[SPEAKER_00]: I have.

[SPEAKER_00]: So I participated in an Eliot's study that he described and so I've gotten the wish results back from my department.

[SPEAKER_00]: So I'm using that to guide, just sort of pragmatic day-to-day stuff, outside of research.

[SPEAKER_00]: And that has been really very helpful to bring back to my leadership and I think that's a huge resource to provide for the period of an acute setting clinician population out there.

[SPEAKER_00]: But in terms of research, I've got a gratitude study going right now.

[SPEAKER_00]: And there clearly was going to use the wish metric for this.

[SPEAKER_00]: In fact, I filed the IRB using the wish metric prior to the wish metric actually getting.

[SPEAKER_00]: published because I believed in it so much.

[SPEAKER_00]: So we're just starting to go through that data right now.

[SPEAKER_00]: That's a whole parry operative initiative looking at a gratitude intervention.

[SPEAKER_00]: And my suspicion is that it's going to improve sense of belonging in the workplace and social support.

[SPEAKER_00]: So it'll be one of those tools that can be added to the toolbox.

[SPEAKER_00]: And that's what I mean, you can get a little more successful in our research endeavors using this as a tool.

[SPEAKER_00]: We can, I don't mean to say this in the way it's properly going to sound initially, but we can aim a little lower than aiming for the stars in terms of research outcomes.

[SPEAKER_00]: We can target research protocols to improving [SPEAKER_00]: systems.

[SPEAKER_00]: And in so doing, we're going to get a whole lot more small successes that we can build upon.

[SPEAKER_00]: And then, you know, you brought up the central line bundle, which is a great example, we're reverse engineering it.

[SPEAKER_00]: So we're building the central line bundle based on data.

[SPEAKER_00]: And so we'll have a series of recommendations.

[SPEAKER_00]: And that's because we're doing these little studies of small interventions that show demonstrable impact.

[SPEAKER_00]: And the way that this is going to work is [SPEAKER_00]: I'll do a research, so looking at gratitude in this one to intervention, and I'll use the wish metric, and it'll show an impact in some area, right?

[SPEAKER_00]: Then I'm going to use the research consortium that we've built through the ASA's Committee on Physician Wellbeing and engage with some colleagues around the country from very departments including private practices, and we'll do the same study there.

[SPEAKER_00]: and prove generalizability using the wish metric again.

[SPEAKER_00]: And so that's going to validate this tool and this intervention.

[SPEAKER_00]: And we're going to rinse and repeat many, many, many times.

[SPEAKER_00]: And so doing, we're going to create a toolbox.

[SPEAKER_00]: So that what we can do is we can walk into a department and that's having high intention to leave, you know, high, high attrition, and we can say, [SPEAKER_00]: Let's see what's going on, let's, let's diagnose your department, not your people, let's diagnose your department and, you know, oh, you're having problem with this, this, and this, these are the things we've shown can improve that, let's help you get these going.

[SPEAKER_00]: And in so doing, I mean, this is the vision for this group of people who have come together and want to improve the lives of their colleagues.

[SPEAKER_00]: what's fascinating and just a quick shout out to this entire group of people who I could never name all of them.

[SPEAKER_00]: So I'm not even going to try.

[SPEAKER_00]: You know who you are and I love you.

[SPEAKER_00]: This group of people has no ego in this game.

[SPEAKER_00]: It's the most refreshing and extraordinary group I have ever worked with.

[SPEAKER_00]: These are all people who genuinely love and care for their co-workers.

[SPEAKER_00]: and are distressed that they are distressed and want to see them live healthier, happier lives with a longer career.

[SPEAKER_00]: We also want more colleagues because staffing shortages are no fun.

[SPEAKER_00]: So...

[SPEAKER_00]: It's really inspiring work and if you're listening to this podcast and you want to get involved, please contact us.

[SPEAKER_00]: We're always looking for people to get involved.

[SPEAKER_00]: But it's a great group of people and people are making careers on this, and they're getting promoted on this stuff, but that's not why they're doing it.

[SPEAKER_00]: And that's a really important distinction.

[SPEAKER_02]: Yeah, well, it's amazing.

[SPEAKER_02]: And the fact that it's free is amazing.

[SPEAKER_02]: I mean, there's some tools out there, the well being index is one we've used in the past, but then I said that are incredibly expensive and even prohibitively.

[SPEAKER_02]: So so who do you guys from making this available at Elliott?

[SPEAKER_02]: What are you seeing as more people use wish?

[SPEAKER_02]: Has anything surprised you about how it's been received?

[SPEAKER_01]: Yeah, um, you know, there's a couple of things that I mind to play.

[SPEAKER_01]: So I'll tell you about both them quickly.

[SPEAKER_01]: For some time well-being has suffered from a taxonomy issue and pragmatically, if I take off the research and just around my department, I have noticed that wish has had a capacity building effect, where people are talking less about [SPEAKER_01]: topics that always bubble to the surface, which are undeniably important, but are sometimes incredibly hard to manage, burnout, compensation, things that are extremely easy targets, but often maybe some of them are difficult ones to tackle.

[SPEAKER_01]: We're now talking a lot about culture and, you know, that happens at all levels of my department.

[SPEAKER_01]: I've had individual department members come up to me and ask about various aspects of culture and how they can think about, you know, what they should be looking for in their divisions in terms of finding a good mentor.

[SPEAKER_01]: And there's sort of using these influencers as a road map to guard their career.

[SPEAKER_01]: That's pretty cool to see.

[SPEAKER_01]: I've even had a division [SPEAKER_01]: In my department, we're trying to do more division level well-being work, and in the past, we would have kind of a conversation around, oh, my division has as much burnout why should we do about it.

[SPEAKER_01]: And now I'm having a division director come to me and say, hey, Ali, I want to do an initiative that's centers on organizational fairness and perceptions of shared decision making.

[SPEAKER_01]: You know, like, oh my gosh, that's a much more centered problem statement.

[SPEAKER_01]: That's very different.

[SPEAKER_01]: I think we're just played a part in that.

[SPEAKER_01]: And if that similar capacity building effect is happening beyond our walls, I think that would be incredible.

[SPEAKER_01]: So the big thing I'm seeing is honestly the language beginning to shift around well-being to something that's a little bit more nuanced and system grounded and it's giving people this lexicon for change.

[SPEAKER_01]: That's been probably one of [SPEAKER_02]: that's awesome.

[SPEAKER_02]: So let's talk about kind of what we can look ahead to.

[SPEAKER_02]: What do you think this will unlock for the broader well-being improvement efforts that are going on or that people want to start thinking about?

[SPEAKER_00]: I think it's going to get people tools.

[SPEAKER_00]: I think we've needed this tool for a long time to be able to show impact and we honestly haven't had it.

[SPEAKER_00]: The bar [SPEAKER_00]: You know, if your if your bar is showing improvement in burnout in a one to three month period.

[SPEAKER_00]: it's a recipe for disaster and you're not going to show what you want to show in a research project.

[SPEAKER_00]: And then if you do show it, you're not going to get a publish because there's too many confounders, right?

[SPEAKER_00]: So what it's going to do is give us tools to validate what we're doing.

[SPEAKER_00]: And it's going to give us tools to actually push culture change forward.

[SPEAKER_00]: It's also going to, I mean, the number of chairs and division chiefs that reach out and say, I want to improve this, but I don't even know where to start.

[SPEAKER_00]: Well, this tells you where to start.

[SPEAKER_00]: It gives you a diagnosis and a phenotype of your, of your group, and gives you at least a direction and a place to start making improvements that feel attainable.

[SPEAKER_00]: problem in medicine.

[SPEAKER_00]: Now we can break it down into chunks and change things one at a time.

[SPEAKER_00]: And I genuinely think we can make improvements.

[SPEAKER_00]: The other thing is that once you make those improvements once you show these things, you're going to be able to influence [SPEAKER_00]: decisions being made above you, below you, but particularly above you, at the hospital level, at the C-suite level, this is data and data is powerful.

[SPEAKER_02]: What do you think it will take for which to become standard across parioperative systems and departments?

[SPEAKER_02]: I mean, it's clearly something we would benefit from seeing.

[SPEAKER_02]: If it's more spread and use more often, so how is that gonna happen?

[SPEAKER_00]: I know in anesthesia, we've pretty much declared which is the standard.

[SPEAKER_00]: So for well-being research in anesthesia, you can expect to see which being the standard metric used in our research going forward.

[SPEAKER_00]: So most of the people involved in research at least associated with the ASA are going to be using wish, go ahead, Elliot.

[SPEAKER_01]: Yeah, I'll just take on to the, I mean, it'd be incredible if that happens with which beyond our walls, beyond anesthesiology, we're starting to see examples of recognition for organizations for departments that meet certain benchmarks, the American medical associations, join medicine program is one example that comes to mind.

[SPEAKER_01]: I do think it'll be important for health workers going forward for occupation and well being that there is adoption of certain basic tenants and that people organize around certain language and expectations around what it means to be adequately cared for so that we can better support our patients.

[SPEAKER_01]: I think that's essential and I think that's starting to happen and if which is a part of that, that would be great.

[SPEAKER_01]: In terms of a little bit more of a field specific focus, we've talked a little bit about intention to leave over this conversation.

[SPEAKER_01]: I don't know if we've pointed out yet that anesthesiology across multiple large data sets has the highest measurable intention to leave of any specialty in medicine right now.

[SPEAKER_01]: That data has led to a lot of people in the field at very high levels saying a very basic question, which is what do we do about this?

[SPEAKER_01]: And I think what our data is beginning to unlock is both a metric and a framework for beginning to address that question.

[SPEAKER_01]: We've been able to demonstrate that wish better predicts intention to leave than burnout, even after you account for the contribution of burnout in a generalizable fashion.

[SPEAKER_01]: So we're being able to empirically demonstrate, oh, what should we be talking about?

[SPEAKER_01]: We should be talking about this stuff.

[SPEAKER_01]: And if we can focus the conversation on this, then as a field, we may be able to make progress.

[SPEAKER_01]: And instead of fretting so much about people wanting to leave, we can be talking about how people want to stay.

[SPEAKER_01]: And I think that would be an ultimate goal for this work.

[SPEAKER_02]: And so you mentioned how kind of bad it is in anesthesiology, do you think we're uniquely positioned to lead across medicine in well-being or is it just that we are kind of where it's hurting the most?

[SPEAKER_00]: We are absolutely positioned to lead.

[SPEAKER_00]: We have spent the last five to 10 years developing a national consortium of serious and pragmatic researchers from a broad array of expertise, from quantitative qualitative research, implementation science, metrics, peer support, implementation, quality improvement.

[SPEAKER_00]: I mean, you name it, we have expertise in those areas.

[SPEAKER_00]: We are well-nashed, work well together, and are sort of mutually inspired, so that's a good recipe.

[SPEAKER_00]: We also understand the charge, which is the messes in our house, and it's our responsibility to clean it up.

[SPEAKER_00]: And we take that very seriously.

[SPEAKER_00]: of set it a number of times.

[SPEAKER_00]: These are serious people.

[SPEAKER_00]: This is not rainbows in unicorns while we believe intently on certain aspects of good self care in mindfulness, yoga, fitness, exercise, all those things are excellent.

[SPEAKER_00]: that is not the focus of this group, this group is focused very strongly on systemic improvements and changing our organizational cultures.

[SPEAKER_00]: So I believe we are very well positioned to lead this charge and that's what we are going to do.

[SPEAKER_01]: We have an obligation in some ways to lead this charge for our field, our profile of distress and strain is pretty unique.

[SPEAKER_01]: And I think no one knows our work and our work environment better than we do.

[SPEAKER_01]: And so I think it is a little bit incumbent on us to take a good hard look about our work cultures [SPEAKER_01]: setting goals and then working towards them to that are a bit field specific.

[SPEAKER_02]: Yeah, awesome.

[SPEAKER_02]: Well, Elliott, let's end by asking, you know, what's your hope for wish as a positive force from proving wellness and anesthesiology and beyond?

[SPEAKER_01]: I think it's honestly pretty simple.

[SPEAKER_01]: I hope that wishes part of a broader conversation that makes things better for us and anesthesiology.

[SPEAKER_01]: If this helps lead in efforts that can ultimately to real, measurable, long lasting durable change, [SPEAKER_01]: that would be incredible and so yeah I think Dr.

Vincent just alluded to a lot of this we've a lot of people here who are stepping up to do some of this hard science with these very messy and nebulus topics like wellness or well-being and to try and figure out how we can make things better and so it gives you a lot of hope and I think the ultimate goal is you know to see if we can't make things better for people.

[SPEAKER_02]: Well I have no doubt this will and I'm incredibly grateful [SPEAKER_02]: Anything else that either of you want to say before we move on?

[SPEAKER_01]: You know, can I give just a shouting kudos to like, everyone who's been a part of this, I will not be able to think of everyone by name, but it's dozens of people across many institutions.

[SPEAKER_01]: If you go to the wish well-being website, wishwellbeing.com, you can see a number of those people, but this has been a massive team effort, and I just wanted to acknowledge that and give some well-earned kudos to all of those people.

[SPEAKER_02]: Yeah, well, I'm sure they all have worked really hard at this and that's fabulous for the rest of us.

[SPEAKER_02]: Well, let's turn to the portion of our show where we make random recommendations.

[SPEAKER_02]: Elliot, anything you would recommend the audience check out for fun.

[SPEAKER_01]: Yeah, so for coffee heads out there, I'm in California, specifically Los Angeles, and so Cal, we've got some pretty mean roasters.

[SPEAKER_01]: So if you're a very big coffee fanatic, I'm gonna shut out steady state.

[SPEAKER_01]: I am not a player with them, but steady state coffee roasters is probably my latest favorite being to roaster company, small company.

[SPEAKER_01]: They're just in San Diego.

[SPEAKER_01]: their specific being that I've been messing with recently is the wish wish being and it's incredible copies.

[SPEAKER_01]: I'd be like coffee check out state.

[SPEAKER_02]: Awesome.

[SPEAKER_02]: Thanks.

[SPEAKER_02]: Amy, anything you want to recommend?

[SPEAKER_00]: Absolutely.

[SPEAKER_00]: Having just moved to a new home, I cannot recommend command picture hanging strips enough.

[SPEAKER_00]: Um, absolutely game-changing.

[SPEAKER_00]: I'm going to go with the hot really high brow recommendations here, after that coffee endorsement.

[SPEAKER_00]: Um, yeah.

[SPEAKER_02]: That's awesome.

[SPEAKER_02]: Yeah, I mean, those things are awesome.

[SPEAKER_02]: Command doesn't end up like all their things are amazing.

[SPEAKER_02]: Awesome.

[SPEAKER_02]: And I'm going to recommend a podcast that I just finished.

[SPEAKER_02]: It's just three episodes.

[SPEAKER_02]: I'm called the preventionist from serial production.

[SPEAKER_02]: So if you've listened to serial, various things, they just did this new one.

[SPEAKER_02]: It's pretty heavy in the sense that it's about families that were strongly accused of child abuse when they brought their kids into the hospital.

[SPEAKER_02]: But I really liked it.

[SPEAKER_02]: It was well done.

[SPEAKER_02]: demonstrates just an example as we see in many places of how many issues are just really hard, right?

[SPEAKER_02]: Like there aren't bad people on either side of this.

[SPEAKER_02]: It's just that some people are like, look, wouldn't we should do whatever is possible to prevent kids from being heard and on the other end, people are like, yes, but it's bad for kids and families if we pull them away.

[SPEAKER_02]: And so how do you figure that out?

[SPEAKER_02]: And it's just [SPEAKER_02]: I think it highlights how there are so many issues in our society and in life that are just really hard.

[SPEAKER_02]: And we have to think really hard about them and it's easy to want to just say, oh, it's all bad or it's all good, but you know, we have to really put in a lot of time and effort to try to figure out a way forward.

[SPEAKER_02]: So I thought it was well done as usual from Serial, so I recommend checking it out.

[SPEAKER_02]: Elliot and Amy, thank you so much for your work on Wish and for coming on the show to talk about it.

[SPEAKER_02]: Thank you, Jen.

[SPEAKER_02]: All right, hopefully you got as much out of that as I did.

[SPEAKER_02]: That was really fantastic.

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[SPEAKER_02]: For the ACRAG podcast, I'm Jed Wolpa.

[SPEAKER_02]: Thanks for listening.

[SPEAKER_02]: Remember what you're doing out there every day.

[SPEAKER_00]: It's really important and valued.