SCCM Pod-527 The Impact of Clinician Retention on ICU Care Quality

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The importance of retaining seasoned physicians in the ICU is crucial for maintaining high standards of patient care. In the second episode of SCCM’s podcast series on quality and safety in critical care, Elizabeth H. Mack, MD, MS, FCCM, is joined by Alexander O. Sy, MBA, MD, MSL, FCCM, to discuss effective retention strategies, their direct impact on patient outcomes, and the broader effects on healthcare teams and organizational efficiency.

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Transcript:

Dr. Mack: Hello and welcome to the Society of Critical Care Medicine podcast. I’m your host, Dr. Elizabeth Mack. Today we are joined by Dr. Alex Sy in the second episode of our multipart series discussing quality and safety in critical care. Dr. Sy is a professor at Loma Linda University School of Medicine in Loma Linda, California. He is a pulmonary critical care physician and has been in that field for the last 25 years. He is currently at Loma Linda’s VA and is also serving as a member of SCCM’s Quality and Safety Committee. Additionally, he serves as a board member on the critical care specialty board of the ABIM. Welcome, Dr. Sy.

Dr. Sy: Thank you, Elizabeth.

Dr. Mack: Before we start, do you have any disclosures to report?

Dr. Sy: I work for the VA and am a member of the board of ABIM, so whatever I express here is not reflective or official stance of any of those two institutions.

Dr. Mack: Awesome. Thank you. Today we are here to talk about the importance of maintaining, we’ll call them seasoned physicians, in the ICU, in terms of the overall experience for patients and families but also for our teams. We’ll touch on best practices in terms of retention and the benefits to the rest of our team. Let’s dive in. Why is it important that we have seasoned physicians on our ICU teams? What’s the benefit for patients and their families?

Dr. Sy: Well, after doing this for more than 20-some years, as you said, we learn and we all know that experience is important since not all knowledge is learned in the classroom during our training in medical school. It’s very important to keep learning even after we finish our medical school and training, and we try to encourage everybody in our field to be lifelong learners because we learn not only from our books and our journals, but we also learn from our patients.

Dr. Mack: Yeah, that is really important. I think there’s obviously a bell curve in terms of age and performance, but there is certainly a lot that we learn as we are in practice, and I think there’s a reason we call it practice in medicine, and that is not taught formally to us. I really appreciate your thoughts on that. In addition, what would you say are the benefits for both our faculty teams as well as our multidisciplinary teams to having experienced or seasoned clinicians serving on our teams?

Dr. Sy: Well, we’ve always emphasized in our field the importance of having multidisciplinary team involvement, especially in our daily rounds and even in our big projects and strategic planning. We get a lot of input and a lot of views that we may not be aware of, just being from the physician side, especially like from the nursing side, from our dietitians, from our respiratory therapists, our colleagues in pharmacy. I cannot overemphasize how much through all these years they’re so important in our overall care of our patients. We rely on them so much, especially nowadays with our pharmacy colleagues. They’re essential already in our team that if they’re absent for a day or two, we feel very lost already.

Dr. Mack: Yeah, absolutely. When I think about the importance of mentoring our junior colleagues within critical care, I think about a lot of ways that I personally was mentored along the way that may not really reflect those core competencies that we were trained on or the textbook knowledge, but we are in a field where there is a lot of moral distress, and I think our seasoned physician colleagues are really useful in that space. They can commiserate. They’ve often been there, and they additionally can remind us that this too shall pass or how we should handle it or who we might reach out to to help us process these very distressing cases or situations.

I know that, in thinking back on my career, that’s certainly a space where I feel like those faculty members in particular have been incredibly useful. What are your thoughts?

Dr. Sy: Yeah, exactly. It can’t be helped that our discipline, being the healthcare system, we’re always trained that you come out of medical school, you come out of training, patients and families rely on you, and you feel like you have this obligation that you have to do something or be the problem-solver for all of these things.

Through those years, through my experience, I tell my fellows it’s almost like the more you do this during your career, the more you realize how much you don’t know, and it’s very humbling. I try to teach our fellows, when you come out, you feel like you just passed your boards, you know everything, then you meet the patient who, no matter how we try, how much you do, there’s only so much you can do, and it’s very humbling.

Dr. Mack: Yes, that is so true. I think the more I try to guess an outcome in my career, you know, it’s not a linear relationship. The longer you’ve been in this field, the more accurate you are in your predictions. I think that is incredibly humbling.

I’m curious, we talk and think a lot about sustainability of our field. This work can be extremely stressful, it can be very physically demanding, so very important to think not only about recruitment, but retention. Any thoughts on how we might effectively retain seasoned clinicians as they go through the trajectory of their career, not just intensivists, but multiprofessional clinicians, how we might retain that experience, that talent?

Dr. Sy: That’s a very good question. There are so many articles or comments or personal opinions. I also believe that compensation or money alone can only go so far. I remember when I started an APP program in critical care.

That was early in 2010, when we were one of the first programs and trying to establish how many staffing needs can we afford or do we really need, and just calculating number of shifts and FTEs, and we go to the administration and, based on our calculations, they say, okay, you have so much FTEs and, as we go along, we realize we undercalculated and we didn’t take into consideration people getting sick, families getting sick and having to take leave. And we were being told, just pay them overtime. And sure enough, after so many overtimes, my APP just says, that’s not enough anymore. It’s like, it’s not the money anymore. Even the overtime pay is not going to carry you over.

I think it’s very important to realize that there are other things that are important to our healthcare providers. One of the things that I’ve been reading about in terms of this topic, about burnout, a lot of us or a lot of our colleagues, it’s not only about the money, but they want to feel valued, to be heard, that their opinions are counted. That’s very important; being in a toxic environment where people are told to shut up and just do what we’re told, that’s not very healthy for our healthcare providers. Soon enough, they’ll know, and they’ll say, you know what, it’s not worth it, and they’ll find other alternatives. Unfortunately, we’re already seeing that, and it’s even made more obvious or accelerated during the past COVID pandemic, unfortunately.

Dr. Mack: Thank you for that. Incredibly important. I think a positive workplace culture, that really couldn’t be more important, where people have agency over things that affect them, where they have psychological safety, where there’s transparency regarding decision-making, all of those aspects are so important.

I think another thing that strikes me is, I will say, when I was early in my career, I did not take the vacation, I did not use the PTO that I was afforded, and that is something I have corrected. Setting that example, because nobody wants to be the one person because otherwise it puts more work disproportionately on the rest of the group. I’m curious about your take on that.

Dr. Sy: You raise a very good point. At least I can speak for myself, we are the baby boomers’ age, where we were raised that you pick your career and you work hard and you dedicate everything to your career. And that’s it, no questions asked. You just keep working, working. Unfortunately we realized that that’s not true. I mean, it may have worked for our parents, but that was a totally different generation and they were totally exposed to a different environment.

During that time, as a healthcare worker, you go to the hospital or you do a house call, you only get to see the patients or the patients get to talk to you during those visits. Nowadays, you have text, pages, instant messaging, everything, and social media that they 1) can get hold of you and 2) get all the other information that may or may not be true. And you’re fighting also all this misinformation. It can exhaust you a lot, trying to not only teach them, but trying to dispute what they think they believe is right. And that takes a lot of toll.

Dr. Mack: Yeah, thank you for that. I appreciate you alluding to generational differences. Any further thoughts on that? Obviously this contributes to a lot of workplace dynamics, regardless of the profession. I think we probably can all take a page out of each other’s playbooks. Each generation has its own attributes but I think we boomers and other generations are learning that maybe we could actually be more healthy and have a more sustainable profession if we listened a little.

Dr. Sy: Exactly. It’s so true. I mean, like you and unfortunately for me, I learned much later how important it is to take time off and take care of yourself. The main thing is we have generational differences. I think it’s very important that what may work for us as baby boomers may not work for gen Y or gen Z or the millennials. We need to respect each and everybody’s opinion and not force it in a dogmatic way and say, this is how we did it and this is how you’re going to do it. That’s not going to work anymore and I don’t think that’s right anymore.

Dr. Mack: Thank you for your thoughts on that. I’m curious, what’s your strategy for burnout prevention or anything that you’ve found useful in that space?

Dr. Sy: If I knew how to prevent it, I would not have come to this point where I got burned out, unfortunately. In retrospect, like you said, taking time off, learning how to say no to so many projects and just drawing a line. It used to be, especially in my academic field, it’s like being a clinician and not a researcher with grants.

I’m supposed to generate my salary seeing patients. But then how about the part of academia, the teaching, the development, the curriculum, all the other stuff? How am I supposed to do that? There’s no protected time for that. We used to say, yeah, that’s understood that you do that on top of your clinical time and you do that on your own time. The expectation is that helps you get your academic development and promotion. Now we realize that’s not sustainable. We see the newer graduates and wanting, well, if I want to go teach, how much time do I get protected to do this? Do I get what we call an FTE supplement in your salary?

I’m happy that at least some academic centers, and hopefully more, will realize that this is important now, like the ACGME now is very specific as far as X number of fellows. I’m just thinking, for example, the ACGME requirement for pulmonary care fellowship, you have X number of fellows, you’re supposed to have a program director. If you go beyond X number of fellows, then you’re supposed to have associate program directors. Then they really specify how much protected time, be it 0.1 FTE, 0.05 or 0.2 FTE, that this program director should be given to be able to fulfill this work that they’re supposed to do on top of the clinical work.

Dr. Mack: And of course, that’s all based on a 40-hour workweek.

Dr. Sy: Exactly. Which nobody does in healthcare, right?

Dr. Mack: Right. Anything else that you wanted to mention that we haven’t discussed?

Dr. Sy: I think the status of healthcare right now is unfortunately becoming very business oriented. I mean, there are good things that we can learn from the business field that we can apply in healthcare. I read, and to quote, Richard Branson said that you take care of your employees and they will take care of your customers. That’s the important thing.

Unfortunately, healthcare being so financially driven now, a lot of our business administrators forget about that and they always go for the short-term goal of profits, you know, what are the profits and what is the return on the investment? All the short-term goals, they just see the profits and they say, okay, we need to save money, we need to cut resources, we need to cut staffing. Then the demand is even higher for your productivity with shortened staffing so that they can make more money.

It’s not going to work. I think we’re already seeing that in our current system in healthcare. It’s very unfortunate. Eventually people will say this is not the right atmosphere for them, and we will see less and less of our youth going to our field in healthcare and say it’s not worth it anymore. That will just exacerbate our staffing shortage, which we already are in a big crunch right now, especially after the last pandemic.

Dr. Mack: I appreciate you sharing that. It’s reflecting as you were talking, I think my antidote to burnout is advocacy work. That has its own set of challenges and frustrations but I think one of the reasons why it’s so refreshing is that it’s actually, sadly, I don’t get paid to do that for the most part, so it’s really on your own time and that sort of thing. But again, not without its own set of stressors. But I was just reflecting as you were sharing your thoughts on the business of medicine.

Dr. Sy: Also, I think there was a joint group statement on burnout of our healthcare workers. Very important to emphasize that burnout is not just about the individuals. The easy fix is like, oh, yeah, tell the individuals here you can go do meditation, you can do yoga. You can only do so much yoga, but you keep pushing our staff to go back to the same toxic environment, high demands, and limited resources. It’s not going to work. It’s about the system. We have to see what’s wrong with the system and try to improve on it and not just say, oh, yeah, you just need to suck it up. No, that’s not it.

Dr. Mack: Absolutely. I really appreciate you sharing your thoughts. It’s been a pleasure to chat with you today.

Dr. Sy: Thank you for giving me the opportunity to talk about this, which is very important for me, too.

Dr. Mack: This concludes another episode of the Society of Critical Care Medicine Podcast. For more on this topic, please listen to the series. Don’t forget, you’re listening to your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Elizabeth Mack. Thank you.

Announcer: Elizabeth H. Mack, MD, MS, FCCM, is a professor of pediatrics and chief of pediatric critical care at Medical University of South Carolina Children’s Health in Charleston, South Carolina.

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