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A Bite-Sized Approach to Well-being | Quality Time with Dr. Schaal

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0:00 | 47:06

In this episode, Dr. Bryan Sexton, discusses how emotional exhaustion and burnout impact clinical outcomes—and how measuring and improving well-being through bite-sized interventions can lead to better teamwork, leadership and patient care.

Expert: J. Bryan Sexton, Ph.D., chief wellness officer of Duke Health Integrated Practice and director of the Duke Center for the Advancement of Well-being Science. 

Notable Topics Covered:

  • Measuring clinician well-being to predict and improve quality outcomes
  • Addressing well-being through bite-sized Interventions

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DR. SHLOMIT SCHAAL:

Welcome to Quality Time, a Houston Methodist Leading Medicine podcast. I'm your host, Dr. Shlomit Schaal, a clinician scientist and a retina specialist. And I serve as the Chief Physician Executive of Houston Methodist, located in the world-renowned Texas Medical Center. I passionately believe that quality is the heart of healthcare, and a commitment to quality is essential for every healthcare system. Join us each month as we discuss the latest advancement in quality in healthcare with clinicians, researchers, physicians, industry experts, and thought leaders who are as passionate as I am. Today, I am delighted to welcome Dr. J. Bryan Sexton. He is the Chief Wellness Officer of Duke Health Integrated Practice and the Director of the Duke Center for the Advancement of Well-being Science. After 30 years as a psychologist, psychometrician, and investigator, he now works with leaders to assess and improve culture and workforce well-being. We are recording this episode in October, the day before his keynote address at our second annual Joy In Medicine Initiative, JIMI Symposium. Thank you so much for joining us today, Dr. Sexton.

DR. J. BRYAN SEXTON:

Excited to be here, thank you.

DR. SCHAAL:

So, can I call you Bryan?

DR. SEXTON:

Please do.

DR. SCHAAL:

All right, so Bryan, tell us a little bit about yourself.

DR. SEXTON:

So, I like to say I'm a perpetually recovering father of four, which has taught me a lot about well-being.

DR. SCHAAL:

I'm a mother of four, so we have something in common.

DR. SEXTON:

Daughters are more difficult than sons has been my experience, my personal experience.

DR. SCHAAL:

I have only daughters so I cannot tell you if it's more or less.

DR. SEXTON:

So, yeah I became a psychologist first studying flight safety and then transitioned into patient safety. Then moved from, like, what are the patient safety things that predict outcomes to what are the well-being things that predict outcomes? And that was, kind of, my trajectory that, kinda, got me to where I am right now.

DR. SCHAAL:

So, tell me about your institute at Duke. What is that exactly? When was it established and what are the missions and the goals?

DR. SEXTON:

For a long time, I was the Director of the Duke Center for the -- for Healthcare Safety and Quality. And what we learned was that if you do team training, you can improve teamwork norms, and if you do leadership training, you can improve perceptions of leadership. In that you can link those things to clinical outcomes and operational outcomes. Everything from, you know, mortality rates to medication error rates, to -- even things like turnover and, like, disruptive behavior rates. So, it can all be predicted by those kind of patient safety culture metrics. But we learned that if you measure well-being, you can predict those outcomes at about twice the magnitude of just patient safety norms and behaviors.

DR. SCHAAL:

So, what is measure well-being?

DR. SEXTON:

So, there's a lot --

DR. SCHAAL:

How do you measure well-being?

DR. SEXTON:

Well, that's what psychometricians do, is they create -- they can create and refine and validate metrics to measure things and to measure so that you know you're measuring what you think you're measuring. So, there's lots of ways of going about saying,"Here's a metric for well-being," and we know that because it links to all these different behaviors, it links to all these different outcomes. So, my favorite way of measuring well-being, which I'll be talking about tomorrow, is emotional exhaustion. It's just a really -- as far as metrics go, it's really hard to be beat that. It's short, it's concise, it's commonly just referred to as burnout by people."I'm so burned out." What they typically mean is,"I'm so, you know, depleted. I'm so emotionally exhausted. I'm just frustrated by my job. I'm working too hard. I'm just so burned out." They usually mean emotional exhaustion.

DR. SCHAAL:

We'll get back to that, but back to your institute. So, you said it started from quality and safety, which obviously we are all about that at Houston Methodist. Started there and then?

DR. SEXTON:

It morphed into well-being. Well, to be honest, in my role as the Director of Patient Safety and Quality, I spend over 90% of my time doing well-being activities to get groups ready to do quality improvement again. Oftentimes, what we found was that the issue wasn't that people don't know how to communicate or speak up, it's not that they don't know how to do the right thing for the patient, it's that they're physically, spiritually, and morally just exhausted. And so, they're not communicating effectively because of a well-being issue not because of a lack of knowledge on their part.

DR. SCHAAL:

That's very interesting. So, you dis -- Or you and your team discovered that along the way of your work, and when was that?

DR. SEXTON:

You know, I wanna say it was around 2014 -- 2013, 2014 when we went live with Epic at Duke, and we saw a big tank of our well-being data. Our teamwork -- our teamwork norms really took a hit and our well-being norms took a hit. And we, kind of, split up the debriefings of all of these safety culture data into two camps. One camp was -- if you had a low teamwork score and a low well-being score, you were just given a teamwork training intervention. The other camp, which was mine, was if you had low teamwork and a low well-being score, you were given a well-being intervention. And we found when we surveyed again the next year, those work settings that had a team training intervention, they were able to maintain their teamwork. It didn't get better and it didn't get worse, they maintained it. But the ones that got the well-being intervention improved well-being and improved on teamwork even though we didn't do any team training in those work settings. And so, that was the first real aha. Like, "Maybe we should be working more to put gas back in the tank of people instead of just saying,'Go attend this training, or go do this -- Use this new protocol.'"

DR. SCHAAL:

So, this is very interesting, you know? In my role, I'm responsible for quality, safety, well-being, and other things at Houston Methodist, but we don't really tie it so closely. So -- and we are actually intending to. We have a new institute that we're standing up and that institute is gonna be called The Institute for Safety, Quality, and Well-being. So, this is the first time we're tying it up, but in my mind, it's still a little bit separate. So, tell me how you tie it up and tell me how one is affecting the other in your experience.

DR. SEXTON:

That's a great question. And I've seen that you're doing that. And I think that's a real leap forward. So, congratulations, it is an exciting thing that you're doing there. The -- you know, I'm biased because I create metrics. So, one of the things that I would start with is when you have an employee engagement, or a safety culture survey, or a workforce well-being survey, why on Earth would you do three surveys for the price of three and for the effort of three when you could do one survey that assesses employee engagement, workforce well-being, safety culture, what do I think of my leader, you know, professional fulfillment. All of that, when it's in one survey, can be -- it's easier to conduct that survey administration to get better response rates, and then you don't have to do multiple surveys with low response rates, you do one with a lot of focus behind it for a higher response rate.

DR. SCHAAL:

So, which survey do you do? It's your own survey, or you do a Press Ganey survey, or how?

DR. SEXTON:

We do a survey called SCORE which is a combined survey that includes engagement, culture, safety culture, and workforce well-being. It's all in one instrument.

DR. SCHAAL:

And this is for everyone, or?

DR. SEXTON:

Everyone. Clinical, non-clinical. Yup, everyone.

DR. SCHAAL:

So, everybody gets the same survey. And then you develop the metrics there -- to measure well-being?

DR. SEXTON:

I did, actually. I developed all of them except for the engagement domains, which we greedily stole from Arnold Baker and some colleagues who had done some really great work on that in Europe.

DR. SCHAAL:

So, tell me about these metrics. What are the metrics? If I wanna measure well-being in my institution at Houston Methodist, what should I ask?

DR. SEXTON:

Well, first and foremost, I like that emotional exhaustion scale is really powerful.

DR. SCHAAL:

So, what do you ask for emotional exhaustion? How do I know if I'm emotionally exhausted?

DR. SEXTON:

You wanna know what the questions are?

DR. SCHAAL:

No, yeah what are the questions?

DR. SEXTON:

So, "I feel burned out from my work," agree, disagree."I fell frustrated by my job. I feel I'm working too hard at my job. I feel exhausted when I wake up and have to face another day at work." If you're agreeing, agreeing, agreeing, that's exhaustion. If you're neutral, neutral, neutral. That's still exhaustion. You have to be disagreeing with those items for it not to be burnout.

DR. SCHAAL:

So, let me be a little bit argumentative because I actually like to lead with joy.

DR. SEXTON:

Please, let's go, yeah.

DR. SCHAAL:

So, we -- this is why we established the Joy In Medicine Initiative, JIMI. So, what -- always try to start to have the conversation for first of all, tell me what's going well and then we'll talk about what's taking away or what's standing in between you and the joy. And what I'm hearing you ask is,"Are you burned out? Are you exhausted? Are you tired? Do you hate your job?" This is very negative.

DR. SEXTON:

Sure. DR. SCHAAL: So, tell me more. Yeah. So, that's one domain.

DR. SCHAAL:

Okay.

DR. SEXTON:

I like to use four or five domains to measure. So the other domains that I'm pretty -- and we use these in our randomized control trials when we're looking at interventions that improve well-being, that improve, like, perceptions of leadership, that improve, you know, culture. The other domains that I'm very fond of are emotional recovery, which is how readily you bounce back after upheaval, after, like, an emotional upheaval. So, those are things like,"I can adapt to things I can't change." You know, "I can bounce back after difficulties." Things like that. That's a great -- those are all positively phrased, positively valenced, you know, items. The other one that I am a big fan of is work-life integration. So, work-life integration items give you a lot of interesting information about well-being. So, things like -- and it's not -- it's not like agree, disagree. The work-life integration items are like how often do you do these things?

DR. SCHAAL:

So, work-life integration we hear a lot of discussion about, you know, work-life balance, and then people have their own kind of philosophy around that. What's yours?

DR. SEXTON:

About -- around work-life integration?

DR. SCHAAL:

Yes. Integration versus balance, you know? What's your -- you know, your philosophy? After being 30 years in the field, you know, what's your philosophy? Is there a balance?

DR. SEXTON:

Is there such a thing as work-life balance?

DR. SCHAAL:

Yes. DR. SEXTON: No. There's no?

DR. SEXTON:

No, I think it's a -- that's like saying, you know, "Are you older?" Like, you're always getting older, you know? It's a moving target all the time. There are moments where you're like,"I hit a good balance today," but that's not -- it's not a state that you aspire to achieve overall. That's why I like work-life integration as a -- I think is a probably better moniker.

DR. SCHAAL:

So, what is work-life integration?

DR. SEXTON:

So, the way we measure it using a balance scale is to say, "How often in the past week did you skip a meal? How often in the past week did you get home late from work? How often in the past week did you work through an entire day without taking a break?" DR. SCHAAL: Ooh. I have to -- I have to have my assistant listen to this. Okay, tell me more. There's some -- ones about food. Like, "How often in the past week did you skip a meal? How often in the past week did you eat a poorly balanced meal?" I -- there's one that -- one of my favorites is "How often in the past week did you feel frustrated by technology?" That's a big one that really, kinda, feeds into it. The one that's the tipping point variable in that scale is, "How often in the past week did you change personal or family plans because of work?" And so, if you say,"Oh yeah, I did that three times in the past week." The more you -- the more that domino falls in the wrong direction, the more all the dominoes fall in that wrong direction.

DR. SCHAAL:

So, I am, kind of, struck by the fact that you ask about the past week. I mean, you're not doing these surveys every week, right? So, what's the rationale behind that? Why are you asking the past week and not the past year?

DR. SEXTON:

That's more of a measurement issue because people can recall, like, how many times in the past week they, you know, got home late from work. It's hard to do that if you say over the past six months or the past year. Interestingly, it's pretty consistent. It doesn't change very quickly. So, if I measure that for you today, it's a pretty good gauge of your work-life integration for about 12 to 18 months. It doesn't shift too far off of it. You can have a bad week, you know, that happens. But that's why you ask so many different questions so that you can, kind of, get more of a diverse sampling of things that impact your work-life integration.

DR. SCHAAL:

So, you measure these well-being, you know, metrics that you have developed at Duke, and then what do you do with that?

DR. SEXTON:

Well, we measure it at Duke and we measure it outside of Duke, so we actually collect these data from hundreds of hospitals across the country every year and then pull them together then publish it in medical journals. Just to show here's -- Like, we did this recently where we showed here's what emotional exhaustion looked like before, during, and after the COVID-19 pandemic.

DR. SCHAAL:

So how -- tell us. Tell us about the results, yes.

DR. SEXTON:

Well, things didn't get better during the pandemic, they actually went a little bit worse. About 27% increase in exhaustion rates as a result of the pandemic, and that was true across, you know, professions, you know --

DR. SCHAAL:

Seven -- 27% increase in exhaustion. And then after the pandemic?

DR. SEXTON:

It came down slightly but on nearly back to baseline level.

DR. SCHAAL:

And this is for all health professions?

DR. SEXTON:

This is for all healthcare workers like physicians, nurses, APPs.

DR. SCHAAL:

So, tell me specifically about physicians. I'm interested.

DR. SEXTON:

Okay, well physicians was interesting. If you wanna -- let me start by saying for nurses, they started off with a high level of exhaustion. That exhaustion level went up in the first year of the pandemic and then up again in the second year of the pandemic. So, they started off high, went higher and higher. Physicians looked a little different. Their emotional exhaustion rates actually went down. And Tait Shanafelt and his colleagues found the same thing. It went down in the first year of the pandemic, likely due to a decrease in patient volumes, increased use of telehealth and things like that. Like, my very good friend at Duke who's an interventional radiologist, for the first time in 2020, was having lunch at home with his wife and his two daughters two or three times a week in 2020. That never happened before. It never happened since. It was a weird year, 2020 was. But then between 2020 and 2021, there was the largest single year increase in emotional exhaustion for physicians ever reported anywhere in the literature. It's still quite high. Yeah, it's come down a little but nowhere near back to, kind of, pre --

DR. SCHAAL:

Okay, so we have the data, what are you guys doing about it?

DR. SEXTON:

It looks different in your cath lab than it does in your perioperative suites, than it does, you know, in some of your clinics. And so, you have to -- when you're measuring, you say, "Well, here are some sites that are still really struggling with well-being. Before we give them new and more work to do for quality, let's deliberately put some gas back in their tank.

DR. SCHAAL:

So, how do you do that?

DR. SEXTON:

Well, we have interventions.

DR. SCHAAL:

So what for example?

DR. SEXTON:

So, there's a lot of things -- you're full of questions. This is great. So, there's two kind of categories of interventions, one of them is more like how do we help groups of people simultaneously? Those are often called, kind of, system or organizational or department level kind of interventions. And then there's like individual things that you can do to help the individual. I'm a big fan of both of those.

DR. SCHAAL:

So, what do you do for a group for example?

DR. SEXTON:

So, I'll give you one example. Let me give you two examples. The first would be peer support programs. So, if you're an APP struggling with an APP issue, you can talk to another APP about being an APP. Which is very different from calling somebody who's maybe a trained counselor but doesn't know what your life is like. And the vast majority of physicians, and of APPs and nurses, they would feel -- they actually report feeling much better after just having a conversation with someone else in their role who knows, kind of, how to have that conversation. So, a trained peer supporter. DR. SCHAAL: Yeah. We started this program, by the way, only last year here at Houston Methodist, peer support. We started it for physicians specifically and we trained peer supporters and I got great feedback about it. Exactly what you said. I mean, I need to talk to somebody but nobody understands me. I need to talk to another physician. And a surgeon, I need to talk to another surgeon. Absolutely.

DR. SCHAAL:

You know, anesthesia, I need to talk to another anesthesiologist. Different, you know, people that feel this trust, they don't necessarily need professional advice, but they need somebody to listen that --

DR. SEXTON:

Take the edge off of that feeling of,"Did I do something wrong?" Or, "Am I weird?"

DR. SCHAAL:

Yes.

DR. SEXTON:

And connecting with a colleague is really powerful.

DR. SCHAAL:

So, you have it both for physicians and APPs?

DR. SEXTON:

Yeah. And nurses, and basically all healthcare workers. It's a pretty robust program at Duke, but let me tell you a little bit about the data then I'm going to give you a second example. DR. SCHAAL: Okay, okay. So, when we measure this at Duke, we asked a question -- we try to avoid the phrase,"second victim," because second victim is kind of loaded. You know, if the patient is the first victim of harm, then the family members are the second victim, not the healthcare workers involved. So, we try to -- but one of the -- I think the phrasing was,"In the past year, I'm aware of someone in my work setting who was exposed to a traumatic clinical event." And then, "In the aftermath of that event, did they receive appropriate support from our health system?" And they're just saying, like, agree to disagree. If you take out of the ten thousand plus people that responded at Duke, if you take the ones that said yes, they received appropriate support, peer support, and you compare them to the ones that said no, they did not receive appropriate support, it is the single largest differentiator between a good culture and a bad culture, or a good well-being kind of metric, and a bad well-being metric. Or a good engagement score and a bad engagement. It is -- we have not found anything that comes close to differentiating healthy from unhealthy.

DR. SCHAAL:

That's so interesting. That's fascinating and actually highlights the importance of us as an institution…

DR. SEXTON:

100% percent.

DR. SCHAAL:

in providing tools to support individuals. Because what you said, you know, a lot of our work is pretty traumatic. You can carry it with you for a long time…

DR. SEXTON:

And many of us do, yeah.

DR. SCHAAL:

And it doesn't have to be, you know, dramatic and traumatic, it can be just traumatic and without the drama. But still, you carry it with you. And does the institution have really frameworks, structures, infrastructure to help you and the team cope with that? And then do people know about it? Do people use it? Do people benefit from it?

DR. SEXTON:

Do they use it? Do they -- have they heard good things about it from their colleagues who have used it? And what we found in our study was that -- and we published this. Was that even people who had not experienced this traumatic event, they had not needed the institutional supp -- if they had heard that their colleagues who had the exposure and got the support, and it was good for them, they too felt supported. So, here's the takeaway, this is like the bumper sticker, is if my mothership has my back on a really bad day, I'm all in. But if I can't trust that my institution is gonna support me on my worst day at work, I don't bring my whole self to work. I don't -- I'm not all in.

DR. SCHAAL:

You try to guard yourself. Try to, you know, be with your armor on all the time not to get injured. That's fascinating. That's one example of --

DR. SEXTON:

You want one more? I'll give you -- okay.

DR. SCHAAL:

Go ahead. DR. SEXTON: Let's do one more. So -- I'm learning from you, right? So -- DR. SEXTON: This is good. I love this. So, I'm sure you've participated in and been exposed to, kind of, a leader rounding. Like senior leader rounding. And we published a lot on that. And, you know, it works. If you have a leader walking into a work setting and saying,"So, how are we gonna harm the next patient? And what can we do to prevent that?" Like, in 1999, that was a fantastic way to surface patient safety and quality, get people to talk about what's the pebble in your shoe? What do we need to do? That was great. In 2025, that's a good way to get something heavy thrown at your head if you walk into a struggling, you know, clinic and say, "Hey, how are we gonna harm the next patient around here?" So, we've adjusted that. And I'll tell you a little bit more about this later if you're interested. But we do what's called positive rounding. Oh, there you go. Taking a page from my book.

DR. SEXTON:

Yeah. So, it's literally like,"What are three things that are going well and one thing that could be better?" And there's actually something that happens when a leader asks you to talk about who you wanna give a shout-out to, what are you particular -- what really brings you purpose in your role? You know, what are you looking forward to? Oh and then if we could just --

DR. SCHAAL:

So, when you say leader, who are the leaders?

DR. SEXTON:

So, positive rounding can be done by -- when we say --

DR. SCHAAL:

That's called positive rounding?

DR. SEXTON:

Positive rounding, yeah.

DR. SCHAAL:

So, who are the leaders?

DR. SEXTON:

It can be C-suite. It can be directors oftentimes. But it's -- we try not to have it be someone from that work setting. So, they don't have the baggage or the history from that work setting and --

DR. SCHAAL:

And how often is this rounding done?

DR. SEXTON:

Once a month. DR. SCHAAL: Okay. So, once a month you go in as a senior leader, you go into a unit… DR. SEXTON: Yup.

DR. SCHAAL:

And you're saying,"Okay, what's good here?"

DR. SEXTON:

Yeah. Tell me some things that don't suck right now. Despite that fact that we don't have the resources that we need and -- where are we still pulling through and delivering for our patients, you know, despite the difficulties that we're all having right now?" Now, at the height of, like, the Delta, you know variant or the Omicron variant, we were not asking people,"What are three things going well?" We would shift then to, kind of, emotional support rounding where we'd bring them food, something to drink. We'd say, "Do you need to talk to someone right now?" But then we pivoted back to, kind of, positive rounding and -- DR. SCHAAL: I love it. That's awesome. Okay, very good. So, these are two examples of group support. What are you doing for the individual support? That's my jam is the individual support. So, can I just preface it by saying there's a lot of people in healthcare that -- And I don't begrudge them wanting to do this. But they like to shake their fist at the sky and say,"Stop telling me that I need to do something to make myself better. Just fix the system. And the have every right to feel that way because the system's been broken for a long time and there are -- there's some collateral damage from that broken system. It's not just the healthcare workers but it's the healthcare workers families that have had to, kind of, absorb a lot of that -- a lot of those difficulties. So that said, we really try to make sure that if you show interest, if you're interested in doing something for your well-being, you deserve to have options, those options should be evidence-based, they should not take very long to do. If you do it, you should feel better right away. And if you do it, you should feel better for a long time. I don't wanna feel better for an afternoon, I wanna feel better for months on end. And so, we created a whole series of what are called bite sized interventions. So, small things that you can do that make a big difference in your well-being.

DR. SCHAAL:

What are bite sized intervention? I love the, you know, kind of -- bite sized reminds me of food, and food brings pleasure and happiness, so that's great. But what are these bite sized intervention?

DR. SEXTON:

So, there's a -- to date, we have 21 of them on our -- DR. SCHAAL: Twenty one? Twenty one of them on our website. So, that gives you an opportunity to select. We have one for sleep. For helping you with your sleep --

DR. SCHAAL:

So, give me an example.

DR. SEXTON:

So, we -- first of all, let me just say we embed the bite sized interventions in CMEs and CEUs. So, we've run randomized controlled trials to show that we can cause improvements in well-being using these brief bite sized interventions, then we kind of put these interventions into CME sessions or into CEU sessions so that if you're gonna show up for some continuing education…

DR. SCHAAL:

You're gonna get CME credit.

DR. SEXTON:

You're gonna get some CME credit and you're gonna get an intervention, so.

DR. SCHAAL:

Okay so you developed that -- these 21 bite sized. DR. SEXTON: Yeah. For example, for sleep.

DR. SEXTON:

So, for sleep for example, we'll give you the evidence- based strategies for sleep hygiene and there's a lot of really cool stuff that most peop -- If you finished your training more than six or seven years ago, a lot of the sleep science has evolved just in the past five years. So, really -- DR. SCHAAL: So, it's what? It's an article that you read about how to sleep better? What is that intervention? It gives you tips for managing your own sleep hygiene. So we'll give you -- I'll give you a couple examples. We call it the 3-2-1 method, which is three hours before sleep, no more food. Two hours before sleep, no more liquid. One hour before sleep, dim the lights. If that's the only thing that you do, watch how much easier it is to fall asleep. To fall asleep and stay asleep. Also when you're trying to fall asleep, a part of what happens physiologically is your core body temperature has to drop two degrees Fahrenheit. So, one way of doing that is take a hot shower and then go straight to bed, but lay on top of the covers because you actually speed up the process physiologically of lowering your core body temperature that way.

DR. SCHAAL:

So, in order to get the CME credit, I just need to read the article or actually I need to sleep better?

DR. SEXTON:

So, to get the CME credit, you're watching a pre recorded video or you're attending in one of our, you know, bite sized monthly -- we offer a different topic every month. And so, you can log in.

DR. SCHAAL:

It is live or it's rec --

DR. SEXTON:

It's live but then afterwards, the recording is available to everybody.

DR. SCHAAL:

Okay, and this is all healthcare workers?

DR. SEXTON:

All healthcare workers, yeah.

DR. SCHAAL:

Okay, so sleep is one. Another example.

DR. SEXTON:

So, we have one for gratitude, which is very -- it's very simple, and that's a very safe one. I like the gratitude one 'cause regardless of your level of well-being right now, the gratitude one is a safe one to do.

DR. SCHAAL:

So, tell me about that.

DR. SEXTON:

So, you spend --

DR. SCHAAL:

You know, my daughters are gonna listen to this podcast. And so, all these advice, I hope they're gonna take.

DR. SEXTON:

Well here's what they should do. They should -- your daughters should write a brief note to mom…

DR. SCHAAL:

Oh absolutely every morning saying,"Mom, I love you. Good morning. It's gonna be a great day."

DR. SEXTON:

Even more than that. They should write a letter to mom that says,"Mom, I wanna tell you about something you did for me that you didn't have to do, but you did, and here's how I've benefited, and here's why it's so important to me, and here's why I wanna say thank you." If you spend seven minutes responding to that prompt, right? To anybody, it doesn't have to be your mom. Anybody who's done something for you that really made you more prepared to deal with things that are happening in your life. They could be alive or no longer with us. Seven to ten minute dose of gratitude, we can measure an impact on your well-being six to eight weeks later.

DR. SCHAAL:

So, this is fascinating. So, it's not only -- and because I love to get love letters, right? But you're saying actually write the love letter, the thank you letter, the gratitude letter. Spend time on thanking or thinking about somebody that has improved your life in some way, shape, or form. Spend time and then say -- does it have to be handwritten or it can be a text, or?

DR. SEXTON:

It doesn't have to be handwritten, you can do -- it's pretty agnostic to application so you can text it, you can write it in an email, you can handwrite it. There's a little bit of research that shows that when you do it handwritten, you get a -- it's not a huge boost, but it's a slightly larger effect. We think it's because when you're writing out by hand, you're being more deliberate, intentional, yeah. So, there's a slight, you know, benefit there. But we've done that with gratitude, we've done that with awe and wonder where you write about that time when you took a trip to Yellowstone National Park or --

DR. SCHAAL:

That's why I love postcards. I always send handwritten post cards from everywhere I go, right?

DR. SEXTON:

Sounds like you have pretty good well-being portfolio.

DR. SCHAAL:

I'm learning now, right now. But that's amazing. So, it's interesting. So, you have -- it's a website that you have, and how is the engagement? How has it taken off by your healthcare providers?

DR. SEXTON:

Well, we advertised it, it at first just at grand rounds and when we'd have annual conferences and things, and now we have a little over 40 almost 50,000 healthcare workers use it a year.

DR. SCHAAL:

Interesting. And what's the -- out of the 21 bites, what's the most popular bite that people take?

DR. SEXTON:

The most popular one, I have to say is called,"Three good things." So…

DR. SCHAAL:

Three good things. Tell us about that.

DR. SEXTON:

So every day for basically -- we've done different doses. So, part of what we've been doing over the past, kind of, 30 years is figuring out what's the dose that's the most -- what's the minimally effective dose for one of these things because we don't wanna ask people to do more than is necessary. So, three good things is simply at the end of the day, within two hours of sleep on set, I'll send you a text and that text says, you know...

DR. SCHAAL:

Who is gonna send me? You are gonna send me a text?

DR. SEXTON:

It's automated. It's automated.

DR. SCHAAL:

Okay, okay. DR. SEXTON: So -- At the end of the day.

DR. SEXTON:

At the end of the day.

DR. SCHAAL:

Like, three hours before I go to sleep, not to mess with my sleep hygiene, right?

DR. SEXTON:

It's usually at 7 P.M.

DR. SCHAAL:

Okay.

DR. SEXTON:

7 P.M. is where we target for people. And -- So 7 P.M. you get a text and it says,"What are three things today that went well?" And you just -- and it could just say,"Delicious lunch, took a walk with my friend, and got good news about my dog's health from the vet," or something. We get -- Just three things that weren't terrible. And what happens not the first time, not the second time, but once you've been doing this for about four days in a row, is your brain switches into a mode where as you go through your day, you're looking for things that you can put on your list that night. By looking for them, you see the things that are there that usually you skip over --

DR. SCHAAL:

So do they send you back a text or just --

DR. SEXTON:

We have hundreds of thousands of three good things from people. DR. SCHAAL: Really? Yes, very, very cool.

DR. SCHAAL:

And did you collect the number one thing that people say? What is that? Is that food? If I had to guess, it would be food, no?

DR. SEXTON:

The big categories are like good things at work, good things with family, and then places people go. Those are common things that people will write about. But it's interesting. We thought that well if people spend ten minutes doing this, that's gonna be better than if they spend 30 seconds. And that's not what we found, actually. Like, whether you have single word responses or you write a paragraph, you get the benefit.

DR. SCHAAL:

Fantastic. So, this is all fascinating. And is this, you know, work both the individual, you know bite sized intervention and the group intervention that you have implemented and executed, has this impacted your safety and quality metrics? Yes or no? DR. SEXTON: Yes. So, it was really exciting. I think we did this, I wanna say in 2015, we actually -- because at the time,"Three good things" was new to do. Now, it's kind of an old hat. But when it was new, when I was giving grand rounds and introducing each of the departments to this new intervention that we were trying to make easy, it's free, it's accessible, it takes less than two minutes to do it, it's very simple. We surveyed, and out of the entire health system, we had about 35% -- I think it was 37% of the health system had already used this intervention. And if you compared the ones that had used it… Mm-hmm.

DR. SEXTON:

To the ones that had not yet used it or didn't know what it was, we call it an exposure variable. Like, have you've done this? And the answer is yes, no, or not sure. So, if you just compare the yeses to the nos, huge differences in the way I view my leadership, the teamwork that I experience. Can I speak up? Can I resolve conflicts? Can I ask questions to clarify ambiguities? Big differences in would I feel safe being treated here as a patient? Are errors handled appropriately at my work setting? Like, across the board, whether you're talking about safety or teamwork or leadership or especially well-being. So, we also measured work-life integration and emotional exhaustion and yeah. So, it's very --

DR. SCHAAL:

So, it's impactful. So, it's impactful on the well-being measurement obviously, what it's meant to do. But it's also impactful on the safety and quality measurement and leadership views or how people view the leadership. And how about actual patient outcomes like mortality and complications after surgery. Did you look at that?

DR. SEXTON:

We didn't look at patient outcomes like mortality, no. But we have done work, like, in primary care where we look at clinics that are implementing, not a specific intervention, but they're doing something for well-being versus ones that are not. And you can see differences in, like, diabetes management and heart disease management.

DR. SCHAAL:

So, you're doing this at Duke but you also spread it around the country in, you said, several healthcare systems across the country. The question that I have for you, and I don't know if there is a -- if you know the answer but are these healthcare workers at these systems, are they healthier, you know, mentally less exhausted emotionally than other healthcare workers?

DR. SEXTON:

So, that's where having a good metric comes in handy. So, the answer is yes. They are doing better. They are definitely doing better. And so, we measure in addition to things like emotional exhaustion, we measure depression, and we measure subjective well-being, and we measure, you know, anxiety, and we measure optimism, and we me -- you know, so we measure all these things, and we've done it in our randomized controlled trials as well. So, in our randomized controlled trials, we have, like, a one month, and a six month, and a twelve month follow up. And so, one of the things that we're really proud of is we've gotten the bite sized interventions down to eight days now. If you just use, you know, eight days in a row, then you're done, then we can look at you a month, and six months, and twelve months later, and you're still doing better.

DR. SCHAAL:

After eight days?

DR. SEXTON:

After just eight -- DR. SCHAAL: That sounds like a very good deal, okay. So, this is easily copied, or sharable, or this is -- It's all 100% free on our website.

DR. SCHAAL:

Really? So we can go and copy it if we want to. So, anybody that is listening, the website is…

DR. SEXTON:

www.caws.dukehealth.org.

DR. SCHAAL:

Okay, so we can go and see what these bite sized interventions, and then you know, leaders all over the country that may be listening to us right now.

DR. SEXTON:

Grab an intervention that you like, and use it, and share it with somebody else. Be a candle in the darkness because that's what we need right now.

DR. SCHAAL:

So, what is your, kind of, impression of the well-being of healthcare workers around the country and the globe? You told us what you learned before the pandemic, during the pandemic, and immediately after. But I know that you are a national leader, and you're participating in many conferences and discussions around this topic which is a very important topic. What's your sense? Are we getting better? DR. SEXTON: No. Oh, so why not?

DR. SEXTON:

Because the world's becoming more complex at the same time that we're learning how to do things. I think that the curve of improvement will catch up with the curve of drama that we're kind of trying to absorb at the same time. But it's a difficult time to be in healthcare right now. It's a very difficult time. And for those folks that are doing, you know, active things for their well-being, they're not slipping as much as others are for sure. And that's the beauty of having good metrics over time. My friend Tait Shanafelt has done a lot of work on tracking that over time. And he measures it in one -- using one method and I measure it using a different method, and our data overlap nicely to show that those trends are --

DR. SCHAAL:

So, when you say it's a, you know, tough world in healthcare, I suppose you mean that it's getting more and more complex to treat patients because we have more and more knowledge, more and more expertise, more and more technical skills. We know more about the pathology but then it costs a lot more. And then, you know, the bottom line is not always there. So, the cost of all these fancy robots, and fancy technologies, and diagnostics, and imaging is enormous. And then as, you know, physicians or healthcare systems, we're paid actually less, and less, and less. So, there's no -- the margins are eroding…

DR. SEXTON:

Increasingly smaller, yes.

DR. SCHAAL:

And so, if the margins are eroding, maybe there's less money to really invest in well-being. And maybe it's all about,"Okay, well how can we make ends meet to get these technology and buy the new robot for our hospital to -- for our patients?"

DR. SEXTON:

Yeah. So, in my training, my mentor used to pound this into me and he would say,"You're gonna get a lot of arrows when you go out and try to change things. So, whatever you do, make sure you bring data." Whatever you do, wherever you go, you gotta bring good data, and make sure it's the best quality data, the biggest data set you can manage so that you can support what you're trying to do when you're changing things. When I -- let's just take one example real quick. So AI… DR. SCHAAL: Yup. Huge right now. And the big question mark by the way is well, like, there's fear associated with it, there's optimism associated with it, and it kind of depends on, you know, what you've been looking at online. Well, we have surgical residents at Duke that spend eight to ten hours a week, each resident spends eight to ten hours a week grabbing information from the medical record and pasting it in a PowerPoint for the surgical cases for next week.

DR. SCHAAL:

Mm-hmm.

DR. SEXTON:

That's eight to ten hours a week for these residents. We can now do that with AI in about 60 to maybe 90 seconds. Usually closer to 60 seconds.

DR. SCHAAL:

So, take the data, make a PowerPoint.

DR. SEXTON:

It does the whole thing. It's all hyperlinked so you can go straight back to the medical record where, you know, to see what medication they're on, when they changed this, or when was the last visit. And that really begs the question, now, if these surgical residents are gonna gain back ten hours of their time in their week, what do we do with that philosophically, and at what point do we make an argument for generating more RVUs versus providing more opportunities for professional fulfillment? And I think that we need -- one of the reasons we need such good data is 'cause we're about to have to answer some really tricky questions about where do we go from here? DR. SCHAAL: Yeah. So, you know, we have implemented ambient listening in our physician organization and it's gonna cost us about two million dollars in 2026. But we had this exact discussion, you know. So, how many more patients do you need to see to cover that, because it's a lot of money. But, you know, my personal view on this is that some things are priceless. So, if this brings the joy back, if this allows, and you talked about the physician's families. It's not only -- this allows the physician to get, you know, done by 5 o'clock and be with their families afterwards, then it is priceless. But it's difficult to sell that to our CFOs that are like,"Okay, well where is the return on investment in that?" Yes, people are happier, it brings them -- you know, they can be at home but it's still two million dollars so who is gonna pay for it? How are we gonna pay for it? Any thoughts about that? Well, first of all, I think it's really important that we get to the point where if you're home, you're home, right? And you're not also simultaneously, you know, worrying about eight of your patients from earlier in the day or in the week, which puts gas back in their tank. So, that's a big -- that's a really -- that's a really big deal. And to put a price tag on that is going to take some time because you're not gonna be able to tell what happens with the Bridge or Dax, or one of these other programs. In terms of how it impacts turnover, it's gonna take years to show that. But if you prevent two physicians from departing from Houston Methodist and it cost you two million dollars, you just paid for your program. DR. SCHAAL: Correct. Exactly. So, I think it really, really illustrates how organizations that are going to invest in the well-being of their healthcare, and the healthcare, you know, workforce in general, but physicians specifically, they're gonna be preferred organizations or destination places to work, and people would love to work there rather than other institutions that may not have that. And you know, it's kind of -- this is the way of the future. So, I think, you know -- I think we're gonna have a push from physicians to where they prefer to work, and they will prefer to work in organizations that value these well-being metrics. And have something-- and have a way of showing that too. So, that's gonna be in recruitment, you know, interviews, that's gonna be a big deal when you're --

DR. SCHAAL:

So, you know, what I would encourage you to do is really look also on, you know, how does this affect patient experience. I don't know if you have looked at that, you know, a more engaged physician, one that slept well last night. One that, you know, did their gratitude to their mom in the morning, whatever that is. Does this transfer into the patient experience? In other words, if I come to you as a patient and you're a happy doctor, well, you know, being, you know, kind of a shiny, joyful doctor is this -- is my experience as a patient better?

DR. SEXTON:

Now, what do your HCAP scores look like for physicians that are reporting good well-being relative to physicians that are reporting, you know?

DR. SCHAAL:

Did you look at that?

DR. SEXTON:

We're doing a study on that right now. So, to be continued. DR. SCHAAL: Okay, fantastic. And don't forget the ambulatory side of things because 70% of our healthcare delivery is actually done outside the hospital. So, what is the patient experience in the clinic as well? So, fantastic. And I'm gonna ask you a question that I ask all my guests in this podcast, and this is really what does quality mean to you? What does quality mean to me? Well, I'm gonna have to put my well-being hat on and say quality means being able to do things well in a way that's fulfilling at the same time. So, quality, from the lens of the individual delivering the care, is I'm able to do stuff. If you're able to do stuff, that's good. If you feel like you're not able to do stuff, quality is compromised, it just is.

DR. SCHAAL:

It's fascinating that you, actually -- you know, every time I ask this question I get a different answer. But what's fascinating about your answer is that you gave it from the lens of the provider and that's exactly what we have heard in our JIMI tour, that people, what brings them joy is exactly what you said. Is the ability to provide high quality of care. The fact that they are able to do that here at Houston Methodist brings them joy and that's why they wanna stay. So Bryan, thank you very much. I'm gonna look at your bite sized intervention, maybe adopt some tonight, and thank you for being our keynote speaker in the JIMI Symposium.

DR. SEXTON:

It's my great pleasure. Thank you for having me.

DR. SCHAAL:

And thank you for listening. Quality Time is part of Houston Methodist Leading Medicine series of physician- led podcasts. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. If you enjoyed our conversation today, please consider rating this episode and sharing it with your colleagues. I appreciate your support, thank you, and until next time, I am always listening.♪ ♪