Chapter 11: Creating a Department Culture of Support and Wellness

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Chapter 11: Creating a Department Culture of Support and Wellness

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In this chapter, Dr. Bruera talks about the practices he has instituted to support faculty, fellows, and staff as the department has growth through very stressful times with challenging workloads. These include creating 100% transparency in decision-making about operations, workflow, and hiring. Dr. Bruera specifies that this is to provide department members with a sense of autonomy and control over their work environment. He also explains his own open-door policy, his views of serving as a role model for the rest of the department, and the use of anonymous surveys to assess the results of decisions and his own performance. He also discusses how the department has assembled a good team over the years, citing the fact that all the faculty have been fellows and trained through a rigorous monthly review process to perform according to the department's standards for excellence and emotional intelligence. Dr. Bruera shares an anecdote about a VIP patient and how he had full confidence that anyone on call on the supportive care service could provide the appropriate standard of care.Next, Dr. Bruera talks about the high rates of burnout in palliative care. He also explains how the department has created a culture the values self-care and support among faculty and staff. He explains the department's self-care handbooks, how they were created and how the department is not reviewing them to make them even more effective. He notes that instituting this kind of self care is good ethical practice for the institution.

Identifier

BrueraE_02_20180813_C11

Publication Date

8-13-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Leadership; On Leadership; Overview; MD Anderson Culture; Professional Practice; The Professional at Work; MD Anderson Culture; Working Environment; Collaborations; Professional Values, Ethics, Purpose; The Researcher; Ethics

Transcript

Tacey A. Rosolowsi, PhD:

I wanted to kind of go back a little bit and ask you some more about the practices that you instituted as a department. You talked about how that was really tough to build the clinical then get the resources, build the clinical, get the resources. Always this retroactive filling in the people that you need, and you said that you began to do a lot of things to support one another. What were those in-house initiatives that you took to kind of save people’s necks during all this?

Eduardo Bruera, MD:

Well, we started saying that first the area of governance was the most important one. At times where it was not always possible for us to understand what was going on, where was the money going, where were the decisions being made, we said well, in the area where we can have access, there will be one hundred percent transparency on anything. So the number of hours that each person worked, the number of patients that each person saw, the number of money that each one got paid, the number of weekends on call and evenings on call, were all transparent and actually the decision of allocation was done by an open committee in the auditorium, where everybody could show up and decide how we were going to organize. We usually do it three times a year for four months each time and then we basically have everybody show up and say what their needs are, and to review the process, so that there was completely transparency on those things. Whatever I learned, I would share with everybody in the team and occasionally, I would warn people that I was going to share that with my faculty, that I was not going to not share with my faculty when it affected them, so that they would feel that they were completely aware of what was going on, and we knew. We didn’t know a lot of other things, but we thought the transparency was a very important value. Decision making became one hundred percent collective, and that meant that you were going to hire someone, one hundred percent of the faculty sitting around the table says yes or no, and finally we get literally voting on hiring a new faculty. And so it’s not me hiring the faculty, it’s me hiring the faculty on behalf of our faculty team. If one of our members is going to ask for another 20 percent more protected time, and that’s going to have impact on the rest, that’s discussed by everybody. So we have everybody saying, yes, David might bring another grant and this might help all of us, let’s have that protected time and let’s do it this way, and so on. It takes more time. It’s more time consuming for me, but it does ensure that people feel that they have autonomy, that they have a certain amount of control of their working environment, control of the decision making, that they can opine on how things are going and how people are doing. We also emphasized a lot the open-door policy, so the door is always open for anyone who wants to show up with a problem or a need. They can email, they can page, or they can just walk in, and I made it a point that everybody could walk in at any time and interrupt me, to the point that when I need to do something, I sometimes have to leave the office, because I need to hide somewhere where I can do some work, either in the library or the coffee shop or whatever, because that way I can focus on something in an uninterrupted way. Otherwise, the door was always open. But that I think provides a little bit of guidance for other ones to be available too, because then if I am making myself one hundred percent open, well the rest should also be open to others, right? I think that promoted a bit more of collaboration, sharing ideas. That is my idea board where I have all kind of ideas, but one hundred percent, I give away. So, when I have an idea of a new study, I just find someone who wants to do it and coach them into getting it done, rather than doing it myself, and so that way, that person starts to learn how to ride a bike and becomes more independent. We started doing anonymous surveys about workload. How is the workload this month or the last three or four months. Which is the area that you find more difficult? And then bringing those to our business meetings allows us to reallocate people to different places, based on how they express things. We try to do anonymous because I have a bigger microphone than an assistant professor, and if we say let’s do it at an open table, then that assistant professor might try to please me, instead of expressing their dissent. I have to say with great pride, that when we have our business meetings, people feel totally confident about dissenting with me on anything and I find that that’s an incredibly good thing, because that means that they feel free, they feel that they are not going to be paying any consequences for speaking their mind.

Tacey A. Rosolowsi, PhD:

Has there ever been an instance where you were genuinely surprised about something that someone brought to your attention in one of these contexts?

Eduardo Bruera, MD:

You mean surprised about something that was wrong?

Tacey A. Rosolowsi, PhD:

Whatever it might be. I mean because you obviously, you have an intimate knowledge of this department, but things go on. Was there ever a time when somebody brought something to your attention, and you had really been surprised that this was there?

Eduardo Bruera, MD:

There have been instances in which people, for example noticed that some of the medical procedures that we had established for a long time were not being honored as much as two or three years before, and then some of the assessments of the patients that we thought were part of a routine, were not being done as much. Some of them had been abandoned because of time constraints or because of people feeling that it was not so important, and then that allowed us to have a conversation collectively and say what do we need to change so that the patients benefit from these assessments and they don’t get the short end of the stick. That was brought up to my attention once in a while. I have to say that I don’t really deal too much with personal issues. I deal with things and concepts and ideas and so on, so I’m usually the last to learn when there are kind of personal difficulties, but they have been once in a while. When it’s non-faculty, they all go to [Natalie?], who is my business manager and firm director, when it’s a faculty issue I might learn, but I have to say that we’ve been extremely lucky because when I hear what happens in other areas and our program, my goodness, we have so few in the process of nineteen years, so few situations where we had a major ethical issue or a major personal issue that involved a faculty member. That, I think has been so easy from that perspective. It might be because we focus on playing the game together. We don’t have to be one single burg, but we focus on playing the game together and I think we’ve been lucky in the hirings too. We perhaps brought onboard, people who were positive characters, who were sensitive people, and I also wonder, I always wondered, if partially, this might not be related to our specialty. When you are dealing with dying people all the time, there is less time for petty problems or conflict, because you are seeing what real problems are, and then when you’re exposed to real problems, I suspect that you don’t want to generate a lot of little problems. I don’t know that as a fact, but I have this suspicion that our personhood-based practice permeates into our life, has an impact on our lives.

Tacey A. Rosolowsi, PhD:

Yeah, that may very well. Well then also, I mean you have stressed and you’ve said it’s luck, and I’m sure some of it is luck that you’ve gotten good people, but as we’ve discussed in earlier conversations, you’ve been very clear that one has to search for individuals who have those qualities of emotional intelligence. So part of it is you as a department, have made a commitment to look for people like that and too, in your collaborative decision making, intentionally select for those individuals to join your group. How do you go about, in a hiring process, finding people with those qualities? How do you assess people so that you know you’re making a good decision in that arena?

Eduardo Bruera, MD:

Well, almost one hundred percent, one hundred percent of our faculty for the last fifteen years or sixteen years, one hundred percent of them have been our fellows before. So we got to know them for a whole year, we knew which ones had all those qualities, which ones could learn, and then our fellowship is funny. Suresh Reddy has been running our fellowship for many years and I’ve been working very, very close with him, extremely close, and our fellowship assessment is every month, all the faculty meet and discuss each one of the fellows. Each one of the fellows is discussed in great depth, so that if somebody is finding any warning signs, those are brought back to the fellow immediately and we also put together the puzzle of how is that fellow.

Tacey A. Rosolowsi, PhD:

Can I ask just quickly, what might be some issues that would arise, kind of warning signs that you need to jump on?

Eduardo Bruera, MD:

Well, a fellow that does not have enough emotional intelligence when they go to see a patient and a family member, a fellow that does not display the empathy that might be necessary, a fellow that is not willing to help the other fellows, a fellow that does not show respect or team effort with the nurses and the counselors. We, for many years, have had representation of our nurses and representation of our counselors in the fellows evaluation meeting, so the nurses at the center and the nurses of the Palliative Care Unit, as well as the counselors, all come to the meeting, and they do their evaluation of our fellows.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

We do a very thorough evaluation of all our fellows. Many of them are shocked, because they’ve gone through residency and sometimes from another fellowship, and they never had that thorough level of evaluation, but we reassure them that the idea is that they play the game better, that they become better persons, better professionals, and they usually are happy at the end. In the beginning, they are not happy when they see the amount of scrutiny that has taken place, that results in their monthly evaluation, and so at the end of a year, we’ve got a very good understanding of who is who, and I credit our hiring from our fellowship for 90 percent of the success in having harmony and team operations. We also have people that we hire who have had similar training. Our training, we believe is the best in the nation and therefore, these people land already running and they are able to do things the way we do them. They have bought our model, our model of counseling, our model of medications, our model of assessment. We prime access to service for patients, we are proud of that. We get a call at four-thirty in the afternoon that we know is going to be an hour and a half and we say that’s fine, there we go, we’ll see that patient, no problem. We don’t leave it until tomorrow, we’ll see them today. We pride on taking phone calls and addressing them, so these people who are fellows have internalized that and they’ve demonstrated that they are feeling good with that. So I think we hire, in a sense, the best fellows that we have here. Sometimes we don’t hire any because we didn’t have any openings unfortunately, like the last group had two or three extraordinary fellows but we couldn’t hire them because we had no openings. We have wonderful fellows this year, I hope we’ll be able to keep one or two of them, because we do a very thorough job of assessing them for those qualities and I think that a lot of our success in the institution is that. I had an extremely VIP come on Saturday. They phoned me, what was it on Saturday? No, it was on Friday evening. I was in Galveston, and I got a call from this extreme VIP from one of the doctors that was sending this extreme VIP to the emergency center. They said, “What are you going to do, Eduardo?” And I said well, “I’m going to send them to whoever is on call,” and they said, “Well, watch out, this is a big, big VIP and how can you be sure?” They said, “Who’s on call?” I said, “I don’t know.” They said, “Well, this is a big, big, big VIP and you’ve got to be careful about who you send.” I told that colleague, I don’t know how you guys operate, but I want to reassure you about something. There’s none of the doctors who work on my team, I would not have them treat my daughter, my wife, or me. If one of them was someone I would not trust—I mean, they may have slightly different styles-- but if I did not trust them, I’m not sure I could possibly go to Galveston, I would probably stay in Houston, camping there and trying to see what holes are there. So, they have slightly different styles but… And of course they did an extraordinary job. I sent an email there, this person is going out of there, who can see them? In about fifteen seconds, I had a response from one, “I’m heading out there right now.” And then the person who was on call for the weekend, I contacted her and basically there she was, in another person in the ER and they fixed the problem and that was it. My experiences with the worst possible cases of VIPs that you could imagine, has been a variation of our regular product for those people is zero.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

Nothing. They are just seen by the member of our team who is seeing the patients that day, and I feel personally, very proud of that, because what that means is that huge VIP does not need different care from the poorest Medicaid patient we see, because they are all kind of—the people we deploy out there are so good, they’re so extraordinarily good, that basically they show up on any floor, they show up in any area, and they will fix the problem, they will take care. They also know that they can call me at any time, they know that if they get stuck, and maybe eight or ten times a year they will call me and they said, I’m really stuck here, let me tell you about a problem I’m having. Sure, tell me. And then I have to tell you, 90 percent of the time, it’s reassurance, then 10 percent of the time I find something that I might do different, and I tell them oh, why don’t you try this, try that, and so on. But 90 percent of the time is so wonderful, there’s nothing to add. I have no comments.

Tacey A. Rosolowsi, PhD:

That’s wonderful testimony to the entire group, the strength of the group. I was going to say the flipside is, that the VIP deserves exactly the same treatment as the poorest patient, you know they’re both ends of the spectrum and there’s no difference, I mean that’s quite lovely.

Eduardo Bruera, MD:

Yes, yes. But you know programs that are erratic, they know that if you get one of the real jockeys or one of the people who published a lot of papers but are not clinically very solid, and you get a very, very big VIP, they’re going to kindly remove that one because that one is not that good at dealing with the clinical issues. They might need to bring another one to do that type of work. Or, if somebody is on call that is not very reliable, they will call someone else, we’ve never had to do that. It just never, ever happened. I don’t remember one single time. We have had cases in which a very unreasonable patient became very aggressive with one of our faculty and one hundred percent of the time, that faculty is removed from the trench and another faculty goes in place. I remove them myself, but that’s for protection of the faculty, because sometimes that clash occurs and then that is hurtful.

Tacey A. Rosolowsi, PhD:

It damages that rapport and it’s hard to rebuild it. Absolutely.

Eduardo Bruera, MD:

Completely. And for the benefit of the patient and for the benefit of the faculty, I always make the point of changing them. I go with them, most of the time I end up going with them to that room where the conflict is happening, to try to understand what is going on. Then what I usually says is, that’s fine, that’s fine, and then I stay with the patient and say we’re going to change the doctor who is seeing you and so on. It again, happens very rarely. Very, very rarely. Not once a year. Less than once a year it happens. But when it happens, I make a point of relieving that. But in terms of me ever feeling that someone else should be deployed to see a patient, we’ve been very, very lucky because we don’t have that problem.

Tacey A. Rosolowsi, PhD:

Now, we had occasion a bit last time, and then we happened to be at a meeting on Friday and you were talking about the issue of burnout, which has become a topic within the institution. So, I wondered if—you know, we have a few minutes remaining today. I wondered if you’d say a little bit about that issue of burnout within the department, and some of the things that you’ve done to kind of address that reality.

Eduardo Bruera, MD:

Right. Well, burnout in palliative care is rampant, it’s the specialty that I know of, that has reported the highest level of burnout in medicine. That is not surprising, because of all the things we said. Faculties of medicine do not have palliative and supportive care departments. The specialty is not really well recognized, there are not very good solid clinical programs. The patients are very ill. So in that situation of not having a tremendous amount of credibility and respect and having big demands, is a position of great responsibility, dealing with ill patients and so on, and lack of autonomy to run things. The combination of high responsibility with no autonomy is what essentially leads to burnout, and basically, palliative care would be almost a picture-perfect case for that. So we early recognized that support was important and we implemented a lot of those previously mentioned institutional --institutional meaning our own team --department self-support strategies. But also, we implemented a whole series of measures for self-care, and actually they are part of our departmental protocol for many years now. So, when you open our little department protocol of things, you see what you do in terms of opiate rotation, delirium, phone call counseling, nonmalignant pain, family conference, but you also see the palliative clinician self-care checklist, and that is something that tells us a series of measures. There are thirteen different measures that you can apply every week to take care of yourself, anywhere from exercise, healthy food, meditation, yoga or mindfulness, literature reading, no junk reading, art, movie, theater, no junk movie, watch visual arts, meet with family members in person, meet with friends in person, participate in spiritual religious activities, palliative care professional education activities, avoid noise most days, TV sponsored Web or work telephone, when you’re at home. Avoid at least one personal item of maladaptive coping that you know, nobody else needs to know, and achieve one personalized self-care goal. When you get more than eight of those, you are completely successful, between four and seven, partial success, and then when you get less than four of those, there’s always next week. So that’s our goal. [Contact the Research Medical Library for these documents]

Tacey A. Rosolowsi, PhD:

Now, can I ask how you use this as a group. I mean obviously, people have this little booklet in their pockets, they can refer to it at any time, but is there—you know, do people come together to talk about what they’ve done, or is there kind of community support? How does that piece work?

Eduardo Bruera, MD:

Yes. We have, every Wednesday morning, a fellows round, where a case is presented, a complex patient case that is very important because it’s a palliative care education activity, where we present difficult cases that have been there before problems. In the middle of the round there’s something called the commercial break, and the commercial break is a moment in which we announce a clinical research protocol. Or if there is no clinical research protocol that needs to be advertised, and then I bring naptime or I bring the importance of timeout, or we have a meditation five minute video that everybody takes into the screen. That was done by Ale [Alejandro] Chaoul for us, and then we take that video of meditation. So, the different aspects of self-care are emphasized every week when there is no—so we would say at least twice a month, those aspects are emphasized specifically in that five-minute commercial break. And then we are now doing some anonymous surveys about which aspects of that are people using and which aspects are they not using, and which aspects do they find particularly useful. We are trying to learn, from our faculty and our APPs, what they are finding. We also have a second booklet, there is a whole booklet about self-care at work, that is basically what things can you do for yourself during your working day that will make your day a little bit less painful, that is anywhere from offer to help when you are not busy, that improves your immune system and your well-being, but also ask for help when you are overwhelmed. Play some music, take your headphones and listen to music. Eat not too heavy. Take your time out and choose where you are going to take your time out. Drink water, because most Americans in the workplace are dehydrated. Take a nap. Move. And so those are things that we are—and then when you have a really bad thing, debrief, you know come to my office or some to somebody else’s office and debrief about a traumatic situation, don’t go home carrying it, debrief, and debrief if possible, immediately after.

Tacey A. Rosolowsi, PhD:

When did you decide to create these booklets for the benefit of your faculty and the team’s self-care?

Eduardo Bruera, MD:

The first one must be about three or four years ago, about four years ago, five years ago, when things were getting difficult at MD Anderson, especially for teams like ours, that were getting a lot of hard work and not always resources to get the work done, et cetera. We felt that it was necessary to make sure that people took advantage. I spent my life coaching soccer and basically, I felt that coaching people was something that I liked to do, but I also wanted to learn a bit more about the area, because I did not want to coach people wrong. So I had to do some reading about this and then find what are the practices that appear to be more successful and I put those into that weekly self-care checklist. The other one was probably about a year ago, a year and a half ago, and the other one was because what you do on a weekly basis to take care of yourself, it’s okay, it’s your lifestyle modification, but we sensed that you have to take advantage of what you can do for yourself here, during your working hours. It’s not what you do only when you are home, but it’s what do you do during your working hours at MD Anderson that can make you feel better. About a year, a year and a half ago, I came up with this other one, and Aimee [Anderson] and I have been working at helping people use it and also tell us which parts work and which parts don’t. The feedback we received generally has been very positive, that faculty and APPs feel that being reminded of the things that they can do for themselves, make you feel less helpless. If you feel that there are some things you can do for your distress yourself, you feel in a sense more empowered.

Tacey A. Rosolowsi, PhD:

I’m also thinking too, I mean the very fact that you’ve written these things down and it’s an official department little publication, it’s giving people permission. It’s not saying no, do this when you can sneak it in, don’t let us know about it. It’s saying no, we want you to do this. It is part of your working day.

Eduardo Bruera, MD:

Yes.

Tacey A. Rosolowsi, PhD:

That’s an enormously important message.

Eduardo Bruera, MD:

Yeah, we made that a point, you’re absolutely correct, because I also told our people that’s why I’m putting it in writing, because if someone from any department or from any other area, brings it to your attention, show them this and send them to me. Whether it is the president of the institution or the head of Human Resources, or the director of another service, send them to me. I will assume personal responsibility for people really being upset about the fact that you are taking of yourself, because in my view, this is what is good ethical practice for the institution. You cannot go and see a suffering patient and a family in a state of distress. You cannot serve the institution well if you are feeling really bad within yourself. So if you take care of yourself, then you can take care of others, but there’s no need for self-neglect to be helpful to others. So, I think you’re absolutely correct. Maybe some of the reasons the feedback is positive is not so much because there’s anything original there that they may not have read or thought, but it’s because in a sense it’s an official welcoming of those things as ways in which you can take care of yourself. I heard some people say, you know there are some days where I could barely keep my eyes open, but I felt so embarrassed about taking a fifteen minute nap, and since you said that, I’m going to my desk, I put on my facemask. I slept exactly ten minutes, fifteen minutes, then I went and had a wonderful day.

Tacey A. Rosolowsi, PhD:

It made all the difference.

Eduardo Bruera, MD:

So, it was just that short period, or you know, people who want to walk from here to there, they walked outside, they went by the trees and so on. They crossed the street, then they went in again, and that minimal time off, of walking among the trees and crossing the street and being outside, brought them back to the real world and now they were ready to go back. So, I think there is great value in small things. People overemphasize the big picture and we try to emphasize the little things.

Tacey A. Rosolowsi, PhD:

Well I know we’re a bit over time, so I wanted to thank you for that and for your time this morning.

Eduardo Bruera, MD:

Oh, thank you so much for your patience and your time, listening to all these stories.

Tacey A. Rosolowsi, PhD:

No, no. No, I’m delighted, and I actually do have a few more questions, so if you’re amenable, I’ll ask Carlos to work with your schedule.

Eduardo Bruera, MD:

Oh sure, sure. Wonderful.

Tacey A. Rosolowsi, PhD:

All right. Well, I want to thank you again, for taking the time today, Dr. Bruera.

Eduardo Bruera, MD:

Oh thanks for coming, it was wonderful.

Tacey A. Rosolowsi, PhD:

And for the record, I’m turning off the recorder at five minutes after three.

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Chapter 11: Creating a Department Culture of Support and Wellness

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