All right, well, I'll follow you. Yeah, so remind us where y'all are from. I'm Colleen Schmidt, Chattanooga. Joe Vacari, right up the road, Rockford, Illinois. I'm Zoe from the University of Buffalo. Yes. Buffalo. I'm Quinton from the University of Michigan. OK. I'm Nathan from VCU. VCU? Yep. I'm Quinton from the University of Michigan. I'm David from Baylor. Yeah. I'm Sarah from Baylor. Sarah. I remember y'all from the RFA. I had dinner with my team last night, so I know them well. Excellent RFA, by the way. We wanted to talk about work-life balance and sustaining your career. So y'all have any questions to start things off or thoughts? Come on in. This is the second iteration of this? OK. It is. We were in the boardroom first, and now we're here. OK. And maybe you guys are going to touch on this. I was wondering about charting for the concept of boundaries with the in-basket. We just had a lovely conversation about this. Perfect question. Normalized tools versus informal tools. I've tried to look at it. My personal interest is in functional and mobility patients, but I'm very cognizant of that potential burnout factor. So I'm trying to think proactively, how do I create a proactive, thoughtful relationship with the in-basket and with my patients and that type of stuff. That can be a particularly exhausting group. So let's just talk about some general concepts about boundaries and expectations. So you're moving from fellowship into an academic or a private practice. And one of the things you're going to have to teach or expect from your staff is how your inbox is managed. We were just talking about portal messages. That's a requirement, really, for all high-level practices, patient-centered. But the staff that work with you need to be able to filter those messages. And I will leave you with this. We don't expect our physicians to have a 24-7 access with their patients. And our patients are taught that they shouldn't expect that either. So the first level of filtering is with our medical assistants. If we're out of town on vacation or we're not on call, there could be an advanced practice provider. And then finally, our partner is going to take care of the urgent things that need to be taken care of. So patient expectation is a necessity in terms of education and what they should expect in terms of response time. Expectations and training your staff is another way to manage that. Joe? I think I'm just going to repeat one or two things just to be clear. Boundaries on expectations of timeline. These are not urgent. It's 4.30 in the afternoon. You're going to be done at 5. One of your patients calls, same thing, last call, same thing, last call. That can wait till tomorrow. Those are the boundaries that have to be set. And then who's ever helping you with your calls, many of the calls that you will get, they can answer. They're going to send it to you as an FYI. So those type of things. Finally, you cannot take your work home. You have to stop with your chart work when it is time to go home because it will never end. It won't end at 6 o'clock. It won't end at 7. It will go on and on and on. And that is a real bad indicator for burnout. We've seen in the pandemic in medical and non-medical practices, one of my partners, I'll use this as an example, his sister was working till 5 and then it became 6 and then it became 8 and 9. Yes, she maybe went to pick up the kids at 3 o'clock, but all she did was time shift and she was becoming a little depressed, a little anxious. So you have to set those boundaries for the patients and for you. Your work has to stop. So how many of you would describe yourselves as your work expands to fill the time available? Say that again. So just one in this, your work expands to fill the time available. That can be a problem. You need to look at your schedule for the week. You need to look at your schedule for the day. Know when your last patient is in the office and be able to let your family know, last patient's at 4, I should be finished by 5. We can plan dinner at 6. And don't disappoint them too many times. I mean, there'll be times when you're at the hospital where the wheels are going to fall off and you're never going to be able to predict what time. So control what you can. Same thing goes for your outside work life also. So what do you do outside work that you enjoy? Spending time with my family, my daughter. Yeah, excellent. Other fun things outside of work because this is an absolute necessity. I have just a comment on the in-basket and the stuff. I mean, I'm just a fellow in my third year. You're a fellow, not just a fellow. Thank you. I appreciate that. But I'm at the University of Chicago. We're a very high-volume IBD center, and those patients tend to communicate a lot. And I found, and I've learned this from David Rubin who's mentored me, the best way, if it goes beyond one or two back and forth messages, is to break the cycle because the patient needs something. And it's the easiest way is to call them and address it. That'd be the end of it. Or if you can't do that, get them in for a visit. And it's so easy to manage that way. I found myself, I was so worried about this in the beginning of the year. I didn't know. I kept back and forth and back and forth. And let's add this, and let's add that. But if you cut the cycle short, rarely you may even need to admit them to the hospital. I couldn't agree more. And try to multitask when you're doing that. And then taking that into your practice and figure out how that works for you and the practice you're at. Exactly. Practice setting is not relevant, but how it works for you and the staff and resources you have and make that work. So I save phone calls like that for when I'm reading a small bowel capsule study. And really try to get as much of it. Because it doesn't drive you crazy when you're reading a capsule study. You might want to stop and turn some music on. There's nothing else going on. The best thing that can happen is somebody walks in and I see their reflection in the doorway and they can ask me questions while I'm reading the capsule study. While you're reading, yeah. You guys are not off the hook. So what else do you like to do? Because you've got to find stuff you like to do. Sports and hiking. Excellent, excellent. Same thing. Sports. Sports. Excellent. Other things? Everybody's got to say something. Yeah. Tennis. Tennis, that came up in the last group. Rounding, hiking came up in the last group. Anything else? Baking. Baking. Baking, excellent. Who doesn't like to eat? So everybody should learn how to cook. Classes every week. What classes? High intensity interval training classes. Excellent, excellent. One person was learning a new language. Two people in my group are learning a new language, including this old guy. So really important to find stuff outside. The best way to prevent burnout and work-life balance is actually to start in the practice with your schedule, setting some of the boundaries we've talked about, with your clinic time slots. You can't do colonoscopy in 15 minutes, and on and on to get that schedule right. And then that perfect balance with outside. You need time off. You need time for yourself. And you have to schedule it. And your family. And that's right. It has to be scheduled. It just can't happen. I know that sounds weird, schedule time with my family. But that's what I mean by looking at that schedule and telling yourself, I'm going to have more labs to look at. There will probably be some histopath that'll come back this afternoon. I'm leaving at 430. Give you a simple example, my youngest daughter was really into competitive cheer. I made sure I made every event, traveled all over. Thankfully, when she got to high school, she saw the light. Got to cheer for your high school team. Really good football team. So Friday nights became sacred. I would switch call if I had to, get somebody to cover for a few hours. Because we'd go to the game, we'd go to the cheer, and we'd go out for pizza. That was our thing, every Friday night during football. I told you guys last night this story once. It was my first senior year. I was post-call, I was exhausted. I literally couldn't do it. And I told her, I apologized, and she said something to me where I knew my group had gotten it right for me. She said, oh, don't worry, dad. You have never missed anything. This is just fine. So it worked. You've got to schedule that to make it work. You can't make everything, but the times you don't go, it works out just fine. Now, the boundaries go for you, too, right? So it's so easy to get to that end, and you're just racing to get to that last part and then leave. And then you're at home, and you want to break open that electronic health record and kind of work just a little bit. That's like a poison. It'll suck you in every night. The boundaries apply at home, too. And if you're with your family, it has to be very intentional and let the work stay at work. And my husband asked me about my day, but it's a lot more fun to ask about his. He's a saxophonist. And I hope it can stay interesting. You don't have to be. And there's the occasional food bolus that's worth talking about, right, that this is let work stay at work and try not to stay in front of the computer at home. Make a deal with yourself. You're far enough into this game. You know what it means to be a physician. It is not an easy life. But if you create this balance, it is an incredibly rewarding life. Colleen's still very young. I'm not. We've been at this a while. We both still love what we do. We are extremely happy at what we do. But we've had that balance. If you do that, it's an amazing career. It's an amazing life. If you don't, medicine can chew you up and spit you out. The secret is it stays fun. I had a question, since both of you are in practice. One of my worries about practice, I'm open to all practice settings, is can I do five days a week of full-time clinical work that's relatively high volume for 30 years? Or am I going to, even if you stop at five, and even if you have your weekends, how do you do that? That's a lot of work. I don't know about Joe, but I suspect they're maybe even less strict than we are. We value the time that makes our practice healthy. And we recognize that that's not necessarily all the office or in the GI lab. So all of our associates have a half day off. They have an afternoon to go play golf or go to tennis or whatever they want. As your practice matures, you actually have a full day to do with what you will. Some of my partners do endoscopy. That's their golf day. Every day is their golf. And some spend time with their kids or do volunteer work, which is what I did. Now I do administrative work. But I think you'll see that evolve. And I bet you guys do it at least as aggressively. Yeah, we just do it differently. So we have 55 weekdays off. So it's 11 weeks. And you can use those any way you want. So people have used a half a day. If you do that, you still have tons of time for vacation. I don't think it matters how you do it, if it's that half day a week or becomes a day a week. You need time away with your family, sitting around your house just doing things you want to do. It doesn't matter how you do it, but you have to have the time off. And if you do that, because our workday is about based on a basic 10 and 1⁄2 hour workday. So that gets you 55. It's a 55 hour or so workweek. It's almost 11 hours. And then you have call and weekends. I can tell you after doing all these years, it is a vacation policy that has saved me. Because I'm an all in type of guy. I kind of don't do well with my toe half in. So if I'm working, I'm working. But when I'm off, I'm off. So again, it all comes down to balance. Whether it's a half day, it's the 11 weeks. Once you're away, you come back energized, ready to work. And you can do it for the long haul. But if you don't, then you'll end up with these sobering statistics. So this was when I was the chair of the Practice Operations Committee, one of the committee members did a paper called Let's Talk About Physician Burnout. And then we did a podcast. So from Medscape February 2020, so data from 2019, only 23% of gastroenterologists were happy at their work. Six lowest of any specialty. Here's the more sobering numbers. 26% felt burned out. 5% had depression. 10% experienced both. That's 41% of respondents. You don't want to be in that group. And you are early enough and young enough in your career to find the right practice setting to kind of do the things you've heard all weekend and to do the things we're talking about now. There'll be nuances. I mean, if somebody interviewed with our group and said, by the way, on the day after I'm on call, I want a day off, I would just start laughing. But if they said, I've got 10 weeks of vacation time, to use that as I choose, I'm going to plan to use a half day after call. That's a very mature professional way to look at it. And I would endorse that 100%. It's a little bit different than asking for another day off after call. Just understand how the group works or how the academic institution works and try to be intentional about it accordingly. The other tip I would please give you permission to embrace is unload unwanted baggage. I like having a clean house. I don't mind cleaning house, but I can't get my whole house clean at the same time, much less do that every week. I outsource that. You're going to be in a position where you can outsource some of the baggage that you just don't really love or you might love but don't have time for and the other things rank higher. Do that for yourself. I'd say about half my partners will take the Monday off after the weekend they're on call. But since there's a number of us, we do about eight or nine weekends a year total. So if you've got 55 days, you're taking eight or nine days off, you still have plenty of time to spend three weeks in Europe, and then still have more time. So again, it's all about being off work. When you work your work, when you're off, you are off. No phone calls, no handling your patients. You have to be in a practice that either has a plan in place for that or you have to create that. But when you're off, you're off. Or again, you're working when you're supposed to be off, and then the monster just starts chewing you up. I'm assuming these policies, and I try to do this in an admin role as well. We have chief fellows. I'm one of the chief fellows, and so I'm navigating also now all the emails and the tyranny of Outlook. And the wanting to have responses and feeling like I'm a responsible person. You'll like me if I respond to you quickly. And how do I navigate that? And some people email back at 9 PM, and I'm just like, that's not how I want to be. But this is like your staff. You're going to teach them what kind of behavior they should have with you. So some of the strategies or tactics that we implemented through the LEAD program, which is where we talked about this the most, teach them that you're going to check your email this time a day, or that you will respond by tomorrow. But let's face it, most of those are not emergencies. And if someone learns that you're going to respond, respond. You're checking your cell phone in between cases. And basically, you're trying to manage the inbox, right? But that's a learned behavior on their part. And you can either tell them, or they can learn it in a more passive way. But I would let them know what to expect. And you want the expectation to be generous on your part. If it's not an emergency, why should you be that reactive to it? I don't think it's good for them. I would start to implement these strategies now. You were talking the whole length of your career. Start now. If you don't even have to go down the path, you won't have to worry about it. Find those passions outside of medicine. Set the new boundaries for how you're going to deal with these things. Refine it. Make it better over time. Don't wait two or three years. Do it now. The good news about the article is more questions first. We can always finish up at the end with this. And I'll go. So here are steps you can take today if you're feeling burnout. And again, you can use these as preventative. Most importantly, you can say no. You don't have to say yes to everybody. Be selfish with quotations around it. Find those passions. Be selfish. Find value in your job. Do work with ASGE. Work with a medical school like we do to do some teaching. Do some research within your practice if you're in a private practice. In academics, find that niche for research. You're going to think I'm crazy. But if you've had an easy week and your partner's getting killed, and you're like, what can I do to help you? It's like volunteer work. It'll make you feel good. It'll make them feel great. And it's kind of fun when you're not on the schedule to do it, if you've got the free time. Volunteer work. Take care of yourself. So exercise, healthy things, meditation, yoga, whatever you like to do. Mentors when needed. Take time off. And then there are things the institution can do. Good leadership. Good mentors. Culture. Again, we come back to culture. Always patients first. But that culture that fosters all of these things. You get to the group. They're working 27 hours a day, 100 miles an hour, 900 days a year. Red flag. You're out. Well, I guess that brings up a larger question that I have with burnout literature and other types of things. Thus far, I feel like burnout literature, a lot of times, whenever there is an intervention that's discussed, it's on us. It's like, you do this, you do this, you do yoga more, you do this. When we found, with all this literature, that it's actually more systemic problems that are the things that are contributing to our burnout. And yes, you can do all these mitigation strategies, but it's kind of like deck chairs on a sinking ship to a certain extent. So how do we engage with the systems to try and bring change to protect ourselves to address these things? When you say systems, do you mean the institution of medicine or the institution of practice? Yeah, the institution that you're in. I mean, there's obviously larger, I can't march up to Capitol Hill and be like, change the way we do insurance and we do value-based care. I think, honestly, that's probably easier to answer from a private practice standpoint, because we do create that culture. Our group creates the culture of, when you're on vacation, we're going to take care of this for you. At an academic institution, I would start having those conversations at a very high level, because it's not sustainable. And if the people in leadership haven't lived this, then the faculty need to sit down with them to talk to them about it becoming a systemic change. It's leadership, leadership, leadership. Practice, it's much easier, because you can have a real, more of an impact. Large institutions, it's harder, but it really comes down to leadership. And so you'd have to try to change leadership, which means, if it's failing, which means change the culture. Tough, tough problem. These days, it may be even tougher to have that kind of ask, because some of the bigger institutions might really their nose may be just above the water. So the conversation has to be, one, about sustaining the health of the practice. And much easier in private practice, you would think all models would want a partner for life. When we hire somebody, we're hiring for life. We don't want them to leave. We are, too, by the way. It's emotionally and financially exhausting to move on and change over and over again. And expensive. And expensive. So if someone has a problem, and we've had physicians who needed help, we were all in. We did everything we could to make it work, and we fixed the problem, and they stayed. So it comes down to leadership within the practice. Much easier for us to pivot from this to this very quickly, because we don't have to ask too many people. We can get on the phone, call everybody quickly, and have an answer in a half an hour. Is there data on that, on turnover in private practice versus academia? Because from what I'm hearing, it sounds like maybe there is higher turnover in academia, which in some ways now reflecting on it. I'm like, that's probably true. I think it's true. But often in academia, what is it? You disdain those that are near to you. I think often people search outside the institution for promotion. It's the old familiarity builds contempt. So you're building your portfolio, and you're shopping that around and looking for that next promotion and tenure. In private practice, you've got two years of accounts receivable and reputation that you've built. You don't want to abandon that and go someplace else. So I've heard it is right to tell you that you shouldn't feel locked into a situation that's untenable for you. I would never tell you otherwise. But when we look for a partner, we're looking for a lifelong marriage, not someone that's going to come try us out and date for a few years and then move on. Something else that is a correct observation. It's exhausting, emotionally and financially. It's not fun. You mean to get new partners? No, to get new partners we love. To lose them, yes. Yes, it's like a divorce act. It's terrible. Very painful. All right, schedule time for yourselves. Get rid of unwanted baggage and create boundaries that are reasonable inside and outside. Take care of yourselves. OK, we're the ones who are. Thank you.

work-life balance

sustaining a career

setting boundaries with work

managing patient expectations

taking time off

engaging in activities outside of work