561 - Practice Culture “By Design”, Postpartum Morbidity, Tolerations
From the Literature
1) Creating a 5 STARRS Practice “Culture By Design”
How would you describe your “practice culture?” It may be a question you’ve never really considered. And yet, all organizations and practices have a culture. In the book, “Inside the Magic Kingdom” about the Disney culture, author Tom Connellan contends that all cultures are either by design or by default – and if you don’t know which yours is, then it is a culture by default. A culture by default is not necessarily a toxic or dysfunctional culture. It may be a highly functioning one. The challenge is that without creating such culture deliberately and proactively, teams have no idea how to replicate it, sustain it, or adapt it if things aren’t going well.
The practice of medicine and the provision of health care is a challenging and often energy-draining one. Statistics would indicate that as those working in health care, we are constantly at risk for burnout (emotional exhaustion, depersonalization, meaninglessness), compassion fatigue (find it difficult to care), and moral distress (deviate from core values). The busyness and intensity of our work can also quickly place us in “survival mode,” where we end up focusing on just getting through the day rather than being present to those who are seeking our care and to our teammates providing that care throughout the day.
In the spirit of “practicing prevention,” what might a high functioning practice “culture by design” look like? Let’s go one step further. What would it look like to live out, on a day-to-day basis, the Vision below for your practice?”
“We are a thriving ‘Culture by Design’ medical practice characterized by exceptional care and heart-felt caring where we enjoy being together and doing our work.”
I’ve created an acronym to help guide such an inquiry. The inquiry has 2 parts: The first is individual reflection examining the impact (positive or negative) you might be having on your team, and the second is doing the same reflection with your teammates.
STARRS:
· Service – What is our philosophy for both patient care and “customer service” and are we implementing this consistently? Additionally, how are we serving each other in the process of serving our patients? There should be a consistent feedback mechanism in place to measure performance and a process in place to improve it.
· Teamwork – Is there a common and explicit understanding of everyone’s role and are they trained and empowered to be able to perform this role effectively? We commonly think of teamwork in the context of care delivery, or what we do together for our patients. Teamwork also refers to how we connect with each other as coworkers and teammates. It requires presence and awareness, not only knowing each other by our titles and roles but also knowing about each other.
· Attitude – Is everyone “choosing” and “owning” their attitude moment by moment, and is there a process in place for teammates to check in with each other and encourage each other during the course of our high pace, high pressure days?
· Reflection – Is there a regular time put aside to dialogue about not only the “business” of the practice, but also to reflect on the challenges and joys of taking care of those who are often experiencing significant suffering and distress?
· Renewal – Is time set aside for everyone to reenergize during the course of work? How are having fun and celebrating successes part of the culture?
· Self-Care – How do we emphasize self-care? Is holistic health and well-being encouraged and supported for each team member, including physical, emotional, mental, spiritual, and relational health?
Mark’s Comments:
Effective relationships are the foundation of the good work that we do. We speak often and appropriately of the importance of our relationships with our patients. Equally if not more essential to both our clinical effectiveness and the sustainability of our work are our relationships with our colleagues and care team. I encourage each of you to use the tools in the referenced article (or you can reach out to me) to help facilitate your reflection; one focused on you (Being a 5 STARR Person) and one focused on your team (Being a 5 STARR Team). I also encourage you to have each of your team members complete the Team survey and to use this for discussion as to the “State of the CommUnity” at your next practice team meeting. Then make a plan to take action on those areas that have not achieved 5 STARRS!
Reference:
· Greenawald MH. How to create a culture of well-being in your practice. Fam Pract Manag. 2018;25(4):11-15. Link
· American Academy of Family Physicians: Practice and Career. Clinic Practice Culture: Moving from Surviving to Thriving. Link
From the Literature
2) A Primary Care Response to Postpartum Morbidity
There has been extensive documentation of the problem of postpartum morbidity and mortality – a phenomenon that doesn’t have a high overall incidence but reveals highly impactful disparities related to social and structural determinants of health. A report from an Expert Panel (disclosure: I served on this panel) called for high-quality research focused on patients through their life course and entailing creative systems innovation to address the problems of postpartum health. Sounds a lot like a job for primary care to me.
A recent article in JAMA Network Open tested an intervention based on behavioral economics – a default choice intervention – to automatically arrange a primary care visit for post-partum women. The thinking behind this intervention was: 1) 30% of postpartum women have some chronic disease (e.g., hypertension, obesity, diabetes) and 11-22% have a mood disorder and 2) a defaulted primary care visit helps patients avoid the administrative burden associated with the healthcare system.
Pregnant or very recently postpartum patients with obesity, hypertension, diabetes, depression or anxiety were randomized to the default appointment intervention (notification of which was achieved by several patient-focused text messages) vs. usual care (a single text reminder to schedule an appointment in primary care). The primary outcome was a successful primary care appointment within 4 months of delivery, and secondary outcomes measured various aspects of the content of these visits.
There was an 19% absolute risk increase (+18.7%, 95% confidence interval 9.1% to 28.2%) of a successful primary care appointment in the intervention group. There was also a nearly 4% absolute risk reduction (−3.9%, 95% CI −7.8% to −0.1%) in postpartum readmission. There were a greater number of interventions directed at the postpartum conditions (e.g., weight loss plans, blood pressure assessment, diabetes assessment, mood screening) in the intervention group than in the control.
The authors emphasize that the point of such interventions is “to make it easier for people to make choices they already want to undertake but do not.” The study is limited by testing a bundled intervention (instead of the component parts individually) and by limiting the sample to those who already had primary care clinicians.
John’s Comments:
Our research group at Carilion Clinic has studied healthcare-associated administrative burdens (we call them “sludge”) and found that patients are dispirited by sludge, with the result that they don’t get the care they need. The problems associated with postpartum morbidity and mortality aren’t rare new diseases, but inadequate management of common conditions (e.g., hypertension, diabetes, depression) – due to complex structural determinants of health such as poor access and sludge. To improve the health of the populations we care for, we cannot continue to expect people to show up at our doors to seek care for what amount to risk factors and subclinical disease – we have to devise creative ways to ensure that these risks are managed before they turn into bad outcomes. “Default choice” interventions have the advantage of making the healthy choice easy while still preserving the patient’s right to opt out.
References:
· Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen JL. Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging. JAMA Netw Open. 2024;7(7):e2422500. Link
· Davidson KW, Terry MB, Braveman P, Reis PJ, Timmermans S, Epling JW. Maternal Mortality: A National Institutes of Health Pathways to Prevention Panel Report. Obstetrics & Gynecology. 2024;143(3):e78. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Tolerations: The Silent Energy Drainers in Our Lives
We all have things in our lives that we “tolerate” – a cluttered office, a squeaky door, a physical symptom, a messy inbox, or unresolved tension with a colleague,. They’re the small, nagging things we “put up with” because, in the grand scheme of life, they don’t seem like a big deal. But these tolerations can come at a cost. They quietly drain our energy, steal our focus, and add to the overall stress we carry.
Recently, I had a tooth filled. While that in itself may not seem like a big deal (or perhaps it does!), it was a minor procedure I had put off for years. The reasons for this are many, but one day something finally “snapped” for me when the water flosser I had become dependent on for symptom relief was not working and I realized how much of my daily life was being impacted (no pun intended) by this small gap in my teeth. In retrospect, that chip in my tooth became symbolic of all the things in my life that bother me, but not enough to do something about them. That inaction slowly chips away at my mental and emotional bandwidth, eroding any sense of control over my environment and causing unneeded frustration in my life.
Research confirms that these unresolved stressors, such as clutter, inefficiency, and unresolved conflict, no matter how minor, can cause cumulative distress and ultimately become chronic energy drains. In healthcare, where we’re already juggling high-stakes decisions and overflowing schedules, these tolerations add an unnecessary layer of mental and even emotional fatigue that can impact not only our ability to perform at our best, but also diminish our quality of life.
That chipped tooth wasn’t the only thing I was tolerating. Like many of you, I also had a backlog of unread emails, a colleague I needed to have a tough conversation with, and a growing sense of weariness from managing so many unresolved stressors. In the past few weeks when I finally started addressing some of them, beginning with having that tooth fixed, I’ve noticed an immediate sense of relief. Suddenly, I felt more in control, “lighter,” and more focused on the things that truly mattered to me. When I reflect back on the cumulative amount of emotional energy that was invested in that tooth, it is stunning – even embarrassing.
The truth is, when we allow tolerations to pile up, we unknowingly create an environment where stress thrives. By proactively identifying and eliminating these energy drains, we free up mental space and emotional energy for a more meaningful life. So what things are you tolerating? Take a moment today to reflect on the small things you’ve been putting up with, whether at work or at home. Make a list and identify one you could easily address in the next week – and repeat weekly. Ask your PeerRx partner to help hold you accountable by naming your intentions in advance. Then celebrate each small “victory.” Notice how much lighter you feel and be reminded, sometimes it’s the smallest shifts that make the biggest difference.
Oh, and in case you’re wondering, after a decade, I haven’t had to use the water flosser since my procedure. So many tolerations, so little time …
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Mark and John
Carilion Clinic Department of Family and Community Medicine