 Hello and welcome to this second webinar on human factors and primary care. My name is Maude Nauta. Welcome on behalf of WUNCA and the human factor core group. Today we're going to have Krzysinski as speaker on the relationship between burnout and human factors. She's going to present some tools to you, interesting tools. I will first hand you over to John Beasley. He will introduce her. And now I'm going to tell you a bit about our core group and background within WUNCA. Here we go. I'm going to hand over now to a message to you all, from myself to you, introducing our core group within WUNCA. Enjoy the afternoon. On behalf of the human factors core group of the World Organization of Family Doctors WUNCA, welcome to this series on human factors and primary care. My name is Maude Nauta, leader of the core group. Human factor science is a fundamental pillar of the WHO Global Patient Safety Action Plan 2021-2030 and human factors core group was established in WUNCA in 2023. Our mission is to lead within the organization on human factors integration in family medicine worldwide by supporting family doctors and their teams to develop their own human factors language, applications, research and education and adapted for their local circumstances. Our vision is that by applying human factor science principles in the strategic day-to-day activities at individual and organizational level, family medicine, our primary care patients will have the highest attainable health and well-being with care that is both patient-centered and free from affordable harm. Next, you will hear an introduction of our speaker by another core group member, John Beasley. Over to you, John. Hello. On behalf of WUNCA's human factors core group, I warmly welcome you to join this second in our series of webinars on the role of human factor science in improving primary health care. I'm John Beasley, Professor Emeritus at the University of Wisconsin in the U.S., and for this webinar, it's both an honor and a delight to introduce my colleague and friend, Dr. Christine Sinski, MD. Dr. Sinski has expertise from over 30 years in practice as a primary care physician and for the past 10 years. She served as the vice president for professional satisfaction for the American Medical Association, bringing her vast personal experience to the national stage to promote better policies and practice. She has been a speaker at countless national and international meetings to help people and health systems better support physicians and their patients. Her publications are too numerous to mention, but I will comment that a majority of them center on how our care system used technology and the implication of that for work for for better care and work for satisfaction. Join on an analogy to aviation, where human factor sciences brought remarkable improvements in safety. She will discuss creating a manageable cockpit for clinicians fixing the workplace, not the worker. So, Dr. Sinski, please proceed. Hello, everyone. I'm Dr. Christine Sinski, Vice President of Professional Satisfaction at the American Medical Association. Thank you so much for asking me to join you. Today, we'll be talking about creating a manageable cockpit for clinicians fixing the workplace, not the worker. Our agenda will be some brief introductory comments, and I'll introduce you to four takeaways, four major principles that I'd like you to be aware of. And then we'll turn to burnout and what we know about burnout internationally. And we'll talk about the prevalence and the drivers of burnout. And then we'll spend most of our time talking about solutions for burnout. And as we go through some of those interventions, I'll try to link that to principles within the human factors area of study. And throughout, I'll point to some resources that are available from the American Medical Association, and they are available to physicians and other healthcare workers across the globe. They are free. You don't need to be an AMA member. You don't need a username or password. You can just simply go to the sites. So let's start by saying, Houston, we have a problem here. Those of you from the U.S. will recall that phrase from Apollo 13. Houston, we have a problem here. If I told any of you leaders that there was an issue that affected over half your workforce, that impacted the quality, the safety, the morale, the financial stability of your organization. In any other industry, as leaders, you would get right on that. You would assign your crack team to address this issue. And that's the issue we are facing globally with respect to health professional burnout. That health professional burnout is affecting quality, safety, morale, and the financial stability of our health systems and our organizations. In the U.S., we talk about a health system goal of the quadruple aim. And the idea here is that the way we'll get to better care for individuals, better health for populations at lower cost is by considering the fourth aim of clinician well-being. In fact, I submit that that's the shortcut, one of the shortcuts to achieving all of the outcomes that we strive for. Another principle that I'd like to share with you is that while burnout manifests in individuals, it originates in systems. And so our efforts should go toward fixing the workplace rather than fixing the worker. Healthcare professionals are not what's broken. It is the system in which they are heroically working and trying to compensate for that system is broken. And last, I want to share that over the four decades now of my own career as a primary care internist, similar to what in many countries would be a family doctor, I have observed that we have evolved to a very transactional understanding of healthcare. But healthcare is a series of independent transactions that can be delivered by any individual. That's a series of tick boxes, bullet points, collection of discrete data. Anyone can be on the other side of the telemedicine screen. Anyone can round on any given day on hospitals, on patients who are in the hospital. And anyone can see the patient in follow up. But I believe, in fact, that at its core, our work in healthcare is relational, that we are better diagnosticians when we have a deep relationship with the patient, that we work better together as a team, when we have worked together over time and built up trust and reliance within that team. And so I believe that all of the infrastructures of healthcare can be improved if they are prioritizing relationship, the regulations under which we practice, the staffing models for our clinics and hospitals, the technology that supports our work. When those are designed to prioritize relationships, I believe our care is better. So I'd like to share then that I believe that relationships are our superpower. There is a wealth of evidence that when there's continuity between physicians or other clinicians and their patients, whether it's over years in the outpatient setting and even over days and weeks in the inpatient setting, and most especially when the same physician is caring for the patient, both inpatient and outpatient, we have a wealth of evidence that that continuity is associated with higher quality, lower cost, reduced rates of emergency remuse and hospitalization, and reduced mortality. Similarly, continuity within teams, the same nurses and physicians working together in the outpatient clinic, the same OR teams, the same ER teams working together, costs are lower, quality is higher, access to care is better, and burnout among all the team members is lower. And one example of that that I'd like to share with you was published with a team from several organizations in the United States, Stanford, UCSF, and Kaiser Permanente of Northern California. And what this group of researchers did is they looked at emergency room care for a patient with a stroke, and they looked at the door to needle time, the time between when the patient arrived and when they received their thrombolytic for their stroke. And what they found by looking at EHR event log data was that when the same individual people had been working together in the past, they provided better care. So when there was more stability within the team, the door to needle time was less than when there was less stability within the team, when those team members had not been working together as often. So let's turn our attention now to burnout and its prevalence and its drivers. So burnout is a global crisis and it's a global primary care crisis in particular. And so we have data at both high income countries and lower and middle income countries that all show a very similar picture. So in the study of high income countries, primary care burnout was common. And again, primary care here would refer to what many people call their family physician or a family doctor. And in the US, a general internist would also be a primary care physician. And you can see the rates across the various countries here in this survey. We've highlighted the US here, where 50% of our physicians under 55 and 39% over 55 in this study were evidencing burnout. But you can see that this is not limited to the US. It's across all of these high income countries. But the exception of the Netherlands and Switzerland, these numbers are much higher than one would hope for. But it's not limited just to high income countries. In fact, primary care burnout is common in low and middle income countries as well, with a prevalence very similar to that of high income countries. So the drivers, we can boil down the primary drivers of burnout across all physician specialties, but in particular in our primary care specialties to excessive workload, when the work demands are greater than the work resources. Time pressure, where there simply isn't enough time to do all the work that needs to be done. Years ago, as estimated, it would take over 18 hours a day for a primary care physician in the US to do all the work that's been recommended. 18 hours a day. A recent update on that indicated it would take over 26 hours every single day for primary care physicians for family docs to do all the recommended tasks. So there's a time pressure that's built into the nature of the work and primary care, particularly when we think about job demands and job resources. What's expected of our family physicians and the number of support staff and team members who are helping in sharing in that work. The third major driver is simply not feeling valued, and we know that physicians who do feel valued by their organization have much lower rates of burnout than those who do not. And then finally, I believe that among our nurses and physicians and other healthcare workers, there's a general sense of being disconnected from their mission, that the way they're spending their every day in terms of how they're spending their, what they're doing at work, it's not really what they imagined when they went to nursing school or to medical school. And it's not really where they feel they add the most value. One of the things I've noticed was that with the implementation of the electronic health record in my own practice, and I've seen this in many other practices in the United States, and I'll tell you, I spent 16 years in my practice looking forward to the day when we would have an electronic health record, because there are limitations to delivering care on a paper record. And then I spent the next 16 years really feeling pretty frustrated and constrained by the changes that were brought by the electronic health record. And this was partly how it was designed in the first place by the vendor, but also how it was implemented at the local level and how it's regulated at the country level. And so I observed what I've called the great work transfer where with the implementation of the electronic health record, work that might previously have been done by the receptionist, a pharmacist, a transcriptionist, a medical records clerk, all of that work got transferred to physicians. And as physicians, the majority of us took that work on. There's that underlying ethos within medical culture of the iron dock of we can do it. And we kept doing it and kept doing it until we couldn't any longer. And so what happened was we did have more of that time pressure. A study that I'll tell you about in a moment shows that there's two hours of EHR and desk work for every one hour of direct face to face time with patients. There's a cognitive overload. Our brains are just doing too many things at once. And we can't multitask. We can only task switch. And with each switch and task, there's an attentional blink. And all of that is what causes physicians and others to feel exhausted at the end of the day. And then there's simply task overload. And when our highest trained individuals are spending at least half their day doing work that does not require their level of training that someone else on the team could do if there was someone else on the team, then we know that we are wasting precious resources. So here's that study I mentioned. We did this in 2016. And we train medical students to do direct observation of physicians across four specialties, four different states within the US, and seven different EHR. So this is not dependent on one EHR being better or worse than another. And what we found was that these physicians were spending fully 50% of their work day on the EHR and desk work. Said another way for every one hour of direct face-to-face time with patients, these physicians were spending an additional two hours on EHR and desk work. And despite spending half their day at work on the EHR, our family physicians and internists, that would be our primary care docs. We're taking one to two hours of EHR work home every night, chart work to finish up, inbox work to finish up, orders to continue to enter, all of those tasks that now are part of the physician responsibility in the United States. And we call that pajama time, worth that physicians are doing late at night after the kids go to bed. But that removes that important time for physicians to recharge and has been a major driver of burnout. Just for clarification, the EHR is the electronic health record. And that has been what's replaced the paper record almost universally in the United States. And I know in other countries that's happening some but not completely might be happening in the hospital, not in the clinic might be happening in the clinic. And yet it might be something still to come. Now that data that I've shared with you so far, that's all pre-pandemic. But in 2020, when the pandemic hit, as we all experienced, there was a shift in the way care was delivered. And so we've been able to look at the entire user base of one of the largest electronic health record vendors in the United States and actually in the world. But we looked at their entire user base in the US. And we looked at the number of inbox messages that were coming from patients. That's one type of message that comes into the inbox. The inbox is where test results come, communications from other doctors come, system notifications from your organization come, and then patient medical advice requests come in. And those patient medical advice requests are the ones that take the longest for physicians to resolve because they need to research the patient's situation and review their labs and their meds and make medical decisions. Well, the number of those inbox messages increased abruptly in the spring of 2020, a 57% increase over baseline. Now initially, the number of in-person visits also went down. But over time, the number of in-person visits in the US has gone back up to the baseline. But the number of inbox patient medical advice requests have not gone down. And this has then turned out to be a second full-time job for many of our family physicians. Pre-pandemic, if you had more than 300 inbox messages of all types, not just patient medical advice requests, if you had more than 300 of those messages in a week, your odds ratio of burnout was six full of that if you had 150 or less. So that was the top quintile and the lower quintile. This is again, this pre-pandemic. Pre-pandemic, the average family physician in the US had over 100 inbox messages a day. So you can see where this volume of work, this work overload, this incursion of work into our personal time taking away from recovery time has been a major driver of burnout. Patients appreciate this access to their patients, but we haven't yet built the systems and built in the time for this additional work, this second job to happen. So what are some of the consequences of burnout? Well, burnout affects patient care. We make more mistakes. In fact, there's twice the risk of making a mistake if you're burned out versus not. This is true for nurses as well. In fact, when nurses and physicians are burned out, ICU mortality rates go up. When nurses are burned out, hospital-acquired infections go up. And patients notice when their health care professionals are burned out, and they are less satisfied with the care that we're able to deliver. In fact, among burnout physicians, there are twice as many patient complaints than physicians who are not experiencing burnout. What else should we care about burnout because of the impact it has on individual human beings on our colleagues? It is bad for our health. It's bad for our social lives. So among physicians, higher rates of disease and death when burned out, higher rates of divorce. It's also bad for our organizations. So physicians who have higher rates of burnout also have higher rates of malpractice claims. The cost of care that physicians deliver is higher when they're burned out. If you're burned out, it's kind of easier just to order some tests and refer the patient on to another physician rather than really staying with them and listening to the story. And then it's costly in terms of turnover. Physicians who are burned out at time zero two years later are twice as likely to have left their organization. In the U.S., every physician who leaves a practice cost that organization between $500,000 and $1.5 million to replace them very costly. So let's switch our attention to some solutions. What are some of the interventions that might improve the care environment? And let's look at these through a human factor's lens. So sometimes that human factor's approach will be implicit in the solution that I'm sharing with you. And sometimes I'll be explicit and call that out. I wanted to mention that there are at least two centers in the U.S. where there's human factors in healthcare. So at MedStar, which is in Washington, D.C., there's a national center for human factors in healthcare at the MedStar is one of our larger healthcare delivery organizations in the country. Likewise, at Johns Hopkins Academic Medical Center, there is the Armstrong Institute Center for Healthcare Human Factors. We know that there is an incredible need for having a human factor's lens on the technology that we use in healthcare on the staffing models, on the workflow, on the test distribution, and just simply understanding the work of our healthcare professionals. This is a quote from Herbert Simon talking about information overload. And he indicates, a wealth of information creates a poverty of attention. Many people have said that we live in that age of information and that we have an information economy. But other wise thinkers, I think, have improved on that and indicate it's not an information economy. It is an attention economy. The thing that is a scarce resource in healthcare today is our attention. In fact, in most family physicians, general insurance practices in the U.S., and I would submit in other countries as well, we practice in a state of persistent divided attention. Rather than being able to give our patients our full and undivided attention, we are constantly trying to multitask. And again, that's not possible. That leads to task switching, which leads to attentional blinks, which means we miss some of those important signals that patients are sending our way. And the idea that one can type the note while listening to the note, that one can put in the orders while talking to the patient, that is actually very hazardous activity and is very prone to error. And I think it's one of the many myths that have accompanied our evolution toward a very transactional notion of healthcare. So with a couple of colleagues, we've put together a measure, a measure of undivided attention. And this is an aspirational measure that I believe will be very helpful for healthcare organizations to guide their interventions for physicians and other healthcare workers. And this is a measure that can be extracted from EHR event log data. That's from the back end data of the electronic health record from the metadata, if you will. And so we have estimated that the outer envelope of the amount of undivided attention available to a patient is the number of patient scheduled hours that day minus the number of EHR hours during patient scheduled hours divided by patient scheduled hours. And I invite you to look at that QR code and look at this article where we talk about both the importance of undivided attention and how it can be used as a measure of health system function of unit function. So let's talk about interventions also, not only through a human factors lens, but also on the Stanford well MD well being model. And I like this model because of its simplicity. And it looks at the drivers of burnout or its inverse of professional fulfillment in three pie slices. Organizational culture, practice efficiency, and personal resilience. And we'll spend most of our time as leaders addressing those two pie slices in red, the things that are systems drivers of well being or of burnout. So organizational culture, this includes things like trust that healthcare workers have in their leadership, control that workers have over their local environment, the feeling of connectedness they have with each other, and the sense of meaning and purpose in work. In terms of practice efficiency, that's really driven by team structure skill level and size, and by how our technology either helps or hinders as we're going about our daily work. And then in that lower pie slice, I like to think of that as institutional support for individual self care. So does the way the policies and practices of the organization play out help or get in the way of self care? Are there vacation policies that allow physicians and others to fully unplug from work when they're away? Or is it like the majority of organizations that I'm familiar with in the United States, where physicians are still expected to maintain management of their inbox, respond to those patient medical advice requests, respond to all the other messages that are coming in, even while they're on vacation. So let's look at practice efficiency first. It's my observation that most practices, most physicians in most specialties, and in most settings, both inpatient and outpatient, can save three to five hours a day by reengineering the way the work is done, and by more strategically delegating work to an upskilled team member. Now I've had the chance to shadow family physicians in the UK have less experience internationally, of course, than in the United States. But I would say I'm pretty confident that there are opportunities in many practices globally to improve our workflow, to improve operational efficiency. I've listed some of the things here that can be helpful. And I'll mention just a couple as we go forward. One of the sites that I had the chance to visit is a clinic, a large clinic in Minneapolis, Minnesota, in the central part of the state. One of many interventions that they did, innovations that they had implemented, was line of sight. And so they built their clinic from the ground up to be efficient. And so this medical assistant who is responsible for the setup of the patient for rooming the patient and other aspects of the care, she can see the status of each of the exam rooms from her workstation. She's not blinded off in a corner. And so when she is needed for some element of patient care, she knows that right away. This is another setup. This happens to be from a group in Massachusetts in the US, where the physician and the medical assistant are seated side by side. And so rather than sending electronic messages back and forth to each other, which is very cumbersome and time-consuming and doesn't lead to rich conversation, they can just turn to each other as the needs arise and address questions and develop that stronger relationship. One of the groups in another organization found that by seating physicians and their teens in this kind of co-location, they've been able to save 30 minutes of physician time every day. Well, let's talk about workload and that unfinished work, that work that physicians or advanced practice clinicians carry with them throughout the day. When you see one patient, but you haven't finished everything for that patient, and you go to the next patient, and then because there's another patient waiting, you can't finish everything for that patient, and you go to the next patient, you have all that unfinished homework that you're carrying around. And that causes an attentional residue. And with all that work hanging over your head, it's harder to give your next patient undivided attention. And you just feel that stress building up, and your functional cognitive work space, it shrinks. Your active working memory shrinks. So it's important to build systems where you can close the loop of care at the visit. So for example, in the outpatient setting, if you can do all the labs before the visit for chronic illness care and prevention, and then you can wrap up the care by having the physician or ideally a teen member put in the orders into the electronic health record in real time during the visit, and then finish all the documentation during the visit. I used to dictate in front of my patients while we were together. Then when I left that room and went to the next patient, all the work for this patient was done. And that allows you to have less cognitive burden and allows you to work more efficiently. At the AMA, we've created a wealth of resources that are all free. And we have over 75 toolkits. We have one on doing pre-visit planning, which is a component of closing the loop of care, a way of engineering the workload, engineering the information flow. And you can go to that Steps Forward tool kit to learn more about pre-visit lab testing. I also recommend that people reduce the amount of work involved in renewing patients prescriptions. We recommend for all chronic stable medications, 90 days plus four refills, 90 plus four. This saves about 30 minutes of physician time and about 60 minutes of nursing time per physician. It also decreases the number of weeks that patients are without their prescription. And so it increases adherence to prescriptions. And you can learn more about that at the toolkit I've identified, and there's QR code for it as well. Another innovation is advanced team-based care with in-room support. This is at one of our large academic centers in California, UCLA. And they have trained clerical individuals to accompany the physician and in real time enter orders and begin to draft the visit note while the physician is able to give her undivided attention to the patient. They found that this model saved three hours of physician time every single day for primary care physicians for their equivalent of a family physician. This is the University of Colorado where they have done something similar. They found that burnout rates dropped from 53% to 23% in just one year. They also found that the capacity to see patients increase spontaneously to three and a half more patients per day that their physicians could comfortably see. They weren't mandated to see more patients, but they spontaneously just opened up more space because they were able to see more patients. They carried less work around with them all day long because they were able to close the loop of care for the patient at that visit. So if you want to learn more about some of these strategies, here's a QR code. And because we have over 75 individual toolkits, we've wrapped a number of these up into what we call playbooks. And you can learn about how each of these relate to each other through an abbreviated playbook. And in this case, we talk about how to stop doing unnecessary work, how to incorporate practice fundamentals, how to make the case to your leadership to make changes. We have podcasts and webinars that accompany most of our toolkits and they're all available online. So let's switch to organizational culture. And I want to focus on leadership here because leadership really matters. We know that the leadership score of a physician's immediate supervisor will predict the degree of burnout that that physician will have two years later. And this is even after adjusting for burnout at baseline and adjusting for age and gender and length of service and specialty. So leadership matters. And what some organizations do then is they measure the leadership score, that is they ask the people being led to reflect on their leader with very specific questions. If that leader's score is not optimal, then that leader is given additional training to improve their ability to lead. So what are some of the things that a high quality leader will do? They'll talk, they'll hold conversations with the physicians in their unit about career development. They'll solicit their members of their unit's opinion, ideas for improvement. They'll treat their physicians and others with respect and dignity. They'll give feedback and coaching. They'll recognize individuals for job well done. So we have then put together a wellness centered leadership playbook that again talks about the importance of wellness centered leadership, about strategies for building trust, strategies for giving and receiving feedback, and ways to prioritize clinician well being. And then we have associated toolkits, podcasts, webinars, and success stories, ways that these principles have been put into place in individual practices. Another example of leadership comes from this article in the New England Journal of Medicine from 2018, Getting Rid of Stupid Stuff, Melinda Ashton, a leader at Hawaii Pacific Health. And we then worked with Dr. Ashton and she wrote a toolkit for us on how to implement a Getting Rid of Stupid Stuff initiative at your institution. And so you can go there and find a step by step guidance on how you can help get rid of some of those policies and practices that may have made sense at one point, but have either never lived up to their potential or have outlived their usefulness. Along the same lines at the AMA, we've created a de-implementation checklist, a checklist of ideas of things that are policies that are fairly common that we believe can be de-implemented safely. We sent this checklist to one of our standard-setting organizations responsible for quality and safety called the Joint Commission. So we know, and they've reviewed it and we modified, so we know that it is consistent with some of the standard setting within the United States. And so we feel quite confident that these are appropriate sorts of things to consider de-implementing. So to conclude, I'd like to go back to some of those initial principles, those takeaways that we started with. One, while burnout manifests in individuals, it originates in systems. And so it's really important for us to focus our efforts at understanding and improving the work environment rather than understanding and improving the individual's ability to do yoga or mindfulness as important as those things are. We need to focus on fixing the system and that the way we'll get to better care for individuals, better health for populations at reasonable costs is to consider the well-being of our workforce. And then finally, I'd like to restate that quadruple aim as care better than we've ever seen, health better than we've ever known, cost we can all afford, delivered by professionals who find joy in their work as they commit to serve others. And I am so glad that a group of family physician leaders from around the globe are gathering to consider how do we deliver better care by having better systems in place and by taking better care of our caregivers. And that we are starting to look at the care environment through a human factors lens, a lens that takes into account both the enormous human capacity and our capacity for relationships, for empathy, for intuition, for knowledge of our patients. There's a lot of knowledge that's housed in the relationship that isn't housed in our paper or electronic health records. So the tremendous power within humans and potential, as well as our human limitations, that we can no longer have healthcare systems that are dependent on physicians being heroes and who are able to take on more and more and somehow heroically, heroically compensate for systems that aren't built for human limitations. Likewise, our nurses, our therapists, our other healthcare providers have a mission and they need to work in a system that supports them in living up to that mission, rather than having to daily pull on all those heroic resources, because we can't keep doing that day after day after day. So I'm so grateful that this group of global leaders is addressing the problem and I look forward to our conversation. Thank you so much. Thank you, Chris, for a wonderful presentation. Really enjoyed that. You've given us some thought provoking ideas. And we will now go over to our live question and answer session moderated by Professor Richard Roberts, Wonka, past president and member of the human factor score group. Over to you, Rich. Thanks, Maude and apologies to everyone for our short-lived audio problems. Though I was impressed that Chris's presentation and slides were so clear that I was able to follow them, even though I thought as an older guy, it was just my hearing going bad. So I'm thankful for the restoration of that and thanks to Harris. And we'd welcome questions that you'd like to put to Dr. Sinski. And Dr. Roberts, while we wait for people to either raise their hand or put questions in the chat, someone did mention that they were not able to see the QR codes. So I did put URL link in the chat for most of the resources that were mentioned. Yeah, thanks, Chris. The other thing that I noted was that all the articles and resources that you spoke about and cited are in fact free. There's no cost to people and that's certainly helpful, especially when people are sometimes having to pay excessive amounts for reprints and things like that. So that's appreciated. Maybe I could just start with a quick question. As you've talked with many physicians, certainly around the U.S., but in other countries as well, what differences are you seeing around burnout between specialties, between genders, between countries? Are there any sort of trends that you've noticed? Sure. Well, let's start with gender. Many different studies have shown that burnout seems to be worse for women physicians. And there's some evidence that the EHR is more burdensome for women physicians. That is, women spend more time on the EHR than men. Women have more workout kind of work than male physicians. Women do more work on vacation than male physicians. And how much of this is sort of culturally induced and how much is how that environment differently? I think we don't know. There was an intriguing study that showed that it's not been published yet, but it's been shared with me that inbox messages are sent to women physicians less well-matured, less well-researched than the inbox messages that are forwarded by the staff to their male physicians. So that's a gender difference. Internationally, my experience has been primarily to visit and shadow three different primary physicians in the UK. And I was impressed with the amount of community social services that my colleagues in the UK had compared to what we do. And there was a tighter connection with what we would consider public health or community here in the UK than here. And the EHR was more fit for purpose. EHRs, they had several that were in play and they had been designed by physicians or physicians. So that was more, I think, less burdensome. We know that looking at all of EPIC's clients, documentation in the US is four times as long as documentation in all of their international services. Meaning to me that physicians in the US live in a very different payment and regulatory environment than those some of our colleagues in another country. Thank you, Chris. I don't see any hands up yet or questions in the chat box. One thing that I might raise while we're still sort of getting our questions developed, if we are, is we have all these different systems around the world and I've visited with many, many doctors in their practice is actually in over 100 countries now. And there were several things that struck me. The first was our systems of care are quite different. I mean, even within the United States, it's quite different. You might be in a single-handed practice, you might be in a group of 5,000 doctors and each of those cultures can be quite different. But at the same time, you're dealing with broader societal differences, expectations. What's the health system supposed to do? What's its role? And I think that makes all of this a lot more complex. My experience, for example, in the UK or in Scandinavia is that the public health system just is assumed to have a whole series of responsibilities that we don't really expect them to take on in the US. And so I'm bringing this up because I think our challenge is we can do a lot in our practices and many doctors have been interested in trying to improve things. But at another level, we've somehow got to have an impact on the broader systems around the organization we might work for or the society at large. What advice as a leader would you have, Chris, for helping doctors with that kind of challenge? Sure. I think one of the earliest studies around professional satisfaction, it was a study done by the Land Corporation identified that a physician's professional fulfillment came from being able to competently care for patients. That is to be working in a system where they would meet the patient's needs. And so when the system is dependent on individuals solving social determinants and health issues at a one-on-one level in the office structure, and it's a physician without a medical assistant or a nurse or a social worker, it's just a situation destined to fail. Whereas, yes, the system is designed so that there are, there is a strong stable team, tightly related to the physician delivering the care, and then there's an extended care team, for example, of a social worker. And they also include others, like the pharmacist, who can meet those social needs of the patient, then the care is better, and the professional fulfillment is better, the work is, there's less burnout. Something you brought up, Ed Roberts, makes me think about boundaries. And I think in the U.S., we are less good as physicians at setting boundaries on our work. And we know that in a couple of, some data points. So we just published a study about at risk work hours. And the average full-time position in the U.S. works 54 hours a week in the U.S. compared to 40 hours in the general population. And that's at a level that the WHO has found is associated with greater risk of stroke and coronary disease. They think the issue problem that people aren't as aware of is 25 percent of U.S. physicians work part-time. But what that really means is they're getting part-time pay still doing more than full-time work. So an 80 percent FTE physician in U.S. still works 46 hours a week. So they make a reduction in pay to virtually reduce their hours, but it doesn't proportionally reduce. And then our physicians are not reducing their piano time. So they're moving more of the patient care to the unreimbursed virtual environment. And so we have this part-time graph in the U.S. We also did a study of vacation behaviors in U.S. and my guess is that this is quite different than in other countries. And I'd love to hear from others about this. But we found that 70 percent of U.S. physicians did some sort of patient care work on a typical vacation day. And a third did at least 30 minutes a day on a typical vacation day. And people did that at the same time they were taking generally three weeks in the U.S. and the majority of physicians don't have full inbox coverage when they're on vacation. And so they feel obligated because their patient care needs continue. And if there's no one else who's responsible for addressing those needs that come through the inbox then the physician as part of their mission and their personal sense of responsibility is doing inbox work. My guess is that those numbers are not typical of most other countries. Although I do love to hear from people who practice in other countries to know what that means. Certainly if there are folks from around the world that want to offer some insights that would be great. There was one question that came up in the chat box from Lori Wolf just asking whether you had any tips for how to justify to our organizations the extra cost that we might incur by using a scribe to help do the note-taking while we're consulting with patients. Right. Right. And I would broaden that and move away from the term scribe which some people kind of trigger this notion of medieval and disrespect to assistance and that can be documentation assistance that can be assistance with other clinical staff. And the majority of primary care physicians in the US spend the majority of their time on tasks that do not require their medical school education. Visit note documentation, keyboarding in the orders, doing some of the patient education activities, doing some of the closing of care gaps. All of that could be shared with a stable team who worked with that same physician. And I would say in no other industry does the highest trained individual spend the majority of their day doing work that another individual could do and have it be considered a business model. Or did the problem has been as physicians and that iron die, so we just taken there is there are multiple studies that show that if you add an additional member to your team, if it's a medical assistant, seeing two more patients a day covers the cost of that additional step. So going from a half of an MA to one and a half and you will nearly only remember since you can see but you only need to see two more patients a day to cover the cost of the individual. If you hire a nurse, it's generally three or four more patients in a day that would cover the cost. So the cost issue, the business case is very straightforward and solid that you will see many more patients a day for that additional staff and it will go beyond the cost of that but more importantly, it has other benefits in terms of the patient experience, the quality of the care, the physician burnout and therefore the physician's attention and turnover among physicians is very expensive to the organization that has occurred 800,000 or more per physician. There's also a sense of interpretation. There's $80,000 in excess health care expenditures in the year when the population of patients loses their primary care positions and that's because they go to the ER instead of the office, they have more tests within your physician who don't know them as well. So patients and operators end up paying a lot of additional when the continuity between patient and physician is lost. Thanks, Chris. Fabulous job. Great answers. Let me hand it back now to Dr. Nauta to help us wrap up in our last minute or so. Yes, so thank you Chris and Rich for the inspirational exchanges you shared with all of us. Ladies and gentlemen, in sum, we've seen that burnout is common among worldwide family doctors group for you and your family doctors. There are some useful tools out there in this webinar Chris presented some of these tools that can reduce workload, burnout and focus more on our attention. That's a scarce resource. These are the tools for day-to-day practice and leadership around the organizational culture and systems change and that is precisely the aim of Human Factor Science, built systems that make your work easier and support your own well-being and that of your team. So integration of this science, adapting it and weaving it through your primary care systems locally, that is what is advocated by WHO for the next decade. And as you do so in these beginning years, we hope to meet all of you again in one of our next WONCA webinars on human factors and primary care, exploring more tools. Thank you very much for WONCA head office, in particular our chief executive, Harris Liefriedakis, for supporting us in setting up this webinar and we from the Human Factor Score Group say goodbye to you all. Thank you for your attendance. We wish you a good continuation of your day and evening. Bye for now.