Well, good afternoon, everyone. Do you have my slides? Okay. Let me back up. Here we go. Yeah, my name is Dan Cole. I am your moderator, and it's a pleasure to have been asked by Helen to moderate this panel. It should be a really outstanding panel. When we had our early discussion, there was a lot of different opinions, and so we hope to generate some of that and hear from you all. This kind of bubbled up to Helen and CMSS from my role as president of the Anesthesia Patient Safety Foundation, where we were concerned about workforce issues being kind of a top patient safety priority. And although that was the genesis of this panel, it has proved to be a much, much bigger issue. The core question that I would like to ask is the next generation, actually the current generation of the healthcare workforce, will we meet the needs of the American population? I'm not entirely bullish on an answer to that question. I think we've got some challenges ahead. But to put that in context, here is an excerpt from an article 30 years ago, and this question has been around for decades. But in 1993, basically I quote saying, in both numbers and competency, the physician workforce does not match well with the nation's healthcare needs. So it's not an old question or it's not a new question, but it does feel like a new complexity to the problem. And there's a lot of issues as we start to address taking care of the American population and actually taking care of us so that we can have vitality as we work to take care of patients. And here's just a few of them, and I could have scores up here. But everyone knows we have an aging population that carries a chronic burden of disease or burden of chronic disease. We have an aging workforce, and that workforce is going to be retiring out of the workforce. There's a lot of issues about burnout, moral distress. Employment models and private equity are here, where basically physicians feel like they have lost agency. And that has changed how they feel. And we'll hear about unions from a firsthand experience here. The pandemic certainly did not help. We have people even in their 30s, 40s, and 50s exiting the workforce. And a changing expectation, probably better expectations for work-life balance of kind of the new generation. No longer when you go into medicine 30, 40 years ago was an expectation that I'm going to work 12-hour days. I'm not going to see my kids. I'm not going to see my spouse, et cetera. I want better work-life balance, and my hours at work are going to be less. Let me introduce our panel. And I'm going to make very quick introductions, even though they each deserve a long introduction, because I think you want to hear from them and not me. I have one more slide after this. We have Atul Grover, Executive Director of the AAMC Research and Action Institute. He's going to talk about the current state of physician shortages. He's an internal medicine physician, health services researcher, and nationally recognized expert in health policy. He has experience in healthcare finance and applied economics consulting, and he's previously worked for the U.S. Public Health Service Human Resources and Service Administration. After Atul, we will have Jessica Dudley. She's going to talk about the path forward, and I love this title, shifting from a vicious to a virtuous cycle. She's the Chief Clinical Officer at Press Ganey, and she leads efforts to support organizations in increasing physician engagement and improving patient care outcomes. Specific areas include clinical care redesign, addressing clinical clinician burnout, and advancing professional fulfillment. Previously, she was the CMO and Vice President of Care Innovation at Brigham and Women's. And then last but not least, we're going to have a real-life experience about forming a union. We have Philip Sassenheimer, who is a fellow in Hospital and Palliative Medicine at Stanford, and the residents really are kind of the nidus of union formation. There are unions in the physician market. Certainly, there was recent news about what happened at Elina, but certainly the residents are most active in collective action. And again, he's going to give us a real-life experience about work conditions, burnout, patient safety, and basically a quote from him taken from the Stanford Daily there that I think will synopsis his presentation. The fight for a health care system, or we are fighting for a health care system that values people over profits, and we refuse to settle for less. So with that, I'll turn the stage over to Atul. Thank you very much. All right. Good to see everybody. And thank you for having me, Helen. Thanks for letting me enjoy your company on a rainy Friday afternoon on Veterans Day, and thanks to those of you who have served. What? If I can finish this. Nope. Nope. There we go. And happy to share these slides, any data with anyone. Just want to give you a current state of kind of what we know about the workforce. But first, so my disclaimer is I work for the AAMC. We represent the 158 M.D. granting institutions in the U.S., a dozen or so in Canada, 400 major teaching hospitals and health systems, including children's hospitals, VAs, public hospitals, et cetera, and about 70 academic and professional societies. So many of your specialties either in and of themselves or their academic counterparts or both are members. And through that, we have about 200,000 faculty, another 150,000 residents and fellows, and almost 100,000 medical students. So at any given time, roughly one-third of the physicians or physicians-to-be are actually in these academic centers. So the other thing is these are large institutions, even though the health systems and hospitals are about 5% of all the clinical systems in the country, they provide 20% to 25% of all the clinical care. And moreover, certainly a lot of the highly specialized care, as you would expect, is delivered in this handful of institutions, level one trauma, burn units, burn beds, pediatric ICU, but increasingly a lot of the other loss leader services that many of our institutions have trouble staffing, like psychiatric inpatient beds, are heavily concentrated in academic centers. The interesting thing also is that when we talk to residents now, surveys show that about 70% of them that are finishing training, they want to be employees, right? So they're looking for a different balance. And I would argue that that generation of physicians that Dan had mentioned working 12 hours a day was generally a white guy married to a woman who took care of everything else, right? So if you remember Marcus Welby, Quincy, I think that was the model that's gone, right? And probably for good reason. And we know that a lot of this care is even on the outpatient side. Most of our institutions are 50%, 60% outpatient care, not inpatient care. If you look at the total shortages, as Dan was saying, this is largely driven by an aging of the population. We tend to put this into a range, roughly, of where all these various scenarios of more NPs, more PAs, more entry in the system, healthier people. We kind of put all that stuff in there, and we always come up with a shortage since the late 2000s. And that shortage might be as small as 30,000, 40,000, might be as high as over 100,000. But, again, really driven by the aging of the population and the fact that the baby boomers apparently refuse to die. So if you consider health equity, this is even worse. And we know that in primary care, there are shortages that everybody gives a lot of attention to. But, in fact, if you add up all the specialties, it's a greater share of the shortage. And those shortages become worse if people access care at the level of white, suburban, employed Americans. If everybody accessed care at that level, the shortages would be much, much worse. So I like to sort of dispel myths and give you a little contrary view of things. And, certainly, it's not just primary care. We have record numbers of people applying to medical school. The challenge is that we haven't had enough residency positions to actually accommodate growth in the physician workforce because that ends up being the bottleneck most of the time. And, again, these are lumped together. I hate doing individual specialty projections. Anybody remember anesthesia in the 90s? Yeah. So there was an article in the Wall Street Journal and one in the New York Times talking to, I think, IMG anesthesiologists who were driving taxis, right? And so we saw the applications from USMDs plummet. At the same time, so I graduated from med school in 95, we were all told, if you go into primary care, then you will have a job. You will all be employed. And if you're an interventional cardiologist, which barely existed then, or a radiologist, good luck finding a job. You may be out there driving a taxi, right? And students respond to this. When you do that, you get kind of a weird effect, but if you collapse all this stuff, you also hide things, right? So it's important to understand that these are not all specialties. So the other specialties, emergency medicine, pathology, radiology, anesthesia, you actually kind of mask some of the larger shortages there because, and I'm putting up HRSA's workforce projections because they're public, they do them by specialty, so I can't get blamed for them, but they projected there are 14,000 too many ER docs in 2034, 4,000 too many critical care physicians, 500 too many colorectal surgeons. I don't actually believe that, right? So those surpluses I don't think will materialize, certainly not to that level, and that's a challenge with projections. Look at historic utilization trends and move them forward. And, of course, that sort of reaction of the learners, these are people going in for a 30-, 40-year career, hopefully, and so when ASAP published their findings back in 2021 and said, we think there will be 8,000 too many ER doctors, well, guess what happened? And that's just HRSA's projections. This is what happened to U.S. seniors that were applying for emergency medicine, right? All of a sudden you had 500 unfilled spots because they were spying to the market. So even by doing the projections, it's like putting your thumb on the scale. So I am always very wary of doing this specialty by specialty, but even in the way that HRSA does it, and most of the models have been limited, we're building one with the RAND Corporation right now. We will co-own that. It will come out next year. Hopefully, we can take into account not sort of physicians over here, everybody else over here, but how do they provide care together? Now, I would say that as much as we talk about care in teams, when I've talked to the PAs and the NPs and others, they are often providing care in parallel, not in teams, right? So the NPs and PAs are out there providing care independently in many cases, especially in primary care. One of the challenges we have is that even if you're in a large health system, yes, theoretically, I could get patients seen by others, not necessarily physicians, and it would be appropriate, good care, but people don't know how to triage themselves. We don't triage everybody. There's not a national line we all call with one entry into the system, and so you have to think about how do you get from A to B to C, which my friends in the Obama administration, actually lots of administrations have said, no, no, no, no, we had a tool go on this article. Thirty percent of this is waste, so we don't need 30 percent of the physicians, and we just got to get people to the right place. We got to get them to lose weight, and now we've actually got drugs to do that, but let's see what happens, right? And if everybody just behaves, they will all die in their sleep at age 95, and we will not need surgeons or oncologists. Yeah, maybe. But in the meantime, HRSA says I'm going to have 15,000 too many PAs. I don't believe that, right? They're not all going to go into primary care, so you end up with this wacky stuff, right? And I think in primary care in particular, this is a challenge, because HRSA would say we've got about a 6, 7, 8 percent shortage in family medicine. The next decade, 20 percent shortage in internists. Why? Because we're all becoming geriatricians, right? If you think about as we age, our patients age, and young people opt out of having a regular source of care that's a physician because we really are kind of annoying and not very convenient. So they're going to go to Amazon, and when they actually need us in their 40s and 50s and 60s, they're there because they're complex. But, you know, this idea that you're going to have 100 percent too many nurse practitioners is nonsense, right? They will go into other specialties. They will figure out how to take up care, and there's a lot of elasticity in the nursing workforce historically. We have not seen that in the pandemic and post-pandemic years, where nurses would just happily reenter the clinical workforce if the wages were high enough. So it's a little difficult to predict their behavior as well. But, again, in a lot of our surgical subspecialties, the absolute number is decreasing, right? Not the per capita numbers. The absolute number of orthopedic surgeons decreases before it goes back up again, and that's a challenge. Because if you think about those older patients and the services they use, orthopedic surgery, oncology, you know, cardiovascular care, neurology, right? So now what happens is, yes, if we do a great job keeping people healthy, they won't need the services now, but they will probably need them eventually, hopefully much, much later. So now, you know, my dad had his first cabbage at the age of 49, revascularization about ten years later, right? I'm on statins, and we all get stented, and hopefully we avoid that. If I get lucky enough, I'll live long enough to get prostate cancer. Hopefully they won't do anything crazy there. And then I'll be really lucky, and I will end up with Parkinson's or Alzheimer's. I don't think you're going to save any care, right? It's just moving that care later, adding some care to it, which is why historically in public health we always use the example that cigarette taxes are actually good for the economy because, you know, we collect money, people keep smoking, and they die early, and so they're less expensive to take care of, right? That's the public health example. Part of this is you're saying, okay, so why should we listen to you at all? Well, on the supply side, on the left are HRSA's estimates. They tend to over-project supply. They think everybody's going to be working full-time, more hours, and we're going to magically train more people. WMC estimates, my colleagues in workforce studies, have been a little closer, but the demand-slash-need-slash-utilization Venn diagram is sometimes very hard to predict. Somebody was asking about distribution. Here's the other thing. We put out a rural healthcare brief. If you go to amcresearchinstitute.org, you can find these briefs. They're just a couple of pages. But actually the actual numbers per capita of family docs in rural areas is higher than it is in urban areas, right? And in some areas, like emergency medicine, it's much, much lower. But here's the thing. If you look at utilization, this is just Medicare beneficiaries, a data we had handy, but it's true across most insurances at most age groups, that utilization, particularly in primary care, is about the same per capita in rural and urban areas. Let me say that again. Utilization is about the same in rural and urban areas. What the rural areas really seem to be having trouble with right now is pre-hospital care and subspecialty care. And I would say, and this is my opinion, we have actually been trying for 100 years to put a primary care doctor in every county. I would argue it will never happen, and I'm not sure it's actually going to solve the problems that people are trying to solve, which are much more related to social determinants. States are doing all kinds of wacky things with how they legislate care, and we know that med students are responding. This is another brief we did basically saying, you know, USMD seniors are disproportionately avoiding those states that highly restrict reproductive health care or transgender rights. So, in short, we've got a challenge. How this all plays out, I think, and part of it will be how we would like it to, part of it is really going to be very organic because we are an ecosystem, not a system, in health care. And I think we have to think carefully about the ways we actually address these issues, and I know Jessica and Phillip are going to talk a little bit about this because just complaining about the problem is not going to get us anywhere, particularly complaining about the problem with a highly educated, highly paid workforce when other people are really having problems. Other thing is mental health. We need to recognize there's just chatting with somebody. There are about, how many psychiatrists are there in the US? 200,000? About 35,000, 30,000. There are about 100,000 PhD psychologists. There are 500,000 social workers, LCSWs, who are providing all of that care that none of us can seem to get without paying out of pocket, right, and essentially paying for concierge care to a social worker or a counselor. So we have to think about how we're using these other people and get better data on it. There's a gray market in mental health. Trying to figure all this out is a little bit tough. But here's the other thing. We know that the proportion of outpatient care being delivered, particularly in primary care but also in specialties, is really growing with nurse practitioners. Something like 44% of the primary care visits and counters are being provided by non-physicians, which may be okay, particularly when they're in respiratory infections, acute urinary tract infections, acute back pain, right? That all makes sense, less so if it comes to eye care, cardiac care. But, again, how do I get the right patients to the right provider is not something we're going to solve in the next decade. So have fun. We're going to keep watching this stuff. You can find more information there. There's your thank you slide. Jessica. Okay. Can you guys hear me? Yes. That was fantastic, and I'm going to, like, shift us a little bit. What I'm going to share with you is the data that we have. So I work for Press Ganey. We actually survey an enormous number of patients, which most of you are probably aware of, but we also have the largest healthcare database for employees in healthcare. I am going to share with you some of our employee data, but I'm going to focus on a physician and a little bit on the APP data as well. And I think it's going to be a really nice kind of complement to what Atul just walked us through. So I called this the path forward, shifting from a vicious to a virtuous cycle. And the vicious cycle right now, I think, you know, Dan had that nice circle with all the circles that kind of pointed to all the challenges facing the healthcare workforce right now, for sure. It hasn't been great for patients either the past few years, and I'm sure any of you who've tried to access care or have a family member trying to access care, it's been challenging. So the vicious cycle is when patients are struggling to get care. All of us who are in healthcare are doing it to try to make sure patients have great care and access and excellence in care. But if we don't have the resources to be able to support and deliver that, then that creates, and Philip will probably talk about this, some moral distress, moral injury, frustration, which is going to be felt by the patients. And that's this kind of downward cycle. And the data really supports this. So this is patient experience data. We measure this in all settings. This is in-hospital likelihood to recommend, and you can see this pretty dramatic downward trend. Now, there's a good news piece of this, which is at the very end in this last few months, we're seeing a real uptick. We are nowhere near what we're used to for, you know, in a positive place, but it looks very real that we are kind of coming out of this very low spot where we've been for the last couple of years in the pandemic, and it's starting to look better, at least the patients reported experience of care. This is inpatient emergency department. This trend is worse and lower, but also coming up, and then for the clinic space, we call it medical practice, it's actually higher overall and has actually trended slightly upward, so that's good. This is the workforce. This is called engagement. We have six questions that capture an engagement score, which is really the workforces going above and beyond. Are they willing to go above and beyond in the work that they're doing? It really is about connection with the organization, the tools shared, how many physicians are working in hospital settings, so this is showing just both the employee data, that's the lighter purple, and then the physician data, and the one thing that's interesting during COVID, that's the gray block period, there was an uptick initially in engagement for physicians, and this was early in the pandemic. People felt, physicians felt that they were very involved in decision making, that they felt proud of the care that was being delivered, and they were very committed. If they stayed in for COVID, they were staying in, in the beginning part, but then since that peak, we've seen this really dramatic downward trend. Two of the questions that we ask for engagement are about likelihood to stay. Would I stay here if I got another job offer, and do I still think I'll be here in three years? This is the first of those questions, and the reason why I put this in here, you can't probably read it from the back, but every single job profession has gone down, and this is actually this past year, the year before the drop was even more dramatic, so you can see, this is every job profession, the clinical providers are the pink bars on the right of the slide, and that those absolute scores are the lowest, and higher is better, this is a one to five Likert scale, and you can see that those professions score this question significantly lower than everybody else on the left, and they've dropped greater, so physicians and APPs have had the biggest decline in this past year of would I stay here, so less likely to want to stay, and then the far right are the lowest overall, so I don't think there's a surplus right now. I agree with that. Okay, so this is not the physicians, this is the rest of the workforce, but we're all in this together, and that is definitely one of the points that I want to make, and I do think like physicians, providers are really in a position, it may not feel that way, and I think when Philip talks, you know, he's going to have an interesting different perspective, but they are the linchpin right now, I think, to helping shift and turn things around. This is turnover for every other job profession right now in the healthcare workforce, and so you can see one in five left last year, up to 25 percent of the kind of nursing support roles, and then almost 20 percent of RNs are turning over. This is why this is important, this engagement metric, so when employees kind of score these engagement questions low, we call them disengaged, they have a 30 percent likelihood of turning over, so when they don't feel the pride in their organization, when they don't think that they would recommend friends and family to get care there, when they don't think they're going to still be there in three years, their turnover rates are super high versus those that are highly engaged and committed to that organization, their turnover rates are so much lower. I'm going to shift, and I had a lot of data, and I didn't include all of it because I felt like this is Friday afternoon, there's a lot of data, but I'm happy to share more of it with you. This is the data we have on the perception of safety culture by the workforce, and again, just to, I didn't say this number before, but we're surveying about 1.6 million employees, that's what's in this database, and about 140,000 physicians and 40,000 APPs, so those are the numbers that I have here, so these small changes, this 0.01 and 0.02, they're actually significant for this cohort. The overall perception of safety culture by the workforce, we saw that it was actually beginning to improve before COVID, that's the first aggregated graph on the left, but then, as you can see, with COVID, that perception of safety culture went down, and then there is some hope, and this past year, we've seen this beginning of an uptick, which is great news. When you break it into, that's 19 questions that make up a safety culture survey here, and it's broken into three different cohorts, so prevention and reporting, that's that next one, and you can see this uptick, and that's actually really great that we are seeing more of the workforce feeling comfortable and having systems in place to be able to report when things are not going the way that they should. The one that's really concerning here, the two that are more concerning here, so one is pride and reputation. This has continued to trend downward, and this is very concerning, especially in the physician and APP data, where this is an even more dramatic downturn, and then the last, and these numbers are lower overall, is resources and teamwork. This is staffing, which, you know, we know has been a challenge, and in fact, nobody has enough staff right now. Who's in it? Are you guys in organizations, like, or affiliated with hospitals? Some of you, but who feels like they've got all the staff that they need, right? Nobody, and even places, you know, that have reduced their turnover, maybe from, like, 30% down to 20% for their nursing staff, they still have a tremendous number of vacancies. I'm going to shift now to physicians specifically, and this is a set of questions that we ask, and the metric is called alignment. It's six questions, and it's about really a physician's connection with hospital leadership, and this includes feeling like leadership is communicating with you, and that you're involved in decision making. It includes the communication style of leaders, and you can see, if you look at the white numbers, that's the mean score, and it has been trending downward over these past few years, that 3.71 is this most recent, that's the calendar year ending in 2022. The other thing, though, that's interesting about this, so in addition to the downward trend on alignment, there's been this spread, this widening of the 10th to 90th percentile, so there are some organizations, a lot, actually, that are really struggling with this. They have very low engagement and very low alignment scores, but there are plenty that are still doing well or improving, that's that top decile, and we've really looked at this data to really understand what are they doing that looks different? What's happening in those that are higher performers that are doing better with their employees' perception of alignment? These are the five areas that those organizations that are doing better, or if you're doing worse and you want to move the needle, this is really the focal areas that are the areas of opportunity to improve both alignment as well as engagement, but this is very much focused on alignment, so it's respect, and I know that may sound soft, but lack of staff in my clinic is a disrespect for me when I'm then being asked to do all of these other things, and that is definitely one of the challenges here. Leadership actions, I meet with folks around the country, and I think a big chunk of this leadership action piece is around communication, and you as hospital leaders, most of them are working as hard as they can to do the best they can, and then they see these downward alignment and downward engagement, and a lot of this has to do with transparency and communication. Involvement in decisions, like we have to involve the physician workforce in decisions because they are going to affect them. Recognition, this may seem like trivial, but actually the entire workforce really needs to know that the work they're doing is making a difference, and recognizing them for that is really important, and then I put this last bucket as business practices, and it's a kind of a catch bucket, but it includes things like me feeling that the organization is making good choices and supporting patients the way I would like patients to be supported. We have another metric that we use. It's called resilience, and it's two parts to it. It's finding meaning in work and being activated, and it's being able to then recover, go home, and decompress, and that set is what makes up our resilience score, and for most of our workforce over this past couple of years, we've begun to see a flattening out. People's activation, if you're still working in healthcare, for the most part, you're finding meaning in your work. You're connecting with patients. The place where we're really struggling is the ability to go home and recover, and that's what these decompression scores are, and you can see here they are downward trending, especially for physicians and APPs, so nurses have had an uptick, but the other two have not. I threw this slide in because we are not all having the same experience. I did not include my diversity slides, and I'm sorry about that, but I will tell you that the underrepresented minority workforce is having a different experience just like minority patients are having a different experience, and it's not as good an experience. I put this in here because we have a big data set. This is 30,000 or so female and 34,000 male physicians, and for these clusters of metrics that we have, I've mentioned engagement, alignment, resilience, and then the bottom one is diversity and equity. There's a huge gap between female physicians' perceptions of these and male physicians' perceptions of these. This is kind of part of my argument as to it's actually all connected, so you all probably would agree that if the goal is to have patients feel great about their care and want to recommend the hospital, we probably need a workforce that's highly engaged, and this is the data that shows that direct correlation. The first graph is showing that if your goal is to get patients in that 80th percentile of likelihood to recommend, that matches, that correlates with a workforce that's in that high quartile. Similarly, from a safety culture perspective, to really get to that high safety culture of prevention and reporting, that's happening far more often in organizations that are in that top quartile for engagement, so my three take-home messages are just it's all connected. Patients, the experience of the workforce, the safety culture, everybody matters, so we can talk about physicians and APPs, and we need to talk about minorities and women, and we need to talk about every job profession in the workforce, and then finally, most of your organizations I know are collecting the data. It is not a one-size-fits-all fix, so segmenting the data is really the path forward. Thank you. All right, let's see if we've got the clicker here. Okay. Thank you all so much. It's a pleasure to be here, and I'm so grateful to CMSS for inviting me to speak. As Helen or Dan introduced me, I'm a fellow in palliative medicine at Stanford, but I'm really here today in my capacity as an organizer with the Committee of Interns and Residents, which is the largest physicians union in the country that represents residents and fellows, and I'm thrilled to see the plenary session today be about the importance of emerging workforce issues, and I loved hearing Jessica talk about the disengagement that a lot of physicians and healthcare providers in general are feeling in the workforce, and I think this is something that, as fellows and residents, as we stand on the brink of our careers, we feel very intimately, and we look out at a landscape and a healthcare system where we don't always see a place for ourselves, and so I want to talk a little bit about the history and the context, the material context that has changed our profession over time and reflect on what we could do to advocate for ourselves. So the practice of medicine now and our relationship to the healthcare system as a whole is very different than it was, you know, 100 years ago, obviously. In the 1990s and again in the 2010s, we saw a surge in mergers and acquisitions and in consolidation in the healthcare marketplace, both horizontally with physicians groups buying up other physicians groups, but also vertically with hospitals and insurance agencies buying up physicians groups as well, and the largest employer of physicians now is actually Optum, which is a subsidiary of UnitedHealthcare, an insurance agency, and so our relationship to the healthcare system has changed in a fundamental way, where we used to be, you know, very authoritative figures and be, you know, owners of our own practices. Increasingly now, we are employees. This has been taking up a lot in the news. CVS recently acquired primary care clinics, I mean, the $10 billion acquisition. I don't know if you saw it. Amazon obviously purchased one medical, but they also recently announced a $9 a month subscription service for primary care services, and Walmart has also expanded their own telehealth services. So we're seeing entry of a lot of, you know, multinational corporations that haven't historically been interested in healthcare into this sector, and as physicians, we are people who are going to be taking these jobs, and I think it would behoove us as a profession to reflect on our relationship to our employers. Another thing that's been in the news a lot recently has been the entry of private equity into healthcare. A lot of these buyouts that are happening by private equity firms are financed with large amounts of debt, and they are expected to return a profit in short time, as I'm sure all of you know. Relevant to residents and fellows was the closure of Hanneman Hospital a few years ago in Philadelphia, where we saw a private equity firm purchase the hospital system, sell off the real estate, and then the hospital system was left behind with a lot of debt and wasn't able to meet its financial obligations. And not only did the hospital close, the residents and fellows now had to search for new positions. So this is something that's already having real world impacts, and I know a lot of people are worried about what it means when increasingly profit-motivated companies are entering into healthcare and how that might not only affect our working conditions but also affect the care that we can provide to our patients. Anecdotally, I saw an investor presentation from a private equity firm—sorry, a physician emergency medicine group owned in part by a private equity firm, and the strategies that they talk about to generate further profit involve decreasing staffing ratios, involve cutting benefits that physicians have historically enjoyed, including differential pay, things like that. So I think a lot of people are understandably worried about what this means not only for our patients but also for us. And there's cause for concern. It's hard to know a lot about what is happening in these private equity deals because they're by their very nature private, and a lot of them aren't reported to the FTC. But the estimates suggest that the total valuation of deals has increased from $40 billion to $120 billion in 2019, and it's only expected to grow, as in the post-pandemic market a lot of these firms are flush with cash and healthcare is looking like a prime place for investing it. And so what does this mean for us as physicians? It means that increasingly we are employees, and where we historically owned our own practices, now we are employed by other corporate agencies. And that's not to say that that's a universally bad thing. I'm not trying to make a value judgment about this, and like Atul said, I think many people prefer to be employees. But I think the thing that we have to reflect on as a profession is what it means when we are now economically dependent upon another organization, and when a hospital system or one of these insurance agencies enters into financial straits, what will that mean for our profession, and what will that mean for the care that we're able to deliver to our patients? We've lost a significant amount of power in the healthcare system as a profession. I think it's interesting to reflect upon historically how our own professional societies talked about these issues. In the 1930s, the AMA, in response to some early corporatization of medicine, wrote that where physicians become employees and permit their services to be peddled as commodities, the medical services usually deteriorate, and the public which purchased such services is injured. And this is by no means an endorsement of the AMA in the 1930s, and I don't think that this is an accurate reflection. It's just more to show us how far, how drastically things have changed. And I don't know that our self-concept as a profession has really kept up with that. I don't think most of us in medicine think of ourselves as workers, especially people who are leaders in medicine. I think we think of ourselves as educators. We think of ourselves as scientists. And I think there is some professional arrogance, to be honest, that we have towards our position as workers. And we look at other groups that are unionized, like nurses. We look at groups like environmental services, workers, and we say, well, this isn't for us. That's not what we're about. And what I would ask is what's different, right? What's different about physicians? We are now in a contractual relationship with an employer where we no longer get to set the terms, right? We don't get to decide how many patients we necessarily see in a day, how long those visits are, how frequently we're going to see our patients for follow-up. We don't have input on the corporate governance strategies, on the corporate strategy, what payer mix is my clinic going to accept, right? And I think a lot of people feel frustrated by that. And they're now the end executor of a health system that might be you know, not up to the standards that we hold for ourselves professionally, but we don't have any control over that system. For example, you know, when I discharge a patient who's homeless to the street and I tell them, I'm sorry, you know, our hospital closed its outpatient pharmacy, so I'm going to have to trust that you can make it to Walgreens to get your prescription. I'm doing something that transgresses my morals, but it's not a decision that I have any say in. And so, you know, this is not something obviously that is the fault of hospital corporations alone or the employers of physicians alone. A lot of this obviously has to do with the insurance industry, but I think it's important for us to reflect on the way that the practice that we are in right now is very different than the practice that we were in historically. There was a great piece in the New York Times that I'm sure all of you read that I think reflects a lot upon this, the moral injury that people experience when they are in a situation that they deem to be immoral, but they don't see a path out of it. And the question that I would have, you know, for Jessica and for all of you to reflect on is people are disengaged at work. People do feel disempowered at work. And what do we do about that? What is our response as a professional society? How do we empower individual people to take back some ownership and take back some, get some engagement into their workplace? And for many people across the country right now, I think the answer has been unionization. And Kevin Shulman and Barack Richman have written some nice pieces in JAMA over the past year that reflect on these questions. And they ask the question of how, as a profession, as we lose our economic independence, how we can maintain our professional independence. And at the end of the day, you know, if you are a physician working for a private equity firm that is facing financial straits and they're making decisions that might push you into clinical situations that you don't agree with, or you feel have unsafe practice patterns, how will we meet our professional obligation to our patients? And I think one way to do that is through collective action and collective organization of physicians through physicians unions. And I will admit that unions are not a panacea. This is a very difficult labor environment in the United States, unfortunately. I'm privileged to live in California where we have fairly strong labor law. We are not a right to work state, but many other physicians don't have that privilege. And unionization might have to look, or this type of collective action might have to look different for them. But I think as professional societies, we need to reflect on the fact that we are now representing a profession of laborers and our, as we think about our politics and how we support our, you know, physicians moving forward, we need to think about how we can support them in their role as laborers, because that's what we are. This is something that residents and fellows have recognized. Over the past seven years, we've seen a pretty profound growth in the membership of the committee of interns and residents. So in 2016, our union represented 14,000 residents and fellows, and that number is now over doubled in just seven years. And we're seeing this play out among attending physicians as well. In the New York Times, there was just an article about Alena Health in the Midwest forming a union. And we now have an entire generation of residents and fellows who have been working in union shops, have learned to organize, have seen the change that can come with collective action, and they're going to be going out and getting attending jobs. And so I think that this trend will only continue to increase. So I'd love to hear everybody else's perspective and thoughts on these issues. I don't claim to have all the answers, and I recognize that one union isn't going to be able to change the world. I think I naively thought that maybe we could at least change one hospital, and we're butting up against the realities of how much collective bargaining can actually obtain. But I think over the long term, if we begin advocating together as physicians, and I think on a grassroots level, where we're not just advocating only for federal policy change, which is important, but obviously is very difficult right now, but if we can generate a movement where physicians at every local hospital feel empowered to engage in conversation with hospital leadership about changes that they'd like to see in a form that has legal protection through the National Labor Relations Act, I think we'd be fools not to take advantage of that. So that's my perspective, and I'm excited to hear the conversation that comes from this. I recognize that other people might have a different perspective, and I'd love to hear from you as well. So thank you. Thank you. Should we sit up here now? So let me ask the speakers to come up to the front. And Atul, I think I was so excited to hear your lecture that I forgot to show my fourth slide. Oh, go ahead. So let me pose that in the form of the first question. The headline of the first slide, and it was the LA Times yesterday, the headline was LA County Physicians Waste Strike, A Mid-Alarm About Staff Vacancies, which kind of ties all of this together. Now, in California, admittedly, we have a lot of unicorns. Is this just a unicorn? Is it the canary in the coal mine of what's going to be happening in the future? And I'm going to save Philip for last. Jessica, any comments on that? Well, I mean, I hadn't seen this particular slide, I mean, this particular article. But I mean, this is consistent with the data I was showing about turnover, right? So we know vacancy rates are high. And the impact of the entire workforce, this is part of the discussion Philip and I were having earlier, and this is part of my argument why I don't think physicians should be unionized. But it does leave the physicians there standing. And most of them aren't going to leave their posts. But it is getting really, it's very tough right now. I mean, many places, it does feel like when the vacancies hit, those who are still there are doing double work. And so I'm not, I don't, yes, we see this. And it's really tough. I will say, though, and I am probably the more optimistic the most up here, and that's probably because I have the privilege of being able to work with organizations all around the country. And the bottom line is rural hospitals, most places, need to keep going. And so they're figuring out how to make it work, in spite of the staffing shortages. And they have to figure out how to engage their workforce, or they won't keep them. So they're working really hard, and many of them are making progress. But it is a tough time right now. And please come to the microphone if you have any comments or questions at all. Any comments? Yeah, I think related to some of the slides that Jessica showed around alignment and engagement, and some of the points that Philip made, there is a sense of a lack of control. We all hate that, right? The sense of I am powerless. And I think physicians in particular are not used to feeling that way. And historically, we have been told you are in charge. When that's taken away from you, I think it's a challenge. It's a struggle. So one more reason there's a shortage of mental health providers, because we all need therapy. But I think the other challenge is that so then physicians will grasp at anything to say, what is the answer, because they feel powerless, including unionization. And I don't think they'll eventually all get there. I think there are concerns among physicians to engage in that way in most settings. But I do think that Jessica made a really important point about if my clinic's not staffed, it's a lack of respect for me and my professional abilities and autonomy. And I think these things are related. But from a health system perspective, remember that on average, 55% now approaching 60%, 65% of costs are labor. And the only way, which is why I say we will not reduce the cost of care in the next 10 years, probably not in my lifetime, because no one is ready to say, let's shed bodies from the labor force. And no one's ready to say, yeah, let's pay everybody less. We are talking about a lack of bodies. And health systems are being told, get your costs down, get your costs down, get your costs down, which we didn't talk about the fact that, yes, there is hospital and health system consolidation, but there are five major insurers in this country. That leaves out even the individual Blue Cross plans state by state. In Alabama, Blue Cross has 94% of the private payer market. None of our hospitals or health systems has more than 20% from a statewide perspective. And individual MSAs came from Boston, and that's a unique case. And I think that's where you have state regulators step in. But there is just this real aggravation now, all up and down the health care system, where we're all being asked to do more with less. And none of us knows how to solve that problem. I think the communication issue that arises is that senior management, health system administrators have not done a good job of communicating with everybody up and down the line to say, here's where we're trying to go, and here's where I'm struggling, and I need your help. And I think that communication has to improve. And before I ask Philip if he has any of the additional comments, I would point out 20, 30 years ago, crossing that boundary of striking was considered unethical. And it certainly puts physicians in a moral dilemma about, am I going to do something that affects today's patient care, or am I going to start taking care of tomorrow's patient care? Any comments, Philip? Yeah, I think it's a great point, Dan. And it's a philosophical question that I can't answer for all of you. I think we all need to reflect on what issues would be strikable and when enough is enough. And if we are in a position where physicians feel that they can't safely care for patients long-term under the working conditions that they're under, then that might become a strikable issue for them. And if you actually look, there's unfortunately not a lot of literature on strikes among the physician workforce in the United States, because there, frankly, haven't been a lot. There was a meta-analysis from 2008 that looked at some physician strikes worldwide and didn't find a substantial impact on patient mortality during the period of a strike. Similar data for health care workers more broadly that during the periods of strike, there's not necessarily increased mortality. And that's because it's not like these strikes are coming in a vacuum. The physicians didn't go on strike this week. They announced a strike vote for next week. And if they authorize a strike, then there will be a 10-day moratorium on a labor stoppage. The physicians will keep working before a strike goes into effect. And that's baked into the law that was modified in the 1970s, the National Labor Relations Act. Any strike in health care has to have a 10-day waiting period. So the point of a strike is not to take a health care system out. It's not to blindside an employer and not offer any opportunity for a shift in staffing, a shift in care delivery. Obviously, there will be implications. Elective surgeries will be delayed during a period of strike. People will have to spend more money getting locums physicians, which is already very difficult to do, because we have a workforce shortage. So it's not to say that there's not costs. But I think that we overestimate the degree to which a physician strike, which would be time-limited and announced in advance, will actually cause material patient harm. And again, it's a question that I think everybody has to come to on their own. But we all know that the systems that we work in are very difficult. And I've seen many people in my residency classes leave medicine. And a lot of people are not choosing jobs in primary care because of the workload that they have to see. When we think about how we can develop a system that's more patient-centered, you know, we had some wonderful presentations this morning on initiatives and a variety of specialties to help improve patient experience. But as a patient, if I'm seeing my physician for 15 minutes for a follow-up on my antidepressant medication, that's not a positive experience, you know? And so, if as a profession, we find ways to advocate for a system that affords us better working conditions and more time to spend with our patients, I think in the long term, there is potential benefit there. And it's not to say that it doesn't have short-term cost and that it might not hurt. But I think, you know, we tend to focus a lot on the emotional aspect that comes up when we hear the word strike. We've all been in nursing strikes, you know what I mean, as physicians. And we've had to pick up the slack, potentially, that's left behind when our nurses walk out. But what I will say is, you know, I think we have a lot to learn from the nurses. And at my hospital, if nurses feel that there's some unsafe issue, that there are staffing issues or the patient-to-nurse ratios aren't appropriate, that gets fixed. If my intern on nights who's carrying 60 patients feels that they're not able to safely take care of those patients, that's a sign of weakness in our profession, you know? And I think that we need to readjust our expectations and realize that, you know, taking care of each other and doing so in a way that potentially is disruptive to the health ecosystem might have positive effects in the longer term. And I would absolutely agree with the last couple of sentences that Phillip stated in terms of needing to change the culture, wanting to get to a certain place. I think the question is, is what are the steps to realistically get us there? And that's what we're all trying to do. Yeah, exactly, yeah. Question out there. Yeah, hi. Sue Sidori, American College of Emergency Physicians. One of these areas where we're kind of number one in terms of all of these problems. Private equity, workforce, burnout, moral injury, you name it, right? And we are finding ourselves feeling pitted, employer to physician. But we also know that, as you said, Atul, it's about the payment. It's about the triggers. It's about the problems that are kind of bringing that in. And I do think there's a real value and a place for unions. And I think we're seeing that, right? We get that. But, I mean, are we just continuing to fight among ourselves when, in fact, the bigger issue is the consolidation in the insurance industry? Is that kind of the pressures and the payments that kind of keep coming down? And, you know, will unionization get us to the bigger problem? Or will it actually make us implode even more and feel even more like Cogs and Whales? And this is what we struggle with as an organization. And I don't know if I'm giving you a question or just asking for some therapy. I mean, it is the thing we need to talk about too, right? And I'd be curious, you know, the nursing issue is the same, but it's different because they're not there for the reimbursement cycle, right? The resident issue is the same, but it's different because they're not there for the reimbursement cycle. It is the payment. And how do we get there? Yeah, it's a great question. And I think one in which physicians and hospital leadership might actually potentially be aligned in taking on the insurance industry. You know, I wish that I had a solution. If I did, you know, I would be advocating for it. I think the opportunity with unionization is that it gives people, right now, I think our professional societies are relatively weak compared to where they used to be. Membership in the AMA is very low. And I think that's because people have a perception that those professional societies can't do a lot for them on the ground. And unionization at least generates, gives people an immediate path towards self-advocacy. And what I would hope for would be for a larger physician's organization to develop. And this is a long-term project, but what we see with, for example, CIR is once you have 20% of people under the same institutional umbrella, people who are now engaged on the ground level and in a grassroots way, then you can start to think about solutions that are bigger picture. So absolutely not one union at one hospital can't do something. And unfortunately, we're not in a position where we have a large national doctor's union who could. But I do think that by starting from the bottom up and building a movement at every hospital, that is what gives the potential for something bigger. Because what we're talking about is structural change, this is, we would need foundational change to the healthcare system. And that is not gonna be, that's not politically feasible right now, right? That this is not possible, sorry. Yeah, so let's see if Atul or Jessica have any comments. How many of you are physicians in this room? Like God help the rest of you. Because we don't play well together. And I think that's part of the issue, Sue, is that I, so I used to be a registered lobbyist and a decade or 15 years ago, I remember being in conversation with physician specialty society lobbyists, where one said to another, I think I'm violating any confidence here, we would rather see a cut in our payment than see any of our money go to you people, right? This is one physician specialty society talking to another. And so we have this very closed kind of view of the resources, which in part is really reinforced by the way that Medicare pays. But I do think that, you know, it doesn't help when AMA or physician societies are saying like, oh, there can't be deconsolidation, but great, how are you guys gonna negotiate with these payers, you can't. And there was an interesting presentation, a panel by AEI a couple weeks ago, where, you know, economists are always interesting, but somebody took a look at this and they said, yeah, you know, prices keep going up on the health system side. And I'm like, all right, prices and costs are totally different. This is a opening of a negotiation. But what happens is with the insurer consolidation is they are able to ratchet down the reimbursements to providers, but none of that money is going back to the patients, right? Despite the MLRs we put in place in 2010 with the Affordable Care Act. The other thing I think could help if we all got behind it is there is administrative waste in our system, in part driven by the hundreds of insurers that individual offices have to deal with, not to mention these big five, plus Blue Cross. If we could just get to a unified claims form, that would make our lives a lot easier. Up until now, those insurance companies have balked and said that their claims forms are proprietary. So, okay, I have a slightly different perspective on this, but I would say, you know, yes, there's a lot of waste. I actually really liked, I don't know where she went, the emergency medicine. Sue. Oh, she's right there, yeah. I actually, one of the things you said, I think is really important. Like, I think the only way we're gonna go forward, I think, yes, all these things have to change and we have to fix and we have to have payment reform. I've been saying that for, you know, decades. It is yes, but each hospital or hospital system has to stop. Like, I don't think the infighting is going to move anybody forward. And we are seeing when organizations are able to improve alignment, can, you know, do the listening to support the engagement. They have, you have to get rid of some stuff. Like, you can't ask the doctor to do everything when they don't have all that staff. But, like, solving that problem is how we're seeing organizations do well. Not looking to, like, band together as a community in the entire country. I think that the solutions have to start with folks within the organization sitting down, talking, listening, and supporting one another. Like, medicine is a team sport now. It isn't an individual sport, so. I would, before you get to the question, sorry. One, I do think we need to, and this is a charge to you all working with your society members to say, we need to figure out how to get people in agreement again on some of this stuff rather than just giving you the talking points of like, go get us more money, right? This is not gonna work. And so the other example that I have from my lobbying days is the physician societies was one set. It was like, well, I don't know what to do with you people. And then on the hospital association side, there's like three or five of us. What do we do? Can the public call? Hey, we have to take a cut. We're gonna take this cut here? Yeah, okay, let's go in, let's go. Yeah, we're all agreed. It is totally different. And you have to get at least somewhere closer to that point. I know there's a lot of you, but you gotta try. A question? Yeah, one comment, one question. Bill Thorpe with the American College of Radiology. And my apologies to the CEO group who heard this rant a little bit yesterday. But I do think that there is substantial inappropriate care delivery that's going on out there. And I think it is the responsibility and duty, quite frankly, of the specialty societies to look at guidelines for appropriate care, whether you call them appropriate use criteria or appropriateness criteria, and then apply them at the point of care. So it'll address the workforce issue because the useless work goes away. It'll approach the burnout issue because you're doing stuff that really is meaningful as opposed to why did I do this CT scan or an MRI of this lumbar spine when this patient cleaned out their garage last Friday. But so I put that out there and I hope our specialty societies can coalesce around that as physician-developed, evidence-based criteria for what's appropriate care. But my real question, in a little bit turn, you mentioned NPs and PAs and other advanced practice providers. There's pretty good evidence, I think, actually a study of the VA through Stanford, Hattiesburg, Mississippi, other studies that care provided independently without physician supervision by those providers is more expensive and has lesser outcomes. Is that gaining traction in the worlds that you all live in? And is that being looked at seriously as state-by-state more independent practice by those folks seems to progress? Yeah, so most of the hospital systems that we work with, some are really small, some are much larger, but that's not what we're seeing. We're actually seeing, it's more of like what Atul was even saying with some of the other entrants into healthcare, there's a huge demand for care. So figuring out how to use all the resources you have is pretty critical right now. So I know there's some in parallel stuff, but most of the primary care practices that I spoke to, right, or even smaller practices that have APPs in them, they do try to work in a supportive way so that there's shared learning and they are trying to triage so that they're not in over their heads on patients that they can't manage. So I'm actually pretty optimistic on the, well, I don't see how we move forward without APPs. Like I don't think that we can support care without it. Most of it, in my experience with our academic centers, has been in trying to meet unmet demand and a lot of the same day stuff. So the neurosurgeons will have an NP that was in neurologic care for 10 years, helping them figure out, okay, who really needs to be seen, figuring out the non-operative patients that can be offloaded so the surgeon can stay in the OR where we really can't replace them yet. But most of the points where NPs and PAs exist out there just become additional points of entry for unmet demand, which is why a lot of people in various administrations have said, oh, you get them into clinics out there, that'll drive down the need for the doctors. No, it just means that everybody goes to them because they happen more quickly, even those people for whom had a self-limited illness that probably just couldn't get into the doctor in the two weeks it would take to go away anyway. And now they'll get referred to specialists, which is why some of the data suggests that it's more expensive. I have not seen anything that suggests that the outcomes are worse. So before we go there, maybe, Philip, you could give us your perspective from kind of the resident fellow point of view on, quotes, NPs, PAs, and how they might be best integrated into the workforce. Are they your savior or a threat? Yeah, a tool kind of showed us some graphs where there's- I think this is a very divisive subject among our house staff. I will say I have loved the advanced practice providers that I've worked with, in palliative medicine especially. I think they're amazing. And so, especially, you know, this is one perspective being at Stanford. I think where people worry is where there's, you know, maybe, I don't, and I just genuinely don't know, but if the care standardization or like the training requirements are sufficient to meet, you know, the needs that you're describing, and I think that for the most part they are, but there's still a perception among residents and fellows, certainly, that that might not be the case, especially out in the community. And whether or not that's accurate, I think, you know, is not as much the point. I think that, but yeah, there is a perception, maybe, that is not the saviors. Yeah. Supervision's in the eye of the beholder. Right, I think that's awesome. Next question. Hi, my name is Greg Chang. I'm CEO of Healthy Careers. We're the largest health care job board in the U.S. so I have the privilege of working with about 6,000 employers every year and we talk a lot with these employers about what's going on. So just one comment and then one question. The comment is, you know, there's a lot of talk about retention. What I hear universally from my clients is that I have filled a record number of openings this year but I have lost even more health care workers. So you've got this supply problem, you've got a maldistribution problem of specialists, and you've also got a churn problem that's more acute than ever before. I don't have anything but qualitative feedback to provide but I think it's another thing that we have to consider. So I recently was in a room with a bunch of in-house recruiters, recruiters who work at hospitals, talking about what do we do about this and it all came down to supply. So it's interesting a comment earlier about controlled demand and appropriate care but until we can get there what do we do about supply and finding funding for residency slots and if that is a solution how do the people in this room who I think can have a really big impact on that lock arms and work towards pushing for more supply, more funding for supply. So I guess it's more directed to a tool and anyone else has comments. Yeah I would say that the physician groups have done a terrific job in the last 15 years of coming together and saying yes we need more resident physician training. That's come down to a money issue for the most part. We got a thousand more positions which is a couple hundred per year when you probably need a couple thousand more per year but a lot of pushback from rural places, a lot of pushback from states that don't do as much training and a lot of barriers in terms of the ability to expand programs versus having to start new ones. So not perfect but I do think that that has been an area with the exception of one or two specialties we have really spoken with one voice which I greatly appreciate. So I think this is, I don't have to answer it. I mean I can. No no go ahead. So I so I think their attention issue is huge it's not just the physician workforce it's the entire healthcare workforce. That was the slide that I showed with the turnover rates and a lot of it happens early like in the first six months to two year period is where we see a huge amount of high turnover and the organizations that are bucking that trend are really investing in onboarding and training up that early set that's coming in and we haven't talked about this here but whether it's a physician leader or a manager in the workforce like how they go is how the folks under them go and it's never been more clear that like have training up your managers and your leaders so that they have the skills to lead their their people is really critical. We haven't been talking about that but that's a huge area of opportunity that organizations should be investing in internally. So my watch says 328 the clock up here says five minutes but I'll give Helen the final question. I have a comment and a question I also just want to note that you may notice on the program it said this session was sponsored by the National Academy of Medicine so I did want to note that we actually have been working with the National Academy of Medicine's collaborative on wellness and resilience and I want to specifically thank Frida Ahmed our project officer at the National Academy. We are co-sponsoring an in-person meeting we're having in Kansas City on this issue and we're going to expand beyond the physician workforce to the larger health care workforce and specifically a focus on rural and underserved communities. I just want to plug for that anybody wants to join us let us know. My question is actually for you Jessica and I had to take a picture of this your slide that really struck me there are many that were but the one that said I would stay with this organization if similar offered a similar position the low scores for physicians at the bottom were really striking but the one that really hit me was the fact that senior management was incredibly high and I have to say that you could say the you know so what really struck me in and in light of this panel is that I think this all comes down to the sense of a loss of autonomy and I think the the the C-suites really content and I think that the clinicians are really unhappy and I'm just curious as we think about and I think unionization is is really one tool in our armamentarium here but I think we have to think about how you return to having the physicians and the other clinician workforce feel a sense of control feel a sense of empowerment over how to control their clinical environment and I wonder whether some of this and we talked about this a little bit the other day as part of our leadership program and when Sue and I were talking with our group on burnout and how much of this is also potentially the fact that a lot of that senior leadership in hospitals and other health care settings is no longer is no longer physicians and other clinicians it has turned to being a much more business oriented leadership of our health care systems and not the traditional clinical physician and other audience groups who previously led hospitals and health systems. Yeah so excellent point or set of points I would say this I think so the good news is most organizations are now listening so they're surveying their workforce like you have to survey patients for patient experience if you want to get reimbursed you don't have to survey your workforce but most organizations are now doing that and when they see this huge gap that you are talking about you know it's not I would say that there are many who are very concerned about this and are working to change their communication styles and how they're supporting their workforce and trying to do the listening and the involvement in decision-makings that might ultimately be leading some of the trainees to unionize because they don't feel they have a voice there are plenty of places and I would say the pandemic helped this that have regrouped and said huh we got to figure out how to be more flexible with working and maybe we set those schedules and they were these eight-hour blocks and like that was it but no we've got to regroup on that and think about this so I see a shift and I don't think it's like senior leaders aren't listening I actually think there are some incredible leaders that are hearing this pain of their workforce and really working hard to fix it. I met with a large academic CEO about ten days ago and I said what's keeping you up at night and that person said to me everybody is so unhappy from my you know full professors and attendings research all the way down to my students trainees they are so deflated and I can't figure out how to help them with the resources I have it wasn't about money it wasn't about you know regulation it was like my people are unhappy I'd love to know if there are some behaviors whether they're clinicians or not that seem to bring those other scores up closer. Yes and those key drivers that I had for alignment like so respect and you know that can mean a lot of things the organizations that are fixing that are asking in smaller settings and using different tools to say well what does that mean to you in your primary care clinic what does that mean to you our environmental service support people like what does respect I'll send you a I'll send you the stuff like we've got organizations who are really doing the listening because it means something different for a female physician that it might mean for you know somebody else I think we really need to know what those drivers are because I think just you know the strategies to date clearly aren't working right so I know I wish I could believe you and I know that those are the conversations that that you're hearing but I think that a lot of physicians throughout in the community are hearing a different conversation you know and I was at the bargaining table last night until midnight with Stanford and we're not asking for the pie in the sky you know we're asking for two extra weeks of parental leave for mothers and Stanford has a ton of public branding about how they want to bring more women into medicine but they won't give it to us right why it doesn't make sense they have the resources and if the CEO is staying up at night really feeling the pain of his workforce I mean we have a lot of very reasonable proposals that we know that the institution can afford but I think at the end of the day no matter how someone in the c-suite feels about how their organization is doing when it comes down to the bottom line the incentives for that person aren't there you know and there's really not an incentive for them especially for people in residency and fellowship but I think also for attendings who you know in a consolidated market might have less opportunity to change jobs and whatever you know have relatively less bargaining power you know whether or not you're staying up at night if your board is telling you that we got to make these metrics you need more than just a feeling at night to actually get action and that's just been my experience and I hope that you're right you know but I have been fighting for what I think are pretty basic changes you know expanded parental leave a little bit of contribution to a child care FSA some stipends to allow our residents to be able to you know survive rent in the Bay Area and yet there's some disconnect so I don't know why that disconnect is happening but we've tried asking nicely and it hasn't worked and so now we need to try asking a little bit less nicely as a group yeah and thank thank you Helen for that question I mean that slide jumped out at me and particularly the happiness of the health care executives was very important and could be a subject of a whole new panel or a whole new workshop but I want to will close and I want to thank the panelists is superb panel thank you so much

workforce challenges

physician shortages

patient experience

staff engagement

burnout

employment models

private equity

work-life balance expectations

aging population

shortage of physicians

patient satisfaction