In this edition, Tait Shanafelt, MD, talks about his journey to becoming an expert in physician wellness, with a stop as a house-painting business owner along the way.
Where did you grow up? What was your childhood like?
I had an idyllic childhood in the suburbs of Seattle. My father was an engineer who spent his entire career at Boeing and my mother was a teacher. She taught all different ages, but mostly elementary and special education. My parents have always been a steadfast and loving force who encouraged me to pursue my passion and make a difference. When my sister and I weren’t in school, Mom would turn us loose and we were free to play with friends in the woods around our house for hours. I was an avid soccer player growing up, so that also consumed much of my time.
How did you become interested in medicine as a career?
It was a little bit out of the blue since no one in my family was in medicine. In high school, I excelled in math and science, but I enjoyed English literature more than other subjects. Medicine seemed like the ideal intersection of science and humanities, so I began college with an interest in becoming a physician. As I experienced medicine through volunteering, shadowing, and getting deeper into the coursework, it became clear that a career in medicine was the right fit.
Did you consider any other careers while you were in college?
I did, somewhat accidentally. My friend and I operated a successful house-painting business while we were in college. It started out as a summer job: We put signs up around the neighborhood offering to refinish decks. (There’s a widespread need in Seattle because the finish on decks doesn’t last long with all the rain.) By the end of that first summer, customers started asking us if we would paint their houses as well. At first, we said “no,” but then my dad – who had put himself through college by painting houses – said, “You go back and tell them you paint houses.”
So, we gave it a try. Over the next couple of years, it became quite a burgeoning business. We were getting commercial contracts and doing a high volume of work.
I learned a great deal in those few years running our own company. We had to convince business owners and homeowners to trust two wet-behind-the-ears college kids and establish our company’s reputation for doing quality work. It also demanded a solid work ethic: We bid by the job, so if we could finish a job in 3 or 4 days instead of 5, we could move onto the next one. To make that happen, we were on the job by sunrise and would paint until dark – working 7:00 a.m. to 10:00 p.m., 7 days per week, all summer long. When we finished a day’s work, we would eat dinner at the same restaurant every night, and then we’d be back at it early the next morning.
Owning our own business brought us a great sense of pride. It was hard work but satisfying. I also built relationships with many of our elderly customers, which ultimately led to a desire to care for patients in that age group when I entered practice.
What led you to focus on hematology when you entered medical school?
I thought seriously about pursuing a career in geriatrics, but once I started sampling various medical specialties, I realized I could have a practice that focused on working with older adults in many different disciplines. Ultimately, it was the science of oncology that captivated me. It is such a fascinating and dynamic field. By the time I graduated from medical school, I was pretty sure I would ultimately pursue an oncology fellowship and become a solid tumor oncologist.
However, when I began my fellowship at the Mayo Clinic in Rochester, Minnesota, I met Neil Kay, MD, a hematologist and chronic lymphocytic leukemia (CLL) expert. That relationship changed my life and my career. Neil had recently moved to Mayo Clinic and did not have many fellows working with him yet. He became my mentor and still is today. Neil is a brilliant, creative, patient, and humble man. Beyond that, he is an amazing human being. He always looked out for my best interest and opportunities to advance my professional development and career. He has been the ideal mentor and has become one of my closest friends.
I worked with Neil for 3 years as a fellow conducting research projects on CLL, while simultaneously doing research work in solid tumors. At the end of fellowship, I was offered a position at Mayo in both the oncology and hematology divisions. My choice to join the hematology department was absolutely influenced by Neil and his mentorship. Hematology was never the plan – there was no point in the journey of pre-college, college, medical school, residency or early fellowship when I thought I would become a hematologist or would spend my career leading translational research in lymphoid malignancies. Working with an amazing mentor is what directed my career that way.
Physician wellness is another focus of your career. When did that concept enter the picture?
It was a bit serendipitous: It started when I was a senior resident at the University of Washington. This was 20 years ago, which was a different era in terms of the duties and responsibilities of senior residents. The faculty were around for an hour or an hour-and-a-half in the morning, and then it was up to the supervising resident to lead the team. I knew the interns I was working with were dedicated, altruistic people who had committed themselves to medicine for noble reasons. But, when I’d call them with an admission or we’d have a heavy call night, the way they would talk about patients and their responses to patients needing their help was incongruent with those qualities. At the same time, I empathized with them, because I remembered what it felt like being in their position – getting a couple admissions during the last hour of your shift when you’ve been up all night and were already staring down a full day of work. It disturbed me, however, because it was abundantly clear that the process of training and practice was eroding some of our fundamental professional values.
In the fall of my third year of residency, I was preparing to start a research rotation with another mentor, Anthony Back, MD, an oncology communications expert. When we met to plan projects, I told Tony that I wanted to study the experience of training. He asked me many questions about what I was observing and why I cared. I told him, “Because it is affecting our patients.” He responded with, “I think you’re talking about burnout. It’s not my area of expertise, but let me pull together a team and we’ll try to study this.”
That study was one of the first to look at the link between physician burnout and quality of care. When we published our findings, the paper became a lightning rod – it was on the front page of USA Today and was covered in many newspapers around the country. I was a first-year hematology/oncology fellow on the consult service at Mayo Clinic at the time the paper was published. I remember commuting on the shuttle bus between two hospitals for a consult when Paul Harvey came on the radio and said, “New study from the University of Washington shows that physician burnout impacts patients’ quality of care and leads to increased medical errors.” It was an out-of-body experience to be listening to the radio and realize, That’s our study!
It struck me that here was an unfunded study, conducted by a resident, that was galvanizing a national conversation, not only within medicine but at the societal level. Why? Because we had approached a problem that people knew about and experienced, but that no one had studied in a scientific and methodologically rigorous manner.
“As physicians, we are therapeutic instruments for our patients. Just as the PET scan machine needs care and maintenance, we need care and maintenance to best serve our patients.”
One thing led to another, and the Dean of Education at Mayo asked for a meeting to discuss starting an extension of the study there. Seventeen years later, that longitudinal study is still going on. Several national professional societies started asking if I would help lead studies of their members. It kept snowballing, in a sense, and my research on physician wellness and burnout developed in parallel to my CLL research and hematology career.
In 2007, the chair of medicine at Mayo was retiring and said, “I want to leave a legacy gift to the department. I want to create a program on physician well-being, and I want you to lead it. Would you bring me a proposal of what it should look like?” That’s when we started looking at the systemic, environmental, and organizational factors driving burnout and began developing and testing interventions to address them. Rather than simply telling physicians to take better care of themselves, we wanted to identify the root causes of burnout – the characteristics of organizational culture, professional culture, and the workflows and work characteristics that contributed to it.
After we and other groups published a series of scientific papers, health care organizations began to wake up to the concept of physician burnout and well-being. Around 2012, more than a decade after we began this research, the entire health care delivery system realized it needed to get serious about addressing burnout because it was not only harming physicians, other health care workers, and their families, it was also undermining quality of and access to care and worsening patient experience.
While my work on CLL had always been my priority, my wellness work continued to grow. The team I led was the first in the field to be doing robust, extensive research in that space, which was clearly the only way to drive change. I am still engaged in CLL clinical trials and research but eventually, physician well-being became my focus. In 2017, I came to Stanford to become its Chief Wellness Officer and Associate Dean of the School of Medicine.
As someone who researches wellness and burnout prevention, how do you practice that in your daily life?
One of the many positive things about being involved in this work is that it forces you to look in the mirror. While 75 to 80% of what drives occupational burnout is related to characteristics of the work environment, that doesn’t mean individual physicians are powerless to make personal choices that can help us navigate those choppy waters.
I organize the key individual strategies into three areas: defining your values and priorities, optimizing meaning in work, and caring for yourself.
Defining values and priorities is about acknowledging that, as physicians, we have an incredibly demanding professional life. Whether we’re caring for patients or advancing science to enable better care in the future, our work is vitally important. It can be all-consuming. We do, however, have other things in life we care about – family, children, avocational interests, and or other pursuits. Often, if we map out our full list of priorities, we find that they are incompatible – it’s impossible to accomplish all of personal and professional goals. For example, if I say, “I want to be an expert in CLL” and “I want to be a father who never misses a soccer game,” I have incompatible goals. To make a difference for the patients with the disease I dedicated my career to, I had to miss some soccer games. The question is, “How many soccer games can I miss to accomplish that goal while still cultivating the relationship I want with my kids?” In an similar manner, the rubber meets the road for many physicians when we have to ask ourselves, am I willing to take a slower career trajectory or a lengthier path to promotion in order to have a stronger relationship with my family or do something else that’s important to me?
The second strategy, optimizing meaning in work, is key. Our interests evolve and change as we master things, and we need to come up for air every year or two to ask, “What do I want to do with my career? What is the most rewarding and fulfilling aspect of my work? How much time am I spending there? Where do I want to take that interest? What do I need to do to spend more time there?” Asking these questions can help optimize a sense of purpose and meaning in our professional lives. Our research team has found that physicians who spend less than 20% of their professional time in the aspect of work they find most meaningful are at high risk for burnout.
The third area – and this is where one’s mind usually goes before the others – is caring for self. As physicians, we are therapeutic instruments for our patients. Just as the PET scan machine needs care and maintenance, we need care and maintenance to best serve our patients. We need to rest, take breaks, and attend to relationships and interests outside of work to stay at our best for the long haul. We have also found in our research that, while they are compassionate with others, physicians have lower self-compassion than workers in other fields. This puts us at an increased risk for burnout. Self-compassion is a skill, and one that physicians need to strengthen as part of their self-care efforts.
What does self-care look like to you?
For me, it means exercising regularly, scheduling breaks and vacations, and making sure that I have activities outside of work that I care about. My wife and I have 4 children: 3 daughters (ages 15, 10, and 6) and a son who is 13. So, my wife is my accountability partner in that regard – she keeps me honest and lets me know if I’ve been a little disconnected or need to spend more time with one of the kids.
Based on our research, I have also become much more attentive to my sleep habits. Personally, I need 58 hours of sleep each week. How I get it over the course of 7 days can vary, but that is the number I need over the week and I am vigilant in getting it.
Soon after I finished fellowship, one of my daughters had a life-threatening health problem. She’s doing better now, but it was a dominant part of our lives for 3 to 4 years and had a powerful reframing effect on my priorities and even on my career. We certainly lived through an intense season as a family.
That experience forced me to live day to day and just enjoy and appreciate each moment with my kids. We never know what the next day will hold and we also never know what might be going on with our colleagues when they’re not presenting at the podium or in the clinic. Most of us have something going on behind the scenes, and support and empathy from one another is critical to preserving our ability to do our work.
Where did you meet your wife? What does she do?
We met at work during my first year of fellowship. She was a first-year nurse on the oncology ward. Our birthdays are 1 day apart, so she had brought in cupcakes for hers and that started a conversation. Fifteen months later, we were married.
Having 4 kids must keep you busy. What do you enjoy doing when you have free time?
Kid activities dominate our lives right now, obviously, but I like to exercise. I still love soccer, and three of our children are avid soccer players, so we all play together. The other child is into drama and acting.
Fixing things around the house is therapeutic for me, as long as I get to pick the project instead of something breaking at the wrong time. I also like to read – typically novels by Michael Crichton or John Grisham or detective fiction… preferably stories that have nothing to do with medicine so I can turn my brain off and escape.
What does your perfect Sunday look like?
For me, Sundays are for stillness. That means getting coffee and reading the newspaper, going to church with the family, watching a bit of football, and probably falling asleep on the couch during the game. Sundays are also time for one of our anchor points as a family: We always have a family dinner on Sunday nights. After dinner we have what we refer to as “family coaching” time. We’ll take a topic – something in the news or something going on in one of our lives – and explore it together. I don’t remember exactly when it started or where the idea came from, but it’s been part of our weekly tradition for about 5 or 6 years now. After, we usually play a game or go for a family walk, then go to bed early so we’re refreshed for the week.