Tracy Gaudet, MD Founding Director, VA Office of Patient-Centered Care and Cultural Transformation
Through my prior work directing the Academic Collaborative for Integrative Health (ACIH), I was, from 2012 to the Spring of 2018, involved at the U.S. National Academy of Medicine with the most significant, ongoing interprofessional initiative internationally: the Global Forum on Innovation in Health Professional Education. Through the urging of the Collaborative's Board of Directors, the core charge to my ACIH colleague, Elizabeth A. Goldblatt, PhD, MPA/HA, and myself was to promote exploration of any innovation that would move the medical industry toward a delivery-and-payment model that could earn the title of “healthcare system.” Our interest in a health model met the interests of others who were rattled by a wave of burnout, depression, and suicide among medical students, residents, practicing doctors, and other practitioners. This led to a Global Forum workshop on April 26–27, 2018 entitled “A Systems Approach to Alleviating Work-Induced Stress and Improving Health, Well-Being, and Resilience of Health Professionals Within and Beyond Education.”
I served on the Planning Committee. One task was to interview change agents at the leading edge of this transformative work. Tracy Gaudet, MD, was one I had the privilege of interviewing. Dr. Gaudet's work led to selection of her by the committee to be featured in a live interview at the workshop. A past director of integrative medicine programs at the University of Arizona and Duke University, Dr. Gaudet had been, since 2011, the founding director of the Office of Patient Centered Care and Cultural Transformation at the U.S. Veteran's Health Administration—the nation's largest health delivery organization. In that role, for instance, she oversaw development of an Integrative Health Coordinating Council, the hiring of Ben Kligler, MD, MPH—guest editor of this Special Issue—and the subsequent rollout of these strategies as adjuncts to the patient-centered, whole-health model she championed. The following is an edited transcript based on our 17-minute video dialogue.* This edited transcript has been reviewed and approved by Dr. Gaudet, prior to publication. We hope you will find it valuable.
—John Weeks
Mr. Weeks: When the Committee began working on this workshop, I immediately thought how, after your 15 years at University of Arizona and at Duke leading integrative medicine—with the focus there on health and well-being and how to shift the paradigm in that direction—and now with your position the last half decade at the Veteran's Administration as the leader of cultural transformation there, that we needed to have you here. Would you please start by sharing a little bit about the whole-health model you are building?
Dr. Gaudet: It is such an honor to be here. Thank you to the Committee for allowing me to drop in this afternoon. The concept of whole health—we have kind-of coined that phrase, and it seems to work for people. The fundamental essence is: if health care were truly about helping people to live their fullest life, if that were the goal of health care, what would it look like? How would we design for it? How would we talk about systems approaches? How would we not just add a little fluff around the corners and a few more tools, but fundamentally change what we do with people? What would we do if that were the goal?
That is fundamentally what we have been up to. It has been an amazing process. Despite the system. and the bureaucracy. and the politics, there is tremendous momentum. The momentum is largely because the health care professionals and the employees want and need this. They are driving it. It starts with their own reflections on their sense of health and wellness and meaning and purpose. We all learn about that and help them address that in their own lives. That focus carries that throughout the system. That is the concept. It is really rewiring how health care works. Disease care is still important. It is still a big piece of it, but our whole-health model does not start with disease. The whole health model is about completely rewiring the whole approach to what our role is.
Mr. Weeks: One of the things I learned in our interview during the Planning Committee process is that, because you are in the VA system, you are in a context that necessarily includes family, that includes soldiers getting out of the service and getting homes. That is an interesting characteristic—the population health focus.
Dr. Gaudet: Yes, that is part of the reason we have been able to make such progress in this model. The whole-system philosophies are not new to the VA. It has been about education and housing and many aspects of one's life, not just health care. And yet, when we started, we were still trying to create health just through a medical paradigm, just through the clinical visit. Now, we are getting to totally rewire what the process looks like. We start with peer conversations between the veterans and their peers about what is important to them. Then, circling out from that, we have well-being centers, and, then—only then—there is the clinic when one needs it. I say it again—it's a total rewiring of what health care is and how it works.
Mr. Weeks: Okay, so there you are, inside of this system, which, because we all own it, we get to read about it and learn about its issues—and the VA has had some. My question is: “What do you do yourself to keep your own act together amidst all that?” To put it in a positive way, “what do you do to maintain your own health and well-being while working there?”
Dr. Gaudet: Am I blushing? You know why? Because when we talked about this interview, I thought of what I often do, and what I have always done, that has been really been important in my self-care: I sit…on a pillow and breathe. I do that and just kind of let go of the craziness. For me, it is not about chasing something that I think is going to bring me happiness. It is just about letting go of the stuff that is in the way. That is one answer.
But this week, I had to go to extreme measures as I was tossing and turning and could not sleep. I was doing my meditation. I was doing my imagery. And none of this was working. Then, I came back to something somebody said to me ages ago: “What, if nothing is wrong.” Right? What if nothing is wrong? Sometimes, it is like no matter what stress is around us and what horrific things. … I mean, the VA is just a political mess often, you know, really suffering. But what if nothing is wrong? And I find it helpful to just sit with that. It may not be what I want or what I am expecting or what I think, but what if nothing is wrong? So that was something that came to me this week when I was tossing and turning. What if nothing is wrong?
Mr. Weeks: Usually, we need mathematicians with obscure theories to teach us this is the best of all possible worlds.
Dr. Gaudet: Yeah [laughter].
Mr. Weeks: The next question I have for you will lead us into a little bit of group work. In our preinterview, you mentioned one specific thing that you did to change culture yourself, through your own behavior. I wonder if you would share that. Then we will give the rest of the group 30 seconds to think about the one thing they might change, and do. Some members might share with the group. The question is—practically—“what can we change in ourselves to help create that culture in our organizations?”
Dr. Gaudet: In the VA—and I am sure this is consistent in health care across, at least in our nation, if not around the globe—there is an expectation that one is plugged in 24/7. That is the expectation. How unhealthy is that? I thought of how one thing I am so conscious of is modeling communicating to show that 24/7 is not my expectation. I do not want to see e-mails coming in from my team after hours or in the middle of the night. I realized I needed to model that, too. So, sometimes on the weekends, I feel I need to do e-mails, and that I want to do that. And I do it, but I put them in drafts. I do not send them until Monday. Because, if I start sending them all weekend, people think: “Oh, the boss is doing it. I need to do it. I should be responsive.” How can we sustain ourselves if we are plugged in 24/7? That is a small thing, but my team has said that this is an impactful thing.
Mr. Weeks: I just love the idea of, “If you want to write them, you can write them.”
Dr. Gaudet: Write them. Just do not send them—
A period of group activity followed with the participants considering acts they might engage in that might make a difference in the health and well-being of their workplaces. Some participants then shared their ideas briefly. One person suggested that, at least once a day, she could either walk over or call someone in her workplace, instead of e-mailing. Another person suggested that she could have compassion toward people who had different viewpoints. A third person added to Dr. Gaudet's method by providing a framework for thinking about it: “Do not borrow tomorrow's problems by checking e-mails late on Sunday evening and losing sleep.” A man referred to Francis Collins, MD, PhD, the director of the National Institutes of Health in his response: “I get asked this question a lot, especially from my dean. What can I do tomorrow to make a difference? And I tell him the same thing I told Dr. Francis Collins when I sat next to him. Put a sign outside your door that says: ‘Come back in five minutes. I am breathing.’ ” [laughter]
A former college president shared a transformative action she took at a campus that, on her arrival, seemed bleak, with people there depressed: “Spring came, and I asked, ‘where are the flowers?’ So, we planted flowers. The entire community planted flowers. Ten years later, the campus is a showplace and people have invested—donors have invested—in beautiful gardens.” Another executive mentioned “a real difficult endeavor” her leadership team had faced, and she shared how she had chosen to send notes to the spouses or partners of the coworkers because they were spending a great deal of time away from their families. “They very grateful and really surprised by that note.” At the end, Mr. Weeks asked Dr. Gaudet if she had specific responses.
Dr. Gaudet: Only that I love how so often these are such simple things. It really just takes the change in the mindset. That is a “take away” for me—it does not have to be big and grandiose, but it has to be conscious. These are great ideas.
Mr. Weeks: And I like the visual of the work on the garden. In some ways, this whole exercise is about “planting flowers.” How do we “plant flowers” every day with our actions? To have the actual flower planting as one of the suggestions was quite nice. Next question for you. “How much do leaders themselves need to be actively engaged in their own personal wellness process to lead institutional change toward well-being? How much do they have to be engaged with their own stubborn personal habit-change issues on an ongoing basis in trying to become well themselves?”
Dr. Gaudet: I think these things are critically important. And what you said that I would like to underscore that is important is that it's not about “doing it right” but about being engaged in the process. I think that is a greater gift to our people to say: “Hey, I am not doing—I am not here to model how perfectly my self-care program is, but I am here to model that this is important for all of us for our personal lives, for our resiliency and for our work. And so, let us be on the journey together.” And it helps to share. Making changes is hard. It is a struggle. Everybody knows it, and we share that. That becomes part of what rejuvenates us.
Mr. Weeks: My thinking about it is that a leader's own engagement in his or her own health and well-being process is actually a necessary, but not sufficient, factor. Do you agree that it is necessary for system change?
Dr. Gaudet: I agree with that. I think it is necessary, and I agree that just caring for one's own well-being is not sufficient. And what do I mean by that? I think that we can model it and speak it, but, if people have not experienced it, they have not felt it. If they have not—and they have only managed their own stress one way or their own eating one way, or dealing whatever their issues are—they are not. … we are not going to shift the culture. We have to find ways to bake that stuff into the day-to-day practice of the organizations. For instance, our intention is to start every meeting with a moment of mindfulness. We start to model—“Oh, just 60 seconds. Breathe. Take some space between the last thing you were doing and this thing. Notice how you are feeling in your body, as an example.” We are not perfect. We do not do it at every single meeting. We have also set the intention to let us do random acts of kindness for each other, like the thank-you note —that example is a great one. What are we grateful for? We do grateful rounds at meetings, wherein people share that. So, we are baking some of those things into our team processes and our organization. This helps people think: “Oh, that is what we are talking about. That is what it feels like. That is how you do it.”
Then, they begin to be able to incorporate it. The last piece of that, in my opinion, is the reflection of that process. Let me explain. First, we began engaging these processes. We went from talking about them to having the experiences. Then, people begin to notice changes. We ask them to reflect on these changes. We did this with residents, trying to help people with stress management in obstetrics/gynecology, pediatrics, and internal medicine residencies. The fascinating thing was that, when people reflected the changes from these self-care practices, these people said: “Wow, not only did that help my stress. I was better in the operating room.”; or “I ran the code better.”; or “My meeting was more productive.” They begin to see the benefits—the personal benefits and the professional benefits. That begins to shift the culture. Then, it is like they have an “Aha moment,” and the process we are putting in place becomes self-reinforcing.
Mr. Weeks: This is the last question we have time for. You have chosen to call this a whole-health initiative. You put a positive frame on what you are doing—making clear that this is not focused on “limiting stress and burnout in the workforce.” Talk about how important you feel this positive frame is. I know that is a key to your philosophy, and that you and your team went through a significant process at the VA to establish this direction.
Dr. Gaudet: That is absolutely right. The phrase that we have come to use in our work—just because it seems to resonate with people—is “exploring a sense of mission, aspiration, or purpose.” We are helping people—again, not to look at what is wrong, or: “What is my chief complaint and what do I need to fix?” We do not focus on people “not being happy enough,” or whatever way they speak of what is wrong. Instead, we peel back the layers for people to reconnect with a sense of mission or aspiration or purpose in in their lives. We have processes to help people to do that with each other—the peer counseling—and we do it with our patients. Then, we build their health around that. Everything flips. Everything flips. The pain flips. It is just. … it is a real shift. I appreciate the chance to talk about that.
Mr. Weeks: We must close. I will do so with a recollection you have inspired—of my first conversation this morning at breakfast with one of the members who I have come to know here over these 6 years. We were talking about personal health things—she looked healthier and I commented on it. And the member said: “Well, I did what I am doing for my health because of what I wanted to do with my grandkids.” Right? And that is what you are peeling back the layers to find. It's locating that.
Dr. Gaudet: That is it. That is it.
Mr. Weeks: Thank you. It is terrific to have you here as part of our exploration of systemic methods in finding our way to greater well-being and resilience.