“I happen to be called a pulmonary and critical care doc and no, I'll never make it into the WNBA, but I do believe I'm an elite athlete. And can we imagine taking any real elite athlete and doing something like putting weights on their legs and shackling them together and expecting them to feel comfortable that they can win the game?”

Dr. Tina Shah is a pulmonary critical care specialist and chief clinical officer of Abridge, a technology company that leverages generative AI to support physician note taking and clinical documentation.

She is a leading voice on physician burnout and brings her expertise as both a healthcare professional and an advocate for systemic change in medicine. Tina believes that physician burnout is a pervasive and systemic workplace issue, not just an individual physician’s struggle.

“If we all accept the definition of burnout, that it's an occupational diagnosis, it really requires a system or occupational treatment. So this is why we're really at danger…if we use these words like resilience and wellness in the wrong way, we will batter the soldier, AKA the physician. And they will think that means something's wrong with them and they have to do more, like yoga or pizza parties.”

In this episode of How I Doctor, Dr. Graham Walker, co-founder of Offcall and an emergency physician in San Francisco, talks with Tina about actionable strategies that could help to create a more sustainable work environment for doctors. Here are five high-impact tactics that would meaningfully improve physicians' lives and combat burnout:

1. Leverage AI Tools to Reduce Physicians’ Cognitive Load

High cognitive load occurs when physicians manage a large volume of complex information daily, often compounded by administrative burdens like EHR documentation. According to Tina, a high cognitive load is closely related to burnout.

“Cognitive load is a precursor to burnout. So high cognitive load, high odds of burning out, high odds of leaving the industry,” she says.

Importantly, Tina describes how AI tools meaningfully reduce physicians' cognitive load by helping with mundane and repetitive tasks such as note taking:

“When the extraneous load from the task switches, from taking multiple extra steps just to find that consult that the person you actually need to call or to put in those orders when that gets so high that you literally have no room left for the medical decision making … that's what's happening today. I really like to harp on cognitive load.”

2. Empower Clinicians to Share Solutions

Doctors know exactly what's wrong and how to fix it, and healthcare systems should give physicians the ability to voice concerns and solutions. This helps them feel valued and directly improves their satisfaction within the healthcare system.

“We need to give clinicians the ability to give input because doctors know exactly what's wrong and how to fix it. We often don't get the space to tell the people that can make those decisions what needs to be done. So give us the ability to give input,” Tina says.

3. Help Physicians With Anything That Makes Them Inefficient

Removing barriers to efficiency like frequent retraining of staff or outdated processes can reduce unnecessary stress on clinicians.

“If the process to find the on-call cardiologist has just gotten more clunky, then we're inefficient and that's actually going to drive burnout,” Tina says.

These inefficiencies add to physicians’ cognitive load and drive frustration. Streamlining workflows with better training protocols, enhanced communication systems, and tools to reduce repetitive tasks allows physicians to focus more on patient care rather than logistical hurdles.

4. Help Physicians Fix Anything That Reduces Quality of Care

Ensuring that physicians have timely access to high-quality diagnostic and treatment tools is critical to reducing burnout related to compromised patient care. For example, Tina highlights common problems which occur in the hospital setting, such as when an MRI machine goes down, which can be extremely disheartening and increase burnout.

Hospitals can help by maintaining and updating essential equipment, streamlining access to diagnostics, and implementing real-time troubleshooting for equipment issues to support physicians in delivering the best possible care.

5. Recognize and Acknowledge Physicians' Daily “Above and Beyond” Work

Doctors often perform above and beyond their required duties, yet these contributions frequently go unrecognized and that absence of acknowledgment, combined with a constant stream of negative feedback from patients, can erode morale.

Graham agrees: “I don't think there's anything better than just a handwritten thank you card, [saying] You totally saved that patient and I just feel so appreciated and so lucky to have you as a colleague.”

You can connect with Dr. Shah on her LinkedIn at https://www.linkedin.com/in/tinashahmd/ and follow her writing at https://www.tinashahmd.com/.

To make sure you don’t miss an episode of How I Doctor, subscribe to the show wherever you listen to podcasts. You can also read the full transcript of the episode below.

Transript

Tina Shah:

If I really had to distill it down, there are expectations of what you should be doing, and then there's the reality of what you can humanly do, and there's a disconnect. I think it's really hard, because we're all elite athletes. I happen to be called a pulmonary and critical care doc. And no, I'll never make it into the WNBA, but I do believe I'm an elite athlete. Can we imagine taking any real elite athlete, and doing something like putting weights on their legs, and shackling them together, and expecting them to feel comfortable that they can win the game?

Graham Walker:

Today, I get the opportunity to chat with Dr. Tina Shaw, an intensivist in New Jersey, and leading expert on workforce wellbeing, digital health, and healthcare policy. Dr. Shaw worked across two different White House Administrations, serving as the first director of clinician wellbeing at the Department of Veteran's Affairs. Then later, as a senior advisor to the Surgeon General, where she spearheaded workforce burnout. Dr. Shaw is a leading voice on the topic of physician burnout, and is currently the chief clinical officer at Abridge, a fast-growing company that's developing AI scribe tools for clinicians.

I'm extremely excited to talk to Tina today. Tina really exemplifies not just talking the talk, but walking the walk. Every time I have had the chance to talk with her, I feel a little bit more hopeful about reshaping healthcare, the way we, as clinicians, want to see it for ourselves and for our patients.

Welcome to the show, Dr. Tina Shaw. Thanks for being here.

TS:

Thanks for having me. Wow! What a very warm welcome. I actually feel kind of optimistic after hearing that, too.

GW:

We've got a fighting chance, Tina.

TS:

There we go.

GW:

Yeah. We call it burnout. We call it moral injury. I equate those two as a larger catch-all for the feeling that I feel. When you say that, I feel like I know what you mean, but you acknowledged that you were burnt out. I think that's becoming a little bit more of an acceptable thing for physicians to talk about. I think for a very long time, head down, keep working, don't complain.

Fundamentally, with your experience, do you have an opinion about where this is all coming from?

TS:

I always like to go back to this classic definition of burnout. It's a workplace situation in which the job demands outweigh the job resources.

GW:

Yeah.

TS:

Don't get me wrong. If I have a trauma in my family, let's say a loved one days, let's say I have situational or other reasons for having major depression, that is certainly going to increase my risk of burnout. Or rather, we know that there is a high association between mental health conditions and burnout, which is an occupational condition.

If I really had to distill it down, there are expectations of what you should be doing, and then there's the reality of what you can humanly do, and there's a disconnect. I think it's really hard, because we're all elite athletes. I happen to be called a pulmonary and critical care doc. And no, I'll never make it into the WNBA, but I do believe I'm an elite athlete.

GW:

Yeah.

TS:

Can we imagine taking any real elite athlete, and doing something like putting weights on their legs, and shackling them together, and expecting them to feel comfortable that they can win the game?

GW:

When you said demand exceeds supply, I first went to heart attack, the oxygen demands, a Type 2 MI. Then I went to lactic acidosis. I think that really resonates with me. I say that nobody goes into medicine as a get rich quick scheme. It's just that we want the amount of work to meet, on most days, meet the ability to deliver the care.

To me, it feels like the burnout is when it becomes a cycle, or it's a pattern. It's not once in a blue moon, "God, the ER is an absolute zoo, and I got out of there two hours after my shift, and I still didn't feel like I helped anybody." But it's when it becomes a pattern and when it becomes the norm is, I think, particularly when you go from you can't clear the lactate. You can't get rid of the lactic acidosis and it's building up.

TS:

Yeah, I think you hit it on the nail. It's like this. One, the lactate production itself is going up. When we could have given antibiotics, let's say we haven't yet done it.

GW:

Yeah.

TS:

What we're starting to see is we're starting to get some gut ischemia, and that's causing the lactate to build up.

GW:

Yeah.

TS:

The parallel to that, or I guess the analogy to that, is that there really is more regulation now. There really are more documentation requirements now than ever before.

GW:

Yes.

TS:

It's not just coming from the federal government, by the way. It's from our divisions all the way up to our C-suites where we work, to our states, to the Joint Commission, to the federal government, to the health insurance companies. It feels sometimes like it's coming from everywhere. The guts are dying, and the lactate is going up.

Then, we have this other side where there's AKI developing, so we literally can't clear it. Let's say you're a doctor that has access to an MA, or an RN, or a scribe of some sort. We all know what it's like when you have that turnover, and all of a sudden you can't manage. That, to me, is well, you've gotten the AKI, the kidneys have shut down, so the lactate is not being cleared. Any support we're given, many of the times, is temporary. We keep having these temporary Band-Aids.

We have a lactate production problem, in addition to a lactate clearance problem. In a nutshell, Graham, that's US healthcare.

GW:

If we can't clear our lactate and we're producing it, certainly all the stressors and the requirements aren't helping. Have you seen anything that is helping on the other side?

TS:

There's a whole range of things that can help with burnout. But if we all accept the definition of burnout, that it's an occupational diagnosis, it really requires a system or occupational treatment.

GW:

Yeah.

TS:

This is why we're really at danger of using, I think ... I'd agree with you, Graham. If we use these words like resilience and wellness in the wrong way, we will batter the soldier, AKA the physician, and they will think that that means something's wrong with them and they have to do more. Like yoga, or pizza parties, or whatever.

GW:

Right.

TS:

What are things that actually have worked? I'm going to go backwards. Let's talk about the elephant in the room, which is AI. Maybe I need to toss it back to you.

I'm chief clinical officer of an AI company called Abridge. We're getting really close to analyzing what will be, I think, the industry's first multi-center study that uses validated measures for cognitive load and burnout. Cognitive load is a precursor to burnout. High cognitive load, high odds of burning out, high odds of leaving the industry.

GW:

Oh, interesting.

TS:

I'm pretty sure where we're going to end up, because our early evidence has shown some pretty favorable responses. But I'm curious what you think about ambient AI?

GW:

It does feel to me that the cognitive load piece definitely feels real. When I have 10 patients and a line of nurses waiting to ask me stuff, both the cognitive fatigue and the decision fatigue definitely make me I think more prone to feeling overwhelmed. I do think that AI, once validated, and evaluated, and tested, and thumbs up, does have a significant ability to reduce that cognitive burden substantially, which is the reason I'm particularly excited about it. That it has the ability to do the chart biopsy for me. It has the ability to write my note for me. It goes from maybe it takes me five minutes to skim through a chart, to it takes me two minutes.

I tell people that I don't see it as I'm going to spend three more minutes seeing an extra patient. It's that I am just going to be less cognitively loaded. I'm not going to be operating at 100% of my brain cells for my entire shift. That is going to allow me the time to practice medicine, which is this thing ... It's a place I go to in my head, thinking about what could be going wrong with the person, and I'm thinking of all the things I need to do. It does feel like it's a place I go to and I can't go there if I have a full cognitive load as well.

TS:

Oh, I really love what you just said, Graham. I want to throw out a beautiful visual, which of course I will describe since we're talking.

Imagine your brain being a battery. It's finite. You have a finite amount of charge that you can use up. Every time we task switch ... You're manning 10 active patients you're working up in the ED. But every time you flip between patient to patient, you actually expend some of your brain battery.

GW:

Yeah.

TS:

Every time you have extra steps, let's say you're trying to order a medication, or you're trying to call in a consultant but you can't find who's on call, and then you have to go from person to person, all those little administrative type of works we do also eat at the brain battery.

Then, there's a bit of load of working memory that is. The brain battery is basically working memory. There's a bit of load for synthesizing the data. Us, as attendings that have been out for some time, we're way faster than when we were med students.

GW:

Yeah.

TS:

Then there's appropriate brain battery to do that thinking you described. Which is how do I know that it's SCAD or not?

But the problem is, when the extraneous load from the task switching, from taking multiple extra steps just to find that consult, the person you actually need to call, or to put in those orders, when that gets so high, you literally have no room left for the medical decision making. That's what's happening today.

I really like to harp on cognitive load. It doesn't have the stigma that some of the other words we've used, like burnout and wellbeing. It's brass tacks. It's also been associated with an increased risk of medical errors, particularly in studies that have included in spaces like critical care and inpatient spaces.

My framing, just independent of thinking about technology, is that there are four things we can do. One is we need to give clinicians the ability to give input, because doctors know exactly what's wrong and how to fix it, and we often don't get the space to tell the people that can make those decisions what needs to be done. Give us the ability to give input.

The second one is help us with anything that makes us inefficient. We just talked about this. If you're training a new scribe every two months, or if the process to find the on-call cardiologist has just gotten more clunky, then we're inefficient and that's actually going to drive burnout. Can we fix that?

The next one is anything that inhibits our quality of care, that's going to burn us out. When the MRI machine goes down, or when it's there, I know it's there, but somehow it's been seven days and I still can't get that MRI brain when the patient's in the ICU, that's really tough. I'm like, "Is there something there or not?" But anything that inhibits our quality of care.

And the last one the one that's for free. We need to be acknowledged for the daily works that we do that are above-and-beyond. You mentioned this a little bit before with, "I left my shift. Did I even do anything?" The truth is, you're doing these heroic works probably on the hour, if not more. But the absence of a thank you, and the presence of so much negative feedback is what's burning us out, too.

On one hand, it's overly simplistic, but I find this framework of four things which is give us input, allow us to practice at the highest quality of care, allows us to practice more efficiently, and acknowledge the hard work and the above-and-beyond work we're doing, those are the four things that can address burnout. There are evidence-based ways that are cheap to implement these things.

GW:

Tina, I said at the beginning you were going to make me feel hopeful and inspired. It's a self-fulfilling prophecy there. I totally agree. I've seen people posting questions online like, "Oh, I really like my colleague." Or, "Gosh, I have such a great relationship with my ICU consultant," whatever. "What should I do for them? Should I buy them some coffee or a pizza party?" I tell them I don't think there's anything better than a handwritten thank you card, where you are brutally honest about what it means to you that you have a trusted colleague that has helped them. Or, "Oh my gosh, you totally saved that patient. I never would have thought it was thyroid storm. I just feel so appreciated and so lucky to have you as a colleague."

TS:

I wanted to add one more thing, because I find this really hilarious. Have you seen that New England Journal? It was a very short article that was written years ago called GROSS.

GW:

Oh, Get Rid of Stupid Stuff?

TS:

You got it! Let me explain it, just in case folks haven't seen it.

GW:

Please.

TS:

I think it was Hawaii Pacific Health. Literally, what they did was they sent out a survey. It said, "What doesn't make any sense? What should we fix?" They literally got rid of stupid stuff. The key to this-

GW:

In HR I think predominantly, as well. I think it could be any workflow.

TS:

That's right.

GW:

But a lot of it was EHR flow sheet rows, or dot phrases that were no longer necessary or they were stupid, essentially.

TS:

Yeah. You're right that we often focus on the EHR. I think that's valid because we've created workflows that are overly complicated. But the key to what they did was not only asking the question, they solved for they gave us input, they had a running list. It might have been something as simple and effective as an Excel sheet that everyone that worked for the company could see, so on a SharePoint. They listed all the recommendations that came from the survey, and then they had a traffic light system. Yellow, here's what's in progress, here's where it's at. Green, here's the growing running list of what we've solved. And red, here's why we can't do it, and just at least being able to give you that feedback. Let's start slow and effective.

GW:

Tina, let me ask you one more question before our little wrap-up segment. As you're the chief clinical officer of Abridge, what have you found is a successful argument or a good way for a physician who maybe doesn't have an ambient scribe technology, or platform, or strategy. I'm a frontline nephrologist, I'm not involved in my IT decision making of my health system. Is there a good way for someone to be able to access the CMIO, the CIO, the CTO, the people that might make that decision and influence that?

TS:

With a grain of salt, I'm going to reveal a Tina Shah trade secret, but please feel free to pinch this. You ready?

GW:

Okay. I'm ready.

TS:

All right. I have this theory only because it feels like it's true since every time I use it, it works. You know who checks their email on the weekends? Executives do. I think there's really nothing stopping us from dropping a note to the very people that are there to try and make healthcare better. We deserve to. In fact, they want to hear from us. We should keep it succinct. Everyone's struggling with information overload.

GW:

Yeah.

TS:

We shouldn't bring problems, we should really bring solutions. But, what about at 7:00 or 8:00 AM, a short little note to say, "Hey, I'm a nephrologist, I've been working at this hospital for some time. I have this idea. I'm wondering if we can talk about," whatever it is, "ambient scribes. I heard that it's reducing cognitive load." In fact, we're hopefully, fingers crossed, going to show some data showing that we did a randomized trial, and cognitive load is reduced by 61% with the ambient tool that we have. Or, "I have this idea on how we can get rid of this one low-value task that is always happening when CRRT gets started. Do you have five minutes to talk about it?" That's it.

GW:

Yeah, love it. Short and simple, and on the weekend mornings.

All right, Tina, in our last few minutes, we've got some rapid fire questions. Whatever comes to the top of your head, top of mind. We call it On the Clock, because it's supposed to be as fast as possible.

Tina, what are the best and worst parts of your specialty?

TS:

I guess I would say some of the best is the highs when we save lives, which I think many specialties share. The lows are that patients come to us too late.

GW:

Tina, if you could instantly cure one disease, you only get one, one disease forever, which would it be and why?

TS:

Loneliness. Loneliness is actually more deadly than many of our chronic conditions. It's equivalent to smoking a very large number of cigarettes. It is directly associated with diabetes development, cardiovascular diseases. It's something that appears to be growing as our society fractures more. I think we should heed the Surgeon General's warning and focus on loneliness. It's what's underlying a lot of what we experience today.

GW:

I love asking that question because I never have once correctly predicted what people are going to say. I love it.

Tina, what is something you didn't learn in med school, but is crucial to your daily practice?

TS:

I think it's getting to know all the people you work with, not just the people that have titles.

GW:

Tina, if you were not a doctor, what would you be doing?

TS:

I don't think I would have strayed too far from science. I probably would have been an engineer, based on just watching my dad do amazing things.

GW:

Tina, you win $1 million today. Are you still practicing medicine tomorrow?

TS:

Yes, but I would definitely have ambient AI by my side.

GW:

Here's the harder question, Tina. Tomorrow you win $100 million. Are you still practicing medicine tomorrow?

TS:

Wholeheartedly, yes. For as along as I can be a good physician. I think what that means is the 100 million allows me to get rid of all those other things that are in my way, so I can just be a doctor.

GW:

Get rid of stupid stuff.

TS:

That's right.

GW:

Okay, Tina, you may have an answer for this one already. What is the best use case for AI in medicine today?

TS:

The most effective, in my opinion, is using AI to help with our medical documentation, namely our soap notes.

GW:

Yeah.

TS:

That's not a theoretical, that's in use by tens of thousands of physicians today.

GW:

Tina, what's the most ridiculous thing you've been dinged for?

TS:

Oh, man. That's a tough one. I'm going to give a classic.

GW:

Go for it.

TS:

Well, what type of CHF was it? Was it acute or was it chronic? Was it preserved DF or was it reduced DF?

GW:

Reduced DF. I love it.

Tina, what's the most ridiculous thing you've had to argue for prior auth?

TS:

Imagine having a patient who has had childhood asthma and is well into their 30s, and you still have to argue. They've been on inhalers for their entire life that they'd had asthma.

GW:

Yeah, that doesn't surprise me, unfortunately.

Tina, what's a medical myth you wish would just disappear forever?

TS:

I think we've got a couple of things we need to remove that are embedded structural racism that we're tackling. One that comes to mind is how we calculate creatinine clearance, and how that's shifted over the last decade. I'd love to see that fully go away.

GW:

If you could design a new medical specialty, what would it focus on and why?

TS:

I think I would design a new medical specialty focused on the wellbeing of the workforce. I think if we don't do this, then we will continue to see attrition across all the health professions.

GW:

I agree with you. Tina, do you have a lesson from a mentor in medicine that still shapes your practice or how you see the world?

TS:

Resist the temptation to go to the EHR first, go into the bedside.

GW:

I tell the residents, "When in doubt, see the patient."

TS:

I love it. I love it. Yes.

GW:

That's the snarky ER version.

Tina, thank you. It's been really such a pleasure to get to talk with you again. Thanks for taking the time away from your practice, and students, and everything to spend time with us today.

TS:

It's my pleasure. Thanks for having me.

GW:

Thanks for joining me today. For more strategies on managing burnout in healthcare, visit offcall.com/podcast. Make an account on Offcall to confidentially share your details about your work, and sign up for our newsletter where you can hear more about the latest trends we're seeing in physician pay. You can find How I Doctor on Apple, Spotify, or wherever you listen to podcasts. We'll have new episodes weekly. This has been and continues to be Dr. Graham Walker. Stay well, stay inspired, and practice with purpose.