A Chat with Better Together: A Scalable Solution to Physician Burnout

View Transcript

Dr. Elizabeth Harry welcomes guests Drs. Adrienne Mann and Tyra Fainstad, co-founders of Better Together, an evidence-based group coaching program transforming physician well-being.

They share their personal journeys from burnout to coaching, explain how metacognitive group coaching builds community and resilience, and present compelling data showing significant reductions in burnout, imposter syndrome, and moral injury.

The episode explores how scalable, confidential coaching can reshape medical culture and restore meaning in medicine.

• Learn more about Better Together Physician Coaching here

Transcript

Dr. Elizabeth Harry:

Welcome to the Well-Being at Michigan Medicine Podcast. I'm your host, Dr. Elizabeth Harry, and today I am joined by two of my favorite people, Dr. Adrienne Mann and Dr. Tyra Fainstad, the co-founders of Better Together, which is an innovative online group coaching program, which is designed to reduce burnout and promote well-being among physicians.

As burnout continues to rise across the medical profession, scalable evidence-based solutions are more critical than ever, and Better Together offers just that. Using a metacognitive coaching approach, the program equips participants with practical tools to reframe their thoughts, drive meaningful change, and adopt healthier coping strategies. Participants who complete the program report significant improvements, including lower rates of burnout and imposter syndrome and increased levels of self-compassion.

In this episode, we'll explore how Better Together works, why it's so impactful, and how this model can be used to scale across hospitals, residency programs, and academic institutions to support the future of health care teams. So welcome, Adrienne and Tyra. I'm so excited to have you guys here. Could you just tell us a little bit about yourselves and how you got into this? How did you come to coaching to begin with, and when did you realize that something like Better Together needed to be built?

Dr. Tyra Fainstad:

We would love to. Thanks so much for having us. Yeah, I will start with by saying that my come to coaching story is really one of deep skepticism and hesitancy. I was a pretty classic internal medicine resident trainee at the time. I was in Seattle, Washington, and I was bolstering my ego with approval, as many medical residents do.

And I was collecting positive feedback and perseverating on negative feedback and sort of barely keeping my head above water and somehow made it through residency and chief residency and got what I thought was my dream job, which was an attending position at the clinic that I had been working at and really had an expectation that this is when I'll finally feel like my head is not about to go underwater. And the opposite happened.

What I know now, looking back, is that addiction that I had to praise was being fed along the way of training. And when I graduated and became an attending, almost all forms of feedback came to a complete halt for me. And that was very jarring. We really don't get anybody watching us in the room with patients anymore. Sometimes you get interesting pieces of patient feedback, which I'll put a pin in for now, but it felt like the floor dropped out from under me.

And I was really only left with this very loud inner critic that I had cultivated during training to try and force me to work really hard. At the same time, I had two kids right out of residency, and they were terrible feedback givers, I would say. They were super colicky, and I seemed to be doing everything wrong in motherhood. My inner critic was telling me I was doing everything wrong in my career, and I hit rock bottom. I struggled so much in those early attending years.

I felt like I was doing a terrible job in basically all of my roles, and I looked outside of myself to try and fix it. I tried harder at everything. I tried a couple of SSRIs. In my case, that wasn't the silver bullet. I tried scaling down at work, thinking like, "Maybe I'm not cut out for this." I ended up feeling worse, so then I scaled up at work. That wasn't helping either. And I had a friend going through coach certification at the time offer me a free call for feedback.

And I mean, I rolled my way into that conversation because I was a Western medicine-trained doctor at the University of Washington. I like evidence-based interventions, and life coaching sounded basically like a fancy term for cheerleader. But because it was a dear friend, I agreed to that conversation. And I mean, more in my life, my mind, my experience changed after that 50-minute conversation than probably the last decade of my life.

I learned some really crazy epiphanies that I still am relearning to this day, but I was totally hooked. Hired my own coach and fell back in love with my job, fell in love with motherhood, and came out of that pretty grateful, but also really angry that these skills weren't taught to me in medical training. Like, how do I know all the steps of the coagulation cascade, but I can't name and process a feeling, seriously, in one of the most emotionally ridden fields that exist? And so the idea was born, and then I crossed paths with Adrienne.

Dr. Elizabeth Harry:

I love that. So Adrienne, do you want to rewind a little bit and tell us what your journey was happening at the same time, or when did yours start in relationship with you guys crossing paths?

Dr. Adrienne Mann:

It's so funny because Tyra and I were med school classmates, but weren't really in the same circles during medical school. And it was a medical school mutual friend who kind of, this year, right before we got everything started, was like, "Hey, you guys are doing the same thing. You should combine your efforts." And so I mean, my story's really similar to Tyra's. I got my dream job after residency, but probably if I look back through medical school and residency, I also was constantly feeling like the house of cards might be exposed.

People might see that I'm not as good as the feedback I'm getting, or I got my dream job, and it is like, "When are they going to find out that I don't belong here?" And my real on-ramp to coaching was I had taken on an institutional leadership role at my hospital when I was fairly junior, and that was not on my bingo card. I thought I was going to be a big e-medical educator, and I wanted to be the medical student site director. But an opportunity opened that was not that, and I said yes to that. I was running my group.

And in that same year, I was going through fertility treatments and trying to conceive my second kid, who was then born early. And when it came time to come back, I didn't recognize myself really in any part of my life. I didn't recognize myself as a clinician. I didn't recognize myself as a leader. I didn't recognize myself as a mom or as a wife or as a partner. I didn't recognize myself in my body. I felt really disconnected from all of the versions of myself that I'd kind of crafted that were outward-facing. And I didn't really have any tools to relate to myself at all.

I was really good when other people said, "Do this. Jump here." And I could say, "How high?" And I could do it. And I did everything I was supposed to do, but after coming back from that second kid, couldn't see the way forward. And I hired a coach for similar reasons and really learned a lot about how I had learned to kind of outsource my opinion of myself to other people's opinions of me, how I'd learned to say yes because I was uncomfortable saying no, and what that would mean about my relationships or opportunities.

And so I did a lot of work of trying to understand myself better, which was something I hadn't ever taken the time or learned how to do. And so I did that through coaching. I'm sure there's many different ways for people to learn how to understand themselves better, but this is the way that was transformative for me. And I thought I needed something like this as a resident. I needed something like this as early junior faculty. And so when Tyra and I were reconnected, it really felt like this is an opportunity to build something that our past selves needed, even though we didn't know we needed it at the time.

And so Tyra got a grant through SGIM, and I got an internal grant at CU. Tyra was recruited back to the University of Colorado, and we kind of joined forces to build what started out as a program for women in GME, but now has expanded to be a program for clinicians at really all stages of training, medical students, residents, faculty, advanced practice providers, and we're building on that every year. So it's the biggest gift of my career, I think, to be able to be doing this work with Tyra.

Dr. Elizabeth Harry:

That's amazing. And what I love listening to your stories is it almost seems like both of you found a solution that you didn't quite realize you needed, couldn't really understand exactly why things didn't feel right. And so I'm curious, as you've built this and coached [inaudible 00:09:02]-

Dr. Adrienne Mann:

Thousands.

Dr. Elizabeth Harry:

Thousands of physicians, how many people fit into that bucket do you think of, have this sort of problem that they didn't know they needed this solution for? And how has this coaching closed that gap for them?

Dr. Adrienne Mann:

That's such a-

Dr. Tyra Fainstad:

I think the people that come to us come to us for that reason. There's a problem and they can't quite put their finger on it, or they want to feel better, but they're not sure how to get there, or they feel like something's in their way, but it's very vague.

And so probably the people that land with us, it's got to be a majority, if not all of them, share that story. I mean, what we know from coaching, especially in a group format, is that everybody thinks that their thoughts are unique. Everyone thinks that they're some very flawed, special snowflake. And then what we discover is actually the thoughts are shared by all of us. And so I would say this is not... it's not a coincidence that Adrienne and I have such similar stories. I think this is the story, and it's created because we have human brains, but also because medicine as a field probably has its hand in creating those narratives.

Dr. Elizabeth Harry:

And so you mentioned a little bit of frustration that you weren't taught this information sooner, or how to think about this as a trainee and then as a practicing physician. What gap do you notice in our education that you think this is able to fill?

Dr. Tyra Fainstad:

I mean, emotional agility or the ability to name and move through an emotion is, I think, still seen as a soft skill for better or worse. And it pales in comparison to the harder skills that clinicians need like memorizing facts and procedural skills and the actual doing of the medicine, which on its surface feels really compelling. I mean, those things are pretty easily teachable, and we can all become expert in them, and the stakes are so high. It's literally life or death when it's you and a patient.

And so it's very important that you meet a level of competency. However, I think the downstream effects of not managing your emotions are that every single one of those skills suffer. I mean, the stories that we hear of burnout and moral injury and worse are inherent in every single person that comes to us, and it has affected their clinical life, their personal life, their career arc in so many ways. And so I think the gap is that we aren't... lip service is given to emotions, but no tangible skills in medical training.

Dr. Adrienne Mann:

I wonder, I mean, I'm thinking back to the preclinical and early clinical years in medical school, and we do spend some time talking about emotions, but it's never our own.

Dr. Tyra Fainstad:

Yes.

Dr. Adrienne Mann:

So for good reason, we learned how to be empathetic with the patient, and we learned how to invite and listen and summarize, and we learn how to manage other people's emotions actually. And I think we get really good at that, almost too good at that. And in doing that, don't learn how to manage our own.

And so we get really uncomfortable experiencing disappointment, experiencing failure, experiencing when our reality doesn't meet our expectations, experiencing injustice or unfairness in our training scenario or our work environments. And so, because we're so outward-facing on managing what other people do and think of us, the skill I think we're missing is learning how to examine and understand our own thinking and doing.

Dr. Elizabeth Harry:

And so you take a group of professionals that are sort of... maybe haven't been taught this skill. And I'm hopeful, looking at my own kids and sort of the conversations they come home from school having, that this won't be consistent. That, as we're putting different generations through that are getting different educations when they're younger, maybe folks will have more mental fitness, mental flexibility, more metacognition, and the ability to sort of watch and manage their mind.

But you've identified a real gap in this sort of cohort of physicians that are coming out of training that really didn't get that when they were younger. The growth mindset and all that came out later. And then they're put in this system that has all of its own difficulties, and they're doing a profession that's really hard. When you interact with these thousands of folks that you guys have coached, what do you think are the drivers that are creating this sort of burnout epidemic that we're seeing?

Dr. Tyra Fainstad:

There are so many drivers that you are very familiar with that much of our landscape is becoming familiar with. I mean, I could talk till I'm blue in the face about EMRs and work compression and understaffing and all of that. What I'm really interested in, in addition to all of those sort of flaws inherent in the corporatization of medicine, is actually what I think we're getting at within our coaching conversations, which is a sense of agency that is necessary for well-being, a sense of competency or doing well, and a sense of relatedness.

So those three senses or perceptions, autonomy, relatedness, and competency, we know from decades of research in organizational psychology and other fields, are necessary for fulfillment. It creates self-determination, and it creates intrinsic motivation. And the more I have learned about this, the more I realize medicine as a field and as it's become more and more corporate, has stripped... unintentionally stripped those things from us.

And so I think with well-intentions, the landscape of medicine has changed into a more standardized trying to get better patient outcomes, but unfortunately has stripped physicians really of their purpose and meaning for being here. And so I think really we'd have to start kind of from the ground up, building a system that gives physicians their meaning and their mission back, specifically thinking about those three facets.

Dr. Elizabeth Harry:

And what I think is so impressive about what you're saying is that I could see pushback. If we were to tell someone, "Hey, we have this coaching program and you can go through it, and it's going to help you with your burnout," I could see the story of like... But the work compression and the EHR and all the system things, which we know drive burnout, and we know are real things, and yet you're not just anecdotally telling us people feel better after this. You guys actually have really rigorous data that this reduces burnout. Tell us about that.

Dr. Tyra Fainstad:

Well, yeah. And I think inherent in that argument, where it's sort of, is it the system's responsibility to change, or is it my responsibility to change? Of course, the system has to change. I'm ready to burn it all down and rebuild a better system that supports physicians and patients alike. I have many ideas that I won't waste time here talking about. And the system is oppressive in many ways systemically.

There's racism and sexism and a million problems with the system and with our culture at large that are contributing to the burnout that physicians are feeling. And, and even if we were to wave a magic wand and fix it, if we had the perfect EMR and we figured out the exact right service sizes and the exact right ratios and staffing, the physicians that trained and grew up in the old system would still have their same thoughts.

They would still have that hardwiring that tells them to push themselves past their capacity, that tells them that they're never enough because we learned that somewhere in medical school. And so if we don't also address that hardwiring, they're not even going to notice that we've come up with better systemic changes. And that's what we're finding. I mean, in the training level, lots of things have gotten better in the last 20 years.

Lots of things about the work-life balance and what we're asking trainees to do, and burnout has continued to rise. I mean, it's doubled almost in that time. So I think the missing piece is that we aren't addressing the hardwiring, which is what we're doing in Better Together, and probably responsible for the real impact we're seeing in outcomes. So our largest study to date has been that cohort that we ran in 2022, where we had a thousand resident and fellow physicians.

Our study design has been to take half of those who enroll and give them the Better Together program, the coaching program, and then the other half becomes a waitlist control. And we measure pre- and post-burnout, moral injury, imposter syndrome, self-compassion, flourishing. In that study, every single outcome we looked at improved statistically and in a clinically meaningful way. We had a seven-point improvement in total burnout between the coaching group and the waitlist group.

This has been... Now, actually, we just completed our fifth randomized control trial. So we've replicated that trial in medical students, in faculty, in APPs, and then twice in residents and fellows. And every single one of those has a positive impact in the coaching group. So we can say, for sure, that the coaching works. We know that this works. This helps people feel better and do better. We've also started to dive into why it was some qualitative work.

Dr. Elizabeth Harry:

Well, so tell us more about the program? Adrienne, could you walk us through what a typical week in the four-month program would look like and how does this even logistically work for...

Yeah. Yeah. I'm thinking back to my residency and being like, "Well, when would I have done this?" And honestly, people even say that now. Faculty are like, "I don't have room for anything else, so how could you even think about asking this?" And yet I feel so compelled to look at this because we don't have effect sizes that reduce burnout like this from other interventions.

Dr. Adrienne Mann:

Yes.

Dr. Elizabeth Harry:

It's really quite remarkable.

Dr. Adrienne Mann:

Thank you. Yeah, let me tell you. So I'll tell you first of how our relationships work with institutions and stuff like that, because I think that's important. So Better Together, we're a curricular offering from the University of Colorado. We're not a business, but we partner with groups like Michigan Medicine or any institution, residency program, hospital system, any group that wants to provide coaching to their people. They can be trainees, medical students, faculty, whoever. And they tell us, "Hey, here's the eligible group."

It's the Department of Medicine, or it's the medicine residency program, or whatever. And all of those eligible folks, the institution pays for the subscription to Better Together. And all of the people who are in that group get invitations to join either or both of our sessions, which run over the course of an academic year. So we run one program in the fall and one program in the spring. Each of those is 16 weeks or four months long, and folks can opt in and participate absolutely anonymously and confidentially.

So what that means is my program director never finds out if I signed up and got coaching about my burnout, or my department chair never gets to know that I am unhappy or thinking about leaving. Everything that happens in Better Together stays in Better Together and never is reported back to the institution or the partnering site. And so, what folks sign up for when they register to participate in one of our cohorts is a really, really participant-centric and flexible thing.

So we know, and we built this for residents, everybody is super busy, and nobody has five hours a week or even five hours a month or maybe even five hours over four months to spend a lot of time scheduling with someone else or doing homework or feeling behind. And so what we built is a web-based platform where participants can access kind of four different types of coaching, and they can do all of them or whichever combination of them feel right. The first is a 16-week self-study. Basically, we teach one concept a week over 16 weeks.

There's some worksheets that go along with it, and they can take each of those weeks of the program at their own pace. Along with that, there's group coaching, which is what we think is the really transformative part of our program. But that's where we host between one and three calls per week for the different groups. And those are open to everybody across the country. So, right now, we've got about 1700 people in the program, about a thousand of them are residents. We have one resident call a week.

Of those thousand residents, whoever's available might show up to the live call, and they can raise their hand and have a coaching conversation with me or Tyra or one of our coaches about anything that's going on for them. Those conversations are about 15 minutes, 20 minutes long. We usually have three or four of them over the course of the hour. And again, they're confidential and nothing that happens in a Better Together group call leaves the Better Together group call or the cohort that we're in.

We know folks are busy, so if they're not able to attend live, they can listen to the call recording later. And then we also have written coaching, which is on our website. Say somebody's on call in the middle of the night and they're having something they want to work through, they type into us, and we respond and post it back on the website. This is a really great asynchronous way to do it, or for someone who doesn't really want to do the face-to-face. And then the final way folks get coached with us is in one-on-one coaching.

And so we have a team of, I think this season we have 30 really incredible certified coaches, all of whom are physicians or advanced practice providers. So they all know what our participants are going through, and participants can take up to four one-on-one coaching calls over each four-month block. So that's what the whole program looks like. What we really see is people coming and going into and out of the program and participating in the parts that work for them.

You can be active in Better Together with five minutes or two hours per week, like whatever feels right. And we're really flexible and make sure that people know that. The last thing I'll add, which is new for the past year, is that for folks who are done with training, we also offer CME. So folks can claim 16 hours of CME after completing each of the four-month blocks. And so we're really trying to make it so their time is spent not only meaningfully for them, but also getting credit for the work they're doing.

Dr. Elizabeth Harry:

And you said that... I mean, it sounds really comprehensive, and you said that you feel like the group coaching is kind of the secret sauce. Why is that?

Dr. Adrienne Mann:

I think it's because when we're on a group call and some brave person raises their hand to come up and talk about feedback that they got that stung or a relationship that they're in that they're struggling with, I think if we were one-on-one, it would still be possible to leave that coaching conversation thinking, "Yeah, I don't know. I still don't... I don't know. I feel alone in this."

And there's something about the group coaching where if you're listening, you see yourself in the person who's being vulnerable on the screen in front of you, or you hear yourself or your experience in what they're sharing. And so I think the most powerful thing about our group coaching model is for the audience to realize even if they never raise their hand, like, "I'm not alone in my experience of the world."

And sometimes when you hear someone else get coached about a challenge, you can see the path forward for them maybe better than you can see the path forward for yourself. So, sometimes hearing somebody else work through something opens up something in you that you might not have been able to get to. And so, that's really what we found about group coaching is that people appreciate seeing other people go through what they're going through.

Dr. Elizabeth Harry:

Yeah. It hits on that relatedness piece. And then my experience, having also gotten group coaching, is that I think physicians are really tied to their beliefs, as like, "But my brain offered it to me. It must be [inaudible 00:26:09]-"

Dr. Adrienne Mann:

Right.

Dr. Elizabeth Harry:

Right. But then, when you see someone else, and they're like, "But your belief, I don't believe that. So clearly your belief is wrong." It's so much easier to see the cognitive error in someone else's brain than your own. And then you're like, "Well, maybe my brain does that too." And I just-

Dr. Adrienne Mann:

Yeah.

Dr. Elizabeth Harry:

"... My brain does that." Yeah. It sort of accelerates it, right. It's an accelerant for the process. It feels like it makes it go a lot faster.

Dr. Adrienne Mann:

Totally. And the vast majority of our participants never raise their hand for group coaching. And so, what's really remarkable about the results that Tyra shared and how dramatic our impacts were, were that this is a tiny minority of people who are raising their hand for the coaching, but a big impact across the population. So there's something about even the passive consumption or the fly on the wall.

Dr. Elizabeth Harry:

Yeah.

Dr. Adrienne Mann:

[inaudible 00:27:01]-

Dr. Elizabeth Harry:

It's a positive whereas a... Yeah. Well, and what I... Gosh, what I... There's so many things I love about it, but one of the things I love about it is that I think when this started, there was sort of this viewpoint of like, "That'll never work. Physicians need a one-on-one executive coach." Right.

Dr. Adrienne Mann:

[inaudible 00:27:15] feeling special.

Dr. Elizabeth Harry:

Right.

Dr. Adrienne Mann:

Yeah.

Dr. Elizabeth Harry:

Because we're so special, right. Sitting in a room with a bunch of people talking about whatever story it is that they're challenged with at the moment, how could they ever feel safe to do that, and how could that ever work? And so what is it? Why do you think that has worked?

Dr. Tyra Fainstad:

Yeah, that's so interesting because when we first were thinking about creating this program, it was like late 2019, early 2020, and we pictured, we knew group coaching was going to be foundational, but we did picture the group like a fireside chat in person with Adrienne and I, and then the pandemic hit. And so almost by accident did we pivot to what it is now.

We thought for sure we were giving up a feeling of psychological safety and community in order to, of course, keep ourselves physically safe now that the pandemic was there. But actually, the opposite happened. So with those very... that first cohort, we did a qualitative analysis of their experiences. And in addition to liking our model and the multi-modes that they could choose from, the biggest theme that came out of that was that they felt a sense of community with these people that they never had met or were in the same room with.

They felt connected to people. And this was replicated in our national trial. People said, "I felt more connected to this PGY9 as an intern over here on the other side of the country, never having met them, than I do to my best friend in this moment." Actually, as the program has grown, so it went from being a very local internal medicine residents at the University of Colorado to any clinician at any stage of training across the country.

And as it's grown, the impact has also improved, and so has engagement. And so we think there's something about the anonymity that being on a Zoom call with hundreds of other people gives you. The fact that everybody's there and you don't necessarily know who's there. And we definitely allow people, of course, to come up with their cameras off or a pseudonym, but that anonymity allows them to be much more vulnerable than they would if it was their peers in some medicine small group or something.

And so I think that happy silver lining of the pandemic is responsible for how much we've grown, first of all, how impactful it is, but also how incredibly scalable this program is now. I mean, we can host one call with Adrienne and I as the coach from 5:00 to 6:00 on a Tuesday afternoon, and there could be three people that get that coaching, or there could be 3000 people in that Zoom audience, and it's the same amount of our time. It's just incredible scalable.

Dr. Adrienne Mann:

I think what's powerful too about that is as we've grown across the country, I think it's common for people, specifically at an institution or if you have a group that shares an identity within an institution, that they think the problem is local.

And there's been something about having groups that are across the country to be like, "Oh, the EMR is also bad over there," or, "Everybody hates charting." Or whatever the problem is, it normalizes a lot of like, "Okay, a lot of physician culture sometimes is a problem or beliefs we have around how we need to be perfect" and hearing that that's no different here than it is there, but we are all thinking similarly and that is a problem. How do we readdress that collectively? In conversations like this we're willing to talk about it.

Dr. Elizabeth Harry:

I just love it so much. There's so many pieces about what you guys said that I love. One is this collective vulnerability, right. And I was thinking about this even. I took a course last week, and in the five days of the course, they do all these things where everybody gets to know each other, and you sort of share challenging things or whatever.

And by the end, you have this feeling of closeness with these people that you've spent five days with as compared to people that you may see regularly, but there's no sort of structured opportunity to create that authentic connection or that real sort of humanness and being present with one another in our a little bit more messy, vulnerable selves in a way that feels safe. And it's like you've been able to sort of package that and create a space for that, which I think is so incredible.

And then the other piece that I just love about it is this idea of that there's something within our control. And that's so important because I can't tell you how many times I talk to people, that it's like, "Well, all of this is outside of my control, and I am a victim of the circumstances." And that's not to say that, Tyra, you said this very well earlier, that there aren't things that shouldn't be changed. There are. And if we don't have control over any of those things, that's incredibly disempowering. And so it's really-

Dr. Tyra Fainstad:

It's forever.

Dr. Elizabeth Harry:

Yeah. It's really nice to hear that there are things within our control that actually make a really big impact. And so you've mentioned a lot of data. What surprised you most out of all of your data that you've seen?

Dr. Tyra Fainstad:

The two things that have surprised me most, one I already hit on, which was that people feel a deep sense of community with perfect strangers. That was completely unexpected and came from a inductive qualitative analysis, so sort of rose up through our interviews. And the second thing that has surprised me is that the group model and the passive. I think, as Adrienne was saying, a lot of the impact that we see is in people who never even get directly coached and the impact seems to grow as the program spreads even wider.

And so it is easy to think that you need a one-on-one executive coach in order to get a really tailored, impactful experience. And our trials have rival trials that look at one-on-one coaching with the same study design, and our impact is better. It's more in magnitude. And I think that has been really surprising in learning you don't need this perfect person, very expensive coach to help you have an epiphany, but really it's this sense of probably community and normalization that we can get so easily.

Dr. Elizabeth Harry:

So you do have this really diverse group of coaches that you've talked about, and they have a lot of diverse backgrounds. They're from all over the country, and you mentioned physicians, APPs. Do they have to be a physician, do you think?

Dr. Adrienne Mann:

I think it helps with the coachee, or the person who's coming to the conversation, doesn't have to explain why this is hard or why this is a challenge. I think it helps to have somebody who's had at least some part of a shared lived experience around that identity that we hold, I think, as clinicians.

So there are coaches who aren't physicians who can be tremendous and brilliant coaches of physicians. And I think for us, what we're able to do is dive deep really quick into saying, "Yeah, yeah. We know 80-hour workweeks are too long, and we shouldn't have them, but now what? How do you want to show up?" And they don't have to build the case for why an 80-hour workweek is done. You know what I mean?

Dr. Tyra Fainstad:

Yeah. I'll also add, and we didn't necessarily say this explicitly, but coaching or wearing the coaching hat is so different than other mental health resources. We are not doing therapy, and specifically in our coaching hat, we are not diagnosing or treating ever. And so any... non-physicians and non-mental health practitioners can, of course, be coaches. And what gives me a deep sense of safety is that all of our coaches are clinicians and so can sense or screen for decompensated mental health issues, which, not frequently, but occasionally do come up on these calls.

And so one of our stipulations with all participating sites is that they do have mental health resources available on the ground of where a person is. And so then if you have a coach who, though they're wearing their coaching hat on the call, can also diagnose in their other hat, "Gosh, it really sounds like you're struggling in a way that is beyond what I can do here. Is it okay if I keep you on the call and hook you up with resources?" That gives an enormous sense of safety that I think a non-physician coach, you can't necessarily get that level.

Dr. Elizabeth Harry:

Thank you for bringing that up because it's a really important point. And I think a lot of these terms get thrown around a little bit right now because it is sort of an unregulated industry, and there's coaching, and there's mentoring, and there's sponsorship, and everything's super in vogue, and anyone can sort of hang a shingle and say, "I'm a coach." And so, do you have particular processes to kind of vet your coaches or make sure that they're singing from the same hymnal, if you will?

Dr. Adrienne Mann:

We do. And I'll also just say to that note, it's such an important skill to have to be able to navigate between, we call them different hats, but the mentor hat and the advisor hat, and the teacher hat, and the evaluator hat, and the coach hat. And what we tell our participants is that, "When we're in the coach hat, I don't know what's best for you. I can't tell you the path forward or what next step to take. My job is to sit here with you, and look at the problem, and ask questions so that you can define the next steps for yourself.

And I do that with full belief and love for you as a person, not contingent on whether you get that IRB in or not, contingent on whether the patients like it, none of that." So we make sure that we're really clear in what hat we're wearing and what that means. And to that end, we like to make sure that all of our coaches utilize the same kind of foundational tools that we use in our coaching. One of them is a metacognitive tool that we teach all of our participants for how to think about their thinking.

And I think about it like a SOAP note. When you were in training, you learned how to communicate in a SOAP note, and it was awkward and weird for me for a really long time. I was presenting the assessment during this objective, and everything was messy, but we teach this tool to help people separate the circumstances or the facts that are outside of them, their thoughts in response to those circumstances, how their thoughts drive their feelings, how those feelings drive actions, and then what the sum of those actions creates as a result for them.

And so that foundational tool is important for... it's foundational to our curriculum, and so all of our coaches need to be trained in how to apply that tool. For that reason, all of our coaches, right now, are certified through a group called The Life Coach School. I think, right now, they're not offering certification, so we're exploring how to bring other coaches trained in other programs up to speed on the tools we use, but we wanted to make sure that all of us are consistent in our application of that tool.

Dr. Tyra Fainstad:

Yeah. And in addition to coming out of that institution, knowing how to use that same sort of metacognitive model, Adrienne and I have created an onboarding process and a process for coach peer observation and feedback that we implement regularly. We have coach development sessions monthly with all of our wonderful volunteer coaches, and try to ensure as much as possible that we've got inter-coach reliability in these calls because I think you need to have that.

So we have a really rigorous onboarding and sort of maintenance algorithm for our coaches. And I think we have to do that in order to study this intervention because otherwise, what would we be studying? Is it Adrienne's coaching or my coaching or what exactly is it? And so we're working on continuously making that a little bit more rigorous. Also, we'll probably be studying that in the future to figure out how can we standardize coaching in what you said is an unregulated industry.

I think physicians are the prime field to do that because we're all about regulation and credentialing. And so I think we're probably the most uncomfortable. Like I mentioned, my come-to-coaching story, that's got to be shared with our entire field because, oh my gosh, how can you trust anything that's not regulated? And so I do see us moving in that direction. There are coaching competencies that have been published that we're sort of using and incorporating in how we decide to evaluate each other. I think that's definitely a step in the right direction.

Dr. Elizabeth Harry:

Yeah. It feels like it's a really growing and evolving field, especially with the literature base that you guys are very much helping build. And so I'm curious, what are you most excited about in the next five years for Better Together?

Dr. Adrienne Mann:

Oh, man. Well, we're about to launch BT2, which is a second-level curriculum for folks who participated in the first... the foundational Better Together curriculum. And so in that curriculum, that's funded by an ACGME and Macy grant. So we're building out 16 more weeks where we're going to focus on leadership, relationships, boundaries, and transitions, so professional and personal transitions. And so, I'm super excited for that.

We launched that in the spring. So anybody who's done BT before can join up in BT2 in the spring, and that'll be in blast. And then I'm just excited. I just get such great connection and fulfillment with the participants at BT. So what I look forward to is always just expanding the reach of our program and having more people participate with us because it makes for such a rich experience selfishly, both personally and for the other participants.

Dr. Tyra Fainstad:

Yeah.

Dr. Elizabeth Harry:

It's amazing. And as we think about it expanding, so you've had a lot of organizations that have participated. And so I'm sure you've seen ones where you felt like, "That went really well, and sort of the infrastructure and everything was there to set this up for success," and maybe others where you're like, "No, that is not how we had hoped it would go."

If an organization is listening to this or a residency program or a department and they're like, "We want to do this," what recommendations would you make for ways that they can set this up for success for you guys to come in or for a partnership to be built to be as successful as possible?

Dr. Adrienne Mann:

Totally. So first, you can email us at bettertogethercoaching@cuanschutz, that's A N-S-C-H-U-T-Z.edu, or you can Google Better Together Physician Coaching, and we have a website there where you can reach us.

But the partnerships that we have that work best are ones where the institution does the work of saying, "Hey, we believe in this thing, and we want you to do it, and we will never ask if you did. And we will respect the anonymity and the confidentiality of your participation in this group."

It is our sincere hope that you participate because it looks great, and it is safe for you to do so. Those are the places that really have the best participation and engagement, and we see return over time, year over year.

Dr. Tyra Fainstad:

Yeah. We do the work of providing marketing materials to institutional partners. And so they get sort of an onboarding packet... package with us, and then we host some calls about how you can do this best. But it has been a learning curve for us to understand how very differently communication structures and funnels work at different institutions.

And there are some where our marketing materials unfortunately end up on the wrong desk and just don't get sent out. And so they don't have any participation, or perhaps one email goes out, but it ends up in a spam folder for whatever reason. The ones where we get a lot of participation are the folks that get those emails and those materials that we provide right in front of them.

It is a battle against email fatigue and emails coming from someone top down at an institution. And for obvious reasons, Better Together doesn't ever get individual participant emails. Those emails come from the leadership at that institution. And so it really hinges on the buy-in from the leadership and how they're communicating that information. We are still working on how to optimize that.

Dr. Adrienne Mann:

It turns out we're just... we're both doctors and neither of us went to business school or know how to do marketing or B2B or B2C or any of the things that make a business work. So we just want to get in front of the right people, let them know they're welcome with us, and continue to work.

Dr. Elizabeth Harry:

Well, and it really feels like you guys have positioned this as a cultural... You're at this cultural inflection point where we're sort of teaching a new way of thinking to up and coming physicians and physician leaders.

And it strikes me that then we have this cohort of people that might be thinking differently, and maybe in a way that's a little bit different than the culture that they have been raised in, if you will.

And so if you were able to give any advice to a more senior-level faculty member of one thing that they could do to make the environment safer for this to be successful for those that are going through the program, what would you say?

Dr. Adrienne Mann:

I would say to them to say, "It's okay to struggle, and it makes sense if you do. And I needed resources to help me advance myself to new levels all of the time. And this is a resource that really helped me, or resources like this have really helped me. And so I hope you would take advantage of it because..."

Dr. Tyra Fainstad:

Yeah.

Dr. Adrienne Mann:

"... because we're on the other side."

Dr. Tyra Fainstad:

I think it would make the case for investing in your employees' personal lives, which isn't usually a case that leaders are used to doing. They're used to pushing the line on how can we help you get... see more patients. How can we get people through quicker? How can we help you do your job better?

And, "Oh, if you're kind of struggling emotionally, you can deal with that on your own time." Nope. Turns out that time bleeds over into work. And so it is going to help you to invest in what you consider the personal life. I don't think there is a boundary between personal and professional life. They're the same, especially in this field. And so the quicker we can accept that and invest in it, the more everybody's going to benefit.

Dr. Adrienne Mann:

And I think the more leaders model and normalize that, that is something that people who are successful do is get help managing their naming and processing their emotions and figuring out where they're still stuck in a fixed mindset because none of us arrive at the place where we're done. And so I think leaders who model that effectively do amazing things for the culture of their team.

Dr. Tyra Fainstad:

Yeah. We have institutions where the leadership participate in Better Together with their folks, which we highly encourage. And we have institutions where the leaders take kind of a like, "Okay, I will pass this along from my ivory tower, and I would never participate because they don't want to see me there, and I have to keep it professional over here."

And honestly, the places that do the best are the ones where the dean of the med school is on that call, or the department chief is on that call, struggling in front of their folks. That is real [inaudible 00:46:47] modeling that is aspirational.

Dr. Elizabeth Harry:

Oh my gosh, you guys are just really pushing the cultural envelope, which I love because I could hear all the pushback that would come of like, "But I can't be vulnerable in front of the people I teach," and all of-

Dr. Adrienne Mann:

[inaudible 00:47:01].

Dr. Elizabeth Harry:

... things. And I love it. And I think also you're right that the literature for organizational psychology and our business school friends would suggest that we are better leaders when we are able to connect with people personally and when we're able to model vulnerability and authenticity, recognizing that there's all these caveats around that. But I think it's amazing work. And first, I just want to thank you, guys, for what you're doing.

I know you both personally. I know how much you have sacrificed to do this. You guys are not out there to make money, really are out there to make a difference for people in medicine. It's a calling, and I'm just so inspired by you both and so grateful for the way that you're changing medicine for the better. And to close, I'm hoping that maybe you could share one thing that keeps you hopeful about the future of health care.

Dr. Adrienne Mann:

Tyra, you go.

Dr. Tyra Fainstad:

The enormity of the change that has happened already since I was a resident is mind-blowing. I think the rapidness of transformation that is happening is accelerating. And so though sometimes it's scary, it also is incredibly hopeful.

I think our minds are more flexible than they ever have been. People are pushing back in ways that they never have been. And though that is very uncomfortable, it's something that the culture is embracing more and more. And so it's only a matter of time before we make these shifts that need to happen. I feel very hopeful.

Dr. Adrienne Mann:

I feel hopeful too. I just came off of a week on the teaching service, and so I was on with a bunch of learners. And I'm always hopeful when I come off of the inpatient service because I see so much of how learners care and what they care about is changing over time, and that's really cool.

They care about patients, but they also care about their learning environment and their work environment, and they aren't as hesitant about advocacy as maybe we were. I don't think I knew what I needed then.

And I see generations coming through that are better at articulating what their needs are and what their expectations are. And while that's uncomfortable if you're on the other side of that request, I think that there's a lot that rising generations are going to bring to our culture and our communities.

Dr. Elizabeth Harry:

Well, I'm hopeful too, and I'm hopeful largely because of the work you guys are doing, and I'm just very grateful. So Dr. Mann, Dr. Fainstad, thank you so much for the transformative work you're doing for sharing your insights with us today.

And to our listeners, if this conversation sparked ideas, you can subscribe, leave a review, and pass the episode along to colleagues who care about well-being in medicine. You can check out the Better Together Physician Coaching website, and we'll have the links in the show notes. And if you have any questions or comments, please pass them along. Thank you so much. Thank you.