Learning Together: Making Space for Growth at Work

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What if well-being starts with how we learn together? On this episode of Well-Being at Michigan Medicine, Elizabeth Harry, M.D., is joined by Rajesh Mangrulkar, M.D., FNAP, Executive Director of U-M’s Center for Interprofessional Practice and Education (IPE), Executive Director of Michigan Medicine RISE (Research. Innovation. Scholarship. Education), and primary care physician of internal medicine whose work focuses on organizational leadership and innovation, and Johnny McGraw, M.A., Marketing & Communications Specialist for both RISE and IPE, about building teams through human connection, psychological safety and learning. 

They discuss a meeting practice, why leaders shape culture and how investments in collaboration can help health care teams work without asking people to carry everything alone.

Guests:

• Rajesh Mangrulkar, M.D., FNAP
• Johnny McGraw, M.A.

Transcript

Dr. Elizabeth Harry:

Welcome to Well-Being at Michigan Medicine. So before we start, I just wanted to start with a question for you to sit with on your drive home. When was the last time someone at work taught you something, not in a mandatory training, but because they genuinely wanted you to grow? So for a lot of healthcare workers, the honest answer is I can't remember. But today we get to speak with two people who think about education, culture, and belonging for a living. One who spent his career transforming how clinicians learn and one who shapes how that story gets told. Talk about why a growth mindset might be one of the most underused tools we have for workforce well-being. So welcome Raj and Johnny to the podcast. Raj leads Michigan Medicine RISE and the Center for Interprofessional Practice and Education, is a Glaser Award recipient for medical student teaching and has given a TEDMED Talk on transforming medical education.

Johnny came to this work through public media and now shapes how RISE and the Center for Interprofessional Education, or as we might call it the center, tell their story. Welcome to the podcast.

Dr. Rajesh Mangrulkar:

Thank you for having us, Liz.

Johnny McGraw:

Thank you.

Dr. Elizabeth Harry:

Thank you very much. So we're going to just jump right into it. Raj, you have spent a decade reshaping medical student education and now you lead RISE. And Johnny, you came to this work through communications at WKAR Public Media, then in higher ed and healthcare marketing. You each sort of arrived at education and well-being from completely different directions. What did your earlier work teach you that brought you to where you are today?

Dr. Rajesh Mangrulkar:

Well, Liz, thank you again for having us. I realized that I didn't go to medical school to be a director or an associate dean. I went to medical school to be a physician and I'm a practicing primary care physician at the VA. And through that work, I really have realized that the work we do to train future physicians really has a direct impact on health, but we don't often see that when we're running educational programs. So I've become obsessed with how education and health are tied together. And I think the thing I've learned the most that it's tied together through relationships. Sometimes we think about it through curriculum or through competence, but I think the relationships are the underpinning to how we bring those two things together. I think systems work starts with relationships and I feel like that's my job as a leader. I feel like my style has evolved over time where I've realized that my goal is to help learners and students become who they were meant to be through these relationships and through the systems work we do in curriculum and in health systems.

And honestly, my hope has been, as I've been in an academic medical center for so long, that everyone in this center, in the health system sees themselves as a learner. Certainly we see ourselves as practitioners and people who are there at the front lines or in leadership roles to help patients, but that we see ourselves as learners because we're in these academic environments and we think of ourselves as part of a growth trajectory, striving to become who we were meant to be.

Dr. Elizabeth Harry:

Yeah. I love that. Lifelong learners and really putting the human connection at the center. And it's really great because that ties into so many podcasts or podcast episodes we've had where we really are thinking about how do you bring the human connection back to the center, and you're thinking about that from an education standpoint. So how about you, Johnny?

Johnny McGraw:

Yeah. So my earlier work, similar to what Raj said about learning being this ongoing kind of constant conversation, it's really one that never ends. So I think my earlier work taught me a ton about the importance of interpersonal communication, especially during my college years at Michigan State, or as my colleagues like to call it, that other school in East Lansing.

Dr. Elizabeth Harry:

We won't talk about it.

Johnny McGraw:

I was fortunate to learn early about this concept of the relational art, which is something I think Raj really loves to talk about and has helped inform how I approach teamwork. So really my professors in these interpersonal comms courses laid a really rich foundation for the importance of clear communication, trust, and really treating relationships as a means to better teamwork and more satisfying life overall. So when we approach challenges from this point of view of me being solely up against this problem, then more often than not, we're destined to fail. But when we come at these challenges of the point of view of we are up against this challenge, how can we harness our different skills and what makes us unique to solve it, then I believe that's where we're really at our best. And so I think that ties into learning a great deal and that being a constant opportunity for us.

And then in public media, we really found ourselves asking how do we help someone understand something new? So we quickly realized that the stories that stuck most often were the ones that made people feel curious and connected to an issue, a community or a piece of history. And so really at the end of the day, if learning feels transactional, it can kind of feel like another obligation. But with interprofessional practice and education especially, we found that if people feel invited to learn together, solve these real problems and contribute their own experiences, we found that they feel like growing instead of just keeping up. So because so much of the work in healthcare is so demanding, it can be easy for practitioners to feel like everything rests on their shoulders. I think one of the most encouraging things that I've seen through our work at CIPE and at RISE is that learning can help remind people that they're part of something bigger.

So when we're learning with colleagues from different professions, you're building up trust and a shared sense of purpose. And so to me, that's where education and well-being intersect. The best learning experiences make us feel more connected to our work and to each other.

Dr. Rajesh Mangrulkar:

I love what Johnny is saying there because there's actually evidence behind everything he said that we don't really access. There is evidence that shows that when you are cared for or caring for others, you learn better. And so I would always talk to students or applicants. I said, "You will have a lot of choices. Don't go to the best program where you check all the boxes or it has that one sort of program that I want to do. Whether you're a student or a learner or a staff member, go to places where you feel cared for and where you have the opportunity to care for others because your learning will be better in those environments." The evidence is really clear about that.

Dr. Elizabeth Harry:

Well, and what I love about it is that you're framing education through the lens of community and how we use our sort of human connectedness as a vehicle for learning, lifelong learning, as you pointed out Raj. And so Raj, you've had a whole career focused on this and have become an absolute expert in this, but one day you were not an expert, you were early in your career and you got introduced to this concept. Take me to that moment where you either watched someone learn something and it changed how they showed up at work or you saw something that you were like, "This is where I want to spend my time and attention." What was that moment?

Dr. Rajesh Mangrulkar:

It was in 2017. And we were in the midst... I was in the dean's office at the time and we were in the midst of transforming our curriculum. And that change, it was the biggest change in the medical school curriculum in 75 years. That change was hard. I loved that change, but a lot of my team members were really struggling with the pace of change and the intensity of the change and the delta of how much we were changing. And I wasn't as in touch with that pain that was going along with the change journey. And so they sat me down and really kind of started to communicate how difficult this was. They were all bought in, but they said, "Raj, you need to be more intentional about understanding how difficult this is."

And so I invited learning about how we were feeling as we were doing change. And that moment when we did, I was introduced to something called a mood check that started to articulate with vocabulary, what is the mood that we're bringing to our meeting, our patient interaction, our lecture, wherever it might be, but doing it in a deliberate way so that everyone would do a one word mood check at the beginning of a meeting, and then we understood how people were showing up.

And it did so many things because you may be coming with a difficult mood, not because you have a difficult meeting, but because you just came from a difficult conversation or something's happening in your life. But we would often just assume that, okay, I just got to show up. And if we weren't at our best, people didn't know why. So we introduced this concept of the mood check in 2017 to everything we did in our dean's office meetings, and then it started spreading and it allowed us to be more present, more empathetic. If someone had a difficult mood, we could just say, "You don't have to explain it, but just know we're here." And we could support people in circle as opposed to, "All right. You've got a job as the curriculum dean. You've got a job as the admissions dean, just report out on what you're doing." And it brought us so much closer together.

For me, that was transformational and it was something I had to learn because I was terrible at my mood vocabulary. People would say, "How do you feel?" "Happy. Great. Wonderful."

Dr. Elizabeth Harry:

There's like four.

Dr. Rajesh Mangrulkar:

Terrible. But there are hundreds of words now-

Dr. Elizabeth Harry:

Right. Right.

Dr. Rajesh Mangrulkar:

That I have access to that really give me a sense of, "Oh, I'm feeling disappointed. I'm feeling uninspired or I'm feeling optimistic or I'm feeling pleased." There are different subtleties and that vocabulary, people might say, "Oh, that's just kind of fluff." It was central to our work and it allowed us over the next years to actually become closer as we were leading the change in the curriculum.

Dr. Elizabeth Harry:

Well, what's amazing about that too, speaking of data, is that we know that there's data that just labeling an affect decreases its negative impact on us. And so affect, the sort of underlying automatic feeling or internal experience of emotion can range anywhere from pleasant to unpleasant. Another term that's used sometimes is valence, and they have to have the vocabulary to do it. But if they can put a label on a negative affect, it actually decreases the impact of that negative affect. And so that's huge. So you were not only understanding and learning about your team, but you were also actually doing an intervention to help them with whatever they were experiencing.

Dr. Rajesh Mangrulkar:

I honestly didn't know that there was data behind labeling an affect.

Dr. Elizabeth Harry:

Yes.

Dr. Rajesh Mangrulkar:

I would love to see that because I will say that every place that me and Johnny and others on our team introduced this concept, it has incredible resonance. People just start saying, "I'm just going to do that. It's something small to do, but I would love to see what that data is behind it because that sounds fascinating."

Dr. Elizabeth Harry:

Interestingly, it's actually a negotiation technique because if you can label somebody else's affect, you can help bring down the tone of the conversation. And so it's often used in negotiation. But what I love is that you used it in the service of taking something from being very transactional, which we can do at work, to being very relational for the end of this really important initiative that was happening in the medical school. And also what a beginner's mind to bring to something when you were in this space of being sort of this expert, this leader, but you were willing to really hear people and bring this beginner's mind to it. What is something that you think that this experience taught you that a lecture never could?

Dr. Rajesh Mangrulkar:

I think we focus a lot in academic healthcare, regardless of what profession we're coming from, on our expertise. And a lecture often focuses on content and expertise, which is super important. Don't get me wrong. I think it's really critical. But I would like to see the value of expertise be similarly high level and received well for expertise in moods or expertise in relationships or expertise in the evidence behind social connection and how it improves health, how it improves learning. So that, to me, is something that would be hard to communicate in a lecture. I think it requires practice. I always think about this very much influenced by people we've worked with, that to think of this as like a sport, that we need a practice partner. Soon we're going to play the game, but we need to do the practice and you can't practice in a lecture.

Dr. Elizabeth Harry:

Yeah. Well, and what's so critical about what you're saying too is if you think about a lot of other sort of high intensity performance areas, in other words, the way that you show up really, really matters in the moment, whether it's sports or military or arts, people spend a great deal of their time preparing for a very small-time where they're performing. And in healthcare, we spend a great deal performing and often small to no time working on preparing for that. And so we've really not... Obviously our entire medical education is about preparing and then you're supposed to be doing continuing medical education and all of that, but a lot of that isn't geared towards the things that you're talking about.

Dr. Rajesh Mangrulkar:

Yeah. In many ways, many of the incentives are towards performance as opposed to preparation. And so we've almost lined up some systems to be opposite to what we need. And sometimes preparation, people get very afraid of preparation because they think it takes so much time. A mood check takes 10 seconds to actually do, which could be preparation for an encounter. If I was going to have a difficult family conversation with my team walking in, I would do a mood check outside the door before I would walk into that patient's room to say, "What moods are we bringing to this? Because that's going to matter." It's something very small, but yet it feels like I just don't have time to do it. That's how we are kind of feeling in this moment across healthcare. And I'd invite us to think of it as an investment in something that will make our performance so much better.

Dr. Elizabeth Harry:

And I wonder if there's a time piece and also a boundaries piece. If people feel uncomfortable crossing that question, they're not familiar with how to engage on that level with their team. It might feel a little vulnerable. It might feel a little more vulnerable than they're used to being. And so I guess I would ask, because you've really described so nicely how in your experience, this was really important for a leader to understand. And I'd love to understand your thoughts about if you think about leaders in general, if you think about every leader sitting in a room that has the ability to impact a team, what is their role in promoting workplace well-being and promoting this sort of relational environment that you're describing?

Dr. Rajesh Mangrulkar:

So I'll start, but I'd love Johnny's perspective as sort of someone new to our team over the last couple of years and sort of seeing how I try to lead our team. We have a small team, but it's a small and mighty and intimate team, but it might have been different than other teams that you've been part of. I think as a leader, we have to own the culture. I would always say I have this repetitive thing, leaders can only not delegate one thing. So leaders can only not delegate one thing and that is culture. Everything else, we pretty much can delegate and check back and look back as long as we've got the good relationships. But I think leaders, we have to see ourselves as not only owners, but as shapers of that culture. And I think the only way we can do that is to be authentic with those that we're with.

It doesn't mean that we ignore hierarchy. I think there has to be natural roles for hierarchy. There has to be deciders and then there have to be people that are following, but we have to create the culture where everyone's voice is heard, even if it's not followed. And that happens when we are present and it happens when we see ourselves as bringing the kind of practices that shape culture in our teams, not just assume that it's going to happen because people are nice. Johnny, I wonder how that felt to you when you encountered this team, which may be different than others.

Johnny McGraw:

It was such a different approach, but one that I'm very grateful for certainly. I think one thing I'm especially appreciative of is how if we do these mood checks, sometimes it'll take 20 minutes of an hour long meeting just for us to unpack our mood. Maybe something's especially bothering someone on a given day, maybe it's personal, maybe it's work related, but by leading with that mood and checking in and being present, then that allows us to be more productive later on in the meeting because otherwise if that goes unresolved, I've seen that happen so many times on other teams I've been on and you're just not going to have as productive of a meeting that way. Another great thing that Raj does that I really value is putting a feeler out to the team for how they're feeling, for what's on their minds before he'll even offer his own perspective sometimes.

And so then I think you get a much more accurate gauge of what's on everyone's nighttime or what everyone's thinking about or maybe stressing them out in a given week. And so then at the end he can offer his perspective and kind of start addressing those different needs effectively.

Dr. Rajesh Mangrulkar:

Yeah. There's a tension between leaders going first and leaders listening first. And I think as a leader, we have to be more conscious about the times when it is time to check in, when it is time to lean in first and shape the conversation, when it's time to sit back and listen first to what everyone's doing, synthesize and then move the organization forward. But I think oftentimes I worry that this is not what any of us went to medical school, pharmacy school, nursing school to do. So where are we developing ourselves for these cultural leadership needs and skills that we all, I think, desperately need?

Dr. Elizabeth Harry:

Yeah. And it's so interesting too because the leader can really set the tone. I mean, I can think of meetings I've been in where there's a handful of very senior leaders present and depending on the way people talk too, it can sort of escalate the anxiety in the room or just sort of immediately calm it down depending on how people frame things and how they speak and how they also-

Dr. Rajesh Mangrulkar:

Body language.

Dr. Elizabeth Harry:

Body language, all of-

Dr. Rajesh Mangrulkar:

Yeah. Right.

Dr. Elizabeth Harry:

Their tone of voice, all of this. So Johnny, you have a really exciting job. You design communication strategies for two really big initiatives. So the Center for Interprofessional Education and RISE. And these are for our listeners fundamentally about helping people learn from and with each other across professions as we've been talking about. And so I'm curious from a storytelling perspective, what is the hardest part about getting a nurse, a physician, a pharmacist, or any member of our care team to really feel that this interprofessional learning is not only for them, but will benefit them, will benefit their team and isn't just like another thing that they have to do?

Johnny McGraw:

Exactly. Yeah. That's a great question. So I'll start just by acknowledging it's very difficult to understand good teamwork if you haven't been on an excellent team. So I don't think the biggest challenge is always convincing people that teamwork matters because I think most people would agree with that. But really I think the challenge lies within the fact that many people have never experienced truly great teamwork themselves. We have so much evidence that teams with stronger collaboration often report better engagement, belonging and well-being. And so that's a really important statistic, but I also found that statistics themselves really rarely change behavior on their own. Stories are what help people believe the statistics and those stories are frequently what bring about actual change in action or belief. And so if you spent your career in environments where communication's fragmented or professions work in parallel instead of together, then this concept of interprofessional collaboration can kind of just sound like another administrative initiative that might not feel real to someone.

So communications can't manufacture that experience, but what we can do is tell stories that help people recognize themselves as vital members of those teams, no matter their role. So we share moments when a nurse caught something a physician missed or where a pharmacist prevented an error or where a student said, "I finally realized I wasn't expected to solve everything alone." And I think for our med students especially, they often feel that everything rests on their shoulders. And so it's important that they realize that they actually have a really incredible support system to lean on when they need to.

Last year, just to bring up a specific example, we did a story on Raj's team at the Ann Arbor VA, where he practices, and their team uses something called the PACT model, which stands for Patient Aligned Care Team. And there was a specific part of the story that really resonated with me.

I spoke with Tiffany Parker, who's a really great medical support assistant there at the VA, and she talked about the importance of observing the waiting room. She said very clearly to me, "When you get to know your patients, you'll notice when something is off." And that really stuck with me because she's observing the waiting room. She's a medical support assistant. And I think sometimes as a society, we can think about these hierarchies within healthcare teams, but at the end of the day, every single role really just matters a great deal in making sure it's a well-oiled machine. And more specifically, when I was talking to Tiffany, actually, she recalled a moment when she observed a patient experiencing abnormal breathing in the waiting room. And so she recognized the urgency of this, alerted the care team, and it turned out the patient required emergency care. And then another quote of hers that really stuck with me at the end actually, she said, "That's why being present and paying attention matters. We're all watching out for our patients."

And I just thought that sense of belonging and ownership of that role was so terrific to see. And I think if all of us showed up with the energy that Tiffany does, we'd be in a much more effective and more empathetic world. So stories like this, I really think help people recognize what good teamwork feels like. And then once someone experiences that themselves, they usually don't need convincing anymore.

Dr. Rajesh Mangrulkar:

The story that Johnny published was just so beautifully done, and it really elevated everyone's feeling in our primary care clinic. People started talking about it a lot and you could tell they felt that the words going out in public, it was shared on the VA national newsletter that kind of went out everywhere. People said, "Thank you for telling the story of what they do constantly." But it was told in such an elegant way that really showed why we come together mission-centered and why we choose to work together. And it made us even closer than we were, I think, before. It really resonated with so many members.

Dr. Elizabeth Harry:

What I love about this story is I think it highlights the almost, if you will, natural state of humans, it feels like is to come together and is to work together. And we do our best in that state, right? We really do. And yet there seems to be a little bit of a natural tendency when stress goes up to sort of clamp down in silo a little bit.

And I've noticed that... And there's lots of places that stress can come from, but as we're feeling a lot of stress, particularly maybe tasks related to our jobs, tasks that we have to get done, I've noticed a little bit of this sort of zero-sum game mindset that can pop up. And so I'm curious, you've seen an example, you've seen probably many examples of when this works beautifully, when people come together and they help support each other and they see the value of that. And I'm wondering if you can share about coming in and finding people in that space where these silos have developed and maybe it's a little bit protective, maybe it's a zero-sum game mindset or maybe there's other reasons that they've developed, but watching it break, why did it break and how do we help people see that having this silo break doesn't mean we will need more from you. It doesn't mean that you're putting down a protection that you need because it feels a little bit sometimes like those silos feel like they're protective for some reason.

Dr. Rajesh Mangrulkar:

I appreciate that question so much because first of all, when we are, we are largely under stress. Healthcare is an extraordinarily stressful environment and we learn that our emotions really change and how we show up changes when we're under stress. We almost become caricatures of ourselves.

Dr. Elizabeth Harry:

It's so great when you say it.

Dr. Rajesh Mangrulkar:

We almost emphasize the things that are our gifts and our challenges even more when we're under stress. So imagine an environment where we're all doing that because we're largely swimming in that environment.

Dr. Elizabeth Harry:

I love that visual.

Dr. Rajesh Mangrulkar:

Right?

Dr. Elizabeth Harry:

You can just almost picture the drawings at the -

Dr. Rajesh Mangrulkar:

A cartoon.

Dr. Elizabeth Harry:

Yeah. At the fair that people would do with you to sort of exaggerate your features. It's like that.

Dr. Rajesh Mangrulkar:

And we see this all the time when that's happening. So what is our natural space is to be protective, is to protect the tribe, is to stay within our lanes. And so if we're under stress, we have to recognize that that is going to be our natural state, which means it requires deliberate intent and again, practices that break us out of those silos or an external factor that really forces us to break across silos. The place I think we all experienced was during the pandemic. I think the pandemic was a unifying force across the country, across the world, which required us to break our silos. And we saw countless examples here at U of M. We saw countless examples across the country of us just saying, "All right, we're just going to roll up our sleeves." When people are at war, when we're in those crisis situations that this happens, it's been shown over and over again. So what happened after the pandemic is really intriguing.

There's a lot of data that showed that pre-pandemic, if you had a good team culture in your health system, you actually survived the pandemic as a health system much more effectively. You were able to care for patients better. Your outcomes were a little bit better, both in terms of well-being, but also in terms of patient outcomes. Having an interprofessional approach to teamwork that was deeply enrooted in the culture pre-pandemic allowed you to thrive better than maybe other organizations did. The other thing that has been shown is that those that had that culture pre-pandemic or used the pandemic to work on their culture of teamwork recovered from the pandemic better and those that didn't regressed back to where they were before and maybe even worse than they were before. So there's something in the external environment which forced us out of our silos that allowed us to really come together, but it required deliberate intent after the crisis was gone for us to maintain and grow.

And I think there's high variability in actually whether that happened really across the country and I think we need to learn from it. So deliberate acts are also part of that as well. And what did we do afterwards to maintain or grow in our team culture I think is essential to how we continue to go forward.

Dr. Elizabeth Harry:

And I think there's probably someone listening who is like, "This sounds great and I would love to be on that team and it's all well and good, but I don't have time. I don't have the time to practice. You talked about it being like a sport. I barely have the time to get through my shift. I'm drowning in the number of work tasks, home tasks." And I think that's a fair thing to feel. We hear that a lot from people when we try to talk about this preparation, performance balance in healthcare. We hear, "But I have so much time I'm expected to perform. I just can't give another minute to prepare even if it would make that performance time easier." What would you say to that person?

Dr. Rajesh Mangrulkar:

I would first say you're absolutely right. In the current model that we have, there is so little time in the system to even envision this, this extra work. It feels like extra work. It felt like extra work to me. And I would say, I wonder if we're framing this the right way. If we're in a much more of a transactional model of how we deliver healthcare, because we have to, we have to have operational efficiencies, but do we need to see everything as an operational efficiency? If we add time here, do we have to take time away or is there a way to frame this as an investment? Is there a way to frame this that I understand that I would need to devote a little bit of time, but the payoff down the road in how we come together and get more operationally efficient because we're working better as a team, actually we will save time down the road. So that's one way I think to look at it.

The other way to look at it is maybe there are small moves we can do, but we have to make sure that those small moves become habits. I'm always inspired by the quote from, I think it was Aristotle, but I might be wrong. But excellence is a habit. We are what we do every day as opposed to what we do in a moment or in a big project. So are there small moves of things that we can do every day that then don't add time because they're part of what we do every day? I think going back to the coaching analogy, one of my favorite sports is basketball. And if you're practicing and those small moves are what you do in the game, they become excellent. They promote excellence. They promote excellence among the team.

So I wonder if maybe we're framing it not the most efficient way, we're thinking about it in terms of a transactional way. It's hard because we're all under siege for time, but I'd invite us to maybe think about it a little different way.

Dr. Elizabeth Harry:

I almost think about this. I do lifestyle medicine in addition to internal medicine, primary care. And I think about this a lot with our health behaviors, that you can actually make lots of little choices that add up in this tremendous way over time. And it doesn't take a ton. It does take that planning though, that activation energy. And that I think can be really hard. Johnny, this is the whole way you think about this work, how we frame it. So what would you say? How would you frame it to this person that is struggling with this balance?

Johnny McGraw:

Yeah. I think just admitting that in the first place is one of the most honest things someone could say. I think growth can often feel like just one more thing added to an already impossible list. I think Raj said it great about taking that time to grow now can free up so much time in the long run, even when it does feel like the last priority you want to get to in the moment. I think that's very relatable. And so I just believe that the teams who intentionally spend that extra time reflecting, solving these recurring problems usually become more efficient in the long run. It might feel counterintuitive at first, but then just taking an hour away from work to improve the work often saves many more hours down the road. So in my own work, like I mentioned earlier, some of our most productive meetings aren't the ones where we race through an agenda. They're the ones where we stop and ask what's getting in our way. And then that's where the real improvement starts.

Dr. Rajesh Mangrulkar:

Oh, I love that so much. That last question, what's getting in our way invites everyone to be systems engineers. And one of the most powerful antidotes to a drift downwards and well-being is a feeling of empowerment. So maybe part of our, I don't have enough time, is I'm just doing my work and I don't feel like I can improve the environment around me. What happens if we invest a little bit of time of inviting everyone to be systems engineers? And then that empowerment sort of begets, it feeds forward, I think, an accelerating cycle of both well-being, productivity, efficiency and patient experience.

Dr. Elizabeth Harry:

Well, the other piece I would add to that is kind of generative energy and an innovative energy. And I think when people are just coming in and doing the job, we're just doing the job. And when we can get in that space where we feel like we have permission to be a little bit creative and think about what's getting in our way or how could we do this better? Surely just because we've always done it this way doesn't mean we have to do it this way. And maybe there's a new way now that we could do it that would feel more aligned with our team's values and these sorts of things. But if people are so spent, it's hard for people to get into that sort of generative, creative space, but it feels so much better to be in that space. And so anything we can do to help move people there.

So you guys have spent time with teams thinking about this and you've watched teams intimately and know them, you know the inner workings of them. And you guys have talked about teamwork, shared leadership, psychological safety, human connection as being really important. If you could put your nickel down on one and say, "In the next 16 months, we are going to invest everything in this space because I think this would be the place that would move us the farthest," what would you say?

Dr. Rajesh Mangrulkar:

That's a great question. I hate only having a nickel.

Dr. Elizabeth Harry:

I know.

Dr. Rajesh Mangrulkar:

But I'll put a nickel down.

Dr. Elizabeth Harry:

You only have a nickel.

Dr. Rajesh Mangrulkar:

I love what Johnny's thought on this, but I think they're all interconnected. So I'm not going to straddle the fence though. I think if we could focus on one thing, it would be psychological safety. I really do think that's where we all struggle.

Dr. Elizabeth Harry:

And what does that mean to you when you say that?

Dr. Rajesh Mangrulkar:

Yeah. I think it can mean different things because they manifest in different ways. Sometimes it's about speaking up when you see something unsafe about to happen. Sometimes it's just about being able to be authentic at work and bringing the mood that comes from home here to be supported in circle. Sometimes it's about being comfortable in giving feedback that's intended to be generative. Being comfortable making mistakes when you give that feedback and to say, "Oh, I didn't frame that right. That really did hurt you. I'm really sorry. Help me frame it better." And then at the end, I think it's about how do we solve problems together so we're not just reporting up the chain of command, which we do need to do at times, but sometimes most of the problems we can come together. But if we don't feel safe in those environments, then we won't do that.

So I think it manifests in terms of this comfort of being authentic and leaning in places where it requires us to lean in with so many different factors kind of interfering with that.

Johnny McGraw:

Yeah. And adding to that, I think Raj just put it on the money there, but I think in our team meetings, for instance, psychological safety can mean healthy disagreement too and fostering a space for that disagreement. I think so often we have people in our mood checks at the start of our meetings check in as secure and trusting. So I think when you check in with that security and that trust, it opens up the playing field to have those healthy disagreements and not have egos be hurt or have feelings damaged. And so when you can approach a meeting in that very mature, emotionally intelligent way, again, I think that just leads to great results.

Dr. Rajesh Mangrulkar:

The trust word that you mentioned, Johnny, is so critical. It really is the foundation of healthy teamwork. It's the foundation of healthy relationships as well. Tom Lee talks about social capital. In order to have social capital, the relationships and trust are at its foundation. So that is the real sort of key ingredient towards psychological safety. But what does that actually mean? It means that not only that we have each other's back, but we will be there, we will be present with each other and be there emotionally for each other while we do this hard work.

Dr. Elizabeth Harry:

You may have taken a couple pennies and put it on human connection there.

Dr. Rajesh Mangrulkar:

Yeah. A little bit. Sorry. I just took a penny and put it there. Yeah.

Dr. Elizabeth Harry:

So I'm curious for both of you, what is something you used to believe about education and well-being that you don't anymore?

Dr. Rajesh Mangrulkar:

Well, I guess I'll start. When I was in the dean's office, and I think even to this day, and in all professions really, there is a focus on becoming an independent practitioner and there's a focus on being competent and excellence. And I'd like to introduce alternative language to that that we just learned about at a recent conference that we're at that I'm really starting to become curious about. Rather than competence or individual competence, what does it mean to have collective competence? What does it mean to be able to measure a team's competence without ascribing it to an individual's performance on that team? And so thinking about collective competence rather than individual competence. And rather than thinking of us, our ultimate goal to become independent practitioners, what if we were to say that our ultimate goal is to become interdependent practitioners where actually our identity is shaped by how we show up with each other across the disciplines, across the professions, that that should actually be our ultimate goal.

But so many of our curricula, our accreditation or how we line up the incentives are towards competence and independence. And I think we need a shift, not only in our language, but how we line up the geographic space that we spend in the curriculum towards these different goals, how we line up incentives towards interdependence, not independence, how accreditation and licensure bodies value interdependence over independence. I think this is going to take a big shift, but that's where my head's right now.

Dr. Elizabeth Harry:

Very cool.

Johnny McGraw:

Yeah. I just agree with Raj there. I think there used to be this conception that well-being and high performance were competing priorities perhaps for some people, that if you wanted excellence, you had to be exhausted as part of the deal. But the more that I've worked with students and educators and staff here, you realize that there are a lot of really great energizing spaces that can really enrich the experience overall. I think people who really dive into those additional opportunities end up feeling more energized at the end of the day as well. And that's why I'm so grateful for Michigan Medicine and U of M and the med school for creating those spaces and investing in those spaces that push people to be innovative or think outside the box and ultimately energize them at the end of the day.

Dr. Elizabeth Harry:

I love what both of you are saying so much. And I just want to tack onto this idea of sort of mutual exclusivity because I think not only is there this belief that you can be well or you can be high performing and they're mutually exclusive. And we know the literature says quite the opposite, right? That you are well, you are more likely to be high performing in healthcare specifically. I mean, it says it in lots of places, but it also says it in healthcare. I just want to underscore that. But we also, I think, have the wrong belief that is also against the literature in healthcare that high quality patient care and well-being are mutually exclusive. And of course the literature refutes that as well. And I think this is important when we think about how we're managing being able to get care to everyone, which we want to do.

And we want to get care to everyone and we want to do it in a really high quality way. And the answer to that can't be just run as fast as you can and see as many people as you can as quickly as you can because we won't get there that way. So we have to be more creative. And that's why I love that you're talking about bringing in all these minds and bringing in this generative energy because the only way we're going to solve a problem, you can't solve a problem with the same brain that created it, right? You need sort of a collection of brains. Then you mentioned sort of engineering and thinking differently about the problem. And that makes me excited about the future of healthcare. That makes me feel like there's hope and that we can figure out how to solve this without it being on the backs of the people that are trying to do the work. I love that framing so much. I think that's huge.

So I want to ask you a question, Raj, about a little bit of your history. You were a distinguished fellow in the National Academy of Practice and now Chair-Elect, the Physicians Academy. And that's a recognition that puts you in a national conversation about the future of collaborative practice and health professions education that you were just talking about, where this needs to go. So from that vantage point, are we actually getting better at protecting well-being or are we still teaching and practicing the way we always have and hoping that culture sort of catches up?

Dr. Rajesh Mangrulkar:

Great question. I think there's a mixed bag out there. I will start by saying I have optimism, but I also have a lot of worries. I have worries in how we may be backsliding between our academies as opposed to moving forward with this vision. And I'll explain. The National Academies of Practice was founded in the '70s and it brings together 17 different professional academies that each have their own individual academy, including physicians, but also nursing and physical therapy and athletic training and veterinary science thinking about sort of one health. It's a really beautiful place. But what we are noticing in the national academies, we will be at Congress. And what we do is we do collective advocacy for systems change on payer reform or collaborative care models. And when we meet with members of Congress in this role, they say, "It is refreshing to have a single voice representing different professions," because what they usually do is get 17 different voices advocating for their piece of the pie, and it's getting worse.

When you actually talk to people at state legislative bodies, they're seeing the sort of what you had described as the zero-sum game. I need to advocate for mine and it means less for the others and vice versa. And my job is only to advocate for my profession. So I worry about the fact that our advocacy isn't collective. I worry that our accreditation is still not collective in our educational programs. We're just thinking about what medicine needs or what nursing needs. One of the refreshing movements I'm starting to see is a movement towards interprofessional accreditation for areas that we share. A good example is artificial intelligence and how it's going to disrupt healthcare workforce. Rather than saying, "Well, what are the competencies that a pharmacist needs to use AI and what about for physicians?" We're starting to say, "Well, what does the team need to use AI and start to define those competencies?"

We're still early, but I worry our usual ways are still in those silos, advocating for our own needs, sometimes at the expense of others. I really do think that my role as a physician leader in the national academies is to role model how we, as physicians, should step back and work effectively with the 16 other academies to collectively advocate for what is needed, understanding that in all honesty, physicians are largely the ones getting paid, which means we have the greatest responsibility to share, to open doors for the other academies. That's my personal belief and that's what I'm excited about in my role as chair-elect next year and then as chair the following years to say, "How can I role model the way that I think physicians should be to open the doors for the other professions?"

Dr. Elizabeth Harry:

It's very meta. It's almost bringing the Center for Interprofessional Education mindset to the National Academies.

Dr. Rajesh Mangrulkar:

Into that space. Absolutely.

Dr. Elizabeth Harry:

Yeah. That's very cool.

Dr. Rajesh Mangrulkar:

And there are many people that care about IPE in that space. Not all. We're kind of sort of a smaller group, but there still is those shared values are there instantly when you walk into the NAP meetings.

Dr. Elizabeth Harry:

So I'll add one more way that we don't do things collaboratively now that sort of adds to cognitive load, which is documentation.

Dr. Rajesh Mangrulkar:

Oh, yeah.

Dr. Elizabeth Harry:

If you think about, and we could do inpatient, outpatient, it doesn't matter, but if you think about a patient's experience, they have an experience for the day that happened. And we have anywhere from one to 20 plus notes that describe that. And now we have AI, as you mentioned, and it would be feasible to have one note that has everybody's input. Obviously we'd have to redo how we can bill and all of these things. There'd be a lot of changes that would have to be made, but can you imagine if you open the chart and there was just one note that described everything that happened for a patient that day with everybody's input in a coherent way that things aren't contradicting each other across consultants' notes, et cetera. It's a great marker of our collaboration of how we put things in the chart and how we think about this.

Dr. Rajesh Mangrulkar:

Oh, I love that vision because that's a very specific describable future.

Dr. Elizabeth Harry:

Yes.

Dr. Rajesh Mangrulkar:

It's clearly technologically feasible right now.

Dr. Elizabeth Harry:

Totally possible.

Dr. Rajesh Mangrulkar:

The question is how do we map it to billing? And if AI can get... These are kind of the not very cool ways of doing innovating, but they're so important. The innovation of systems is what we should be doing.

Dr. Elizabeth Harry:

Yes.

Dr. Rajesh Mangrulkar:

How would AI influence billing so that it could be received as a billing document?

Dr. Elizabeth Harry:

Yes.

Dr. Rajesh Mangrulkar:

And then how all the downstream and upstream benefits of that are just so clearly apparent of what you described.

Dr. Elizabeth Harry:

Yes, we should do it. I love it.

Dr. Rajesh Mangrulkar:

We should do it. Yeah.

Dr. Elizabeth Harry:

So I'm curious, and Johnny, I'll start with you. You're going around and you're talking to teams as you are thinking about engaging with them, and maybe someone candidly says to you, "I just feel like I've stopped growing here. I'm just going through the motions." What would you say to them, human to human?

Johnny McGraw:

Yeah. Man, I think I would just start by asking them what used to energize them and then start from there. I don't think people stop growing overnight generally, and so more often they might lose connection to the parts of the work that gave them purpose initially. And so one thing I've been fortunate to see through CIPE and through RISE is that learning environments can become these really special little pockets in your community. People will leave a workshop or in a specially collaborative meeting and feel really energized because they found other people who care about the same things they do. So I really believe firmly that growth starts with finding your people. Lucky for Raj and me, we're in these very kind of fun and exciting and simulating spaces with education innovation and with interprofessional collaboration. So just finding those spaces that excite you and fill your cup can be the best of both worlds, I think.

Two of our most exciting spaces, I'd say to get specific, so the RISE Innovator Development Program is one of our big initiatives with RISE and our CIPE community of practice. So both of these communities are very unique, but they really create a lot of great connections between curious and innovative people. So our teams are lucky enough to see those relationships and collaborations blossom in real time. And so I wouldn't necessarily point that person asking this question to a specific program necessarily in the first place, but I would recommend that they look for the spaces that align with their values and where they leave feeling more energized than when they walked in.

Dr. Elizabeth Harry:

I love that.

Dr. Rajesh Mangrulkar:

I love that. I completely agree with Johnny about it being a reflective conversation. Where are your energy adding activities, I completely agree with. We often talk about what is your vision for yourself? And a vision is a very specific definition. It's a definition of the future. It's a description of the future at some point in time so that you know when you're there. And so do we each have our own personal vision for ourselves? And it could be anybody in the healthcare environment. What do you want to be doing five years from now? What moods do you want to be feeling more of five years from now? Where would you be so that you can start taking those steps towards it and then the programs will emerge. And then you start saying, "Oh, I'm being much more intentional." You must be thinking about this in your work in lifestyle medicine and life coaching and we get coaching as well, but it's not ubiquitous.

A lot of people are just kind of trying to get through the day. And I think this reflective practice that Johnny talked about in answer to that question should involve what brings you energy and where do you want to go?

Dr. Elizabeth Harry:

Yeah. And I think what I would tie into that too is values. What do you value? And because some people, I know I've always struggled with that vision question because for me, it's always been much less about what I do than the impact I'm trying to make. And so I think if you can connect to the values or what brings you energy, what impact are you trying to make, that's another way to get there too.

Dr. Rajesh Mangrulkar:

Yeah. That's a great point.

Dr. Elizabeth Harry:

Because sometimes I do have people come to me and say, "Well, what if I don't know that five year answer?" And I don't think you always have to. I've never had it. I still don't have it. For anyone listening, I think it's fine if you don't have it, but it is very helpful if you do. If you don't, really connecting to those values. But what I love too is this focus on this generative energy, right? What gets you going? What really excites you? And so as we talk about sort of inspiration and excitement, as you two are looking at the next generation of healthcare professionals and leaders, you're looking at our learners, you're looking at our folks coming up, what gives you hope and inspiration?

Johnny McGraw:

I just see the younger generation as having this incredible yearning and hunger to make positive change in the world. So I think very simply, a desire to collaborate, certainly reach across those silos inspires me a great deal, but there's a reason why people join the healthcare field to make a difference. And so I have a great deal of optimism and promise about the future ahead.

Dr. Rajesh Mangrulkar:

I love that. I also am very much invigorated and energized by learners and why they choose to enter this space. It's different than, Liz, when you and I went to medical school and maybe even 20 years prior to that as well. There is a real calling for making a difference, as Johnny said, and for really thinking about their place in the world in the wholeness of themselves that I don't think was always as apparent or as articulated when we were applying to these different health professional schools. The other thing that gives me optimism is that I think we're starting to see resonance with leaders. Everyone's seeing themselves as the leaders, but even those that are actually in the organizational leadership structure, recognizing that there is a real opportunity to foster better teamwork by being a cultural champion of the environment where these teams lead. I'm starting to detect that in real meaningful ways and that gives me a lot of hope.

Dr. Elizabeth Harry:

Oh, that is exciting. So if someone's listening and they want to learn more or they want to get involved, how can they get in touch with you two?

Johnny McGraw:

Yeah. So if people want to find us online, so for the Center for Interprofessional Practice and Education, they can find us right at interprofessional.umich.edu. And then for Michigan Medicine RISE, they can find us at rise.med.umich.edu.

Dr. Rajesh Mangrulkar:

And of course we're available. My email is everywhere. I'm at [email protected]. I have a very easy email to access, and I just love having conversations with people that are really passionate about this work, because I think we need a movement here. I'd really encourage us to think about this as not an initiative, but we're trying to build a movement and that takes not just hundreds of people, it takes thousands of people to move this culture forward.

Dr. Elizabeth Harry:

You heard them folks. Email him.

Dr. Rajesh Mangrulkar:

Absolutely.

Dr. Elizabeth Harry:

So I want to thank you. I want to thank you both so much for the work that you're doing. I think it's really important. I think the work that you're doing both here and in your national work, trying to unite people is the energy that I am hopeful about. It is so important in our culture right now to remember that I really do believe our default state is to come together, to work together. I think we perform better. I think we feel better when we're in that state. If you're not in that state, that's okay, but then look for maybe a little bit of reflective time about how we got there. And there are resources to help, and we just shared some of them. And of course, our office is always available. You can always go to the Office of Well-Being website, and we have lots of resources available to support people.

And I just want to thank you both for what was, for me, a very energizing conversation, a very generative conversation, built a lot of energy and hope and inspiration for me. And thank you all for tuning in to Well-Being at Michigan Medicine.