Gaslighting in ID and the Push for Fair Compensation

Paul Sax: [00:00:14] Hi everybody. This is Paul Sax. I'm the editor in chief of Clinical Infectious Diseases. And welcome to the Let's Talk podcast. In this episode, we tackle something that every ID clinician knows all too well, the invisible labor, the corporate speak, and yes, even gaslighting that can undermine our work and our wellbeing. To help us address these systemic challenges, I am thrilled to be joined by two leaders in outspoken advocates for ID professionals. First, Dr. Priya Nori, who's associate professor at Albert Einstein and medical director of antimicrobial stewardship at Montefiore Health, and Dr. Gonzalo Bearman, chair of infectious diseases at Virginia Commonwealth University Health. Welcome, Priya and Gonzalo. So together they have written two provocative, and I mean provocative and timely papers. Both have recently been published in Clinical Infectious Diseases, a very fine journal, if I may be so biased. The two papers are called first, Minimizing Low Value Uncompensated Work in Academic ID: A Six Step Program, and the second is called, Are We Being Gaslit? A Primer for Recognizing Corporate Jargon to Overcome Gaslighting for the Infectious Disease Workforce, They're here not only to talk about the problems, but how we can push back and advocate for ourselves and each other and to reclaim the value of our work. You know, I'm going to start off this podcast like I do all of them. Just give us the short story of how you got involved in medicine in general and ID in particular. Let's start with you, Gonzalo.

Gonzalo Bearman: [00:01:50] Huge pleasure to be with you, Andrea, today. So I wish I could say that, you know, I blazed the trail, but anything but I'm actually the fifth doctor in the family, so this definitely was not going to uncharted waters. Essentially, in college, I really didn't think of anything else but studying, going into medicine eventually. I was a college soccer player and kind of focused on that and got good enough grades to go to med school, I guess. And then from there, I was not very sophisticated. I knew nothing about infectious disease and public health, and I credit it to being at the right places at the right time. Meeting fantastic infectious disease lecturers at the University of Buffalo, where I studied medicine, and then coming across really great mentors, not only in internal medicine at University of Buffalo, but then in my training at Cornell and Columbia to learn about infectious disease epidemiology and research related to that. After I finished my training, I ended up here at Virginia Commonwealth University. I had amazing mentors with Dr. Richard Wenzel and Michael Edmunds, so that's how I ended up doing what I do.

Paul Sax: [00:02:45] Yeah, so it's amazing how often it's mentors who pave the way.

Priya Nori: [00:02:49] Yeah, my experience echoes that. I think largely I'm a kind of typical South Asian kid, a two doctor family. Many doctors also between the states and India, so didn't really think about doing much else. But where I had the opportunity to exercise, my voice was going into ID. Neither of my folks are ID physicians, and so that was totally unchartered and, you know, absolutely no regrets there. And that's some incredible people, several of whom, you know, Paul, who are at my institution, my mentors, including my chief, Lisa Borowski. So that's how I kind of got here.

Paul Sax: [00:03:26] My grandmother, when she heard I was going to medical school, told me you should go into ophthalmology. It's a very good living. I didn't listen to her.

Priya Nori: [00:03:34] My mother still wants me to open up like a Botox practice and just drop ID and just do cosmetic injections.

Paul Sax: [00:03:42] Back to these papers, which, uh, really kind of, as I said, provocative. Gonzalo, what prompted you to write them? Did something tip you over to thinking that this needed to be addressed?

Gonzalo Bearman: [00:03:54] I don't think there was a single episode, but I've been now the division chair here at VCU for 11 years. So I can't say I've heard it all, but I've heard a lot, and I've seen a lot with respect to faculty members struggling with what to do and what not to do, feeling overextended and undervalued. And then through the course of negotiations for either program or division development or resources, or even fighting for contracts, the terminology, the corporate speak that's used sometimes I think in a fashion that is meant to either delay or deflect us and to move us in a different direction without getting clarity and answers. So it comes from some frustrations, some personal victories here and there, some meditations and some learning, some lessons from mistakes made also.

Paul Sax: [00:04:39] Priya, was there something that you thought made you want to do this all of a sudden?

Priya Nori: [00:04:43] Yeah, I would say so. So I'm glad you started with Gonzalo on this question, because you could probably tell that the ideas kind of stem from him in terms of the guts to take on these types of projects. And then I sort of echo like, yeah, that's happened to me too. So I like to think of our collaboration as somebody at the top looking around and looking maybe down, and then someone at the bottom or like squarely in the middle, looking around and being like, yeah, that's totally happened to me. And so several of these experiences and in these articles, there are parts where I actually share some personal experiences at work. I've certainly experienced those things. By those things, I mean doing a lot of street cred type of work for my colleagues outside of ID, also maybe being subject to language that is clearly gaslighting.

Paul Sax: [00:05:48] Let's go right to that word. Do you know the origins of it? Gaslighting. It's a term you hear a lot, but what does it mean?

Priya Nori: [00:05:55] Yeah. So gaslighting when we kind of looked into both broadly speaking, the societal definition and then as applied to health care. It's kind of, um, manipulative use of language to either get an outcome where you do what maybe somebody else wants, or maybe you don't do what someone else wants, and you put to rest a great idea that you have, or it's a way to kind of kick the can down the road and not enable your success in some way. And so while that has a tone of a superior person or a leader, kind of doing that to a subordinate can happen all the time. We can even do it to each other. We can do it to our patients. I mean, my daughter gaslights me all the time when she tells me she finished her dinner or her homework. So it's kind of all around us. It can be applied to lots of different situations, I think.

Paul Sax: [00:06:47] So let's hear some examples. Corporate jargon, phrases, behaviors, something that just kind of stands out for you.

Priya Nori: [00:06:54] Yeah, absolutely. So the example that we give in the paper is one of epic, and I know that we've all experienced this. Paul, you've written extensively about this, but it's a certain kind of speak that they have, which educates you really quickly on where your request is on the priority list, which is typically extremely low. And instead of just kind of being straightforward with you, they use a lot of tech speak that may not be obvious to us. Like we have to scope this out. We have to take this to the governance committee. We have to get a green light from the board at the governance committee. And it's just like, just level with me, please. This is either not happening or not happening anytime soon. If you kind of just stated it that way, I would temper my expectations and move on to something else. But this is more like a string along type of approach, which certainly nobody appreciates.

Paul Sax: [00:07:54] And what about certain phrases used to sort of bring out the desire for you to do uncompensated work, like a team player or passion project or something like that. Gonzalo, do you have any examples?

Gonzalo Bearman: [00:08:07] Most of us in medicine and infectious disease, we want to get along with people, right? We want to be part of the group and be accepted. So we want to be team players. So our inclination is to say yes to things because we want to be part of the team and we don't want to let people down. And that team could be your immediate divisional team or your subdivision if you're a transplant ID group, or you could be the team, could be the Department of Medicine or even the School of Medicine if you want to think bigger or the health system. So our inclination is to say yes to things, and we end up saying yes to things too often such that we become overwhelmed. And I think that's where the issue of really being clear on identifying what the values are, and also what the individual and team needs are, is critically important. I guess what I'm referring to is taking inventory, an inventory of what you do and don't do, and what's compensated and what's not compensated.

Paul Sax: [00:08:55] These non-revenue revenue generating tasks that ID doctors do. They must intersect with this jargon and bring it out a lot. Priya, you have some examples in your papers. Give us some of those examples of these tasks.

Priya Nori: [00:09:08] Yeah. So the immediate experience that comes to mind is what we did during Covid when roles were really undefined. It was truly an honor to lead the charge of a new illness, try to decipher that for folks and figure out how to get control of the situation. Unfortunately, the lines were blurred and we ended up doing a lot of, um, stuff for people. We ended up doing a lot of personal favors or testing or treatment or treating colleagues, family members. It was sort of 24/7, and I don't think any ID person did not experience that. I think largely that a lot of that is calmed down, but there are certainly residual impacts of that. I think that speaks to our desire to always please, always be the guy for some reason, always being the guy or the gal really drives us inside and we have a hard time setting boundaries. An example for me just from this week is that I suddenly ended up with a panel full of family members of colleagues who apparently I'm the only like op ed doc, or the only ID doc that would respond to their texts, essentially. So I tend to do a lot of things like that, and there's a lot of joy and honor in that, but it can at times really blur boundaries. But I think it is a relatable situation that I can really connect with folks just like me who are sort of mid-career throughout the country. We can commiserate, but it's time to stop commiserating and actually come up with solutions.

Paul Sax: [00:10:42] Brings us to some solutions. So, Gonzalo, you in your paper, you introduced a six step program to reduce uncompensated work.

Gonzalo Bearman: [00:10:50] That's right. I mean, it's a little tongue in cheek if you think of AA 12 step program. And not to minimize that. Of course, it's hugely important, but the first step with any problem is to acknowledge that you have a problem. The call here is for us to acknowledge that we do have a problem of uncompensated work, frequently low value. There's high value, uncompensated work. Maybe we can explore that later. But the first thing to do is to take inventory, inventory of what you do on a given week, or a given month or a given day. What's compensated, what's not? What's high versus low value for you personally? Professionally? It's not just at the individual level. Your division chair or your mentors should be helping you with that. Give you some clarity on what to do. And there are other steps that we talk about also as to how to make your days more efficient, how to seek help from trusted people so that you get the appropriate feedback. How to be a team player. And if I may just mention this, really, we're all want to professionally develop as faculty members in a division of infectious disease or any division. But you also have to respect the team dynamic. And we all know that teams have certain things they need to deliver, whether it's numbers of clinic sessions, number of sessions for fellows in the clinic. Core lecturers for fellows. Core lecturers for the medical school. Those are team obligations. We can't necessarily say we're not going to do that because it's not my professional goals to teach a medical school class. Well, that may not be high value to you, but it's part of the team effort too. So you have to be a team player at a certain level. Otherwise the dynamic gets strained.

Paul Sax: [00:12:15] So let's say a junior faculty member comes to you and says that they've been asked to join a committee that meets weekly at 4 p.m. on Tuesday afternoons, and it's for a hospital service that they don't have much to do with, but they know that they need an ID representative. So what would you say to that junior faculty member?

Gonzalo Bearman: [00:12:36] So absolutely, I would have them question like, how valuable is that to you and to your professional goals for your development? Remember, all the faculty members, at least in my group, are promotion and tenure kind of on the track. So is that something that would advance them professionally? If it's something that interests them, but it may not be of high value for promotion and tenure. I would not say don't do that. Do it. But be very clear on your time commitment. I have an hour to give you every week or two hours maximum week. Don't let that continue to ebb and flow and grow so that you go from 2 to 4 to five hours and it bleeds into your family time and your home time and things like that. So it's clarity on what's being asked of you, clarity on how it falls into the matrix of your professional development and that of the group's needs and clarity as to what you're really willing to give to that project.

Paul Sax: [00:13:24] It can take an emotional toll. Right, Priya?

Priya Nori: [00:13:27] Oh, yeah. It can take an emotional toll where you feel like, okay, I'm just banking all the street cred, but I'm not cashing in on it. And what is cashing in even look like anymore? And then, not to mention a hard reality that I face post Covid is there's an expiration date on that street cred, and people may not necessarily remember what you may have done for them in the extremes of a pandemic three, 4 or 5 years ago. And so it kind of resets. So don't expect that your version of cashing in is going to look like somebody suddenly putting you up or sponsoring you for an executive position or none of that. None of that stuff is expected. I've learned this over time with senior folks, mentors like Gonzalo, which is you do it for you. You do it because it's high value to your value system, but not because it's going to get you somewhere. It gets you somewhere. That's cool. That's great. That's a bonus. But don't expect that.

Paul Sax: [00:14:27] Mhm.

Priya Nori: [00:14:27] And when you take away that expectation, you're probably be a little bit happier. So one thing that I do that goes honestly, it's not going to maybe it makes me feel younger because I get to hang with a lot of med students. I'm the faculty mentor for like our South Asian and Asian medical students interest groups, which means a lot of after hours stuff. A lot of me kind of going over to the med school through traffic after hours for their events. A lot of hours spent just helping to shape them and mentor them. But there's no, I guess, tangible outcome from that, except that I feel awesome. And I don't think there's a price tag on that.

Paul Sax: [00:15:07] That's important, I mean, uncompensated work can be tremendously rewarding. I'm just thinking, I meet with our first year ID fellows every Thursday morning and we go over cases, and I just love that. They would have to, like, drive me away because it's just so rewarding to me, even though I'm not getting paid extra to do it. But anyway, I totally get it. It's like, what does it mean to you? So institutions, do they have a role in helping support people beyond wellness seminars or giving them a new fleece?

Gonzalo Bearman: [00:15:36] I think so. I think that institutions, the first thing that they could do, at least academic institutions, is to not speak out of both sides of their mouths, saying like, we want you to be clinically productive in the rvus and the ROI. I mean, I get that we need money for the mission, but if they're also requesting the same side that we have to do some education, be responsive to the medical students, even be academic, whether it's abstracts, a couple of manuscripts a year, etc., etc. then that has to be budgeted into the salary or the time that's expected of us to spend in clinic and out of clinic. We generally argue for 10 to 20% time to do all the academic mission kind of things that we're supposed to do here at VCU health. We don't always get there, but I think by advocating aggressively, it's opened the eyes to the team that, you know, you've got to have some of your time put aside to do those kind of academic components of your job. And we're very clear with the compensation plan and the administration. That's what we're doing.

Paul Sax: [00:16:31] That brings up your role as a division chief, Gonzalo, you know, you must you must feel like you need to advocate for your faculty and also be very transparent about things like compensation and what the metrics of evaluation are. Are there examples at your institutions where leaders have been really helpful? You know, I'm not talking now about you, Gonzalo, but I'm talking about other people where you work. And same for you, Priya.

Priya Nori: [00:16:55] I think the flexibility lately around telework or more flexible work schedules, or when folks are expected to be present in the office and when it's okay not to be. Another unexpected effect of the pandemic that I think has been positive, especially for female faculty, people with families and responsibilities at home. That has been a nice change. That seems like it's here to stay. It has brought good balance to folks, but it also needs to have its own boundaries where you're not plugged in 24 over seven or hooked up to your epic chat 24/7 on vacation, etc. so I think that has been enabling good change from the top down.

Gonzalo Bearman: [00:17:44] What I've seen is department chairs or practice plan presidents or chairs that are open and receptive to new ideas on compensation and new metrics for specialties such as infectious disease. Well, we've really argued for is not so much an rvu based compensation, but one based on sessions. If you're a clinical doctor, you do X number of sessions and each session is four hours at a time. If you do a week of service, that's 14 sessions because it's seven days mornings and afternoons. So we count sessions that take some of the pressure off people to like, I need to generate these views, or else my salary is going to fluctuate. And we argue for compensation that's pegged to a double standard at a certain percentile. That's all been very helpful to preserve our, let's call it fiscal sanity and allow us to do some things that are not covered by direct dollars, but allow us to do the education, the professional development and things I think are critically important.

Paul Sax: [00:18:36] Playing the rvu game is a losing game for ID doctors, almost inevitably.

Priya Nori: [00:18:40] Where we tend to overcompensate, if you look at us versus our maybe other general, or department of medicine colleagues, is we're like overrepresented in clerkship directors and medical school course directorship. And like all these other academic things, we certainly pull our weight. And so we ought to be recognized and protected for that, if not compensated in some way.

Paul Sax: [00:19:07] So if you were to give the ideal metric for valuing an ID physician, how would you do it?

Gonzalo Bearman: [00:19:14] So from the level of the ID doctor, what I ask the faculty is do you feel satisfied or engaged in your role? If you can answer that, in a way that's clear and direct, that's one way to measure your professional experience. Now you're looking from the administration component, which is obviously the school of medicine, the health system, etc., etc. I think our rvus are the wrong measure. So again, sessions, traditional things like grants and papers and abstracts and talks are great. We should also recognize important things that people do that are sometimes frequently uncompensated but can still be valuable. An example that comes to mind is to be on a clinical committee that results in a practice guideline change in your institution that doesn't generally count in PNT. I think this is the bias of a journal editor, and you may agree with me, sir, is that we don't give enough credit for reviewers. There should be a section like you have reviewed 50 papers in the last five years that's legit. You give some serious points for that, and then any cool, innovative clinical and or community outreach things or educational components or programs, those should all be measured also.

Paul Sax: [00:20:20] I got a couple of standouts that every ID division struggles with. Ready? You tell me how you handle it. So Opat. Outpatient parenteral antimicrobial therapy. The ultimate hot potato. Nobody wants it. And yet it always falls to ID doctors to manage it. And it's not compensated. Solve that problem for us. The administration doesn't want to pay for it.

Priya Nori: [00:20:42] So I can tell you our unique version of Opat. I happen to be in my Opat sessions right now. It's kind of cool the arrangement that [inaudible] and I have worked out over time, which is that because we reframed Opat as a discharge program and an admission and readmission aversion program, we were able to bring it under the umbrella of our care management organization, whose whole business is to prevent readmissions and provide a safety net for folks who are high risk for admission and readmission. So we're kind of in the same under the same umbrella as like their CHF clinic or lots of these other chronic care management. And that has been really cool because that for our program, it gives us access to all kinds of folks like data analytic folks, case management, and a lot of people who can help build the safety net along with me.

Paul Sax: [00:21:41] Clinician to clinician advice, sometimes called curbside consults or e consults or however you want to frame it. People we work with, our colleagues, who want our expertise. They don't necessarily want to refer us to the patient. Maybe sometimes it's not even necessary, but they want our opinion on management of their patients.

Gonzalo Bearman: [00:22:00] Okay. So internal to the system. That's a hard one to tackle. We try to make ourselves responsive to internal requests. However, I do suggest to the faculty that we not be staffing these consoles via Epic Chat. An occasional one off phone call isn't bad, is not a bad idea, but if someone truly wants our expertise to call a proper console, that's the default. External the institution, you know, private hospitals etc., etc. we generally don't make ourselves available for those calls at all.

Paul Sax: [00:22:29] We have a e-consult system where we staff it and we give advice in epic. After reviewing the chart, many of the questions are quite appropriate for that level of interaction. Some, of course, are more complex, but paying for it is an impossible process, so they pay a small amount that has not increased in a decade. Argue I might, that, you know, the cost of living has gone up. So the price for this service should go up as well. Still falling on deaf ears.

Gonzalo Bearman: [00:22:56] Well, Priya mentioned I think earlier was spot on. It doesn't quite apply to that internal consult. You have to take the argument of what's in it for them and for Opat for example, she was spot on, it's decreasing readmissions, length of stay, etc. etc. That's what usually results in changing someone's, or administration, opinion on funding those things. But internal consults are tough. You're already there.

Paul Sax: [00:23:17] Well, the argument I've made is that, you know, specialty access is so poor, and what we're doing is we're providing specialty access in an efficient way that benefits the providers and the patients. It saves everybody time and money, and yet nobody seems to want to return that time and money back to the ID doctor. So this moves us into a last section, which is basically you used all kinds of terminology in these papers that are kind of funny. You know, my daughter, who's in business school, this is like right in her wheelhouse. So if you were to take one of the phrases that you used, one of these business school 101 phrases, and could eliminate it, which one would you eliminate? Gonzalo, you go first.

Gonzalo Bearman: [00:23:59] The one I hear a lot. It drives you a bit nuts is the word pivot. It basically means we started something and we changed our mind. And frequently, you don't know why. Or we started something, and now we changed our mind, but we completely went the other direction. So it's way overused. And I hear that one dropped all the time. We're going to pivot. So if we're pivoting all the time, what really are our values and what are our goals?

Paul Sax: [00:24:20] All right Priya, one term for you.

Priya Nori: [00:24:23] Okay I think I speak for both of us when I say bandwidth. It's very frustrating because it is also grossly overused. It automatically sets barriers in communication between the requester for something and the person who's invoking bandwidth as a reason not to do something. As someone who almost never says no, but that's for good reasons. Not bad reasons, and never say no because I find everything exciting and interesting. And then to put so much energy into an idea and then to kick it to, let's say, someone I work with junior faculty, a mentor or something, and for them to say to throw bandwidth back in my face, I shut off. I may not come back to them again with another cool idea.

Paul Sax: [00:25:08] All right. So if you're going to not use the term bandwidth, what would you replace it with?

Priya Nori: [00:25:12] I'd rather they didn't even. I'd rather they just take some time with that request, really think it through and work with me on a way to make that happen after, together, coming to the conclusion that this is something that's going to be good for everyone.

Gonzalo Bearman: [00:25:29] What I would add to that, Paul, is like, I don't say the word bandwidth. I would just say, and I have said this at this time, I'm unable to focus on this at the present moment. However, I think your idea is good or bad or whatever, and we'll come back to it. Usually in about a month or a week or whatever the time. Just be clear on what your intentions are. If your intentions are never to get to it, say, listen, I'm sorry, I just can't help you with that. But perhaps you can look for help over there.

Paul Sax: [00:25:51] I think return on investment is the one that makes the hair stand up on the back of my neck. Because, you know, if someone's proposing something, they think it's a good idea clinically for patients. Sometimes it doesn't have a return on investment. So anyway, this was a really fascinating conversation, and huge thanks to doctors Priya Nori and Gonzalo Berman for joining us and for their leadership in making this invisible work visible. Also, like the fact that you're challenging the culture that too often takes ID clinicians and professionals for granted. So if you're listening, please read these papers. They're really wonderful. And start the conversations at your institutions. And once again, thanks to doctors Nori and Bearman. This has been fun.

Gonzalo Bearman: [00:26:34] Thank you sir.

Priya Nori: [00:26:35] Thanks very much. This is great fun.