AMA STEPS Forward® Podcast – Eliminating “Pebbles in the Shoe” for Our Emergency Physicians

AMA STEPS Forward® Podcast – Eliminating “Pebbles in the Shoe” for Our Emergency Physicians

Published Online: August 26, 2025

Activity Information and Disclosures

STEPS Forward Podcasts 29 min 33 sec

Host Dr. Marie Brown, internist and Physician Director of Practice Redesign at the AMA, joins Dr. Diana Savitzky, pediatric emergency medicine physician and Chair of the Well-Being Section of the American College of Emergency Physicians (ACEP) to discuss the unique stressors that impact emergency physicians and how alleviating “pebbles in the shoe” can improve physician well-being and team operations.

• Case Study of How Alleviating “Pebbles in the Shoe” Improves Operations in the Emergency Department
• Getting Rid of Stupid Stuff Toolkit
• ACEP supports the ABC-ED Act
• ACEP AHRQ Summit on Boarding
• ACEP Well Workplace Policy Link
• Info about Lorna Breen Act & Credentialing
• POLICY Violence Prevention
• Access the transcript for this episode
• Audio Transcript

Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA's STEPS Forward program is open access at STEPSForward.org.

Marie Brown, MD: Hello, and welcome to this episode in the AMA STEPS Forward podcast series. I'm your host, Dr Marie Brown, physician director of practice redesign here at the AMA and an internist here in Chicago.

Our guest today is Dr Diana Savitzky, chair of the ACEP Well-Being Section of the American College of Emergency Physicians, here to speak about the unique challenges emergency physicians face and focusing on practical solutions to some of their most common problems. Welcome to the podcast, Dr Savitzky.

Diana Savitsky, MD: Thank you so much, Dr Brown. I'm really excited to talk to you today and represent emergency medicine physicians.

I'm a PEM physician, so I did a pediatric residency and then a pediatric emergency medicine fellowship. I've been working in the same emergency department since I graduated from my fellowship, and that's been about 8 or 9 years now, and I love working there. I'm an educator and a clinician, and so I experience, you know, the burdens, you say the frustrations of work. I really know what emergency medicine physicians are feeling and living and dealing with every day.

I'm also a wife and a mom to two young girls and I live in a suburb of New York City on Long Island. I currently serve as the chair of the ACEP Professional Well-Being Section. I served as the chair elect for the past 2 years, since 2023, and I will have a two year term, which ends at our national meeting in 2026. But of course, I plan to stay in touch and work closely with the group. I'm also a member of our ACEP Professional Well-Being Committee, which does a lot of the good work that I get to promote and use as the section chair.

Dr Brown: Wow. Tell me more about how you began working with ACEP, the Professional Well-Being section that you now chair.

Dr Savitsky: Well, probably stems from sort of experiencing burnout, but you know, essentially, I got to a point where I thought, okay, I can only work on myself, say, you know, to some extent and you know, it's going to take more than just improving myself to my safe, highest thriving level to get out of burnout or to prevent it from say, happening again. And so I sought out the section that seems to really speak to me and I felt that it was really important to get involved. And, you know, I was fortunate enough to get into the leadership role. Feels great to, to know that that same kind of work that I'm going to benefit from will benefit my colleagues, benefit people I don't even know, colleagues in other parts of our country. You know, there's a large amount of personal satisfaction that comes from that. So that's really how I fell into this section and this workspace.

Dr Brown: Great. We do know, as you mentioned, that burnout manifests in individuals, but it originates in the system. So you can only work on your own resilience for so long and then you go back into a dysfunctional or in inefficient culture or department and there's opportunity there to improve the efficiency. So what are the unique stressors that impact physician wellness in emergency medicine?

Dr Savitsky: I would say the unique pressures for emergency medicine is the fact that we work in a high stress environment. You can have some unpredictable work environments or working conditions, and we really have no control over patients as far as the type of patient that comes in, the resources that we might need in order to address their needs. And that's actually where the stress of, you know, EMTALA comes in, where a federal law that ensures hospitals participating in Medicare, you know, receiving the federal funding, would provide emergency medical care to everyone regardless of their ability to pay or their insurance status.

And, you know, it's important. You know, I have a lot of pride in being an emergency medicine physician where I can feel like I can provide anyone care, you know, the right care regardless of insurance status or ability to pay, but at the end of the day, if my hospital doesn't receive, you know, the funding for it, it creates strain, which I'm sure is what leads to a lot of stress in both the emergency department, but health care, US health care in general. And so aside from the high stress, unpredictable environment, and no control over our patients, you know, this can just be different and fluctuate day to day. And what often results is that it overwhelms our resources. You know, it can become much more challenging to provide, you know, the care that we feel patients need and deserve.

Dr Brown: So there is a federal policy that prohibits any limitation on the number, the volume of patients that you could see in a shift.

Dr Savitsky: Yeah, exactly. I mean, there's no cap. We have to provide care. If we need to transfer someone or receive a transfer for, you know, an appropriate higher level of care, it can't be refused.

Dr Brown: So with all those unique stressors in the in emergency medicine, where does the busy physician start to address some of these levers?

Dr Savitsky: Yes. I'm glad you asked that because sometimes the first step or knowing where to start is among the hardest things to kind of overcome. Sometimes the stress could be so much you almost give up and you might not even want to get started. But our ACEP Well-Being Committee created this great Well Workplace policy. They took a group of experts to think about the challenges in emergency medicine, you know, and just sort of think about and basically dream up a much more ideal and a well workplace. You know, what factors, what resources, and just how it really should be in the most ideal state.

And so they published this. They broke it down into three categories consisting of organizational influences, practice environment influences, and culture. Within each of these three categories, there's about 6 or 7, say, item lines. I'm happy to kind of read out to you one or two from each, just so you get a sense of what that means. But this is just an example.

If you want to have a well workplace in your emergency department, the organizational influences you know you should have are as follows: provision of adequate site resources to meet patient needs at all time; or attention to facilities addressing essentials such as lactation rooms, break rooms, and charting space.

And then moving on to some of the practice environment influences: there should be full staffing of all workers in the department required for patient care, including ancillary staff, nondepartmental employees such as transportation, environmental services, lab, radiology, and security. You know, these are all the kind of extra support staff that try to, you know, decrease the less meaningful work, and try to offload it so that we can focus on kind of using our skills and education as physicians to our best ability.

And then finally, for the factor of culture, some recommendations are, you know, making sure that there's anonymous and comprehensive objective evaluation of wellness outcomes and departmental leadership by staff so that that can ensure accountability to address, maintain, and improve workplace wellness. It's sort of keeping everything in the positive trajectory to keep working on and improving on the workplace.

And there should also be something like transparent and equitable compensation, promotion, due process policies, and clearly defined and reasonable and sustainable productivity metrics. So a lot of this has to do with how you're salaried and how hard you have to work in order to achieve a bonus or achieve, you know, your paycheck.

These are, you know, just a couple of examples. You know, we're also happy to kind of share that in the link for the podcast. But, you know, it would be kind of fun, I think to, you know, if you don't know where to start, if you take a look at the policy and you just take an inventory. You could just take each item. You could sit down with your leadership or your, you know, your chair of your department and go through each item and sort of score yourself in a very informal way. Do we have something in place or not? A yes or no. Or you could kind of think of it like, “We have something, but it isn't really that, you know, effective or impactful. You know, could it be improved?” So, you know, you could kind of take all 20 items from this really impressive document of how it should be in emergency department, and that can guide you and you can see areas that there might be some, you know, overlooked areas, shortcomings. And then you could actually, you might notice that we have a lot in place for certain factors and kind of feel like, grateful, and, you know, happy that this was already being worked on. But this, Well Workplace policy is a great place and a great reference to start with.

Dr Brown: I would agree. And I love that ACEP has made that open access. And it's, oh, it's a two page document with wonderful references, and it's a very good place to start.

But here at the AMA, and especially with STEPS Forward, we focus on sharing some simple solutions. And you just published, you're the lead author, a research report on alleviating “pebbles in the shoe” to improve operations in the emergency department. Can you share, some of the details of that study?

Dr Savitsky: Yes, absolutely. Well, it's kind of funny that we're talking now because I will say, you know, the term “fixing, say, a pebble in the shoe,” I certainly didn't invent that term. That's like a very kind of colloquial and well understood term. Nobody likes the way it feels to have a pebble in the shoe, but when you apply it to your work experience, these things that are small, yet significant, you know, they really could make a, big impact in your day, positive or negative. If you have a pebble in your shoe, you're running around the ED, you're, you know, it's going to sort of break you at some point.

Any workplace, not just an emergency department, but any workplace has frustrations or issues or any, you know, processes that could be improved. And when my group, the well-being committee within my own department, you know, we got together, we're brainstorming what are just general things we want to be doing within our ED to improve our work experience, you know, somebody brought up this kind of concept of like fixing or working on things that you perceive as frustrating at work.

And it kind of naturally led me to remembering about, like an AMA story that was published about how one health care system in the Midwest, they had their sort of highest level C-suite physicians, the leadership, meet with the clinicians and ask them, what are your pebbles in the shoe? They gave them about like a, sort of a once a year opportunity to tell them what are some frustrations that haven't been able to be fixed. And one example was the anesthesiologist. They said their toilet is broken. They have to walk all the way down the hallway in order to get to wherever they need to get to for the bathroom. And it was frustrating them. It was slowing down, I guess, their ability to kind of pop in and pop out of the OR and do their work. And when the C-suite, the CEOs, when they found out about this happening, they kind of made it happen. They realized that that was a great pebble in the shoe. That's something that they can do to fix.

And so what I thought would be really helpful for an emergency department—it's a very dynamic place, it's a relatively, say, high-paced type of work environment. You know, we already talked about, this is unpredictable, it's high stress. You know, we have no control of who walks in one day and to some extent, like exactly what resources we have on a certain day. And so I felt that, you know, maybe we could take this idea and run with it and give, our group, at least in emergency medicine, give our physicians and clinicians an opportunity to submit or talk about their pebble problems much more frequently.

So we actually, we created a process where a clinician could submit a pebble in more real time. And we created QR codes that we post all throughout the department at all the clinical workstations. We make it really easy to access because, you know, I had to ask my friends and my colleagues, you know, what do you normally do on a shift that you're working in the ED, a pebble, like a problem, comes up where you think, you know, like, this is it, this is the last straw? You know, what do you usually do? I would say most of the time, you keep it to yourself or you know, perhaps you might wait at the end of your shift to kind of email your boss or your medical director. And what might actually happen is you kind of, you get to the end of your shift and you've forgotten it already, so it's a missed opportunity. Or you just might change your mind and say like, “oh, is this really so big and so important? It is pretty small. Maybe, you know, I don't want to seem like I'm complaining, so maybe I'll not reach out.”

Dr Brown: I love that. And I know that the QR codes you placed in strategic places where physicians are working and you called, you labeled them “real-time pebbles.”

Dr Savitsky: Exactly. Let me walk you through, how to submit a pebble and how it really works. So the frustrating thing happened, I sit down at my workstation, I scan my QR code, and there's really three simple questions. There's the more like open-ended free text area to just submit, what's the pebble problem? Like what is the problem? And we always encourage everyone to give as much detail as possible so that we can better understand it. We also want to know what the location that the problem is occurring. And for our department, what works best is differentiating the adult side versus the pediatric side. And then we also ask like what type of clinicians submitted the pebble? Was it a physician, was it a resident? Was it a APP?

Generally speaking, this is an anonymous submission. We are not looking for names, we're not looking kind of to point out who sort of brought this up. It's really meant to be a sort of a psychologically safe space where you can, you know, voice your frustrations in a constructive way. You're sharing the information so that this pebbles task force or this group that's working on it, that works with our leadership, everybody can understand it and, you know, fix it, essentially. It's really a joy to kind of check off on a list, something. And that's, that's kind of how we feel when the pebble submission comes in and we can actually fix it and, fulfill it.

Dr Brown: So you mentioned leadership. Who was on the leadership team? And how important was that?

Dr Savitsky: When we decided to start this project, it was really just a group of passionate, dedicated clinicians that, you know, wanted things improved in our workplace for the sake of say, well-being for everyone.

But, you know, like I mentioned in the beginning, I'm a regular clinician. I work, I know what it's like to work and experience this. I think that, you know, leadership, whether it's physicians or the admin who don't necessarily work at the bedside, you know, they experience work differently. They may not really know exactly what it's like to work. And so we're kind of bridging that gap by, I think, you know, giving them a better pulse on their department.

Like I said, nobody really runs to their boss at the end of every shift and tell them like every little thing that goes wrong. But when, you know, we give them a platform in an anonymous way to submit sort of the issues, then our leadership, you know, knows what's going on and can work on it and fix it. It's really important to have them buy in to the project and the program because if they don't feel a sense of urgency to, you know, fix the pebbles, I could see it really leading to kind of a disaster with the project. If you're a busy clinician and you take the time to submit a pebble, you're voicing, you know, say, your frustration or your kind of opinion, you're giving your input, and you feel that it's going nowhere, nothing's being done about that, you're probably not going to take the time and submit it again. And again, that's really a missed opportunity for leadership.

I actually think this project is gold and really helps leadership. I have found in my working group that you know, like none of the leadership is threatened by the project showing them, say, areas that need improvement.

Dr Brown: Could you list the people who were on the pebbles task force?

Dr Savitsky: Yes. So we have a category of clinicians that we view as project team leads. Then we have one of our administrators, like the head administrator of the department. We have our chair of our department sits in these meetings and hears it and weighs in, you know, when it's appropriate, how things can be fixed. Our division leaders. So like in my pediatric ED, our medical director for the pediatric ED sits in on these meetings. That way kind of these higher, these highest levels of leadership within my department are, you know, aware and can sort of discuss as a group.

We also have nursing leadership and our supply chain director also sit in on these meetings. And you know, essentially what happens is a pebble problem will come up, we'll discuss it as a group, and we'll assign the pebble to a specific person, you know, where it's appropriate, where something could be fixed and worked on. And so, you know, simple things like we need a supply, we need, you know, a new cordless, chargeable otoscope. That would go to our supply person to order it and make it available, or if the light bulbs are not working for an otoscope, that would be the point person to work on it. I wouldn't be asking like my chair to work on it.

When there's other, items that are being discussed about interprofessional relationships and experiences, like a different way to get in touch with a consult group that, you know, it was difficult to get in touch with and, you know, there we need to speak to the departments, like that's when our administrator or our chair will get involved. At that level, it's not just about asking our clinicians to submit their, you know, frustrations and their problems, fixing them. We have to close the loop of communication. We have to show them what we've done and make them feel like their voice was heard and their, you know, opinions or suggestions were valued.

And so we make sure that we have a very visual stoplight report that essentially reports out what has come from these pebble problems. So we'll organize it. If it was completed, we'll kind of put it next to a green light for the stoplight report. And things that are currently being worked on, we kind of give them the progress and that's in yellow. And then there might be some pebble problems that are red, it's in the red stoplight and it can't be fixed or fulfilled. We'd like to give an explanation and say why.

I'll give you a great example. One of the physicians on the adult side asked if there could be rapid strep tests placed in the equipment bins where there's COVID tests. You know, there's like simple kind of items, tongue depressors, so that when they go to see patients, it might be all over the ED, might be in the waiting room, you know, they feel, “Oh, that might reduce a step I have to do, walk all the way to this room in the pediatric ED and grab it and go.” And it was, it sounded great. It was, sounded like a good idea. When we spoke to our leadership and our nursing administrator, she kind of explained something to me that I never knew. And so therefore we pass this on to our group. The rapid strep tests have to be kept at a temperature-controlled room, and if they're not, the test might not be valid. So it's kind of worthless to keep them wherever you want if we don't know if the test is valid. And so that's just something simple, you know, if we close the loop and tell them why it can't be fulfilled, they don't, you know, feel so bad. And then they move on from it.

Dr Brown: And over seven months, you received about 280 pebble suggestions. And what was your ability to complete or respond to or resolve those 284 pebbles?

Dr Savitsky: So the work that we did to fix the pebbles occurred in web-based meetings twice a month, and we were actually able to complete about 75%, we completed.

Dr Brown: That's a really high completion rate. I know your survey showed that over 80% of people felt that this is a very effective program. So I hope it's ongoing. It's very similar to a toolkit that we have available and open access at STEPS Forward called Getting Rid of Stupid Stuff or G.R.O.S.S., Written by Dr Melinda Ashton, to get started wherever you are working.

But I want to move on to some of the other really unique problems, if we could. Some of the other stressors, and I know you've spent a fair amount of time thinking about boarding.

Dr Savitsky: Yes. So I think that the term like boarding or ED boarding has the kind of another misconception that it's like an ED, emergency department, problem, but it's actually really a hospital-wide problem, because the concept of an admitted patient not necessarily moving to an inpatient bed, I mean, it tends to be upstairs.

The idea that the patient that requires, say, inpatient care is staying in the ED is a problem for lots of reasons. The care, you know, coming from a nurse, like an ER nurse, is probably very different than a nurse that kind of lives on the floor. They have just like a different approach, a different way, you know, of being. And of course the downstream effects of the patient boarding in the ED is a real problem for the next set of patients wanting to come in to be seen in the ED. It leads to high, you know, wait times, and sometimes that can be really dangerous. You know, the waiting room can become crowded. Depending on where you work, the wait times can be quite high. And so, you know, you have to cultivate a practice of waiting room medicine and, you know, not everybody is comfortable with that.

Dr Brown: Boarding is a institution-wide problem. So if a patient is discharged, it's downstream. You can't move the patient from the ED up to the bed because the bed is full, maybe waiting for somebody in the family to pick that patient up. They've been discharged.

Are there some institutions that have addressed that problem, so that frees up some beds a little earlier in the day?

Dr Savitsky: Yeah, so some of the institutions I've trained at, they have a results waiting area. And so a patient will come through the ED, just, say, just like an ordinary ED patient. They're seen by emergency medicine physicians next to critical cases, just kind of the way things are regularly run, and they might feel that this patient either needs the results of a lab test or results of an imaging test, or sort of to be seen by a consult. They're waiting, you know, for something in order to determine the disposition or most likely a disposition home. And so they'll have these more large format, large open areas, you know, with multiple chairs side by side as opposed to the traditional gurney or bed. And they'll have these like kind of waiting, results waiting area or discharge, say concierge suites, where it's a bit more comfortable and it's a bit more efficient and a bit more comfortable to be waiting for whatever it is that you need, those results, and trying to improve the experience and satisfaction for patients, and frees up the bed.

Dr Brown: Fabulous. I want to hear your thoughts about addressing another unique stressor, which is workplace violence. And I wonder if there are some solutions ACEP has, put in place that would help your colleagues in working in the ER and keep them safe?

Dr Savitsky: Yes. So I think workplace violence in health care is not completely unique to the emergency department, but I do think for some of the factors we already spoke about, the boarding issues, the crowding, the wait times. You know, we do see, you know, there's a mental health crisis, so there are some violent or kind of uncontrolled patients and they really, they don't have the capacity, that is a problem. But then there's some patients that do have capacity and you know, they're sitting and stewing and it can lead to this violence. And actually, ACEP did a poll in 2024 just to better understand the problem. And they actually found a pretty staggering statistic that more than 9 in 10 emergency physicians have been threatened or attacked in the past year. So it's 91% of the polled emergency physicians had some experience with, say, workplace violence.

Dr Brown: Wow, that's, that, that is a frightening number.

Dr Savitsky: Yeah. And at least through ACEP and, you know, we just, we don't really want everyone to just accept this as part of the job. It's really unfair. You shouldn't really have to fear for your life or your physical sort of safety when you go to work because really, you know, this is for the health of our workforce. Who's going to do this job if we won't?

So one way ACEP is really instrumental in improving this problem with workplace violence—it's not going to be a one quick fix, it's a huge problem—they've spent a lot of time working on creating policies that you know, you could kind of take directly from the site and show or give to your administrators or leadership in your department. And you know, they have explicitly written out, you know, this is a policy ACEP supports to maintain protection from violence and the threat of violence in the emergency department. A policy that's asking for safer working conditions for ED staff, having in place policies for violence protection, you know, in general.

Dr Brown: Could you share a little bit more about the Lorna Breen Healthcare Protection Act?

Dr Savitsky: Of course, this Lorna Breen Act helped create this push to remove the stigmatizing language in medical licensure statewide, and also individual, say, hospital credentialing. And what's nice about the Lorna Breen Foundation, they have a website, we'll add a link, where you can take your own, either your state medical licensing questions and you can also take your personal, like the hospital that you work in, you can take the credentialing language in the contracts and see. You could actually submit and have someone else take a look and see: is there any kind of stigmatizing language? Is there any area that's sort of violating this rule that you need to remove questions about mental health? And they can really help you in getting this to make a big change and impact for clinicians and physicians so that is not a barrier. That they can seek the help. You know, and our hope is that more people can seek out help that they need, there could be less suicide, there could just be less suffering, less burnout in general. That's really the hope from this Healthcare Protection Act.

Dr Brown: So we encourage listeners to look at that, the Lorna Breen Foundation, and that'll be in the resources, as well. In closing, are there any other pearls of wisdom you'd like to share with our audience?

Dr Savitsky: I think that it can be overwhelming to work in an emergency department. And it might be even more challenging for the more, say, seasoned, physicians who have been working this for a long time. They didn't, you know, train recently. They don't have as much in place to support their well-being. I hope that if any of them are listening to this podcast, that this instills some level of hope, gives some type of framework to you know, help them feel like they can tackle this, both, you know, themselves, but also with their colleagues and their leadership. Like there are real solutions, real tangible things to do: assessing your own department, kind of surveying your department relative to the Well Workplace policy, seeing where you end up, where your areas for improvement or areas of attention could be. The pebbles in the shoe project is really like a very easy, safe place to start to improve your workplace areas. And then lastly, in order to, you know, help your colleagues at your own hospital and possibly in your own state, if you take the time to advocate and work on removing the stigmatizing language, you might be really helping some physicians and clinicians in need where it's as simple as they will refuse to seek out help due to fear and due to stigma, and this might be the thing that removes that barrier.

Dr Brown: Wonderful. We can't thank you enough for sharing your wisdom.

Dr Diana Savitzky, chair of the Wellness Section of the American College of Emergency Physicians has been our guest today. Check out the episode description to explore the resources mentioned in today's episode. And until next time, stay well.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward podcast series.AMA's STEPS Forward program is open access at STEPSForward.org. STEPS Forward can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMAs STEPS Forward podcast series, STEPS Forward.org.

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