CHAPTER
1 The Good Physician
THE GOOD DOCTOR
WHY EXPLORE WHAT it means to be a good physician in the modern era, when there is so much to admire in traditional notions? Can we really do better than hope for empathic doctors who take pride in easing the suffering of patients and their families? Responsible people who ensure that every “i” is dotted and every “t” is crossed? Hard workers, who love what they do and will settle for nothing less than excellence in the care of their patients?
In truth, those characteristics have never gone out of style. They remain the core of the ego-identities of most physicians, nurses, and pretty much everyone else who works in healthcare. Patients hope for nothing less. But clinicians find that these noble characteristics are increasingly difficult to sustain.
The reason is a perfect storm of good news. The scientific good news is that progress has made medicine more powerful. But research advances have also made medicine more complex—in fact, so complex that no one can deliver state-of-the-science care by themselves anymore. Physicians must collaborate with colleagues even for routine conditions such as diabetes.
The demographic good news is that people are living longer, and as they do their health is dominated by chronic conditions that do not surrender easily to the right drug or the right operation, or simply working harder and longer. When numerous clinicians need to collaborate for long periods on difficult challenges, “coordination” and “compassion” become potential failings. Patients feel the effects of those failures when they occur, and caregivers are pained by them, too.
To deliver care that really meets patients’ needs, good physicians need good teams around them—and that means they themselves must be good team members. That requires time, energy, emotional intelligence—and some new skills. In the old days, a good physician had to explain things well; today, a good physician has to listen well, too. Everyone on the team, physicians included, has to keep everyone else informed and pay attention to what everyone else has done.
Being a good physician today also requires use of information technology tools. There is, quite simply, too much to know. New drugs and new tests are constantly emerging, and the best ways to use them are often far from clear—even to experts. In theory, electronic medical records (EMRs) help by enabling physicians to access information about their patients and tap into the wisdom of experts. The problem is that physicians are overwhelmed by the amount of information on almost every patient and by the amount of wisdom thrust in their faces by their EMRs.
It isn’t hard to understand why many physicians have focused their ire on the EMRs that bring the flood of data to them. These EMRs seem to frustrate physicians daily with small humiliations as they try to accomplish simple tasks.
I am thinking of my own recent exasperation as I tried to get rid of a reminder to give a patient a flu shot. Like many physicians, I try to do everything I am supposed to do, and a reminder to give a patient something that should benefit them bugs me until the task is completed and the reminder has disappeared. In this case, the patient had already had a flu shot at work, but to make the reminder go away, I needed to tell the EMR that the task had already been done.
I looked and looked, but I could not find a way to document that the patient had already had his flu shot. I tried clicking on this, clicking on that, and got nowhere. Finally, I saw a nurse practitioner on our team and said, with obvious exasperation, “How the hell do we document past immunizations?” She paused and then showed me a button in the middle of the task bar near the top of the screen. It said, “Document Past Immunizations.”
I could swear that until that instant the button had been invisible. It was embarrassing. It was one more episode in which I was revealed to be something less than the capable, all-knowing, all-powerful healer I liked to think of myself as being.
Adjusting to using new information technology is just one of the potential insults to physicians’ self-images. The widespread dissemination of medical information is another. Many people used to hold their doctors in awe and would defer to their judgments on almost anything. That’s over. Today, patients do their own web searches before agreeing to go to a recommended physician or facility, or have recommended tests.
Most physicians understand that increased patient engagement with their care constitutes change for the better. Having patients learn more about their conditions and treatments, and speak up about their questions and concerns—who can be against that? But still . . . that moment of hesitation while patients weigh whether physicians’ advice is worth taking can feel like part of a multipronged attack on our dignity—on our ability to feel consistently good about our work and ourselves. That makes it harder for us to sustain our passion for medicine.
The result is an epidemic of burnout and the need to understand the nature of resilience.
Burnout and Resilience
Burnout is a term tossed around loosely, and one can find wildly varying “data” on its prevalence—in part because many different definitions are in use. It isn’t a disease that can be diagnosed or excluded with a lab test; it is a type of stress and is usually related to work. It is characterized by three key types of symptoms—exhaustion, feeling ineffective, and depersonalization.
Almost everyone has some of these feelings some of the time. Problems arise when their frequency increases and when symptoms of burnout spread within a society like a contagious disease. In fact, burnout is behaving like an epidemic in healthcare today—its prevalence is higher than ever in the past and still rising. And there is also evidence that the presence of burnout symptoms in one person increases the risk of development of such symptoms in others.
Burnout is more than a morale issue—it causes harm to patients as well as to the clinicians themselves. Burned-out doctors and nurses deliver care that is lower in quality and less safe. Burnout among doctors is believed to contribute to an unusually high suicide rate, but the emotional toll is real and measurable in other ways, too. For example, clinicians who are burned out are more likely to leave their jobs; why would they stay if they feel so unhappy? The financial consequences of high turnover are enormous. Some organizations estimate that every time a physician leaves, the cost of replacing that physician is one and a half times their salary due to the cost of hiring temporary help, recruiting a replacement, and the delays involved in getting the replacement credentialed with health plans, and so on. With clinical and financial stakes so high, virtually every organization in healthcare is worried about the problem of burnout in physicians.
Interest in physician burnout and concern about its impact raises the question of resilience. Why are some physicians less likely to show symptoms of burnout and more likely to remain charged up about their work through years and decades? It’s as if they have been injected with a vaccine that has given them complete or partial immunity. What can the rest learn from their apparent immunity?
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One thing that becomes clear as soon as one looks closely at physician burnout is that no magic bullet will cure it. More compensation isn’t the answer. “Mindfulness training”—which helps clinicians “be in the moment” and thus do a better job easing the fears of their patients and receive the psychological rewards of doing so—does have some impact, but it is not enough to stem the tide alone. If there are information technology fixes that will reduce burnout, I haven’t seen them yet.
The reason there is no magic bullet is that burnout is a complex multidimensional problem, with multiple causes, and thus can only be addressed through multidimensional solutions. My colleague at Press Ganey, Deirdre Mylod, developed a framework for “deconstructing” the drivers of burnout—that is, breaking them down and placing them into simpler categories that can be addressed individually. In the following figure, this framework categorizes stressors and rewards according to whether they are inherent to the role of care provider (bottom row) or are a function of external forces. Further, it acknowledges that other factors influence how individual clinicians experience the balance of stresses and rewards—that is, how resilient they might be when stresses increase.1
Let’s start with the bottom row of the figure—the rewards and stresses inherent to taking care of patients. The fact is, it’s a tough job—inherent stresses include the emotional toll of caring for suffering patients and their families, and the burden of taking responsibility for the safety and effectiveness of patients’ care. But it’s a great job, too—the inherent rewards include the respect from friends, family, and the community that results from clinicians’ role in helping people, and the personal pride that comes from doing work that has meaning.
Figure 1.1 Framework for Deconstructing Burnout
This framework distinguishes rewards and stresses inherent to the role of caring for patients (bottom boxes) from those that are added (upper boxes). Resilience is a moderating influence that nudges the fulcrum to a point where more stress is bearable. EMR indicates electronic medical record.
One key insight from this framework is that these inherent stresses and rewards are intertwined—that is, decreasing one’s sense of responsibility or one’s empathy in an effort to decrease the inherent stresses also decreases the ability to enjoy the rewards. The implication is that to improve the balance between inherent stresses and rewards, the emphasis must be on the rewards side of the figure—for example, increasing individuals’ sense that their work has meaning and is respected by the people who surround them.
Keep that bottom left box in mind—we’ll be coming back to it.
The upper row of the figure focuses on the external or added rewards and stresses. The term added is used to differentiate the inherent stresses and rewards. Most clinicians respond to descriptions of inherent stresses by agreeing, “This is what we signed up for.” But when they see a list of external stresses like the burden of documentation, managing EMR systems, and coping with inefficiencies in the practice environment—they say, “No one told me I was signing up for that!” The oft-quoted estimate is that physicians spend two hours of bureaucratic catch-up work for every hour of patient care. The former represents added stress, while the latter represents what they signed up for.
External rewards are real, too, and include financial compensation, the prestige of membership in a trusted profession and affiliations with respected organizations, and positive working relationships with peers and health system leaders. However, in contrast with the inherent rewards and stresses, there is essentially no direct relationship between external rewards and stresses. For example, increased compensation cannot allay the frustration that results from a dysfunctional EMR. The implication that follows from this lack of connection between external rewards and stresses is that organizations must take on the “upper right box”—they cannot mitigate the angst that results from external stresses by increasing external rewards. Instead, organizations must show that they understand that these stresses are real and an enormous problem, and that the organization is working to ameliorate them.
Collectively, these stressors and rewards define the clinician experience, and the balance between them influences clinicians’ vulnerability to burnout. But it is not the only influence. The fulcrum upon which stressors and rewards are balanced is where resilience is determined. There are some individuals for whom stressors have less impact, and there are times in any individual’s life when they can better deal with stresses. In such people and in such situations, the fulcrum is moved to the right, resilience is greater and more stress can be absorbed while still experiencing the rewards of patient care and avoiding burnout.
There are thus three opportunities in this framework for reducing burnout: reducing the added stresses, enhancing inherent rewards, and increasing resilience. A key takeaway is that resilience is not the opposite of burnout; it’s an improvement in the ability of clinicians to absorb the stresses that occur through their work, and not “tip over” into burnout because the stresses are overwhelming the rewards. Organizations need to reduce the added stresses and enhance inherent rewards, but they should work to improve resilience as well.
These approaches are not theoretical. An example of an organizational initiative to reduce added stress is Hawaii Pacific Health’s Get Rid of Stupid Stuff (GROSS) program, through which the organization asks personnel to identify work that does not add value—such as documentation that was either never intended to be performed routinely with every encounter—or could be accomplished more efficiently in some other way. Clinicians and other personnel have been vigorously appreciative of this program. This program was described in a New England Journal of Medicine article in November 2018,2 and GROSS went viral. The Cleveland Clinic had already started its GROSS program in February 2019.
Researchers at the Mayo Clinic developed and evaluated an intervention to increase inherent rewards by giving physicians a chance to talk about their work with each other. They randomized 74 physicians to two groups, both of which got an hour of protected (paid) time off every other week. The control group could use that hour however they liked. The study group spent that hour participating in small-group discussions over dinner that incorporated elements of mindfulness, reflection, and shared experience. The trial showed that physicians who participated in regular small group meetings had a 5.6 percent increase in engagement and a 15.5 percent decrease in depersonalization symptoms, while the control group had little improvement in either.3 Based on such data, many organizations now support dinners and other gatherings that foster socialization among clinicians.
To increase resilience, interventions targeted at the individual can be helpful; for example, “mindfulness” programs have been shown to be associated with small reductions in burnout. But my belief (and it is a belief, because evidence from research in this area is sparse at best) is that a larger sustained impact can result from strengthening an individual’s interpretation of their role and connection to the organization. If clinicians identify strongly with their organization and that relationship brings them pride and respect, the fulcrum moves to the right. If clinicians believe that the leaders and other personnel of the organization share values that make them proud, like a commitment to zero harm and reducing patients’ fear and suffering, that also helps the fulcrum move to the right, where stress feels more manageable. But if clinicians feel like they are being used as “RVU (relative value unit) machines” by an organization that is mainly concerned with margin growth, the fulcrum moves to the left, and they are destabilized by even minor increases in stress.
Two of my favorite interventions that have strengthened a sense of “why we are here” among individuals within organizations are the Cleveland Clinic Empathy video and the Grady Health System turnaround campaign, “Atlanta Can’t Live Without Grady.”
The first was an internal training video that used scenes showing patients, family members, and caregivers on a typical day at a healthcare facility. There were no spoken words, only captions that expressed their thoughts and emotions. It ends with the question, “If you could stand in someone’s shoes . . . Hear what they hear . . . See what they see . . . Feel what they feel . . . Would you treat them differently?”4
It was made in 2013 with $40,000 for Cleveland Clinic’s personnel. At its debut showing, CEO Toby Cosgrove simply said at the end, “This is why we are here.” It went viral almost immediately; nearly 5 million people have watched the YouTube version. Mention the video to anyone who has seen it, and they are likely to respond, “I still get choked up when the little girl pets the dog.” Like everyone at Cleveland Clinic who watched the video, you will have established that you share the same values and that they are noble ones. You’ve also experienced the fulcrum moving to the right.
The Grady Health System campaign occurred during the first decade of the century when the Atlanta safety-net provider was on the verge of bankruptcy. Financial performance was only part of Grady’s problems—quality and morale among the personnel were both in terrible shape. Leaders from Grady and local government developed a brilliant, moving public relations campaign with the tagline “Atlanta Can’t Live Without Grady.” It began with black-and-white photos of patients or prominent Atlantans (like baseball star Tom Glavine) with the Grady logo over their hearts and the “Atlanta Can’t Live Without Grady” tagline. Then other images and videos of patients whose lives were saved at Grady appeared, each with the quote “I Wouldn’t Be Here Without Grady.” The campaign continues to this day.
Many other initiatives were undertaken to improve quality of care and business performance at Grady during this time. But talk to people who work there, and they will tell you that this campaign did more than change the way politicians and other Atlantans looked at Grady. It also changed the way Grady personnel viewed the place where they worked, and that was critical to the turnaround.
Is this real or is it hype? Here is a small “biopsy”—information posted by a former physical therapist on Glassdoor.com on June 18, 2018, about working at Grady.5 The therapist acknowledged the stress of working there, but used the campaign slogan in the post, and ended her description of the “Pros” with “pride in the mission of serving everyone who walks through the door.”
The path forward suggested by this framework is multidimensional. Organizations should work to reduce clinicians’ work that isn’t related to patient care, reinforce individual clinicians’ ability to find meaning in their work, and define an organizational culture with values that make clinicians proud. They need to work relentlessly to reduce stress and increase rewards; they cannot just suggest to individuals that “the problem is you—you need to become more resilient.” But they should understand how to measure and improve resilience, because healthcare is a field in which the unpredictable happens, well, predictably. Doctors, nurses, and other personnel need to be resilient to deal with the resulting stress.
Resilience, Activation, and Decompression
If resilience is a modulator that helps clinicians keep the rewards and stresses in balance even when there are surges in stress, what drives resilience? My colleagues at Press Ganey who were studying this issue concluded that there were two dimensions that could and should be measured—activation (the degree of an individual’s engagement with their work) and decompression (the ability of an individual to disconnect from work). They developed an eight-item “resilience” tool with two separate four-item subscales and validated it by correlating its results with the Maslach Burnout Index. As you might expect, rates of burnout symptoms were lower in people whose survey responses suggested that they were more “activated” and/or better at “decompressing.”
Scores are calculated for individuals based upon their level of agreement with survey questions.
The questions used to measure activation are:
1. I care for all patients equally even when it is difficult.
2. I see every patient as an individual with specific needs.
3. The work I do makes a real difference.
4. My work is meaningful.
The questions used to measure decompression are:
1. I can enjoy my personal time without focusing on work matters.
2. I rarely lose sleep over work issues.
3. I am able to free my mind from work when I am away from it.
4. I am able to disconnect from work communications during my free time.
The greater an individual’s agreement with these statements, the higher his or her activation or decompression score will be. Those with higher scores have more resilience in the face of stress and are more resistant to burnout.
As more and more data become available on activation and decompression, the results have been . . . fascinating! Deirdre Mylod and I published some of them in Harvard Business Review in October 2018. Our article was based on data from 40 health systems on about 80,000 healthcare personnel, including about 5,000 physicians, 19,000 nurses, and 60,000 other personnel.6 We found that all three groups had about the same average activation score (4.5), and there was a modest correlation between activation and decompression—that is, people who were better at disconnecting from their work tended to have higher activation, too. But if relaxation is good for the soul, doctors have the cards stacked against them—physicians in this analysis had lower scores for decompression compared to the other two groups.
We examined the relationships between activation/decompression and another variable—engagement—in this group. Engagement gets at issues like how satisfied individuals are as employees, whether they would recommend the organization as a good place to work or get care, and whether they are proud of the organization. Employers, including healthcare organizations, have been measuring engagement with increasing frequency in recent years, and many now report such data to their boards. Ample data demonstrate that having a workforce that is more engaged is associated with better quality, better safety, better efficiency, and better financial performance.
We found that, for both doctors and nurses, activation and decompression were important correlates of engagement—but there were subtle nuances in the types of engagement that seemed influenced by these two different components of resilience. Decompression was more strongly correlated with how nurses and physicians felt about their role as employees in an organization (based upon survey items such as “Overall, I am a satisfied employee,” or “I would recommend this organization as a good place to work.”). In contrast, activation was more strongly correlated than decompression with how doctors and nurses felt about their organization (“I would recommend this organization to family and friends who needed care,” or “I am proud to tell people I work for this organization.”). In short, decompression is related to how clinicians feel about their specific jobs, while activation is a marker for how clinicians feel about their organizations.
Recalling the framework for burnout described earlier in this chapter, think of activation as something that plays important roles in inherent rewards and the location of the fulcrum representing clinicians’ resilience. Clinicians who have greater activation can reasonably be expected to have lower burnout rates and be better able to deal with surges in stress.
Initiatives to help personnel decompress are good ideas. An even better idea is to reduce preventable stress, such as Hawaii Pacific’s GROSS initiative. But these ideas are neither mutually exclusive nor enough. Working to enhance the meaning that people find in their work and demonstrating that the organization’s values resonate with the most noble self-images of clinicians is a critical complementary task.
Grit
The last major term to introduce as part of the modern definition of the good physician is grit. My tutor for thinking about grit and its implications for healthcare and physicians is Angela Duckworth, PhD, the University of Pennsylvania psychologist whose research on grit led to a McArthur Fellowship, a famous TED talk, a bestselling book, and a reunion with me. We are cousins, but she is 17 years younger than I am, and we had seen little of each other since her childhood—until 2016, when we saw each other at a meeting and started talking about grit in healthcare.
Angela’s research—and her obsession—has been on people who have a goal about which they feel passionate, and then persevere in their efforts to pursue that goal over years and decades. Gritty people love what they do, and do not waver even when there are easier paths they could pursue. They are ready to sacrifice because they love what they do.
Angela has studied which cadets drop out at West Point and which hang in there. She has studied “grit paragons” in sports, the arts, and many other disciplines. And after we reconnected in 2016, we started thinking together about gritty people in medicine.
We wrote an article together in the fall of 2018 in Harvard Business Review entitled “Organizational Grit.”7 This article offers a framework for thinking about grit in healthcare at three different levels—the individual, the team, and the overall organization. The reason that we gave attention to teams and the overall organization was because of the changes in healthcare described at the beginning of this chapter. Medical progress has made state-of-the-science a team sport. We need teams that are more than multidisciplinary groups composed so that everyone can practice “at the top of their license.” Gritty teams function like macrocosms of gritty individuals, focused on meeting their patients’ needs, measuring success, and trying relentlessly to improve. And we need a gritty organizational culture, one that has clarity on the values that are most important to it and perseveres in work to pursue those values.
Thinking about gritty groups is important because an organization that hires a lot of gritty individuals is not necessarily gritty itself. In fact, because it is hard to sustain the drive to improve without encouragement from others around them, the risk of “burning out” for gritty individuals is high, unless they are immersed with other gritty individuals who are working with them, giving them positive feedback when they do good work, and negative feedback if quality slips. We describe four key elements that are important to nurture and sustain grit at all three levels (individual, team, and organization).
The first is a goal hierarchy—arrays of goals at three or more distinct levels. At the bottom are specific tasks—for example, for a primary care physician, they might include seeing patients with acute needs, tracking relevant conditions, and prescribing treatments as needed. These constitute a to-do list that, in isolation, can be a numbing inventory of tasks and a driver of burnout.
Low-level goals must track clearly and cleanly to mid-level goals (e.g., prevent complications, coordinate care, reduce symptoms) that clinicians and other personnel understand as the essential goals of their work. And above these mid-level goals there should be a top-level goal, which in isolation might seem fuzzy, abstract, and noble—like “reducing suffering.” But if this top-level goal is clearly linked to mid-level goals, and those mid-level goals are clearly linked to low-level goals, then you have a goal hierarchy that can bring individuals’ and organizations’ passions to life and sustain them. In other words, if individuals can see how mind-numbing tasks relate to high-level goals that are important to how they see themselves, well, maybe they won’t seem so mind-numbing.
Gritty people and organizations tend to have clear goal hierarchies with minimal conflict, if any, among the various goals at each level. Less gritty people and organizations have fuzziness about the overall goal, and get distracted by mid- and low-level goals that do not contribute to higher goals, or worse, conflict with other goals.
The second key ingredient is a growth mindset—the term coined by Stanford psychologist Carol Dweck for the belief that abilities can be developed through hard work and feedback. People with a fixed mindset believe that things are about as good as they can be. Gritty people with a growth mindset believe that they can get better and that they have to try to improve. Even if they might be at the top of their field, they still want to get better. They push themselves. They are chronically restless.
The third key ingredient is a resilience orientation. Gritty individuals and gritty groups pride themselves on bouncing back and learning from setbacks, and on being able to adapt to unforeseen challenges (e.g., natural disasters). Angela likes to invoke the Japanese saying, “Get knocked down seven times, get up eight.” Gritty people keep getting up not because they are stupid, but because they think they can make things turn out differently this time. Thus learning and innovation are intertwined with resilience in gritty individuals.
The fourth ingredient is identification with something larger than oneself. At an individual level, that might mean identifying with a mentor. At a group level, it means individuals really think of themselves as members of the group. This means more than wearing a fleece, or a special necktie or scarf. There are values and a track record of performance that cause individuals to want to wear those fleeces, ties, and scarves.
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With some familiarity with these key terms—burnout, resilience, activation, decompression, and grit—we turn now to the stories of the physicians who inspired this book. As you read them, look for how they have found meaning in their work—how a lofty, abstract notion became a clear and consuming high-level aim in their personal goal hierarchies. You will find that these physicians did not emerge from the womb gritty—they were influenced by their families and their role models. You will see a resistance to accepting the status quo and a push to improve—both personally and in the performance of their organizations. You will see a resilience—a determination to overcome setbacks.
They bring the concepts of grit to life—and, in doing so, find meaning in their work as clinicians, and help immunize others around them from the effects of burnout.