Category Archives: Engagement

We need more dialogue at meetings

A discussion is an exchange of words; a dialogue is an unfolding of new thought.   Dialogue is a conversation where people learn from each other, where there are as many questions asked as there are answers given.  It shapes thinking and creates new ideas.  One flaw in many meetings is the premeditated avoidance of dialogue

Meetings are often designed to avoid conflict by how the participation is structured and the agenda constructed.  If there is conflict the meeting is often facilitated to be a discussion rather than a dialogue.  When conflict is present the discussion  is much like a debate where people assert and defend their positions.  Who “wins” is based on how well arguments were made rather than the merit of the arguments themselves.  Often no one wins because the intent of most meetings is to formulate a plan for the group and coordinate its execution, which requires dialogue.   After a debate many leave the room without any idea what they’re supposed to do next.

Dialogue by definition will have surprises, and often will change minds, shift attitudes and create something new.  Yet, meetings are often designed to avoid surprises.  How would a team improve their meetings over time if a simple outcome measure were the number of minds and opinions changed?

Inquiry is at the essence of dialogue; inquiry that surfaces ideas, perceptions and understandings that weren’t present previously.  How would a team change the structure of their meetings if a simple process measure were the number of questions asked?

Increasing the number of questions requires balancing advocacy with inquiry.  Advocacy is our human default mode at meetings and during conversations (i.e. we defend and assert our opinions, the opinions we walked in with).  It’s nearly impossible to eliminate it.  Yet, if advocacy can be balanced with inquiry then dialogue will emerge.  The more people who have a questioning attitude the more likely that balance will be struck.  This is why whom you hire and the culture you inculcate matter.  If you hire stubborn, opinionated, arrogant know-it-alls, then achieving dialogue will be extremely difficult.  If the culture you foster is one of competition and authority, dialogue will be hard.

When was the last time you had a dialogue about something?  When was the last time you asked clarifying and exploratory questions at a meeting?  When was the last time you changed your mind about something?  If the answer to any of these questions is not in the last 24 hours, then ask yourself, “how open am I to learning from others and seeing things differently?”

A short course on human relations slightly expanded

An old poster some still have on their office wall called “A Short Course in Human Relations”  goes like this:

The SIX most important words:  “I admit I made a mistake”

The FIVE most important words:  “You did a good job”

The FOUR most important words:  “What is your opinion”

The THREE most important words:  “If you please”

The TWO most important words:  “Thank you”

The ONE most important word:  “We”

The LEAST most important word:  “I”

In my searches to find the origin, I came across a blog that told a story from the 1980s.  The author first saw the poster on her boss’ office wall.  The boss noticed she was studying it and said, “You know that’s not the whole course.  There is also the SEVEN most important words, ‘I don’t know, but I’ll find out.’  Now you know the complete course.”

What keeps people from saying these phrases and practicing their intent?   Perhaps they aren’t telling themselves the EIGHT most important words: “I have the courage to say these words.”

Now you know the complete revised course.  Here it is again:

The EIGHT most important words:  “I have the courage to say these words.”

The SEVEN most important words:  “I don’t know, but I’ll find out.”

The SIX most important words:  “I admit I made a mistake”

The FIVE most important words:  “You did a good job”

The FOUR most important words:  “What is your opinion”

The THREE most important words:  “If you please”

The TWO most important words:  “Thank you”

The ONE most important word:  “We”

The LEAST most important word:  “I”

 

Back to basics for bashing burnout

I recently created 2 documents outlining expectations for physicians: one addressed professionalism and the other productivity.  The intent was to articulate what is needed as a baseline from each physician, and point out the importance of discretionary (extra) effort for us to be successful.  Acknowledging and thanking those who go above and beyond on a regular basis was essential to this exercise.

The activity was undertaken because of complaints from a number of colleagues about low productivity and poor professionalism among a few; this small minority was threatening the joy and pride in work of those many who go above and beyond.  Although obvious but not always front of mind is the connection of professionalism and productivity to burnout – the more individuals in the workforce underperforming in either, or both, the higher turnover, the lower overall engagement, and the more likely burnout will occur.  The underperforming few can drag the hardworking majority down.

As leaders we know clarifying expectations is important.  It sets the bar, and it also provides the opportunity for us to remind those pushing themselves way beyond the bar to cut back and strike a healthier balance.

Expectations need to be clear before people can be held accountable, self-reflect and resolve to improve where appropriate, whether it be on one’s balance, commitment or focus.  The under performing who feel burned out despite doing the minimum need to improve efficiency and cut out activities that aren’t aligned with what is needed (i.e. essentialism).

The explanation of professionalism I drafted centered on the following principles:

Respect for the voice and value of others – listen to learn and understand; value others contributions.

Kindness – speak with humility and respect, not dogmatism or for the purpose of demoralizing another.

Focus on the mission and core functions of the team; avoid drama, avoid drawing attention to oneself unnecessarily.

Professionalism – balanced and non-judgmental communication; courage balanced with consideration

The explanation of productivity centered on the following:

Time– >50 hours a week on average outside of night call is almost always needed – professionals who need to work less than this may need to go part-time.

RVUs– a starting place for reflecting on efficiency and contribution – it’s not a 4-letter word, but it is an imperfect measure, and needs to be taken in context.  Yet its needed because it’s too easy (and very human) to be biased about how hard one works.

Discretionary effort for certain committees, projects (e.g. quality improvement) and activities (e.g. teaching) is a must for us to be successful.  Yet one must feel that this work is meaningful and making a difference.

Triaging– invariably individuals and teams need to prioritize their activities, schedules, patient care, phone calls, who and what they teach, etc.  We can’t do it all.

Still a work in progress, yet it does drive a good dialogue.

 

The art of dialogue: an indispensable leadership skill

I became a physician “leader” frankly because staff asked me to change things or they would quit.   It started 17 years ago.  I was an informal “leader”, becoming increasingly formal over the next 5 years.  It was a rough road for many reasons, but my lack of skills, knowledge, awareness, maturity, preparedness, good mentoring, and sleep were at the top of the list.

Because I was so bad, I was given the gift of a professional coach, which was helpful with guiding my self-learning and reflecting. Thankfully, I was able to improve on some of my deficiencies; the one that I had to work on the most, both because of my ineptitude and the importance of it, was having discussions and dialogues with people.

I’m still learning and practicing dialogue. I wish it were easier, but its not. The biggest problem is that it takes time, which we don’t have a lot of. The second biggest problem is that we’re human, and have learned some unfortunate human habits. The biggest of these habits is a tendency to be defensive, to take things personally and to hold onto ideas and memories with too much dogma, blinding ideology, and just plain old-fashioned emotion. This internal milieu interferes with listening, learning, and most importantly thinking. We’ve all seen how egos and lack of humility (hubris) can derail good conversations, but that’s only part of the story. The other big problem we humans have is judging (criticus).   We judge, judge, judge.  Dialogue can be derailed by hubris and criticus. Being aware of these barriers is the first step, doing our best to abate them, without beating each other up about them, is the second.

Suppressing our hubris and criticus is important when having a dialogue, but without respect, appreciation, a desire to learn, and time, it still won’t happen. Stepping outside ourselves, our attachments and our preoccupations isn’t easy, but necessary.  Try asking yourself: do I really know everything that needs to be known? Is my view truly the only possible viewpoint that has merit? Have I thought of all the possibilities? Am I showing how much I care about the people in the room? What else might we face in the future that makes how we accomplish this conversation as important as what the conversation is about?

William Isaacs in his famous 1999 book Dialogue and the Art of Thinking Together describes 4 steps we can take when participating in dialogue: Listening, Respecting, Suspending and Voicing. Out of these 4, suspending is often the hardest (aside from leaving voicing until the end). Edgar Schein has talked about “accessing your ignorance” as a means to start the suspending process. To access one’s ignorance, one must pause, embrace humility and suspend judgment. This practice naturally leads to the advice that one ought to ask questions first, then voice their opinion second; seek to understand before being understood.  Questions are most effective when coming from a place of ignorance.

Dialogue is about reducing our collective ignorance.  It doesn’t make it completely go away, but we’re better prepared to face our challenges nonetheless, and face them together.

Total Leadership Revisited

Almost 10 years ago I heard an interview on NPR with Stewart Friedman regarding what was then a new book called Total Leadership. At the time I was nearing the end of a long recovery from burnout.  Total Leadership was one of the better books for helping me achieve better balance in my life, and for helping me envision a healthier professional life as a physician leader.

There are two major premises in his book: 1) by integrating your professional, personal, family and community realms, finding common ground and synergy, you can be a total “leader” and achieve better work-life balance, and 2) by being your self, your whole self, and respecting the whole of others, and embracing your creativity, you will find joy and fulfillment in what you do.

Perhaps the best active advice this book provided for me were those that involved reflection.   For example, acting with integrity (being whole) sounds easy, but when you reflect on key crucial moments you may discover that the values you hold dear when calm and collected, can sometimes take a back seat when the heat is on or when things don’t go well.  If you truly value respecting the diverse views of others then you’ll listen even when emotions are high. You don’t have to agree but you’re able to acknowledge and kindly consider their perspective, which by the way takes longer than a few seconds.   Another example is honesty and trustworthiness. Most of us value these, yet, we are often dogmatic about things, which when truly dissected, the facts of which aren’t quite as black and white. In other words we aren’t as dedicated to the truth as we are our attachments to our own biases, our own perspectives.

This last point, reflecting to get closer to the truth of things, is actually a key daily activity for beating burnout. Burnout spirals because our reality is adversely shifted by negative bias.  Be Real, Be Whole, Be Innovative and Be Reflective and you can reduce/prevent burnout.

Being innovative is more about experimenting with new ideas and new ways of doing things than it is about dreaming up the next big idea and thinking it will fix everything (remember be dedicated to the truth). True innovators are doers. Its action on an idea and learning from that action, which takes honest reflection that makes innovation truly energizing (and successful).  And energy is an antidote for burnout (and we all like succeeding).

One of the exercises described in this book is to write a vision of you as a Total Leader in 10 years.  It’s been almost 10 years and as I read what I wrote back then, I realize that I achieved the vision (mostly).  Thank you Stewart Friedman.

Stop, Drop and Roll if you’re burning

All this talk about burnout has me… well… burned out. Theories abound and prevalence data is flying about.  Are 54% of physicians burned out, or is it 25%? Is it because we’re worked too hard, or because the “new-trophy-for-everyone” generation is finally being hit with reality?

I can tell you from experience, burnout occurs when there are big things about your work you resent, and the rewards become overshadowed by these key persistent resentments. Working 24/7/365 isn’t the problem, its what you’re not doing because you’re working all the time that is. Its not what we’re doing, it’s what we aren’t that leads to burnout.

Duh? Well… it’s not that simple, and once again it comes back to resentment. Most of us resent what we can’t do because we work so hard, but not all resentments are the same; expectations are the second key contributing factor. If you expected to have a lot of purchasing power because of excellent compensation as a physician only to found out that you really don’t because you chose a lower paying specialty, then you may resent what you do. If you expected to be home by 6 pm most nights only to find out that to finish your charting and phone calls you have to stay until 8pm, you may resent what you do. Know your expectations and be aware of your resentments.

Burnout is best prevented, because fixing it can be hard. Both prevention and cure takes efforts on the part of the individual as well as the “system”. The microsystem (your team/clinic or pod), the mesosystem (the group practice, department or service line), and the macrosystem (hospital or network) all need to participate in the process. But without the individual taking ownership, efforts often fail.

The 4 horsemen of burnout from the HappyMD (https://www.thehappymd.com/blog/bid/290379/Physician-Burnout-The-Four-Horsemen-of-the-Physician-Burnout-Apocalypse) are around every corner and their momentum can be difficult to slow. The Workaholic, the Superhero, the Perfectionist, and the Lone Ranger are wicked creatures. All four have haunted me, possessed me and driven me into the ground (nearly literally). The system can’t exorcise them unless the individual desires it so.

But often the individual who carries the burden won’t let go of it unless others are there to take some of it away.  I survived by lowering my expectations (forget about getting home to see the kids before bed, forget about exercising or having friends, forget about doing those things that bring you joy to your work).  What I didn’t know was that constant stress kills.  My advice to anyone who is approaching burnout or is cooking at a broil: be true to yourself, your family and your patients and stop the 4 horsemen in their tracks, because once you’re toast, scraping off the burnt parts is painful, and what’s left isn’t all that appetizing.  If you’re on one of those horses or all of them, stop, drop and rock and roll on your own terms (and take your family and friends with you).

Driving organizational success in children’s healthcare

In 1998 Jeffrey Pfeffer published an article in California Management Review describing what he sees as the seven practices of a successful organization. Comparing these practices to your typical health care organization today portends a crisis (some say the crisis has arrived).   Here is the list (with sarcastic commentary included for comedic effect – because if we didn’t laugh…) :

Employment security – apparently the data suggests that when employees fear for their jobs, they under perform – who knew?

Selective Hiring – the larger the applicant pool the better your workforce…mmmm – pediatric professionals weren’t in abundance as of … yesterday. Choosing employees to your organizational culture and the unique needs of your teams… is currently a luxury.

Self-managed teams and decentralization as basic elements of organizational design – uh – I’m not sure Dr Pfeffer realizes this… but it’s hard to empower practices and units in health care to actually manage their own performance – it takes time, training, dedicated people and robust real time data management – not to mention team meetings and engagement of front-line staff in analysis, action plan formulation, testing ideas, and managing sustained change. It’s easier to just tell them what to do, even if it’s wrong.

High compensation contingent on organizational performance – define performance, define high.   Is it ok to do high compensation no matter what? That would be great, because then we wouldn’t have to change anything.

Extensive training – Doesn’t everyone come into the health care workforce already trained?  Can’t they train themselves?

Reduction of status differences – we might actually be improving on this one in health care, but I’m not sure it’s having the impact we had hoped for.  Instead of collaborating we created more silos. Professionals who do shift work can’t make it to meeting where having reduced status differences allow for free exchange of perspectives and ideas.  Physician burnout has increased, because more and more tends to be dumped on them in this new order of everyone is equal and no one should do menial work, except the person who is ultimately responsible (oh, right, that difference still exists).

Sharing of financial and performance information throughout the organization- we have been tying to get better at this, but it’s …well… complicated.

So, what is the secret sauce for changing our organizational practices?  Sarcasm aside, let me put on my sunshine hat (yes, I actually have one). Accountable care will create the forces needed to shift health care into the realm of organizational success.  Fee for brief units or services of care has created a system of volume rather than value with regulatory and tort systems that drive fear rather than rationale thinking.

Working in teams, driving local continuous improvement, and driving true waste out of our processes, using the data management and sharing necessary to do so, with the staff training and professional development required, which will attract people to health care where professional joy is a given, will get us to the seven practices, and will create a care system that patients and families find value in and the workforce is proud of.

Great teams start with members who are there to serve

I recently attended a conference of health care administrators and executives and one of the topics was developing high-performance teams. I was asked to sit on a panel and give a brief presentation on the subject. I’m not entirely sure why I was standing up there, but I assumed it was to give a physician’s perspective. I struggled with where to start and where to end; the capacity and capability for physicians to be part of effective teams is variable.  Some physicians are great at it most of the time and some aren’t some times and other not most of the time, and the reasons range from lack of skill to lack of sleep.

The other 2 panel members had great insights and advice: 1) Teams are critical to success now and in the future given the rapid changing landscape of healthcare, 2) Teams need to be interdisciplinary, 3) Clinical teams benefit when there is a physician co-leader, and 4) Common ground is reached when making the patient the focus of the goals of the team. They gave examples of successful teams in their organizations: the key elements were clear purpose and goals, senior leadership support and involvement, openness, and transparency. I decided to focus on the key attributes of successful teams, which boiled down to 1) collective leadership, 2) strong culture, 3)  inspiring purpose and 4) focused discipline.

I also discussed the importance of the attributes of each member of the team.  A great team member has 1) commitment to the task, 2) openness to discuss crucial and sensitive topics, 3) humility for listening and learning, 4) ability to maintain group optimism and enthusiasm, and 5) skills for acknowledging the dogmatic, then help them be better team members. These attributes were taken from the literature on teamwork and #5 seemed especially pertinent to physicians. Physicians tend to be dogmatic. And dogmatism can squash a team, especially in today’s rapidly changing environment and evolving workforce of generation Xers and Yers.  The message is that good teams have individuals who can acknowledge dogmatism  in a constructive way and help that person contribute.

There is a passage in Managing the Unexpected by Karl Weick and Kathleen Sutcliffe that speaks to how individuals on teams create a culture that drives team effectiveness: “Expertise resides in the heed with which people view their inputs as contributions rather than as solitary acts, represent the system within which their contributions and those of others interlock to produce outcomes, and subordinate their contributions to the well-being of the system, constantly mindful of what that system needs to remain productive and resilient.” [Managing the Unexpected p. 78]  When physicians are on teams, it’s usually because they bring critical expertise. Physicians are great team members when their actions and words serve the best interest of the organization, its people and the patients and communities they serve.