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?”

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.

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).

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.