How Conversations become Culture – Physicians Leading in Complex Times

A version of this article was first published in the Canadian Journal of Physician Leadership, Volume 3, no. 2 (2016)

As physicians, we are part of an influential community, one that initiates, influences and perpetuates important conversations.   Our community has a collective culture and it is shaped completely by them. Our conversations get noticed.  They are held publicly when doctors hold positions of leadership, but also privately with our peers, at meetings, when teaching, and when we speak, write and blog. I am worried …worried that our conversations have soured in recent times… worried that our view of the absolute joy and privilege to be had in being a doctor is being tainted.  I am concerned that in difficult times our perspective and positivity change. Collectively we appear pessimistic, downtrodden and beleaguered.  In this, we fail to lead.

We have an external face. 

It is the one we put in front of our patients and practices.  This takes many forms.  While we are with patients, in many cases our professionalism ensures that the conversation never really changes.  It stays focused on the needs of the patient and population we are looking after.  We place their needs before our own, as we always have.

And we have a face that we present to our peers, where conversations are somewhat more private and thoughts can flow more freely.  Here is where we hear stories about how the challenge of practicing medicine in 2016 and where we tell each other about our worries and doubts.  Our collective internal voice worries me the most.  There is a new tone in private conversations had with peers, and this tone is often exposed more broadly in what are now very public diaries accessible on social media and in the blog space.

What are we saying to each other, and how does this speak to our private internal narratives?

In scanning all that I see online (though understanding that this isn’t entirely representative), some common themes emerge.  

• Doctors do not appear to be happy.
• We talk of hopelessness and helplessness.
•  We complain that we are no longer valued in the system.
•  We are burdened by the concepts of accountability and quality improvement.
• We are pessimistic about being responsible for the health of the populations we look after.
•  We appear to have lost any sense of control over the environment we work in.
• We show anger at governments who make changes seemingly without consultation.
• We speak with contempt about the need to control spiraling healthcare budgets, stating that the ever-increasing cost is not in any way our fault.
•  We have started to distrust patients, feeling that they are more foe than friend.
•  We worry about things like the examination of patient experience, requests for quality improvement activities, and public reporting of outcomes.
• We express dismay at the loss of our professional autonomy.

This is reflected in our actions as well.

We begin to hunker down and defend the status quo, at the expense of any perceived change.  Where once we had been inquisitive and full of wonder, in quiet hallways we express thoughts of being disconnected from the health care system.  We wonder if all the time and energy we put into our practice is worth it.  We look at change as something to be feared rather than embraced, with the concern that change is inherently negative — rarely neutral, and certainly not positive.  And in some jurisdictions, where contract negotiations have gone astray, we are starting to resist, even ideas and changes that could add quality to the care we give.  We do so because it is not remunerated, or because we are being paid less–even when we are still being paid well.

In the press we see more and more statistics being bantered around regarding the burned-out physician.  Some studies like that published in the CMAJ by Fralick and Flegel in 2014 (http://www.cmaj.ca/content/early/2014/06/02/cmaj.140588.full.pdf) show that at any given time up to 50% of resident doctors show one or more symptoms of burnout. Other less formal surveys such as that publicized in the news recently by Concerned Ontario Doctors state that 78% of us are actually burned out in Canada’s largest province (https://www.facebook.com/notes/we-are-your-ontario-doctors/doctors-burning-out-in-a-failing-healthcare-system/835170386617069).  The actual rates aren’t the point here. Rather, if collectively we have not built in the systems of resilience that are going to protect us and let us lead with confidence and competence into the future we are doomed.  Our conversations can form part of that resilience.

It is true that it is not getting easier to either practice or manage our careers in the current health care system. 

Physicians — as scientists — are happiest with a certain degree of predictability in their world.  They become confident in their clinical skills and the experiences that allow them to make educated informed decisions in guiding patients toward battling illness or improving health.  They understand that the practice of medicine is complicated.  What they are perhaps less prepared for, however, is its complexity.  And this is now the world we live and work in.  The difference between complicated systems and complex ones was fully explored in the work of Dr. Brenda Zimmerman and Paul Plsek in their book Edgeware (Brenda Zimmerman, Curt Lindberg, and Paul Plsek, Edgeware: Insights from Complexity Science for Health Care Leaders (Irving, Tex.: VHA Inc, 1998).  A complicated system is one where the success of one outcome is highly predicted by the outcomes of events that came before it.  This is like launching a rocket into space.  It improves when it is done repeatedly, with each iteration informing the next.  With patients, our expertise comes from practice:  doing procedures over and over lets us become adept at the technical aspects and speed required to treat a trauma patient or suture a wound.  Specialization depends on complicated issues being mastered through residency and years of work.  But a complex system, conversely, is the opposite.  The success of one outcome has nothing to do with the success of any that preceded it.  This is like parenting.  The issues of second children are in no way predicted by the path taken by first-borns. (And a third child is completely random!).  Complex adaptive systems are not like throwing a baseball, where practicing again and again to know exactly how much power, spin and curve is needed to strike out a batter will yield success.  They are more like throwing a bird.  Once the bird has left your hand, you have no control whatsoever over where it flies. (And if it is an “Angry Bird”, it may even split into three and hit many unintended targets!) Our healthcare system right now can best be described as a complex adaptive system.  Sometimes the generalist fares better in this environment, as he or she sees much more clinically that is undefined or unpredictable, but even these physicians are challenged in current times.  Again, our stories and comfort with ambiguity define our culture in this domain.

So how can we best show leadership in times of great uncertainty?

How can we create a new conversation that keeps us positive, hopeful, and energized in front of our patients, our peers and in our own thoughts?  I would propose nine ways to ensure that we remain the best physicians and physician leaders possible, moving the profession along in a proactive and constructive way.

1.  Show up.  When physicians feel like they are over a barrel for any reason, we hear calls from doctors to withdraw.  Reduce services.  Stop attending meetings.  Quit providing advice.  I believe this is wrong.  When under duress it behooves us to actually double down in our activities.  A truly adaptive response to leading in this space would be to not just send one physician representative to meetings that require our presence, but rather two or three! The time to be most present is the time when our presence is most threatened.  Withdrawal accomplishes nothing other than allowing others voices to be heard in our place.  Change is happening whether we like it or not.  One can only hope to influence the outcome if one is present and commenting.  Absence from tables diminishes our voice to the point of irrelevance.
2. Remain optimistic.  It is possible to be critical and still maintain an air of optimism.  Constructive and reasoned criticism is warranted and indeed needed when contemplating large-scale transformation.  Careful consideration of possible outcomes with an educated eye and from the front line is always important.  But optimism, or hope for the future of these changes, is ultimately required to ensure that others listen to what we have to say.  Pessimists are frequently looked past and their opinions cast aside as others assume “that doctor never has anything good to say”.  Optimists are listened to far more often, and even when others disagree with them, they do so after hearing and listening and examining the idea and are more educated as a result.
3. Never lose civility.  In social media, especially, where people feel protected by avatars and a sense of anonymity, they say things about each other that would never be uttered to another person’s face.  Private Facebook posts are easily seen by a much larger audience and never go away.  Cutting words disparaging a colleague, a bureaucrat or even a Minister of Health will go much further in this electronic age than those in printed or spoken form. They are searchable, savable, archivable and can be widely disseminated.  And they persist.  Being trusted and heard involves doing a large amount of listening yourself, and listening to oneself.
4. Tell stories, but ensure that great ideas are celebrated and repeated as much if not more than negative ones.  Our mind is a constant stream of consciousness and the stories we tell quickly become the reality we believe in and convey to others.  Even in difficult times there are multiple reasons to be happy and trumpet successes that should be expounded upon.  This provides necessary resilience for negativity that comes from outside.
5. Innovate.  As leaders, we must constantly be on the lookout for things that are new… for concepts that have never before been tried… for thoughts that are outside of the box.  True leaders explore these and encourage them in others. They find excitement in building and creating.  This excitement is infectious and has the advantage of strongly influencing the work of others.
6. Fail.  Then celebrate the failure in creating a space where the same failure cannot be repeated and others can learn from it.  A start-up mentality is required here.  Companies that innovate and create expect up to 70% of their big ideas to fall flat.  But when they fail they do so quickly by constantly examining and pivoting their thinking to move past failures quickly—and find the hot idea that takes off.
7. Ask “Why?”…. a lot.  Physician leaders are often looked to for answers, and more often than not we pride ourselves on being able to provide them.  But frequently we do better in difficult situations by asking questions rather than providing answers.  This is often the hallmark of an effective leader.  He or she will not be quick to supply all the answers, which usually ends the exploration of a topic, but rather allows it to go deeper by asking more questions for others to think about or respond to.
8. Build a support system.  Leading is tough work, and leadership is often a very lonely experience.  Having a circle of other physicians, not necessarily those who think exactly like you, but rather whom you trust, is paramount in ensuring that you can maintain the freshness needed to continue to lead well.  You can connect in a myriad of ways:  random telephone calls, email, quick lunches or even emoticon filled text messages!  Reaching out to other leaders and sharing ideas is incredibly helpful in ensuring that you remain able to act in this capacity.  And if you sense that a friend is under attack, this is even more important.  Support in this way can be very private, or very public.
9. Learn to be a good follower.  Many of us are used to and encouraged to constantly be at the front of the room or at the podium.  Equally important, though, is the creation of a space where others can lead well.  This means sitting back and often saying nothing, allowing people to shine in their own spotlight, and then encouraging them by reinforcing the greatness you have just witnessed.  Staying involved and following another’s lead as a difficult project moves to completion can be a complete pleasure.

Effective leadership in an environment of complexity, in a system that is rapidly changing around us requires tremendous adaptability and resilience.   

Really great leaders influence more than they dictate.  They remain open to new ideas and resist the status quo.  They lead sometimes by doing, but often just by questioning and listening, then allowing others to move ahead.  They remain eternally optimistic even in the face of great pessimism.  They support their peers and thereby support the health system.  And they rarely back away from adversity.  Most importantly, though, leaders in complex adaptive systems have given up their need to completely control every environment they work in.  For them leading is much more about the journey than the destination.  Most importantly, though, they tell stories.  Their stories are personal and actually change the greater conversation going on around them.  Over time, these changed conversations become the culture in which we all work, practice, teach and manage.  Even when feeling the weight of the world on our shoulders professionally, this culture will save us.  It will keep us in strong positions of leadership and ensure that the system represents not just our own best interests, but more importantly those of our patients and the larger health system we work for.

Our conversations create our culture.  Everyone is listening!