Where does changing the culture of medicine begin?
“It starts with the point of care leader: selecting the right leader, developing him or her, and then helping them learn by doing,” says Stephen Swensen.
He describes the Mayo Clinic’s onboarding process for physicians and scientists, which involves dozens of hours of professionalism and communication training, as well as an emotional intelligence assessment. “It’s not pass/fail, but to help them understand how important it is how they work with other human beings on the team,” says Swensen. “You can improve your emotional intelligence; you can change how those relationships work, and then measure it.”
Mayo Clinic’s physician leader index measures gratitude and thoughtfulness: “I appreciate you” and “I’m interested in your ideas.”
“We saw a clear, strong relationship with levels of engagement, esprit de corps, and satisfaction, and an inverse relationship with burnout,” says Swensen. “We managed to do that because you can change [the culture of medicine] one behavior at a time, and the point of care leader is in a very powerful position to make that happen.”
“We have to address the culture of medicine on all levels; it matters in every facet — how we practice, how we educate, how we communicate with each other,” adds Mary O’Connor. “Learning how to effect change is one of the most important things for us as leaders. To shrink the change, to shape the path” — she references Switch — “those are the things that I think of when I’m trying to operationalize a change, because once you get people seeing that you can make the change and that they can do it, then you can start to change the culture.”
O’Connor describes a culture change in Yale’s operating rooms around briefing and debriefing. She asked the surgical team to hold a briefing in the OR 15 minutes prior to a patient’s surgery. At first, this decision faced resistance. “My partners were like, ‘Really? What’s that going to do except take 15 minutes of my time?’” In response, she offered the team a draft of what they might include in the briefing — “shape the path, shrink the change” — and asked the team to hold a briefing only once over the next couple of weeks.
“Two weeks go by, everybody has done a briefing, we have a team meeting, the sky didn’t fall, it was good, the non-surgeons on the team loved it,” O’Connor says. “They loved it. This is a chance for communication, this is a chance for blunting the hierarchy, this is a chance for their voice to be heard and for them to contribute in a meaningful way. They have skill and experience and knowledge that could make that surgery go better.”
From there, they kept ratcheting up the volume of briefings until the point where they stopped measuring them, because that aspect of their culture of medicine had changed. “It’s just working at it, and you can get there,” she says.
Tom Lee chimes in with optimism for the younger generation of doctors changing the culture of medicine. “My oldest daughter is a 30-year-old medical resident at the Brigham, and I am dazzled by how she and her colleagues are able to do what Amy Edmondson at Harvard Business School talks about: ‘teaming’ — forming groups of people that really work together on the fly,” he says.
“For us older guys, our generation is kind of lonely, and we’re tired of the isolation,” he adds. “If you create ways that we can get together and talk about the work we do, we like it. It makes us happier about our job.”
Swensen’s Mayo colleagues have studied physician camaraderie and commensality, or sharing a meal together. “Basically, if doctors get together and talk about professionalism — ‘what’s your best patient story ever?’ — their cortisol levels go down, joy goes up, emotional exhaustion goes down, social isolation goes down, positive feelings about the organization go up, all from spending a time over a meal talking with colleagues about life as a professional. We’ve lost track of that,” Swensen says. But we can fix it.
Groups of physicians who talk to each other about patient cases have the best engagement and satisfaction, “whereas a lot of people who are going through life just generating RVUs don’t feel so good,” says Lee.
“We look at physicians in that scenario, but that extends to every member of the care team,” O’Connor adds. “You can take that down to the nurses, physician assistants, residents, anybody, that if it’s just about the RVUs, dollars do not feed the soul. That is not producing an inner sense of satisfaction. As humans, we want to feel a connection; we want to feel that the work that we’re doing makes a difference. That’s what we as leaders need to achieve with our teams.”
From the NEJM Catalyst event Essentials of High-Performing Organizations, held at the University of Michigan’s Institute for Healthcare Policy and Innovation, July 25, 2018.