Leadership
Clip
Changing the Culture of Medicine: A Starting Point (07:35)

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.

More From Leadership
Sands01_pullquote clinical research partnership for learning health care

Real-World Advice for Generating Real-World Evidence

If envisioned and implemented properly, a partnership between clinical delivery systems and clinical research programs can get us closer to the goal of achieving learning within the care continuum and discovering evidence that is available when it is needed.

The Largest Share of Organizations Do Not Have a Formal Strategy for Clinician Engagement

Leadership Survey: Why Clinicians Are Not Engaged, and What Leaders Must Do About It

Clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet nearly half of health care organizations are not very effective or not at all effective at clinician engagement.

Rowe01_pullquote - clinician well-being - fighting clinician burnout and creating culture of wellness takes all stakeholders

Defending the Term “Burnout”: A Useful Tool in the Quest to Ease Clinician Suffering

Health care leaders must take a preemptive approach to clinician well-being that is supported by all stakeholders and prioritized on an equal footing with essential clinical and financial measures.

Screenshot from the NewYork Quality Care Chronic Condition Dashboard

Success in a Hospital-Integrated Accountable Care Organization

How NewYork Quality Care achieved shared savings — by strengthening collaboration, enhancing care management with telehealth, and transparently sharing performance data.

Miller03_pullquote social determinants whole-person

How a State Advances Whole-Person Health Care

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations to expand access to vital resources.

Abigail Geisinger Scholars Program for Medical Students -Ryu02_pullquote

Why a Teaching Hospital Offers an Employment-Based Tuition Waiver Program

Geisinger Commonwealth School of Medicine subsidizes medical students’ education in exchange for their willingness to practice at Geisinger Health System.

Michael Dowling and Charles Kenney headshots

Rebooting Health Care: An Optimistic Outlook

The U.S. health care system may seem broken, but it’s on its way to greatness, according to the authors of Health Care Reboot. They discuss their optimism for U.S. health care reform, particularly on the social determinants of health, payment, consumerism, and technology.

Action Steps for Risk-Share Contracts for Medical Devices

Challenges and Best Practices for Health Systems to Consider When Implementing Risk-Share Contracts for Medical Devices

When done right, value-based contracting for medical devices can ameliorate shrinking margins at health systems, leading to a virtuous circle.

Health Care Organizational Culture Emphasizes Patient Care Only Slightly More Than the Bottom Line

Survey Snapshot: Who Should Lead Culture Change?

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in the right direction, but differ on who it should come from, and reveal too much balance between emphasis on bottom line and emphasis on patient care.

Culture Change Within Health Care Organizations Is Changing for the Better

Leadership Survey: Organizational Culture Is the Key to Better Health Care

Although three-quarters of Insights Council survey respondents say culture change is a high or moderate priority at their organizations, survey results show a lot of work on organizational culture remains to be done.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Leading Transformation

280 Articles

Ripe for Disruption: Why and How…

For big tech companies like Amazon, Apple, and Google, the health care sector looks ripe…

Physician Burnout

52 Articles

Survey Snapshot: How Do You Know…

The NEJM Catalyst Insights Council discusses strategies for clinical engagement.

The Next Frontier in Reducing Costs…

To create meaningful point-of-care guidance so that patients can make informed medical and financial decisions,…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now