Leaders Go First

The Hidden Cost of Conflict Among Healthcare Teams

The conflict, low morale, dissatisfaction and disruption that often go hand in hand with a mismatch in culture carries with it significant costs that may not be immediately apparent.  However, they can be quantified.  Here are a few examples of calculations used to quantify the costs:

·         One study done by the American Management Association on the cost of conflict showed that a manager will spend between 20% to as much as 50% of his/her time dealing with conflict in the work place.  In one particular healthcare system, the cost of conflict in managers’ time alone calculates out to

45 Managers x $85K/year x 30% = $1.147 Million

·         The Gallup Organization calculates the cost of the loss of one employee at 6 times that person’s annual salary.

1 Nurse x $65K/year = $390K

·         A business analyst uses the following formula to calculate the cost of dissatisfied employees:

Number of employees in the organization	50
What percentage is dissatisfied? (for any reason)	20%
Motivation level of dissatisfied employees - (what is their productivity as a percentage of the productivity of satisfied employees or as an ideal employee?)	60%
De-motivated level of dissatisfied employee	40%
Average hourly salary of de-motivated employ	$25
Average number of hours worked per week	40
Dissatisfied employee weekly wage bill:
(20% of 50 employees) x ($25 x 40 hours)	$10,000
Dissatisfaction cost per week (40% x $10,000)	$4,000
Annual dissatisfaction cost (50 weeks)	$200,000

·         The loss of one highly productive surgeon because of dissatisfaction with the service provided by disgruntled and inefficient OR staff will have a significant impact on revenue.

·         A surgeon performing an average of 20 cases/month at an average of $900/case
will take $216K/year in revenue with him should he go to a competitor.
Over 5 years, the loss in revenue would total over a million dollars.

The Benefits of High Employee Morale

A study published in Fast Company, May 2001, “Maister Class: Transform Morale Into Money” by Jennifer Reingold found that a company could boost its financial performance by as much as 42% by raising employee satisfaction by 20%.  In comparing financial performance of global offices, the top 20% of these offices significantly outranked the other offices by scoring one particular statement regarding employee satisfaction higher than their counterparts: "Enthusiasm and morale are high."

See One, Do One, Write One

I was reading one of Graham's older posts at Over My Med Body!  - See One, Say One, Teach One from May 2004.  Graham, a medical student was sharing an important insight he had as he suddenly realized the power he wielded as a physician baring bad, life-changing tidings to a patient.  Graham had a BFO (Blinding Flash of the Obvious) and he wrote about it in his blog. 

One of the most powerful learning tools I've ever experienced was a monthly assignment I had during my two years of graduate school.  Each month, my assignment was to write a five page reflective essay applying what I was learning in graduate school to what I was doing in real life.

During the second year, we were required to share our essays with the entire cohort and were then required to make written comments on at least two classmates' papers. In addition to learning to coherently articulate my thoughts, I learned to write constructive commentary and to accept and value feedback, which furthered my learning even more. 

These papers were not about learning to write like an English major (I can feel some of you shuddering across the Internet at the idea of writing anything more in depth than an op note.)  They taught me to think about what I was reading, studying and hearing in lectures, to apply it to what I was doing in real life and to express my thoughts in a way that others could understand.

I'm glad some med students are blogging.  It's a fabulous form of self-reflection.  But what I would really love to see is reflective writing integrated into a medical school curriculum.  It would be a powerful way for students to capture their emotions and experiences before they get lost forever in the mountains of information and reams of data that must be assimilated during medical training. 

In my opinion, we'd be taking a major step toward graduating emotionally intelligent doctors who, having gone through the exercise of tying their thoughts, feelings and experiences to what they had learned, would be more in touch with themselves and their patients.  What's not to like about that?

Peak Performers & the Vertical Learning Curve

One of the hallmarks of peak performers is that they are acelerated learners.  They reframe what others might label as mistakes or failures as "learning opportunities".  They are constantly and voraciously learning. 

Most of us arrive in medical school because we ARE peak performers.  Being a peak performer is the price of entry. But something seems to happen between the end of school/training and mid life.  I'm not sure whether we get tired of learning or we just get so busy that its easier to fall back on what we already know, or perhaps there's so much learning to do to keep up with advances in clinical medicine that we sometimes feel maxed out and just give up.

Regardless of the reason, as an industry, we are now paying a heavy price - specifically in our unwillingness to learn to use technology.  And until we buck up and embrace technology, we will continue to pay. 

The American College of Physician Executives (ACPE) did a survey last year on physicians and technology.  Read the article entitled Survey Reveals Physicians' Love Hate Relationship with Technology by David O. Weber from The Physician Executive, March-April 2004 pp. 4-10.  The results are enlightening and I highly recommend it.

There's an excellent article in the latest edition (March-April 2005 p.40) of The Physician Executive entitled Professionalism in Medicine:  The New Authority by Dr. Anthony Oliva.  This article, published exactly one year after the article above points out how physicians are losing ground as a result of our slow adoption of technology.

Oliva starts off by describing how the medical profession struggled to create and confer professsional authority over a period of many years.  But now our authority is being quickly eroded by forces in the marketplace like consumerism, performance information (now dissimenated electronically in the form of "best doctor lists") and marketing by pharmaceutical companies and other entities.

Oliva stresses the importance of physicians taking a leadership role in securing our professional authority for the next generation of healthcare practitioners rather than allowing the marketplace to usurp it.

Barriers to our success (roughly paraphrased from the article) are:

1. We have failed to set our own standards (allowing the marketplace to set them for us).
2. We lack the technology infrastructure to document and evaluate performance.
3. We do not have the systems in place to hold ourselves accountable.
4. We have not even begun to allow for the transparency needed to create the cultural shift.

We must, as a profession embrace technology - but even more basic still, I think we should be looking deeper for what might potentially be an even greater problem.  Even though our young physicians are graduating with great savvy in technology, will there just be some other disruptive phenomenon that comes along when these physicians are in mid-life?  Will they be as resistant to change as we physicians in mid-life are now?

Because acelerated learning is so critical to the success of peak performers, if physicians are to thrive as peak performers now and in the future, perhaps we should be teaching young physicians not just how to use technology (which in my mind is just content), rather we should be teaching them how to learn.

Pandora's Box

Empathy is one of the Emotional Intelligence (EI) competencies that falls under the domain of Social Awareness (the 3 other EI domains are Self-Awareness, Self-Management, and Relationship Management).  I came across an article on empathy today as I was visiting Dr. Maurice Bernstein's blog the Bioethics Discussion Blog.   The article by Dr. James T. Hardy is entitled An Overview of Empathy.  It's a great read, as is Dr. Bernstein's post.

Dr. Hardy addresses the exact issue I was just discussing in my previous post on Emotional Intelligence and that is that many physicians are unwilling to make the effort to exercise their emotional intelligence.  Here's what he says in the article:

"Because empathy is such a powerful communication skill, we might suppose that clinicians would scramble to learn about and use it at every available opportunity. However, this is not necessarily the case. Clinicians have many reasons for not offering empathy to patients. An informal survey of practicing clinicians participating in a recent clinician-patient communication course revealed misgivings (and misconceptions) about empathetic communication. Concerns mentioned included:

• "There is not enough time during the visit to give empathy."
• "It is not relevant, and I'm too busy focusing on the acute medical problem."
• "Giving empathy is emotionally exhausting for me."
• "I don't want to open that Pandora's box."
• "I haven't had enough training in empathetic communication."
• "I'm concerned that if I use up all my empathy at work I won't have anything left for my family."

"In our experience, empathy facilitates the clinical interview, increases efficiency of gathering information, and honors the patient. Empathy need not be awkward nor emotionally exhausting; unlike sympathy, empathy does not require emotional effort on the part of the clinician. An appropriate statement or gesture of empathy takes only a moment and can go a long way to enhance rapport, build positive relationships, and even improve difficult ones. Studies have shown that when opportunities for empathy were repeatedly missed, visits tended to be longer and more frustrating for both physician and patient. (references 18,20) Conversely, empathy may save time and expense and often is a cost-effective method of facilitating early diagnosis and proper treatment."  (reference 10).

In reading through the reasons physicians gave for not employing empathy more often, I got a sense that we physicians are almost afraid of being too emotional.  The idea of "opening up Pandora's Box" smacks of fear of that which might be unknown and therefore uncontrollable.

I think Hardy's article speaks to the tremendous need for educating medical students, residents and physicians about emotional intelligence - what it is, why it's important and how to develop it. While many training programs do have courses to teach empathy, I think that teaching the emotional intelligence competencies would be much more effective through an integral approach rather than to pull out one competency and teach it in isolation.

Maurice's new blog and the article offer some definitions of empathy, sympathy and pity.  Both are worth the read.

Emotional Intelligence - How to Get Some In Healthcare

An interesting assortment of people attended our introductory class on coaching physicians this past Wednesday night.  One of the topics we discussed was the lack of awareness in the health care industry of the extensive work being done on emotional intelligence (EI)** and how EI impacts performance. 

My masters thesis - A Leadership Model for Transformative Change in Healthcare addresses this topic.  In the research I did for my thesis, I discovered very few references to studies being done on emotional intelligence in health care despite the fact that numerous studies in other industries have documented its importance as a key differentiator for high performers vs. average performers.

I've spoken many times on this topic and have found that physicians are less likely to be open to learning about it than nurses, managers and other health care professionals.

One possible reason is that emotional intelligence CAN be developed, but it takes conscious awareness over a period of time.  Although it can be learned ABOUT in a classroom, to actually increase one's emotional intelligence in any of the four areas (self-awareness, self-management, social awareness and relationship management) does take practice. 

Because it requires implicit learning (like breaking and making a habit) rather than cognitive learning (like memorizing a formula), increasing emotional intelligence will only happen through practice over time.  I think physicians hear this and decide its not worth the effort. Much of medicine today is geared toward the quick fix.  No wonder physicians don't get enthused about EI. 

On Wednesday night in our class, all of the participants (physicians, nurses, coaches and consultants) agreed that physicians as a group seem to have very little self-awareness regarding the way their actions and behavior impact others.  Research has shown that without self-awareness there is virtually a zero percent chance of developing the other three areas of emotional intelligence.  So lack of self-awareness just perpetuates the problem.

In my opinion, the only way for us to begin creating the shift that needs to occur is to start early by helping medical students to both appreciate and develop their own emotional intelligence.   It CAN be done and in fact, medical training would provide a rich, if not ideal environment in which to practice the skills.  With the right kind of program, medical students could graduate with a big head start in life, if only...

** For more info on Emotional Intelligence, I recommend reading any work by Daniel Goleman, but particularly Primal Leadership by Goleman, Boyatzis and McKee.  See the description in the left hand side panel of this site.

For more info about the courses we offer go to www.encompasshealth.com/class_hc.html.

Five Basic Needs

I read this poem, author unknown, a few years ago and saved it.  I think it captures the essence of my earlier post... "Still Pimping".  Whether I'm teaching medical students and residents, mentoring younger physician partners, interacting with nursing and administrative staff and especially in communicating with patients and their families, to the degree that I remember the other person has these five basic needs, I will be more successful.

My Five Basic Needs

I need to be seen.

   I need to be heard.

      I need to be respected.

         I need to be safe.

            I need to belong.

When all of my basic needs are met…then…

     I am ready to learn.

                                             Anonymous

From the book The Heart of Coaching: Using Transformational Coaching To Create a High-Performance Culture, by Thomas G. Crane, FTA Press, 1999. San Diego, California.

Still Pimping...

I enjoy reading the blogs written by medical students and residents because they often take me back to the days of my own training, which, for the most part I remember with great fondness! 

However, reading this excerpt from Doc Shazam's blog Mr. Hassle's Long Underpants I felt frustrated and sad.  It captures, in my opinion, one of the biggest problems with medical school education today and it seems that things haven't really changed since I was the med student. 

Doc Shazam (a resident in Emergency Medicine): "The medical students (student doctors) are frequently intimidated and do what they're told no matter how hard you try to make it a friendly working environment for them...and have the impression that if I like them, they'll get into our residency (far from true).   Medical school ingrains such an attitude of hierarchy and teaching by "pimping" (the Socratic method), that trying to have an easy going conversation is next to impossible, especially for medical students that have come straight from college."

Not too long ago, I had an opportunity to teach some 1st, 2nd and 3rd year residents on styles of leadership.  After I had presented some material, I divided them into groups and assigned each group a particular leadership style.  Using some reflective questions as a guide, I asked them to discuss when each style might be most effective and to come up with examples of when they had either used or witnessed that style being used. I asked each group to choose a spokesperson to share the results of his/her group discussion with the larger group (about 30 residents).  To my surprise, there were several groups in which no one would volunteer to be the spokesperson. 

I think this was the direct result of the teaching methods described by Doc Shazam that are still being used in medical education today.  These methods teach students to keep a low profile, to avoid risk and never to do anything that might cause them to "look bad" in front of their peers.

In my opinion, we are training doctors who then go out into the world and carry these attitudes forward. 

Three unfortunate outcomes are:

1. Physicians who go into teaching turn around and use the same tactics that were modeled to them because those are the only tactics they know. This is self perpetuating.
2. Even worse, some physicians use these tactics with great gusto because for a moment, they have the opportunity to feel powerful superior to the student by humiliating him in front of his peers, staff and even patients.
3. But worst of all, physicians complete their education trained to keep a low profile and go into self-protection mode when challenged.  In my opinion, this is one of the root causes for the great shortage we have in the number of physicians willing to step up to the challenge of leading the change we so desperately need in healthcare.

For two years ending in 2002, I had the privilege of attending Antioch University (Seattle campus) where I earned the degree of Master of Science in Management.  During that time, I discovered the absolute joy of learning in an environment of mutual respect where students and professors learn equally from each other and the process is as valuable as the end result. 

Each student is valued for his or her contribution to the class and to the learning process.  Students are accountable for their own learning and there is no place for fear and "teaching" methods like "pimping."   

I also discovered my own love for teaching in a course I took on Transformative Learning Design as part of my Masters.  During that class, I developed my own philosophy on teaching.  I believe there are some medical schools working to develop more effective teaching skills for their faculty members.  I am committed to finding them and figuring out how I might contribute.  I think I have some excellent ideas.