COMMENTARY

Healers in Need of Healing Cannot Heal

Herdley O. Paolini, PhD; Mark H. Greenawald, MD

Disclosures

May 20, 2016

In This Article

The "triple aim" of healthcare—enhancing patient outcomes of care, improving population health, and reducing costs—was first introduced in the literature in 2008 and has become healthcare's Holy Grail.[1] And, unfortunately, it appears as elusive as its counterpart in mythology. This should be no surprise given that, on the average, more than half of the key players are exhibiting a range of burnout symptoms.

The desired shift from "volume to value" continues to elude us. Are the high rates of physician burnout and distress an overlooked but critical issue? A "fourth aim" to address caregiver burnout has been proposed.[2,3,4] But, rather than a fourth aim—an afterthought—we believe that this aim is so essential to the triple aim that it is a prerequisite. It should be the first aim.

We will continue to fall short of achieving the triple aim if we do not proactively attend to the health and wellness of physicians and not simply react to extremes of physician distress. In addition, we believe that our success in achieving all of the aims will depend on our ability to provide physician leaders with the core skills and holistic wellness to achieve such transformation.

All Physicians Are Leaders—For Better or Worse

Both formal and informal physician leadership is needed for healthcare transformation. Contrary to popular opinion, leaders are not born. They are formed. This process involves a personal inner journey, one involving the courageous development of self-awareness through a reflective process that instructs as to how one's strengths and shadows are affecting one's ability to inspire, enlist others, and create collaboration for needed change. Formal leaders need to be effective in their position to enlist collaboration in creating disruptive innovation and transformative change. But informal leaders (ie, all physicians) need to be effective in both collaborating in its creation and taking ownership by operationalizing it. If physicians are not taking ownership of their leading role, they will be barriers.

In concert with the popular definition of insanity (ie, doing the same things while expecting different results), management often continues to try to go around physicians, run over them, or "carrot and stick" them, all while getting the same negative results. One physician in a senior management position said, "I don't understand why (our) physicians can't find purpose and meaning on my agenda." He demonstrated the frustration experienced by those who attempt to lead without the necessary formation to have the skills that inspire, gain others' respect, and enlist others into collaboration.

Missing the Mark

Physicians are now being thrust in leadership positions, whether formal or informal, to an unprecedented degree. Physician leadership programs are being developed with solid material, competent faculty, and seemingly logical, well-designed curricula. Unfortunately, many miss the mark. We observed multiple instances of eye rolling during physician interviews when leadership training was mentioned. Upon probing, it became apparent that the system's program—and the entire idea of physician leadership development—had developed a bad name within the medical staff. It wasn't presented in a context that resonated with their reality. "Waste of time. I learned nothing," was the judgment of one elected medical staff leader.

This MBA-style traditional approach, which focuses mostly on management theory and practice, does not adequately address the inner transformation needed to take us from transforming processes to transforming our mental models and habits of relating to self and others.[5] The content is not sufficient because it does not address that proposed first aim of supporting the clinician experience and sustainability of the work and often does not reflect an understanding of the physician worldview and their starting point relative to leadership.

Instead, what is required is moving from what Spiegelman and Berrett call "transactional" leadership to "transformative" leadership, which have different outcomes (Table).[6] This will necessitate leaders to effectively communicate the "why" of the new initiatives they're pursuing.

Table. Comparison of Transactional and Transformational Leadership Styles

Transactional Transformational
• Clarifies issues and focuses on problem solving; prefers and makes high use of cognitive knowledge primarily • Clarifies personal purpose and integrity through an ongoing inner journey; uses emotional, cognitive, spiritual, and experiential knowledge
• Attempts to fix what is broken • Listens and asks honest, open questions; collegial style; attends to relational aspects
• Communicates strategy plan • Applies appreciative inquiry, looking for what is going well and what is working
• Charts strategy course and communicates it to the team • Facilitates emergence of strategy from the collective intelligence of the group
• Develops meeting agenda and conducts meetings according to this preset and pressing agenda; expects agreement • Translates values into clear specific meeting practices that ensure everyone's participation and keep egos in check
• Intentionally works to avoid or circumvent conflicts and to contain contradiction • Devotes time to bringing conflicts to light and addressing them; applies multistep conflict resolution process
• Asks: What is happening out there? What should I/we do? • Asks: What is happening in me? How are others experiencing it? What is trying to or needs to emerge?
• Stays focused on what they perceive to be the best idea • The leader is able to hold different points of view and integrate complex divergent ideas
• Builds alliances of interest • Builds trustworthy relationships
Outcomes Outcomes
Individuals may feel like a "cog in the wheel" and do the minimum required Individuals feel valued, inspired, and want to be involved
Defenses remain high Defenses are lowered
Disagreements often go underground; they may show up again in passive-aggressive or other undermining behaviors Disagreements are worked through and resolved, resulting in team cohesion
Relationships are strained Relationships are deepened through trust building and personal understanding of each other
Issues may be temporarily resolved, but relationships and long-term success are compromised Issues are resolved in a sustainable way
Disengagement and cynicism Buy in, engagement, and personal commitment

We lead from who we are, and we gain meaning from why we do what we do. If the "who we are" is burned out, cynical, and lacking in self and other compassion—and yet we feel we have to save face and not admit to it, and the "why we do it" is focused on economic transactions—no amount of academic education on leadership theory will help us engage ourselves or others in the healing process.

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