Beyond Toxic Organizations
Recently I suggested the “burnout” epidemic in medicine widely discussed these days was really a manifestation of toxic institutions, that is, ones that were not just and inflicted moral injury on their employees. I doubt anyone in leadership set out to create this situation, but it seems widespread, and I thought it might be worthwhile to reflect more on how we got into this dilemma.
One objection to my formulation is that the “modern generation” is different. For instance, a story on NPR last year emphasized that Americans, but particularly young people, are lonely. The report focused on a study done by Cigna of some 20,000 adults, showing 54% felt “no one knows them well,” and 56% reported they sometimes or always felt like people around them are “not necessarily with them.” The instrument used yielded numerical scores, and when the researchers looked at scores by “generations,” generation Z, those born in the mid-1990’s and early 2000’s, scored 48.3, millennials, 45.3, baby boomers, 42.4, and the Greatest Generation, 38.6. As noted, these results are somewhat counter-intuitive.
Derek Thompson has described the rise of “workism,” which he characterizes as the new American religion, which particularly afflicts the millennial generation. He notes particularly the disturbances of new social media and notes: “Among millennial workers, it seems, overwork and “burnout” are outwardly celebrated, (even if, one suspects, they’re inwardly mourned.)” Related, but slightly different is the nature of the way we train people to “succeed.” I think this is more important over the long-run.
William Deresiewicz gave a talk at West Point in October 2009, which he subsequently published on the Internet. He began by considering the question of what constituted leadership. He reflected on his experience as a member of the admissions committee and Yale and noted:
“The first thing the admissions officer would do when presenting a case to the rest of the committee was read what they called the “brag” in admissions lingo, the list of the student’s extracurriculars. Well, it turned out that a student who had six or seven extracurriculars was already in trouble. Because the students who got in—in addition to perfect grades and top scores—usually had 10 or 12. So what I saw around me were great kids who had been trained to be world-class hoop jumpers. Any goal you set them, they could achieve. Any test you gave them they could pass with flying colors. They were, as one of them put it herself, “world-class sheep…”
This is exactly what places like Yale mean when they talk about training leaders. Educating people who make a big name for themselves in the world, people with impressive titles, people the university can brag about. People who make it to the top. People who can climb the greasy pole of whatever hierarchy they decide to attach themselves to.
But I think there’s something desperately wrong, and even dangerous, about that idea.”
Although he was talking to cadets at West Point about students at Yale, the description rings true for physicians and for many of the administrative people who populate health care organizations. We have created a system where “working the system” is rewarded. By extension, thinking about changing the is seen as unnecessarily disruptive.
“That’s the really great mystery about bureaucracies. Why is it that so often the best people are stuck in the middle and the people who are running things—the leaders—are the mediocrities? Because excellence isn’t usually what gets you up the greasy pole. What gets you up is a talent for maneuvering. Kissing up to the people above you, kicking down to the people below you. Pleasing your teachers, pleasing your superiors, picking a powerful mentor and riding his coattails until its time to stab him in the back. Jumping through hoops. Getting along by going along. Being what other people want you to be…Not taking stupid risks like changing how things are done or question why they are done. Just keeping the routine going.”
For physicians of my era, these attributes are antithetical to what we understood to be the essence of being a “good physician.” Our job was to study, reflect, and act, based on our understanding of the needs of the patient and the tools available. I sense that notion is in the process of being replaced, and perhaps, if the new model is sufficiently bureaucratic, the medical young will not feel “moral injury” operating in our new, large, healthcare organizations. On the other hand, I think it probable patients won’t like the new model very much, and it will take a couple of generations to become dominant. So, wouldn’t it make more sense to figure out how to encourage independent thinking and action at the patient-care level, while operating within the bureaucratic structure? Lest you think this is unattainable, let me conclude by quoting again from Deresiewicz.
“Most people, when thinking of this institution, [West Point], assume that it’s the last place anyone would want to talk about thinking creatively or cultivating independence of mind. It’s the Army after all…Anyone who’s been paying attention for the last few years understands that the changing nature of warfare means that officers, including junior officers, are required more than ever to think independently, creatively, flexibly. To deploy a whole range of skills in a fluid and complex situation. Lieutenant Colonels who are essentially functioning as provincial governors in Iraq, or captains who find themselves in charge of a remote town somewhere in Afghanistan. People who know how to do more than follow orders and execute routines.”
Many of these young officers will be forced out of the peacetime Army. But medical organizations are at war now, and likely to remain that way for the foreseeable future. We need young people who are trained, encouraged, and supported in thinking and acting locally, using the principles they have learned, be they clinical or administrative. Without this, we won’t get out of the impasse we find ourselves now, and we won’t get beyond toxic organizations.
9 March 2019
 Chaterjee R. Americans Are A Lonely Lot, and Young People Bear the Heaviest Burden. 1 May 2018. https://www.npr.org/sections/health-shots/2018/05/01/606588504/americans-are-a-lonely-lot-and-young-people-bear-the-heaviest-burden. Accessed 1 May 2018.
 Thompson D. Workism is Making Americans Miserable. The Atlantic, 24 February 2019. https://www.theatlantic.com/ideas/archive/2019/02/religion-workism-making-americans-miserable/583441/. Accessed 7 March 2019.
 Deresiewicz W. Solitude and Leadership. 8 December 2017. https://onbeing.org/blog/william-deresiewicz-solitude-and-leadership/. Accessed 22 December 2017.
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