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Toxic Institutions
I went to a seminar on physician wellness and burnout presented at my alma mater. The organization became concerned about the topic several years ago, but initially thought in terms of helping individual physicians cope/recover. They started by looking for data using survey methodologies. Most of the studies presented had a response rate between 30 and 40%, which is typical for voluntary surveys. Of course, in this case there is concern that non-responders have become too apathetic or burned out to even bother to report. Nonetheless, a consistent finding was that about a third of respondents were reporting significant psychosocial distress. This finding was more common in medical students, then tended to level off. Curiously, among faculty in one department, the stress rate was highest at the associate professor level and lowest in the full professor ranks. As I listened to the presentations it became clear to me that we have a systemic problem. We have created institutions that are toxic to the people who work there and there are no quick fixes for the problem. Although the presentations were focused on physicians, the findings in other healthcare workers are even more dramatic. Now the foundation stories of all health care organizations begin with people coming together to help alleviate pain, suffering, and disability for other persons. So how did we end up in this situation? Certainly no one in a leadership role wants to be leading a toxic culture, but what can they reasonably be expected to do about it? David Brooks has published an article called “An Agenda for Moderates.”[1] He argues that ideas which drive history, what he calls magnetic ideas, are in a state of change. Quoting a book written in 1999, he describes three ideas in American history. First was the idea of God and the Holy City. Second was the idea of the nation, or Manifest Destiny. Third was the idea of self and self-fulfillment which has characterized the current era. He notes we are leaving the era of self but are being presented with two different ideas of the future. The conservative idea is “the tribe.” The liberal idea is “social justice.” He notes both ideas are inherently negative. For the conservative, the enemy is the other. For the liberal the enemy is oppression by the other, often hidden, elites. As a raging moderate he wants to consider what policy options are open to him. With all due respect to Mr. Brooks, another way of interpreting the big idea of our recent history is the growth of “big” organizations. My father grew up while his father was an active duty Army physician. As he reminisces about those days, what strikes me is how small the Army was. People he knew as a Boy Scout in Hawaii in the early 1930’s became classmates at West Point, and he had a visceral family connection to many senior officers even as a cadet. One “lesson” of the Second World War, though, was that we needed big institutions to combat the enemy. After the war, we continued with “big” business, such as General Motors or General Electric, and had “big” government. For 20 years or so after the war, the country had faith in its big institutions. Of course, the consensus broke down in the late 1960’s. But the decades since then have seen those big institutions become even bigger. In return, many people, having no faith in the benign nature of those big institutions, have retreated to more private and personal goals and motives, the self if you will, to the point where today the conversation is about atomization and echo chambers and the decline of the public sphere. I believe the challenge in medicine, then, is to find ways to humanize our big organizations so that people can feel good about where they work as they do in the work itself. I don’t hold out hope for reversing the bureaucratization of medicine, which I have certainly seen grow exponentially in my lifetime. Rather, how can we create connections that lead to meaning? A traditional answer is small group formation. Now some executives fear small groups as leading to rebellion and dissent. But if Dunbar’s number is real, which I think it is, then we need to create subunits of 100 people or less that function together in important ways. In medicine, I have called these the clinical microsystem. Just as the body is made up of cells grouped into organs, so too our organizations need organs as well. I don’t want to push the analogy too far, so I concede organizational groupings are looser and more ad hoc. How might such clinical microsystems function and stay integrated into the whole? Interestingly, the use of technology, currently the bane of effective communication, might be turned into the means of creating the connective tissue of these systems. It does, however, require rethinking the purpose of our technology. The EMR, for instance, might work if it were re-constructed as a clinical tool to guide and record patient care rather than as it is now—a billing document that serves institutional needs first and patients only as an afterthought. Wiki technology could be used to serve broader institutional communication needs and to develop some cohesion within and between microsystems. Yes, it probably also involves committee meetings, but these can be organized to create systems for decision making rather than reporting and ratification as is now often the case. What I don’t think would work is the sort of rah-rah enthusiasm used to motivate sports teams or by the military in basic training of recruits. Such efforts are helpful only in the short-term and won’t suffice for the sort of long-term effort needed to make our institutions better places to be. I also don’t think this is something than can be achieved by a single program with a catchy slogan. What leaders need to do is recognize the pervasive nature of the toxic environment and find ways to nurture the growth and development of the small units—the microsystems. One interpretation of the departmental data described earlier is that the senior members of the department are generally content with the status quo. They may not even recognize the problem is not that their juniors can’t “cope” or are just too soft, but that we have created systems that guarantee everyone eventually fails. This is not a matter of blame—no one set out to create these toxic environments. But I have seen many highly motivated young leaders give up when the organization proves too rigid and resistant, and where implementing good ideas takes too long and too much effort. Yes, making changes might cost money. But can we afford to keep burning up our talent as we are doing now? Which is cheaper in the long-term? 27 February 2019 [1] Brooks, David. An Agenda for Moderates. The New York Times. 25 February 2019. Accessed at https://nytimes.com/2019/02/25/opinion/moderate-politics.html. |
Further Reading
A Good Place To Work Is your organization a just one? How do you know? Big Medicine Big medicine may be financially necessary, but it poses risks unless care is taken to become a real system, which requires putting the clinical enterprise at the center. Clinical Microsystems Clinical microsystems are composed of front-line clinicians engaged in direct patient care. Despite a lack of formal authority, they are the key to successful healthcare reform. Communications Messaging is replacing dialogue in clinical practice to the detriment of all. Dunbar's Number Dunbar's research suggests a practical limit to our human capacity for emotional connection with others. This has important implications for dialysis unit function. |