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How to heal medical culture

Fully reversing the tide of physician burnout requires addressing deep issues within the culture of the health care system, Stanford Medicine leaders write.

Proposed solutions for physician burnout often focus on getting doctors through their work days: helping them navigate increasing documentation requirements, for example, or offering strategies for strengthening their personal resilience.

These are valuable and essential initiatives, Dean Lloyd Minor, MD, said, but a more profound reckoning is also necessary for the medical profession's long-term health.

"Though electronic health records and other clerical work burden physicians, fully reversing the tide of physician burnout requires addressing deeper issues within the culture of the health care system," he said. "We need to identify and mitigate what is causing doctors to feel an erosion of meaning in their work."

To understand the big picture, he and Tait Shanafelt, MD, Stanford Medicine's chief wellness officer, teamed with organizational culture theorist Edgar Schein, PhD, to view the medical profession through the lens of organizational science. Their paper was published in Mayo Clinic Proceedings. Other co-authors are Darrell Kirch, MD, president of the Association of American Medical Colleges; Mickey Trockel, MD, PhD, Stanford Medicine associate professor of psychiatry and behavioral sciences; and Peter Schein, MBA.

The paper suggests that, taken together, many of the daily frustrations of physicians represent an ominous sign that the health care system isn't in sync with stated values and beliefs of the medical profession.  

In one example of such a contradiction, the paper notes that health care organizations often claim in their mission statements to value "the needs of patients, social justice and fair distribution of resources," while actually limiting patients' access to care based on ability to pay. Similarly, health care organizations assert that physicians are trustworthy, highly trained professionals who represent a precious resource; however, the U.S. health care system also allows insurers to require that they authorize medical procedures for individual patients before physicians can move forward with the care they deem appropriate.

As the authors explain:

These incongruities between stated values and organizational behavior are clear to physicians and create cognitive dissonance that breeds cynicism and a sense of misalignment between the organization's goals and the altruistic aims of the profession.

Organizations typically only grapple with these kinds of contradictions when they believe something bad will happen if not addressed, Shanafelt explained. He and his co-authors suggest there is extensive evidence that undesirable things are already happening in the health care system through physician burnout and its ripple effects.

But it's not smooth sailing even after leaders recognize the need for change in an organization, Shanafelt said. That realization can create fear because they aren't sure they will be able to make the changes necessary to solve the problem. This can lead them to deny or minimize the problem, blame individuals, and defend the status quo.

Fear must be minimized for an organization's culture to successfully evolve, Minor said: "A key element is buy-in from senior leaders. They must clearly articulate the ideal future scenario and commit to leading the organization there."

As an example, he said, the current state at a health organization might include "an inefficient practice environment that places no limits on work and often makes it challenging to provide the care a patient needs." The future ideal would be "an environment that minimizes low value work, makes it easy to do the right thing, and acknowledges human limitations," Minor said.

To achieve that -- or any -- future ideal for medicine, small groups of innovators must be allowed to experiment with new approaches and share their experiences, Shanafelt said. These trailblazers can be individuals, departments and divisions, or even whole organizations. 

"We've got to help people see what the new way looks like and demonstrate that it can work," Shanafelt said. "It's much easier for other leaders to buy in when they see there's a proven path they can follow."

Minor said this journey is a priority for him, Stanford Health Care CEO David Entwistle, and Stanford Children's Health CEO Paul King. Stanford Medicine already has taken the first steps. For the first time, "improvement in the efficiency of the practice environment for physicians" is listed as a top-level priority in the 2020 operational plans of the adult hospital; and the leaders have identified specific metrics for evaluating progress. Additionally, "improvement teams" in several clinical departments have been empowered to innovate and lead the way for others, Minor said.

Shanafelt said it's a solid start, and he's optimistic.

If we admit where we're starting, understand that we're having a conversation about fundamental culture issues, and recognize that there is a defined roadmap from the field of organizational science to get to a better state, then we can move much faster. We must not settle for just tinkering with incremental things. We must also get at the underlying core issues.

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