A book was recommended to me recently by a resident of mine. It is written by Simon Sinek and called Leaders Eat Last. I already knew that I agreed with a lot of what Sinek says, because I’ve seen You Tube Videos by Sinek that feel like he has reached inside my head and ripped my ideas directly from my mind.
Today, I don’t want to deliver a book review to you. Instead, I want to discuss what I learned from this book. Specifically, I want to talk about how lessons from this book apply to the morally injured doctors that our burned out medical system creates.
Leaders Eat Last
The premise – and the title – of Leaders Eat Last comes from the Marine Corp where leaders are the last to enjoy their meals. When the soldiers approach the mess hall where they are to consume their next meal, the most junior soldiers line up first. Then, the next most senior. Finally, the leaders eat last…if there is food left to eat.
This is more than a tradition. It is a system that tells all of the soldiers that they matter to those who are overseeing their work. It produces trust, reliance, and loyalty. And, it is very intentional.
This culture is created in the military so that soldiers would be willing to not only do the bidding of their superior but to risk life and limb for their fellow solider. It is a powerful example of effective leadership. When we feel that we fit in safely with those that surround us, there is very little humans won’t do to prove their loyalty. They will work until they can’t, and will be proud to say that they are a member of the team.
Do Hospital Administrators Eat Last?
Compare the military experience to that experienced by most medical professionals. Do we have the same experience with our administrators in hospitals? It seems that we have learned that the hospital won’t always love us back.
In the book, Sinek argues that when those armed with the power to make change don’t talk to those on the front line, they don’t have the necessary information to make helpful changes. When those on the front line have the information that is needed, but don’t have the power, necessary changes are ignored.
Instead, administrators who run very big organizations rely on metrics and numbers to make decisions. They can’t possibly know everyone. They must trust their middle-management.
Those of us on the front line impacted by these metric-based decisions seem unreal to those who lead. We simply become numbers on a spread sheet. Metric based leadership does not know your spouse, how many kids you have, or the fact that your grandmother is struggling through Lewy-body dementia.
This is a human phenomenon. We must know people in order to care about them, and to lead effectively.
The further distanced we are from someone and the more “statistical” they become, the less we care about their well-being. It is easy to lay-off hundreds of people you don’t know based on spreadsheets showing the company’s margin. This quote, which is referenced in Leaders Eat Last, captures it well:
“If only one man dies of hunger, that is a tragedy. If millions die, that’s only statistics.” ~Joseph Stalin
Unfortunately, when decisions are based on metrics and statistics, and not on the humans that these decisions impact… there is no drive or desire for the leaders to protect those they lead. We aren’t in their “circle of safety” as Sinek calls it.
This inevitably leads to a situation where people lose loyalty, feel less safe about their job security, and it also reduces productivity.
Leaders Eating First Causes Moral Injury
Despite having the abilities and desires to do what is best for our patients, many physicians experience an environment where they are provided too little time to see patients and are forced to spend too much time in front of an electronic medical record system.
Or perhaps you have been placed in an environment that is more concerned with RVU production, shift requirements, or academic expectations? All of this is pitted against our desire to be good doctors. It also prevents our ability at times to be a good spouse, parent, and friend.
This situation is not sustainable.
Should doctors spend the extra two hours charting at home? Or do they eat dinner with their family? Do they perform the extra operation to meet their RVU goal? Or do they plan to be at their kid’s tee-ball game?
These metric based goals can systematically impact the wellness of doctors. They seem to have also created a system that is more concerned with the bottom line than the moral injury caused to the physicians on the front line.
Open and Honest Cultures
One of the biggest reasons that medicine is currently in a sad existence is because of the culture.
Instead of feeling safe to share our thoughts, beliefs, and opinions; many of us live in a constant fear that during the next economic down turn we will be let go from our jobs, we will be paid less, or that our benefits will be reduced or taken. Why would we feel this way? Because it has happened to us, or to our close friends.
Unlike well-run organizations, who produce a culture where trust is paramount, many doctors feel like cogs in the wheels of giant machines. They feel like they would be easily replaced. They are just a number. Does anyone from the C-suite even know our names, who we are, and what we do?
It doesn’t take many meetings with employees to figure out what produces our resentment towards the current system. Yet, I know many people who have never even seen executives and administrators at their hospitals. Far fewer have actually attended meetings where they have been encouraged to share openly and honestly about what troubles them.
Yes, surveys are performed to “better” the organization. These are the same surveys that many of us are coerced into completing. This “checks the box” of showing concern for the people on the front lines, but none of us are truly fooled.
An Employee First Approach
An open, honest, and just culture must be created.
We can fashion ours after the culture that was created in the airline industry after it started crashing planes. They fixed the problem by fixing the culture. And so can we.
We must create a culture where retribution will not be tolerated, and we are encouraged – maybe even honored – when we point out problems that need correcting. A culture where we feel like our voice is actually heard. Or perhaps a culture where the almighty dollar bill isn’t what we focus on most.
Instead, we focus on making our employees feel happy, safe, and secure. Why? Because good leaders know that this sort of culture will produce loyal and hardworking physicians.
If medicine is to be fixed, it must occur from a top-down approach. While I believe the power ultimately rests with those that control our jobs, I also believe that it is the responsibility of the employees to stand up for what they know is right.
We must be willing to be bold and concerned about our fellow brothers and sisters that fight the good fight along side of us. It is our responsibility to not sit idly by while doctors fade into a deep and dark burnout. Or worse, to sit silently while physicians quietly commit suicide at epidemic rates.
I encourage you to stand up for what is right. Hold our administrators to the standards that we would want for the leaders that represent us. Be willing and courageous to speak when others can’t or won’t.
Seek financial independence so that you will possess the ultimate trump card in a broken system. It will help you find your way off of the broken road to burnout.
I’ve held for sometime now that the main fix to the current problems that we face in medicine can be found in fixing our culture. Often, I look to the aviation industry as a shining example of what that might look like, but Leaders Eat Last also provided an excellent image of how our failing system might be saved.
It will require our leaders to stand up and to lead. However, it also calls us to force our leaders to act the way a leader should.
It remains my dream that there will be a group of physicians who find the courage through financial independence to stand up, and to fix this sinking ship that is the business based medical model we currently inhabit.
Do your leaders eat last? Have you felt empowered to speak up? Or are you perfectly happy with your current situation? Leave a comment below.
Unfortunately, as the mergers and takeovers get bigger and all consuming, the answer is not in the administrators, but in our own organization as doctors. Smaller, independent hospitals with strong medical staffs and bylaws will right the ship in certain areas of our country. Being a private practice surgeon, I also think the answer is in independence so physicians sit in a position of strength. I can call or text my CEO, I can walk into his office and set up a meeting and be heard. I try to show my worth to the hospital on a daily basis, not just by my case load or downstream revenue, but in process improvement, employee recognition, and being kind. While it may seem naive, I think you reap what you sow, and it is on us as physicians to figure out what is going to make us happy and give us a better quality of life and not keep looking to others to fix our burnout problem. While I completely agree that administration is not our friend and the hospital is never looking out for your best interest whether you are employed or in private practice, they are a necessary partner in the medical equation, certainly for my specialty.
I agree that there is some responsibility on the part of the physician to have a seat at the table. After all, if you aren’t at the table, you are probably on the menu.
However, the current system that burns out many doctors is out of their control. While they can control some things, many are determined by administrators they’ve never met and they don’t have the same opportunity it sounds like you do to speak up and make change. Possibly because many work at larger hospitals or for larger companies that treat employees like numbers.
Yours is a good reminder to take onus of what is ours and to find a job that allows us to find a better balance, if possible.
Maybe this rule should apply to politicians also. Just saying….
Great piece, TPP. I totally agree with you that the culture of medicine (and other institutions as well) must change. We need to value people over money. Creating a culture where leaders eat last is definitely in the right direction.
Thanks, DMF. This would be an important step towards not only figuring out what the problems are, but how to solve them, too.
Thanks for the comment!
In many ways the military is the model of the modern mega health system. The system will not run without loyal soldiers who need to be fed and encouraged comeraderie, for sure, but the generals are the original metric based people. They anticipate casualties, AWOLs, equipment, backup when they underestimate the casualties. In our own lifetimes, and in many places right now, there aren’t enough volunteers so constription supplies an unwilling work force. Re-enlistments are a paltry amount of those who complete their obligation, voluntary or not. In many ways, that is where the modern medical model originates. A volunteer army ups the ante a little, and the non-army branches of the US military have been volunteers mostly. We see a little more accountability as scandals like Tailhook become public despite attempts to avoid disclosure.
I think that is not where medicine needs to go. A better course would be higher stakes for talent short-falls or turnover. Accountability of the middle management for this has been a lot less than it was in the international conglomerate where my wife spent her career. Scientists going someplace else were a big demerit. In our churches or synagogues, members taking their dues as well as their talent someplace else comes back to haunt the clergy at contract renewal time. It is those middle managers who create the pool for upper managers and they will do anything to stay in that pool and maximize their bonuses. Change the way the bonuses are calculated and culture will change.
I agree and disagree.
I think that there are many flaws in the military system that are not necessarily the best to emulate. You highlight some of them. I do think that that premise of leaders putting their soldiers first is a good one.
Where I disagree is the idea of incentives and bonuses driving people. That’s actually part of the problem. That sort of system is bent on metrics and data where people are driven by a dopamine rush caused by bonuses. It implies that there are other people who may or may not make their bonus, and often these bonuses create a competitive environment where colleagues are working against each other to “Get theirs” while others don’t. In other words, the way I get my bonus is by making sure you don’t (or that yours is less).
Taking the long view by creating the right culture is the way to lead, in my opinion. Not chasing bonuses and metrics.
Great message! Leaders Eat Last is an excellent book. Pretty much everything from Simon Sinek is great. Another book of his, Start With WHY, is in my top 10 books for leaders.
Your point is very well taken. I’ve worked at a half dozen different hospitals in the last 10 years, and the ones that are the best are ones with a lot of physician participation. The hospitals that are run by administrators without front-lines medical experience tend to run like corporations, not health care facilities.
I have appreciated being at a level now that I have the ear of my department head and director (both practicing physicians), and they really listen to my advice and concerns. I’ve given presentations on how to run my division more efficiently and they’ve taken a lot of my suggestions. This really empowers my team to feel like they have a real stake in what’s going on at the hospital.
The best hospital administrators listen to their physicians who actually know what is needed on the front lines to care for patients. At my facility, I always encourage my colleagues as well as our residents to get involved. Get on committees, get an audience with their department heads, write letters, fill out surveys, give presentations. The best way to shape our future is to participate in it.
I know that not everyone has a receptive administration, so I think your article definitely speaks to those situations very clearly. Thanks so much!