The Physician Philosopher Podcast

TPP #66: What Communism and Physician Culture Have in Common

Physician burnout is expensive.  Each year it costs us multiple BILLIONS of dollars. That’s billions with a “B”.  At an individual level, physician burnout has been shown to cost an average of $7600 per physician.  This isn’t surprising when you consider that replacing one physician costs an institution on average $250,000 to $1 million.  That’s a lot of money.

Physician Disability Insurance

This is one reason that organizations like the Cleveland Clinic have not only invested money into physician coaching, but reaped massive rewards for providing that help.  In fact, it is estimated that they have saved over $133 million do to the coaching program that exists there.  Really incredible stuff.  

For this reason, I wanted to spend some time explaining a fundamental concept that will help physician leaders to make decision that not only reduce burnout, but provide a return on their investment.  

Leaders Do Care

It is important to first point out that the reason that burnout happens in medicine is because well-meaning leaders attempt to make decisions with the information they have.  In other words, these leaders use what they can measure to make decisions.

The argument goes something like this, “If I cannot keep the lights on, then I cannot pay people’s salaries.  So, my main job is to make sure we are profitable.”  And when the organization is profitable, THAT is when we will take care of the medical professionals on the front line. 

Sometimes the mantra that is used in this setting is called “No margin, no mission.”  In other words, if there is no profit margin, then the mission of the healthcare organization cannot be accomplished.  This includes taking care of the nurses and doctors on the front line who are burnout out at epidemic rates.

This is what I call a profit over people model.  It is well-meaning, but having this sort of metrics-based model has unintended consequences.  When we focus on quarterly budgets, annual balance sheets, and fail to keep a long-term view that is when our systems inevitably burn people out.

I will say that for most leaders I know, this doesn’t come from a place of hatred or malicious intent.  It comes from a place of trying to make decisions through things we can measure.

The ABC’s of the Self Determined Physician 

We have talked previously about the importance of autonomy, belonging, and competence on this show before.  Briefly, these are the three elements that every person needs in order to become a Self Determined Physician – or someone who is fulfilled, intrinsically motivated, and engaged at work.

These ABC’s of Self-Determination can be broken up into five sub-components.  These include personal and professional autonomy.  That’s the two subcategories of autonomy.  This means that you have control over your personal life, including when your schedule. You are able to get home when you want, make the tennis practice and tee ball games.  And you don’t have to continually find new childcare because you are constantly late.

The professional autonomy is also really important. This means you control how you practice medicine, the way you take care of patients, and have the ability to not only diagnose your patients but enact your plan.  Professional autonomy occurs when doctors are able to provide the care they know their patients need.  These are the first two elements of the Self-Determined Physician.

The third and fourth elements of the Self-Determined Physician exist in the area of belonging.  Each doctor needs to feel like they are (1) a valued member of the team who is (2) accomplishing a deeper purpose.  In other words, doctors need to feel appreciated, respected, and heard.  In addition to this, they need to feel called to something that is bigger than the team itself.  

Feeling like a valued member of the team who is also attached to a deeper purpose are the two components of belonging, and make up the third and fourth components of a Self-Determined Physician.

The final component of the Self-Determined Physician is confidence.  Doctors need to be successful clinically and (just as importantly) they need to BELIEVE they are good at what they do.  In other words, they need to have confidence in their skills and abilities.

Downstream impact of People Over Profit

When you think about the five elements of a Self-Determined Physician, this is when the profit over people model falls apart.  

For example, when hospitals install a new electronic medical record system to better capture patient billing without fully considering the impact of those who will be using the system… that can lead to massive rates of burnout as doctors feel like their autonomy is being attacked.  In fact, I’ve known clients in the Alpha Coaching Experience who have changed jobs because of bad EMR’s that were installed where they work.

Similarly, when insurance companies require peer to peer conversations to justify the care doctors know their patients need… this is a direct affront on professional autonomy.  So are the pre-authorizations that are often required.  

When administrators institute quality hold backs (which by the way, what the actual hell… why would you call something like this a “hold back” instead of an incentive?)  to try and provide extrinsic motivation to reach annual metrics… all this does is destroy any sense of belonging doctors have.  This is when they start to feel like cogs in the wheel or numbers on a balance sheet.

Again, it is important to realize that the people putting these things in place likely think they are driving down costs and improving patient care.  Yet, the end result is a profit focused system that results in physician burnout.  In turn, this causes higher physician turnover, and actually decreases profit margin.

And this is a life lesson… when money is our goal (instead of helping people)… the end result is usually a loss of profit.  Not more profit.  

Errors of Commission versus Errors of Omission 

After coaching a lot of physicians in ACE, I’ve come to realize that people regret not doing things more than they regret trying something and making a mistake.  This is why some have said that “errors of omission” (i.e. not doing something you feel you should) causes more regret than errors of commission (i.e. when we try something, and it doesn’t work out).

Knowing this, I often wonder why more organizations aren’t doing what the Cleveland Clinic is doing?  Why aren’t they investing in figuring out how to flip the script on this people over profit model?  

If leaders would instead put in place an employee first model (what I call the “People Over Profit” model shown below) where every decision they make is focused on whether it increases the five elements of self-determination, they would see that this not only decreases physician burnout.  It would also result in lower rates of physician turnover, which is where the estimated savings from the Cleveland Clinic coaching program are made.  This, in turn, INCREASES profit margin.

People Are Always The Best Investment

Can you measure how much an organization will save on the front end by putting their employees first?  Not usually.  Of course, you can make an estimate.  

Yet, we know that when we invest in people, this will produce a better culture.  A better culture will lead to less burnout, and lower rates of turnover which costs hospitals TONS of money.  This, in turn, will produce higher profit margins.  

And since we know that errors of omission bother us more than errors of commission, why aren’t more healthcare leaders taking a leap of faith knowing that when they fix the culture, the profit will take care of itself?  The answer is that it is harder to measure… even when we know it is the right thing to do, it takes true leadership to trust in the process.

Practical Examples of People Over Profit

Sometimes when I discuss this model with administrators, they ask for some specific ways the model might be applied.  As any good coach would, I often tell them that they know their people best and that it will look different for each department and organization.

That said, here is one great example of what this might look like called Results Only Work Environments (ROWE).  In ROWE’s employers are less concerned with how long a person works, when they work, or how they work.  Instead, they place their focus on results.  If the results get done, employees get paid regardless of how they accomplish the goal.

Why would they focus on this?  Because of the ABC’s of self-determination.  They want people to have control over their own schedule (personal autonomy), get work done how they see fit (professional autonomy).  It also provides an atmosphere where people feel like valued members of the team all working toward a goal that is bigger than themselves (taking really good care of people in a way that also allows them to love their job).

This transitions the operating room environment from one of communism (where everyone gets paid the same no matter how hard they work) to one of capitalism (you get rewarded for getting more done in less time).  

ROWE’s in the Operating Room

For example, in many operating room environments when you work harder, your just and right reward is getting more work added to your operating room.  You can imagine that if you are in the shoes of the circulating nurse, scrub tech, or anesthesia teams who often get paid by the hour or by the shift… their incentive is not aligned with a system where when you work harder, you just get more work.  

On the other hand, the surgeon (who is often paid by the RVU) has every incentive to operate as much as possible.  This misaligned incentive causes major cultural issues and often leads to late starts, long turnovers, and inefficient operating room practices.  The surgeon is upset that they cannot operate more and get home when they want.  The operating room staff are upset that they are continually asked to work harder without being paid like the surgeons.

This sort of misaligned model attacks people’s self determination.  They don’t feel valued as a team member when surgeons get upset with them.  No one gets home when they want, and people cannot take care of people how they want because incentives are misaligned.

In a ROWE, a set amount of work would be required and everyone knows that when that work gets done, they get paid.  Regardless of how long it takes.  The only metrics that the hospital cares about then are patient outcomes and efficiency.  ROWE’s are something that many companies outside of healthcare employ to encourage autonomy while getting the work done. 

A Transition from Communism to Capitalism in the Operating Room

Initially, this may lead to less surgical volume being accomplished in less time as surgeons are asked to operate within certain hours.  However, as we place our focus on the staff in the OR (instead of on profit), staff start to have more control over their personal autonomy and schedules. Inevitably, the result is higher efficiency and more work getting done in less time.   

This transitions the operating room environment from one of communism (where everyone gets paid the same no matter how hard they work) to one of capitalism (you get rewarded for getting more done in less time).

When everyone is on the same page… guess what?  That also improves team dynamics and helps everyone feel like they are working together to accomplish a deeper purpose of caring for patients. 

This is just one example of how the People Over Profit framework might be applied in medicine. The possibilities are endless, but one truth remains.  When we invest in the people on the front lines of healthcare and make sure they are fulfilled, engaged, and intrinsically motivated… this leads to better cultures, lower burnout and physician turnover, and ultimately increases the profit margins healthcare organizations desperately want.  

It is time to start focusing on our people.  They are always the best investment.

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  1. Abby

    Did this get censored on Apple Podcasts? The episode is unavailable.


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