Scenario

The silver sport utility vehicle meandered down the gravel driveway, tossing dust and loose stones into the otherwise peaceful summer morning. Pulling out onto the narrow road ahead, the driver caught a glimpse of his whitewashed, sprawling house, surrounded by his cherished garden. He had spent the past 10 years planting, pruning, and caring for a true country garden full of roses, verbena, and lavender. The trees lining the edges were weighted with full crops of oranges and cherries. His real prize was the massive burgundy bougainvillea climbing across the entrance to the house. Dr. Jack Shaper took great pleasure in his lush garden, knowing his own sweat and hard work had gone into planting every plant and tree over many years. The perfume of his variegated roses lining the driveway permeated the air, making it harder for him to leave. What a contrast to the many childhood homes on military bases that he had lived in as an “army brat” moving around the world, changing homes and schools most years, learning that it was not worthwhile making friends because such relationships never lasted.

As he turned onto the road, he noticed his wife, Laura, in his rearview mirror, waving goodbye from the porch steps. As usual, Laura had been up for hours organizing their lives. A dedicated teacher at the local high school, she was able to leave for work half an hour after her husband of 20 years and had the convenience of taking their two relatively independent teenage children with her. He knew that she would go inside and have a second cup of coffee with them while they finished their inevitably hurried breakfast, valuable minutes that she enjoyed and that kept her abreast of their news and activities.

Like his wife, Dr. Shaper also valued and enjoyed this time of the morning. His drive to the large primary-care clinic where he had worked for the past decade usually took about 15–20 minutes. In previous years, he had generally put the car radio on for the journey, listening to the morning news or some favorite music. Since taking up the role of medical director a year before, he found he preferred silence and some quiet time to contemplate the daily issues he faced and the decisions he might have to make.

Dr. Shaper was a thoughtful and careful man in all that he did. Tall and slim, with graying hair and glasses, he was a physician straight out of central casting, always impeccably dressed in a range of conservative navy-blue suits. He drove with care, keeping just at the speed limit and giving himself plenty of space from other cars so that he would always have time to react and avoid collisions. During the course of his career he had seen too many patients injured, often permanently, in motor vehicle accidents and had had several fatalities from this cause among his patient panel as well, so he was determined not to become such a victim.

Driving through the country roads this morning, he was a little anxious as he ruminated about his 16-year-old daughter, Melanie, who was ready to start learning to drive. He and Laura had been trying to work out ways that they could put her off this activity for a year or so, because they were both very aware of the number of adolescent fatalities in car crashes. Tragically, two seniors at the high school had died in this way the year before, and he was contemplating telling Melanie about a motor vehicle accident in which he had nearly been killed when he was 19, when he had foolishly accepted a ride home from a drunken friend. He knew Laura planned to discuss the subject with Melanie on the way to school with her that day. As parents, they admitted they felt conflicted because Melanie was a responsible girl who wanted the freedom that driving would allow.

Within a few minutes, he reverted to his usual habit of going over the upcoming workday’s meeting and patient schedule in his mind. Much of his focus at work was on improving the morale of the 40 staff members, including 10 physicians, who worked for him. He knew this was the single most important reason he had applied for, and been appointed as, the clinic medical director. His first meeting this morning was likely the most important interaction he would have that day, a mentoring session with Dr. Lindy Isla, one of the other primary care internal medicine physicians at the clinic. He liked Dr. Isla. Despite being a relative newcomer to the clinic, she had already shown herself to be a natural leader and an influential member of the overall clinic team. If he was going to be able to make the changes he wanted, he had to have her fully committed to them.

Dr. Shaper reflected on how different the atmosphere in the clinic was now, compared with a year ago, and thought about the changes that had already occurred. As much as anything, he felt they were the result of his deliberate strategy of encouraging staff turnover and a gradual generational change in attitudes throughout the clinic. Adding several younger and more flexible clinicians who understood and supported the emerging plans of his new leadership team had helped, and he counted Dr. Isla as one of his key recruits.

He rubbed his head and smiled ruefully to himself. To think that just over a year ago he had been one of the younger physicians in the clinic and had been so fed up with his work that he had applied to work elsewhere, even though he didn’t really want to move from the area. Rather to his surprise, he had been offered a position as medical director in a large inner-city clinic two states away. At that time, he had been at the local clinic for more than a decade. The positive side of this tenure had been his ability to finally, for the first time in his life, live a stable existence in one home, with a loving family and the opportunity to put down roots in the local community, and in his garden! No more constant moves to another cheap condo as had happened in college and medical school. He liked the area, with its great climate, good schools, and cultural diversity, and he had found new friends through the golf club and his children’s school. The downside to working at the clinic at a time during which staff turnover had been minimal, except for occasional retirements, was that he could sense the stagnation and lack of change. The medical director at the time, Dr. Tobin, although pleasant enough, had clearly just been waiting for her own retirement and was averse to innovations. She had made it clear to everyone that she opposed the modernization of medical practice and was not keen to resource or pay for the necessary equipment upgrades that other clinics of this size received as routine. She preferred what she called “old style” medicine, where the doctor was always the kingpin in the organization and patients’ needs were not as often prioritized.

Dr. Shaper didn’t regret any of the increasingly difficult confrontations that he and four other primary care colleagues had had with Dr. Tobin that had led to his thoughts of leaving. She had nicknamed them the “changelings” and had belittled them openly in response to their attempts to suggest improvements to increase the morale of the staff. She had opposed these ideas by telling stories of her own training, recounting at length how she had always had to work 80-hour weeks at a minimum, with minimal support or backup from more senior physicians. She had seemed proud of telling everyone that medicine was not a job but a vocation, and that anyone who didn’t agree should get out of the proverbial kitchen. Interestingly, Dr. Tobin couldn’t see that she had become chronically burned out, even though this actually had been pointed out to her numerous times and had led to her spending as much time as possible on administrative issues to reduce her patient care hours. Dr. Shaper recalled the massive blowup that had occurred when she unilaterally decided to increase the size of every other doctor’s panel of patients by 10% without giving them any extra support or time. By then, the disputes about clinical care and workloads had become so serious that he and his four colleagues threatened to resign en masse, all of them feeling very unsupported and fed up with having to finish their work at night and on weekends. This threat, and the fact that he already had another job offer, had led to frantic negotiations with the clinic owners and to the sudden “retirement” of Dr. Tobin, along with two of her main supporters and friends of many years—the clinic administrator and another senior physician.

And the rest is history, he thought to himself, recalling how he had been encouraged by several colleagues to apply for the vacant medical director position. His wife and daughters did not want to move, and it was they who had finally persuaded him to apply for the director position. What a year it had been. He had been surprised at how much the clinic owners, a large health chain, had supported him, even paying for him to attend a series of conferences and workshops to upgrade his knowledge and skills in management and leadership. He had insisted that he still work half-time seeing patients when he was in the clinic, and he was pleased that he had done this because it gave him the opportunity to really see what was going on at the ground floor. Several of his younger physician recruits had expressed their surprise at how much clinic work he did, but he was pleased that they said it gave him much more “street credibility,” to use their term. He remembered how he and Laura had discussed this, and she had advised him to always remember that he was a doctor first, but that being a doctor didn’t mean he had to—or could—do all of his administrative duties himself. She had encouraged him to recruit really good administrative support staff to ensure he would be able to get home at a reasonable time and stay fully connected with his family and outside interests.

As he rounded the corner, past the local government offices, and drove the last half-mile to the clinic, Dr. Shaper finished his morning reverie by smiling to himself at Laura’s encouragement of his outside interests. He looked forward to asking her tonight if she had really expected his golf handicap to improve in parallel with taking up this new job at a clinic in crisis. He hadn’t seen “golf handicap” as a marker of physician well-being in any of the academic literature he had read and wondered lightheartedly if it should be. He certainly acknowledged internally that part of the reason for his improved scores was that he was really trying hard to “walk the talk” of the whole clinic, where his staff were now strongly being encouraged and supported to have a fair work-life balance.

Dr. Shaper drove onto the clinic grounds and parked under the large sycamore tree where he knew his car would be partly protected from the constant heat of the day. He added an extra shade over the back window to protect his new golf bag and clubs, a recent birthday present from Laura, so that they would be in perfect condition for him to use in the nine-hole competition in which they were partnering at their community golf club that evening. He walked across the parking lot and entered the clinic, a stately two-story Spanish colonial in white stucco with wide arches, a covered external walkway on the ground floor, and slim windows to keep out the heat on the second floor, all finished off with red clay roof tiles. He felt proud of the refurbishment of the building, now nearly complete, and especially liked entering the main door to see the clinic’s mission statement painted on the wall for patients and staff to see. The creation of this statement had been one of his early wins, and he thought the process of developing it had really brought staff and patients together. He stopped to read the words painted in tall letters in the main waiting room: “We provide high-quality health care and have trusting relationships with our patients to meet their needs.”

As Dr. Shaper moved through the clinic, he made sure to speak to everyone he met, briefly acknowledging some, asking about their families or other personal interests; congratulating several; thanking others; and generally speaking or smiling in a positive, supportive way. He gradually made his way up to the administrative offices in a suite at the back of the second floor. No longer did the administrators have the largest rooms with a beautiful view at the front of the clinic; those rooms were now used for patient education, meetings, and groups. He arrived at the administrative suite, the only non–patient care area in the building, and entered his office, a well-appointed and professional room that could be used by other staff for private meetings when he was working in the clinic downstairs. He sat in one of the four soft, cushioned chairs and took out Lindy Isla’s file. He wanted to review his notes on their past mentoring sessions prior to her arrival for this morning’s meeting.

Five minutes later, Dr. Isla appeared in the open doorway. Her well-pressed white lab coat had her name embroidered on the pocket. A stethoscope hung around her neck.

“Come in, Lindy. It’s good to see you. I hope all is well. Please sit down,” said Dr. Shaper.

Dr. Isla entered, shut the door, and sat opposite Dr. Shaper. She looked calm and confident and smiled warmly at him.

“Good morning. I can’t believe it’s been a month since our last mentoring session, Jack. So much has been going on, and I know we’ve talked about a lot of the issues in the clinic meetings with other staff. Before we get into my career plans, which I know we planned to focus on today, can I quickly get your advice about a patient-care concern I have?”

Dr. Shaper was not surprised at his junior colleague asking for advice about a patient before focusing on herself and her own needs. Only 2 years out of her internal medicine residency and fellowship in endocrinology, she was without doubt the endocrine-medicine expert in the clinic. With his encouragement, she was already overseeing the management of all the clinic’s patients who had diabetes and other related endocrine disorders. Much of this was being done via e-consultations in the electronic medical record (EMR), with the aim that all diabetic patients treated in the clinic would ultimately be reviewed by her. The difficulty came when she inevitably found poor medical practice among some of the other physicians and had to tactfully suggest alternative treatment regimens to them, and sometimes she needed his support in this. Not surprisingly, her need for advice today was not really for a technical clinical problem but about how she could best improve the medication regimen that one of the few remaining older, long-term physicians in the clinic was prescribing for a patient, without offending their colleague.

As they finished discussing her concern, Dr. Shaper reflected on how clinically effective she was being; the average hemoglobin A1c, the best measure of diabetic control, of all the patients with diabetes treated at the clinic had dropped by more than a point since Lindy had begun her routine reviews only 6 months earlier. He decided to ask more about this result, because he knew that she was fascinated by these sorts of group outcomes.

Commentary

The clinic described in this scenario had been fairly run down and behind the times for several years. Not surprisingly, morale was low; staffing was difficult to maintain, as demonstrated in Dr. Shaper’s case when he almost left; and clinical services most likely were mediocre. In this setting, any physicians who wanted to make changes were likely to leave, and levels of provider burnout across all health care disciplines, although not formally measured, would certainly have been at similarly high levels as measured in a number of institutions. My previous book (Yellowlees 2018) summarized the literature on burnout and its causes, and Shanafelt et al. (2015) identified that between 40% and 50% of doctors in large community surveys have at least one symptom complex of the three burnout-syndrome sets described in Chapter 2.

In this setting, Dr. Shaper had stepped in as the new medical director, determined to make a number of organizational changes that would improve the quality of care provided at the clinic while at the same time also improving the well-being of the providers and clinic staff to boost their morale and help them rediscover joy in medicine. The scenario hints that Dr. Shaper had a difficult childhood and medical training, and that his response has been to have a strong focus on stability and on working to improve both his home and work environments. Shanafelt and Noseworthy (2017) described a connection between physician burnout levels and quality of care, patient safety, physician turnover, and patient satisfaction. It is likely that Dr. Shaper reviewed the nine organizational strategies that those authors described and learned how to implement the goals of the three domains of the Stanford Wellness Framework (Stanford Medical Center 2019), both of which are discussed in Chapter 2. He then introduced several very specific changes in his first year running the clinic, seemingly with some considerable success. These comprised

1. 
   

   Development of a shared mission

   
   
2. 
   

   Improved communication and involving physicians and other providers in management decisions, thus improving their local knowledge and feeling of being influential and in control

   
   
3. 
   

   Development of improved workflows and efficient practices

   
   
4. 
   

   Placing a strong focus on mentoring and individual physician career development plans

   
   
5. 
   

   Establishing individual and personal resilience supporting activities

This leads to two questions. First, what are effective ways of introducing change within a clinical environment, and second, why should these specific changes be likely to reduce burnout and improve patient care and safety?

Dr. Shaper’s leadership director, as described in the scenario, had been talking about Rogers’ (2003) seminal work on change management and the diffusion of innovations when he mentioned “early adopters” and “laggards.” Although the first edition of Rogers’ book was written almost 40 years ago, it is still highly relevant to anyone wanting to drive changes in an environment as complicated and regulated as health care, and his messages and techniques have been particularly successful in situations that require technology innovations. The core message from the change management literature is to carefully plan any initiatives or change projects, to involve a group of individuals who are committed and interested early on (the early adopters), and to run pilot projects with them to prove the effectiveness of the innovation internally. Once this is proved, have the early adopters—who will ideally be representative of as wide a range of professionals as possible—tell their colleagues and the rest of the workforce about their projects, in the knowledge that most of their colleagues will be prepared to change if appropriately persuaded. These internal “salespeople” will be much more effective than most outside experts, although some experts still may need to be brought in to validate the activity.

The critical issue about any change management initiative is to be aware that, inevitably, a small group of people will fight against it and try to undermine what is happening. It is crucial to be aware of this and to not let these individuals succeed. Sometimes it may be necessary to specifically identify them and work with them separately—or isolate them—so that they do not get too much of a stage to oppose ideas. That may sometimes even mean moving them to alternative areas or putting pressure on them to cease being disruptive. In the scenario, several individuals who would have been in that “laggard” group, as Rogers defined them, decided to leave the clinic, and in this situation where a lot of change was planned, that was probably the best result for both the individuals and for Dr. Shaper. Similar results have been seen with the introduction of the EMR over the past decade; a number of physicians have used their objection to learning such a new and sometimes awkward and time-consuming technology as a rationale to retire, rather than go through a difficult learning and change-related process.

The final step in any change process is to constantly communicate the outcomes; celebrate successes and reward those involved as positively as possible, as Dr. Shaper was doing with his after-clinic celebration; and evaluate the overall results. Then the cycle must begin again to determine if more changes can be made so that, ultimately, a change-friendly culture is developed.

Dr. Shaper used a lot of leadership approaches learned from industry, notably those promoted by Bob Chapman (Chapman and Sisodia 2015), a charismatic CEO who developed a number of leadership programs, which Dr. Shaper might have attended, that focused on his personal lifelong leadership learning. Chapman describes leadership as being the stewardship of the lives entrusted to you and notes that people want to know who they are and that they matter, as shown in the clinic meeting. This is in contrast to management, which he describes as a manipulative process. Instead Chapman promotes listening with empathy as a crucial skill and the most powerful act of caring and says that giving recognition and celebrating successes at work is essential. His other key theme, which Dr. Shaper adopts, is the similarity between parenting and leadership, with his view that all leaders should be the leader you want your children to have. So with this approach to leadership in mind, why should the five interventions that Dr. Shaper introduced in his first year reduce burnout, improve the well-being of the clinic workforce, and thereby improve the quality of care and patient safety parameters in the clinic?

First was the development of a shared mission. Why is this important? A mission statement provides a way of judging the overall success of an organization and its various programs and helps to verify that an organization is making the right decisions and is on the correct track. It is really a direction indicator within a strategic planning framework, and in most cases would certainly not be developed in isolation but as part of a wider strategic plan that would also include a vision, objectives, strategies, and action plans. Numerous websites cover strategic planning, and many consultants or educational experts are available who can assist in their development if required. In the scenario, this was Dr. Shaper’s first initiative, and developing a strategic plan had allowed him to demonstrate his caring for his staff by getting groups of diverse clinicians and administrative staff together to start planning a new, alternative path for the clinic. This activity also gives physicians and all involved the opportunity to have real input into the direction and priorities of the clinic, something that is well known to be very important in improving morale and reducing burnout levels.

Thus, the mission statement and associated plans, and the process of development, have the very beneficial extra consequence of bringing staff together and giving them a greater sense of meaning and control over their workplace environment. We have all worked on projects on which everyone seems to be pulling in opposite directions, and the project ultimately fails. It seems a very basic requirement that everyone should understand why an organization exists, what products or services they produce, who their primary customers are, and what outcomes they hope to achieve. Dr. Shaper’s focus on this as his first change initiative made a lot of sense, as did his promotion of the mission statement by having it painted in prominent places and regularly mentioning it in clinic presentations.

The second initiative was involving physicians and other staff more in management decisions, whether in specific committees or by just asking and listening to them and then taking action, such as with the electric vehicle charging stations. Shanafelt et al. (2017) wrote about the importance of the business case in investing in physician well-being, yet one of the most stressful situations for us all is feeling out of control, for whatever reason. Therefore, being included in decision-making processes and being constantly educated and brought up to date on what is happening throughout the work environment is not only settling for all but actually makes economic sense. Making sure that physicians and other staff are involved in committees and any decision-making processes as much as possible is not only good for the clinic but also for the health of the staff. A substantial literature is available on how feeling more in control at work, especially of personal time, improves productivity, reduces unwanted emotions, and leads to an improved professional reputation. One of the interesting concepts about the health care industry is that, unlike most Americans, two-thirds of whom report routinely in surveys that they dislike their jobs, the great majority of health care professionals, especially physicians, report that they enjoy their work and, in particular, find it meaningful. This is a very positive and important issue because it is extremely difficult to engage successfully with individuals who do not enjoy their work and who see little sense in it.

Dr. Shaper’s third priority was developing improved clinical and business workflows and more efficient practices. There are many approaches to this. He mentioned improved use of EMRs, which are often cited as an extra stressor for clinicians (National Academy of Medicine 2019) but which, if used well with appropriate training in place, can dramatically improve patient care, particularly when delivered by teams. In the clinic, Dr. Shaper was focusing on having individual providers work at the top of their licenses. That likely would have involved having medical assistants or physician assistants room patients and perform initial documentation, allowing physicians and other high-level practitioners to take supervisory or analytic roles. These physicians then were likely to be less focused on taking basic information (e.g., required surveys and questionnaires) or reviewing medication lists and vital physical assessments and better able to concentrate on more difficult aspects of each patient’s case. Moawad (2017) recently wrote about practicing at the top of a license, which she defined as “the idea that physicians often have to gain multiple certifications and that the top of the license is the certification that takes the longest to attain, has the highest number of prerequisites, allows a physician to perform procedures commanding the highest reimbursement or for which few are qualified.” She identified five rationales for this approach:

1. 
   

   Practice and experience: Patients benefit because doctors are constantly using and improving their knowledge and skills.

   
   
2. 
   

   Working as consultants: Experts can assist other practitioners with difficult referrals.

   
   
3. 
   

   Improved reimbursement: Higher certification should translate to being better paid for specialist skills and procedures.

   
   
4. 
   

   Easier identification of roles: Tasks and procedures and who can perform them is more clearly delineated, which improves efficiency, instead of higher-level providers being expected to pick up the slack and fill gaps at disproportionate cost.

   
   
5. 
   

   Payers gain: When as many people as possible are doing work that no one else on a lower pay scale can do, the overall cost of this work goes down, so clinics like Dr. Shaper’s become more financially efficient.

The fourth area of innovation Dr. Shaper mentioned was to increase the emphasis on mentoring and mentee outcomes. This chapter features Dr. Shaper’s perspective on mentoring and his uncertainties around his relationship with his younger mentee, Dr. Isla, who at times seemed to intimidate him, to a certain extent, with her confidence and differing generational expectations. The literature on mentoring is extensive across many professional and work-related areas, and the usual process is very much a two-way street, with benefits for both mentee and mentor. Dr. Shaper was clearly gaining some of the advantages for mentors that are widely described in the literature (Lyman 2016), including the ability to better understand and to learn from his mentees. In this instance, Dr. Shaper learned more about the capacity of technology to improve clinical care while being reminded that the lessons he had taught to Dr. Isla still also applied to him. At the same time, Dr. Shaper was able to gain a wider social perspective through his discussions with Dr. Isla and through examining and helping her with her projects, increasingly trying to see issues and problems through her eyes and not just his own. This, he hoped, then would enable him to improve his own leadership capacity, not just individually but also by working through Dr. Isla and having her influence changes in others. Mentoring is a key intervention and well-being process that appears in several case studies in this book, and Chapter 4 in particular has a stronger focus on mentoring, from Dr. Isla’s perspective, with a more extended discussion in the commentary.