When I arrived with my husband Dave and daughter Claire in Orlando in June of 2013, I was suppressing my anxiety and awareness that I didn’t have a manual called “How to Be a Division Chief” at a free-standing children’s hospital.
Explore this issue:January 2019
I joined the largest pediatric health system without much knowledge or understanding of the realities of healthcare access in the fourth most populous state and perhaps the one with the most underserved children and families for decades. As I reflect on the past five and a half years, I am in awe at what my incredible team and I have been able to achieve, and at the level of care delivered despite all of the challenges we have faced internally and externally. Since September of 2016, I have also assumed the role of surgeon-in-chief for our hospital. Writing my own job description and vision for what I believed necessary and what a physician leader in this role should and could accomplish was daunting and surreal.
As I have lived and breathed challenges from both leadership roles, I am even more grateful I have been grounded only by my clinic and OR days, like all my front-line colleagues. The countless issues, big or small, simple or complex, made it necessary and, frankly, self-preserving, to gain a new perspective as a physician on both “leadership” and “engagement.” I must give credit to Kari Granger, my external coach for this past year (an investment in me from my organization), for helping me discover my new perspective and self-awareness. I want to share some key points about leadership and engagement because, it turns out, both directly influence physician well-being and the degree of burnout experienced by physicians.
Impact of Leadership on Burnout
Of the many publications by Tait Shanafelt, MD, an expert in physician wellness and currently Stanford Medicine’s chief wellness officer, I find one of high relevance for physician well-being: “Impact of organizational leadership on physician burnout and satisfaction” (Mayo Clin Proc. 2015;90(4):432-440). This study used a survey to assess burnout in physicians and scientists working at Mayo Clinic in 2013, but what was unique was that physicians also rated the leadership qualities of their immediate supervisor in 12 specific dimensions. Supervisor scores in each leadership dimension and composite leadership score strongly correlated with the burnout and satisfaction scores of individual physicians (all P<.001).
On multivariate analysis, adjusting for age, sex, duration of employment, and specialty, each 1-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout (P<.001) and a 9.0% increase in the likelihood of satisfaction (P<.001) of the physicians supervised. The mean composite leadership rating of each division/department chair (n=128) also correlated with the prevalence of burnout (correlation=-0.330; r(2)=0.11; P<.001) and satisfaction (correlation=0.684; r(2)=0.47; P<.001) at the division/department level. This is why developing our own competency as a leader and having an organization focus on the competency of those who are in leadership positions is critical as we hope to not only survive but thrive in the face of the burnout epidemic.
What this all points to is that being a successful leader in our specialty, societies, and organization mandates relational leadership, which physicians have never been formally or informally taught. Relational leadership is a perspective on leadership focused on the idea that leadership effectiveness has to do with the ability of the leader to create positive relationships within an organization. Having individual expertise based on clinical or research excellence in a niche or particular domain is still recognized but is no longer enough to lead an entire “army” of fatigued and wounded physician workforce. This applies not only to physicians, but also is equally critical for non-physicians in administrative leadership roles.
A Demanding Health System
A recent article by Simon G. Talbot, MD, a plastic and reconstructive surgeon at Brigham and Women’s Hospital in Boston, and Wendy Dean, MD, a psychiatrist in Carlisle, Penn., entitled “Physicians aren’t ‘burning out.’ They are suffering from moral injury,” shines profound truth on what we are experiencing today (Statnews.com. Published July 26, 2018.). They define “moral injury” as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society,” and say that the moral injury of healthcare is being unable to provide high-quality care and healing in the context of healthcare.
Developing our own competency as a leader and having an organization focus on the competency of those who are in leadership positions is critical as we hope to not only survive but thrive in the face of the burnout epidemic.
Many of you probably practice in very large and complex health systems, whether in academic centers or hospitals. Even if you are in private practice, we all face similar challenges in the following areas: billing/coding/clinical documentation improvements, ever-increasing budget/RVU/productivity demands, joint commission readiness, EHR meaningful use/requirements, and all related daily demands (your epic inbox, results review, patient calls, medication orders, FMLA paperwork, DME orders….). Our reality as we approach “value-based care” will likely continue to mean that frontline physicians are under-resourced in FTEs and/or equipment to do our work and have inadequate time to communicate (with partners, nurses, advanced practitioners, patients, colleagues inside and outside of our institutions to optimize care for our patients, the physician and non-physician leaders we report to, those who report to us, our schedulers, and everyone whose existence impacts our “realm” and day-to-day experience).
With so many continuous, constant, and often unannounced changes, there are countless reasons why a physician becomes disengaged, frustrated, angry, and inefficient, and feels constantly like a “victim” instead of the empowered healer we set out to be when we entered medical school. There is simply too much that is out of our individual control.
Our reality is why leadership and engagement are so critical for our individual and organizational well-being. If we individually are not well, then the organization will likely be neither well nor poised to deliver the safest and highest quality care nor the optimal patient “experience” that every organization is focusing on, Press Ganey or not. I’ve listed my core beliefs on leadership in “Leadership Principals”.
Explore your leadership, gain self-awareness, and embrace your leadership potential. I wish you an incredible leadership journey, but most importantly, you must believe in your own ability to heal yourself first and then all those around you. Today is a brand new day and anything is possible.
Dr. Wei is surgeon-in-chief and division chief of pediatric otolaryngology/audiology at Nemours Children’s Hospital and professor of otolaryngology-head neck surgery, as well as chair of otolaryngology education at the University of Central Florida College of Medicine in Orlando. She is also a member of the ENTtoday editorial advisory board.