s the only physician attending a leadership seminar inspired by a course at the Stanford Graduate School of Business, I was curious to learn what goals my executive colleagues had for the weekend session. Many wanted to practice giving feedback to their employees in ways that engendered results but didn’t foment anger, sadness, or alienation in the employee.
The seminar leader told us that frequent encouragement early in the employer-employee relationship helps establish the bed of trust and support needed before giving negative feedback. We learned that empathy and warmth in leaders produces better results from employees. The seminar participants practiced giving feedback on each other, with lots of expressions of appreciation for what the recipient of the feedback was doing well.
The participants were shocked, even indignant, when I explained that this kind of trust and respect building is almost nonexistent in the medical profession. There is an information gap between doctors’ employers and their actual work. Patients can, and often do, tell me that “You saved my life” or “I wish you were my regular doctor.” That’s terrific feedback. But there is almost no way for my employer to hear that.
Most physicians who are employed by medical groups or hospitals are called on to do three types of tasks: take care of patients, hit metrics involving billing in a manner that maximizes revenue for the hospital, and do clerical work involving electronic charting and ordering of medications and tests.
It is relatively easy for employers to measure performance on the latter two tasks. So it’s common to get feedback like “Your percentage of electronically captured high-risk diagnosis codes isn’t high enough” from a supervisor. Measuring patient care and satisfaction is trickier, meaning it’s not so common to have her say, “Wow, you really bought that patient a lot of time by diagnosing her gastric cancer so early.” These achievements disappear into the ether; supervisors in medicine do not stop into patient rooms to see what the care is actually like.
Studies, including one from the University of Michigan, have suggested that employees need as many as six pieces of positive feedback for every negative. In part that’s because negative feedback imprints differently on the brain than does positive feedback. That’s simply human nature. So if a doctor hears “You’ve really helped me feel better” from a patient, then gets chided about needing to complete prescription refills faster, bring in more patients for lucrative Medicare wellness visits, add more diagnosis codes to visits as a way to improve the health system’s “star rating,” and attend more unpaid committee meetings, the positive feedback fades away like smoke.
Once upon a time, most doctors were employees of their patients. A good doctor heard “Thank you” and “You’ve really made a difference” all day long. That led to patients coming in droves, which translated into making decent money. Physicians’ respected identity, strong status in the community, and little perks and privileges — from homemade cookies to preferred seating in restaurants — also helped balance out the 3 a.m. phone calls and births. For bad doctors, the phone stopped ringing.
Solo practitioners may still enjoy some of the autonomy of yore, if not the cachet. But employed doctors look essentially the same to an administrator whether they are clinically outstanding, mediocre, or bad.
My seminar colleagues were used to working in teams and getting frequent feedback on their work. While health policy writers often refer to the medical “team,” it exists mainly in surgery and emergency department settings. Office-based doctors work in a vacuum, alone with the patient in an exam room.
Supervisors such as department chairs, medical directors, and administrators tend to be alerted to negative information and feed that back to the doctors: Your patient was disgruntled and wrote a bad Yelp review. You got impatient during surgery and a nurse reported that you were being rude. You have four unclosed charts and, by the way, please complete the three hours of online HIPAA training you should have done last week.
Even when patients appreciate a physician’s diagnostic and healing skills, it is often difficult — if not impossible — for them to know who to give kudos to, even if writing a note to Clinical Team Manager, Zone 16, would help lead their doctors to a promotion or a higher salary.
Medicare offers financial incentives for doctors who complete certain measures, like asking specific questions during an annual wellness visit, in the hopes that this will lead to better and cheaper care. Yet the beneficiaries of these incentives are often the doctor’s employers, not the doctors themselves. Salaries can remain stagnant in the face of the best care or the worst, the most checkbox-compliant performance or the least.
That means employed physicians often work through the day desperately trying to avoid censure and reprimands.
There are consequences to environments with carrot-less sticks. Emma Seppala and Kim Cameron, writing in the Harvard Business Review, assert, “While a cut-throat environment and a culture of fear can ensure engagement (and sometimes even excitement) for some time, research suggests that the inevitable stress it creates will likely lead to disengagement over the long term.” It is no wonder, then, that in private online forums some physicians refer to themselves as “check box monkeys” who no longer want to try hard, but just want to do the minimum to collect their paychecks. Disengagement leads to turnover, and physician turnover is expensive; it can cost up to $600,000 to replace a hospital physician who quits.
Could positive feedback and a culture of well-being help combat the epidemic of physician disengagement and unhappiness, often codified as burnout? From her research, Seppala has identified specific practices for creating such a culture. These include caring for and being interested in one’s employees, avoiding blame, and treating employees with respect and gratitude. Considering that employed physicians are highly likely to complain about a lack of respect, such practices may be a good starting point.
In the medical workplace, administrators cannot always observe physicians actively engaged in their clinical work. Applying Seppala’s techniques could mean thanking a physician for covering for a sick colleague; asking a surgeon what kind of support she needs to decrease her postoperative infection rates (sending a message that the administration believes she is otherwise competent), or appreciating that a physician father works a few shifts a week while raising three children. These actions stand in stark contrast to the usual mantras prescribed for burnout — yoga, mindfulness, exercise, healing seminars, and the like — all of which place extra demands on a physician’s time.
Building the bed of trust costs nothing, and will make physicians more receptive to the changes they need to make for the whole health system to be successful.
Monya De, M.D., is a Los Angeles-based internist and journalist.