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Much has been written about the decades-long erosion of the once-solid relationship between patients and their doctors. The implosion of another important health care dyad — clinicians and C-suite administrators — has received much less attention, despite the fact that those relationships are on life support.

Overshadowed by all the talk about health care provider well-being, burnout, and resilience, there are almost no conversations about professional satisfaction or burnout among health system and hospital administrators, or about their essential relationships with clinicians. Having done an often-thankless job before Covid-19 emerged, leaders had to find ways to shepherd their organizations through a global pandemic and all of the workflow, policy, and financial changes that came with inventing entirely new ways of working and caring for patients.


It’s been a wild ride for them as well as for clinicians, from trying to keep organizations afloat during the height of the pandemic during which dramatic drops in revenue turned balance sheets red, through the Great Resignation of 2021, and now during fears of an impending recession. Is it any wonder that the number of hospital CEOs who resigned between 2020 and 2021 has nearly doubled?

Just before the pandemic emerged in late 2019, our organization, X4 Health, conducted research to better understand the mindset of C-suite leaders and the state of relationships between them and clinicians. This research directly informed one of our social impact initiatives, 3rd Conversation, a national, grant-funded program designed to reinvigorate relationships in health care.

The team began by interviewing 10 health care system leaders and administrators around the country. Striking similarities emerged from those interviews.


All 10 leaders said they:

  • felt isolated, frustrated, and defensive;
  • yearned to connect with colleagues at a deeper level;
  • knew that the strained relationships between clinicians and leaders contribute to poor working conditions, turnover, and staffing shortages; some acknowledged that these frayed relationships lead to safety and inefficiency issues;
  • were anxious about the impact of leadership on staffing levels, explaining that “people don’t leave organizations — they leave leaders when they don’t feel like they have a trusted relationship.”

Top challenges cited by clinicians in administrator roles

As a follow-up, we worked with Edna Luther & Associates, an independent research firm, to field a survey of 168 health care professionals, predominantly primary care clinicians who work in administrator roles. The top three issues respondents cited as their biggest challenges included, in order (Figure 1):

1) too much time spent on documentation versus patient care;

2) clinician burnout;

3) staffing shortages.

Minimal resources for improving clinician-administrator relationships

Despite these challenges, only 33% of survey respondents said they had programs in place to improve clinician-administrator relationships.

These findings were corroborated in a separate survey of 650 physicians and administrators conducted in June and July 2021 by Jackson Physician Search in partnership with the Medical Group Management Association. When it comes to burnout and staffing shortage challenges, the survey found an increase in physicians looking for new employment, and nearly half of respondents reported they were considering early retirement. Clinicians cited "one-way communication" between administrators and clinicians as a leading contributor to burnout and early retirement. The clinician respondents suggested that more two-way communication would enhance satisfaction and retention.

An approach to revitalizing relationships and institutions

Based on these findings, we used human-centered design methods to develop and test a program to improve relationships between C-suite leaders and clinicians. Our hypothesis was that a professionally facilitated forum could be designed to help both groups recognize how much they have in common, create bidirectional empathy and communication, and identify changes that would help them collectively at their institutions.

This program was piloted in 2021 by Finger Lakes Community Health, a rural, federally qualified health center in New York, and the University of Mississippi Medical Center. The program involved clinicians and administrators sharing personal stories, connecting as human beings — not just in their professional roles — processing the impact of Covid-19, and imagining a better future together.

Conversations that occurred during the program, and feedback received afterward, indicated three levels of impact from the experience:

Clinicians and administrators reset personally, feeling relief and hope:

  • "I feel glad that I'm not the only one feeling like I'm feeling; I appreciated the opportunity to get things out."
  • "This was a very good experience. My career…has been on life support for a while, and I'm hopeful things will change."

Clinicians and administrators committed to showing up differently for each other:

  • "I need to be more communicative with everyone … Sometimes I can come off as not caring. I'm going to promote that I do care."
  • "I'll take part in more of these conversations, so that I can be of better service to [clinicians]; truly engaging with them about their profession and what they need."

Clinicians and administrators committed to act with and for each other:

  • "I'll continue to ask for feedback and more ideas to improve what we're doing."
  • "We'll mentor [clinicians], find out what matters to people (whether that's research, flex, schedules, etc.) and then respond accordingly."
  • "I'm going to find ways to engage clinicians in decision-making to ensure organizational decisions reflect front-line clinicians' experiences."

Individual examples of action taken by participants after taking part in the 3rd Conversation experiences demonstrated a potential for lasting impact on all levels:

  • One clinician approached ongoing contract negotiations with a new tone and sentiment, expressing collegiality and positivity about the negotiations.
  • Another clinician approached his CEO, explained some challenges he observed in patient care delivery, suggested solutions, elicited her ideas, then took action. He had never approached the CEO in such a way before.
  • One department began hosting gatherings for clinicians and administrators to interact informally as a means of improving relationships, empathy, and communication.

Although these observations are preliminary, they affirm that clinicians and administrators share a commitment to making a difference, and show that carving out intentional time and space to share challenges, frustrations, and hopes is valuable.

We believe that providing opportunities for administrators and clinicians to be explicit about what they need and what they can offer each other, grounded in a foundation of bidirectional empathy, will play a key role in catalyzing larger institutional change efforts, such as patient safety or quality improvement. We also believe these opportunities are one useful strategy for improving staff and clinician well-being and improving staff retention at a time of significant shortages.

The Covid-19 pandemic has made many things clear for the U.S. health care system. Two of them are:

We believe it is time to apply this capacity to prioritize humanity across the health care system. Investing in programs that elevate the importance of the relationships in health care — between clinicians, administrators, patients, and others — can ease the human suffering in the workforce, address root causes of staffing shortages, and ultimately lead to better health and well-being for all.

Christine Bechtel is a co-founder of X4 Health and a co-creator of 3rd Conversation. Lois Frankel directs the 3rd Conversation program at X4 Health. Jennifer Sweeney is a co-founder of X4 Health and co-creator of 3rd Conversation. 3rd Conversation is funded by a grant from the Morris-Singer Foundation.

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