Physicians just want to be physicians. Their goal is to provide best-practice care that leads to best-practice outcomes. But idealism and reality are beginning to clash. Increasing complexity, the introduction of new technologies, growing metric-based performance accountability and a changing reimbursement landscape have caused significant alterations in structure and process for medical care.
Many physicians have become frustrated, angry or overly stressed to the point of burnout, and are looking to either change practice models or leave the profession entirely. In the face of a looming physician shortage, we need to look for ways to help support physicians and re-energize their passion for patient care. As leaders of the healthcare team, physician attitudes and behaviors that drive engagement, accountability and compliance with best-practice standards of care has a crucial effect on patient outcomes. Gaining a better understanding of their concerns and needs, and providing appropriate support and assistance will help them better adjust to the pressures of today's healthcare environment and lead to improvements in care management efficiency and work satisfaction.
What influences physician behavior?
The first step is to gain a better understanding of physician behaviors. Individual behaviors are molded by a number of different influencing factors which include age (generational preferences), gender, culture and ethnicity, and other life experiences that help shape a person's individual personality. Behavioral issues affected by these factors may be addressed through a variety of programs that include diversity training, conflict management training or education on best ways to approach values influenced by generation, gender, cultural or personality differences.
A second factor influencing behaviors is training. This is particularly true for physicians where the training environment is often conducted in a hierarchal hazing type of setting. You start out with low self-esteem, learn independently, study and practice to gain knowledge and technical competency, and assume your role in dictating orders. This is not advantageous to today's healthcare model. The side effect of this type of training is that it breeds autonomous demanding behaviors, lower sensitivity to other's wants and needs, and is the antithesis of effective communication and collaboration. The good news is that many of the more progressive training programs have recognized this issue and are looking more to enroll students who have studied more in the social sciences and humanities, and once they begin, have them work on multidisciplinary projects that emphasize team coordination and collaboration. Post-training many organizations are beginning to provide courses on emotional intelligence in an effort to foster greater physician understanding, empathy and compassion for the patient's needs and priorities.
A third influencing factor is the environment. Healthcare reform and other healthcare initiatives have changed traditional practice patterns to the extent that they have added increasing levels of stress and burnout, which has adversely affected physician lives. The problem is that many physicians either don't recognize that they are under stress and how it's impacting their behaviors and performance, feel like they can handle it by themselves, or are reluctant to share their situation with others due to concerns about self-ego or confidentiality. Even if they know they need to have a better work- life balance, they never seem to get around to it. If the physician won't reach out by themselves, the organization should reach out to them by listening to their concerns and providing the necessary administrative, operational and/or clinical support to help them better adjust. Issues involving emotional or behavioral disturbances can be handled through human resources or medical staff service support, coaching, counseling or through an available physician/employee assistance program. More severe behavioral problems can be handled through a variety of external programs depending on the need.1
Providing necessary skill sets
Working on modifying the background issues is important, but is not enough. The next step is to provide the necessary skill sets to improve care efficiency. The key training here is to provide skill sets that enhance communication efficiency and promote the values of team training. Given today's complex world, physicians who have the overall responsibility for patient care need to be able to integrate all the contributing participants that are involved in order to come up with a consensus-driven, appropriate and effective healthcare plan. This includes coordinating input and treatment recommendations from multiple consultants, discussing care plans with the case managers, discharge planners and social workers, and reaching out to nursing and other support services to gain insight into their perspectives of the patient's needs. They also need to discuss care plans and priorities with the patient and their families and be respectful of their values and wishes.2
There are several modalities which can help in this regard. One tool frequently utilized is the SBAR (Situation, Background, Assessment, Recommendation) tool which was originally designed for nurses as a "script" to enable them to present the necessary information in a timely and effective manner to help the physician provide an appropriate response. From the team/collaboration perspective, many organizations have implemented one of the many crew resource management programs (e.g., TeamStepps) to facilitate team dynamics by emphasizing principles of accountability and responsibility; understanding roles and responsibilities; the importance of trust and respect, willingness to assist and assertiveness techniques; and the importance of pre, concurrent and post- event interactions and discussions. Many organizations have introduced new mobile technologies as another tool to help facilitate information flow and exchange. All this helps, but the key to effective communication is the one-on-one interaction.
The skill sets required to be an effective communicator include: setting the right tone (engage, dedicate the time, avoid distractions, exhibit appropriate voice tone and body language, take the time to listen, focus on what the other person is saying, show compassion), providing explanation and clarity, avoiding confrontation, seeking their perspective, and then arriving at a mutually agreed-upon course of action.
A final layer to consider is the underlying influence of organizational culture and leadership that affects both organizational morale and productivity. Having a dedicated focus toward best-practice patient centric care and providing appropriate leadership and resource support to facilitate appropriate, efficient, high-quality, safe, satisfying care is paramount for success. Organizations should assess their own individual status through appropriate survey techniques and assess opportunities for improvement. Many organizations have utilized external consultants (e.g., Just Culture) to help in this regard. For physicians, providing an on-boarding process where the organization makes a concerted effort to welcome the physician, follows up with a discussion of organizational responsibilities, and sets expectations for compliance is critical. The on-boarding process should then extend into an in-boarding process where physicians are encouraged to provide on-going input. The organization can respond by offering appropriate solutions or support services. Physicians who are non-compliant or exhibit truly disruptive behaviors must be dealt with accordingly.3
What are the benefits of these efforts? From the organizational perspective, there will be an enhanced staff feeling of worth and importance resulting in increased levels of satisfaction that positively affect reputation, recruitment and retention, and care efficiency. From a financial perspective, this will enhance patient satisfaction scores, improve compliance with value-based metrics, and improve overall utilization and resource efficiency. From the physician perspective, gaining a new understanding of the medical business world, being allowed to have input and discussion around key issues, having access to resources that provide administrative, clinical and/or emotional support, and feeling like they are respected and valued as a precious resource will re-energize their passion for care, increase satisfaction, improve work place dynamics and improve efficiencies in care. It's certainly worth the effort.
Alan H. Rosenstein, MD, MBA, is a practicing Internist, a consultant in health care management, and medical director for Physician Wellness Services. He can be reached at ahrosensteinmd@aol.com.
1 Rosenstein, A. “Physician Stress and Burnout: What Can We Do?” Physician Executive Journal Vol.38 No.6 November/ December 2012 p.22-30
2 Rosenstein, A. “Physician Communication and Care Management: The Good, the Bad, and the Ugly” Physician Executive Journal Vol. 38 Issue 4 July/ August 2012 p.34-37
3 Rosenstein, A. “Bad Medicine: Managing the Risks of Disruptive Behaviors in Health Care Settings” Risk Management Vol. 60 No.10 December 2013 p.38-42