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Management is about doing things right. Leadership is about doing the right things. ‑- Peter Drucker

Lee M. Duke II, M.D.

The volume of comments about the unprecedented changes in health care has become mind-numbing.  Yet reports of professional dissatisfaction and physician burnout seem to surprise health-care leadership. National studies, including one sponsored by the Mayo Clinic, reveal that 30 to 50 percent of physicians experience at least one element of burnout, including emotional exhaustion, isolation and ineffectiveness.   

Years of training and apprenticeships required for clinical practice have failed to prepare physicians for not just the rapid expansion of clinical knowledge but also the seismic changes in health-care delivery. Electronic documentation, team-based care, fee-for-value/outcomes management and shifting regulatory/reporting requirements are far easier to articulate than to implement at the front lines. Seeking shelter, the majority of physicians now work in an employment model, blurring past professional and stakeholder physician roles and further diluting control of the work environment.
Researchers Maslach and Leiter predict higher professional burnout when key imbalances occur between a person and the job they perform. National and local dialogue often references these imbalances between workload, control/autonomy, reward/recognition, community/culture, fairness and shared values.   
Many regard current state as a call to action, referencing the impact of clinician burnout on patient quality, safety and experience. The growth in consultants and the language lexicon surrounding burnout, resilience and returning the “joy of medicine” often focus on narrow operational or tactical efforts, not sustained improvement. Experts in the field support a more comprehensive approach, combining leadership, operations and individual interventions. PN spoke to this in my New Year’s column.
Aligned or engaged physicians are not immune to burnout; in fact their identification with mission, vision and values may push motivated doctors beyond their limits. Carillion Health System in southwestern Virginia found this, and you will see it in our survey results as well. 
In response to local dialogue, physician focus groups last summer provided feedback on system communication, changes in health-care delivery and the merger with Penn Medicine. Earlier this year, Med Staff and LGHP leadership commissioned The Advisory Board for a physician survey on alignment and burnout. More than 250 physicians responded, 33 percent of those surveyed. We thank those who took the time to complete the survey, especially the 52 respondents who took additional time to enter candid, revealing and often passionate comments.
The results and comments provide a call to action. Here is the data.

The good: organization and physician alignment

  • 81.7 percent of LG Health Physicians are Aligned or Loyal.

  • This includes 43.5 percent who are Aligned – the 97th percentile nationally.                                                             

  • 18.3 percent are At Risk or Disaffected

For more than 10 years, surveys by a variety of services have reported tight alignment between Lancaster General Health and the community’s physicians. Two groups so committed to quality patient care and the community’s well-being provide the rare combination of clinical skill, operational excellence and the resources to provide necessary patient-care services.
The survey probed key alignment indicators, from strategy to operations and values:

  • I view the organization as a strategic partner navigating the changing health-care landscape: 71.5 percent agree or strongly agree.

  • I have a high degree of confidence in this organization’s nursing staff: 85.4 percent agree or strongly agree.

  • This organization is pursuing an effective EMR/EHR strategy: 73.8 percent agree or strongly agree.

  • This organization makes safety a priority: 83 percent agree or strongly agree.  

These results range from 8 to 26 percent above national benchmarks and support the results from prior alignment questions with high scores from physicians (“I would recommend this hospital/organization for the health care of friends and family.”)
Even within the top alignment driver improvement opportunities, only one scored below (.3%) national benchmarks: “My patients are able to obtain appointments with consulting physicians in a timely manner.” Perhaps this in part reflects the heterogeneity of employed and non-employed specialty services.
Other alignment OFIs included:

  • This organization is open and responsive to my input: 39.1 percent agree or strongly agree.

  • The actions of this organization’s executive team reflect the goals and priorities of participating physicians: 44 percent agree or strongly agree.

These lower scores perhaps identify a gap between leadership and front-line clinicians. 

The bad: physician burnout

Unlike the alignment queries, many of the questions around physician burnout were crafted by Advisory Board and LGHP/Med Staff leadership to more accurately investigate local concerns and could not be applied to national experience.
For those with national comparisons:

  • I am experiencing more work-related stress and burnout now than I did three years ago: 55.8 percent agree or strongly agree (greater than 99th percentile nationally).

  • Lancaster General provides effective team-based care: 47.5 percent (19th percentile nationally).

Reports of physician stress are consistent with the rapid changes and challenging demands of moving to team-based care, electronic documentation, increased regulatory reporting and fee-for-service to fee- for-value services while working within this transitional time. The Advisory Board helped develop questions exploring themes around workload, teamwork and organizational support.
Some responses were positive:

  • I am confident in Lancaster General’s clinical staff: 82.8 percent agree or strongly agree.

  • I have conflicts with administrators at Lancaster General: 13.3 percent agree or strongly agree.

Others were not so positive:

  • Lancaster General supports my efforts to relieve stress: 13.3 percent agree or strongly agree.

  • Lancaster General is well-prepared to handle changes to our workload: 24.5 percent agree or strongly agree.

  • I have adequate support for administrative tasks (paperwork, charting, etc.): 31.2 percent agree or strongly agree.

  • Administrators at Lancaster General understand the factors that contribute to my stress and/or burnout: 18.2 percent agree or strongly agree.

The comments

A substantial number of respondents offered comments in addition to the survey questions. Positive comments recognized LG Health for its commitment to the community and investment of energy and resources for the community benefit. A few expressed gratitude to administration for the survey and for listening to the stress and burnout dialogue.
The majority of comments centered on opportunities, many calling out leadership/administration for failing to anticipate or mitigate the growth of nonclinical work, the complex regulatory and reporting demands, or the impact of the electronic health record. Many expressed frustration and lack of empowerment to adjust to the changing environment. These comments moved and humbled all those in leadership who read them.

Next steps

Address the operational flashpoints. Both the comments and the survey questions identified chronic problems confronting physicians, making it difficult to get through a day or a week. Many authors cite the electronic health record as part of the explosion of physicians’ clerical work. LGHP leadership is considering a pilot program utilizing scribes. Team-based care requires staffing, resources and training/standard work to create functional and effective teams. Value stream mapping to accelerate that process is underway. Several commented on access to specialty consultation. Efforts are underway to improve doctor-to-doctor communication and expand virtual consultation. Hospitalists and nurses are developing an aggregated rounding model and unit-based huddling to make inpatient care a team event.  The Medical Staff Office, working with LGHP, is developing provider-specific onboarding so that answers can find the questions.
Lean process improvement and management transformation. Respect and empowerment of the individual to not just do their job but improve their job is fundamental to bringing leadership to the individual and unit level. By reducing waste and implementing small tests of change, front-line staff can address pain points, better serve our patients and improve the health of the organization -- something our alignment survey identifies as a common purpose. Ideas then come from the collective wisdom of the entire staff. Problems identified that require higher-level support can now be elevated in a standard process. Physicians should not miss this opportunity.
Leadership. Dramatic, adaptive change tasks leadership to clearly articulate/communicate the destination and vision, while consistently walking the talk. The MSO is researching platforms for timely 360-degree evaluations for Med Staff leadership to better understand and respond to practicing physicians. We hope to have something in place by next fiscal year.

Burnout through a changing lens

The light shines brightest just before it burns out.
With the changing and challenging health-care environment, we should expect work and role imbalances leading to uncertainty, frustration and burnout. Heifetz, in “The Work of Leadership” (Harvard Business Review, 2001), writes that adaptive change reflecting market forces that alter the way we conduct business seldom have scripted solutions. Kotter, in “Leading Change” (HBR, 2001), tasks leadership with both interpreting and coping with these fundamental changes. Both agree that resilience and success depend upon the organization’s collective wisdom and horizontal connectivity outside normal vertical reporting hierarchy.
Collins, in his article, “Level 5 Leadership,” spotlights a leadership style that “attends to people first and strategy second … finding those critical elements that ignite people’s passions.” A second article by Kotter, “What Leaders Really Do” (HBR, 2001), challenges leaders to identify and communicate a clear vision that both motivates and inspires, with reaching both professional and human needs an aspiration.
Dr. Gerald Kraines, Harvard psychiatrist and CEO of the Levinson Institute on Leadership Psychology, believes that a psychological contract structures the relationship between leadership and staff. The contract is characterized by: a bond built on common purpose (alignment); constructive and respectful distance (respect/empowerment); and commitment to support one another during times of change (trust). Change requires re-examination and often renegotiation of the contract. Otherwise violation can result in a fracture of sense of self and trust in organizational leadership, manifested by resistance, isolation and emotional distress. Sounds a lot like burnout.
Sheryl Sandberg, author of the leadership book “Lean In,” spoke about her life changes that resulted from the tragic loss of her husband in the June 2017 HBR article “Above All, Acknowledge the Pain.” With the help of both friends and experts, she discovered that to build resilience, she first had to acknowledge the loss. Not until she faced adversity could she build strength and resilience, and rediscover joy. Perhaps a lesson for health-care professionals.      

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