What is the relationship between physician leadership, especially on the departmental level, and front line physician satisfaction and burnout?
In Dr. Thomas H. Lee’s reflections on physician leadership in the Harvard Business review, we see the problem first arise as a generational problem or as a clash between different styles of medicine. During Dr. Lee’s training as a doctor, quality was a question of personal ethics. Lee writes “the only way to ensure quality was to adopt high personal standards for ourselves and then meet them.”
In fact the whole question of contemporary physician leadership can be seen as the question of how to transform personal ethics into institutional ethics without of course forgetting the former.
Dr. Tait Shanafelt, as the director of the Mayo Clinic Department of Medicine Program on Physician Well-being, has published many studies on physician burnout. His most recent study was on the relationship between leadership and physician burnout and satisfaction, which he describes in a Mayo Clinic video. The 3896 physicians surveyed were asked to rate both their own level of burnout, depersonalization (“viewing/treating people as if they were objects”) and satisfaction as well as an evaluation of their supervisor. The leadership evaluation considered 12 items using a five point Likert scale. Some of the items included “inspires me to do my best,” “treats me with respect and dignity,” and “is interested in my opinion.”
Shanafelt et al concludes “Leadership ratings demonstrated a strong association with burnout and satisfaction at the level of individual physicians after adjusting for age, sex, duration of employment at the Mayo Clinic, and specialty area. At the work unit level, 11% of the variation in burnout and 47% of the variation in satisfaction with the organization was explained by the leadership rating of the division/department chairperson.” Shanafelt et al go on to comment on how “remarkable” this finding is when one considers all the other issues, including salary and workload, that might also lead to burnout.
If leadership plays such a large role in patient satisfaction and burnout what can hospitals and physicians do to improve this relationship? Dr. Lee points to the concept of autonomy as an obstacle to the kind of collaboration and leadership that hospitals now demand. He asks “Why is collaboration so hard in a field that attracts idealistic people who want to do good?” He answers: “In a word, autonomy. The cultural barriers to change in health care- doctors’ resistance to being measured, their need [to] be ‘perfect,’ their reluctance to criticize colleagues, their resistance to teamwork- reflect a deep-seated belief that physician autonomy is crucial to quality in health care.”
That quote comes from an article entitled “Turning Doctors into Leaders” and its purpose is to demonstrate how leaders can overcome this ‘autonomy’ of physicians by “appealing to the better angels.”
But we would argue that while the new evidence based, data driven work force may no longer support the outdated individual autonomy of old- the kind we see in television shows such as House and M.A.S.H. for example- it still calls for physician autonomy of a different kind. Shanafelt et al describe effective leadership and explain that “Physicians are inherently critical thinkers and problem solvers who want to be involved in assessing and improving their practice environment.” What is this if not a call for a new form of institutional autonomy that allows doctors the freedom to solve problems and serve their patients from within the institution.
Perhaps another way to understand leadership and autonomy is to use Dr. Gabel’s distinction between formal and informal leaders. One way to define this distinction is that the influence and power of formal leaders is based on their position in the hospital while the influence of the informal leader is based on “expert, informational, or referent power (the power that derives from the personal qualities of the individual and his or her ability to become a reference point for others).” Dr. Gabel calls for the training of all physicians as leaders in so far as we hope all doctors take a leadership position (formal or informal) at some point in their career.
But perhaps to take this a step further we can think of informal leadership as a description of this new form of institutional autonomy. While we understand the power and limitations of formal leadership it is useful to consider the opportunities and freedom of informal leadership. Dr. Gabel writes “while informal leaders must complete the duties of their own positions, they are not weighed down by the administrative, financial, and personnel decisions and responsibilities that are part of formal or positional authority. Thus, informal leaders potentially are freer to express their views and ideals and to motivate others to their cause. This freedom may allow informal leaders to be more authentic than formal leaders.”
Gabel’s description of the informal leader is also a good description of the new institutional autonomy that departmental chairmen should be encouraging. This type of autonomy, unlike Lee’s description of autonomy which he seems to view as an obstacle, creates the type of environment that Shanafelt suggests will lead to greater satisfaction and less burnout.