“Working here makes us better humans”

A daily thought from Leandro Herrero:

I have had a brilliant two day meeting with a brilliant client. One aspect of my
work with organizations that I truly enjoy is to help craft the ‘Behavioural DNA’ that shapes the culture of the company. This is a set of actionable behaviours that must be universal, from the CEO to the MRO (Mail Room Officer). They also need to pass the ‘new hire test’: would you put that list in front of a prospect employee and say ‘This is us’?

There was one ‘aspirational’ sentence that I put to the test: ‘Working here makes us better human beings’.

It was met with scepticism by the large group in the meeting, initially mainly manifested through body language including the, difficult to describe, cynical smiles. The rationalists in the group jumped in hard to ‘corporatize’ the sentence. ‘Do you mean better professionals?’ The long discussion had started. Or, perhaps, ‘do you mean…’ – and here the full blown corporate Academy of Language – from anything to do with skills, talent management, empowerment to being better managers, being better leaders, and so on.

‘No, I mean better human beings. Period!’- I pushed back. Silence.

Next stage was the litany of adjectives coming form the collective mental thesaurus: fluffy, fuzzy, soft, vague…

I felt compelled to reframe the question: ‘OK, so who is against working in a place that makes you inhuman? Everybody. OK, ‘ So who is against working in a place that makes you more human? Nobody. But still the defensive smiling.

It went on for a while until the group, ‘organically’, by the collective hearing of pros and cons, turned 180 degrees until everybody agreed that ‘Working in a place that makes you a better human being’ was actually very neat. But – there was a but – ‘Our leadership team wont like it. They will say that its fluffy, fuzzy, soft etc… In the words of the group, it was not ‘them’ anymore who had a problem, it was the infamous ‘they’.

The “difficult to describe” cynical smiles are familiar…. indeed I am sure I have perpetrated such smiles more than once myself!

Medicine can be a dehumanising profession, sometimes literally. Dehumanising in both ways – patients, especially some categories of patient, colleagues, but also we ourselves. Of course, the rationalist part of us can pick apart what “better humans” means…

Leandro Herrero: “An enlightened top leadership is sometimes a fantastic alibi for a non-enlightened management to do whatever they want”

From Leandro Herrero’s  website, a “Daily Thought” which I am going to take the liberty of quoting in full:

Nothing is more rewarding than having a CEO who says world-changing things in the news, and who produces bold, enlightened and progressive quotes for all admirers to be. That organization is lucky to have one of these. The logic says that all those enlightened statements about trust, empowerment, humanity and purpose, will be percolated down the system, and will inform and shape behaviours in the milfeulle of management layers below.

I take a view, observed many times, that this is wishful thinking. In fact, quite the opposite, I have seen more than once how management below devolves all greatness to the top, happily, whilst ignoring it and playing games in very opposite directions. Having the very good and clever and enlightened people at the top is a relief for them. They don’t have to pretend that they are as well, so they can exercise their ‘practical power’ with more freedom. That enlightened department is covered in the system, and the corporate showcase guaranteed.

The distance between the top and the next layer down may not be great in organizational chart terms, yet the top may not have a clue that there is a behavioural fabric mismatch just a few centimeters down in the organization chat.

I used to think years ago, when I was older, that a front page top notch leader stressing human values provided a safe shelter against inhuman values for his/her organization below. I am not so sure today. In fact, my alarm bell system goes mad when I see too much charismatic, purpose driven, top leadership talk. I simply smell lots of alibis below. And I often find them. After all, there is usually no much room for many Good Cops

Yet, I very much welcome the headline grabbing by powerful business people who stress human values, and purpose, and a quest for a decent world. The alternative would be sad. I don’t want them to stop that. But let’s not fool ourselves about how much of that truly represents their organizations. In many cases it represents them.

I guess it all goes back, again, to the grossly overrated Role Model Power attributed to the leadership of organizations, a relic of traditional thinking, well linked to the Big Man Theory of history. Years of Edelman’s Trust Barometer, never attributing the CEO more than 30% of the trust stock in the organization, have not convinced people that the ‘looking up’ is just a small part of the story. What happens in organizations has a far more powerful ‘looking sideways’ traction: manager to manager, employee to employee. Lots of ritualistic dis-empowering management practices can site very nicely under the umbrella of a high empowerment narrative at the top, and nobody would care much. The top floor music and the music coming from the floor below, and below, are parallel universes.

Traditional management and MBA thinking has told us that if this is the case, the dysfunctionality of the system will force it to break down. My view is the opposite. The system survives nicely under those contradictions. In fact it needs them.

 

I found this reflection, especially the final three paragraphs, particularly striking. Health care organisations are getting better and better at talking the talk at the highest levels about empowerment and respect and [insert Good Thing here] – but how much that really has an impact on the daily management practices that are the day to day reality of working within that organisation?

I also like the scepticism about Role Model Power of the Big Man (or Woman) on top. Dr Herrero, described on his Twitter as an “organisational architect”, clearly has a healthy view of the reality that underlies much rhetoric. I look forward to the HSE’s Values in Action project which is very much following the lines of his work.

Review of The Physician As Patient, Myers & Gabbard, Irish Journal of Psychological Medicine 2008

The html version of this isn’t available, so rather unusually here is an image of my review of this book.  I have had reason to return  to this topic  of late.

“Happy Organisations and Happy Workers” – blog post by Maria Quinlan

On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan  has a blog post entitled
“Happy Organisations and Happy Workers – a key factor in implementing digital health”

The whole is worth a read. Of course, having a happy organisation made up of happy workers is inherently important of itself, as well as from the point of view of implementing digital health. As Dr Quinlan writes in the first paragraph:

To paraphrase Tolstoy, “all happy organisations are alike; each unhappy organisation is unhappy in its own way.” The ability for healthcare organisations to innovate is a fundamental requirement for adopting and sustainably scaling digital health solutions.  If an organisation is unhappy, for example if it is failing to communicate openly and honestly, if staff feel overworked and that their opinion isn’t valued, it stands to reason that it will have trouble innovating and handling major complex transitions.

Reading this, I am struck by how important it is to make time in a day with an accumulation of pressing demands for reflection:

 

What these factors combine to achieve is happy, engaged workers – and happy workers are more effective, compassionate, and less likely to suffer burnout [2]. Clear objectives, praise, a sense that your voice matters – these can seem like fluffy ‘soft’ concepts and yet they are found over and over to be central to providing the right context within which new digital health innovations can flourish. Classic ‘high involvement’ management techniques – for example empowering team members to make decisions and not punishing them for every misstep are found to be key [1].  As Don Berwick of the Institute of Healthcare Improvement (IHI) says, people who feel joy in work are “not scared of data”, rather “joy is a resource for excellence” [3]

Managing what Sigal Barsade, Professor of Management at Wharton calls the ‘emotional’ culture of an organisation is a very important concept – especially in the healthcare environment which expects so much of staff [4]. Healthcare workers face pressures which many of us working in other fields can’t really comprehend, a recent systematic review found that clinicians have higher rates of suicidal ideation than the general population, with a high prevalence of burnout, psychiatric morbidity and depression linked to excessive workload [5].  Attempting to introduce innovative new ways of working within such constrained environments can be challenging to say the least. Exhausted workers, those with little time in their day for reflection, or those who work in organisations which fear failure are less likely to innovate [6].

Much of the rhetoric around healthcare innovation tends to be messianic in tone. A gap between this rhetoric and the messy, pressured reality of healthcare can diminish the credibility of innovators.

The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:

Drawing from their work researching healthcare organisations ability to handle complex transitions in the US, Jaen et al (2010) developed a 23-item scale measure for what they term ‘adaptive reserve’. Adaptive reserve is an internal capability for change which includes being agile; capable of continuous learning; and being adept at self-assessment, reflection and improvisation. The Adaptive Reserve questionnaire asks staff to rate their organisation according to a variety of statements which include statements such as; ‘we regularly take time to consider ways to improve how we do things’ and ‘this organisation is a place of joy and hope’.

Overall, this a fascinating blog post on an issue which is close to my heart. I intend to post some more on this topic over the next while.

 

Why are doctors so unhappy?

From the UK junior doctor’s strike to survey after survey , there seems to be growing evidence that a doctor’s lot is not a happy one. Or is it not so much a “doctor’s lot” as a “doctor’s nature?”

I’ve been interested in this question (quite apart from the personal relevance!) ever since working on this review for the TLS of various medical biographies. As I wrote:

In the Western world, at least, the medical profession generally enjoys high status. For sociologists, doctors incarnate various forms of power disparities. Medical science and medical technology have made spectacular progress since the Second World War; procedures such as LASIK laser eye surgery, to give just one example, that once would have seemed magical, are now near-routine.

And yet an air of discontent is evident in much of the discourse of modern medicine. Like many others, the medical profession is under question, if not attack, on a range of fronts. Complementary remedies are increasingly popular, often with practitioners as well as patients, despite the advent of evidence-based medicine and numerous books that have discredited their claims to efficacy. A succession of scandals in Britain and elsewhere has undermined public trust in doctors and nurses. Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

There was somewhat more I wrote originally, but for reasons of space, had to be cut

 

. Much was based on my reading of Myers and Gabbard’s wonderful The Physician as Patient – a book I reviewed some years ago . As I wrote then, Myers and Gabbard illustrate the power of the case vignette, a somewhat neglected form nowadays, and I also wondered about the  self flagellation possibilities of audit (linked I guess to the Imperative Voice one gets so much of in medical journals)

I didn’t write in my 2008 review of one of the points Myers and Gabbard make – based on psychoanalytic literature – about the much-vaunted grandiosity and pomposity of doctors – the “god complex.” In their reading, this (when it occurs) is a defence mechanism against the ultimate power of death against all our efforts. Personally, there are only a handful of doctors I have come across – and at this point I must have come across hundreds in various contexts – who in any way lived up to the “god complex” stereotype.

Are doctors less happy than other citizens? Surveys and so forth can no doubt be adduced to prove the point (though I must admit after the US Presidential Election having an even greater scepticism about ANY survey or poll being used as “evidence”)  and the lived experience of doctors is increasingly one of a beleaguered profession overwhelmed by competing and constant demands. Is this because of specific issues – funding, resources, de-professionalisation – of the contemporary world?  Is it because of a cultural shift from doctor-knows-best to consumerist healthcare? Or is it something deeper and perhaps near-inherent to the kind of person who is drawn to the practice of medicine? Or something deeper and perhaps near-inherent to the practice of medicine itself?

There is, on one level, more discourse about health and healthcare than ever before. On another, there is often a a euphemistic, evasive quality to much of it. So many terms – from “evidence-based” to “patient centered” – have become godterms that conceal the complexity and diversity of healthcare (both complexity and diversity are themselves “godterms”, increasingly, but I use them very deliberately here) and the contending priorities at play.

This is an area ripe for pompous theorising about Society and Culture and so on, and perhaps I have done my share of this already. One final thought: the WHO definition of health is:

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Do you, reader, really believe that? Do you really, when you think of what it is to be healthy, think of”complete social well-being”?  What is “complete physical, mental and social well-being” anyway?

The point is not to denigrate “well being” in some way – or not to recognise the value of a positive rather than negative definition of health. The point is, this  grandiose definition has consequences – underlying not just health policy and practice but how we think about what it means to be healthy, and also what doctors (and nurses, and psychologists, and OTs, and physios, and everyone else with apologies for those left out) are trying to achieve. I would argue that the WHO definition is something out of a kind of worldly messianiac pseudo-religion rather than a workable basis for a human-scale endeavour.

 

The imperative voice in medical journal editorials

I’ve long wanted to do a little study – though in my experience no study is ever “little” – which is available to anyone in the entire world to do if they have the time and inclination (and resources)

Essentially I wished take a year or so of editorials from various medical journals and assess how much imperative language used. The seemingly endless “musts” and “shoulds” and “needs” that tend to be as inescapable a feature as the words “more research is needed.” I would like to assess exactly who “must” do this-or-that, and what the this-or-that tends to be. Often the subjects of this imperative language are those old standbys “stakeholders” or “policymakers”, adding to their holding of stakes and making of policy duties. Often it is rather specific bodies, often it is more generalised groups (“doctors”, “consultants”, “junior doctors”) It would be interesting to have the benefit of some kind of empirical study of this phenomenon.

For all the status of the medical profession, doctors do not seem to be a terribly happy bunch.   In the piece I just linked to I originally had a section in the opening paragraphs more explicitly exploring how much of this was contextual – related to working patterns, social attitudes, etc. – and how much was something inherent in the profession of medicine itself, either in the practitioners or in the practice. As I wrote in that review:

Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

In Myers and Gabbard’s highly readable The Physician as Patient we read of the physicians ultimate impotence in the face of death and much disease, and discussion of the defence mechanisms used to manage this. There is also a tendency to conscientiousness that can easily tip over into obsessionality.

Of course, there are non-conscientious doctors, and no doubt plenty of very happy doctors, and doctors who lack of the feelings of inferiority identified by Terman and Valliant (although Myers and Gabbard write that to a certain degree the oft-purported medical narcissism is a defence against the unknown and uncontrollable)

The essential point remains however. It has always struck me that – admirable as it is – the culture of audit and of quality improvement can all too easily tip into a kind of self-flagellation. There is no end to the potential improvements would could  make to one’s own practice. It can be difficult to separate out the individual from the role, especially the role of the individual within a system, and to over-personalise the findings of an audit.

I wonder too about the endless imperative language of editorials feeding into this tendency. With a certain amount of irony, a recent Lancet editorial “When the doctor is sick too” illustrates the style perfectly in its closing paragraph:

The Academy, the RCP, NHS England, NHS Employers, and Health Education England need to work together to provide solutions without stifling individual actions. Junior doctors need to lead on actions, supported by their organisations. But overall, family structures and small groups work better than huge multidisciplinary teams in supporting the health of junior doctors. Consultants and managers, please take note.

I am not disputing anything that is being said – indeed (perhaps more than most editorials) I would fully support what is being said, especially about the relative benefit of “family structures and small groups.” Yet it is more the tone of the imperative language used that struck me as typical of a certain kind of editorial.
It can be easy to spot the point in an editorial where the author switches from descriptive or evaluative language into something-must-be-done mode.

I find the issue most acute in papers with an educational bent. Surveys of the degree to which topic A is taught in medical schools will almost always find that topic A isn’t taught enough, or taught properly, or taught in a way that students feel emboldened to fill out a Likert scale self-assessing their competence with “Very Competent.” Topic A therefore needs to be, must be, or should be more integrated or even included in the curriculum. In papers on medical education published outside the specialist medical educational literature, rarely if ever is there much discussion beyond a few cursory words on that fact that curricula are already quite overloaded as it is, and while Topic A is no doubt wonderful if not life-saving, not all goods are reconcilable.