“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…

Piece on cardiac surgery in Times Literary Supplement

In the current TLS I have a review of two books on cardiac surgery. One is Stephen Westaby’s  memoir of his career, the other is Thomas Morris’ historical perspective.

The full text is not freely available online, so here is the bit the TLS have made available to tease you all:

It is tempting to place Stephen Westaby’s Fragile Lives, a memoir of his career as a heart surgeon, in the category the journalist Rosamund Urwin recently called “scalpel lit”; following Atul Gawande’s Complications (2002) and Henry Marsh’s Do No Harm (2014) and Admissions (2017), here is another dispatch from a world arcane even for the majority of doctors. To some degree, Westaby’s book follows the Marsh template. In cardiac surgery as in neurosurgery, life and death are finely poised, and even minor technical mishaps by the surgeon, or brief delays in getting equipment to theatre, can have catastrophic consequences.

Like Marsh, Westaby, a consultant at the John Radcliffe hospital in Oxford, is jaundiced about the bureaucracy of health care and the mandatory “training” imposed on even the most experienced practitioners – “writing my personal development plan at the age of sixty-eight”. Now that death rates are published by the NHS,…

Makes you want to read the whole thing, does it not?

As it happens, Henry Marsh’s Admissions is reviewed in the same issue by George Berridge.

“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.