How to heal medical culture

These are valuable and essential initiatives, Dr Dean Lloyd Minor, said, but a more profound reckoning is also necessary for the medical profession's long-term health.

"Though electronic health records and other clerical work burden physicians, fully reversing the tide of physician burnout requires addressing deeper issues within the culture of the healthcare system," he said. "We need to identify and mitigate what is causing doctors to feel an erosion of meaning in their work."

To understand the big picture, he and Dr Tait Shanafelt, Stanford Medicine's chief wellness officer, teamed with organisational culture theorist, Edgar Schein, to view the medical profession through the lens of organisational science.

Their paper published in the Mayo Clinic Proceedings suggests that, taken together, many of the daily frustrations of physicians represent an ominous sign that the health care system isn't in sync with stated values and beliefs of the medical profession.

Ability to pay

In one example of such a contradiction, the paper notes that healthcare organisations often claim in their mission statements to value "the needs of patients, social justice and fair distribution of resources," while actually limiting patients' access to care based on ability to pay. Similarly, healthcare organisations assert that physicians are trustworthy, highly trained professionals who represent a precious resource; however, the US healthcare system also allows insurers to require that they authorise medical procedures for individual patients before physicians can move forward with the care they deem appropriate.

"These incongruities between stated values and organizational behavior are clear to physicians and create cognitive dissonance that breeds cynicism and a sense of misalignment between the organisation's goals and the altruistic aims of the profession," the authors say.

Organisations typically only grapple with these kinds of contradictions when they believe something bad will happen if not addressed, Shanafelt explained. He and his co-authors suggest there is extensive evidence that undesirable things are already happening in the healthcare system through physician burnout and its ripple effects.

But it's not smooth sailing even after leaders recognise the need for change in an organisation, Shanafelt said. That realisation can create fear because they aren't sure they will be able to make the changes necessary to solve the problem. This can lead them to deny or minimise the problem, blame individuals, and defend the status quo.

Fear must be minimised for an organisation's culture to successfully evolve, Minor said: "A key element is buy-in from senior leaders. They must clearly articulate the ideal future scenario and commit to leading the organisation there."

As an example, he said, the current state at a health organisation might include "an inefficient practice environment that places no limits on work and often makes it challenging to provide the care a patient needs." The future ideal would be "an environment that minimises low value work, makes it easy to do the right thing, and acknowledges human limitations," Minor said.

New approaches

To achieve that - or any - future ideal for medicine, small groups of innovators must be allowed to experiment with new approaches and share their experiences, Shanafelt said. These trailblazers can be individuals, departments and divisions, or even whole organisations.

"We've got to help people see what the new way looks like and demonstrate that it can work," Shanafelt said. "It's much easier for other leaders to buy in when they see there's a proven path they can follow."

Minor said this journey is a priority for him, Stanford Health Care CEO David Entwistle, and Stanford Children's Health CEO Paul King. Stanford Medicine already has taken the first steps. For the first time, "improvement in the efficiency of the practice environment for physicians" is listed as a top-level priority in the 2020 operational plans of the adult hospital; and the leaders have identified specific metrics for evaluating progress. Additionally, "improvement teams" in several clinical departments have been empowered to innovate and lead the way for others, Minor said.

"If we admit where we're starting, understand that we're having a conversation about fundamental culture issues, and recognise that there is a defined roadmap from the field of organisational science to get to a better state, then we can move much faster. We must not settle for just tinkering with incremental things. We must also get at the underlying core issues."