Disruptive physician or threat to the hierarchy? Watch out for the Kool-Aid

No doubt you’ve been aware of the latest survey on the topic of disruptive behavior in health care. The results of our joint study with QuantiaMD are the same as our ACPE survey nearly two years ago. We physicians still have a lot of work to do in our own house to solve this patient safety issue. We’re making progress. But it’s time to look at another angle of how physicians become labeled as “disruptive”. Sometimes the label is just plain wrong. Like old Hollywood westerns, or Patrick Swayze movies, the hero is often bullied by powerful people and organizations who feel that their authority is threatened, or who perceive that the status quo might change.

Since this latest study was published, I’ve had lots of interesting discussions with physicians, and senior health system leaders. Some senior leaders who come from non-health care industries comment on the odd culture of health care compared to many other industries. They point out (it’s also my experience) that disagreement, rather than being viewed as a strong cultural attribute for innovation and change, is frequently considered a threat to the hierarchy. Sometimes decision-making is highly centralized in the C-suite, and leaders are very uncomfortable with questions or differing opinions. In these health systems, the organizational Kool-Aid demands “loyalty” to the leaders, rather than legitimate, truthful debate about the merits of strategy, policies, or procedures. More about “loyalty” later!

When faced with a physician who voices distaste with the Kool-Aid of mindless agreement, these leaders label her/him “disruptive” – not because of behavior, but because of disagreement! That can lead to all sorts of problems for the physician who must then answer to the official organizational procedures for dealing with the disruptive physician, such as medical staff or legal proceedings.

In my first health system leadership job, I remember asking the senior physician leader of the system what Dr. X thought of the strategy proposed.
“He disagrees with us, so we’ve removed him from the committee.”

Dr. X was a physician who was respected and admired by his peers, by the nurses, technicians, and support staff who dealt with him, and most importantly, loved and respected by his patients. At least he wasn’t officially labeled disruptive, and made to go through counseling or monitoring! His disagreement with the strategy was shown to be correct a few months later.

Another physician with the same excellent clinical and service reputation came to me looking for a job. He’d been fired from another system because he disagreed with administration, sometimes too aggressively and disrespectfully. After listening to my new management colleagues advise against hiring him, and sharing my obvious concerns with him about his behaviors around managers or executives, I hired him. His dedication to patients, and his remarkable creativity were the characteristics my physician group needed. Working with him to change his behavior when he became frustrated or angry, he gradually learned how to use more productive behaviors. He got his 5-year pin, and eventually was named physician of the year by a well known national health care organization.

Both of these physicians were labeled as cynics by those who didn’t appreciate their disagreement. The best definition of a cynic is “a passionate person who doesn’t want to be disappointed again.” (Benjamin Zander, conductor of Boston Philharmomic) I learned that disagreement, when respectful and done in the spirit of innovation and improvement, is good. It’s what I like about working with talented and passionate people. It should not be extinguished. It should be encouraged.

If you hear your senior leader ask for “loyalty” – watch out! It’s just another way to stifle honest disagreement, or can be viewed as bullying.

I’ve never forgotten what I was told by a senior legal counsel in one of my first health care jobs, “Sometimes loyalty is more important than telling the truth.” Not for me.

You can hear the word “loyalty” used when uncomfortable decisions are made without the input of experts, when leaders don’t want to be questioned, or in a complex situation with public relations implications is unfolding. I don’t believe that a leader should ask for loyalty from followers. Loyalty can only be given freely by those who choose to follow, not forced upon them by a leader. Maybe if you run a monarchy or dictatorship it’s OK to ask for loyalty.

This quote from Col. John Boyd helps me put the issue of loyalty in proper perspective:

“If your boss demands loyalty, give him integrity. But if he demands integrity, give him loyalty.”

What do you ask of your team?

The Tyranny of Infallibility

Why is it so hard for we physicians to acknowledge that we’re human, prone to mistakes, misstatements, lapses in judgment, fatigue, or failure? I’ve had a most amazing week criss-crossing the country, doing presentations and having discussions with very interesting people.

One of those people was Jeff Skiles, co-pilot of USAir Flight 1549 that landed on the Hudson River in January 2009. I guess we say “on” instead of “in” because it didn’t sink - for awhile, at least. In the year and a half since I’ve known Jeff, he’s developed a very effective presentation on the impact of moving from autonomy to teamwork in commercial air transport. It’s that teamwork which contributed to the miraculous result for the passengers and crew.

A key point of Jeff’s comments is acknowledging fallibility, and dealing with it by building a team of people who learn how to communicate without “taking it personal” when they’re questioned by a team member. He said authority used to be based on fear or intimidation by the senior pilot. It’s now role-based authority.

When Capt. Sullenberger declared, “my aircraft” after the A320 hit the geese (Jeff was flying the plane), it was clear that the captain was taking responsibility for bringing the aircraft down. Jeff would go through the checklist to start the engines, if possible. Once it was clear that a crisis was occurring, the cabin crew began their respective autonomous actions to secure the cabin.

Jeff says his training in aviation comes in handy in his other roles as general contractor, husband and father. Now that’s a powerful testament to the effectiveness of these concepts!

I joined other ACPE faculty for some on-site teaching last week, and the topic of human error was discussed as a key component of the engineering science of reliability. I don’t know about you, but my instinct from years of being a physician is to believe that “human error” doesn’t apply to me – I’m a physician and not supposed to be fallible like other humans. That’s crazy!

Once we start talking about human error and the physician’s role, whether in full time clinical practice, or in system leadership, typical comments turn to our inability to admit we make mistakes because of the legal system. Are we using the legitimate but separate issue of the tort system to avoid discussion of our own human foibles, and appropriate methods of building safer care? Maybe we could find humor in our foibles, and have some fun with the topic instead of avoiding a necessary discussion!

Like many of you, and like some of the physicians with whom I teach, on certain occasions I’ve deliberately ignored the advice of a malpractice attorney to not admit I made a mistake in diagnosis or treatment. Knowing the truth of what happened and my role in it, withholding that truth from any human being isn’t right, and it eats away at me.

Most studies of physicians conclude that we do not like to be controlled or directed by others. If we don’t like the control that the tort system and lawyers have over us, then why do we exhibit learned helplessness by agreeing with them that we must not admit our fallibility?

Frankly, it’s liberating to discard the illusion that I should be immune from human error and weakness. That holds true for both clinical care, and in leadership or management roles. It’s self-imposed tyranny to think otherwise. Best yet, I believe that the key to improving safety, reliability – and changing the tort system – is in throwing off the chains of infallibility and perfection that we expect of ourselves, and adopting many of the concepts that helped other industries become much safer.

Notes from the San Antonio Annual Meeting

ACPE's Annual Meeting, held in San Antonio, ended this past week. The participants had an energy, enthusiasm and passion to improve health care that was noticeable to me and the ACPE staff. Here are some comments and observations from the meeting, in no particular pattern, that might be helpful in your daily activities. These thoughts might also help you put the current uncertainty of health care in perspective.

• Kevin Fickenscher, long-time ACPE member and editor of Dell's Washington Report, noting in his Vanguard presentation that in 2009, the federal government collected $1.3 trillion in taxes; expenses for Medicaid, Medicare, Social Security and service on the national debt totaled $1.2 trillion. We borrowed the rest.


• David Nash, dean of Jefferson University School of Population Health, who has an uncanny knack for sound bites, shared his new four word summary of Accountable Care Organizations: "No outcome, no income."


• Grace Terrell, CEO of Cornerstone Health Care in High Point, N.C., and Sue Freeman, CMO at Temple University in Philadelphia, both commented on facilitator Francine Gaillor's thought-provoking statement that "leadership is a stage." Everything a leader does is under a spotlight. Your words, actions, body language and moods are constantly on display. How does your performance come across to your audience?


• Chal Nunn, CMO of CentraHealth in Lynchburg, VA, commenting in a break-out session on quality and safety: "A 99-1 vote is considered a tie by the medical staff."


• One of the participants in the same break-out session commenting on the challenges in getting agreement by the medical staff, got a big laugh when he mentioned, "the 'silverback male' on the medical staff can derail the best laid plans."


• John Kenagy -- surgeon, author, advisor and keynote speaker -- outlined his concept of Adaptive Design, which allows front-line workers to rapidly and energetically spot and solve problems on their own. No layers of bureaucracy and hierarchy needed! Several attendees commented on how useful the A3 Problem-Solving Report will be in developing operational plans to resolve problem areas in their workplaces.


• Tom Royer, physician CEO emeritus of Christus Health System, gave a moving address to the new CPEs and Fellows at the Induction ceremony. Relating several poignant moments in his leadership career, he asked all of us to ponder why we're put on the earth, and to appreciate the opportunities we have to help others.

Now we're changing our focus to the Summer Institute in Boston, July 15-19. In addition to our Integrated Health Systems course, which covers everything from strategic considerations to physician engagement to financial integration, we're launching a new course on entrepreneurial thinking. This new course was developed in response to one of our ACPE Board Task Force's recommendations. It will be taught by the director of the Entrepreneur Program at the University of Southern California's School of Business.

Bostonians say the snow has melted and that summer is a great season to visit their historic city. If you haven't ridden the water taxi there, I can highly recommend the experience as a cool summer mode of transportation.

The Bus or the Rope?

How many times have you heard leaders talk about “getting the right people on the bus”?

I find that analogy in health care to be difficult. It just doesn’t resonate with my experiences or my sense of how we should be thinking of our work on behalf of patients. First, let me outline why the “bus” and its occupants makes me uncomfortable. Then I’ll outline a model that makes more sense to me.

Ask a group of physicians or executives where they’ll be sitting on that bus if they’re the leader. The immediate and most common response is, “In the driver’s seat, of course! I know where I want to go and how to get there. I want people on the bus who support my direction.”

A few want to sit in the back and monitor what’s happening as the bus barrels down the freeway. Some are comfortable with rotating drivers.

Are riders on your bus comfortable pointing out problematic strategic, operational, or patient safety-related decisions? What do you do if your riders disagree with you? Usual responses: “They’re asked to get off the bus” or “They’re thrown under the bus!”

Ask about where the patient rides on the bus. That question gets some very interesting responses: “Somewhere behind the driver”; “In the driver’s seat”; “In the baggage compartment.” That last response gets a lot of laughter, and heads nodding in agreement.

Now imagine a different image. Imagine you, your team of health care professionals, and a patient are on a rope, climbing a mountain in the Rockies, Andes, or Himalayas. You are all linked together on that rope, all with the same goal. In health care, it might be evidence-based medical care, highly reliable and safe care with optimal outcomes, or patient centered care. It’s risky work. There might be many ways to get to your collective goals, but it will require input from everyone.

It might also require vigorous disagreement from time to time about the safest and best way to proceed. If you’re the leader of the team, and know how you want to achieve your goal and how fast you want to get there, are you comfortable with agreement, or perceived agreement? No one speaks up. Do you assume everyone agrees? Do you want to encourage disagreement before starting up that dangerous part of the journey?

As you proceed up that mountain, you’re about to step in a crevasse. We’re all prone to mistakes as human beings. How do you want the team member behind you on that rope to respond? I want to hear, “STOP – that’s not safe!” Or feel the sudden tightening of the rope as an ice axe is plunged into the snow. We’re all in this together – each one of us concerned about one another’s personal and professional safety – regardless of our status in the hierarchy of the team. What happens to one of us is likely to happen to everyone else on that rope.

Finally, imagine a situation where the patient is the only person on the rope who isn’t ready, or in shape, for the push to the top. Not strong enough. Circumstances don’t seem auspicious or comfortable. Do we have the courage, compassion, and situational awareness to listen? Do we decide to wait until another day or moment, or do we drag the patient up to the top because the health care team believes it’s the right thing to do?

Put me on a rope with people who aren’t shy about voicing their concerns for patients, and for safety. People who can be counted on to do what’s right, for the right reasons. I don’t mind if those people are a little rough around the edges. If everyone realizes that the most important individual on that team is the patient, we’ve got a great team! Come to think of it, maybe that patient is the true leader of the team.

Physicians and Disruptive Innovation

Last week, ACPE Vice President of Career Services Barbara Linney hosted a webinar on career options that broke previous attendance records. This one was notable for the number of physicians looking outside the hospital sector for new roles. Consulting, insurance, pharma, or entrepreneurial ventures were mentioned as preferred destinations.

I’ve been racking up frequent flyer miles the past few months doing on site training on clinical leadership and moving from autonomy to teamwork in a health care system undergoing stress and change. If energy, enthusiasm, and engagement of the audience is an indicator of most physicians’ state of mind, it appears that many are thinking about what they can do beyond individual patient care to provide remedies for a broken system, and to get more satisfaction from their professional careers.

The topic of disruptive innovation generates the most animated discussion. They’ve been giving thought – when they can steal a few moments from their roles as production workers in the fee for service system – to what they would change, and the technologies or business models that would help them do just that.

Just as we talk of the ACO concept as moving from “volume to value” for consumers and purchasers, clinicians are thinking how they can provide value beyond their role as patient care “volume producers”. Henry Ford’s comment about the people wanting “a faster horse” before his disruptive innovation of the Model T resonates with physicians. Most don’t believe they can be a “faster horse” in their practice situations. They cite patient safety and quality as their first concerns. Our pledge as physicians to “first, do no harm” is jeopardized.

John Agwunobi, a long time ACPE member and Senior Vice President at WalMart, made some very insightful comments last week on a conference call with us here in Tampa. John is using his background as a MD, MBA and MPH to change the status quo through his role at WalMart. The joint announcement by WalMart and First Lady Michele Obama last week about reducing salt, sugar, and fat content of foods sold at WalMart as one step to improve the health of our population is just one example of that.

John (and I) encourage you to think of being a physician as just the start of your lifelong journey of learning, improving health, and making a difference in people’s lives. Your clinical experience is a foundation for adding new competencies that will give you new opportunities to improve health and health care. Imagine what you might be doing if you didn’t view being a physician as your only identity, or the only valid destination for your learning and education!

Would you learn how to incorporate engineering principles of reliability and safety into patient care? How about learning how to lead people from different professional backgrounds? Does disruptive innovation appeal to you? Starting a new business, or improving the business we’re in? Studying behavioral economics to find ways to change our population’s unhealthy lifestyles and habits?

Like you, I’m proud of my path to becoming a physician, and honored to be recognized as such. Paradoxically, recognizing that there are many other people and professionals – besides physicians - who make important contributions in our society and work just as hard, helped me put my “physicianhood” in proper perspective. It was the foundation to build on – not the ultimate destination in my life.