July 25, 2019

How to Make Changes Without Being Labelled as Disruptive, Part 1: Stop Being a Doctor

If you visited a coal mining town in the early 1900’s, you would have likely seen miners carrying a bird cage as they headed underground for their shift. It seems that canaries had two traits that were quite valuable. First, they never stop singing; second, they die in bad air faster than a human. Miners risked hitting pockets of carbon monoxide or methane as they chipped away at the walls of the mine. So every once in awhile they would pause, and if they heard the canary singing they would continue. But if not, they would run over to check the bird and if the canary was down, they knew to exit the mine pronto.

Those of us working at the front lines of healthcare are the canaries in the coal mine of our practices, organizations, and systems. Wellness certainly depends on being a healthy canary. If we are to do this work well, each of us has an obligation to take care of ourselves -- sleep, nutrition, physical health, meaningful relationships -- and a lot of attention has been focused here. But put even the healthiest canary in a toxic mine and it will still die. Self care is necessary but not sufficient to tackle burnout. Both a canary strategy and a coal mine strategy are essential to be well.

All those clicks, all that paperwork, all those difficult patients, all those who don’t care for what you have to deal with, day in and day out. How can you engage leaders to change what must be changed? How do you make your voice heard?

From a physician who has worked more than 35 years in emergency medicine, both as a member of an independent group for 20 years and having worked now in over 30 organizations, who has worn all sorts of hats, across three different continents, who has made all the mistakes, and from a coach working in an organization that supports doctors struggling with burnout, here are a few things that may be worth your consideration.  But don’t take my word for it; I encourage you to test these for yourself.

Are you familiar with Einstein’s Insanity Trap?  Whether you need to dig yourself out of a hole, or hope to maintain the wellness you have, it will take action on your part.  Are you up for that?  Yes or no?  If so, here’s an important distinction to be aware of.  Do you know the difference between a problem and a dilemma?  Of course you do.  You deal with this every day.  Make a list of the problems where the patient leaves the emergency department cured.  Foreign body, dislocation, laceration, abscess, constipation.  Please add what you can, but it’s likely the list remains short.  A problem is something with a one-step solution. Apply the solution and the problem goes away.  Compare that to the overwhelming majority of people you care for in the ED -- who you can help, but can’t fix.  Rather than problems, these are dilemmas. There is no fix; only a balancing act among multiple, valuable, but competing options.  Address one part and it makes another worse.  Deal with that and something else goes awry.

Think about your last shift.  Which patients left you feeling good about your work? I’m willing to bet it was the patients with a problem. All those patients with dilemmas took more energy and were less satisfying.  They lacked the kind of closure you get from dealing with and fixing a problem.  Your brain prefers to see everything as a problem, and for good reason. It takes a lot more brain power and energy to deal with a dilemma, so we don’t go there unless we have to.

Rather than a solution, a dilemma calls for a strategy: a multi-pronged approach that balances all the competing interests in the best possible way for the best possible outcome at that time.  Put the strategy to work, find the next step, and then the next challenge emerges.  A dilemma may never go away, and it won’t be a quick fix, but it can be successfully addressed.

If you are the only one affected by what bugs you, then fix it the way you want.  However, if the issue affects others then you have yourself a dilemma.  To be clear, the struggle over changing your coal mine will always be a dilemma.  And in order to balance the multiple, valuable, but competing interests -- including yours -- one has to be aware of what all these competing interests are.

In order to do that, stop being a doctor!

Here’s what I mean: in many ways, the training we embrace as a physician gets in the way of successfully working on the coal mine.  We are trained to diagnose the problem, apply a solution, and move on.  We are expertly trained to make the difficult decisions, to be the ‘go to’ when the going gets tough, to turn every challenge into a problem with a solution.  Everyone looks to us for the answer in those situations.  We assess the landscape, give orders, and expect compliance.  In truth, we have gotten to where we are because we have the skill, knowledge, and demonstrated ability to deliver that ‘answer’.  But a dilemma has no answer.  Finding the best possible route requires bringing all those affected by the issue along for the ride with you.

Now pause for a moment to consider this: people in leadership and management positions don’t get to deal with problems.  Problems get fixed long before they arrive on the desk.  Everything on management’s to do list is a dilemma.  And their to do list is already overflowing.

By the way, raise your hand if you are a leader in your organization. (Spoiler alert: everyone raise your hand.)

Whether or not you realize it, each of us is a leader; with the teams of people we work with, with our patients, with our families, with ourselves.  When you guide efforts and ask others to change for your benefit, you are leading.  This may not be the big “L” sense of how people think of a Leader, as someone in the hierarchy with the authority to make the decisions, but in the little ’l’ leadership sense of having the responsibility and capability to factor in every affected voice in the given circumstances.

In the coal mine, you are not the only one assessing the landscape. You aren’t necessarily the ‘go to’ person.  Each person with a view of the circumstances sees that view from their own perspective.  They are each attuned to the consequences of failure and possible benefits to their own particular view.  We each see it our own way.  No wonder their solution doesn’t exactly fit your needs.  Their concerns are different than yours.  And vice versa.

If a change that affects others is what you need, then you are a ‘leader’ in that effort, even when the ‘Leader’ with authority over that issue is someone else.  The challenge in raising your voice about a dilemma, then, is to get your concerns heard by the Leader, rather than dismissed, and then moved far enough up the radar screen to be acknowledged, rather than relegated far down their to-do list.

Tackling a dilemma takes a different skill set from being ‘the doctor’.  The rules are different.  It might be worth learning them.  ‘Stop being a doctor’ is just the first one.

For now, my question to you: how do you tell when you are fixing a problem or addressing a dilemma? What words do you use to describe this?  My challenge: practice recognizing these situations, and when you have a dilemma, practice taking your doctor hat off and putting your small ‘l’ leader hat on.

Once you have mastered switching these hats, it’s time to talk about how to put that to work.

By Mark Jaben, MD, FACEP


Dr. Mark Jaben was a member of an independent EM group for over 20 years, during which time he wore many hats including a managing partner, associate director, and EMS medical director.  He then moved on to locums and independent work.  For the past 10 years, this has included active clinical practice as well as coaching emergency departments, hospitals, administrators, managers and individuals on system improvement.

He has had ample opportunity to experience firsthand the stress of medical care and the health care world, not only here in the United States and abroad, but in institutions ranging from small critical access hospitals to large urban centers in both non-profit and for-profit systems.

He has observed the obvious disconnect between physicians and administrators, and in many situations, a real missed opportunity for the kind of dialogue each institution must have in order to learn what actions really matter in their own unique situations.  We are delighted for him to share some insight into pursuing a successful relationship that leads to change.

Away from work, he spends a good deal of his time kayaking the local whitewater rivers in North Carolina and hiking its beautiful wilderness.

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