Complex problem-solving is difficult for any leader. Fortunately, physicians have an edge, as they solve problems hundreds of times every day in their clinical practice and research endeavors.
That’s the good news. The bad news is that problem-solving does not necessarily come as easily when physicians enter formal leadership roles. There are several reasons for this.
First, unlike in their clinical training, where they have had an opportunity to practice complex problem-solving in rotations, internships, and residencies, there’s nothing comparable to prepare them as leaders.
Second, many physician leaders enter these leadership roles “ad hoc” — sometimes beginning as a project lead, then becoming a team leader, and then perhaps a chief of professional services or chair of a department. Sometimes, it’s so spontaneous that it’s almost by default in that it’s now “your turn.”
Third, we may “throw” them into a formal training program designed either inside or outside the organization with a fair amount of disconnect between the classroom and the “real world.” When situated within the context of these more formal training programs, we prompt physician leaders to consider their prior learning and any evidence-based views that could be incorporated into their responses.
Enter: real-time, real-work simulations.
Defining Real-Time, Real-Work Simulations
When we use the term “real-time,”(1) we refer to the fact that reflections and actions occur closely in time — essentially pondering solutions “out loud” and, at the same time, searching for solutions. “Real-work” refers to case scenarios that closely approximate the lived experiences of physician leaders — both the challenges and opportunities they face.
As physician leadership development consultants, we have used real-time, real-work simulations as a stand-alone process and as one integrated within a more formal training program.
For the sake of brevity, we present this as an independent method; however, if you wish to see how we have integrated the method within a physician leadership development program, we invite you to review our article “The Art and Science of Developing Physician Leaders: A Program Template with Tangible Performance Outcomes” in the November/December 2021 issue of Physician Leadership Journal.(2)
Tailoring the Simulations to Your Organization
Although we have generic templates of the real-time, real-work simulations, many healthcare entities want to adapt these templates to the work and culture of their specific organizations. The most important tailoring is not what each case “sounds like” (which is helpful but not key), but rather how to resolve the problems and address the opportunities in each case that “fit and challenge” the culture of the organization. While the fit can be easy, the challenge is more difficult.
We have discovered that the best way to counter status-quo thinking, which can often be the cause of the challenges and problems the physician leader is facing, is to embed the most cutting-edge and evidence-based research into the problem-solving paradigm. This is a win-win situation because organizations find it so useful to jump-start the problem-solving skill development with new learning, and physician leaders appreciate having sound research and evidence to demonstrate a platform for learning in practical ways.
What Real-Time, Real-Work Simulations Look Like
Before we get too far into the weeds, let’s take a closer look at examples of these simulations. Here we present four case scenarios out of approximately 40 cases that physician leaders solve as a team.
Scenario 1
As head of the Emergency Department Division, I’ve received a fair amount of feedback in recent days that morale is low among nurses and physicians. This feedback has come to my attention through many ways: physicians and nurses themselves, my own observations, patient complaints, and staff reporting morale concerns to nurses and physicians. I must say, I’m a bit surprised since I pride our organization on high staff morale and productivity. I personally believe that if morale is low, stellar patient service will be more difficult to obtain.
Please put together a strategy for dealing with this problem. If morale and productivity are high in your area, please tell me what you’ve done to achieve this.
Scenario 2
You’re about to leave for the day when a staff nurse appears at your door and states that one of the physicians has incorrectly written a medication order. The nurse says this is not the first time this happened with the physician, whom the nurse says is unprofessional, and that no one wants to work with that doctor.
This situation is a surprise to you because you personally see this physician as one of your best. You would like to dismiss this complaint as just a misinterpretation on the part of the nurse; however, this nurse is one of the most dedicated, competent nurses in the NICU. What do you do?
Scenario 3
As the chair of your department, you want to improve understanding of the importance of having your practice reflect perspectives of diversity, equity, and inclusion. To engage this better, you want to incorporate in every one of your one-hour team meetings, 10 minutes devoted to having physicians discuss proactive actions they have engaged as well as obstacles they have encountered/witnessed.
How might you introduce this topic and build this into meetings? What evidence would you provide to help your team understand that this is not just a “nice-to-have” but a “must-do”?
Scenario 4
The vice president of finance has asked everyone with team responsibilities to submit a budget analysis for the past year. Your boss has passed this information on to you. You subsequently ask for some critical information from selected team members so you can complete the report accurately. Someone reporting to you has failed to deliver a key piece of the budget analysis you had requested. From past meetings with this individual, you have noted indifference to the entire budgeting process. In fact, this individual has directly stated, “This is nonsense because we’re a healthcare institution and should not be responsible for the finances here — this is others’ responsibility.”
You decide to call the individual into your office for further discussion. Upon your mention of the budgeting process, the individual just picks it apart. Now what?
Processing Scenarios in Real Time
How are these scenarios processed? We have seen the greatest success when these are reviewed and resolved in teams. The scenarios could be addressed by intact work teams — perhaps department chairs with their team leaders — or by ad hoc teams —
perhaps a team of several chiefs of professional practice.
Whatever the process, it needs to be conducted in real-time. This means that the team members assume the roles of the players in each scenario as they address the issue. Interestingly, we never share with the teams that they should “role play” because most individuals get anxious about doing that; however, because of the ways the case scenarios are presented, physician leaders often spontaneously take on these various roles without any suggestion from us.
We suggest that physician leaders receive the scenarios about a week before they come together as a team. If this process is presented within a more formal physician leadership development program, we suggest that the physician leaders consider their prior learning and any evidence-based perspectives that should be incorporated into the resolutions.
The “Right” Answers
What are the “right” answers to each scenario? This is the primary question physician leaders ask when they engage in this process. Our response is that there are no “right” answers; however, there may be “best” answers that we pull from top research studies on the topic, benchmarked practices in leading organizations, our experiences as consultants, and the real-world experiences of these physician leaders themselves. All make up “best” answers.
To give you a flavor for some of the models, theories, and practices we have engaged in these case scenarios, a sample list identified by content expert is presented in Figure 1.
Figure 1. Sample list of models, theories, and practices identified by content expert
After each team has resolved the challenges or addressed the opportunities in all the cases, we have a debriefing session of the “what, why, how, when, and where” of their work together. This can be done as a small group if it’s outside a formal training program.
If it’s within a formal training program and there are several teams reporting, we do a large-group debrief. First, we hear from the group(s) how they handled each of the scenarios. Second, we share our evidence. Third, as consultants, we embellish each of these solutions with evidence-based literature to support these resolutions. Here are some of these sample resolutions to each of the real-time scenarios.
Possible Solutions to Scenario 1
Engage in conversations that align with the strategic vision of the organization and/or department.
Conduct a needs assessment that extends beyond interests to real issues that impact performance.
Benchmark internally and externally; do not focus on healthcare exclusively.
Review corroborating and conflicting data from your organization’s culture survey. Be a sleuth!
Determine the interpretation of “morale” in concrete and behaviorally specific terms.
Negotiate: use interests-based approaches, avoid the irrational escalation of commitment, engage realistic alternatives to agreement.
Zero-in on best-sourced organizational climate and culture resources.
Possible Solutions to Scenario 2
Determine first that the patient is in no immediate danger.
Consult your organization’s due process guidelines; seek external benchmarks as appropriate.
Do not talk with the physician until more data are gathered; look for behavior patterns.
Engage with the relevant content experts from Quality Assurance, Human Resources, etc., for further guidelines and guidance as needed.
Review appropriate external documentation (e.g., new Joint Commission guidelines).
Provide feedback in ways that are concrete, meaningful, and consequential.
Provide feedback to “toxic protectors”; link to bottom-line and performance-impact model.
Possible Solutions to Scenario 3
Share a particular reading on diversity, equity, and inclusion for all to read before one of your team meetings.
Ask physicians to provide some opportunities they have experienced and obstacles they have witnessed.
Teach physicians the “equity pause”(3) to support their work in being more inclusive in their leadership decision-making.
Possible Solutions to Scenario 4
Get further clarification, engaging a performance-management method.
Use the situational leadership model in which you determine if the individual needs direction, guidance, support, or delegation, based on “task” × “motivation” assessment.
Make sure responsibilities and accountabilities are clear, with the integration of concrete systems thinking.
If no change (after assessing “readiness” based on four specific levels), jump into the “directing” mode.
Describe the problem, explain the impact, pause and get feedback, brainstorm alternatives, select one alternative depending upon the person’s motivation. Ask the person to follow up within a designated period of time.
What Have We Learned?
This real-time, real-work simulation process has helped us learn what has supported the learning of physician leaders. Figure 2 demonstrates top learning and associated sample content areas.
Figure 2. Top learning topic areas with associated sample content
We understand that one size does not fit all; however, based on strong evidence from the research and literature, benchmarked practices, and our own experiences as consultants, we have discovered that about 75% of the 40 real-time, real-work scenarios we have designed apply to any organization. For the remaining 25%, it is critical to engage a planning team of leaders to design scenarios that fit the issues and opportunities of the organization.
A Built-In Needs Assessment Component
To our delight, our clients have discovered that the aggregate data from how teams have addressed challenges and opportunities can become a built-in needs assessment. For example, one client had four teams of physician leaders go through this process. They collected the aggregate data on how the teams handled each case scenario and used this as a way to assess strengths and areas of improvement for physician leaders.
What a stellar way to have a practical assessment of leadership needs that extends beyond the traditional survey, interviews, or focus groups! While the primary purpose is the professional development of physician leaders, understanding these needs can be creative fuel for others in the organization to better understand key challenges and opportunities and address these with effectiveness, efficiency, and collaboration.
References
Kusy M and Holloway E. A Field Guide to Real-Time Culture Change: Just “Rolling Out” a Training Program Won’t Cut It. J Med Prac Manage. Mar-Apr 2014;29(5):294–303.
Kusy M and Wesner S. The Art and Science of Developing Physician Leaders: A Program Template with Tangible Performance Outcomes. Physician Leadership Journal. Nov-Dec 2021;8(6):51–56.
Brookfield SD, Hess ME. Becoming a White Antiracist: A Practical Guide for Leaders, Educators, and Activists. Sterling, VA: Stylus Publishing; 2021.