Being a healthcare administrator in 2023 is challenging. Managing the often-competing agendas of payers, accreditors, internal departments, colleagues, patients, and more requires the ability to balance perspectives, demands, and needs with the administrator’s view of the best interests of the institution. It sometimes calls for implementing unpopular policies and procedures and getting feedback from people who don’t understand existing constraints and who may hold the individual administrator personally responsible.
Administrators who are also clinicians often face additional layers of challenge as they understand the impact of their decisions from a more multi-faceted viewpoint and as their clinician colleagues hold them more solidly to account.
We conducted interviews and conversations in fall 2019 to inform the development of an intervention called 3rd Conversation. In those interviews, several clinician leaders described feelings of isolation and burnout, as well as a lack of trust and interpersonal connections. They shared the impact of these dynamics on their organizations:
Isolation and Burnout: The clinician-administrators shared how lonely and isolated they often feel, yearning to connect with colleagues at a deeper level. They described losing the joy of the job and their sense of psychological safety. These feelings can drive burnout, exhaustion, and the dehumanization of others with whom they come in contact.
Lack of Trust and Connection: They expressed frustration and defensiveness as they tried to do their jobs. The lack of trust makes change management more difficult, and they feel the pressure of fellow clinicians thinking they’ve “sold out.”
Organizational Impact: Clinician-administrators shared that the lack of connection and trust leads to reduced margins, poorer quality care, staff turnover, and waste. They were confident that creating a circle of allies would make patient care safer and create better-performing teams who feel more joy in work.
Academic research supports the value of connection and relationship in reducing burnout and improving the experience of work:
A study of 83 doctors revealed that “nearly all the doctors, although given deliberately general and nondirective instructions, described a [sic] nontechnical, humanistic interactions with patients as experiences that fulfilled them and reaffirmed their commitment to medicine.”(1)
Similar findings were reported regarding what doctors find most satisfying about consultations: developing and maintaining relationships, with a sense of knowing the patient.(2)
Another study found that “loneliness is common in practicing family medicine physicians and is significantly associated with burnout and depression.”(3)
Loneliness can also hinder job performance, including among CEOs.(4)
Conversely, a review of 64 relevant studies demonstrated that having strong connections at work may lead to better job performance.(5)
Leading research also indicates that burnout follows from the social environments in which people work rather than from personal characteristics. However, many interventions are aimed at the individual instead of the organizational level from which some of the root causes emanate.
In August 2021, we surveyed 165 health system leaders on key challenges related to patient experience and clinician well-being, current and planned programming, and attributes of those programs that mattered most to them. The survey had a margin of error of +/- 8 percentage points, with 95% confidence.
When asked about the kinds of programs their organization is planning or has in place, only a slight majority (52%) of survey respondents reported that they had programs in place for improving patient-clinician relationships, and just one-third (33%) had programs in place for enhancing clinician-administrator relationships. When asked to rate the effectiveness of those programs, only 62% said the clinician-administrator relationship-building programs were meeting their needs, and just over half (52%) said the same about the clinician-patient relationship programming.
The Innovation: Relational Conversations
To test whether relational experiences could rebuild relationships between clinicians and administrators more effectively, and to understand how deeper relationships might facilitate organizational change, we implemented an intervention called 3rd Conversation (3C) with 18 healthcare sites over the past four years. 3C is an experiential program that taps into the power of bi-directional empathy to build connection, trust, and hope.
3C experiences leverage evidence-based practices such as appreciative inquiry, narrative leadership, and the science of empathy, along with innovative activities such as “dreamstorming.” By focusing on what works, modeling vulnerability, creating bi-directional empathy, and envisioning a future participants want and need, evaluation data show that these 3C experiences address burnout, build trust and connection, and inspire individual and institutional action.
The 3C program has two types of intervention:
The Spark experience brings patients and clinicians together to repair their fraying connection. Participants spend 2.5 hours having intentionally designed and professionally facilitated discussions and sharing. Feedback has been eye-opening. One physician shared thoughts commonly voiced by clinicians: “I appreciated hearing from the other clinicians that they struggle with the same things I do, and it was helpful to hear how much the patients need from us, appreciate us, and are grateful for what we’re giving.”
Nearly three-quarters of clinician participants surveyed reported that conversations like the 3C Spark experience could help with feelings of burnout. A patient participant noted, “We have to be a little more considerate for the doctors because they are overworked, overburdened; if we could be a little more understanding, the doctors would appreciate that.” More than seven in 10 (73%) patient participants reported feeling more trusting of and connected to the clinicians with whom they spoke, and nearly 60% felt more positive about being a patient at the medical practice.
The Ignite experience convenes clinicians and administrators for similar deep engagement in a three-hour session. Evaluation data reveal that the impact of the Ignite experience on administrators and clinicians has been significant at the individual and organizational levels. By opening a door between the two roles, clinicians become more sympathetic to administrators. This may hold particular promise for administrators who are also practicing clinicians and who may feel additional distancing and even hostility from their clinician colleagues.
Insights and outcomes that emerge from the Ignite experience and which can launch more effective collaboration include:
1. Connections made at the Ignite experience counteract non-administrator clinicians’ tightly held beliefs about administrators’ inhumanity. In one Ignite experience, clinicians reported that going forward, they would remind themselves “that administrators are people, too.” Administrators appreciated hearing something so fundamental to their well-being and their ability to collaborate effectively with clinicians.
2. Administrators and clinicians ardently want more formal opportunities to talk with and listen to each other. Participants spoke about creating or improving on formal opportunities, such as listening sessions and monthly meetings, to understand each other’s needs, wants, and challenges better.
One group of administrators proposed “facilitated listening sessions focused on specific topic matters, to give folks the time and space to express their needs and give the administrative side time to help the others understand the challenges to make changes.” They would then move to action “to transform from listening to working.”
3. Many people simply want to be heard and to hear others with respect. Administrator and clinician participants expressed the innate value of being listened to. Several participants framed it as a request to “give each other grace.” Similarly, clinicians recognize that they need to “stop assuming why certain changes are coming down and move to a space of curiosity and exploration,” putting judgment aside to understand administrators.
4. Engaging intentionally with clinicians affirms for administrators that top-down approaches don’t necessarily work. One CEO shared, “The typical way of doing business in a company is the leadership team develops a plan and tells everyone, this is what we’re going to do. But that model doesn’t work. We have to meet clinicians where they are and with what they need. Everything we try to do can’t be the eight of us from an Admin team sitting around trying to think about how to fix something. I am hearing this loud and clear today. So going forward, I want to hear more voices. I don’t want to inadvertently minimize voices — everyone has to be part of the conversation.”
At the same time, many clinicians share that they want to be involved in decision-making. One group of clinicians framed this beautifully: “We want more involvement when decisions are being made, so we’re not told last-minute. We want to be part of the solution; if we’re more involved, we can be more helpful.”
5. Participants in administrative and solely clinical roles understand the value of administrators having a handle on the work and work experience of clinicians. This clearly is an area where the clinician leader has a leg up. Nonetheless, during 3C experiences, clinicians regularly invite administrators to shadow them during their day, and administrative leaders welcome the opportunity.
Pre- and post-event surveys underscore the value for administrators and clinicians who participate in Ignite experiences, refreshing clinicians and administrators alike and supporting those who are in both roles. Consider these statistics:
More than 9 in 10 clinicians and administrators reported that the Ignite experience improved their likelihood of staying at their organization. This has tremendous implications for retention in organizations that invest in similar activities.
An additional 25% of participants felt confident after the Ignite experience that clinicians and administrators can create positive changes together in their organization or clinic. While this number may appear lower compared to other results, this impact is notable in that it is achieved in just one three-hour session. Improving confidence overall will require time and additional positive interactions.
An additional three participants out of 10 believed after the Ignite experience that they could personally have more influence in creating positive changes in their organization or clinic. Creating a sense of agency is a key element of mitigating burnout.(6)
More than eight in 10 (82%) clinician and administrator participants reported that their trust in the other group increased because of the conversation. As collaborative problem-solving moves at the speed of trust, improving trust can accelerate solutions-finding.
Three Lessons For Thriving Physician Leaders
Pursue a people-first culture. Healthcare cultures that are first and foremost about the people who give and receive care promote well-being among individual leaders, teams, and organizations. Leaders can create and sustain such thriving cultures by ensuring that programs, systems, and interactions are person-centered.
Make it about relationships. Not only is it important to focus on people as individuals, but also on people connecting in meaningful ways. Relationships matter and bi-directional communication programs like 3rd Conversation set the stage for a deeper mutual understanding that in turn fosters collaboration, respect, and effective communication. Strengths-based techniques such as appreciative inquiry and narrative leadership integrated into daily work, formally and informally, reinforce relational practices that build connection and reduce isolation.
Double down on two-way communication. Structure substantive, bi-directional communication between clinicians and leaders to inform leadership and advance initiatives. This may be particularly helpful to the clinician-administrator who straddles and navigates both roles. Leaders can establish formal and informal mechanisms to actively listen to front-line staff, and vice versa. They can create pathways to include voices from the front line in decision-making, sharing information in powerful ways so input is informed by factors important to the organization.
Clinicians often feel the need to show leaders what they do, even if the leaders are clinicians themselves, as not every clinical position or experience is the same. Providing these opportunities will boost trust and provide invaluable information for decision-making. These practices will also make a difference in accepting and implementing organizational decisions. Time and again, participants in Ignite experiences report they better accept divergent decisions when they feel they’ve been seen and heard.
A bi-directional connection that fosters empathy and hope will nurture well-being and inspiration to reach organizational goals, from retaining staff to advancing equity, quality, and safety. It will have particular force for the administrator who is also a practicing clinician navigating the dual role. Time invested in forging deeper connections and trust is time well spent, with organizational-level impacts.
References
Horowitz CR, Suchman AL, Branch WT, Frankel RM. What Do Doctors Find Meaningful about Their Work? Ann Intern Med. 2003 May 6; 138(9): 772–775.
Fairhurst K, May C. What General Practitioners Find Satisfying in Their Work: Implications for Health Care System Reform. Ann Fam Med. 2006 Nov; 4(6):500–505.
Ofei-Dodoo S, Mullen R, Pasternak A, Hester C, Callen E, Bujold EJ, Carroll JK, Kimminau, KS. Loneliness, Burnout, and Other Types of Emotional Distress Among Family Medicine Physicians: Results From a National Survey. J Am Board Fam Med. 2021;34(3):531–541.
Saporito TJ. It’s Time to Acknowledge CEO Loneliness. Harvard Business Review, February 15, 2012. https://hbr.org/2012/02/its-time-to-acknowledge-ceo-lo
Beal, DJ, Cohen RR, Burke MJ, McLendon CL. Cohesion and Performance in Groups: A Meta-analytic Clarification of Construct Relations. J Appl Psychol, 2003 Dec; 88(6):989–1004.
Maslach C, Leiter MP. New Insights into Burnout and Health Care: Strategies for Improving Civility and Alleviating Burnout. Med Teach. 2017; 39(02):160–163.