Earlier this week, Health Affairs Blog published an essay by a group of health care CEOs declaring physician burnout a public health crisis, and recommending steps to address it. The authors concern is genuine and their recommendations should be heeded. But their proposal reveals a paradox that lies behind many of the crises in health care: the thinking being applied to solving the problem is the same thinking that created the problem.
A bias for systems
The executives essay describes the problem clearly: Burnout is an experience of emotional exhaustion, depersonalization, and feelings of low achievement and decreased effectiveness.”
And the CEOs seem the understand the root causes of these feelings:
“The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.”
It seems clear: an unintended consequence of the systematizing of health care is a change in the experience of physicians. Processes and procedures intended to help are inadvertently hurting the people who deliver care.
But when it comes time for the CEOs to propose solutions, where do they turn?
“We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success.”
The article goes on to proscribe eleven interventions to address physician burnout – each focused on measurement, process re-design, regulatory reform, best-practice documentation and technology. They get the goal right – restoration of the joy of a career in medicine – but they propose achieving it through the methods that undermined that joy for so many!
No doubt these solutions are important – vital even – but they are insufficient to address the problem at hand: more systems will not undo the effects of the systems we’ve got.
Seeing the whole thing— an Integral Approach
In our work with clients, my colleagues and I introduce the work of Ken Wilbur to help leaders understand their organization and performance challenges. The model proposes two ways of looking at the world: first, a distinction between the objective, that which is exterior, and can be me
asured and quantified — and the subjective, that which is interior, and felt, thought and believed. Second, the model divides the world into aspects that are individual and apply to one person or instance — and aspects that are groups and apply to multiple people over a period of time. Combining these four halves creates a two by two grid called the integral model.
We assert that effective leaders attend to all four domains and that successful organizations create alignment between the mindset and behavior of individuals, and the systems and culture of the group. Like a chain that is only as strong as its weakest link, so too is an organization limited by its weakest quadrant— great culture cant compensate for lousy systems; the right behavior with the wrong mindset does not lead to success; etc.
This is not controversial — we’ve heard Peter Druckers adage, culture eats strategy for breakfast; white-papers and conference keynotes call for culture change and greater leadership; we know that culture and mindset matter every bit as much as behavior and systems. And yet, as managers we spend most of our time and attention on the domain of systems.
We know culture matters, but when we go to work, we focus on systems.
Going to Work on the Subjective
So whats the answer – how can over-scheduled and over-worked executives in health care go to work on the soft challenges necessary to reduce physician burnout?
We believe that the first step is making time to talk to people. If physician burnout is indeed a public health crisis, then it deserves our time and attention. Leaders who are committed to reducing physician burnout will talk with physicians about burnout – not once a year during a communication blitz… not once a month at meet the boss brown-bag lunches… but every day. If you are not making time in your day to have candid, thoughtful conversations with physicians about burnout, you are sending the message that you’re more worried about other things.
We believe that asking questions is far more useful than making statements or providing direction. Administrators (and physicians!) are sometimes reluctant and ill-equipped to discuss soft issues like fulfillment and personal satisfaction. As leaders, we must help them by creating openings to reflect and speak about their experiences. These neednt be lengthy conversations, but they must be genuine. Ask questions like, What aspects of your work you find most fulfilling? When was a time when you felt most satisfied in your career? What would need to change in order for you to have more work / home balance? 
As managers and physicians, we’ve been trained to focus on problems and look for root causes. But there is much to be learned from looking at bright spots in a system – people who have avoided or solved a problem. Who are the physicians you know who have overcome burnout? Who are the docs who feel energized by their work? Talk to these people! There is a temptation to attribute their success to personal qualities (shes passionate), but watch what they do – what specific behaviors set them apart from others (she greets each staff member by name and introduces herself to people she doesn’t know)? Can you emulate these behaviors? How can you spread them throughout your team? 
A call for leadership
The CEOs who wrote the Health Affairs article are passionate, intelligent and dedicated; they’ve got incredibly difficult jobs and dozens of stakeholders to please each day. They are to be commended for their resolve to address physician burnout.
But we must see the problem of physician burnout for what it is – people feeling disenfranchised, frustrated and afraid. Systemic approaches are necessary – vital, even – to solving the challenges of health care – but more measurement, process improvement and technical innovation alone will not address the emotional experiences of individuals. That requires conversation, engagement, listening – in a word, leadership.
 We highly recommend the book Humble Inquiry by Edgar Schein.
 We recommend reading Chip and Dan Heaths book Switch: How to Change When Change is Hard.
About the author: Andy Erickson is a principal and CTO at Humanus Solutions, a consulting firm specializing in leadership, organizational culture and creating breakthroughs in performance. He can be reached at firstname.lastname@example.org