CJPLEnhancing physician leadership resilience

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Enhancing physician leadership resilience

Greg McQueen, PhD, and Chris Bart, PhD

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Resilience — the capacity to cope with stress and bounce back — is a critical attribute for physician leaders. Two methods for cultivating resilience have received only scant attention, and these are the focus of our article: viewing stressful and painful situations as opportunities to learn and grow rather than wither and die; and engaging in non-arbitrary social cooperation and consensus-building.

Although there are many definitions of the term resilience, we think that Mosby’s Medical Dictionary1 provides one that resonates with most physicians: Top

A concept that proposes a recurrent human need to weather periods of stress and change successfully throughout life. The ability to weather each period of disruption and reintegration leaves the person better able to deal with the next change.

Resilience, therefore, is the positive capacity to cope with stress and adversity resulting in an individual bouncing back and learning from the experience. Like all other assets that humans work with, resilience is a valuable but expendable resource that can be increased or depleted; and, like all other human resources or skills, it can be nurtured and developed through learning and practice. Top

Why physician leaders in particular should take time to enhance their resilience is obvious. The complicated and complex nature of the health care system, with its internal forces and external factors pushing up against each other, creates enormous occupational stress. Moreover, advances in medicine and health care, along with the changing roles of health professionals and changing health care delivery systems, call for a high capacity to bounce back on the part of all those in leadership roles.

As much as physicians may like to delegate, that is not really an option when it comes to resilience. In Robert Smith’s book, Breakfast with Socrates,2 Socrates suggests there are two things that cannot be delegated: going to the doctor and going to the gym. In “Resilience: a responsibility that can’t be delegated,” Kent Helwig3 suggests that this is also true for resilience. If resilience cannot be delegated, what does the physician executive have to consider exploring to build resilience?

When 60 physician executives were surveyed during the 2014 Canadian Conference on Physician Leadership in Toronto, April 2014,4 100% answered yes to the question, “Do you need to have a high degree of resilience to be a good/great leader?” In the same survey, only 55% indicated that current physician leaders have such resilience. Incredibly, 55% of participants rated themselves as either “In a borderline survival state” or “Burnt out.” Top

The urgent need to enhance resilience among physician leaders thus appears to be extraordinarily clear. Fortunately, there is an abundance of literature on the topic of resilience and how one can increase it. Some of the more popular methods are intentional focus and minimizing distractions, a positive predisposition and sense of happiness, narrative medicine, and increased emotional intelligence. However, there are two other methods that have received only scant attention, and these are the focus of our article: viewing stressful and painful situations as opportunities to learn and grow rather than wither and die; and engaging in non-arbitrary social cooperation and consensus-building.

Viewing stressful and painful situations as opportunities to learn and grow

Let us look at a colourful example of the stress one physician leader experienced. A biomedical ethicist in a medical school would often be called to do morning rounds with an infectious disease specialist who also held leadership positions at both the hospital and medical school. Generally, a biomedical ethicist is never called to do rounds if everything is going well; however, this particular physician wanted the ethicist’s opinion regarding some of his most difficult cases. Top

What the bioethicist saw during those consults was a physician with an extraordinary bedside manner. He was sensitive, empathetic, had a broad perspective, and was open to ideas from other team members. He strived to understand what the patient was thinking, helped the patient understand complex medical information, and engaged the patient in shared problem-solving. Yet, at staff meetings (after morning rounds), that same physician became a different person. In meetings, he would be impatient, demeaning of others’ ideas, fixated on his solution to the problem, and not interested in others’ perspectives. Afterward, the bioethicist would have a vigorous discussion regarding the physician’s

“non-constructive behaviour.”

After several months, the physician came to visit the bioethicist. He had been bothered about the post-staff-meeting discussions and said that he had finally asked himself: why is this stress happening to me and what might I do about it? In other words, he started running toward his pain rather than away from it.5 In so doing, he was eventually able to conclude why the staff meetings were so upsetting and stressful for him. Top

He explained that, when he was with patients, he knew his role, i.e., the conduct and behaviour expected by his patients as their physician. He knew the patients’ role, and patients knew their role as well as that of the physician. He went on to explain that, in staff meetings, he was often unsure what role was expected of him and what others’ roles were and, thus, as he described it, he “flailed around and was less than constructive while feeling very agitated.”

The good news was that once he understood this about himself, he clarified his role and that of others in the meetings and applied the skills he used when working with patients. He became a highly contributing participant in staff meetings and experienced a lot less anxiety and agitation. He used his problem-solving and learning skills as part of his resilience strategy to “bounce back,” especially when dealing with highly contentious or controversial medical issues in some intense meetings. Top

We believe that understanding one’s role(s) — and what one is required to do in them — as a leader (as well as becoming more proficient in these roles) is one of the best methods physician leaders can use to avoid unnecessary stress and anxiety and, thereby, avoid having to deploy their resilience skills in the first place. As Bart6 has noted in his 10-year best seller A Tale of Two Employees and the Person Who Wanted to Lead Them, the number 1 reason why anyone does not do what is expected and needed of them (a highly stressful state!) is because they do not know clearly, specifically, precisely, and unambiguously what it is that they are supposed to do. Once such clarity is brought to roles, stress and anxiety are reduced immediately for both the role giver and the role receiver.

Moreover, McQueen’s work in the Niagara Institute’s Leadership Development Program7 has highlighted the critical importance of leaders’ need to enhance their ability to engage effectively in difficult conversations and to do so through their ability to engage in non-arbitrary social cooperation and consensus-building. Top

Engaging in non-arbitrary social cooperation and consensus-building

Change is always stressful. Accordingly, dealing with change well and helping others deal with change is not only important in being an effective leader but it is also an indispensable key to personal resilience and developing resilience in the team one leads. Facilitating or leading change, however, always involves making decisions that will inevitably affect others in varying degrees, typically presenting the necessity for them to change as well.

Kohlberg9 and Rest and colleagues10 have pointed out that decisions that affect others — or that have a social impact — involve moral reasoning (i.e., trying to find the right or fair solution) and are ethical decisions involving the application of a particular system of values and principles of conduct, either held by a person or group of persons (society). Top

In our research with the Directors College of Canada since 2004,11 we have asked over 600 board directors what percentage of the decisions they make on their boards have social implications. Approximately 85% of all their decisions have social implications for individuals or groups and, therefore, require moral reasoning. We suggest that this is also the case, if not more so, for physician leaders given the complexity of the world they work in and the social implications of their decisions. We have also discovered that the secret to successfully working with others in decision-making is the leader’s ability to engage in non-arbitrary social cooperation and consensus-building with those who are party to and potentially affected by the decision.

According to Rest et al.,10 there are three levels of complexity in moral reasoning. The first hinges on the concept of “personal interest,” in which the decision-maker says, “I know what the right decision is because it is what I want [which usually involves his/her seeking pleasure and avoiding pain/punishment with little if any concern for others], and I expect others to support me on my choice. Or else.” This, of course, is the world of the omniscient, bully physician leader. Top

The second level of complexity is based on the concept of “rules” where pre-existing norms or laws tell the decision-maker what he or she must do to fit in and to belong to a group, profession, or society. Under this form of moral reasoning, the world is black and white, and one knows the decision is right because one is following the rules. In the world of medicine and health care, many physicians find comfort — and sometimes legal protection — in the form of guidelines or unwritten rules of the profession or the health care unit of which they are a member.

The most complex level of moral reasoning, “post-conventional morality,” does not rely solely on what one thinks is right (“pre-conventional morality”), nor does it rely predominately on the rules in play (“conventional morality”). Instead, it depends on a more sophisticated and advanced level of decision-making using a process of social cooperation and consensus-building in which meaningful interaction and input from others (who are party to and/or affected by the decision) are both solicited and valued. The opinions of others are thoughtfully considered; a sincere attempt is made to accommodate their concerns; and, at the end, they feel as if they are being treated fairly. Top

We suggest that physician leaders with the capacity and tendency to use this highest level of moral reasoning will be more resilient than others in dealing with, and recovering from, debilitating and enervating decision conflicts and will be a role model for their colleagues regarding being more resilient.

Our research12 and that of others9,10 shows that leaders using the most complex level of moral reasoning tend to understand and appreciate the reasoning used by all others. They also tend to exhibit the following characteristics that make them more resilient and, thus, able to help others be more resilient. Complex moral reasoners:

Have a broader perspective on issues
See more alternatives and potential solutions
See themselves in a larger social context
Are able to step into the shoes of others and see things from another’s point of view
Are more inquisitive
Understand more complex dimensions of justice and fairness

With these characteristics, leaders are more effective in interacting with others and, therefore, engaging in higher-quality decision-making. They are more comfortable dealing with change and helping others work their way through change.9 These characteristics also tend to create more trust between the physician leader and those they lead and work with.13 As a result, physician leaders are more comfortable engaging in difficult conversations. Finally, these physician leaders will be especially more adept at viewing stressful and painful situations as opportunities to learn and grow rather than wither and die. Top

References

1.Mosby’s medical dictionary (8th ed). St. Louis, Mo.: Mosby/Elsevier; 2009.

2.Smith RR. Breakfast with Socrates: an extraordinary (philosophical) journey through your ordinary day. New York: Free Press; 2009.

3.Helwig KR. Resilience: a responsibility that can’t be delegated. Front Health Serv Manage 2013;30(2):31-5.

4.McQueen GP. Medicine: resiliency in the midst of change. Presented at Courage: bringing authenticity to action, Canadian Conference on Physician Leadership, Toronto, Ontario, 11–12 April 2014.

5.Assaiante P, Zug J. Run to the roar. New York: Penguin; 2010.

6.Bart C. A tale of two employees and the person who wanted to lead them. Hamilton: Corporate Missions Inc; 2003.

7.Clark R. Power up your brain: resilience at work. Presented at the Niagara Institute, Niagara-on-the-Lake, Ontario. April 2013.

8.Kotter JP. Leading change. Cambridge, Mass.: Harvard Business Press; 1966.

9.Kohlberg L. 1981). Essays on moral development, vol. I: the philosophy of moral development. San Francisco, CA: Harper & Row; 1981.

10.Rest JR, Narvaez D, Bebeau MJ, Thoma SJ. Postconventional moral thinking: a neo-Kohlbergian approach. Mahwah, N.J.: Lawrence Erlbaum Associates; 1999.

11.McQueen G. A compass for board directors : the convergence of leadership and ethics. Presented at The Directors College, McMaster University, Hamilton; 2005.

12.Bart C, McQueen G. Why women make better directors. Int J Bus Govern Ethics 2013;1:93-8.

13.Bloomgarden K. Trust: the secret weapon of effective business leaders. New York: St. Martin’s Press; 2007.