Thriving health care demands thriving physician leadership

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OPINION: Thriving health care demands thriving physician leadership

A simple approach to 21st century physician leadership

Steve Foran, PEng


The presence of exponential change and the absence of thriving physician leadership create the perfect storm that could leave the health care system vulnerable to disruption and possibly make the system, as we know it, irrelevant. On the other hand, thriving physician leadership has the potential to be the catalyst to drive internal change and create a thriving health care system of the future, one that Canadians will continue to rely on as they have for generations. Thriving physician leadership, while difficult to achieve, is extremely simple and is best developed by building a more grateful frame of mind.


It is critical that we get health care right so that, as a system, it thrives. For me, we need to get it right so that every Canadian can live a respectful, dignified life.


It’s naive to think that the existing system won’t be disrupted. The exponential growth and change in technology and science are driving disruption in all industries, and health care will not be immune. Given the magnitude of the public investment in health care, this disruption is likely to come from outside the system. Frankly, the potential financial reward creates an attractive incentive for the private sector to disrupt the system. Top


I was at a conference last fall where Peter Diamandis spoke on innovation and disruption.1 When asked about how disruption will happen in highly regulated industries that are slow to embrace change (with reference to health care), Diamandis was emphatic. Paraphrasing his words: disruption will be driven from outside the industry and it will make the current system irrelevant. These words still reverberate in my mind, given that he’s a MD with a breadth of first-hand experience in the field of applied innovation. We can have well-equipped hospitals with the most advanced technology and the best models of care, but a thriving health care system also requires thriving physician leadership to deal with disruption from outside.


I’ve come to learn that, although I don’t like discipline, I much prefer self-discipline over external discipline. If I will be disrupted, I would prefer to be the disrupter rather than someone else doing the disrupting. This is where leadership comes in.


If asked to describe leadership in a single word, 10 people are likely to use 10 different words. For me, that one word is “influence.” Leadership encompasses both influence over oneself and influence over others. Your ability and my ability to influence are determined by our mindsets, which are shaped by our established attitudes and beliefs. Our mindset determines how we make sense of the world and dictates how we show up as leaders. Figure 1, The leadership  mindset hierarchy, illustrates four possible mindsets from “surviving” to “thriving.”


Before examining each of the four mindsets, it’s important to note that you don’t have to match every single characteristic associated with each level. In fact, you may be at a point between levels or, depending on the day, you may switch from one level to another. The bottom line is that there are exceptions, so you don’t have to perfectly match the definition to understand where you spend most of your time on the leadership hierarchy.



Surviving is drudgery; your world is a battleground. It feels very lonely and overwhelming. You just can’t seem to get to your priorities and, when you do, it seems like another one or two priorities have been added to the long list. You suffer from poor sleep and don’t pay attention to what you eat. Exercise would help relieve your stress, but you never exercise; there’s no time and, if there were time, you would want to just relax. When you look at others, it seems like everything is stacked against you and what you’re trying to achieve. It is hard to muster the energy to move forward, and it seems that you’re constantly crushed by financial pressures and plagued by a myriad of challenges that never seem to end.



Striving is hard work. You are driven to succeed but there’s seldom enough time in the day to get to everything, let alone work on your priorities. You find this exhausting. You say you get enough sleep, but deep down know you’re fooling yourself. You know what you should be doing when it comes to exercise and nutrition, but you just don’t have the time. You’ve got goals, but you are frustrated because you are not anywhere close to your desired progress, and when you look at what others are doing, you feel like you should be doing better than they are. You hate being unable to spend quality time and quantity time with family and friends or on the fun things you used to always have time for. Financial pressures and other life challenges regularly determine what you can and cannot do. You truly know and believe there is more to life, although there are days when it just doesn’t feel that way.



Arriving is a good place to be. You are generally satisfied in all areas of your life, but the feeling doesn’t last — it’s intermittent. This is also true with family, friends, and doing the fun things, when time just flies by. You’ve got it, but not as much as you’d like. You’re regularly achieving your goals in all areas of your life, have no serious financial challenges, but are easily frustrated by others who you feel don’t deserve the success they’ve attained. You’re generally satisfied with the balance of exercise, sleep, and nutrition, feeling that, for the most part, it works. There are times when you feel that your life is controlled by others and your energy is being spent on the many challenges you face, rather than on the things that bring you joy and happiness. Some days you feel as if you’re back to striving or surviving.



When you are thriving, the world is your playground and you are very satisfied with all aspects of your life. You lead a meaningful, purpose-led life and compare yourself only to your own idea of who you want to become. Family and friends are important, as evidenced by the amount of time you choose to spend with them. When you are with them, you are present without distraction. You don’t apologize for the time spent on hobbies and fun activities that bring you joy. While you may or may not be wealthy, financial pressures are virtually non-existent. You recognize your interdependence with the people around you by contributing with your unique gifts to those in your community, be it down the street or across the planet. You have lots of energy and enjoy optimal health because you adhere to proper sleep, diet, and exercise routines. You’re not a health fanatic; you’ve just figured out that healthy living doesn’t have to be a chore. You still have lots of challenges, but you neither let them define you nor let them get in the way of achieving your goals. You are busy but your schedule is controlled by you, not by others.


The unrelenting force

Within our brains is an unrelenting force that is constantly pulling us back down into survival mode. It is composed of two smaller forces. The first is negative attribution bias, the human tendency to focus on the negative, inducing fear-based behaviour. The second component is adaptation. A universally relatable example is compensation. Remember your first pay raise? You were happy for a while but within a month or two, you adapted and, suddenly, your new pay rate was no longer enough, leaving you with a mindset of scarcity.


The invisible barrier

Finally, there’s a menacing invisible barrier between striving and arriving that keeps most people stuck in the struggle of scarcity and survival. The barrier appears whenever you let your guard down by losing sight of a simple but powerful belief: you are worthy and have much to be grateful for.


When you lose sight of this belief, the barrier appears. It disappears when you consciously hold the belief. The barrier can’t be seen, but it continually influences your mindset and the way you think, feel, and act. The highest risk for the barrier keeping you in survival mode is when you are caught off guard by a hectic patient schedule, when you’re overwhelmed by administrative demands, when you get into an argument with your spouse, or from any of the countless workplace or life stressors.


Obviously, our goal is to spend more time thriving and less time surviving.


Martin Seligman, the founder of positive psychology, developed the PERMA model for human flourishing (think thriving) which is rooted in 24 positive character strengths, such as hope, openness, bravery, and honesty.3 Because it is difficult to work on 24 strengths, Scott Barry Kaufman, one of Seligman’s colleagues, asked, “What if we can work on just one? What is the single character strength that is the best predictor of a flourishing life?”4 So, as part of a larger study on introversion that involved more than 500 participants, he did an analysis on what is the best predictor of human well-being. He found that only gratitude and love of learning independently predicted well-being, and the single best predictor was gratitude. Top


My struggle to thrive

Last year, our son Nick had a full hip replacement four days after his 28th birthday. He had no serious accidents nor sports injuries growing up, and the cause remains unknown. Only one hip was affected; no sign of arthritis. As parents, it was upsetting to learn that one of our kids required a procedure of this magnitude. There was the heartache we felt because of the pain he had been living through, and the impact the surgery would have on his life during recovery. This was magnified by the uncertainty it held for his future, knowing this wouldn’t be his last hip surgery, either. There was the anxiousness as we approached the surgery date: “What if something goes wrong during surgery?” All of this thinking was survival thinking, which is quite natural; however, it did not need to define how we dealt with the situation.


I was committed to finding good in the situation. I asked, “What’s good about the fact that Nick needs a hip replacement at age 28?” I surprised myself with how quickly the list began to grow. Top


  • Nick would no longer be in pain
  • He had a top-notch surgeon, who had successfully completed this operation thousands of times
  • Our health care system took care of the expenses, so it wouldn’t encumber him with any financial burden
  • Nick was in good physical shape, so his recovery would go quickly and he’d be back to normal life in no time
  • He was able to get the surgery scheduled quickly and conveniently between his school terms, so it had little impact on his education
  • Although the new hip is unlikely to last him the rest of his life, technology is making replacement hips last longer and longer, so he may only need one more
  • Nick had a very positive approach to dealing with this
  • His wife Kelsey was there to care for him and help him through his recuperation
  • He was able to borrow a walker and a few assistive aids without any cost to himself


This list of “good” was reassuring to me as a father. The fact that I can see so much good in this situation doesn’t mean that I don’t care or that I’m not compassionate about the pain and suffering our son experienced or would have to deal with through his recovery. It was quite comforting because, like any human, in the lead up to the surgery, I could feel the unrelenting force at work. “What if something bad happens during surgery?” “What if he doesn’t wake up?” Pragmatically, I had little control over either of these nagging concerns, but I would go back to my list of good and realize that my survival mindset was trying to mislead me.


“Look, we’ve got a very talented surgeon who does this surgery almost every day — a couple times each day — and he does it very successfully!” My ability to see the good in the situation, allowed me to turn to logical evidence, which helped me deal with the less than ideal aspects of his circumstances. It returned a sense of control to my world for something that I had absolutely no control over. More important, being able to see the good in this very serious situation prevented anxiety, fear, and a survival mindset from spilling over into the other areas of my life.


As a physician leader, you work within a health care system that is stretched to its limits. To transform this into a thriving health care system, now more than ever, we need thriving physician leaders, who are unwilling to be defined by the daunting challenges they face. Top


In a recent study, researchers asked acute care nurses in Oregon to consider everyone who thanked them — patients, families, physicians, charge nurses, or co-workers.5 They found that being thanked more often at work was positively related to a nurse’s satisfaction with the care they provided that week, which subsequently predicted sleep quality, sleep adequacy, headaches, and attempts to eat healthily.


To be a physician leader who expresses gratitude and brings about a culture in which the entire health care team feels appreciated, it is critical to develop a grateful mindset. The most researched and proven way to do this is to create and maintain the daily habit of making a list of three items for which you are grateful.6 Don’t rely on making the list in your head; write it down or record it electronically. Give this new practice a few weeks and notice the improvements you experience. Try this one habit, and if you want to know more about grateful leadership, email me: steve@gratitudeatwork.ca.

Although building a grateful, thriving mindset is not easy, it enables us to navigate the complexities and challenges of life in a collaborative, proactive manner. Each person has his or her own natural disposition to being grateful, and everyone has their own share of life challenges and tragedies, making it easier for some people to find gratitude and more difficult for others. As we develop the practice of gratitude, it becomes easier over time, and our disposition to gratitude increases. Although not a magic pill that will cure everything, if practised on a regular basis, gratitude has the power to induce positive disruption from within the health care system. That practice of gratitude begins with each one of us.



1.Diamandis P. Exponential tech: innovation & disruption on the road ahead. Presented at the conference, Embracing Innovation & Technology, 4 Oct. 2018, Toronto. North Vancouver: MacKay Forums; 2018.

2.Foran S. Surviving to thriving: the 10 laws of grateful leadership. Halifax: Steve Foran; 2019.

3.Seligman MEP. Flourish: a visionary new understanding of happiness and well-being. New York: Atria; 2011.

4.Kaufman SB. Which character strengths are most predictive of well-being? Beautiful Minds blog. New York: Scientific American; 2015. https://tinyurl.com/y3gl3ax4

5.Starkeya AR, Mohra CD, Cadizb DM, Sinclair RR. Gratitude reception and physical health: examining the mediating role of satisfaction with patient care in a sample of acute care nurses. J Posit Psychol 2019. DOI: 10.1080/17439760.2019.1579353

6.Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental Investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol 2003;44(2):377-89.



Steve Foran, PEng, CSP, runs Halifax-based Gratitude at Work Ltd, which specializes in helping leaders use gratitude to spend more time thriving and less time surviving. He is the author of Surviving to Thriving: The 10 Laws of Grateful Leadership, chosen by the Greater Good Science Center, University of California at Berkeley, as one of eight top summer reads for 2019.


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