Changing the Medical Culture One Team at a Time with Leadership Expert Tosca Bruno-van Vijfeijken

by Jen Barna MD | Burnout Prevention, Leadership, Physician Leadership, Physician Wellness, Podcast, Wellness

“If we want culture change, we need to bring a new top leader and they are going to kind of drive culture change from the top down. That’s not really how it works. It has to be at least a top-down and a bottom-up effort combined.”

– Tosca Bruno-van Vijfeijken

We’re excited to bring back international coach and consultant, Tosca Bruno-van Vijfeijken. She’s a public thought leader and coauthor of the book, “Between Power and Irrelevance: The Future of Transnational NGOs”, published by Oxford University Press in 2020. Tosca is an international expert on leadership and has many insights into physicians and leadership. In fact, she’s recently developed a course along with us at DocWorking on remote leadership for physicians, and the course is available to international leaders in sectors outside of healthcare.

Our thoughtful conversation includes Tosca’s opinions about organizational culture, the culture of medicine, and how her knowledge of cultures in other sectors intersect with the culture of medicine. We discuss the various problems that we have in our culture, especially the systemic problems that we know need to be fixed, and how that can influence individuals within the culture. The good news is that we as individuals, even in a broken culture, have agency. We know enough about organizational culture and what makes something healthy or not healthy, sometimes even toxic or broken, regardless of whether it’s the healthcare sector or another. If you’re a team leader, you have agency through the modeling of healthy habits, daily practices, and behaviors that you want your team members to demonstrate as well. You can support them by encouraging them, giving them positive feedback, and creating a culture of accountability.

Tosca shares her thoughts on the importance of honoring each other as vulnerable human beings and how to best support each other as we move through the workday. We talk about some of the unique challenges in virtual environments as well as within the healthcare community, especially those barriers to setting aside time to connect with team members outside of the day-to-day work with patients. Tosca also provides her insights into how organizational cultures can change from the bottom up.

What’s Inside:

  • Why it’s important for teams to see each other as vulnerable humans.
  • How modeling healthy behaviors can help team leaders create positive change.
  • Challenges within healthcare systems and barriers to organizational culture change.
  • The high costs of turnover, especially within the healthcare sector.
  • How organizational cultures can change from the bottom up.

Mentioned In This Episode:

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Please enjoy the full transcript below


Tosca: If we want culture change, we need to bring a new top leader and they are going to kind of drive culture change from the top down. That’s not really how it works. It has to be at least a top-down and a bottom-up effort combined.

Jen: Welcome to DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna and I’m so thrilled to have you here with me today. And I’m thrilled to have with me a terrific guest and a repeat guest who you may have heard earlier. We’re excited to bring back Tosca Bruno-van Vijfeijken, who is an international coach and consultant. She’s a public thought leader and coauthor of the book Between Power and Irrelevance: The Future of Transnational NGOs, published by Oxford University Press in 2020. Tosca is an international expert on leadership, and I’m really interested in speaking with her because of her insights into physicians and leadership. And in fact, she’s recently developed a course along with us at DocWorking to present to our physicians in the DocWorking community on remote leadership for physicians and also the course is available to international leaders in sectors outside of healthcare. So Tosca, welcome back to DocWorking: The Whole Physician Podcast. 

Tosca: I am so pleased that I’m back with you, Jen. It’s my honor. 

Jen: Thank you. I’m thrilled to have you. And I’m thrilled to have a thoughtful conversation with you today and hear your opinions about some topics that we’ve been talking about outside of the podcast. You and I have had many conversations about organizational culture and about the culture of medicine, and I’m really interested in hearing about how you see your knowledge of cultures and other sectors intersecting with the culture of medicine and the problems that we have in our culture, the systemic problems that we know need to be fixed, and how that can influence individuals within the culture. There’s so much to talk about. Perhaps we could start just by acknowledging that individuals, even in a broken culture, have agency. 

Tosca: Yes, they definitely have some agency. And just let me preface first by saying we know enough about organizational culture, and what makes something healthy or not healthy or toxic, sometimes even or broken, as you said, across sectors, right. So the healthcare sector, the government sector, other private sector realms, as well as nonprofits, whether they’re U.S. domestic or international. So, yes, individual leaders, particularly team leaders and team managers, have agency to affect some aspect of the culture. So as a team leader, you have a big influence on the behaviors of those in your team, because if we define culture as the widely shared, daily practiced and therefore repeated behaviors and habits, if you’re a physician who’s also a team manager or a team leader, you have agency by modeling some of these habits and daily practices and behaviors that you want your team members to also do more of or take on, if you will. So that modeling opportunity is quite big and as a team leader, you can also support your team members to take on habits, new habits or practices or behaviors that they in the beginning may struggle with. So you can support them by encouraging them, by giving them positive feedback. When they exhibit those behaviors or habits or practices, you can celebrate those in front of the rest of the team because team members are watching what you are doing, what your behaviors are as a team leader or team manager, much more than what comes out of your mouth, what you are saying. And at the same time, as a team leader or manager, you have agency because you can hold other team members and yourself to account. You can help hold them accountable for those behaviors and not just at formal moments of team performance reviews, etc., but also actually based on daily kind of regular informal feedback moments. So let me stop there and see what you think. 

Jen: I think that’s a terrific opportunity, and I think that almost all physicians are leaders in that type of a setting, and many physicians are leaders of larger groups. But certainly in the team setting and I’ve also heard people talk about bringing their team together in a huddle at the beginning of the day, for example, to find out what is going on outside of work so that people can support each other and also see each other as vulnerable human beings that they’re working with and understand a little bit about what they’re bringing to work in order to get through the day and support each other in the best way possible. What do you think about that type of an environment? 

Tosca: That is modeling in its own right. If you as a team leader or team manager or group leader or whatever, if you are making a habit of asking people what’s going on in the rest of your life. And by the way, if I can kind of as a side comment in virtual or in hybrid teams that prompt, it’s more difficult to think about that because in a virtual or hybrid environment, we tend to become even more task oriented and not relationship oriented. But yet it is all the more important to ask about the context of somebody’s life, because we don’t see much of that, right? We’re not bumping into each other in the hallways. We’re not having a chat in the kitchen. We’re not at the water cooler talking about our lives. So we miss a lot of that context unless, as you just said, unless we ask about it. So yes, that is definitely part of you are shaping culture. If you ask that question at the beginning of a meeting, if you have a regular one on one check in with individual team members, just ten, 15 minutes in addition to the group huddle can really make a difference if you do that regularly. And also another way, a nice way of shaping culture is asking your team members at the end of that individual or a group huddle, “What can I do to make your work today or this week easier?” Or “How could I manage you differently?” Those are all kind of shapers of organizational culture at a team level or group level. Even if you don’t have enough power or agency to affect what’s happening at the organizational level that might or might not be broken. 

Jen: Well, I love what you’re saying. And you’re making me think about the parallels between how we practice medicine currently and virtual leadership. Some of us do virtual leadership as well. And you’re absolutely right, it does become very task oriented. And everyone is pushing the limits of what they can do in terms of tasks. And you do lose that chance to talk about what’s going on in our lives outside of work, to really understand how someone is approaching their work. And what you’re making me realize is that’s often the case in the way we practice medicine now, even in person, because often we are so overtasked in the course of the day and we really want to hit the ground running. Every single person on the team is expected to do that. We don’t take time to talk at the water cooler. We don’t take time, at least us physicians, to interact with each other in a way that is about our personal lives. We interact to discuss patients and patient care, but we really never make time at work to talk about what’s going on outside of work. There’s just not time in the day. So I never thought about it until you said that, that really is a parallel between how we practice medicine currently and how we might lead a team virtually. That’s how isolated we can be in our practice, even though we’re on location. And I’m curious if you have any insights into ways in addition to, as you just suggested, thinking about starting your day with a huddle, asking people about what’s going on outside of work, do you have any other suggestions on ways to sort of break out of that silo and bring that interaction back into the day, even in the context of a very busy schedule? 

Tosca: Yeah, it’s a very tough one because of course, especially here in the U.S. and I don’t claim to know all of the ins and outs of how healthcare, structurally, if you will, is and systematically is organized. But there are such pressures, as you say, to be constantly task oriented, to achieve and to perform, etc. So I’m wondering if at a team level it is possible, for instance, to say we reserve 2 hours every week where we are not accepting patients and we’re not doing administrative kind of back end work, right. But we each or at least I as a team leader, team manager, I have what sometimes is called open office hours where yes, I am at my desk if I’m in a co-located team setting or I’m at my computer in a virtual hybrid team, but I don’t schedule any meetings and no patients either. And I’m available for people to drop in, too. So doing that, that kind of open, unstructured availability allows people to come and talk to you or allows you to go and talk to others. It’s about either their context, what’s happening in their personal life, or you feel it’s kind of seeping into the work experience and to be available for quick consultations, for seeking some feedback, etc. So that could be one way of carving out a time. 

Jen: That’s a brilliant idea. But I can tell you from experience, it would not happen, sadly, at least in private practice. I think in academia there could be possibly a way to do that. But I think in private practice, you would have to literally schedule it on either end of your day, because at least typically we’re not controlling our own schedules, often. The institution would consider it to be a cost to the institution if we were to block a schedule and also we would get a lot of negative feedback about having less slots available, for example. And so that definitely is a barrier I think, for us because I love the idea of that. It would be very valuable. 

Tosca: Yeah, well, if that is the case, maybe it’s time to start talking about collective action. And I’m not saying this is easy and this may not even be something that you can resolve at the organizational level, maybe even at the sector or subsector or industry level, right? Then really where you would use some data that indicates that unless we are not always task oriented, where we’re either serving patients or doing administrative work on the back end to keep the machinery going, our quality of patient care will go down. If we can use research data that says that and this is true in all other sectors, right? If we don’t take care of ourselves and our teams and our culture, then ultimately, often the performance of each individual will go down or people will leave. And if we think about retention, retaining physicians, because to lose a physician, I do not know what the costs are exactly in the healthcare system, but I know that in other sectors on average, the cost is as much as $40,000 just to replace somebody. 

Jen: To lose a physician, the literature shows it’s $500,000 to $1,000,000 plus because of lost revenue, while the physician is gone it often takes a year or more to replace them and then the cost of recruiting on top of that. So it’s very, very expensive to lose a physician that expensive to an organization. And you’re absolutely right. That’s really where we are in terms of having a crisis with healthcare burnout. And one thing that we talk with organizations about every day is making space and making the time to create a culture of resilience and strengthening that resilience because health care workers are resilient, but resilience is not static. And when a culture begins to appreciate its employees and make them feel valued and give them time at work for professional development, just exactly as you say, it actually improves productivity and job satisfaction and retention, which ultimately can save the organization. 

Tosca: Yes, that’s right. To what extent sometimes physicians as team or unit leaders sometimes try to engage with each other in collective action towards their top leader? Does that ever make a difference to at least start to eke out little bits of time in at least at a weekly level to do that little bit more of that non-task-oriented work? 

Jen: I think the problem that we run into is often that we are so task oriented at work that we don’t make time to try to fix these problems. So I think if you were to take a poll of physicians and say, would you be interested in having this time? I think honestly, I think you would get a variety of answers because we have been trained to hit it as hard as we can and really push our own personal limits to see as many patients as possible. And then the administrative tasks have grown in terms of the time. So now with the current EMR type systems that we use to track all of our patient care, that actually is something that has now taken a larger chunk of our time each day on top of a patient load. So it is a complex problem and it is a problem that is not simple to solve. 

Tosca: No, not at all. It’s a different level then actually. Yeah. Well, we do know from the organizational culture change practices in other parts of both public and private sectors and in the nonprofit sector. For instance, if we say as physicians to our patients that they need to balance their lives, at least to some extent, by taking time out for relationships, for their networks, for being embedded in community, etc. And we don’t practice that in our own work. So in other words, if there is a gap between what we say to others and what we do ourselves, we know that that on its own, if that is not recognized, culture change efforts have very little chance.

 Jen: That’s really a great point. And I know our coaches talk with us in the DocWorking community about the knowing-doing gap. As physicians, you know, we have that regarding our own well-being on multiple levels, nutrition, exercise, you know, and just taking time for ourselves, as you say, building that in. But you bring up a really excellent point, which is that we should be taking that knowledge of how a work culture should be and actually putting it into action in our own lives. 

Tosca: Mm hmm. There’s a couple of myths around when it comes to org culture. So maybe if I could just mention a couple of these and also this, make sure that our listeners are clear when you and I, Jen, are talking about organizational culture again, I am not talking about sometimes, you know, organizational culture efforts are being seen as oh, things that we put on banners, things that we have on our website, things that our top leaders are communicating to the physicians and the teams around the organization, right. It doesn’t affect behaviors. What does affect is the modeling. What I said of very daily practices and habits and behaviors that are widely shared, that are constantly repeated, and therefore become very tenacious because they guide what people do on a day-to-day basis or they guide people what not to do. So with that definition in mind, one of the messages is oh, if we want a culture change, we need to bring a new top leader and they are going to kind of drive culture change from the top down. That’s not really how it works. It has to be at least a top down and a bottom-up effort combined where there are physicians around the organizations who want to change the habits and behaviors that are encouraged or discouraged. And there have to be what we call culture ambassadors. So people who already, even within the strict confines of the systems that you just said that are broken, who still try to do the little bits that they can and those ambassadors bottom up can really make something over time viral and can complement a more top down driven culture change effort, if you will. Does that make sense? 

Jen: That does make complete sense. Absolutely. So when you are working with leaders of organizations, how do you recommend that they implement a culture from the bottom up as they work from the top down? 

Tosca: Yeah. So first of all, unless you practice within the confines and constrictions of the system, right. That you’ve described as being extremely task oriented and output oriented, I need to be seen in my own behavior to as much as possible model something that is a slight alternative that is not exactly adhering to those confines. I need to encourage others to do the same, especially those that I have position of power over, and I need to hold myself and the others accountable. Then I need to ally with others around the organization who have similar desires and are already trying to practice that. It really is about modeling and about being an example. And once you have a critical mass of people who are kind of followers who have become culture champions with you, then perhaps it’s time to talk to your top leadership and say, we’re experiencing that this is beneficial for these and these reasons. And by the way, we are retaining physicians, which is saving you a lot of money and effort in terms of replacement of physicians, etcetera, is we want to talk to you about how to make this culture, this organization wide, it’s really important to start with the people who are already exhibiting the behavior that you want to see more of and not just people with positional power, but people who are informally admired in the organization. Sometimes the people most respected and admired are the people who are like a node in the network that all the information goes through them, for instance, right. Sometimes they have a lot of informal influence, even if they don’t have a lot of positional influence. So those are a couple of kind of initial answers. 

Jen: Terrific, great answers. There’s a new tool that a company that we are collaborating with that will actually go in and be able to assess for metrics that can support which areas in the organization are experiencing higher levels of burnout and likelihood of leaving and vice versa. Which ones are doing well and as an organizational leader could potentially use that information both to implement programs to help prevent people who are in the risk category from leaving that help to provide better support to them, but also to look at the areas that are thriving, relatively speaking, and see what they’re doing differently and to use that. 

Tosca: I love that, what we call the positive deviance. So the people who are managing, even if the system is broken, to still do something positively that is different and asking them. And yes, absolutely. What you said about doing pulse surveys, for instance, quick two or three questions every couple of months and tracking that data, being internally transparent about what that data is showing you over time, trend wise. And then organizations really do better if they also become externally transparent. So if they have it on their website, for instance, right. Or they report on that, because once you are externally transparent about seeking improvements, then the sense of urgency for this change in organizational culture becomes much higher. 

Jen: Great point. That’s a terrific point. And are there any other recommendations that you may have for listeners on a micro culture level? For those of us who may be managing teams within a much larger organization, looking for places where we have agency to better manage our own team and then ultimately hopefully be able to talk with other leaders in the organization, even if they are leaders on the same level, managing other teams and finding out ways to improve from the bottom up. 

Tosca: There are several things I could bring up with, but let me just bring up one, and that is an accountability buddy. So if you can identify another physician who, you know, has a similar wish to at least at a team or unit level to make some culture changes, say, can you both support me and hold me accountable? Can we compare notes? If you see me speak in a meeting. If we’re in a shared meeting, can you tell me later. “Yeah. I really liked what you did there. That was you were accentuating a behavior that you want to see more of and that you’re exhibiting yourself. You’re doing your best effort to do that.” And can you also tell me when I’m not doing that? So I think an accountability buddy is always a good thing because let’s not kid ourselves. Culture change, whether it’s at the team level, but particularly at the organizational level, is a long-term process. It’s not happening in a year and probably not happening in 2 to 3 years. That often takes on average 5 to 7 years of sustained effort by a range of physicians in an organization to change something about what are the desired behaviors and practices and what is less desired. So we need to have a long breath for this, if you will. 

Jen: Yes, absolutely. It’s not a short-term problem. And this, I think, is a really empowering conversation because you’re giving us some tools that we can begin to use right away that I think can make a difference very quickly in our day-to-day practice, even in a system that we know is not going to change overall very quickly.  Tosca: Yeah, we know we can have healthy team cultures within the broken system, but there are definitely obstacles and you’ve pointed out several of them, but there is some agency that we need to have and when then that team on its own becomes a model for other teams, right? Others are watching and saying, “hey, I want more of that too.” So over time, this can in a viral way, this can ripple out. 

Jen: That is very well said, Tosca, and I really appreciate your insights. Is there anything else that you would like to add to our conversation? 

Tosca: I think we want to talk about this in a nutshell that I think we’ve hit upon some of the bigger points. But I’m also truthfully, Jen, I’m taking on board entirely what you say about how at a sector level, the system is broken for the types of cultural values, principles and behaviors that we’re after here. So I fully respect the boundaries that you have reminded me and our audience of, but we are not without any power or agency. I do want to stress that. 

Jen: Yeah, absolutely. I think that has been such a game changer for me to realize with coaching that you can learn to have a different perspective and to identify the areas where you do have agency and you can affect your own well-being and your own career to put it into a sustainable place and make it where you want to be. I think that we often think about things in black and white. It’s either I can’t change the whole system and therefore I just can’t be part of it, when in actuality you can change what’s right around you, your immediate surroundings quite a bit. And when you start brainstorming that with a trusted thinking partner, you realize how many options you do have. And that’s what we’re here to help people do at DocWorking. I think the accountability partner is a really wonderful idea and sometimes that might be someone who’s not even at your institution. That’s another benefit of being in a group where you have peer support with people from all other locations and others, even other specialties, because you do have the opportunity to see what people are doing outside of your institution and maybe they have some ideas you haven’t thought of. 

Tosca: I think that is critical in coaching, that there is a peer coaching element both for support and accountability for motivation when the going gets tough. And yeah, just to emphasize what you just said, Jen, about the power of reframing, reframing an issue for yourself. And I think that’s what DocWorking and other programs, that’s what they help physicians do, right. So my hat off to you. 

Jen: Thank you so much, Tosca. And certainly, hats off to you, too, for all of your leadership programs at Five Oaks Consulting. And we’re very, very honored and privileged to be able to collaborate with you and to be able to bring your programs to the physicians in the DocWorking community. Thank you so much for being here and for sharing with us your expertise. 

Tosca: The privilege goes both ways and thank you once again for this opportunity. 

Jen: If you’re listening and you’re interested in learning more about the Five Oaks Consulting course on leadership for physicians who are working in remote setting, is that the correct title, Tosca? 

Tosca: It’s actually Virtual Team Leadership for Physicians is the title. I personally, Jen, I prefer the term virtual teams over remote teams because the word remote in itself and this is interesting we’re talking about culture and the power of symbols. Remote suggests something that is not necessarily something that I as a team manager would like to accentuate. So we like the term virtual team leadership or hybrid team leadership depending on the setting. 

Jen: And actually that, as we’ve talked about a moment ago, that may also fit with you working right in your practice, even though you may be on site. I know I do a lot of virtual work even when I am on site because we have multiple locations. And so I am working with my team by phone and by computers when I’m practicing radiology. So I know you are absolutely right. A virtual team leadership is actually a much better term for it, so I’m excited to be able to bring that to the DocWorking community. And how can people learn more, in addition to messaging me at DocWorking, which would be [email protected]. If you’d like to email me to find out more, we will be having more information on our website about the course where people can click. And of course, if you’re in the DocWorking community, a member of DocWorking THRIVE, you’ll have the opportunity to join the course as well. How else might people be able to find you if they have questions and would like to learn more? 

Tosca: Oh, I’d love for people to connect, so you can find me by email at Tosca that is T O S C A at 5 as in the number 5 oaks as in oak trees O A K S consulting dot org. And you also can find me on LinkedIn, of course, and I look forward to being in touch. 

Jen: Thank you so much for listening and thank you for joining us on DocWorking: The Whole Physician Podcast. 

Board-certified practicing radiologist, founder and CEO ofDocWorking, and host of top rankedDocWorking: The Whole Physician Podcast

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