From Authority to Anarchy in the Physician-Patient Relationship
“We have to take care of the people we count on to take care of us,” that from a wise mentor early in my training, her words with me still. I am not sure where we got the idea that the physician-patient relationship is a one-way street. It isn’t. We have to take care of our physicians too, by doing our part. And yet, studies have found that most patients with chronic conditions have stopped adhering to medical routines by end of month post hospital discharge, and few report continuing with their medications beyond 6-12 months.
My clients tell me that, given how overwhelmed they feel with everything else in their lives, it often feels easier to manage their conditions as well as they can on their own, with more than a little help from ChatGPT and the internet. Sometimes it can be an anti-authoritarian streak that renders these high-powered individuals unable or unwilling to adhere fully to what their doctors have advised. They get by for a period of time. But, like the frog in the pot of water who kept adapting to the rising temperature until it boiled to death—by the time nonadherent patients register the severity of their conditions, it can be too late.
The nonadherent patient can become dissatisfied as things do not get better and may even get worse. Studies have shown a link between patient satisfaction and outcome. Poor outcomes may then leave physicians feeling the loss of control and purpose associated with the physician burnout we are hearing so much about. Stress can be high. Morale can be low. And physicians feel it in their wallets too. Unhappy patients are less likely to pay their bills, return for appointments, and refer other patients. In addition, reimbursements may suffer as patient satisfaction and outcome become the metrics upon which reimbursements are increasingly based. Patient dissatisfaction is also a problem for employee morale, hurting hospitals and private practices in turnover costs. And, it goes without saying that unhappy patients are more likely to sue.
For the first time in 20 years, a recent Gallup poll found that greater than 50% of adults in the US rated the quality of the nation’s healthcare below good, with greater than 20% rating it poor.
To sum, patient nonadherence, dissatisfaction, and poor outcomes adversely affect the physician’s emotional well-being, job satisfaction, financial performance, and liability exposure—in a downward spiral contributing to record numbers of disaffected and burned-out MDs.
Physician burnout, which had been declining for 6 years preceding Covid, began to rise with the onset of Covid, hitting an all-time high of 62.8% burnout during the winter of 2021-2022. Front line emergency medicine doctors have been hit the hardest. No doubt related, the Association of American Medical Colleges is predicting a shortage of 54,100-139,000 physicians by 2033, while demand continues to rise as people are living longer with better meds.
AI is meaning to help, for example, by listening to patient-physician conversations and writing up the notes. Although, on some level physicians must be wondering along with so many other humans how long it will take for the bots to rule where the physicians used to rule themselves. And now there is evidence that this nightmare may actually be coming true.
Once held in the highest esteem, physicians are now confronted with unprecedented levels of demoralization, as they struggle to keep up with the demands of patient care and the administrative challenges growing horrifically by the day, the latter a leading cause of burnout according to the AMA. The AMA is replete with guidance on how physicians can take care of what they are calling “Stress Injuries”:
Other simpler recommendations for physician well-being include diet, exercise, meditation, connecting with loved ones, and staying focused on issues where there is some control. Meanwhile, most folks blame “the system,” including the organizations, institutions, regulations, and policies involved in the quality, access, and cost of healthcare delivery. To be clear, what is being said here is not that systemic changes are not needed. And, of course, physicians should take good care of themselves. But there is something else at play—CEO Disease—which, better understood and addressed, can help physicians and patients leap ‘Out of The Box’ to leverage new ways of collaborating that would benefit us all.
When CEO Disease Strikes Physicians and Patients
Professor of Leadership, Katleen De Stobbeleir defines CEO disease: “The term refers to the phenomenon of many leaders living in what is known as a ‘feedback vacuum’.” Stobbeleir adds that, although CEO Disease is not a real disease, leaders getting stuck in their own heads (stuck in the box) is why many businesses fail. For physicians, according to patient safety consultant and professor in Emergency Medicine, Pat Croskerry, MD, PhD; it is also more the cognitive conditions (e.g., overload) than lack of knowledge associated with diagnostic failures.
CEOs and MDs are not the only humans who suffer from being stuck in their own heads. Patients can have CEO Disease too. Especially under stress when we may be more likely to withdraw from others to conserve energy, humans, in general, can become confined by their own thoughts, and a lot of us do.
Consider this: The average adult human makes 35,000 decisions every day, not all of them affecting as many lives, and in such magnitude, as the decisions our physicians have on their plates. Even so, this decision load can be exhausting, something doctors are now calling Decision Fatigue that is adversely affecting the quality of our decisions and depleting our lives.
Moreover, the human sense organs send 11,000,000 bits of information to the brain every second, the conscious mind can process only about 50 bits per second—which we mistakenly think of as reality—when it is really only a drop in the bucket of the 6 × 10^80 (or 6 followed by 71 million zeros) bits of information out there in the universe for our senses to pluck from.
Alas, our brains have to make some sense out of this severely limited information or we would feel crazy and unable to function. And, we all need our MDs, especially, to not feel crazy and unable to function. The human brain draws on past experiences, future desires, basic human fears, assumptions, and what knowledge it does have to add, subtract, fill in the gaps, and piece together bits of information into some semblance of a reality.
And that is The Box: The pieced together, faulty confines of our very own minds.
Letting that sink all the way in invites Out of The Box ways our MDs and their patients can proceed to uplevel their personal and professional well-being, and patient care outcomes.
Out of The Box: What This Means and How to Use It
For the Physician: Open Systems Feedback
Business leaders who delude themselves into thinking they know more than they can and do—CEO overconfidence—have been found to show less ability and poorer performance. Similarly, MDs who delude themselves into thinking they know more than is humanly possible—Physician overconfidence—have been found to be more prone to diagnostic error.
A more open system is recommended and can be defined as:“a system with boundaries able of being penetrated which allow the exchanging of data or materials with the framework of the system.” In other words, a system that is open enough to allow an exchange of ideas and support, helping physicians to prevent becoming prisoners in their own heads. Surgeon, writer, and public health researcher, Atul Gawande, makes a compelling case for coaching, as a way for physicians to let an external pair of eyes and ears help them see and hear what they may be missing themselves.
Coaching can also help physicians learn how to detect and master the cognitive difficulties that can lead them astray.
As only one example, George Washington University’s Resilience and Well-being Center provides an impressive array of individual, departmental, and organizational services for physicians, as well as employees and trainees throughout the system.
Dr. Jen Barna is a board-certified, practicing radiologist, who founded DocWorking, inclusive of a 24-7-365 Confidential Support Line, with coaching options, and a podcast dedicated to the well-being of physicians and other healthcare professionals.
Front line innovations include the “Integrated Practice Unit (IPU).” Michael Porter, PhD, MBA, and Thomas Lee, MD, MSc, describe how IPUs assemble multidisciplinary teams, ideally in colocation (physical proximity) to facilitate information sharing and support, in face-to-face real time rather than only through notes.
Porter and Lee acknowledge that a “final necessary ingredient” is the physician’s motivation to collaborate to this extent. For that to have a chance where it may not exist already, the other professionals in the mix need to lighten the physician’s load, rather than add to it. Here is where Gawande’s idea on coaching for physicians applies just as much for physician referrals to executive coaches for their high work stressed patients.
For the Patient: Root Causes of Work Stress and Treatment Nonadherence
Americans suffer 120,000 work stress related deaths per year, at a yearly healthcare cost of $190 Billion. And, The American Institute of Stress reports that 94% of workers are feeling stressed at work. So, especially given my business education and experience, it is not surprising that clients typically present about their work. And, what I have found is that by discovering what my clients have not been telling their doctors (nor even themselves in many cases) about the root causes of both their work stress and treatment nonadherence—they can experience powerful shifts beyond what more generic health coaching and talk therapies can typically achieve.
One case example would be the CEO who, after some trust had been established, said, “We have to talk about my smoking,” to which I responded, “No, we don’t.” Of course, he looked at me quizzically and asked me why not, at which point I said, “Because you are done.”This 40-year-old, highly successful businessman and cardiac patient was raised by immigrant parents. He said that because his parents could barely speak English, he felt he had to rely as much as possible on himself to make his way in the world. His overblown self-reliance had him resisting like 2-year-olds who say “No” simply to assert themselves, even if it nearly cost him his life. In this case, however, he decided to stop smoking, cold turkey. Not too long thereafter, he had bypass surgery with a great outcome, improved collaboration with his doctor, and gratitude for his adherence to quit smoking so his sternum could heal better than he believed it otherwise would have.
This client found me on his own through the Psychology Today Directory. (Other reputable sites are Linkedin and Zencare.) He would have been a great candidate for referral from his physician as well. But physicians may not refer to coaches routinely, possibly because, although the coaching market is exploding, not a whole lot of people even know what coaches do, and not all coaches are good.
One of the “14 Examples Of ‘Bad’ Coaching To Look Out For” in Forbes that really caught my eye was: “3. Placating Without Getting Real Or Going Deep.” Countless clients have told me, “My therapist was very nice but nothing ever changed.” Nice is nice, but not enough. Same for symptom management; not enough. For lives to improve in sustainable ways we must get to root cause.
Great coaches can make a powerful difference by being both kind—and skillfully focused on action and accountability to overcome the gravitational pull of root cause—precisely why I attained board certification in coaching in addition to maintaining my license to practice psychotherapy.
So, here are some of my thoughts on what referring physicians and patients should look for in a coach to help them identify and prevail over the underlying causes of their work related stress (WRS) and treatment nonadherence:
– Credentialing: Education, Training, Accreditation. Two top credentialing bodies are the Center for Credentialing and Education for board certification in coaching (BCC) and The International Coaching Federation (ICF), with 3 levels of credentialing.
– Level of Work Experience/Specialization: For workrelated issues, consider coaches who specialize in Executive, Business, Career, and Professional Coaching;Stress Management, Mindfulness, and Work-Life Quality.
– Assessing Fit: Is this someone who can be trusted toprotect patient confidentiality, and to support and challenge individuals to grow and meet their goals.
– Focus: Great coaches work with the past only as much as is necessary to get the job done. And the job is not the past but rather their health and well-being in the present and future.
– Action and Accountability: Great coaches utilize client–designed action steps routinely, with The Goldilocks Principle of not too big, not too little, but just right to optimize the change and growth their doctors and they are shooting for.
From Anarchy to Collaboration in the Physician-Patient Relationship and Beyond
One thing that physicians and patients can do to make a difference right now for both MD Burnout and Patient Outcome is to get Out of The Box.By Out of The Box, I mean out of their own heads to let in what they cannot see themselves, in collaboration with other people with whom they can share information and support. I mean physicians and patients escaping the confines of thinking they know everything they need to know, or worse, believing that they have to because they are in this all alone.
There are many good programs, professionals, and people right there in our own circles who are ready, willing, and able to pitch in. And, as Gawande points out, even and especially the greatest of all times (the GOATs) have a coach.
My father was a business owner who died when he was 42–years–old and I was 15. The doctor said he died of a cerebral hemorrhage. My mother said, “It was work.” My father made a promise to his mother on her deathbed that he would take care of the family business and his father. It is doubtful, however, that what he took that to mean was what his mother had intended for him.
And, even if someone (his doctor, his father, his wife…) had advised him then to take it a little easier, it is not so clear from what I remember that my dear father would have let in much of anything on this that was not already in his own head.
But we can. Our physicians can. Our patients can. We all can. We can leap Out of The Box to join with others who can see some of what we cannot and lend us a hand—to help us all thrive and prosper a little better in this incredibly challenging world of ours.
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