A book was recommended to me recently by a resident of mine. It is written by Simon Sinek and called Leaders Eat Last. I already knew that I agreed with a lot of what Sinek says because I’ve seen You Tube Videos by Sinek that feel like he has reached inside my head and ripped my ideas directly from my mind.
Today, I don’t want to deliver a book review to you. Instead, I want to discuss what I learned from this book. Specifically, I want to talk about how lessons from this book apply to the morally injured doctors that our burned-out medical system creates.
Leaders eat last
The premise – and the title – of Leaders Eat Last comes from the Marine Corp, where leaders are the last to enjoy their meals. When the soldiers approach the mess hall where they are to consume their next meal, the most junior soldiers line up first. Then, the next most senior. Finally, the leaders eat last…if there is food left to eat.
This is more than a tradition. It is a system that tells all of the soldiers that they matter to those who are overseeing their work. It produces trust, reliance, and loyalty. And it is very intentional.
This culture is created in the military so that soldiers would be willing to not only do the bidding of their superior but to risk life and limb for their fellow solider. It is a powerful example of effective leadership. When we feel that we fit in safely with those that surround us, there is very little humans won’t do to prove their loyalty. They will work until they can’t, and will be proud to say that they are a member of the team.
Do hospital administrators eat last?
Compare the military experience to that experienced by most medical professionals. Do we have the same experience with our administrators in hospitals? It seems that we have learned that the hospital won’t always love us back.
In the book, Sinek argues that when those armed with the power to make change don’t talk to those on the front line, they don’t have the necessary information to make helpful changes. When those on the front line have the information that is needed, but don’t have the power, necessary changes are ignored.
Instead, administrators who run very big organizations rely on metrics and numbers to make decisions. They can’t possibly know everyone. They must trust their middle-management.
Those of us on the front line that these metric-based decisions impact seem unreal to those who lead. We simply become numbers on a spreadsheet. Metric based leadership does not know your spouse, how many kids you have, or the fact that your grandmother is struggling through Lewy-body dementia.
This is a human phenomenon. We must know people in order to care about them and to lead effectively.
The further distanced we are from someone and the more “statistical” they become, the less we care about their well-being. It is easy to lay-off hundreds of people you don’t know based on spreadsheets showing the company’s margin. This quote, which is referenced in Leaders Eat Last, captures it well:
“If only one man dies of hunger, that is a tragedy. If millions die, that’s only statistics.”
– Joseph Stalin
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Unfortunately, when decisions are based on metrics and statistics, and not on the humans that these decisions impact; there is no drive or desire for the leaders to protect those they lead. We aren’t in their “circle of safety” as Sinek calls it.
This inevitably leads to a situation where people lose loyalty, feel less safe about their job security, and it also reduces productivity.
Leaders eating first causes moral injury
Despite having the abilities and desires to do what is best for our patients, many physicians experience an environment where they are provided too little time to see patients and are forced to spend too much time in front of an electronic medical record system.
Or perhaps you have been placed in an environment that is more concerned with RVU production, shift requirements, or academic expectations? All of this is pitted against our desire to be good doctors. It also prevents our ability at times to be a good spouse, parent, and friend.
This situation is not sustainable.
Should doctors spend the extra two hours charting at home? Or do they eat dinner with their family? Do they perform the extra operation to meet their RVU goal? Or do they plan to be at their kid’s tee-ball game?
These metric-based goals can systematically impact the wellness of doctors. They seem to have also created a system that is more concerned with the bottom line than the moral injury caused to the physicians on the front line.
Open and honest cultures
One of the biggest reasons that medicine is currently in a sad existence is because of culture.
Instead of feeling safe to share our thoughts, beliefs, and opinions; many of us live in a constant fear that during the next economic downturn we will be let go from our jobs, we will be paid less, or that our benefits will be reduced or taken. Why would we feel this way? Because it has happened to us, or to our close friends.
Unlike well-run organizations, who produce a culture where trust is paramount, many doctors feel like cogs in the wheels of giant machines. They feel like they would be easily replaced. They are just a number. Does anyone from the C-suite even know our names, who we are, and what we do?
It doesn’t take many meetings with employees to figure out what produces our resentment towards the current system. Yet, I know many people who have never even seen executives and administrators at their hospitals. Far fewer have actually attended meetings where they have been encouraged to share openly and honestly about what troubles them.
Yes, surveys are performed to “better” the organization. These are the same surveys that many of us are coerced into completing. This “checks the box” of showing concern for the people on the front lines, but none of us are truly fooled.
An employee-first approach
An open, honest, and just culture must be created.
We can fashion ours after the culture that was created in the airline industry after it started crashing planes. They fixed the problem by fixing the culture. And so can we.
We must create a culture where retribution will not be tolerated, and we are encouraged – maybe even honored – when we point out problems that need correcting. A culture where we feel like our voice is actually heard. Or perhaps a culture where the almighty dollar bill isn’t what we focus on most.
Instead, we focus on making our employees feel happy, safe, and secure. Why? Because good leaders know that this sort of culture will produce loyal and hardworking physicians.
Fixing medicine
If medicine is to be fixed, it must occur from a top-down approach. While I believe the power ultimately rests with those that control our jobs, I also believe that it is the responsibility of the employees to stand up for what they know is right.
We must be willing to be bold and concerned about our fellow brothers and sisters that fight the good fight alongside us. It is our responsibility not to sit idly by while doctors fade into a deep and dark burnout. Or worse, to sit silently while physicians quietly commit suicide at epidemic rates.
I encourage you to stand up for what is right. Hold our administrators to the standards that we would want for the leaders that represent us. Be willing and courageous to speak when others can’t or won’t.
Seek financial independence so that you will possess the ultimate trump card in a broken system. It will help you find your way off of the broken road to burnout.
Take-home
I’ve held for some time now that the main fix to the current problems that we face in medicine can be found in fixing our culture. Often, I look to the aviation industry as a shining example of what that might look like, but Leaders Eat Last also provided an excellent image of how our failing system might be saved.
It will require our leaders to stand up and to lead. However, it also calls us to force our leaders to act the way a leader should.
It remains my dream that there will be a group of physicians who find the courage through financial independence to stand up and to fix this sinking ship that is the business based medical model we currently inhabit.
James Turner, also known as “The Physician Philosopher,” is an anesthesiologist who blogs at his self-titled site, The Physician Philosopher. He is the author of The Physician Philosopher’s Guide to Personal Finance: The 20% of Personal Finance Doctors Need to Know to Get 80% of the Results.
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