Why the business school mindset doesn’t mind physician burnout [PODCAST]

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“We can’t expect those with a business school mindset to solve physician burnout. What is needed is leadership throughout health care organizations by those with expertise in the core business, deep commitment to health care workers and patients, extensive tacit knowledge, and credibility. Physician CEOs have better outcomes in all critical metrics, including engagement among staff. And physician leaders have an ethical and fiduciary responsibility to serve patients. Those with a business school mindset do not.”

Patty Fahy is an internal medicine physician and founder, Fahy Consulting. She can be reached on Twitter @pattyfahyMD.

She shares her story and discusses her KevinMD article, “The business school mindset doesn’t mind physician burnout.”

This episode is sponsored by Tradeoffs, available on your favorite podcast platform.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Patty Fahy. She is an internal medicine physician and a leadership coaching consultant, and she wrote the KevinMD article “The business school mindset doesn’t mind physician burnout.” Patty, welcome to the show.

Patty Fahy: Kevin, thank you so much for asking me to be on your show.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Patty Fahy: I’ll start with where I am, and then reach into the past and talk a little bit about what the fork in the road was. Currently, I have a small leadership coaching and consulting firm called Fahy Consulting, and I work with a long-term colleague, Lynn Elliott. Everything we do is pretty much focused on transforming organizational culture. So we work with leadership teams, we deliver programs inside organizations over time, over a six- or eight-month period, and we do individual and group coaching. The other element of my work is a podcast called License to Lead, and an accompanying newsletter that we send out twice a month. All of these things are geared towards transforming organizational culture in health care.

And I would say, if I talk about the journey or the path that got me here, a real turning point was when I was working in a health care system and I became dissatisfied, maybe even more so disappointed, with the organizational culture, with some of the behavior of folks at the top of the organization. I think they became mesmerized by some blue-suited McKinsey consultants and became sort of enamored with trying to figure out how to increase efficiency, and in a way adopted what I have more recently come to call the business school mindset.

And I reached a point where I thought, “Well, I can bail out. I can jump ship, like so many excellent physicians who had jumped ship,” which led to more of my disappointment, “or I could get involved and see if I could make any difference in the organization. And if I couldn’t, then I could jump ship later.” So I ran for the board of directors and got elected. And a few years after being on the board of directors, I was asked to be on the leadership team to really start up a strategic HR function, and that was the most fascinating and rewarding work that I can really imagine.

We were able to make really significant changes in physician satisfaction, decreasing physician turnover, and then all the big dots, all the important parameters, followed. Quality improved, quality to the point where the NCQA, the National Committee on Quality Assurance, sent out a couple of executives to see what had gone on in our organization. And this increased physician engagement and transformation of that culture had a ton to do with it, in my opinion. And finances improved; the organization went from being in the red to in the black. Reputation and the community improved. So everything moved as we improved organizational culture and improved physician engagement.

And I was in that role for eight years, and when I left, I started my own firm, really focused again on improving, well, transforming organizational culture. And I would say that the License to Lead podcast was a more recent attempt. I started that almost two years ago, or at least spawned the idea a couple of years ago, and that really is focused on broadening the audience. The work that we’ve done in my firm has really been physician by physician, leader by leader, organization by organization, and the podcast and the newsletter are focused on taking this message out in a bigger way.

Kevin Pho: The whole concept of physician leadership is fascinating to me, and it’s been a constant theme on KevinMD as well as this podcast. I’m a strong believer that in order for our physicians to change a health care system, we need more physicians to be leaders. Now, some physicians make great leaders and some don’t. What separates a great physician leader from someone who isn’t?

Patty Fahy: Well, there are more than a million physicians in the United States. So sometimes my message about physician leadership, and how critical it is for physicians to lead health care, will run up against somebody saying, “Well, I had this chief,” or, “There was this leader of this or that medical group or organization, and he was just awful.” Well, there are over a million of us, and of course there’s a lot of variety among that million-plus when it comes to leadership.

In my opinion, physicians are uniquely suited to leadership: the training, the on-ramp, the academic prowess, the ability to work in teams, financial acumen. Believe it or not, even though the myths abound to the contrary, physicians actually are very astute in managing money. And I’ve got a couple of podcasts that really zero in on these myths and focus in on physician traits and why we are suited to leadership.

But of course, not all of us are. And I think that, unfortunately, not only in medicine but in other organizations as well, it is very typical for people who have more narcissistic traits to want to clamber up the corporate ladder and be the boss of you and me. That’s very typical, not only in the professions, law, engineering, medicine, but in any organization, and that’s something that has to be absolutely watched for. So it’s critical to make sure that narcissists are not promoted and that there is some inoculation against the promotion of narcissists.

As far as your original question, what is the difference between somebody who is a great physician leader, or an excellent physician leader, and maybe more, I don’t know, mundane or unskilled physician leaders? I think that there are a number of things. There are three traits that I call, well, I’ve called them my rumble strips. That sounds a little bit silly, but rumble strips are those little bumps along the side of the road that, if you run into them, make all kinds of racket, and it wakes you up and keeps you from going off the road.

So I have three traits that I call rumble strips of leadership. These aren’t the end-all and be-all of leadership, but these are the ones that are table stakes. These are the traits that, if somebody does not have them, run the other way; they’re the wrong person for the job. The bare minimum is what I’m trying to say.

And so those are being able to be clear, so clarity: somebody who can express what they mean, and what their intention is, and what they’re asking you to do, or be clear about what’s going on in the environment, in the landscape. So providing clarity, and being good with providing clarity, not trying to sort of muddle the edges and be wishy-washy, but being able to be clear.

And then the second one is being exquisitely respectful of people at every level, and this is one inoculation against allowing a narcissist to ascend in your organization. So somebody who’s exquisitely respectful, whether they’re talking to a patient, a family member, the clerk outside your office, or the clerk in the grocery store. So somebody who really understands the importance of, and leans into, developing those interpersonal relationships, and is always respectful. And the narcissist famously will kiss up and kick down. So by checking references, by talking to people who have worked with an individual, you can find out whether or not they have left a bloody wake, especially among the people who are their direct reports, or people that they don’t think can hurt them.

And then the third one, as far as table-stakes traits, is holding people accountable. Is this somebody who can hold themselves and others accountable, do what they said they’re going to do, but also have the courage, and sort of almost methodical approach to leadership, that they will follow up and, in a respectful way, find out if somebody did what they said they were going to do?

And it’s shocking how often people will skate right over these rumble strips criteria and go to, “Yeah, I know, but have they created a great strategic plan before?” They’ll go to this vast array of other criteria or leadership competencies instead. And I would just beg people: Slow down, go right to these three, and then move on to things that are more role-specific as far as characteristics.

Kevin Pho: All right, let’s transition into the KevinMD article that you wrote, and it’s titled “The business school mindset doesn’t mind physician burnout.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Patty Fahy: The reason for the article really was to dispel the notion that burnout is related to lifestyle issues or choices that physicians make, and to point to the underpinning causes of burnout. And of course, this is an occupational diagnosis. Burnout is related to the work that’s being done, and in my opinion, burnout is related to an autonomy deficit that physicians have. And we know the causes of burnout, and we’ve known them for a long time, because there have been a lot of studies done that clearly demonstrate that physicians face barriers in providing high-quality care to patients, and that’s one of the biggest factors in burnout.

And so, when physicians don’t have autonomy over their profession and over their practice, they’re not actually able to fulfill what the corporate practice of medicine statutes are in place to try to safeguard for physicians, which is that physicians are not beholden to managers or others who do not have the same professional obligations and ethics as physicians. So when physicians are faced with situations where they’re unable to provide high-quality care to patients, they face barriers that lead to burnout and moral injury.

And when physicians have autonomy to provide the care in the way that they know is best for the patients, and spend the time with the patients that’s necessary to manage them correctly and to connect with them, then we don’t see high rates of burnout. Then physicians have a rate of burnout that is similar to the rest of the population, or even less than the rest of the population. And so I wanted to dispel that notion and point to the fact that physicians must have a level of autonomy and authority that is commensurate with their level of accountability to patients. So we’ve got an ethical obligation, a professional obligation, to put the patients ahead of ourselves and to do the very best thing for the patients, and when we’re thwarted in that, that’s what leads to burnout.

And my premise in the article was to really highlight what I call the BSM, or business school mindset. And this doesn’t just affect health care or medicine. The business school mindset, the BSM, really is responsible for a lot of misery, pain, dysfunction in institutions across the United States, and sadly, it’s worldwide because of the influence of United States institutions. But it’s really something that comes from graduate business education, and it is a focus on being a fiduciary for shareholders. It is a financial mindset or a financial orientation, and it is not compatible with professionalism.

And that of course is not remotely the same as saying money doesn’t matter. Of course it matters. It’s a tool, and it’s necessary to pay attention to the bottom line and to the finances of any organization in order to keep it alive and keep it able to fulfill its actual goal or purpose. But unfortunately, coming from business schools, the business school mindset is a mindset that puts profits over people and really holds sterile tools, financial tools, in high esteem. That is a main focus in graduate business education, the finances and financial tools.

And there’s a belief coming out of the ideology of the business school that somebody becomes a manager in business school and can emerge from the business school and manage anything, can lead any organization. So the people, the products, the culture, the expertise of that organization are irrelevant, and what matters is the business tools that are used to monitor and evaluate people in the organization. And so you’ve got people who come from graduate business education overseeing an organization filled with people who have expertise in a profession, and they are monetizing the experience and the expertise and the tacit knowledge of professionals and others in the organization.

But it creates this big divide between people who are committed to patients and have expertise in caring for patients, whether physicians or nurses or technicians or others, and then people who have none of that education, who have no education in science or in the care of patients, no ability to diagnose, and certainly no fiduciary responsibility to patients. Their fiduciary responsibility, learned in business school, is to shareholders, and profit is the focus. And so they’re monetizing the expertise of physicians, and it creates a divide, an elite caste, those at the top of the organization who by necessity stay separate from the professionals in the organizations, or those who are absorbed in the process of patient care.

And that’s how you can end up with these ridiculous CEO salaries. Profit is everything; money is the main focus. And there’s no shame in that stratosphere for having incredibly huge CEO salaries, or taking a bonus when people don’t have the PPE that they need in the ED. So that was really the purpose, Kevin. I wanted to point away from lifestyle decisions or wellness issues as a significant underpinning of burnout, and really point toward the business school mindset and the lack of autonomy that has come from business people with a business school mindset leading our health care institutions.

Kevin Pho: You and I know the problem of physician burnout, and a lot of the members of my audience, of course, know how much of a problem physician burnout is. If you look at studies, it’s something like 50 percent of physicians exhibit symptoms that suggest burnout, and those numbers probably are going to be higher after the pandemic. Take us through the lens of the business school mindset. How would the business school mindset analyze the problem of physician burnout?

Patty Fahy: Well, I think that if somebody has a business school mindset, it’s a bit of a dim view of humanity, and dim in a couple of ways, I guess. The idea that people are kind of messy, and it’s unfortunate to have to deal with that. But also dim in the sense of not a real understanding. It’s not a clear view of what an incredible contribution comes from the people in the organization who are being monetized by those with a business school mindset.

And so I think that somebody with a full-on business school mindset, which really is profits over people, is going to see burnout as quite inconvenient, and that it has to be mitigated, that it is necessary to remove people who are burned out, or find ways to expediently remedy the situation. And some of that might be replacing ED physicians, for instance, with people who have lesser education, which is a danger for everybody. I mean, if a PA or NP who hasn’t had a ton of experience takes the place of a physician in the ED, that is a catastrophe for their career. That’s frightening and unfortunate. If they’re not frightened, then all the rest of us must be frightened. It’s problematic for patients. It’s very problematic, of course, for the physicians who have been moved aside after an enormous education and on-ramp.

So I think that the business school mindset would look at the issue of burnout as something that needs to be expediently fixed, and to find a way to perhaps have a group that isn’t as prone to burnout. And I think if it’s in a more enlightened organization, it becomes clear what the actual source of burnout is. In my opinion, if the leaders of an organization would look at the data and really understand engagement, it would be clear what needs to be done. I mean, this should be the skill set that comes out of a business school, but it isn’t.

And you can go to business school professors. Most of the critique of business school education comes from within the business schools. But they’re not privy to what we know, which is that if we take great care of people, and make sure that there is excellent leadership, and that people are the recipients of transparent and clear communication, and that the values are aligned from the top to the bottom, which in a way is not possible if somebody at the top has, you know. It is an ideology. It’s a difference in ideology between a physician or a professional and somebody with a business school mindset, or somebody who embraces the fiduciary responsibility of serving shareholders. So that ideologic gap is huge.

But if they were paying attention to the data, looking at information from Gallup, or all the stuff Jeffrey Pfeffer from Stanford has written about over the years, and any number of other really astute people, the way to be successful in an organization is to have a fantastic, engaged culture. And that’s the pivot that needs to happen somehow in the business schools: recognizing it is all about people. It’s not about financial tools.

Kevin Pho: “The business school mindset takes a dim view of humanity.” Can I quote you on that?

Patty Fahy: Absolutely, yes. Yeah, that’s really part of what I talked about, in the past, when I was triggered to take on a leadership role and run for the board. It was in the face of leadership who took a dim view of physicians. They saw physicians as the problem, not the solution. And I am all about seeing the physicians as really the remaining hope we have for kind of righting the health care ship.

Kevin Pho: We’re talking to Patty Fahy. She’s an internal medicine physician and a leadership coaching consultant, and she wrote the KevinMD article “The business school mindset doesn’t mind physician burnout.” Patty, what’s the path forward? So we have a vast majority of health care organizations run by those who are trained by the business school mindset, but we are also having an increasing number of physicians who are feeling burned out. So there’s an obvious tension that you very articulately expressed earlier on. What’s the path forward?

Patty Fahy: Well, the reason for my podcast, License to Lead, and my twice-a-month newsletter, License to Lead, is about igniting physicians’ interest in leading, and really trying to allow all the stakeholders to see how important it is to get people who have the most expertise in the profession, and in the realm of health care, to be leaders of the profession.

And there’s a lot of data out there about that. It really was sparked by Amanda Goodall, with an article back in 2011, where she really looked at the rankings. It was the U.S. News & World Report rankings of best hospitals, and there were hundreds of best hospitals, because they looked at GI and cancer and heart disease and all that. So, hundreds of best hospitals, and even though physicians were only five percent of the CEOs of all the hospitals, they were 50 percent of the best hospital CEOs. So 50 percent of the very best hospitals had physician CEOs.

And then U.S. News & World Report also did a drill-down of the top 20 or so, best of the best on all the parameters, and physicians were, I think it was 75 percent of that group. So 15 out of 20 or so were physicians, were led by physician CEOs. And then that just sparked a tsunami of studies, and people interested in this topic, and really looking at not only could that be corroborated, and it was, but the underlying why: What is it about physicians?

And so I think it’s getting people to understand how important it is to have values aligned from the top to the bottom of the organization, how important it is to understand that the people in the organization must be engaged, and they are much more engaged when the leaders are experts in the core business of that institution, and that, whether you’re selling shoes, or doing tattoos, or running a health care system, if the leaders of the organization know what you’re doing, and they know what they’re doing. And in fact, if they are elite among the experts in the field, the best of the best, like you would see at Mayo, which has been physician-led since its inception, and Cleveland Clinic, the same thing, the best of the best are the ones who are the best in their field, and then also are the ones who are tapped into the leadership path. And that’s critical.

So I think it’s getting people on boards to recognize it, and getting physicians to not see becoming a formal administrative leader as going to the dark side, but really recognizing that that mindset has to be shifted, and that actually we have to be pretty passionate about taking on and taking over leadership of the organizations, and not having the business school mindset ensconced in the C-suite in every institution where we work.

I think it’s getting that word out, getting physicians willing to dedicate some time every week to understanding more about leadership, getting physicians to recognize that by definition, they are leaders. People look to physicians, and we have to pick up that mantle of leadership and make it work on behalf of patients. Really recognize that when we get the physician license, when we get our MD or DO, we are also picking up that license to lead, and it’s critical to recognize that, embrace it, and act on it.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Patty Fahy: What I would like to see in neon, really, is that people understand that the level of autonomy and authority that physicians have must be commensurate with their level of accountability. So, the degree to which physicians are responsible for patient outcomes, and for their teams, and for the monetization of the organization, even to the extent that physicians are responsible for patient care and for patients, they must have the autonomy and authority to be able to follow through on that. And that really requires physician leadership.

Kevin Pho: And how can people reach you?

Patty Fahy: So, the best way to reach me is at my website, Fahy Consulting. And Fahy has kind of a funny spelling. It’s got an extraneous H, but it’s F-A-H-Y, fahyconsulting.com. And from there, you can subscribe to my newsletter, and you can go to my podcast page and see all the License to Lead podcasts. And you can also send me a voicemail, which would be fantastic. There’s a voicemail tab, and I love to hear the voices of listeners.

Kevin Pho: Patty, thank you so much for sharing your time and insight, and thanks again for being on the show.

Patty Fahy: Thank you so much, Kevin. You do such great work. I really appreciate it.

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