Misaligned expectations lead to conflict, burnout, and disillusioned physician leaders [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“Would you expect the chef at a restaurant to be told that they are not only required to prepare the food in the kitchen but also deliver it to each of the tables and manage the billing? What about sorting out the restaurant’s finances or understanding the number of patrons that need to flow through per night to optimize income? If this sounds unreasonable, how did we end up asking physicians to undertake multiple roles in our health care organizations for which they have not trained? This expectation has led to untenable work environments, and we need to find solutions.”

Amanda Brisebois is an internal medicine physician and palliative medicine specialist. Book a call with Dr. B to talk about conflict in your workplace.

She shares her story and discusses her KevinMD article, “Misaligned expectations lead to conflict, burnout, and disillusioned physician leaders.”

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Click here to earn 1.0 AMA PRA Category 1 CME for this episode.

Also available in Category 1 CME bundles.

Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

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. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Amanda Brisebois. She is an internal medicine physician in Canada, and her KevinMD article is titled “Misaligned expectations lead to conflict, burnout, and disillusioned physician leaders.” Amanda, welcome to the show.

Amanda Brisebois: Thank you so much. I’m excited to be here, Kevin.

Kevin Pho: We’ll get into the article a little bit. First off, briefly share your story and journey to where you are today.

Amanda Brisebois: I started medicine as a bit of an unknown. I never even knew what physicians did. I was just a high achiever. I ended up in palliative medicine and general internal medicine, and I really was a clinician to the core. I loved to teach and mentor students. Then I started seeing gaps in chronic illness care, and I thought, “I’m going to go and work on coaching patients.” This is when I got my wellness coaching certification, and then that led to an executive coaching certification. As I saw the gaps in how we integrate patients with our care, I started to see a lot of gaps in the process in the health system, and in how we as physicians get heard. So I thought, “I’m going to start leadership and start to get involved, so I can make a difference and really learn how we can integrate the physician voice.”

So I started doing that as a facility chief in my organization and then moved up to a medical director role, which started right when the pandemic hit, and I felt very unprepared. As physicians, we don’t get educated in a lot of these things that we’re being asked to do these days. So during the pandemic, to help my brain focus and cope with the pandemic, I did a whole bunch of training to catch up. I did a master’s in health leadership. I did conflict negotiation and mediation training, equity, diversity, and inclusion training, and health information training. Really, I don’t know what I was thinking, but I thought that was the gap. I thought, “Here we are as physicians, and as a high-level leader, they’re asking me to do all these things with quality, leadership, wellness, and equity. I’d better learn it. There’s something wrong with me.”

So I did all that, and I realized that that actually wasn’t the problem. I understand all of that now, but I initially thought it was teaching physicians in medical school how to do this work. Now I’m thinking we’ve got this all wrong. Our organizations have morphed into these massive organizations where physicians are just a small piece, and we have so much to learn in medical school and residency about clinical work. Why are we expected to know how to be a perfect leader and how to be a conflict negotiator? I didn’t know what I was doing through a lot of those leadership roles, because I didn’t have the training.

So what’s happened is I was thinking about going into higher leadership roles, and I realized that the organizations may not be looking for leaders who are really integrating the physician voice. They might be looking for leaders who are integrating their strategic plans into the physician plans. I started to get concerned, because through the pandemic I saw enormous amounts of conflict, conflict between teams, and teams disintegrating. We’re losing physicians. They’re thinking about quitting their profession. They get up in the morning and don’t want to go to work, because there’s some behavior that’s not making them feel included, or that they don’t want to deal with, in the work environment, and it’s impacting patient care and the team environment.

So this is where I started thinking I really want to start leading from the middle. I stepped down from my medical director role, although I do still have some high-level leadership roles in a different capacity, mostly to support physicians through conflict. I’ve taken on some other roles to do this, which our organizations are supporting, and that’s great. So now I’m really looking at how we support physicians through conflict. But it’s not only that; it’s looking upstream at what’s caused the conflict. I really believe it’s these misaligned expectations: that we’re supposed to take on all of this work, including our clinical work, which has morphed into massive amounts of knowledge, and we can’t do it. We’re starting to realize that and burn out, and conflict is arising because of the huge, enormous burden that we’re facing. We’re physicians; we want to do it. But I have multiple people telling me, “I’m not trained to manage this behavior. I’m not trained to manage this conflict.”

I spent four hours sitting in my car in the garage one day, talking to someone, hoping to support them, thinking that was OK and that was enough. But that wasn’t the right approach. I didn’t know the approach. Now that I know all of these approaches, I don’t think everyone has to do that, but I think as organizations, we need to support physicians. We need to get the quality people at the table to talk to our physicians and really integrate them, and get them involved in human resources, like we do for our nurses, our physiotherapists, and our occupational therapists. They help us talk about retirement, leaves of absence, wellness, complaints, and conflict. They do all that for these employees; they just don’t do it for us, because we’re independent practitioners.

Kevin Pho: Now, when you talk about the conflicts that you saw as you moved up the leadership ranks, go into more detail. Tell us a story, an example of such a conflict that you would see physicians face.

Amanda Brisebois: A lot of the problems arise from behavior that is maybe not intended to be poor, but there are different cultures between people. They approach situations differently, and we’re very attuned these days to how we should talk to each other. For example, I’ll have a physician on the ward, and a nurse will be there. The physician is a very assertive person; that’s their personality. They’ve been raised that way. They talk to people in a very stern way, if I can use that word, and they’ll ask for something: “I need this.” It’s a very intense approach, and the nurse will take offense, because they’ll feel that person is angry at them. Because they don’t know each other, the nurse and the physician will notice tension but move on. Then that may happen again, and the physician is unaware.

Because they’re unaware, and I’ve had people from military backgrounds, or just people who get things done and that’s how they do it, they’re not aware that they’re causing problems. Then all of a sudden they get a complaint, because this has happened three times, and they say, “I don’t even know what happened. I don’t know what they’re talking about.” The nurse, or whoever it was that complained, writes this huge letter about the behavior, and the physician writes a letter back: “I don’t know what they’re talking about.” There’s not much support for them. They can go to their leader, who’s not really trained in conflict, so the leader says, “I don’t really know. I guess we’ll get everyone’s perspectives.” And sometimes you can’t even tell it’s the same situation. Then often, what physicians have told me is that nothing happens. So they say, “Well, all right. I don’t really know what happened.”

No one sits down, talks to them, listens, and says, “Hey, how do you approach conflict? Did you know that there are these four different approaches to how people look at things?” Some people are really introspective, some people are very methodical and quiet and think on things a long time, and others are very aggressive and assertive. I use the word aggressive, but assertive. I think that we don’t think about that. We get into a bit of a difficulty, and we walk away because we’re busy, when really that difference of opinion is a massive opportunity.

That’s what I’m trying to get across through these discussions: When you see someone and they’re talking to you in a certain way, and I tell my residents and trainees this too, if someone is very assertive with me and it feels wrong, I’ll say to them, “Something feels wrong. Are you OK, or have I done something that’s upset you in some way?” I’ll say it really nicely, and sometimes I even do a little tear, and they laugh, so it sort of defuses the situation. But I just say, “I’ve had a pretty tough day. Or is that an intention, that I haven’t done something right? Because I’m really hoping to work with you as a colleague, I really want to get things done together, and we have common goals.”

The second you say something like that in the moment, people usually say, “Oh no, I’m swamped. I can’t even keep my head on straight, because I have eight calls in emerg, and I’m just trying to take care of this patient.” And the nurse can say, “Well, how can I help you?” So it can really change into an opportunity. Then those people start to know each other, so one of them says, “Oh, my kid just had their tooth pulled, and I’m running around, and my wife’s doing this,” or, “My partner’s doing this.” Then next time you have a thing, you say to them, “Oh, is there something going on with your kids again?” You really start to know each other. There’s stuff out there talking about this; it’s humble leadership, really knowing the people around you. If you make a comment when you know someone, you’re not going to take it the same way as if you don’t know them.

I always use the analogy of driving by someone in a car. If they cut you off, you might do something not very appropriate. But if they drive by and I go, “Hey, oh, that’s Kevin,” I might just wave at you and say, “Oh, I know he had a pretty busy day.” So it’s about knowing people in the workplace, and this is where I’m really trying to help people get through these enormous conflicts. That’s a very simple one. There are ones that are extremely intense, where teams are fractured: fighting over call, fighting over being on leaves of absence, not wanting to let other people go because there isn’t staff to cover, not being heard in meetings, and not having a process on how to make decisions within a team. There’s a list of many things that are recurring. Those are the things where teams start to fracture, and when they fracture, they have difficulties even trading call.

Kevin Pho: So let’s talk more about this. Your KevinMD article is titled “Misaligned expectations lead to conflict, burnout, and disillusioned physician leaders.” Now, for those of you who get a chance to read that article, just walk my audience through it and share the story.

Amanda Brisebois: As for why I decided to write it, well, I’m writing my master’s thesis for my international health leadership master’s, and I had to think of something to write about. It really evolved over the master’s, but it came to this point where I thought, “Where has the physician voice gone, and why can’t I get the front lines heard in these high-level leadership positions?” I’m an ACMO of my organization. There are only five of us, and it’s a huge organization. What’s happening? It sounds like the people around me want to hear me. They’re nice to me. They talk to me. Where is the problem? So I started thinking about that, and I started thinking about why physicians are so stressed and where the frontline voice has gone.

I’m really realizing, as I was mentioning before, that we’re not being asked to do the things we were trained to do. So yes, we’re supposed to do clinical care, and we’re running around trying to do that. Then we’re asked to see 30 patients in one night to admit them, and also work the next day, and then talk to families all night, and then be on call the next day. I thought, why aren’t we able to figure this out? I had to be on the phone with somebody, and I said, “You have to go in. These patients have to be seen. You’re on call.” And they said, “I’m exhausted.” I was really changed by that conversation, because I do believe that the system has to run, but we’re asking our physicians to make those changes. I thought to myself, we really need the organizations, and someone who’s an expert in health systems operations, to come in and work with us as clinicians to change the system, not to ask us to change it in our free time. And we should be paid for that work.

So that started the article. I thought, why aren’t we being trained? Why aren’t the goals being clearly aligned? Why aren’t the expectations about what we’re supposed to provide consistent? Because we come into organizations that have strategic plans that I don’t think a lot of us are even aware of. So how do we get the physician voice? I’m really trying to get organizations to see that we’re physicians, and we are excellent at patient care. When we want to be leaders, we do need additional training. When we want to be involved in quality, we do also need additional training, and the same thing with wellness and all of these things. They train their nurses, who are employees, in leadership on their time. They get paid, and they send them to courses. Not every organization’s the same, obviously. I feel that because people think physicians are independent practitioners, and we do well, and we’ve got a good profession, they think we should continue to take on more and more work. I think this is where the conflict’s coming from, and where the burnout is coming from.

And if we actually lead organizations and our colleagues, we can actually step up and say, “I understand you’ve asked me to do this project, and you’ve asked me to put through a project charter.” This happened to me just yesterday, with financial information on it: Put together a project charter, give me the expenses, put through a proposal. I’ve done a few, but I had to go on YouTube and try to figure this out. Why can’t they give me someone to do that, and I can just write through what kind of things I need? So I wasted a lot of time.

So this is where the article came from. I thought, how can we support physicians to get back to medicine? It all evolved from the conflict I’m seeing, but the conflict, I believe, is from these misalignments: communication gaps, collaboration gaps, lack of goal alignment, and really expectation differences, and not taking the time to sit down and say, “This is how we can integrate clinical medicine into these other things that these massive organizations have morphed into.” We’re just a tiny piece of this puzzle now. So this is what I’m hoping: that we can get the conversation going. I hope that organizations will start to step up and provide this kind of training like they do for other people in their organizations, because most of our leaders have to take time off clinical work and pay for the training themselves, like I did. I put a lot of money into all that training, and now there’s all this expertise, but it doesn’t seem like they really want to absorb that.

I think the organizations really have health leaders with them and working with them. They have health organization and system leaders who know how the systems work, and we need to know what they’re thinking in order to get our voice heard. So that’s where it came from, and that was the whole point of the article: to really help us think about what we need to tell organizations and ourselves about where we stop.

Kevin Pho: Now, you talk about additional training for these physicians who want to become leaders, and having less of physicians doing this on their own dollar and in their own time. From the individual physician standpoint, is there anything that they can do to make their voices heard? Are there any proactive things that individual physicians can do?

Amanda Brisebois: I think so. When I was a facility chief of medicine, I went to my organizational leaders and said, “Well, what do you have for everyone else? Because I need something. I’m a physician, and I want to be involved. I want to be part of your team.” They actually had this huge yearlong health leadership integrated course that physicians never attended. I didn’t get paid to go; the nurses got paid to go. But it was a fantastic experience. They invited me, and I learned so much about the organization. I also went to the CMO a couple of years ago, when I got the medical director role, and I said, “Look, I would really like to learn and be better.” They said, “I wonder if your colleagues in these ACMO roles would also want to be better,” and they ended up providing us executive coaching. So I think you have to ask.

I had a leader reach out to me. I have a new role as a physician advisor, and just yesterday she reached out to me. She’s taking over a leadership role in a really difficult department. They have a lot of issues going on, and she said, “Will you coach me?” I love teaching. I love mentoring. Absolutely, because she wants to go into the position with eyes open and really get some advice. So get a mentor. A lot of physicians are really willing to mentor, and they’re willing to do it for free. So if you have someone who has the training in your organization, or if your organization will listen, ask. We have to advocate for ourselves. We have to say, “Hands up, I’m not trained for this. I need support.” This is one of the reasons our organization undertook this position that I’m in: Enough people said, “We need help, and we’re not trained to do it.” So I do see change up front.

I think physicians have to know that we’ve got to advocate for ourselves, that we’re really clinicians, and that it’s OK if we are not certain about our leadership skills, our equity, diversity, and inclusion skills, all of these quality skills, and project management. It’s massive, so we’re fine not knowing that. I think we have to give ourselves a pat on the back that we’re trying to integrate all that. If you love it, go for it. Get the extra training. I loved getting the extra training. But I think with people who love medicine, we’re going to drive them out of seeing patients if we continue to load on more and more and more. When you look at health information technology, we are all having more and more asks. I did an extra course in that too. There’s so much.

So I think we really just have to be kind to ourselves and recognize: What am I trained for? What do I actually want to do in my job? Because if I’m not happy when I get up, and I’m too stressed, and I have too much to do in the 24 hours in my day, then I’m not going to enjoy my work, and I’m going to look for something else. So that’s the message I would like to get out: We advocate for ourselves. We know that it’s OK if we’re not trained in all of these things; we’re not supposed to be. And really focus on what we’re good at and what we want to do. If you start to morph your career into something else that you want to do, like you and I have done, that’s fantastic, but recognize what it is.

Kevin Pho: We’re talking to Amanda Brisebois. She’s an internal medicine physician in Canada. Her KevinMD article is titled “Misaligned expectations lead to conflict, burnout, and disillusioned physician leaders.” Amanda, what are some of your take-home messages that you want to leave with the KevinMD audience?

Amanda Brisebois: As physicians, we need to take charge of our careers. We need to integrate with our organizations and be really open and honest with them about what we can do and can’t do. When we’re asked to do things that we are not trained to do, we need to go to our leaders, high-level leaders, and say, “What can we do to help you? Because we need your help too.” And just really be clear that we understand that this is too much for one person to do, and we need to work at it together as a team. When we work as a team, the organizations will function better, and I think they’ll hear our voice better. So that’s what I would suggest: Let’s just talk about this stuff and be aware of it.

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

Amanda Brisebois: Thank you so much for having me, Kevin.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes