How do our own characteristics as doctors limit the change we can make in health care?

All around the world, health care systems are crumbling, resulting in less effective clinical care and damage to health care workers. We all recognize the need for change and want to see it. But could doctors’ psychological makeup hamper the achievement of the actual change we wish to see in our systems?

The nature of doctors

Worldwide, those who enter a medical career are intelligent and driven individuals. Throughout our training, we also learn, implicitly and explicitly, that perfectionism, autonomy, and competitiveness are valued. Work comes before all other concerns, including relationships and our own health. By adopting these attitudes, we are deemed “fit to be part of the profession.” Within this persona, emotions are suppressed so that we can be dispassionate and clinical. We must appear all-knowing and all-powerful.

Unfortunately, the subsequent inability to express vulnerability can cause psychological suffering and limit friendships and connections. Doctors often lead a relatively isolated life, which can limit their understanding of others.

Medical hierarchy and decision making

One ascends the medical hierarchy by demonstrating superior clinical skills. It is often assumed that the “best doctor” is also the best leader. Thus, our leaders are promoted based on length of service and technical excellence, with less regard for leadership qualities such as emotional intelligence. Therefore, the doctors who are consulted about decisions may overwhelmingly demonstrate the above qualities.

In any two-way negotiation, there can be four approaches: competition (I win/you lose), accommodation (I lose/you win), compromise (lose/lose), and collaboration (win/win). The personalities and training of doctors lead them to overwhelmingly negotiate competitively, with a fallback to compromise if there becomes a possibility of defeat (“at least I wasn’t beaten”). As medicos, our own egos reject an accommodation approach, and we find it hard to maintain the trust needed to facilitate a collaborative effort.

With colleagues, we instinctively recognize this pattern and respect each other’s opinions. We try not to speak for others as we would not want our own autonomy restricted by others speaking for us. Therefore, in a group of doctors, it can be difficult to discuss a problem and come to a unified agreement. We each may believe that we are the smartest person in the room and thoughts that stray far from the status quo—perhaps essential for creative solutions—are rejected. In this setting, change is feared and dismissed. We end up with a consensus solution that is the least disagreeable to the majority. We miss out on considering potentially transformative change, as this must necessarily come from a unique viewpoint. Ultimately, there is little change, even when we have all entered the discussion with a desire for change.

Characteristics of management

When negotiating with management or executive representatives, doctors often have an inner belief that we know more than non-medical others, and we struggle to respect or listen to their views. Our almost universal experience is of being rapidly decisive, having our orders (clinical and otherwise) followed immediately, and seeing rapid results. Therefore, when we believe that a meeting has “decided” on an organizational course of action, any delay leads to a feeling of disrespect and grievance. We suspect that this is deliberate, as we are focused on what we see as achievable outcomes. We lose trust and break off meaningful discussions.

What of those executives who are medically trained? These doctors are often understood to have “gone over to the dark side,” and they are similarly mistrusted. Management has a different perspective on decision-making and values a considered approach to the process, often canvassing multiple opinions. The approach of the medical staff can be seen as lacking in appreciation of the complexity of the task and as overly rushed and aggressive.

How to enable change?

Clearly, success is unlikely without senior management and senior medicos collaborating on planned institutional change. So, how can we increase collaboration to achieve the type of change that all desire?

The first element may be to develop increased self-awareness. When we understand our biases and assumptions, we may be able to enter collaboration less flavored by the anger and hurt that we carry from prior interactions. Management may be able to foster less formal communication initially so that all can come to understand each other as people first. For medical leaders, faced with a bunch of doctors who can instantly see the problems or deficiencies in a plan, it might be best to organize the discussion away from agreeing/disagreeing to finding “the best bits” of any proposal and asking how we could improve upon them. In this way, we can unleash creativity and build teamwork.

Acknowledging our understanding of ourselves as experts may allow us to see the executives as experts in their own fields of endeavor. If the overall mission or goal of the change is constantly referred to, it becomes easier to feel a united energy toward the same problem.

Crucially, at the completion of any health care change planning meeting, there must be a period where the discussion is summarized so that all attendees leave with the same understanding. At this point, timelines and next steps can be outlined. Even if there will be delays that the medical staff find objectionable, this must be raised. In this way, a common understanding of challenges can be generated, as can trust. The concluding points, rather than being a difference of opinion about the speed of the process, must be about the shared commitment to goals and a better future for the whole of the organization.