Coach and support physician colleagues
Five years ago, we worked with physicians in a collaborative across four states. Hospitalists, obstetricians, surgeons, and emergency care physicians were the primary participants. They were openly frustrated, demoralized and self-reported as burned out. Their experience was described as being bombarded by new ideas to test to improve patient experience yet no conversation about what mattered to them. While the initial focus of the collaborative was to improve patient engagement, we soon discovered that by returning to the physicians’ sense of purpose, gains were made in both patient and physician experience.
The improvement worked emphasized simplification of physician activities, focused relationship building, and adapting systems to support these activities. As a result, not only did patient engagement show significant improvement, the joy and purpose returned to the physicians who participated in this work. Perhaps most illustrative of this is when a physician who clearly self-identified early on as burned out, said eloquently at the closing session a year later, “I now remember why I became a physician. I was considering changing professions, and now I wake up eager to practice medicine again. I feel like I am once again focused on what matters and why I became a doctor.”
This work has since been replicated with physician colleagues from other health systems. What we have found was that essential leadership support and engagement enabled care teams to do focused tests of change and simplify the work to prioritize what matters most. It was essential to creating Joy and Meaning in work for physicians.
The process - Start strong: Working in partnership with patients
We identified four simple, specific, high impact behaviors that, when consistently applied, had significant impact. The yield was greater than expected. Not only were the physicians able to more quickly establish a sense of respect and trust with patients and their families, but they felt highly focused, and often surprised at what they learned. They discovered their assumptions were often off the mark and that significant information would have been missed in their usual approach to visits. The four behaviors resulted in multiple gains.
What we would add today, given the IHI Joy in Work Framework, is more time on conversations with the physicians exploring the bright spots in their current practice and asking what matters prior to testing the new behaviors. While the collaborative tapped into their sense of meaning and purpose, our prediction is that more focused effort on this step would build energy faster.
The four behaviors are:
1. Knock While it may seem trivial, instant respect is demonstrated when a knock then a brief pause is used to seek permission to enter the personal space of the patient. A simple action goes a long way towards demonstrating partnership and respect.
2. Introduce Introduce yourself (and residents, medical students, and team members with you) and your role within the team. It is difficult for patients and family members to remember every person’s name and their role. Repetition is appreciated and often necessary to ensure everyone understands your role and how it fits within the team.
3. Sit The literature is clear – sitting makes a difference1. The physicians in the collaborative experienced this both in the positive feedback from patients and their own sense that they had time for the patient when they slowed down their sense of rushing. While some were initially concerned that it would take too much time to sit, in fact efficiencies were gained. They learned that the patients shared important information (that also saved physician’s time) when sitting conveyed “I’m here to listen”. Logistics had to be conquered, mainly is there a chair? But conquer it they did, especially when they discovered that the value far outweighed challenges. Purposeful and intentional listening along with eye contact and touch enhanced the interaction for all.
4. Ask Ask: “What are you the most worried, concerned about?” Or “What matters most to you?” Use the language that feels the most comfortable, but this single question proved to be of great value. Patients often fell silent for a moment, touched, surprised and even humbled by being asked such a powerful question. This is also where the physicians reported hearing the most unanticipated and surprising responses. The things shared, revealed layers of fear, worries, symptoms, and hopes that would not have been apparent or revealed after the usual “so how are you doing today?” In an era of time pressures, distractions, and production requirements, getting to the heart of the matter, both respectfully and quickly, is tremendously valuable to both patients and providers. Physicians found that asking this powerful question also enabled them to tap into the rest of the care team to resolve issues of importance – that it did not all fall to physicians to fix. Finally, they also found fewer follow-up calls from care team members following the visit, when patients surfaced the real issues, saving hours of time for everyone throughout the day.
The four steps are simple, not easy. It required conversations, leadership support and coaching for physicians to test, refine, and measure actions to sort through which changes mattered for their settings. The energizing part is that results were seen quickly and became self-sustaining because of the benefits for all involved.
1Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012 Feb;86(2):166-71. doi:
10.1016/j.pec.2011.05.024. Epub 2011 Jun 30. https://www.ncbi.nlm.nih.gov/pubmed/21719234