Search the KHIT Blog

Thursday, March 22, 2018

"Relational Leadership™?"

"Relational Leadership™" -- key component of an effective antidote for clinician burnout?

Read an interesting piece at STATnews that put me on this topic:

I experienced trauma working in Iraq. I see it now among America’s doctors

...Clinician burnout is frequently chalked up to the eight-minute visits with patients, the six hours spent each day entering data into electronic health records, and the demands of a profession where life-and-death decisions must routinely be made. But this short list of factors doesn’t get to the real wounds of practicing medicine…

It’s not just the eight-minute visit: It’s that an eight-minute visit means physicians can’t provide whole-person care to patients whose diagnoses aren’t easily logged into a computer. It’s not just the six hours of daily data entry: It’s that it takes clinicians’ eyes off their patients, missing the very connection with humanity that drove them into this work. And it’s not just the problematic quality metrics that physicians are subjected to: It’s that those metrics have crowded out deeper connections with patients to help them manage triggers and navigate treatment…

…if we continue to disregard the epidemic of trauma among our physicians, lives — of patients and providers — will be unnecessarily lost.
During a panel at last year’s Aspen Ideas Festival, Morris-Singer offered a simple challenge: “The next time you wrap up a visit with a health care provider, ask him or her, ‘How are you doing?'”

I echo that. Let’s start a conversation with our health care providers and listen, really listen, to their needs. As William Osler, father of modern medicine, famously remarked, “Listen to your patients. They are telling you their diagnosis.” Clinicians, too, are telling us their diagnosis. It’s time we responded.


Most innovations have disempowered physicians to use their clinical thinking. Instead, we have morphed into data entry “experts.”

Take EHR's. Aside from distracting physicians from patient encounters, the software dictates what minutes remain of the “clinical interview.” There is minimal time for conversation that might reveal the context of the patient’s concerns. Physicians are forced to ask exhaustive lists of check boxes, some of which are usually irrelevant to that one patient. They have little to no discretion about guiding the interview to what’s relevant or even recording what he learns. There is literally no place for that on some software. If such a text box exists, the volume of unrelated data obscures what might be helpful to the next covering physician.

In fact, most every step of diagnosing, treating, and discharging a patient involves the physician surrendering his expertise to a computer record that presents “yes and no’s” data without nuance or direction. Any shift in treatment from implicit or explicit protocols is fraught with more paperwork and little freedom to follow physician judgement.

In the end, the computer “wins” and administrators are satisfied. The medical record has “evolved” into a billing form. The doctor and patient are left out of that loop. - Peggy Finston MD
"It’s not just the six hours of daily data entry: It’s that it takes clinicians’ eyes off their patients, missing the very connection with humanity that drove them into this work."
More on the "six hours" trope in a bit (dubiety spoiler alert), but the author and the commenter raise undeniably fair points.


This fellow is unsympathetic, to put it mildly
I have several comments regarding this article and the implications made by it. First, I get a quasi-nauseous feeling when people start talking about poor, overworked doctors – overworked mostly by having to code the transactions they make – who are suffering from depression and anxiety, which has now morphed into PTSD. And now the article about these “wounded” docs is being written by someone who has PTSD from slipping on a slick tile floor during a brief firefight. Try watching your best friend’s face get eviscerated from an IED blast.

But that isn’t my main problem with this article. The main thing is that, according to the author, we have PTSD-depressed docs running around treating people with real illnesses and then going home feeling sorry for themselves because they had to spend time on paperwork. Do you have any clue as to how many people in this country die – as in DEAD – from Preventable Medical Error! Over 400,000 every year. And when you count Serious Harm into those statistics the numbers jump into the millions. And now you tell me that some poor guy whose finger hurts from writing codes on a billing statement thinks he had PTSD?? No wonder we have so many people dying over here. We have thousands of Physicians feeling mistreated because they are asked to perform a bureaucratic function. I’ll tell them the same thing I’ve said to other physicians to there face. If you are so put off (‘nee Traumatized) by your job, go be a Hedge Fund Manager. At least we would all know what kind of person we are dealign [sic] with then. - LARRY W PIERCE
Yikes. Make of that what you will. Bit of randomness in that rant.

Broadly, you might want to see my prior post "Are structured data the enemy of health care quality?" See also my snarky"Clinic Monkey" spoof site.

In addition, some of my prior riffs on "Leadership" seem to be relevant, e.g., starting with "What exactly is 'Leadership,' anyway?"

Given my dire family circumstance these days, I could scarcely be more attuned to the physicians' - patients' dynamic, warts and all.

I reached out to the author, Elizabeth Métraux, Director of Communications and Development at

Note that I've posted a permanent link to them in the right-hand links columns. Lots of interesting material there. I'm just starting to search out any independent socio-psych literature supporting this "model." Everything relating to clinical organizational culture is of intrinsic interest to me.

They have an "Institute" -- "RLI" (pdf)

I've uncovered one 2006 paper thus far (pdf).

From the paper's conclusion:
Relationships—rather than authority, superiority, or dominance—appear to be key to new forms of leadership (Drath, 2001). Yet, while relationships are at the heart of many of the new approaches emerging in the leadership literature, e.g., distributed (Gronn, 2002), distributive (Brown & Gioia, 2002), shared (Pearce & Conger, 2003), post-heroic (Fletcher, 2004), and complexity (Marion & Uhl-Bien, 2001), we know surprisingly little about how relationships form and develop in the workplace. Moreover, investigation into the relational dynamics of leadership as a process of organizing has been severely overlooked in leadership research (Hosking, 1988; Hosking and Fineman, 1990)...…
We need to move beyond a focus on the manager–subordinate dyad or a measure  of relationship quality to address the question of, what are the relational dynamics  by which leadership is developed throughout the workplace?

Such an approach opens up the possibility for relational leadership as moving toward a more “postindustrial” model of leadership (Rost, 1991)—one that is not hierarchical, can address various forms of relationships (not just dyadic and not just “leader–follower” relationships), focuses on relational dynamics (rather than a more static state of relational quality with antecedents and outcomes), and allows us to consider leadership as a process of structuring (Giddens, 1984; Murrell, 1997). Investigating relational leadership will require richer methodologies than over-reliance on cross-sectional survey data using limited measures (Bradbury and Lichtenstein, 2000; Bryman, 2004). It would allow us to consider processes  that are not just about the quality of the relationship or even the type of relationship, but rather about the social dynamics by which leadership relationships form and evolve in the workplace. In this way, it moves leadership beyond a focus on simply getting alignment (and productivity) or a manager’s view of what is pro ductive, to a consideration of how leadership arises through the interactions and negotiation of social order among organizational members.
This monograph is 12 years old. Have we made significant progress in this area across the past dozen years? 

Curiously, I find no mention of the word "empathy" in the body of the foregoing UNL paper (though the term appears in the end-note citations referencing one prior wok).


From across the Pond:
Leader-Member Exchange (LMX) Theory (Graen & Uhl-Bien, 1995), also known as the vertical dyad linkage theory, proposes that the quality of the relationship between the leader and the subordinate influences performance-related outcomes (for both the leader and the subordinate). The leadership theories discussed previously have a group-level focus; that is, the leader treats all subordinates in the same way. For example, transformational leadership is usually considered to be a group-level construct. However, LMX theory focuses on the relationship between the leader and each individual subordinate. This model is most appropriate for understanding how a leader manages a team of individuals. As a leader interacts with his or her team, the leader will classify individuals as members of either the in-group or out-group. These classifications, once established, tend to remain fairly stable over time. Although it is not entirely clear what governs the leader's allocation of subordinates to the in-group or the out-group, goal congruence seems to have an influence, in that individuals with similar goals to the leader are selected to the in-group (Uhl-Bien, Graen & Scandura, 2000).

Research in the area of LMX has established the positive benefits for both the leader and the subordinate of being in a high LMX relationship. High quality LMX leads to enhanced employee satisfaction, performance and OCBs (Ilies, Nahrgang & Morgeson, 2007; Phillips & Bedeian, 1994; Settoon, Bennett & Liden, 1996). Furthermore, high quality LMX has a positive impact on leader behaviours. For example, Mayer, Davis and Schoorman (1995) found that leaders in high quality LMX were more trusted by their subordinates, who were in turn, more trusted by their leader. This resulted in leaders delegating tasks to these subordinates and being more willing to empower them. Although there has been considerable research looking at the impact of high quality LMX, there has been less attention given to low quality LMX. In these relationships, the subordinate performs in-role behaviour (i.e., activities required by the job), but does not put extra effort into their work or engage in OCBs (Bauer & Green, 1996). Furthermore, Townsend, Phillips and Elkins (2000) demonstrated that low LMX is associated with negative consequences, such as retaliation behaviour (see Unit 3 in relation to psychological contracts). Recent research has focused on identifying situations in which leaders and subordinates are motivated to invest more work effort within low LMX relationships (Kacmar, Zivnuska & White, 2007).

The strength of LMX theory is its emphasis on the role of both the leader and the subordinate and its recognition of leadership as a dynamic interactive process. However, although there is broad support for LMX theory, there is currently little understanding of the wider context within which dyadic relationships take place. As LMX theory focuses upon each individual dyad, the theory does not take into account the influence of the group or organisational context.
OK. "Relational Leadership™"? A new, useful (albeit electic, incrementally improved) model? Or "old wine in new bottles?" As I've remarked before, I'm more interested in being lean rather than 'Doing Lean," being agile rather than 'Doing Agile," and, now, being relational in lieu of ""Doing Relational."

But, I have much more to learn here.


Primary care practices (e.g., IM, FM, Peds) still rank close to the bottom of the physician compensation bar chart (2017 data).

"Doing more with less..." The "productivity treadmill" bane.

During my two stints in federal Health IT initiatives (DOQ-IT and Meaningful Use) my turf was comprised principally of ambulatory primary care (including OB/Gyn). I remain pretty sensitive to the workflow problems (pdf) they continue to face.

See some of my prior blog riffs on "workflow."

This was interesting:
“The next time you wrap up a visit with a health care provider, ask him or her, ‘How are you doing?'”
 I do that routinely. When I asked it of my cardiologist not too long ago, he almost couldn't stop talking, once he got over his surprise.

Point taken, Elizabeth.

Just getting started here. Gonna post this and go do some caregiver stuff.


Specifically with respect to the "docs spending 6 hours a day entering EHR data" lament.

Like @POTUS, I tweeted

I too have "the best words."

apropos, see, e.g., my old post "Clinical workflow: 'YAWL,' y'all?"


The latter book (Tomasello) provides great science on the evolutionary utility of "prosocial/cooperative" behavior (which goes to its relevance regarding this topic). The tagline of the Marx book is "the price we pay for expecting perfection." Which pairs nicely with Kathryn Schulz's book. Maccoby's work in the Leadership area is both broad and deep. Jeffrey Pfeffer's book is a take-no-prisoners piece of iconoclastic skepticism, highly recommended. Dr. Toussaint is one of my heroes in the lean health care leadership space. My fav quote from him: "Manage processes, lead people."

I've cited, excerpted, and linked all of these on this blog.

More to come...

No comments:

Post a Comment