Originally published on Stat. Co-authored with my wife/partner, Ashley Ramirez, MS, RN, CPNP-AC.
Health care delivery in the United States is being led by practitioners who have ascended to leadership roles primarily through years of loyalty to their organization. But, while burnout worsens and affects the youngest clinicians to the detriment of our system, is this the appropriate cadre to shepherd us towards necessary system transformation?
We share two stories that led us to think about this issue, and offer some suggestions for integrating the junior leaders of tomorrow.
Travis’s story: millennial physicians
Halfway through a recent lunch-hour meeting, I found myself baffled by the scene. My two colleagues and I, a family physician, all in our mid-30s, sat on one side of a giant conference table. On the other side were two senior physicians and the CEO of our medical group.
“What is it,” one was asking, perhaps rhetorically, “about these millennial physicians and burnout?” The CEO announced that he would like to hear from us only to pivot in the same breath to his own rant about younger physicians. He mentioned the existence of a growing body of evidence regarding burnout among millennials, but didn’t support it with any evidence. Before my colleagues or I — presumably expected to speak on behalf of all millennial physicians — could respond, the hour was up and our first patients of the afternoon were waiting for us to get back to work.
This meeting turned impromptu lecture on millennials in medicine revealed management’s poor understanding of the millennial generation’s professional needs. But it did serve to raise an important question: If our local medical group leadership did not understand the future of the health care workforce, what did that suggest about their ability to guide us into the future of health care delivery?
Ashley’s story: nurse teamwork
Despite a decade of nursing experience in cardiothoracic surgery, I felt like a novice in my first role as a nurse practitioner. I shouldn’t have. I quickly noticed that the process to bring me on board lacked structure, did not include up-to-date practices, and failed to convey consistent expectations from the senior practitioner and lead physicians. Educational resources were all on paper, stored in folders stashed in cabinets. The amount of both patient- and nurse-facing education materials that needed to be updated — some handouts on heart failure medication administration had not been revised since 1990 — seemed alarming, yet the other practitioners did not share my sense of urgency.
After settling into my new role, I began to make gentle suggestions to update our practice and improve the efficiency of our processes, but these were consistently met with resistance from the senior practitioner. With critical details about updating our practices dismissed as unimportant, it became apparent that the leadership was resistant to change.
During my schooling to become a nurse practitioner, I learned the importance of teamwork, multidisciplinary collaboration, and patient-centered care. But from the perspective of my bedside work, these appeared to be theoretical concepts rather than part of daily practice.
In the day of networked computers, documenting evidence-based practice and sharing lessons learned from prior changes in clinical workflows should have been easy. But our team’s leadership did not appear to demand (or even aspire to) this. Were they comfortable with the underutilization of available technological resources, or simply unaware that these tools even existed?
The worst metric for leadership: seniority
Health system leaders today are confronted with the constant pressure to innovate. But who are these leaders and why were they appointed? What is it about the rationale for prior appointment and previous success that suggests these leaders are the right voices to be heard when steering health institutions into an uncertain future of increasing complexity and volatility?
Nursing management, medical group leadership, and those in the hospital C-suite seem, in many cases, to have risen to their positions based on perhaps the worst metric: they have been in the organization, or in their job, the longest.
Longevity is often seen as a reflection of loyalty. Years of service represent an accumulation of treasured institutional knowledge, its value infrequently compared to other merits such as prior demonstrated leadership success or potential for creative problem-solving. Instead of an asset for innovation, extended tenure could be a sign of growing comfort with a given status quo or operating context.
If older colleagues are slower to adopt or optimize the use of the latest technology, what can we infer about their eagerness to update local processes to reflect best practices or, further, to make boat-rocking decisions as an organization charts its course? The lure of generous pensions or retirement packages exacerbates the presence of long-lasting leaders.
While leadership ranks remain packed with “experienced” leaders for years, or even decades, what is being done to ensure that organizational change is sustainable? Grooming young talent requires concerted attention, whether that entails the creation of junior leadership roles, the establishment of formal mentorship structures, or simple inclusion in strategic committees. Yet even those efforts leave many young clinicians wanting more.
Institutions have it in their collective best interest to invest in bolstering young clinical leadership sooner rather than later. Input from the newest generation of health workers will be essential for navigating toward a future of safe, high-quality care that leverages technology and other new sources of efficiency along the way.
The health system of the future
In the U.S., the fee-for-service system is gradually giving way to one that rewards value. Technological capabilities are expanding at an incredible pace and infiltrating health care, giving rise to better data and more sophisticated analytics to direct us along this path.
Are our clinical leadership teams made up of the right people to push us towards this future? We don’t think so, at least not in their current forms. A few numbers might be enlightening: There are still far fewer women in leadership roles, and their pay in those roles remains less than for men. Only 12% of health care CEOs are under 50 years of age, while 17% are over age 65. Just 39% of all health care CEOs have a formal succession plan.
Whether or not you buy into the argument that current leadership is not comprised of the right mix of experience or expertise, we might all agree that stronger formalized talent development would benefit everyone.
“What is it about these millennials?”
It is difficult for some to move beyond the lazy stereotype in which all millennials demand a trophy just for showing up, but by doing so it would become apparent that these more junior health workers have a different view of the health care system than their more senior clinical colleagues or leadership. This is informed by their recent education and training, augmented by evolving technology, shaded by the burden of educational debt, and shaped by front-line work in a system that is not serving patients well by many measures. A high level of comfort with digital resources allows many millennials to more easily see them as innovative avenues to improve the patient experience — or even their own experiences as practitioners.
It is important to recognize generational differences between clinical leaders and more junior clinicians because differences and in diversity of perspectives provides value and opportunities for mutual benefit and learning.
Despite our disdain for the common framing of “burnout,” the phenomenon is a problem for clinicians, their employers, and patients. The drained nurse can make an error. The indifferent physician can fail to adequately address a patient’s mental illness. Both can leave patients dissatisfied.
Burnout comes from being pulled in many directions, performing sub-optimally in each, while having little autonomy to control elements of one’s work. Solutions such as on-site yoga, meditation classes for physicians-in-training, or physician coaching are simply Band-Aids that focus on the health worker, an approach that effectively suggests the individual has somehow failed to adapt to the rigors of the work. The true culprit, however, is the system.
If millennials leave practice for non-clinical roles as the health system morphs to meet the needs of the next decade, the looming shortage of health workers will be profoundly worse than anticipated.
Health system leadership, payers, and policymakers would be well served by giving younger nurses and physicians stakes in their local system’s performance and empowering them to direct their own professional service of patients and personal development. The clinician would feel a sense of improved control over and fit within the immediate ecosystem, while the group or hospital would benefit from a different perspective, reduced turnover, and eventually a thoroughly groomed in-house leader of tomorrow.