Published in the August 2016 issue of Today’s Hospitalist
FOR NEARLY A DECADE after several hospitalist groups at the largest private hospital in the Twin Cities merged to create the Abbott Northwestern Hospital Hospitalist Service, an affable facade concealed underlying tensions. The problem? The cultures of the original programs were very different.
Following the merger, “there hadn’t been a big effort at homogenizing the two founding groups,” explains Brian French, MD, lead physician of the 68-physician internal medicine and med-peds hospitalist group, which is part of Allina Health. There was, for instance, a lot of variation in workload among the different segments of the large, heterogeneous group. Meanwhile, misunderstandings and resentments tied to differences in scheduling and coverage had long “simmered under the surface.”
A few years ago, these “bubbled up,” Dr. French says. An Allina employee engagement survey done at the time put the hospitalists’ score at a dismal 59%.
“The more connected you are, the better the outcomes.”
Dr. French recalls struggling with the question of how to improve group cohesiveness. The first move to help build trust and foster understanding was organizing an off-site, consultant-facilitated retreat, which all group members attended. At that retreat, initial steps were taken to define the group’s mission and vision.
Since the retreat, the group has organized multiple activities to foster a sense of community. These include annual group parties, monthly get-to-know-each-other bulletin board postings and weekly team lunches on weekends. The hospitalists now even have an official social committee, charged with generating ideas for events and activities to promote social cohesion and boost group morale.
Not everything they’ve tried has been a success. The group couldn’t, for instance, muster up enthusiasm for happy hours. But “the bottom line of all these interventions is that our hospitalists now report feeling much more connected as a group,” Dr. French says. “A feeling of oneness has since developed.” On last year’s engagement survey, the hospitalists’ score rose into the 90s.
Dr. French’s experience is far from unique. According to Leslie Flores, a partner with the La Quinta, Calif.-based Nelson Flores Hospital Medicine Consultants, a notable feature of the last few years has been “a general decline in hospitalist morale. As a result, we are seeing a lot more groups starting to pay more attention to hospitalist well-being and work-life balance issues.”
In fact, she says, a clue to whether or not a hospitalist group is high-functioning is the extent to which its members view themselves less as free agents and more as members of a collective.
“Groups that invest in promoting social connectedness tend to be the most stable and well-functioning,” Ms. Flores points out. “That’s because people care about their colleagues, and they are not just coming in and picking up their list of patients to see, almost like an independent contractor.”
A worthwhile investment
Building social capital can be formal and costly, like an annual off-site team-building retreat, or informal, like regular pub crawls and pot-lucks at colleagues’ homes.
“I think that as a leader, you should be curious … if the group seems to be all business, no play.”
Sometimes it can be both. In Traverse City, Mich., for instance, the hospitalists with iNDIGO Health Partners enjoy an annual winter family party held at a local venue and monthly lunch-and-learns that group leadership arranges and supports. But they also get together for an annual chili cook-off and bowling, activities that bubbled up from the rank-and-file.
“These events are worthy of our investment,” explains Daniel Ladd, PA, a hospitalist physician assistant with iNDIGO since 2006 who is now chief clinical officer of the private group. “The fact that we haven’t had to replace a lot of providers saves costs. For a little bit of money, this is the least we can do for our well-deserving providers.”
But some groups don’t see the point, let alone the potential payoff, of directing energy, time and money to social activities. Plenty of doctors—like workers in every profession—”will roll their eyes and say we don’t have time for this,” says Ms. Flores. One way for groups to address the time crunch is to look for opportunities to build social connections into the things they are already doing.
“How much are you spending having hospitalist group meetings every month?” Ms. Flores says. “If you are spending all that money having somebody stand up in front of a room and talk at the hospitalists, you are missing a huge opportunity to build relationships and social connectedness.”
Her advice: “Carve out some portion of time during group meetings for an activity that gets people to bring a little bit of who they are outside of work into the room, rather than just always being clinicians focused on work.”
Tackle workload, staffing
Social connectedness often takes thought, planning and action. As Seattle-based Thérèse Franco, MD, notes, many people shudder at the idea of “mandatory fun.”
But she adds that if hospitalists aren’t connecting to one another outside of work spontaneously (and voluntarily) “for aspirational and celebrational” activities and events, it may be a signal that something is wrong with group morale. “If that’s not happening organically,” says Dr. Franco, “I think that as a leader, you should be curious about that. You should be curious if the group seems to be all business, no play.”
At Virginia Mason Medical Center where she works, activities to promote teamwork and esprit de corps over the years have been both informal and formal, although they perhaps need to become more intentional as the group gets larger. “It’s a little easier to get lost in the shuffle these days,” she says.
“That being said, I think our group is particularly cohesive. We invest the time and energy and connect every week, month and year.” Those include both “subtle small ways” like the monthly section meetings where people linger and chat over refreshments, and big events like an off-site Saturday annual retreat.
But sometimes, getting hospitalists to buy into the idea of socializing together is easier said than done. According to Miguel Villagra, MD, medical director of the employed hospitalist program at White River Medical Center in Batesville, Ark., before the growing group of hospital medicine physicians, nurses, advanced practice clinicians and allied health professionals were willing to socialize with each other outside work, the issues of workload and fatigue had to be addressed.
Four years ago, the group was severely understaffed, with only six clinicians. Now they are up to 12, with four more physicians coming on board in the next six months.
“We were very tired and completely disengaged to the point where leaving was a consideration,” Dr. Villagra recollects. Hiring was essential, but just adding bodies was not going to be enough. To build a successful team, he needed to encourage connections and foster friendships.
“So my home became a hub for the hospitalist group,” he says. “I started hosting events such as cook-outs where group members and their families could spend time getting to know one another outside of the hospital.” Once word got around that the hospitalists were “having fun,” as Dr. Villagra remembers it, Gary Bebow, the hospital CEO, said he wanted to attend.
“Now, Mr. Bebow sends me a text to invite our group out for dinner on a regular basis,” he says. “The entire hospitalist group goes to meet the CEO, share a meal and chat. It’s completely social.”
Matching colleagues with like interests
Within Dr. Villagra’s group, one thing has led to another. There’s an ongoing weight-loss challenge where the winner—the person who loses the highest percentage—will pocket a $150 Amazon gift card. Dr. Villagra also works to match up people with like interests, so the tennis players of the group convene on the courts, the golf enthusiasts hit the links together, and a group of young, new hires are studying together for their boards.
“Part of the success is individualizing things because we have a diverse group,” he points out. “Some are right out of residency and some have 30 years of experience.”
His claim of success may be hard to back up with hard evidence, but hopefully not for long. Dr. Villagra is starting to collect data on his group’s cohesiveness and satisfaction using both the Society of Hospital Medicine’s hospitalist engagement benchmarking service and a new physician morale measurement tool developed at Johns Hopkins University and described in the June 2016 issue of the Journal of Hospital Medicine.
Anecdotally, he says, evidence of growing camaraderie comes from the fact that a few of the hospitalists have recently switched from being renters to homeowners. For him, this demonstrates “a commitment to stay with the hospital medicine program.”
The impact of group culture
Like Dr. Villagra, iNDIGO’s Mr. Ladd points out that while social activities are necessary, they’re not sufficient to foster the social cohesion that’s crucial for top-notch teamwork. First comes adequate staffing “so that everybody has a fighting chance at a reasonable workload every day,” says Mr. Ladd.
Second, he adds, is hiring the right people. “You have to like what you are doing and like the people you are doing it with to be in any kind of a mood to spend more time with them,” he says. At White River Medical Center, Dr. Villagra says he now makes a social gathering outside the hospital an important part of the interview process for prospective hospitalist recruits. “I want to see how this person will fit into the culture of the group.”
Encouraging get-togethers has long been a management strategy of Jerome Siy, MD, hospital medicine department chair at Minnesota’s HealthPartners, where a group of 80 physicians works across multiple sites. For years, he has encouraged subsets of like-minded colleagues to socialize outside of work: new parents with playgroups, bike riders with races, or social activism enthusiasts with volunteering together to cook meals for Ronald McDonald House or to pack food boxes for the “Feed My Starving Children” charity.
“Following cues is important,” says Dr. Siy. While he prefers that frontline hospitalists suggest activities for the group, he believes there is a role for a top-down approach as well.
Just last year, his group’s leadership created an official wellness committee, which is charged with vetting proposed operational changes—like new schedules or observation unit management—through the lens of clinician wellness. The committee also arranges and facilitates social interactions.
“We want to be more intentional,” he says, and to make sure there are opportunities for the whole group—not just subsets or cliques—to be engaged. The first group-wide book club invitation went out this spring, for instance. The get-together was at a hospitalist’s house, with food and wine. The book was the Anne Fadiman classic, “The Spirit Catches You and You Fall Down.”
Another activity the wellness committee organized this year was an office clean-up day. “We brought in food and dumpsters so that people could toss and recycle,” Dr. Siy says. “There were free bins for people to take things, and we saw that we can do things to bring fun into our work even during the workday.”
For groups that provide 24/7 coverage, “waiting for the perfect day to do some of these team-building activities can be a huge barrier,” says Kris P. Rehm, MD, division director of the pediatric hospitalists at Nashville’s Vanderbilt University. “So we schedule something every week.”
Right now, for example, a weekly roving “Alphabet Happy Hour” is progressing through area pubs and restaurants, chosen because their names start with A, then B and so on. “People spend a lot of time on e-mail, nominating, debating and picking the pub of the week, which I think really helps bring us together,” Dr. Rehm explains. The Alphabet Happy Hour takes place every Wednesday at 5 p.m., and one-third of the doctors in the division might make it in any given week.
Her group also has a half-day annual off-site retreat that mixes work and play. Last year’s event was at a venue with both meeting rooms and bowling lanes. Another event is packing Christmas stockings for hospitalized children, and the physicians assemble a “Race for the Cure” team every fall. As part of their annual personnel reviews, the hospitalists can mention their involvement in such activities as fitting under the category of “service.”
The same is true at HealthPartners. “Our annual reviews include a ‘people’ dimension,” Dr. Siy notes. “We ask people about all the activities they have been involved with, and our compensation model reflects that.” It covers committee work, “but also if they organized a fitness event, for instance.”
The bottom line, he adds, is that he does not believe work and life are separate spheres. “A lot of people” Dr. Siy explains, “including us, are trying to push the term ‘work-life integration’ instead of ‘work-life balance.’ ”
The claim may be that allowing people to bring their whole selves into their work can’t help but reduce the risk of burnout. But it also can’t help but improve social connectedness too.
“The whole point of having social connectedness is you gain credibility with each other,” Dr. Siy says. “When you build trust in each other, it becomes OK to speak frankly about things.”
Moreover, he adds, “as we think about improving our health care system and wanting to do better for our patients, we will do that better when we are healthier.” In both life and work, says Dr. Siy, “The more connected you are, the better the outcomes.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Right activity, wrong time?
WHEN IT COMES to fostering more social connectedness with your colleagues, not all social activities work for all groups. One endeavor that some groups have tried with mixed results is training for members in mindfulness meditation.
Mindfulness learning and practice was, for instance, the theme of the most recent day-long retreat held by the hospitalists at Seattle’s Virginia Mason Medical Center, and it worked better for some than for others. Thérèse Franco, MD, says she couldn’t help but feel a little distracted from meditation because she wanted to spend socializing at the retreat instead.
“For me,” she explains, “talking and connecting with everybody are an important burnout-buster, and I found it difficult to switch gears and do mindfulness.”
Perhaps it was the right activity, but at the wrong time and in the wrong place, Dr. Franco says. “Mindfulness is somewhat of a personal journey and we were trying to do it as a large group.”
Nonetheless, she says the topic and techniques she learned were “good stuff.” Even better: Mindfulness has turned out to be more than just a one-off social event. Since the retreat, at least some of the hospitalists continue to discuss and practice it, which can only help build and strengthen connections.
According to national hospitalist consultant Leslie Flores, several groups she has worked with that are interested in improving work-life balance within their ranks have tried group-wide mindfulness training. Those groups have likewise had varying degrees of success: Some have loved it, but others not so much.
“Everybody is so busy and you are asking them to take time out of their schedules,” she says.