As part of medical education training, physicians adhere to a prescribed code of ethics, whether formalized by stating the Hippocratic oath (or code of Maimonides) at graduation or informally by following the dictum “First, do no harm.” These traditions point the physician toward a patient-facing world view, in which all the efforts of the clinician are directed to the care and well-being of the patient.
What happens, however, when the physician finds himself part of an organization that is structured to enable the delivery of care and that organization faces intense challenges in its ability to deliver its mission promise?
Healthcare in the United States has been subjected to enormous pressures in the past 30 years, with payment models that continue to compress the margins of providers, rising costs of goods and services, and failures to demonstrate improvements in clinical outcomes as compared with other developed countries. The situation has been exacerbated by the global COVID-19 pandemic with supply chain disruptions, interruptions in service delivery, ongoing labor unrest, and increasing inflationary pressures that continue to threaten even the most resilient care delivery systems.
As the pandemic increased stress on healthcare in the United States, it also shone a bright light onto the structural and systemic design flaws of the healthcare system. Physicians have been articulating the challenges they face in the delivery of care for years, but amid geopolitical and economic challenges, neither policy change nor legislation to enact change seems imminent.
Physician Frustrations
For many practicing physicians, it feels like “deja vu all over again.” Preexisting apathy, discontent, and resentment, to name a few, are creeping back into the physician vernacular on top of the well-described, ever-present, and ever-increasing phenomenon of burnout.(1) More recently, the term “moral injury” is being used to describe a reaction that is occurring among physicians—a phrase that seeks to better describe the misalignment of healthcare delivery and personal adherence to intrinsic values.(2) These sentiments among physicians tend to further widen the gap between administrators and physicians, making it even more difficult than ever to collectively address organizational challenges.
We now turn to the dilemma facing physician–leaders, particularly physician executives, who are tasked with leading physicians as their organizations face these challenges. And we return to the inculcated (or ingrained) notion of physician behavior that drives mindset and priorities toward patient care and not traditionally toward organizational health. One might even accept that while practicing physicians excel at making individual patient diagnoses, they are generally neither trained nor skilled to deliver compound, integrated, organizational solutions. As a result, practicing physicians, while often heroic(3) in the execution of their duties, often find themselves displaying victim behaviors and attitudes about the unyielding systemic impositions on their ability to provide care. With these notions in mind, we offer a potentially powerful construct for physician–leaders to address these entrenched tendencies in healthcare delivery.
A Father’s Wisdom
The authors of this article have worked in healthcare for more than 60 years combined, with a substantial portion of that time devoted to leadership roles. One of us (Nygaard) found himself getting involved in leadership because he was (admittedly) exhausted by the fact that healthcare seemed to be plagued by the thinking that physicians are simply and forever the victims of change. Nygaard recalls, while he was growing up, sitting at a business table and hearing his father say, “If you can’t be a part of the solution, do the company a favor and leave.” This paternal wisdom can be interpreted in several different ways. It can suggest that a worker’s behaviors and choices do not always benefit the company and perhaps departure is best for both parties. Alternatively, it can inspire workers to double down on their organizational commitment to elevate company performance. For practicing physicians in large health systems, there may be a strong tendency to remain in limbo between those two poles of action. Nygaard consciously chose to move to a leadership role to influence positive change and to be a part of the solution, but he also recognizes that if transformation is to be successful, more physicians need to embrace leadership and to support necessary change to best serve their communities. We believe that physicians must lead the process of transformation within organizations with a mindset that encompasses both patient well-being and organizational health. And we have found a useful paradigm to shape organizational transformation that might be of interest to physician–leaders, and Chief Medical Officers (CMOs), in particular.
Responding to Complexity
Nygaard’s decision to step into leadership reflects on the capacity that individuals have within complex organizations and also reflects the profound insights described by Hirschman in Exit, Voice, and Loyalty.(4) The book describes three critical responses to organizations in decline, but this approach also can be applied to organizations facing intense pressure to change before declining. Perhaps most instructional are the implicit tools alluded to in the book that any CMO can use to achieve organizational transformation and increase organizational effectiveness and, possibly, overall organizational commitment, especially in the face of growing discontent within the physician ranks.
Hirschman’s model of organizational response to change rests on the notion that when there is a decline in service, quality, or benefit to its internal membership or external customers, there are two primary possible responses: exit or voice. The former response, exit, is a withdrawal from the organization to effect change, whereas the latter, voice, is the attempt to use communication to effect change. The profound interplay between these two choices is described in the book, and while they often are mutually exclusive, that is not always the case. A third option, loyalty, may be the best option to reduce the disruptive outcomes of exit and voice. The general principle is that the greater the role of exit, the less likely it is that voice will be used, and vice versa. And more importantly, the interplay of loyalty can affect the use of the other responses. The model often is referred to as the exit, voice, and loyalty (EVL) model. In later years, additional experts in the field have added a formal fourth region of choice, neglect. The term refers to the choice of “doing nothing” in the face of limited success from use of the other choices.(5)
To illustrate exit in a physician leadership setting, let’s use the example of a prominent pediatrician who resigned as medical director of an important clinic in a major urban area over charges that the clinic was troubled by existing institutional racism and a resistance to change from hospital leaders.(6) The physician ultimately began to work with another organization to approach the issues that face youth in his area and to continue to have an impact on the health and development of young and underserved people. The institution that he exited faced intense public scrutiny over his resignation, because he had practiced and served as a leader at the clinic for close to 20 years, and the clinic was forced to implement changes to its processes and care delivery as a result of the impact of his exit choice.
An example of voice in the physician–leader setting would be the statements made to the media by the Chief of Staff at a 290-bed hospital over concerns regarding patient safety, particularly in the operating rooms.(7) The statements (i.e., voice) were made public to news outlets during interviews after a special meeting was convened by hospital surgeons to express their concerns about cleanliness, sterility, and staffing to hospital administrators. Not surprisingly, the hospital faced intense public scrutiny once these concerns were made public, and the unwanted publicity put ongoing pressure on the administration, as well as the threat of retaliation onto the outspoken physician.
Additional examples also are found within larger healthcare ecosystems. In terms of exit, we saw public health officials resign during the COVID pandemic, many as a result of incredible frustration over the system’s inertia and inefficiencies, not to mention fractured leadership by state and federal agencies, combined with long hours and low pay. To make matters worse, political voices were used aggressively by communities against health departments across the United States, including the worst type of offense in terms of hate speech and death threats.(8) This has left a tremendous vacuum to fill in the public health system and undoubtedly will change its trajectory—whether this is for better or worse is still to be seen. Another example of exit within healthcare settings includes myriad collective labor force actions, such as calls for strikes by nurses, ancillary providers, medical and surgical residents, and employed physicians.(9,10) Finally, when physician groups (both employed and contracted) are severing ties, either formally or informally, through contract disputes, contract terminations, and litigation as expressions of exit, systems naturally have to restructure as a result.(11-13) In each of these instances, there is either an individual leader (e.g., public health official) or a collective leader (e.g., Chief Resident, medical group CEO) that sets the path forward for exit. In terms of voice, numerous parallels are being played out across the United States, with healthcare organizations hearing individual or collective voices regarding patient satisfaction, customer service, strategic initiatives, diversity, and health equity expressed through letters, social media, and traditional media. These voices serve to increase the pressure on organizations to change their behaviors.
The examples just cited show how we might apply Hirschman’s concept to current events. Several investigators also have rigorously applied the Hirschman model of EVL to describe the impact on healthcare delivery. One such study outlines the role that exit or voice used by citizen patients has on provider behavior though, albeit limited by the structure of the National Health Service in the United Kingdom. The results suggest that an appropriate provider response to the exit or voice of the patient “results in higher satisfaction and lower intention to exit [by patients]” and also results in strengthened loyalty to the provider.(14) Another team studied the choices and decisions made by providers in the Nairobi government-based health system, in reaction to the structure of the governmental delivery system itself. In this study of the Nairobi system, similar to Nygaard’s observations, inaction or the choice of neglect appeared to be the predominant action taken by providers when faced with the perception of an immovable, governmental care delivery system.(15)
Allowing for Response: A Physician Leadership Skill
What is not apparent in published material is the notion of using the understanding of human behavior in the EVL model and applying the principles to physician leadership skill development. Any current or aspiring CMO would be wise to take note of these activities in their organizations and to be prepared to participate as a stakeholder to address either exit or voice in their environments, because those activities could impact the strategic direction of the organization in which they serve. What remains to be seen is whether or not an exit or voice response is doing the organization any favors. Sometimes it may suffice to allow a disgruntled physician to gripe (i.e., to use voice), and the complaint is quieted without significant impact. Or if the complaints that are voiced are legitimate, this may initiate remedies to procedures or policies to have better outcomes. Neither of these voice actions is terribly disruptive, but they can be quite beneficial to smooth operations and keep the voice from becoming unmanageable. Allowing an unhappy physician to exit may not be the worst outcome for the team and its work to continue, unless, of course, he or she is a well-regarded or highly successful physician in terms of physician culture, stakeholder engagement, or revenue generation. Although an exit can be minimally disruptive, especially if the exit brings some improvement in the team dynamics, an exit such as in the latter situation, could have significant negative impact on system operations, key performance indicators, and strategic plans. Finally, when physicians are not engaged or committed to the organization, one can postulate that there will be more use of exit, voice, or neglect, all of which could become very time consuming for managers.
For the past several decades, physician engagement continues to be lower than in other industries. This likely does not come as a surprise to seasoned physician–leaders.(16) The COVID pandemic created substantial opportunities for all stakeholders within health systems to unify around a common cause, and improvements in physician–administration relations certainly improved, but it may be too early to state whether the elevation in engagement was sustainable or transient.(17) Hirschman points out that tolerance of exit and voice is useful, particularly to minimize disruption. An organization that allows for open forums, regular discussions, and multi-channel communication can mitigate both individual and organizational disruptions. On the other hand, if not well managed, tolerance of exit and voice can lead to departures, statements, and declarations that can have lasting effects on culture and direction to such an extent that suppression is required, leading the organization to create an unhealthy culture. The seesaw effect of these two choices needs to be attended to regularly by those in leadership roles, or they risk negative impacts on organizational effectiveness.
An Interpretation of Loyalty for Physician–Leaders
Loyalty, the third aspect of Hirschman’s model, may prove to be one of the physician–leader’s most powerful tools. Loyalty, as described in the book, is best understood when loyal members become committed to the organization, particularly when there is pressure to avoid a decline. As part of loyalty, there is minimal use of the individual exit or voice as disruptions to the organization, but, rather, a particular devotion to the organization’s success and the corresponding use of skills and knowledge to be heard and positioned to be a change agent. Hirschman presents various theoretical constructs regarding how organizations function and react to varying degrees of exit and voice and gives credence to a theory of loyalty that in its best iteration (as opposed to loyalists to evil or maleficent constructs) is extremely elastic. This elasticity allows for injections of both exit and voice to a certain degree, such that loyalty holds the center position so that the organization remains stable, if not improving, rather than on a decline or heading toward deterioration. Further, Hirschman criticizes leaders who, when given an option to allow exit or voice in an appropriate manner to effect change (e.g., the Vietnam war) failed to act for the sake of the public good.(4)
Hirschman’s book presents a study of forces within organizations and produces a model from which to understand organizational behavior. Hirschman, therefore, falls short of offering any proscriptive outline as to how leaders might manage such behavior. Fortunately, organizational behavior experts devote a large body of work to such concepts; however, exploring all of that is beyond the scope of this article. Paramount to the effort at hand for physician–leaders today, is any outline as to how they might lead in their environments to allow for a mobius strip style of both exit and voice to promote loyalty and, thus, to maintain organizational health, if not upward movement.
Cultivating Loyalty
CMOs are well positioned to be individual examples of loyalty and, therefore, to promote an environment that fosters loyalty. As Nygaard has stated, he found himself frustrated by the archetype displayed by so many of his physician colleagues, many of whom simply, perhaps quietly, resigned themselves to the never-ending pathos of their situation and used neither exit nor voice, but, rather, neglect. An effective physician–leader first must turn inward and begin to cultivate a sense of loyalty to his or her role in the organization and seek to make changes necessary for the organization’s best interests, for patient safety, and for quality outcomes. As a physician–leader it is important to recognize the choice one brings to the organization. If a leader chooses to be loyal, then he or she is working to optimize the organization. Although on the surface that may seem intuitive, many physician–leaders find themselves in roles in which they do not always understand where their priorities lie and to what extent that they serve an organization. Many physician–leaders state that they are patient advocates, or that they represent the medical profession—and while those are important values to hold, they are not actual tools for organizational change. By representing stakeholder groups such as patients and physicians, a physician–leader tends to be anchored to those constituencies and, therefore, could be ineffectual making changes needed for the strategic direction of the organization. Rather, the physician–leader can leverage his value promises to his constituents by offering to serve in a role to shape the organization inasmuch as his position and influence allows. But he or she also must recognize that their primary and personal philosophies ought to align with the organization’s mission and vision and, thus, be a loyal and committed participant in the organization’s success. If such alignment is not possible, he or she then should consider the value and organizational impact to oneself and to all stakeholders and “do the company a favor” and leave.
A CMO or CCO often is the best choice in the C-suite to lead the effort to foster physician loyalty and also to best manage exit and voice.
Naturally, then, the question arises: how does a physician–leader become organizationally loyal? It is likely through self-reflection and educating oneself in areas of leadership development (e.g., taking a personal inventory relative to organizational values) to become self-led and more aligned with the organizational mission. Once a physician–leader takes the initiative to clarify his or her leadership style and skill set relative to the organization (and elevate those through education when necessary), then the leader is ready to tackle the organizational situation. Using the example of CMOs again, it is worth considering that in today’s healthcare climate, a CMO or Chief Clinical Officer (CCO) often is the best choice in the C-suite to lead the effort to foster physician loyalty and also to best manage exit and voice.
As an example of efforts in developing loyalty, Nygaard routinely fosters a learning environment at Lee Health wherein physician participants are invited and encouraged to participate in discussions regarding the use of artificial intelligence, innovations, process changes, and design elements to develop local solutions to local problems. He was also instrumental in the institution of a “commitment to excellence” initiative.(18) Furthermore, Dr. Scheinbart, while CMO at his former organization, initiated a physician leadership development program, expanded a physician executive coaching program, and created a mentorship program as well. All of these examples foster opportunities for physicians to lean into organizational problem solving and leadership development, both of which can serve to build loyalty. Hirschman states that, “when a member [displays activity] in an organization and is therefore convinced he can get it “back on track” [he or she] is likely to develop a strong affection for the organization.(4) Action-oriented problem solving and collaboration with physician members ought to serve to develop affection for the system. Likewise, Hirschman says, “a member with a considerable attachment to a product or organization often will search for ways to make himself influential, especially when the organization moves in what he believes is the wrong direction.”(4) Leadership development, theoretically, then, increases influence and considerable attachment as well.
Before a CMO or CCO decides to foster organizational loyalty, he or she must understand the current environment and culture of the physicians in the system. The most commonly used approach to understanding the system’s physician mindset is to evaluate physician engagement. If we borrow the definition of engagement, paraphrased as the “active and positive contribution of doctors, within their normal working roles, to maintaining and enhancing the performance of the organization,” it certainly suggests a directionally accurate description of loyalty, at least the one used by Hirschman, but noting one key difference.(19) In the quoted definition of engagement, the focus of action is toward organizational performance. We suggest, however, that physician loyalty is better defined as the affiliation to the organization as the embodiment of aligned mission and values. This is an area that calls for more study by organizational experts interested in health systems. Studies designed to measure and discern indicators of loyalty (e.g., commitment or affiliation) of physicians to their respective organizations, followed by studies to measure loyalty as an indicator of organizational resiliency, could lead to stronger organizational development. In any event, and for practical purposes, engagement is a very reasonable starting point for the CMO. Work in the area of engagement is plentiful and has shown repeatedly that higher physician engagement promotes higher quality, lower costs, improved patient experience, and lower feelings of burnout.(19-23)
In addition to measuring engagement, we propose some basic ideas to drive physician loyalty (see sidebar). These have been applied elsewhere and would be useful for CMOs and other physician–leaders in any effort to work with their C-suite colleagues to drive physician loyalty. It may be easier to articulate to stakeholders that the goal is increasing physician engagement, affiliation, or commitment, but ultimately these types of interactions serve to build an underlying loyalty mindset. Although the ideas listed in the sidebar require deliberate discussion and operational design within any individual organization, they are widely available tools across the healthcare industry and do not necessarily require reinventing the proverbial wheel.
Sidebar: Ways to Build a Loyalty Mindset Among Physicians
Rely on self-reflection and personal commitment to organizational outcomes (self-directed).
Foster a learning environment (self-directed).
Formulate a measure of physician engagement.(16)
Improve engagement through the diagnose–involve/engage–communicate model.(22)
Develop medical staff compact/commitment.(4)
Offer on-site physician leadership development.(24)
Hirschman’s model of responses to organization pressures, while written as an exegesis of organizational phenomena for economists and social scientists, offers a construct that physician–leaders can use as a blueprint to lead and to shape healthcare organizations under pressure to deliver on their promises to their communities. In an effort to assist physician–leaders to improve organizational health, we offer the concepts of exit, voice, and loyalty as a useful model (one that is highly regarded after several decades of experience and research in the social sciences) in healthcare delivery. We cannot prescribe any specific formula, given that each health system has its own culture and microcultures, especially when it comes to physician behavior. We encourage CMOs and CCOs and their administrator colleagues, however, to set forth initiatives to drive physician loyalty and to make the necessary cultural and operational changes required to foster at least a more loyal tendency amongst the physicians. We propose that this will decrease any disruptive use of voice, exit, or the most self-defeating posture of neglect. We acknowledge that the attempt to increase organizational loyalty is aspirational, but it is with purposeful vision and relentless discipline that leaders drive change. One might even hope that the overall net effect of increasing loyalty within the physician ranks is to increase organizational resiliency during times of intense pressure, whether from natural events or from economic ones. The Merriam-Webster online dictionary states, “LOYALTY implies a faithfulness that is steadfast in the face of any temptation to renounce, desert, or betray.”(26) By creating an environment where physicians find themselves more engaged, more affiliated, and more committed, and, perhaps, more loyal, physician–leaders can drive organizations to be steadfast in the face of strong headwinds and to reach milestones in their plans to succeed.
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