I love the idea of turning a negative approach to improvement in health care—looking for problems—on its head. Appreciative inquiry, a process of focusing on a group’s inherent strengths and fostering positive interactions among group members, is one way of fostering change with a positive approach. Positive deviance (PD) is another.
Basically, PD involves identifying what’s working and usual local solutions owned by the people involved to make improvements. According to Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology, and Relationship-centered Care, a fascinating book I’m currently reading, PD was first developed as a way to address malnutrition in poor communities—by looking for children who were healthy despite the limited resources, learning what the mothers of these children were doing differently (the “deviance”), and creating opportunities for other mothers to practice these different behaviors.
What if we were to apply positive deviance to the problem of clinician burnout? What might that look like?
When I was in residency training, I felt struggled with a conflict between my perception of reality and a seemingly widespread fallacy. As a human being, and especially as a human new at the tasks I was undertaking, I knew I was imperfect, yet the clinical world seemed founded on the belief that it is possible for humans to never make mistakes. Only perfection was acceptable. The possibility of unintentional medical errors was usually just denied. If errors occurred, they were seen as the individual health professional’s fault. In other words, if a mistake happened, I’m to blame, even if I was doing my best in a broken system, one that required multiple error-prone workarounds to complete a task. That conflict ate away at me, and was one of the factors that precipitated burnout and my decision to leave clinical practice several years later.
It was in the course of writing about the health care system that I first learned about organizational culture, which can be loosely defined as “how we do things around here.” It governs how people act, how they respond, how they treat each other. It is shaped by top leaders. They set the tone, model ways of being, and choose which behaviors to reinforce and reward, which to call out, and which to overlook (a choice that usually speaks louder than words). Leaders’ actions and choices demonstrate the organization’s culture for everyone else. Of course, there are micro unit cultures that differ across the organization, but the trickle-down effects of leaders show up here too.
When I left clinical practice, I thought I was prepared for the change in my identity.
I was shocked by the degree to which my sense of myself and my value in the world were rocked by leaving the profession. After all, I left practice less than seven years after I could legally write M.D. after my name. In residency and when practicing (and even to some extent as a medical student), I had reveled in the admiration of people I met at social gatherings—without realizing it. When I introduced myself as a physician, strangers leaned into the conversation, their faces lit up, with questions that were brisk and enthusiastic. Later, when I introduced myself as a writer, the response was completely different. I might get a question about what I wrote or where I was published, but the energy was pretty lackluster. And I saw how much I had basked in the shininess of the physician identity.
Eventually, I learned I could be perfectly happy without the adoration of fellow guests at dinner parties. I saw that my value in the world is not defined by my title or job description, but by how close I come to being the kind of wife, mother, daughter, sister, writer, consultant, coach, community member, and world citizen that I aim to be. It’s about who I am and how I am, not my degrees or title or position or credentials. I wouldn’t have faced this question of my value in the world if I hadn’t experienced burnout and left clinical practice.
Or maybe I would have.
Many of the physicians I’ve spoken with who have tackled the question of whether or not to leave because of burnout have faced this same question of identity—and facing the question seems to be essential to their being able to make different choices in how they practice. The experience of two physicians immediately comes to mind.