It has been well established that physician satisfaction is important to business success. Physician satisfaction has been linked to patient satisfaction,1 patient adherence to medical treatment,2 prescribing patterns,3 and physician performance.4,5 Physician wellness and the development of organizational culture to promote and support physician wellness have been less studied and are not yet well understood, particularly for private group practices. Although there have been studies that have examined either the structure or culture of physician group practices6,7 or considered the relationship between organizational culture and the satisfaction of physicians working in group practice settings, to our knowledge, there are no current studies examining the culture of physician group practice and its impact on physician wellness. We believe this in part because changes with respect to wellness are often incremental and occur on an individual level, 1 doctor at a time.
Building a culture of wellness in an orthopaedic group is a daunting task for those professionally trained in organizational development let alone a busy orthopaedic surgeon charged with leading a dynamic orthopaedic group. As physician wellness has become a more pressing topic for health care systems and physician group practices, there are now many physicians who now find themselves charged with the task of building a culture of wellness within their organization. The purpose of this paper is to list some prerequisites and to offer some key strategies for building a culture of wellness in the unique setting of a group of orthopaedic surgeons.
Organizational culture at OrthoCarolina, a private orthopaedic surgical practice located in Charlotte, North Carolina, was assessed by using an external consulting firm to measure physician satisfaction, as a component of wellness, using a validated instrument. For purposes of this paper, survey results from 2014 to 2018 were used to understand the culture of the group practice and physician satisfaction with certain elements of the group practice. In addition, the group implemented the Patient Advocacy Reporting System, known as PARS, a program developed by Vanderbilt’s Center for Patient and Professional Advocacy to enhance a culture of professionalism within the group. The PARS education and interventions delivered between the period from 2014 to 2018 were assessed for organizational impact. Moreover, from 2014 to 2018, a wide variety of organic, organizational initiatives, and responses were directed and observed by the authors, with findings noted as part of this paper. Finally, the authors have over the course of building these initiatives kept abreast of the current literature relating to physician wellness including Ten Commandments of Physician Wellness8 and more recent publications such as Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis,9Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness and Personal Resilience.10
From 2014 to 2018, OrthoCarolina conducted a comprehensive physician satisfaction and engagement survey of all physicians every other year. The organization utilized an outside vendor (Press Ganey) to ensure confidence in the process by OrthoCarolina physicians, and the confidentiality of the process. In addition, the organization sought to understand its performance relative to national benchmarks. The survey consisted of roughly 60 rated items and several open-ended questions. The survey not only measures overall physician satisfaction but also elements within the practice environment, such as satisfaction with the Electronic Medical record, sufficiency of time with patients, teamwork, and collegiality, that were thought to impact satisfaction. With the implementation of leadership approved wellness initiatives including a formalized mentor program, class dinners, and leadership education, OrthoCarolina’s overall physician engagement, as measured from 2014 to 2018, improved and remained above the 90th percentile as compared with the Press Ganey’s national database of over 95,000 physicians surveyed nationally. Physician resilience, a measure of the predictors of physician burnout, also improved from 2014 to 2018 and is now above the national physician average. During the same time period, significant improvement was noted as it relates to a physician’s ability to disconnect and “recharge” outside of work. Items such as “I am able to disconnect from work communications during my free time” and “I rarely lose sleep over work issues” were used as markers of the physicians’ ability to disconnect, decompress, and recharge from the significant pressures of modern medicine in surgical practice. These measures are viewed as a marker, among many others, of the overall state of wellness of physicians within the group.
In addition, OrthoCarolina partnered with the Center for Patient and Professional Advocacy at Vanderbilt University to implement the PARS program as further described ahead. From 2015 to 2018, PARS interventions aimed at increasing professionalism and identifying at-risk physicians decreased by 23%. This is an indicator that the physician behavior which prompts these sorts of interventions decreased. In 2 instances, physician behavior decreased because the physician opted to leave the group.
Over that same period of time, physicians within the group also reported that supportive avenues such as mentor programs and organized activities outside of the workplace amplified the sense of collegiality, connection, and community within the physician group. As set forth in the comments to the 2018 Physician Satisfaction survey, “camaraderie with my partners is excellent;” “the focus on quality and collegiality among physicians is one of the things that we do well;” and “the ideas related to cultural change are important and I believe, helping improve our experience as physicians and our employee and patient experience.” As 1 physician observed that the surgeons new to the practice realized during one of the mentor dinners that they do not have to “go it alone” in managing their practice in their early years.
A critical prerequisite for building a culture of physician wellness within an organization is support from the leadership of the group. In OrthoCarolina, we created a medical director position that is a nonvoting member of the Executive Committee of the group and provides a direct report to the Board of Directors. In addition to the usual medical director duties, the medical director is specifically charged with developing a culture of physician wellness and more importantly, is given time, funding, and organizational authority to do so. Without this level of group commitment, making a change in culture is unlikely.
Even with this level of support, effecting cultural change is difficult because deeply embedded cultures change slowly over time. Any physician trying to implement such a change needs to understand that this is not a task that enjoys instant gratification either in demonstrably different, immediate results or in the affection from your peers. The administrative mindset and pace are much different than that of the surgeon, so it is necessary to change gears to measure success in this arena. It is important to set very small achievable goals that focus on critical behavior changes that build on each other. Cultural change occurs gradually and requires perseverance and self-compassion when certain events or ideas languish or fail along the journey.
Preliminarily, we have to understand what wellness means in the setting of an orthopaedic group. When we speak of wellness we mean both organizational wellness and individual wellness as both need to be addressed to be successful. We also have to decide which areas of wellness to focus on: physical, psychological, and financial to name a few. Fortunately, orthopaedic surgeons make a fine living and a good financial planner can assist so that we make sound decisions to support financial wellness. In general, orthopaedic surgeons are physically fit and espouse to their patients the importance of fitness for orthopaedic health; so this type of wellness usually does not require a lot of attention. Though as this is an important part of wellness, OrthoCarolina does offer both facilities and classes (exercise and nutrition education) for physicians and employees. The areas in which we, as orthopaedic surgeons, seem to struggle with the most are the organization itself (lack of autonomy and loss of control) and psychological wellness, which is often impacted by a professional environment characterized by rising demands, diminishing control, and an increasing sense of isolation. For many orthopaedic surgeons, there is both a lack of connection with others whether patients or team members and a lack of a community of fellow surgeons to turn to for support. This feeling of isolation is one of the key drivers of physician burnout. Even the most resilient physician in the world will suffer burnout if placed in the wrong environment. All barriers to wellness including those at the organizational level and individual level need to be addressed to achieve a substantial cultural change toward wellness.
At OrthoCarolina, we believe that developing a nurturing environment with good interpersonal connections is foundational to our success. We recognized, however, that to get orthopaedic surgeons to buy into this strategy, we needed data. For that, we turned to the PARS, a program developed by Vanderbilt’s Center for Patient and Professional Advocacy. PARS is a fair, systematic process involving routine surveillance for all physicians within a group. It is a data-driven program that is designed to promote professionalism and lower malpractice risk and cost because of unprofessional behavior. PARS identifies and supports interventions on high-malpractice-risk physicians using nationally-benchmarked scores derived from unsolicited patient complaints. PARS data for the individual can be presented against local and national norms or placed in the context of specialties.
Once physicians are identified by PARS as a result of unsolicited patient complaints, a messenger physician is assigned to meet with them to present the data. The PARS messengers are other physicians in the group practicing at different locations and in different subspecialties who are respected by their colleagues and are committed to confidentiality, fairness, and respect. Each messenger is trained to deliver the interventions. Importantly, the goal of the intervention is simply to share information, to make the high-risk physician aware of the data. There are no diagnoses, prescriptions, or solutions provided by the messenger physician and the message is delivered in a nonjudgmental, supportive way. These PARS interventions, and specifically the training that the physician messengers receive, serve as the cornerstone upon which we teach nurturing, educational, and peer-based communication within our group. The PARS program teaches us that communicating in a nonjudgmental way fosters greater connections with other physicians, improves physician wellness, and ultimately improves patient care.
PARS was foundational for us in many respects. Once you have buy-in from the physicians for a program like PARS, it is easier to launch other related programs. For example, as part of our PARS program, we introduced and invited members of our PARS committee and the greater leadership team to join us in a review and discussion of selected leadership development books and articles including “The Power of the Other” by Henry Cloud11 and “Crucial Conversations” by Kerry Patterson, Joseph Grenny, David Maxfield, Ron McMillan, and Al Switzler.12 Using Henry Cloud’s model, we trained the PARS messengers on how to develop and participate in “Corner Four” relationships, those relationships characterized by trust and safety where both participants can be vulnerable, and where good connections occur. In his book, Cloud posits that you are always in 1 of 4 places of connection with those in your life and presents this dynamic as a map with 4 corners (Fig. 1).
A prime illustration of how each of these connection models plays out in medicine occurs when dealing with complications in patient care. With a “Corner One” relationship, where there is no connection, the physician would not discuss the event with his/her colleagues but would internalize the complication and not reach out for support. With a “Corner Two” relationship, where there is a bad connection, the physician who had the complication would be shamed or berated by the other physician within the group. With a “Corner Three” relationship, where there is a falsely good connection, the physician with the complication would share the event and the other physician might respond by simply saying “oh that’s OK. No big deal,” even if the complication was significant and education needed. Finally, with a “Corner Four” relationship, where there is true connection, the physician with the complication would share the event and receive honest feedback with empathy in a safe and nurturing environment. The physician receiving the information would not brush off the event as in the Corner Three relationship but rather, would fully attend to his/her colleague by being fully present, responding with empathetic phrases, asking questions from a place of curiosity as opposed to judgment (ie, what if anything could or should have been done differently), and concluding the conversation by expressing appreciation for the physician and the mutual learning gained by virtue of each physicians’ willingness to hold this conversation. A Corner Four conversation allows the physician to metabolize the complication and promotes overall learning for the physician, the physician recipient, and the group as a whole.
Once you have set up a platform in which to teach this kind of communication, you may then begin to add additional formal and informal programs to reinforce the type of behavior and connections that you hope to see within the group. For example, at OrthoCarolina, we have a formalized mentor program to help build relationships, normalize certain practices such as operating together and providing peer to peer coaching, and pass on our group’s values. Although the mentoring program is formal for 3 years for any new physician, the program seems to serve as a springboard to informal mentoring over a career. This is a grassroots strategy as the only way to accomplish a true culture change is 1 physician at a time by physician to physician communication and connection.
In addition, we also intentionally have more informal functions to help build a culture of wellness at OrthoCarolina. We organize class dinners. As we are a large orthopaedic group, we hire many new physicians each year. We group them in 1-year to 2-year increments depending on how many new physicians we have and invite them to casual dinners with their mentors and other leaders in the group who promote the culture of wellness. These dinners encourage physician connections across the group throughout different subspecialties and different locations. They foster a sense of community among physicians allowing them get to know each other on a more personal level. During each dinner, there may be specific talking points prompting collective discussion and exploration depending on where each particular group of physicians is in the physician’s lifecycle. We have found that different years in practice have different struggles and we have developed talking points to try to open up a conversation about some of the predictable struggles on the journey of the new practicing physician to those nearing retirement.
Another informal strategy is to take the time to set the stage before meetings or conferences begin to allow physicians to be fully present and engaged. As a specific example, before we begin our morbidity and mortality conference, we will often invite physicians to participate in a brief exercise designed to promote an open, empathetic, and supportive mindset as they listen to the cases being presented. The exercise can be as simple as asking everyone to pause and recall their most recent complication, how they felt when it happened, when they told the family about it, and when they discussed it with their colleagues. This simple practice infuses the meeting with a sense of empathy and commonality (ie, we all have experienced a loss or failure at one point in our practices) and creates an environment built on connections and shared experiences that promote learning and physician wellness.
In summary, it is imperative to have the support of the organization and strong group leaders to promote cultural change within a group. Changes are often incremental and small as they have to happen by building individual connections between doctors, 1 doctor at a time. It helps to start with data-driven programs as physicians respond well to evidence-based information and then use that platform to develop custom formal and informal programs that tailor to the needs of your group (Appendix 1, Supplemental Digital Content, http://links.lww.com/BPO/A276).
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