The first step to changing the culture in healthcare

“Look left, look right”, our group leader told us. No, I was not learning to cross the street. Rather it was my first day of employee orientation at the IBM Software Lab over a decade ago. I was fortunate that our CEO was Lou Gerstner, arguably one of the greatest CEOs who has ever existed. Gerstner stepped into IBM in the early 1990s when the company was struggling. One of the key changes Gerstner made was to change the corporate culture of IBM.

“Culture isn’t just one aspect of the game – it is the game,” he stated, and “looking left and looking right” was a metaphor for teamwork, for doing whatever you can to help others within the organization, no matter where they worked in IBM. Software development, marketing, sales, operations, consulting, and others were all united as one IBM. The end result was that Gerstner became a legend for bringing about one of the most remarkable corporate turnarounds in history, transforming IBM back into the powerhouse that it had been.

The medical field could learn something from Gerstner. No matter what hospital you visit anywhere in the world, chances are you’ll see a distinct demarcation between various fields. As youth, most individuals are taught not to generalize people, but in the medical field I find that rigid generalizations about various professions are thrown around all the time, and there is a lack of respect between fields. There is even criticism between hospitals in the same field; “they screwed up the management there,” is something commonly heard. These criticisms are uttered despite the critics’ limited information of the particulars and despite knowing that medicine is an extremely complex field and decisions are rarely black and white.

I am in internal medicine, and I love and take pride in the field I chose. But I could not imagine what we would do without our surgeons who work their rear ends off into the late hours saving lives, I recognize the massive breadth of information that emergency medicine and family medicine physicians need to know, and I cannot thank our nurses enough for the bedside care they provide to patients. The list goes on and on, with pathologists, pediatricians, radiologists, physical therapists, psychiatrists, pharmacists, social workers, and others. And yes, I have had some extremely unpleasant encounters with certain individuals in many of the fields above. A handful of inappropriate individuals in a field, however, doesn’t mean you lose respect for all individuals in the entire field.

For those who work in healthcare, listen for one day to how many positive comments are made about those in other fields and how many critical comments or negative generalizations are made. Chances are the result will astonish you.

I wouldn’t be surprised if our culture of criticism is one of the worst in any field. But changing the culture of the entire healthcare system is not an easy task. I do not have all the solutions, but I think the first step to changing the culture in healthcare is awareness that it needs to change. People must consciously remember that every person has a different and useful role in the system. Changing how we are educated will make an impact as well. The more people in various fields collaborate, whether it be during the training years or even on the job, the more respect between fields will result. Why? Because when you know individuals in other fields on a personal level and you work together toward a common goal, you tend to respect them more.

The bottom line is that a change in culture that values respect and teamwork amongst health professionals will serve our patients better, and it will make the medical field a much more enjoyable place to work. We in healthcare can either work toward a culture change or stand still and become dinosaurs while the rest of the world reaps the benefits of collaboration and teamwork.

Vipan Nikore is an internal medicine resident physician and the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW).

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  • sFord48

    I often see criticisms of independent nurse practitioners and anyone that does alternative care. Interesting you didn’t mention these often maligned groups.

  • John Key

    I think criticism and conflict is highly overrated as a problem. After all interservice rivalry has existed since at least the days of the Barber Surgeons of London who sought a special charter from Henry VIII. The surgeon vs internist “disrespect” that I’ve witnessed in 40 years has been lighthearted, even jocular. Admittedly I knew of a nationally prominent gastroenterologist 30 years ago who refused to allow surgeons to enroll in his [private, costly] endoscopy training course but that is more restraint of trade than disrespect.

    It is in vogue today to criticize the foibles of the profession, but if criticism and rivalry were as negative as you say, it is unlikely we would have seen the advances in therapy that we have. Now if we could just see advances in results and survival, that would be worth crowing about.

  • Michael Mank

    I think changing the culture of teamwork in health care is very important. Not only is it relevant in situations of intra- and inter-department criticisms and confrontations, but also with follow-up and communication between physician practices; such as when a PCP sends a patient to a specialist. The PCP should receive timely communication and allow their input with that specialist. This would also decrease fragmentation of care.

    However, there also needs to be respect for one’s education and experience. All too often do I hear about nurse practitioners (commonly referred to as noctors in the hospital I worked at) and physician assistants (who now want to be called physician associates) that act and talk like they are doctors to each other, and potentially to their patients. They insult doctors for miscellaneous things and criticize the smallest of mistakes (even if they are mistakes) of doctors- as if doctors are under the greatest scrutiny. However, they rarely put each other in their field under the same microscope.

    It seems that some in the allied health professions feel that their knowledge and education is equivalent or more valuable than a doctors, and so they lobby and pursue that “equality” far beyond the work place. Even chiropractors call themselves doctor after 5 to 6 years of total education (I think it’s 5 to 6 years of education). I often dislike hearing of someone’s anecdotal experience with an individual and then broadly generalize about a group, but I even know a chiropractor that will not respond to you if you don’t call him doctor or will correct you if you don’t.

    If health care professionals want to be treated like or referred to as doctors, then they should have went to medical school. I know there are bad doctors out there, and there are probably more knowledgeable nurse practitioners, etc. than doctors in certain areas of care, but it still stands that doctors have put in the time and effort to be the top health care professional in the system. Many people do not like the people at the top, even if they may rightfully deserve to be there. This lack of respect in the pyramid certainly would lead to lack of respect in a reciprocal sense.

    Good article Dr. Vipan Nikore

    • wiseword

      “They should have went”? I wouldn’t trust you to apply a Band-Aid.

      • Michael Mank

        Should have gone… My mistake. I apologize for writing a grammatically incorrect statement in my post. However, does your response to my post bear more relevance to the conversation at hand here? Thanks for your contribution.

  • Rich_Maxwell

    For those who want to learn how to change the culture of any organization I recommend the book Tribal Leadership, by Dave Logan, John King, and Halee Fischer-Wright. Fischer-Wright is a physician by the way. This book describes a growth path for both individuals and organizations, each characterized by readily identifiable language and a progressively more positive outlook and level of performance: Stage 1 – “Life Sucks”; Stage 2 – “My Life Sucks”; Stage 3 – “I’m Great, and You’re Not” (The authors point to physicians, lawyers, and academicians as prototype of this stage although many of the silos we see in hospitals are really stage 3 groups of people); Stage 4 – “We’re Great, and They’re Not”. Here is where we see real teamwork and collaboration firmly take hold. And finally Stage 5 – “Life is Great” the stage of real innovation and creativity. I use this model in my executive coaching in health care organizations and with physicians, and it is a real eye opener for clients and a useful pathway for moving people out of Stages 2 and 3, into Stage 4 or 5. And here are two frightening statistics from the authors: based on 10 years of research: 24% of the American workplace is Stage 2 and 49% is Stage 3. No wonder it is so hard to change our organizations, yet it is an imperative if we are to make needed systemic changes in the health care system.

    Here is the dirty little secret of leadership and employee development – it happens one person at a time. So leaders and managers must know their people, all their direct reports, and determine what stage each person is. From there, as you will see when you read Tribal Leadership, the action you take is dependent on the stage as well as the skill set the person has. For a Stage 2 person who you want to get out of the “my life sucks” world where passive-aggresive behavior is common place, conspiracy theories abound, and anything from management is met with abject suspicion, you begin using Stage 3 (You are great) language to help the person recognize they do have talents to offer and that they do some things well (i.e., you are great at this and this), and you begin expanding their skill set and build their “greatness” if you will. Pretty soon the employee is seeing the world a lot differently.Stage 3 is a time of great personal and professional development and a necessary step (you cannot skip a stage, although most of us are never in Stage 1 thank goodness). That’s the upside. The downside is that the “greatness” can and often does lead to the inflated ego, the “my way or the highway” attitude. The basic strategy here is the same, once stable in Stage 3 begin looking for ways to converse and act with the employee in a Stage 4 manner – collaborative, team based, etc. Set backs will include the Stage 3 ego stealing the credit of a team effort, for example. But the tribal leader persists. Ultimately the late Stage 3 person will become enormously frustrated because they cannot achieve anymore than they are doing. After all they are just one person and therefore not scalable per se. It is in this funk that the epiphany occurs and the Stage 3 person realizes that others are accomplishing great things…by working together in teams where mutual respect, integrity, and honoring of one another abounds. And when the Stage 3 person makes the commitment to get some of that, the epiphany has occurred and you can move this person into relationships with other people that are scalable where they can achieve far more together than any one of them could alone. The shift from Stage 3 to Stage 4 is noticeable in the change from language dominated by the singular (I, me, etc.) to the plural (us, we, the team, etc.).It happens one person at a time, but it can happen and it can transform an organization’s culture. Most hospitals (I am a former hospital administrator) are predominately Stage 3 organizations, sequestered into silos of “greatness.” But as Margaret Mead said “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.” And also remember Dave Logan’s Corollary (Dave is the lead author of Tribal Leadership): Never doubt that a small group of thoughtless, uncommitted people can prevent change from happening. Indeed, they do so every day.” Rich Maxwell (

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