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In this episode, we’re joined by Susan MacLellan-Tobert, a pediatric cardiologist, to discuss the issue of institutional betrayal in health care. The pandemic has put a strain on health care systems and workers, leading to a term called “institutional betrayal” to describe the feeling of betrayal from employers who fail to support and protect their workers. We’ll explore what institutional betrayal is, the effects it has on employees, and the concept of institutional courage. This is an important conversation for anyone in the health care industry or anyone interested in understanding the impact of the current health care system on its workers.

Susan MacLellan-Tobert is a pediatric cardiologist and can be reached at Health Edge Coaching.

She shares her story and discusses her KevinMD article, “Institutional betrayal vs. courage.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Sue MacLellan-Tobert. She’s a pediatric cardiologist, and her KevinMD article is titled “Institutional betrayal vs. courage.” Sue, welcome to the show.

Susan MacLellan-Tobert: Thank you, Kevin. It’s great to be here. Nice to meet you.

Kevin Pho: So we’ll get into the article in a little bit, but first off, briefly share your story and journey to where you are today.

Susan MacLellan-Tobert: Sure. I am a pediatric cardiologist by trade, and I’ve been in practice for 25 years in the Midwest, originally from Alberta, so the Great White North. I play a lot of roles. I’m a mom, I’m a spouse, but one of my other side gigs that I’ve been doing the past four years internally at our institution is I also practice as a physician coach. We offer those services to our clinicians, and we’ve actually grown a wonderful little support team here at our institution.

Kevin Pho: Yeah, typically when I hear about physician coaches, they’re outside an institution or hospital, so it sounds like this one was formalized within your institution. So tell me how that program works.

Susan MacLellan-Tobert: Sure. I stumbled across physician coaching about five years ago as we were developing a wellness committee, looking at, “Hey, how is our resilience and our well-being among our clinicians?” We’d gathered some internal burnout data, and I did a little retreat at one of the coach offerings that’s out there and came back and said, “You know what? This would be a super thing to offer our clinicians.”

And so we developed a program. Five of us have trained; we took a six-month training program, and we offer free coaching to any one of our almost 1,000 clinicians, including physicians and associate staff. We fit it into their schedule, and we have FTE set aside for it. We do department coaching and individual coaching, we work with our trainees, and it’s really actually become a very robust program. Now we have previous clients, previous coachees, referring others for coaching. The marketing piece of it, we wondered how that was going to go, and it’s just expanded exponentially.

Kevin Pho: Yeah. Tell me about that initial reaction when your institution introduced that, “Hey, now we have clinician coaching services.” In general, at first, what was the initial reaction?

Susan MacLellan-Tobert: So when we developed the program, we wanted to make certain that people knew it was not punitive, it was not remedial. We work with our EAP, but we’re about physician development. So where do you want to go with your career? How do you want to improve communication? How’s your conflict resolution going?

And there was some resistance. I think we sometimes, as physicians, come with the mindset of, “Well, now they must think I’m broken, and they want to fix me.” And in fact, coaching is just the opposite of that, and you’re probably well aware of this. We view the individual as whole, and they can figure out their own life; they’re creative in their own way. So once people began to understand that coaches are coming alongside you, like a thought partner, like an expert companion, like an advocate for you, and it’s not our agenda, it’s not administration’s agenda, it’s your agenda, then I think it just really caught on after that.

Kevin Pho: Now, all the coaches within the organization, are they also physicians?

Susan MacLellan-Tobert: Three of us are physicians, and two are associate staff, so a nurse practitioner and a physician assistant, and that’s the latest branch of our service, adding those two coaches in. There’s just as much challenge, stress, burnout, desire to move forward in careers among the APCs as well, so it’s been a really good addition.

Kevin Pho: Now, when coaching physicians, how important is it that you’re a physician yourself?

Susan MacLellan-Tobert: There’s a preference, but what’s interesting, too, is I think once physicians experience coaching, they realize that it doesn’t necessarily have to be a physician, but someone who understands health care, because it’s such a strange world we live in. And so that piece of it, I think, is the biggest component.

Kevin Pho: And before we get into your article, let me ask: What are some of the most common issues that you coach physicians about?

Susan MacLellan-Tobert: Yeah, career decisions. We went into some of the development thinking, “Well, maybe this is a way to retain physicians,” right? We don’t want them all heading out the door and changing careers and leaving the institution. But in fact, sometimes as people find themselves, they find their stride, they become more self-aware: How can I actually honor my values and what I want to do in life? And people move on. And so I think it’s been interesting seeing how those career decisions evolve.

Certainly when we work with departments, a lot of it is, how can we better communicate? There’s misunderstanding here, conflict, and so that’s a big part of it. And then one of the other areas is about finding your purpose. Why are you doing what you’re doing? Why does your team do what they do? What are your team values, your individual values? So those are the top ones we touch on.

Kevin Pho: All right, let’s talk about your KevinMD article, titled “Institutional betrayal vs. courage.” Now, how did this article come together?

Susan MacLellan-Tobert: So there’s been a little theme, Kevin, that’s come up for us as a coaching group, about trust within institutions, and I do some outside coaching as well, so this isn’t unique just to our institution. It’s a theme. We’ve come out of two and a half years of chaos. Now we’re exhausted; we’re in this sympathetic overdrive, and changes are still occurring. And so as organizations begin to say, “Yep, we got to do something with our short staffing. You need to improve efficiency, you need to see more patients, you need to step up your game,” with more rules and regulations coming down from above, I think it’s only creating this hypervigilance in clinicians. And so there’s pushback, there’s anger, there’s frustration, there are feelings of betrayal.

And so how can an institution look at this differently? I think that was really the purpose behind my commentary. How can we be kinder to one another? How can we preserve each other’s dignity, make us worthy of respect? How do we clearly communicate so the message is not misconstrued? What are our expectations? That’s a big one. How do we manage our expectations? How do we communicate them clearly?

And so some of the work we do actually is between managers and clinicians, or administration and clinicians, that advocacy piece, so that the clinician is not alone as a tiny little voice in the wilderness. There is a way to really come to agreement in how to move forward for the betterment of everyone, not just the institution.

Kevin Pho: Now tell us an example, a case study, your story of how you bridge that gap between administration and physicians, because that scenario that you initially talked about rings true. If an organization tells a clinician that they have to increase their RVUs, that they have to see more patients, there is that sense of betrayal that you exactly describe. So tell me how you move the needle when it comes to bridging that gap and having someone come to an understanding.

Susan MacLellan-Tobert: Sure. I’m going to give you an example from yesterday, a conversation with a manager who had to deliver some hard messages earlier in the week to the clinicians, and the message was, “You’re going to see more patients. You’re going to have these contact hours.” There were some changes in vacation allotment, so just a lot of disturbing news for the clinicians when they’re already feeling strapped. I was witness to that conversation and went back to the manager afterward, and I said, “I just want to share a little bit about the personality and style of clinicians, how they like to receive new information that may affect them personally.” We had a really good dialogue.

So just in a nutshell, the persona of a physician: We begin to shift when we begin to get indoctrinated in medical school, right? It’s a highly competitive environment. We’re kind of special; we made it through a lot of tough assessments to get to where we are. Our egos can be kind of big in the moment. We like our autonomy. We get out into practice, and what we’ve now seen is the autonomy becomes more restricted, with more rules and regulations to abide by just to simply play in the sandbox.

And so how a message can be delivered from a manager actually ties into something that I love to read about, adult development theory. If you’re a fairly high-functioning adult, we don’t like to be told what to do. We want to be engaged in the conversation. We want to join in, maybe bargain a little bit back and forth, sort of work on the outcome together. So if a manager comes and says, “This is how it’s going to be. There’s no choice in the matter. You will do this,” clinicians will immediately flare, and you’ll see the anger, the frustration, the sense of betrayal. If a manager was to come and say, “Hey, this is hard news,” involve your physician leader, invite them into the conversation, “You might not like what you’re about to hear. How can we work on this together? I want to be clear that these are mandates that are coming down, but we want you to have a voice. We want you to share. We want you to share politely,” and really work on that communication piece, then sometimes the manager is able to defuse the situation before hackles get raised. Just a small example.

Kevin Pho: Now, do you feel that most administrators have to be told, like from yourself, in terms of how physicians may take that news, or would their default be some type of top-down style?

Susan MacLellan-Tobert: Interesting question. So top-down is our default style, and I think that’s where we go even as clinicians, how we want to manage the situation, when we’re feeling threatened. And administrators have a sense of duty, very often very strong, to the organization. So something that can happen even in physician-led organizations is objectification. I think this actually is in one of my other blogs that I’ve shared, where instead of me being a human being in the trenches, working to serve my patients and having this huge commitment to both the institution and patient care, I begin to be viewed as a widget. And so I’m just told what to do, and I should get that job done, and then they’re going to go and tell me something else to do, maybe with no human aspect to it anymore, just another cog in the wheel to move that health care process forward.

And so I think all of us have to be very mindful about objectifying one another. I can do it to my nurses when I’m working with them, “Just hand me that, get it to me, let’s get the job done,” and forget that there’s a human being attached to the other end. When our bandwidth is short and we don’t have a lot of time, it’s easy to do that. So I think being careful about objectifying one another, making that human connection, is really important.

Kevin Pho: And you mentioned when you gave that feedback to that manager, it was constructively received. So go into more detail. What exactly did he or she say or do?

Susan MacLellan-Tobert: You know, I think I want to be gentle when I’m providing feedback. I just want to share my perspective; I’m not telling you how it is. So sharing perspective is really important, setting the stage for an open conversation without defensiveness coming into the situation. And so, sharing perspective, I think that she was very open to it. She’s been around the block a few times herself. She’s like, “You know, I know that they don’t like being told what to do. Gosh, we actually could have used more physician leader support in this. Hey, how do you want to do that in the future? Let’s empower our physician leaders to support our managers, too, so that we can have these conversations that are going to go in a more positive way.” So actually, she was very receptive to it.

Kevin Pho: We’re talking to Sue MacLellan-Tobert. She’s a pediatric cardiologist. Her KevinMD article is titled “Institutional betrayal vs. courage.” So, Sue, going forward, from a clinician standpoint, I’m sure that a lot of these conversations that you described, these difficult conversations from administration, are going to be more and more frequent. So as clinicians, what can we do to be more involved with that conversation and be involved with that decision-making process? Any advice that we can give to clinicians? Or else we risk just being, like you said, told what to do, and we won’t like it. How do we prevent ourselves from being in that position in the first place?

Susan MacLellan-Tobert: All right. So just as a little set point, being a coach is not about being an advisor, so that’s one of the points that we really make. I’m not a big advice giver. However, you’re inviting me into this. So I think it’s about being aware that other perspectives exist; being aware that I have my own expectations, as does the person in conversation with me, and we have our own goals that we want to achieve in that conversation; and then being intentional that we’re going to move forward in a positive way, in a kind way, in a way that preserves the dignity of the other person, that preserves the safety of the situation.

And when I say safety, I’m talking about these little micro-betrayals: “Gosh, you kind of talked to me in a sharp tone or an offensive way.” Let’s even it out and become the observer of the situation, rather than invested in the weeds, where we’re judging and blaming. So it’s a moment that sometimes can be very difficult.

Kevin Pho: So at the moment, let’s say you’re coaching a clinician, and like you said, a manager just comes in abruptly and says, “This is what you have to do. You have to see more patients. PTO is going to be decreased.” What are some things clinicians can do in the moment to perhaps appreciate some of those other perspectives? Because it’s very emotional; it can be very difficult, right?

Susan MacLellan-Tobert: Right, so being caught off guard, right? I love it that you bring this up. So this takes practice. It’s a mindset shift. You have to find your little cue, when some painful arrow is thrown at you, that’s going to allow you to pause and think before you just simply react, before you flare up or you spout off. And it’s not perfect, right? By no means am I perfect, but practice helps, and this is like eight years into it.

I would say that when somebody slings something offensive at me in the moment, I have a little technique, which is to pinch my fingers together, because I’m feeling a little aggressive, and I’m going to take a deep breath, pause, and I’m going to harness that moment of time. I don’t have to immediately spout off. That might be what my amygdala wants to do, but I don’t have to. I have a choice. And so finding a little way to practice, and maybe if it’s only successful one time in a week, you’ve done it. You’ve held your tongue, you’ve paused, you’ve thought it through, and you’ve chosen to respond rather than just simply react.

Kevin Pho: My final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Susan MacLellan-Tobert: You know, I think we’re on a new horizon. Trust is breaking down. We’re exhausted still. We’re all on this hyper-alert type of journey. And so take time for yourself. I know that might sound like that canned resilience comment, but it’s vital. Medicine does not have to be our be-all and end-all. There are so many amazing, other wonderful things and people that we can connect with in our lives, and I just encourage people to do that. Just look for that breath of fresh air in the moment.

Kevin Pho: Sue, thank you so much for sharing your time and insight, and thanks again for being on the show.