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?

The first step would be finding “positive deviants.” I imagine practicing PD on two levels:

• At the organizational level, identifying physician practices, clinics, or hospitals with a lower prevalence of burnout than peer organizations
• At the individual level, identifying clinicians within a practice or clinical unit who are thriving

The next step would be observing these organizations and individuals to see what they do differently than their peers. Clearly pinpointing what they do that supports thriving may be tricky, as a multitude of factors affect the risk of burnout and could obscure the results — stage in career, organizational culture, behavior of one’s immediate supervisor, personal stressors — but the exercise is worthwhile even if imperfect. Once these “deviant” behaviors are identified, they could be spread by creating opportunities to practice them.
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Creating opportunities to practice these new behaviors is no simple feat, and organizational leaders would need to be fully on board. Sure, yoga and regular exercise are helpful in maintaining resilience to stress. However, a busy physician who is the parent of young children may need tangible leadership support to actually execute them — in the form of flexible work hours, on-site child care, and on-site exercise facilities, for example. In addition, new behaviors at the practice and organizational levels will require culture change, prioritization, and allocation of resources, which are primarily the bailiwick of executive leaders and board members.

I wrote about a physician who is a perfect example of a “positive deviant.” I asked to shadow this primary care physician precisely because I was intrigued by her enthusiasm about her work and continued energy for her profession. By the end of the clinic session, I identified several factors, some under her control and some organizational, that explained her ability to thrive when so many physicians are not. For example, her clinic had an effective process for rooming patients, creating care plans, and ordering prescriptions and lab tests, which left more time for her to connect with her patients.

Could positive deviance be an effective, efficient way to identify behaviors and factors that support clinicians’ thriving? Given the urgency of the current problem of burnout among clinicians in the U.S. and worldwide, it seems a fruitful (and positive) place to start.