Can strong leadership boost engagement?

By Jessica Sweeney-Platt | August 14, 2017

Data Snapshot

20% of physicians are engaged

Key Takeaways

  1. Physician engagement is low across the board, particularly in primary care.
  2. High-quality physician leadership can improve engagement, even in organizations that aren't physician-led.
  3. Communication, trust, and a supportive working relationship can connect physicians to their organizations.

Editor's note: When this article on physician engagement was originally published, readers weighed in with insightful and thought-provoking comments and questions. We are republishing it in hopes it will spark further conversation. Stay tuned this fall for more research into gender and leadership in healthcare.

Healthcare leaders have been managing unprecedented levels of change to their businesses, jobs, and strategies for the better part of the last decade. Aong the most important stakeholders in all of this change are physicians. At the front lines of patient care, doctors are indispensable for the successful execution of just about any strategy that a healthcare organization might think to execute.

That’s why the results of athenahealth’s 2016 Physician Leadership and Engagement Index, a national survey of physicians conducted by the company’s research team, are both troubling and encouraging. Troubling, because they show that engagement levels for physicians are strikingly low — 20 percent, according to our methodology.

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Encouraging, because the survey reveals some tangible, actionable ideas for how to make physicians more connected to their institutions, and more likely to go above and beyond in their jobs.

The Physician Leadership and Engagement Index consists of survey responses from 2,011 practicing physicians, collected in January 2016 through the Epocrates mobile app.

We asked physicians to characterize their level of engagement by responding to three statements:

1. My organization inspires me to go above and beyond what is required.

2. I am very likely to be working for my current organization three years from now.

3. I would recommend my organization to a friend or relative to receive care.

Respondents answered on a scale of 1-6, with a 6 being “strongly agree” and a 1 being “strongly disagree”. To be considered engaged, a respondent had to answer a 6 for at least two of the questions and no less than a 5 for all three questions.

We asked many more questions to understand some of the drivers that affect engagement. What emerged is a framework that healthcare organizations can use to drive not only physician engagement, but other important outcomes as well — and a snapshot view of how engagement differs based on gender, specialty, and type of organization:

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• Male physicians were more engaged than female physicians (22 percent vs 16 percent)

• Primary care specialties were less engaged than either procedural or medical specialties.

• Physicians who worked in physician-owned, independent medical groups or practices were almost twice as engaged as those in hospital- or health system-owned groups (32 percent vs 17 percent).

• Physicians who described themselves as being in a physician-led organization showed engagement levels that were four times greater than those who reported working in non-physician-led organizations.

These last two patterns, in particular, pose a challenge for many organizations.

Short of a complete change of ownership and leadership, what can health systems do to create an environment that fully enfranchises the physician community in the success and sustainability of the enterprise?

The good news is that three factors closely correlate with engagement, and each of them offers concrete tactical opportunities for improvement.

1. Develop high-quality physician leadership

One of the most powerful learnings from the survey was the impact that high-quality physician leadership can have on engagement, even in those organizations that are not physician-led.

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Only 8 percent of physicians who said they were in non-physician led organizations met the criteria for engagement (compared to 32 percent of physicians who said they were in physician-led organizations).

But when you look at those respondents in non-physician-led organizations who said that their physician leaders were very good or excellent, engagement levels rose to 38 percent.

So even if an organization is not led by physicians at the highest levels, effective physician leadership throughout the ranks can more than make up for the negative impact on engagement.

High performing physician networks know this. Whether it’s through formal leadership development programs or informal mentoring and performance support, they recognize the importance and the value of physician leadership at every level of the organization.

2. Build trust between physicians and non-physician leaders

When physicians indicate that they trust their leaders, and that the organization follows through on its commitments to employees, they are engaged at three to four times the average rate.

Our research into high performing physician networks suggests there are three things successful networks can do to build and maintain trust between physicians and the rest of the organization.

Be transparent with performance data, but give guidance and context for how to use it

One of our top performers, a fast-growing network of nearly 1,400 physicians, provides highly detailed performance reports with granular, provider-level detail on multiple performance indicators. However, leaders don’t just dump the data on physicians and leave them to interpret it. They spend a significant amount of time and effort educating physicians on why the measures matter, and they provide plentiful resources for improving performance, if necessary. Transparency without context can create more problems than it solves.

Focus on two-way communication, not just top-down

Many organizations worry that they haven’t cracked the code on how to communicate with physicians — meetings are poorly attended, emails are left unopened. Top performers think about those issues, too. But they are just as concerned, if not more so, about making sure they have sufficient mechanisms in place to get information from the front lines back up to the top of the organization.

Solutions run the gamut from requiring board members to do rounds at all practice sites to identifying group leaders and tasking them with liaison duties between colleagues and leadership. It all comes back to the same idea: For physicians to trust the organization, there must be a credible series of attempts to get their input into both strategic and operational matters.

Create strong face-to-face relationships between physicians and non-physician leaders

We heard from several top performers that there simply is no substitute for face-to-face conversations when it comes to creating trust. No email, video, or newsletter is going to be as effective as an in-person conversation. “It’s a ground game,” one executive told us. “There are no shortcuts, but those one-on-one conversations are absolutely critical.” Another executive told us that he put 30,000 miles on his car in a single year, driving from practice to practice, talking to physicians and staff.

3. Provide an environment that helps physicians focus on what they do best

Our survey data also revealed a strong correlation between engagement and the kind of working environment that physicians experience. Physicians who strongly agreed that they are provided with an environment that allows them to focus on what they do best showed engagement levels of 75 percent, more than triple the aggregate rate.

This finding supports what we hear anecdotally from many physicians and physician leaders — the increasing complexity of medical practice makes it harder for physicians to focus on the primary thing they went to medical school to do: take care of patients.

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The data suggest that a few factors are associated with this type of “operationally effective environment:” well-defined and consistent metrics (“tell me what I need to do, and don’t change the rules every six months”); workflows that support both continuity and quality of patient care; and technology that supports patient care.

Top performers recognize the value of these features — for example, they spend a great deal of time adapting workflows to ensure that all staff members are focused on what they can do best. One large primary care group opened a walk-in clinic for existing patients; it not only provides on-demand service, but since it’s staffed mainly by nurse practitioners, it allows physicians to focus their valuable time on more complex, more acute problems.

Another attribute that contributes to a robust working environment is the importance of collegial, social peer relationships between physicians. As many medical groups have grown, it has become harder and harder for those social connections to form organically, so top performers create opportunities for those relationships to develop.

One faith-based health system runs a “Finding Meaning in Medicine” program that takes cohorts of 12 physicians through a series of events that encourage them to share their stories with one another, in many cases over a meal. Several top performers commented on the importance of eating together — it sounds incredibly simple, but can be a meaningful foundation for personal interactions.

To meet the challenges facing a broken healthcare system, we’ll need far more than 20 percent of physicians to be actively engaged in that goal. Based on this research, and our ongoing studies of high performance, we are optimistic that this can happen.

We look forward to hearing your ideas and strategies for making that possible — and to tracking progress, through the Physician Leadership and Engagement Index, in years to come.

Jessica Sweeney-Platt is executive director of research at athenahealth


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This study reflects my long-held belief. To be concise, I will say that for ANYONE to become fully engaged in work, a project, etc., there needs to be a large measure of personal involvement and control, which translates to a higher degree of responsibility. Lots more to be said; however, your study is “right on!”
Fae Danner
I’m not surprised at all by these findings. In my institution, our docs are working at break-neck speed at all times. We are still in a very FFS world. There is little time for anything else, so finding a way to communicate, build trust, and improve their lives is a huge challenge. I love the idea of sharing a meal as a way to start that process. The challenges of boosting engagement differ for employed vs. independent physicians but is clearly no less important for one group over the other. Independent physicians, depending on the size of their group, usually lack resources to track performance and improve care delivery. They are more likely to be self-focused, not that employed docs aren’t also, but for both groups it is important to find the message that answers the question “What’s in it for me?”
Scott Tromanhauser, MD, MBA, MHCDS
If physicians weren’t spending most of their patient time inputting data into the healthcare facility’s computer system, they would be able to do what they are trained to do which is to treat patients. I assume it saves a lot of money for them to also be data entry clerks, but burdening them with an entry level support task is lunacy. Whatever happened to medical record transcribers? Bring them back and let the doctors practice medicine!
Jeanne Walpole
I would love to have a transcriber but the cost would be prohibitive. A lot of the surgical specialties use them, of course. I am a pediatrician (pediatrics is the lowest paid medical specialty). They work the longest hours and see more patients, and answer more phone calls from patients than any specialty. I would love to have someone else do all this for me but it’s part of the package and I can afford a scribe or a nurse to do the “busy work” that I have to do every day.
Michael W. Cater, MD
I feel that the medical profession on the whole is good,but in light of the fact that our medicines themselves are not,that they should be pushing the pharmaceutical companies to do more research before they put medicines on the market.I personally am tired of being told “you have to weigh the good it will do against the side effects that will basically destroy other parts of my body.” I also feel that there are holistic medicines out there that are better and every HMO should give space to those patients too explore this side of medicine .
Christine Mackenzie
As a member of a primary care group practice, I will take exception to the basis of your statement. Your use of the word “engagement” was never defined. It appears to reflect the business relationship between a physician and the hospital or other entity that owns or manages their practice. Most primary care physicians view “engagement” as the patient-physician relationship. Your model implies that 80% of physicians are just not that interested in patient care. Nothing could be further from the truth. I do not know of a single physician who doesn’t stress over helping patients obtain the medications they need, take home patient problems to try and solve them, work 2-3 hours at home after “regular business hours” (thanks EMRs!) and write off 20% of collectable fees because they see patients who are not able to pay them. Primary care physicians do not feel a great deal of “brand loyalty”. Most practice managers simply stress the need to see more patients and to generate more revenue. The basic business model for most professions does not fit primary care very well. In seeing more patients, we encounter more people who require their physician to help guide them through the maze that is medical care today. This means more time shuffling paperwork and less time with our families or sleeping. Please do not expect me to show a great deal of loyalty when it is not reciprocated.
William Morris, MD
One should read Catch 22 and thus discover a model for today’s dysfunctional medical world. The “Patient Experience “paradigm exists in contrast to the “:Chose Wisely “paradigm.. Doctors are caught between the two,,,..When doctors’ income was tied to patients’ complaint scores the cost of medical care increased since unnecessary MRI on knees [for example] were ordered by docs worried about their scores . There is a move a foot to get rid of the pain management question in the patient surveys since HHS feels that the question has put pressure on docs to prescribe addictive opioids. Talk about convoluted .Data entry has indeed compromised the time spent on patient care. On the walls of Harvard Medical School is carved “The secret of the care of the patient is caring for the patient ” In contrast to that inspiring phrase is a comment made to me by a lawyer representing a hospital,, “The hospital can do anything it wants as long as it it not illegal” Go figure. Bill Gaalagher MD HMS ’60
william gallagher m.d.
As far as female physician engagement is concerned, I think the survey is missing a couple of important demographics. Is the physician married? Does the physician have children? Those two considerations are going to have a significant impact on the responses to questions 1 and 2.
Michael D. Houst
How can you expect your physician to be engaged when they cannot get through a proper payroll? Financial worries and ruin are plaguing doctors around the United States at a monumental rate, and nobody cares until they are sick themselves. Doctors’ monies have been cut to the point of being a disgrace to all of their training, medical school loans and high insurance rates while requiring more time to be spent with the patient with less reimbursement. When the checks come in from the insurance companies you have to hold your breath and pray to God that your measly reimbursement was not denied or cut completely. And cut and denied they are, for any reason at any time. What happens then? You pay a biller to call and call and wait on hold for 45 minutes to an hour for an answer that she never receives, and you are paying your biller to do this feudal work. It is a lose/lose situation. Fix the reimbursements, and the doctor won’t have so many anxieties of higher bills for rent, staff and equipment needed to render good medicine. I don’t care how rich you think your doctor is, he is suffering financially unless he is out of network totally. I know because I have run offices both in and out of network. Never again will you have the best and brightest going to medical school because they are going to become computer programmers so they won’t have to financially struggle.
Many of these comments are right on the mark. If executives want physicians engaged with their organization, they must engage with the physicians. This is why physician led organizations have more engagement. Execs need to spend time with physicians - listening to them, shadowing them to understand the frustrations they experience, and working with them to address the problems they learn about in the process. This is the first step to making a difference. Organizations that don't do this will suffer in the long run as physicians become even less engaged.
Paul DeChant

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Can strong leadership boost engagement?