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Internal medicine and infectious disease physician and author Joshua D. Hartzell discusses his article “Leading with care: How health care leadership can transform patient and provider well-being.” He addresses the crisis of burnout and attrition in health care, arguing that leaders often fail to extend the same level of care to their teams as they do to patients. Joshua introduces “caring-inspired leadership,” an evidence-based approach where every leadership action centers on caring for the team to improve both provider well-being and patient care. He outlines key strategies: leaders must prioritize their own well-being by setting boundaries and taking vacations to avoid burnout, which impacts leadership effectiveness; they should actively support their team’s well-being by fostering a culture where self-care is expected and possible, offering flexibility and support systems; investing in professional development through mentoring and sponsorship is crucial; and leaders must cultivate a habit of expressing specific gratitude to make staff feel valued. Joshua urges leaders to adopt these practices to build compassionate, excellent cultures in medicine.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Joshua D. Hartzell. He’s an internal medicine and infectious disease physician. Today’s KevinMD article is “Leading with care: How health care leadership can transform patient and provider well-being.” Josh, welcome to the show.
Joshua D. Hartzell: Thanks for having me, Kevin. Glad to be here.
Kevin Pho: All right, so tell us a little bit about yourself and then jump straight into the article and tell us about it, for those who didn’t get a chance to read it yet.
Joshua D. Hartzell: Sure. As you mentioned, I’m an internal medicine infectious disease physician, recently retired from the U.S. Army in military medicine after about 25 years. While I practice medicine, I’m also an advocate for leadership development and spend a lot of time doing faculty development as well.
The article is based off of a book I recently wrote, Prescription for Caring in Healthcare Leadership: Building a Culture of Compassion and Excellence. It’s a compilation of years living within medicine, but also learning from military leaders and others. The bottom line is that as leaders, we need to do a better job of taking care of our people. If we do take care of our people, they will take care of the mission.
The article that I wrote for your blog is a few ideas from that and a few ways that people can intentionally care for the people that they lead.
Kevin Pho: All right, so on this site and podcast, we always talk about things like clinician burnout. Burnout rates are exceeding 50 percent. How much of a role does leadership play in potentially contributing to clinician burnout?
Joshua D. Hartzell: It’s a great question. There’s a lot of data—Tate Shanafelt has definitely published on this—that leadership has a direct influence on both burnout and satisfaction. I always ask people: think about the best leader you’ve worked for. When you think about that particular leader, my guess is you were probably less likely to be burned out. You were excited to go to work. You didn’t want to let that person down, and that person probably, in some way or in many ways, took care of you personally and professionally. So I think the more effectively we lead, the less likely people will be burned out.
The other thing that we see over time is that as health care leaders, we need to change the system. The system wasn’t necessarily, or hasn’t evolved to, best support us, and it’s going to require leadership and advocacy by health care leaders to change that system to create a culture that allows us to thrive.
Kevin Pho: In your article, you talk about this term caring, inspired leadership. Tell us what that is and how that can apply to health care leaders.
Joshua D. Hartzell: Over time, I spent a lot of time thinking about leadership, and when I thought about it more, the thing that came back to me over and over was this idea that as leaders, we need to take care of our people. A lot of that comes from my influence of being in the Army for a long time and being taught very early in my career that my job was to take care of the people I was leading. I think it took a long time actually for that to translate to realizing I should be doing this in health care as well, not just in Army roles.
When I thought about it more, it dawned on me: this is what I can do every day. What are the things I need to do to help support my team so they can be effective? Maybe that is setting high standards for them so that they know I want the best for them. Maybe today they need a piece of feedback to help them on a skill that they’re trying to develop. Maybe they need me to delegate an opportunity to them so that they can stretch and grow. Maybe they need me to come alongside them and ask, “Hey, are you OK? What’s going on?” and support them with something that might be happening in their life.
As I dove into this, and then as I looked in the broader leadership literature, I realized that there were other people out there writing about this specific concept. Caring leadership is what Heather Younger has called it. Mark Crowley, an author, wrote Lead From the Heart. There’s this central idea that leadership has to start with caring.
Kevin Pho: So in the health care setting, what are some examples of what that would look like?
Joshua D. Hartzell: One of the biggest things is how you can support the people that you work with. I’ll give delegation as an example. Because you mentioned burnout earlier, one of the reasons in health care we get burned out is we try to do too much ourselves. Which is maybe a good thing in some ways, but in other ways it’s not. We delegate based on people’s roles and tasks. There are certain things people should be doing, and we should delegate to them. When we don’t delegate to them, it actually sends a potential message that we don’t care about them or we don’t value and respect the work they do, even though our goal is, “Hey, I don’t want to make Kevin do that extra work, so I’ll do it myself.” You might think, “Well, why did Josh not let me do my job?”
Conversely, there are situations where I might have an opportunity and think to myself, “If I delegate this to one of my junior faculty, it’ll be a great opportunity for them to develop a budget, for example, or maybe to lead a meeting regarding a change initiative.” By delegating that task to them, it’s a growth opportunity. Now, when I delegate it to them, I can’t just dump and forget. I have to delegate it and then coach them to be successful. When we delegate, there’s a lot of caring that goes into it. In some ways, when we frame it as a caring activity, it’s easier for us. It’s easier for me to say, “Hey, I’m going to delegate because that’s your job, because I value and respect what you do. I also value and respect my time, which I need to protect.” Or, “Hey, I want you to do this because I care about your professional development.” That’s one example centered around delegation.
When you delegate, it empowers them, and I think that in itself is a pretty powerful act. Early in my career, when I had opportunities where someone more senior said, “Hey, Josh, why don’t you take this and run with it?” you feel good about that. You think, “Wow, he or she must think I’m capable of doing this.” Then what do you want to do? You want to do a good job because I don’t want to let Kevin down because he gave me this amazing opportunity.
Kevin Pho: Now, what are some of the obstacles that currently prevent health care leaders from achieving that aspiration?
Joshua D. Hartzell: Probably more than we can discuss here. A couple of them are—one that I’ve been thinking about a lot recently is history and tradition. We do a lot of things simply because that’s the way we’ve done things, and we’ve gotten to a point in health care where we need to step back and get up on the balcony, look at things, and ask ourselves, “Hey, why are we still doing it this way? Why do we have this scheduling system? Why do we work these hours?” Maybe we need to challenge ourselves to think outside of the box. We’ve got great new technology. We’ve evolved a lot, but our actual system has not.
I think that’s one of the things holding us back. Our job as leaders is to empower, particularly frontline workers, and ask them, “What would make your job easier? How could we do this more effectively?” A lot of times, people that work on the front lines know and have solutions, but we haven’t created the space where they can bring those forward and then given them the resources to actually make them take effect.
Let’s think about telemedicine. Had it not been for COVID, we probably would have maybe half or less of what we do telemedicine-wise. It would’ve taken probably another decade to get where we are because of all the red tape and policies. But because we had a crisis, all of a sudden telemedicine advanced way beyond what a lot of us would have thought it would.
Kevin Pho: Now, in your article, you also talk about the importance of gratitude in terms of creating that environment of caring leadership. Tell us about that.
Joshua D. Hartzell: There are two things with gratitude that I like to emphasize. One is, the people in health care do amazing work every day, day in and day out. When I say the people, I truly mean everyone from the person who meets you in the garage to the person who helps you leave the hospital, every single person in between. All of them have the same mission: patient care. Sometimes that gets lost on the non-clinician staff. Part of our job as health care leaders is to help them recognize their value and impact, which will inspire them to continue to do great things, to support our patients, but also to support us. By saying thank you, by recognizing their work, it helps them feel valued.
The same would go for physicians, nurses, physical therapists, who can sometimes go a long time without somebody other than a patient saying, “Hey look, I saw what you did the other day with that family when you were dealing with them. That was a challenging situation, but I appreciate how well you handled that. Your nursing level was just through the roof.” That should be the norm, but it’s not. I tell a story in the book where I had a colleague who worked for several years, and no one in the leadership had thanked her over that period.
The other thing that sometimes is missed with gratitude is it’s beyond thanking people for the work they do. Thank yous are cues for what we want in our culture. If I want civility and respect or great customer service from my front desk staff, when I see that, I need to recognize it and thank them for it. That’s a cue to them: “I need to continue to do that,” or “I need more of that.”
The example I like to give is sometimes when I’m sitting in a team room and someone calls a consult, you can tell there’s a little bit of tension in the call. When it’s over, I’ll thank the resident or intern or whoever made the call: “Hey, I could tell that sounded a little challenging, but I appreciate how you maintained your civility, you were positive, and you got the job done. That could have definitely gone a different way. So thank you for being that person who is helpful and courteous to everyone else.” That’s a cue to them: yes, I need to keep doing that. So it’s both to recognize people for the amazing work, but also to help build your culture with the behaviors that you want to see in it.
Kevin Pho: Can you share a turnaround story of a hospital, clinic, or medical institution that implemented some of these techniques from caring, inspired leadership and moved the needle, providing a before and after picture? Do you have a story that you could share with us?
Joshua D. Hartzell: This is not my institution, but I interviewed Greg Argyros, who’s president of Washington Hospital Center, MedStar in Washington, D.C. He gives a good example from when he took over as Chief Medical Officer and started doing town halls. We’ve all been to town halls, and a lot of times we roll our eyes and think, “Leadership is here, but are they listening?” But he went, took his communications team with him, and took someone to track the input they received. They tracked it all. Not only did they track it, they worked through the problems and tried to solve them. When they couldn’t solve them, they communicated back to the team why.
Over the course of a couple of years, they were able to tackle—I think he said it was around 700 different issues. I love it because at the end, he tells this story that they would hold these town halls, and barely anyone would bring anything up. Someone said to him offhandedly, “Well, I guess they got frustrated that nothing was going to get done.” He responded, “No, on the contrary, we have fixed so many things.” People realized that the leadership team was committed to fixing things, so they didn’t wait for the town halls to bring up problems. They knew that if they brought these problems up, just as if they did at a town hall, they would be addressed.
I thought it’s a great example of seeking feedback and then taking action on it. There’s a great quote by Pat Lencioni, who wrote The Five Dysfunctions of a Team. I don’t know where the quote originated, but I’ve heard him say on a podcast that the people who work for you don’t expect you to have all the answers, but they do expect you to be working on them. Dr. Arros’s case illustrated that so well. You can’t fix every problem in a hospital; we know that there’s a realism to it. But people want to know you listen and care about them and that you’ll do your best to fix problems. When you can’t, you try to explain why. People will respect that. But you have to listen and value their input.
Kevin Pho: If we have a health care leader listening to this podcast, and they want to create that caring, inspired environment, tell us some of the first steps that they should take.
Joshua D. Hartzell: First steps: read the book. It’s a simple question. One: recognize that whether you’re in health care or not, our job is to take care of our people. If you asked yourself the question before any decision you made, “How does this decision either support my people or how may it harm my people?” we would make better decisions. Leaders ask themselves that question, but sometimes we get lost with metrics and RVUs and access to care. If you asked yourselves those questions, that would be a good start.
The second point would be consistently asking, “How can I invest in my people to help them get better personally and professionally?” What does that look like? What do you need to be successful? What do my frontline nurses need to be better at their jobs? Do they need an extra break so they can eat lunch when they’re on shift? Do they need communication training because while they had some in nursing school, they maybe didn’t have as much specific to some of the challenges they’re going to face? Maybe they need some other type of training. What specifically can we do as leaders to invest in our people?
It goes back to the earlier point: when someone invests in you, we show up a little differently at work. If I know my boss cares about me personally and professionally, I’m going to work a little harder. I’m going to do my best because I don’t want to let him or her down. If you listen to people, advocate for them, and give them growth opportunities, it’s going to motivate your workforce.
Kevin Pho: We’re talking to Josh Hartzell. He’s an internal medicine physician and infectious disease physician. His KevinMD article today is “Leading with care: How health care leadership can transform patient and provider well-being.” Josh, let’s end with some takeaway messages you want to leave with the KevinMD audience.
Joshua D. Hartzell: I would say a couple of things. The first would be that leadership is important. If you are somebody who hasn’t spent a lot of time thinking about your leadership development, I would challenge you over the next year to dedicate 30 minutes a week or maybe an hour a month to it. That could be listening to a podcast, reading a book, or talking to someone who you think is an effective leader, but make leadership development a priority.
Similarly, if you’re a leader already, make it a priority to develop those below you in terms of their leadership skills.
The last point I would mention: we’ve talked a lot about us taking care of others. It’s also essential as leaders that we need to take care of ourselves. If we don’t do the things that we need to show up as our best version of ourselves, then it’s hard to lead effectively. That’s different for every person; I can’t tell you what it is for you. But making sure that you’re taking care of yourself is also vital, not only to leadership but also to providing patient care.
Kevin Pho: Josh, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Joshua D. Hartzell: Thanks so much, Kevin.
