Discovering a Remedy for Physician Work Stress--Making the Case for Team-Based Care and Physician Leadership in Group Practice

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Lee Jacobs, MD, Associate Editor, Health Systems

Perm J 2003 Winter; 7(1):2-5

https://doi.org/10.7812/TPP/15-190

Is your medical practice stressful? Too much to do with too little time? Spending a significant part of your day doing non-doctor work? Are you feeling that you have no influence over your work life? Ready for a different approach?

Remedy: A major solution for physician work stress is found in the linkage of the imperative that all physicians need to be leaders, regardless of job title, with the concept that the most effective work unit is a team rather than an individual.

I'll make my case for this approach to physician well-being by addressing root causes of work-life stress.

I. Prescription For Stress Reduction--The Case For Health Care Teams

Regularly Doing Nonphysician Tasks
Why am I doing this?

The nature of the medical profession is inherently stressful--being responsible for the health of people tends to do that. Although physicians in group and solo practices may incur a significant amount of practice stress, the stressors are somewhat different for each practice setting. Although group practice has successfully managed the intensity of being on call, the frustrations of office management, and, to an extent, economic security, group practice physicians probably have a set of stressors that is not a factor in solo practice. Specifically, solo practitioners typically have surrounded themselves with an office staff (team) who have a strong sense of influence and loyalty and are trained to focus on relieving the physician of all tasks that could be undertaken by another member of the office team. Is there a lesson here?

Only when group practices are organized as teams can innovations be tried to free up doctors to doctor so they are not encumbered with time-consuming activities that can be done by another team member. It takes the dynamics of a strong team to make changes in the scope of responsibilities of all team members; it does not occur just by asking.

Practicing in Isolation
I'm accountable for my schedule regardless ...

However, there is one additional significant source of practice stress that neither group practice nor solo practitioners have solved. This is the pressure felt by an individual physician when s/he alone needs to see an entire schedule of patients, regardless of the extent of health complaints or timeliness of the patient for the visit. A review of the literature (see Annotated Bibliography) reinforces what we probably intuitively know that people working alone are more stressed than those working as part of a team.

Here is a specific illustration: If a practitioner (physician, NP, or PA) is behind in seeing their patients, an empowered staff member assesses the situation and may move the chart of a waiting patient to another practitioner who is on schedule.

While you might think of many reasons why this shouldn't work, this type of team support is being done regularly on KP health care teams in regions throughout the country. Granted, it takes well-trained, empowered team members, and strongly interdependent physicians, but it works.

You want the evidence? I suggest reading "Successful Practices in the Physician Work Environment: We Work Together" in the Fall issue of The Permanente Journal,¹ in which the authors, Karen Tallman, PhD, with Jill Steinbruegge, MD, and Michelle Hatzis, PhD, discuss interviews with physicians from several KP primary care heath care teams around the KP Program. Teams that had high patient satisfaction and high People Pulse scores ("I feel supported ..."; "I have influence ...") addressed the daily stresses of busy practice by building on the dynamics of solid teams and by leveraging the members of their health care teams to take the pressure off individual physicians. While there is much work to be done in this area, it is clear to me that a highly functional team alleviates a significant amount of the pressure from practitioners who feel responsible for their scheduled patients.

Influence Over Practice
I have no control over issues that impact my work life

There is convincing evidence that individuals who feel that they have a high level of influence over their work are more satisfied than those who feel that external forces determine their work environment. This is affirmed by the worksite employment survey of KP (the People Pulse), which repeatedly has identified the level of influence as a primary driver to satisfaction.

Individuals working on a high-performing team have a much greater likelihood of developing a sense of influence over their practice. An isolated practitioner is less likely to feel that s/he has influence as opposed to a team member who is actively involved with the team in addressing issues impacting the work environment.

Conclusion: Remedy for Stress--High-Performing Interdependent Teams
Along with my team members, we can do this job!

The stages of team development are depicted in Figure 1. Phase 1 includes teams that are geographically together and episodically having meetings but the practitioners are still practicing in isolation. Phase 3 includes teams with a clear focus on patient care and service, which are organized to be totally interdependent. No question--this journey is worth taking. As demonstrated in Tallman's work, teams in Phase 3 feel in more control of their practice and overall have a much higher sense of professional well-being.

In conclusion, it is my premise that our stress in busy practice settings is best dealt with by using team-based care models. But hold on, there is one fundamental requirement before physicians and staff can set off on this journey.

II. Prerequisite For The Team Solution To Stress--The Case For Physician Leadership

Figure 1 demonstrates three important factors that create a state of readiness necessary before teams can be organized and successfully developed. First, the teams must have practitioner staffing at the levels determined by the organization. Second, no team will make this journey unless an effective physician team leader is at the helm. Third, what is most often ignored in team development is the necessity of having all physicians on board as strong informal leaders.

As readers of The Permanente Journal are aware every issue since Summer 2000 has included a section titled Physicians as Leaders. This is no exception, and on page 68, Dr Philip Tuso shares six universal and timeless characteristics of great leaders. He feels that these characteristics, if mastered, will help you to become a more effective leader.

Why all this hype? Why is it important to you or me if the physicians on our teams are strong informal leaders?

Answer: If you believe we can diminish our daily job stress by being part of a high-performing, interdependent team, then all physicians on the team must be seen as leaders by the team. I'm not aware of a successful team comprised of physicians who are isolationists and individualists, uninvolved in team activities. Success just won't happen without all physicians on the team modeling high quality patient care and service and team member interpersonal relationships­ie, they are leaders! The Physicians as Leaders section in this issue will define for you what this type of leadership looks like.

III. Summary--Steps To Consider in Diminishing Stress in Your Daily Practice

The journey in developing successful teams starts at the grassroots level by physicians, other practitioners, nurses, and other staff members who want to improve the quality of their work lives while enhancing the patient's care experience. Organizational leadership is needed to support and encourage, but it is front-line people who will make it work. Here are specific prerequisites, as summarized in Figure 1:

1. Before you can start on your journey, the practitioner staffing level, as determined by your organization, is essential. If the team is short of practitioners, the mode will be one of survival instead of team development.
2. It is essential to have a physician team leader who keeps the team focused on their prime mission (high service and care for the team's patients) actively encourages the team members and is considered by team members to be a practitioner role model.
3. All physicians on the team are then asked to be informal leaders.
4. Team development: With these three prerequisites, the team is ready to embark on the journey to becoming a successful team. The various stages of team development are well published, but the vision is essential: a state of daily patient care that is less stressful because physicians are doing less nondoctor work; a staff empowered to make the patient-flow process work, and, overall, feeling a great sense of influence over how work gets done.

I hope you find this helpful and that you now have a reason to pull out your past Permanente Journal articles on Physicians as Leaders and the Tallman article on the results of the physician interviews.

This is one man's opinion, and, as always, we welcome yours!

Team Structure and the Impact on Job Stress
Annotated Bibliography

1. Weaver J. Surviving real world stress. Executive Update Online 2000 Nov. Available from: www.gwsae.org/ExecutiveUpdate/2000/November/stress.htm (accessed January 6, 2003). [annotation]
   People under high levels of stress tend to become isolated. When high-stress events impinge on a person, s/he tends to enter a "survival" mode. As the team develops into a cohesive unit of support, individuals are able to concentrate on adding their talents to the group.
2. Firth-Cozens J, Payne RL, editors. Stress in health professionals: psychological causes and interventions. Chichester (NY): John Wiley; 1999. [annotation]
   Do people in health care settings who work in teams suffer less stress as a consequence? Effectiveness of teamwork has been positively correlated with job satisfaction and the mental health of the team members. A number of studies suggest that working in a team has a beneficial effect on job satisfaction and a higher sense of professional well-being. An extensive study in primary health care suggested that sustained interventions designed to encourage more effective teams lead to improvement both in team processes and in levels of stress. Another rigorous study demonstrated that those who work in a poorly defined team (pseudo-team) or who do not work in a team are significantly more likely to report higher levels of psychological distress and lower job satisfaction than those who work in a clearly defined team.
3. Quick JC, Quick JD, Nelson DL, Hurrell JJ. Preventive stress management in organizations. Washington (DC): American Psychological Association; 1997. [annotation]
   Research demonstrates convincingly that social support is the most effective counterbalance to stress.
4. Kerr S, Jermier JM. Substitutes for leadership: their meaning and measurement. Organizational Behavior and Human Performance 1978;22(3):375-403. [annotation]
   The workgroup may help mollify stressors that impact any single member of the group, particularly in semiautonomous empowered workgroups.
5. Pfeffer J. The human equation: building profits by putting people first. Boston (MA): Harvard Business School Press; 1998. [annotation]
   Organizing people into self-managed teams is a critical component of virtually all high-performance management systems. Numerous articles and case examples as well as rigorous, systematic studies attest to the effectiveness of teams as a principle of organizational design. There is considerable evidence that workers in self-managed teams enjoy greater autonomy and discretion and that this effect translates into intrinsic rewards and job satisfaction.
6. Haasen A, Shea GF. A better place to work: a new sense of motivation leading to higher productivity. New York: American Management Association; 1997. [annotation]
   Observation at Jamestown Advanced Products, Inc, in Jamestown, New York, and their team development and self-directed environment: Employee Comment--"I work harder here than I have anywhere else I've worked, but I enjoy it more and that makes it worthwhile." Working in small teams makes a job more enjoyable and stimulating. It allows for a work structure that gives the team responsibility for a meaningful segment of a task. People can count on the support of their peers. Being part of a successful group is equally stimulating for its members. "Good teams get better." Team success leads to integration and togetherness of workgroups, which is stimulating.
7. Pritchard P, Pritchard J. Teamwork for primary and shared care: a practical handbook. 2nd ed. Oxford: Oxford University Press; 1994. [annotation]
   The patient gets more efficient and understanding care; care given by a group is greater than the sum of individual care; team members have more job satisfaction and cope better.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

References

1.    Tallman K, Steinbruegge J, Hatzis M. Successful practices in the physician work environment: we work together. Perm J 2002 Summer;6(4):39-42.