Increase inclusion to decrease physician burnout and increase wellness

What do you do when your annual physician staff survey identifies these revelations?

• “I don’t feel included”;
• “I feel like an outsider”;
• “You have to be an insider to know what’s going on”;
• “I don’t feel valued or acknowledged”;
• “Leaders don’t encourage open discussion and expression of opinions and ideas”;
• “Recognition and promotion decisions are not made fairly”.

Introduction

While diversity represents “who’s on the team,” inclusion is “who gets to play” (1). Whereas diversity is “counting heads,” inclusion is “making each head count” (2). While diversity is “being invited to the party,” inclusion is “being asked to dance” (3). Diversity refers to the differences and similarities that exist among people based on a multitude of factors. Inclusion describes the incorporation of those on the diverse team. It describes everyone’s opportunity to contribute, as well as grow and advance within the organization. Inclusion means supporting everyone in advancing their careers and achieving their full potential. It means getting everyone’s perspective, for their sake, and the good of the organization. Recruiting diverse employees is just the beginning. Retaining and promoting them requires an inclusion strategy. Creating a welcoming culture of inclusion among a group of employees requires much more effort than initially establishing broad diversity. Without inclusion, diversity is ineffective. “Diversity doesn’t stick without inclusion.” (4). Inclusion is vital to facilitate retention of those who finally “get their foot in the door”. And….it mitigates burnout.

Raytheon Chief Diversity Office Hayward Bell opined (5) that those who feel excluded in an organization waste their time focusing on “access” while insider dominant leaders are laser focused on “success”. People who feel as though they’re looking in from the outside focus valuable effort on simply getting in. Those already on the inside can maintain their focus on what’s really important; their success. Just because you “fit in” to the prescribed matrix (objective “on paper” qualifications) doesn’t imply you actually belong, or genuinely “fit in”. You may simply assimilate; a much less desirable endpoint.

Individuals from diverse backgrounds must be made to feel valued and given an opportunity to succeed. Otherwise, they risk being made to feel like outsiders, taking on the unenviable role of token representatives. They become simply fodder for those collecting the metric and benchmark statistics data.

Organizations must support everyone’s success and career advancement, so all may achieve full potential. In a meritocracy, all feel acknowledged and engaged, not just those pre-selected behind closed doors as individuals “groomed” for future leadership roles in a predictable succession pipeline.

In an equitable workplace, everyone is respected and valued. Leadership seeks out perspectives from a cross-section of people with dissenting opinions; openly comfortable questioning and challenging each other’s choices. Hiring like-minded employees who simply echo each other, or leadership is anathema to long-term organizational success. Free expression of ideas must be encouraged. Engaging those with differing opinions, diverse skill sets, and varied experiences enhances efficiency and explores creative alternatives.

Inclusion creates a sense of belonging, increases engagement, builds loyalty and relationships and improves the bottom line by leveraging individuals’ diverse backgrounds. Allowing a larger pool of potential talent to succeed by assuring recognition and promotion decisions are made objectively, drives innovation, creativity and productivity. Incorporating employees of assorted rather than homogeneous backgrounds to contribute their unique skills delivers broader insights to a team. Because employees and patients all stand to benefit from inclusion, conscious (explicit) and unconscious (implicit) bias must not be allowed to undermine the ability to be inclusive. Team performance and effectiveness is better when differences are acknowledged and valued, people engage in healthy disagreement rather than conflict avoidance, unwritten rules are avoided, and rewarding conformity and obedience are not rewarded (6).

The inclusion matrix

Organizational culture exists on a broad continuum between a less desirable result of assimilation, and the most desirable result of genuine inclusion. Shore (7) provided an organized method by which to view inclusion. H describes high value in uniqueness and belonging with inclusion where an individual is treated as an insider and allowed and encouraged to retain their uniqueness within the group. There is a low value in uniqueness and belongingness with exclusion, where an individual is not treated as an insider with a unique value in the group but, there are others who are insiders. Differentiation occurs when an individual is not treated as an insider, but their unique characteristics are valuable to group success. This results in high uniqueness but low belongingness. High belongingness and low uniqueness occur with assimilation, where an individual is treated as an insider only when they conform to the organization’s cultural norms while at the same time downplaying their uniqueness. Warning behaviors may include an individual altering their attire, grooming or mannerisms to make their identity less obvious. They may refrain from behavior commonly associated with a given identity. They may avoid sticking up for their identity group. Individuals may limit contact with members of a group they belong to (8).

Korn ferry tolerance scale

This describes attitudes toward diversity and their effect on inclusion and belongingness in an organization. The “lowest” range is “repulsion” which describes an attitude that the individual is different in ways that are not normal to you. You do not believe they belong in your workplace and do not want them as a co-worker. Next is “avoidance.” The individual is different in ways that make you feel uncomfortable. You try to avoid them and do not want to work with them or deal with them. The middle of the range is “tolerance.” Individual is different from you in ways that make you feel somewhat uncomfortable. You believe they have a right to be there and be treated respectfully, but, if you had your choice, you would not have them as a co-worker. “Acceptance” acknowledges that these individuals are different but that these differences are not so important to you. You try to focus more on the ways they are the same as you and ignore the differences. You will listen to what they have to say and find ways to work together. In “appreciation,” you celebrate the differences, realizing you need each other and can learn something from them. You see their differences as a positive. You see them as possessing traits, skills, talents and intelligence that you value; including some you may not have but are glad now exist on your team (9).

More inclusion = less burnout

Ignoring inclusion, limiting engagement or practicing subjective promotional/advancement practices contributes to misunderstanding, fosters mistrust and contributes to physician burnout. Olson (10) suggests 50% of practicing clinical physicians are experiencing some degree or manifestation of burnout. These physicians may withdraw from clinical practice, reduce work hours, take more unpaid and sick time, retire early, leave medicine, shift to non-clinical work, limit their practice, or seek new opportunities (11). If burned-out physicians can’t affect change by stepping away from clinical to another component of practice, they may withdraw psychologically (12). Exposure to clinical work hours demonstrates a dose effect with burnout, suggesting cause and effect (13). Withdrawal from clinical work protects against individual burnout, but potentiates burnout in the remaining physicians, by shifting work. Everyone thinks they work harder than everyone else (14). Providing protected non-clinical time to all physicians allows them to shape their work to be more meaningful and fulfilling (15). All perspectives and contributions must be equally valued. Leadership must help align the myriad career paths of all to maintain successful, viable, high quality organizations while carefully monitoring and promptly managing physician burnout. More inclusion = less burnout.

Conclusions

Aligning the best of individuals within an inclusive environment serves to sustain a competitive advantage in any industry. In the health care business, it helps enhance personalized patient care. The input of every team member is needed to optimize performance, as each has worthy contributions to make, and each needs the other to perform at their best. It is not enough to get representatives of distinct cultures in a room. They must listen intently to one another, reflect on each other’s perspectives, and commit to working together for the shared benefit of all. The respectful exchange of ideas between people with varied experiences and different points of view must be encouraged (16).

Diversity and inclusion champions tackle difficult situations, boldly engage in controversial conversations, and sensitively ask the hard questions. Simply maintaining the status quo threatens to create broad-reaching, undesired and unintended consequences. At the same time that the demographics of the US are dramatically changing toward an increasingly diverse population, healthcare organizations are aggressively seeking to stand out as unique players on an ever-expanding global stage. Inclusion must be a priority for organizations. It demands real action—implementing actual, substantial and meaningful changes. Addressing the challenges and embracing the opportunities may require significant, but necessary culture shifts.

Actively embracing and passionately advancing inclusion has benefits for both employees and patients. A compelling business case exists for ensuring a prominent inclusion strategy in any successful modern healthcare organization. Providing culturally appropriate care, in a welcoming environment, to all patients can only be achieved by first improving the inclusiveness and participation of every diverse employee.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jhmhp.2019.07.01). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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