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Perspective |
1 Both authors: Department of Radiology, Indiana University School of Medicine, 702 N Barnhill Dr., Rm. 1053, Indianapolis, IN 46202-5200.
Received July 27, 2007; accepted after revision September 18, 2007.
Address correspondence to R. B. Gunderman
(rbgunder{at}iupui.edu).
Keywords: ethics • leadership • medical education • practice management • professionalism • residency
If I keep a green bough in my heart, the singing bird will come.—Chinese proverb
Some radiologists are becoming pessimistic. Declining levels of reimbursement, battles with other medical specialties over turf, and concerns about the commodification of radiology and radiologists are some of the factors that promote discouragement. A particularly troubling aspect of this discouragement is its potential effect on medical students and residents. Writing more than 20 years ago in The New England Journal of Medicine, Dr. Carola Eisenberg [1], former Dean of Student Affairs at Harvard Medical School, argued that many students become caught up in a culture of negativity sustained by more senior students, residents, and attending physicians. She describes the case of a particular third-year medical student:
[the student] had become profoundly discouraged. The problem was not the work; that was as exciting as he had hoped it would be. It was his interaction with his teachers. Once the formal teaching rounds were over, they talked only about the problems they faced.
This atmosphere can take a substantial toll on the next generation of physicians [2].
There is ample evidence that contemporary physicians are discouraged. A 2006 survey of 1,205 U.S. physicians by the American College of Physician Executives disclosed that nearly 60% of respondents have considered leaving the practice of medicine because they are discouraged by the state of U.S. health care. Almost 70% said they knew of at least one physician who had stopped practicing medicine because of low morale. The factors contributing to low morale are numerous and include low reimbursement, loss of autonomy, bureaucratic red tape, patient overload, and loss of respect. The consequences are significant and include fatigue (77%), emotional burnout (66%), and family discord and depression (32%) [3]. One respondent described the dire state of U.S. physician morale as follows [3]:
I think it is safe to say that no physician is optimistic about the future of medicine at this point.
Another respondent commented,
One thing that rarely gets mentioned is that, unlike other industries that are cyclical, the practice of medicine continually gets worse and worse, more intolerable, more onerous, with absolutely no hope or reason for any optimism either in the near or remote future.
To address this challenge, radiologists who work with medical students and residents need to examine the roots of pessimistic attitudes and look for ways to promote a more hopeful outlook throughout medicine. What hangs in the balance between pessimism and optimism? According to Martin Seligman [4], a founder of the contemporary positive psychology movement, pessimists are up to eight times more likely than optimists to become depressed when adverse events occur. They tend to perform below their potential, underachieving in school, in sports, and at work. They also fall ill more frequently and suffer a lower life expectancy. Their interpersonal relationships tend to be of poorer quality than those of optimists. And because they dwell on difficulties, they set lower expectations for themselves, perform less well, and throw in the towel sooner.
Theorists have long debated whether optimism is an emotion or a state of being and whether it is inborn, habitual, or a matter of cognition. In Optimism: The Biology of Hope, Lionel Tiger [5] describes optimism as a biologically adapted emotion. It helped our ancestors to maintain the strength and courage necessary to carry on with life despite challenges that might easily lead to despair and resignation. Seligman [4] regards optimism as a learnable approach to life and an invaluable motivator. He studied Olympic swimmers 4 months before the 1988 Olympic Games in Seoul. Swimmers with high scores on an optimism scale, including five-time gold medalist Matt Biondi, performed better in the face of obstacles and setbacks than those with low scores [6]. Optimism is a powerful motivator of individuals, but it is also communicable and can lift the performance of whole teams.
We can choose to become more optimistic. Aaron T. Beck [7], widely recognized as the founder of the field of cognitive therapy, provides a method by which each of us can become more hopeful. To do so, we must learn to recognize and modify the stereotypical ways of thinking that discourage us. We need to differentiate between objective accounts of events and our emotional reaction to them. Much of our distress arises not from what happens in our lives, but from the way we interpret those events. Once we see the impact of our interpretations, we can turn even adverse events into opportunities.
Beck [7] warns against thought patterns such as personalization, overgeneralization, and polarization. When we personalize events, we take them personally, supposing that they are aimed at us. Referring physicians who call at inconvenient hours to consult about a patient probably do not intend to ruin our day or express how much they hate us. Overgeneralization assumes that performing poorly once at a task means we will never do that sort of thing well. Residents who fail in their first attempt to catheterize a vessel are not necessarily hopeless at angiography. Polarization, or all-or-none reasoning, assumes that even slight deviations from perfection are the same as complete failure. Not surprisingly, radiologists who cannot tolerate any error are chronically dissatisfied.
Organizational Optimism
Positive psychology focuses on the cultivation of well-being [8]. Examples include organizational citizenship behavior, positive organizational scholarship, and relational energy approaches. Organizational citizenship behavior is an approach based on five core dimensions of attitude and conduct: altruism, courtesy, civic virtue, conscientiousness, and sportsmanship. There is evidence that cultivating such traits can enhance business outcomes [9, 10].
Positive organizational scholarship focuses on "generative dynamics" and seeks to promote "human strength and virtue, resilience and healing, vitality and thriving, capability-building, and cultivating extraordinary individuals, groups, and organizations" [11]. According to this approach, a flourishing workplace cannot be created by simply reducing negative factors, such as stress. Instead, emphasis should be placed on cultivating excellence.
Relational energy focuses on positive leadership as a means of mitigating negative forces and enhancing business outcomes [12]. This approach is a direct outgrowth of the study of emotional intelligence and its application to leadership. Helen Keller once described optimism as "the faith that leads to achievement," arguing that "nothing can be done without hope and confidence."In a study of the Metropolitan Life Insurance Company [6], optimistic agents sold 37% more insurance in their initial 2 years of employment and were less likely to experience job turnover than their less optimistic counterparts. The author [6] of that study found that:
Optimism leads to higher productivity and lower turnover in the workplace, and there is a positive relationship between optimism and workplace outcomes.
In medicine, a study of leadership values and challenges among medical school deans showed that 28% of respondents identified poor morale as one of their greatest leadership challenges, while having a positive attitude emerged as one of the most important factors promoting leadership effectiveness [13].
The first step in cultivating optimism at work is to adjust how we see our jobs [14]:
It starts when we realize that, no matter what job we do, we can have a positive influence on others by how we choose to do it.
When we neglect to correct negative attitudes such as pessimism, despair, and cynicism, we fare poorly. When we fail to cultivate positive attitudes and conduct, we perform below our potential. To develop a better understanding of the role optimism can play in the enhancement of medical performance, it is important to understand the relationships between optimism and three key factors: health care productivity, physician wellbeing, and patient satisfaction.
Optimism and Productivity
Productivity is a major priority for contemporary medicine. The American Association of Medical Colleges has projected a substantial shortage of U.S. physicians in the coming decades and has called for a 30% increase in U.S. medical school enrollment [15]. Although increasing the number of physicians in training will help, it is also important to explore opportunities to increase the productivity of the current physician workforce. Numerous studies of productivity throughout many industries, ranging from the service sector to manufacturing to health care, have shown that a positive climate or positive leadership increases workplace productivity and effectiveness [16–20].
A 1996 study indicated that 75% of Americans experience stressful conditions at work on at least a weekly basis and that stress can undermine worker motivation and engagement and the productivity of an organization [17]. Stress contributes to absenteeism and increased employee turnover [19, 21, 22]. It causes burnout, reducing engagement and compromising quality [10, 12, 21]. By contrast, an optimistic worker tends to be an engaged worker. A number of studies have shown a positive correlation between worker engagement and both efficiency and quality of work [9, 12, 16, 18, 23, 24]. Specifically, a meta-analysis of the Gallup studies, an extensive research database about work performance in various industries, found that organizations with above-average employee engagement had performance levels approximately 0.5 SD above those of organizations with below-average employee engagement [16].
Optimism also fosters a sense of ownership of work. Once we take ownership, we tend to feel an increased sense of responsibility for the achievement of organizational goals, which, in turn, promotes increased productivity [20, 25–27]. Strong social support networks help to dissipate stress and lessen its adverse impact on productivity [9, 23, 28, 29]. Support from coworkers and managers is frequently cited as one of the most important factors in preventing burnout and maintaining organizational productivity [12, 21, 23–25, 30].
The attitudes of workplace interactions also affect a team's level of performance. TDIndustries, a commercial and industrial construction company based in Dallas, TX, fosters teamwork as a means for enhancing productivity. First, it calls each of its 1,400 employees "partners." Every partner is invited at least biannually to join the company's founder and other top managers in small-group round table discussions at breakfast. This team attitude and encouragement of employee suggestions helped the organization maintain a position among the top seven of Fortune Magazine's "Top 100 Companies to Work For" from 1998 to 2004 [17]. Another study of workplace attitudes concluded that "anything you can do to make people experience a positive shift in mood tends to produce more productive and efficient work" [18].
Optimism and Well-Being
Every radiology department's most important asset is its people. Without highly knowledgeable and skilled workers, little could be accomplished. Hence, protecting and promoting the well-being of workers is a major organizational priority. The challenge of doing so is increasing in part because Americans are working harder than ever. Between 1969 and 2002, the number of hours the average employed American spends at work increased by the equivalent of 1 month of additional work per year [16]. Working harder and longer, we are increasingly affected by workplace attitudes.
Optimism is a major contributor to employee well-being [16, 17, 24, 27]. It affects our personal growth, our sense of purpose in work, our relations with others, our pride in our accomplishments, and our general level of happiness in work [16, 17, 19]. These attitudes in turn contribute to personal satisfaction, good health, and work fulfillment [9, 24]. A review of organizational practices at the Container Store, a top-six finisher for each of the past 8 years on Fortune Magazine's "Top 100 Companies to Work For," found that 94% of the corporation's employees "feel they make a difference" [17]. This pervasive sense of personal achievement, which is strongly encouraged and reinforced throughout the organization, results in a strong sense of employee well-being.
Appreciative feedback is important [16, 31]. We share a need to do good work and to be recognized for the good work that we do [32]. If we feel that our employer appreciates our work, our fulfillment is increased. We need to feel that we are contributing to the lives of others [16, 20, 25]. So-called "virtuous organizations" seek to enhance our sense of work as a calling [17]. Lloyd Hill, a former chief executive officer (CEO) of a home health agency became CEO of the restaurant chain Applebee's International, which he described as "going from saving lives to serving beer and pub food." As a means of finding purpose in his work and in the company, he visited each of the corporation's 54 restaurants and discovered that warmth and friendliness between employees and customers produced positive business outcomes and gave workers a sense of doing good. Consequently, he focused on hiring friendly people with a commitment to service. In the ensuing 10 years, Applebee's grew from 54 restaurants in one country to more than 1,600 restaurants in nine countries [33].
The rapid pace of change in contemporary health care creates the potential for emotional conflict, which can adversely affect both mental and physical health [34]. This potential source of conflict is not a trivial matter because the costs of absenteeism, employee turnover, and higher health care costs in the United States that are associated with workplace stresses are estimated to amount to at least $200 billion annually [24]. A study comparing academic primary care and specialty care physicians focused on workplace characteristics, stressors, and social supports as contributors to professional satisfaction. In general, primary care physicians at academic institutions tended to be less satisfied with their jobs than their more specialized counterparts. This low level of job satisfaction is attributable to negative attitudes toward primary care, a lack of collegiality with other specialties, and a perception of decreased administrative support. However, one academic center with research and primary care programs, both of which are highly ranked, manages to buck this trend. A study of the work environment at this institution showed that there is more collegiality, with greater support from other specialties and administration and a generally more positive attitude toward primary care throughout the center than at other less successful centers [35]. Positive attitudes and social support foster satisfaction and can foster more optimistic attitudes and habits among future physicians.
Optimism and Patient Satisfaction
Patient satisfaction is one of the most crucial outcomes of health care. First, patients are more likely to comply with physician recommendations and participate in their care if they are satisfied with it [36]. Second, the likelihood of patients returning to a health care provider depends in large part on the quality of their interactions [37]. Third, patients' accounts of their experiences affect the health care choices of others [37]. Finally, satisfied patients are less likely to pursue malpractice litigation [12].
Key factors in promoting patient satisfaction include friendliness, individualized or personal interest, clear and positive communication, fulfillment of needs, and pleasantness and congeniality [37–40]. All of these are enhanced by optimism. Two different studies of the medical profession have shown that a positive work environment and leadership enable physicians to better meet the needs of patients [12, 25]. The most important determinant of an organization's ability to meet expectations is attending appropriately to the patient's needs. The most important factor in exceeding expectations is to create positive personal interactions [37].
Another key factor in promoting patient satisfaction is the confidence level of the provider. In today's busy radiology practice, time for interaction with patients is short. However, confidence can be enhanced through intent listening and clear communication between radiology personnel and patients [38, 40].
Promoting Optimism
In a variety of contemporary industries, including business, construction, engineering, retail sales, and medicine, attitude and conduct powerfully influence every aspect of an organization. Negative attitudes and conduct undermine productivity, worker well-being, and the satisfaction of clients, whereas positive attitudes and conduct generate a more productive, healthier, and effective workplace. In his farewell address to the medical profession, Sir William Osler [41] wrote,
To each one of you the practice of medicine will be very much as you make it—to one a worry, a care, a perpetual annoyance; to another a daily joy and a life of as much happiness and usefulness as can well fall to the lot of man.
The first step in capitalizing on Osler's insight is to focus on our attitudes. Because radiologists play a variety of roles, there are a number of steps we can take to create a more optimistic outlook.
Clinician
Most radiologists devote a substantial portion of time and effort to
patient care. When we exemplify a positive and inspiring manner, we can
enhance optimism among patients
[24]. If we know what to look
for, we can find hopeful elements in even the most discouraging situations.
For example, when we participate in the care of patients with advanced and
terminal diseases, we can avoid an attitude of futility and instead focus on
the steps physicians and patients can take together to enhance quality of
life.
Educator
As educators, many radiologists enjoy opportunities to shape the future of
the field. Medical students and residents are powerfully influenced by the
attitudes of the physicians with whom they work. When learners have not
performed up to expectations, it is unnecessary and potentially discouraging
to focus exclusively on faults. We can enhance positive outlooks by seeking
opportunities to praise learners and help them find ways to perform
better.
Researcher
As investigators, radiologists encounter situations that could lead to
disappointment, frustration, and resignation. High-quality grant applications
may not receive funding or experimental results may contradict cherished
hypotheses. Claude Bernard
[42] described the joy of
discovery as "certainly the liveliest the mind of man can ever
feel," and there is much that radiologic investigators can do to foster
this sense of joy among learners. Such positive leadership is fundamental to
the success of any investigative team.
Administrator
Radiologists play many important administrative roles, through which we can
powerfully affect the general level of hopefulness in our organizations.
Committed and attentive administrators can provide an important emotional
boost by seeking out opportunities to highlight good work
[32]. One simple way of doing
so is to write occasional notes of appreciation to colleagues, expressing
appreciation for the difference their work has made in the organization.
Colleague
Radiologists are colleagues to many other health professionals. How we
treat them has a huge impact on the level of optimism in our organizations.
Every time we act in an uncivil fashion, it is like dousing the organization
with acid, which eats away at mutual respect. Conversely, if we recognize the
importance of collegiality, we can build a sense of shared mission and trust
that empowers everyone in the organization. When we act as good role models,
we experience greater professional and personal fulfillment
[43].
Personal Life
Another key domain in which to cultivate an optimistic outlook is personal
life. When we return home from work, what attitude do we convey about our
professional life and about the people with whom we work? Conversely, what
impression of home life and its importance do we convey to those with whom we
work? Ideally, each can enrich the other. Insights from personal life can help
us make better decisions at work, and insights and stories from work life can
enrich the lives of family members and friends.
Medical students, residents, and practicing radiologists need not become progressively more pessimistic over the course of our careers. There are legitimate grounds for hopefulness and even celebration about the future of radiology and the profession of medicine. Each of us can promote a more positive outlook. When our style is energizing and empowering, it enables us to provide better service, find more fulfillment in the work we do, and deliver better care to patients. By cultivating a more optimistic outlook and allowing it to shine through in our interactions with medical students and residents, we can help to build a brighter future for all.
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