“How do I thrive in a dysfunctional healthcare system and not let it discourage me or drive me insane?”
Several of my physician clients have presented different versions of this question in sessions. Before discussing “stay-sane” action items, we must start by articulating the nuance of the healthcare dysfunction we’re dealing with.
Know the Function of the Dysfunction
The discouragement and frustration you may be experiencing are not because there’s something wrong with you. You’re not crazy. The US healthcare system is dysfunctional at best. At its worst, it is often immoral.
There are over 900 health insurance companies in the United States.[1] One source estimates over 300,000 health plans, almost 600,000 unique codes to describe healthcare products and services, and ~57 billion negotiated prices.[2]
The plethora of insurers and lack of standardization clearly indicates a payer system evolved for a relatively small number of organizations to extract value. A priority that leads to poor outcomes, some insurers cheating the most vulnerable of our neighbors, stressors pitting administrators against providers, and physicians and other healthcare workers paying the psychological and emotional price.
This is what many of our focus-group physicians are saying:
- Insurance companies make it so some of our patients can’t come to see us.
- We feel like we’re doing click-box medicine.
- We feel like pawns. We feel like we’re doing more work for less reward.
- We are not allowed to be doctors.
- If we speak up, we’re seen as troublemakers.
- We’re resigned to the way things are.
- If we get sidetracked [by getting involved] and miss our metrics, we will jeopardize our careers.
This is what some of our focus-group administrators are saying:
- We feel that we’re being demonized for the decisions we have to make.
- We can’t do business as usual because these are not usual times.
- Physicians often don’t understand the severity of the issues.
- We must get better and communicating the “why” behind our decisions.
- We must provide the bandwidth for the difficult conversations.
- We must help physicians to better understand the business of healthcare.
When we consider that HHS and other governmental agencies are being defunded or dismantled and that the political winds favor capitalistic approaches to healthcare, it’s safe to say that the dysfunction is not going away. It’s going to get worse.
It’s important to note that there are many providers who report being quite happy with their jobs, and putting all the blame on the unethical payer system is like standing on a whale and fishing for minnows. Payer standardization would help, of course, but it wouldn’t come close to solving the problems we face. The population is aging, providing care is getting more expensive, and we face a shortage of up to 86,000 physicians by 2036.[3]
Regardless of the dysfunction’s origin, the operative question becomes, “How do we help healthcare providers sustain their psychological and emotional equilibrium in a dysfunctional healthcare system?”
The good news is that there is an answer to this question.
Staying Sane While Facing a Dysfunction Tsunami
Harvard Professor Robert Kegan says that we essentially have two choices when we feel overwhelmed by the complexities we face. We can try to make the world less complex, or we can grow our ability to engage complexity.
To grow our ability to engage complexity, we must turn toward Adaptive Development, which is, of course, different than the essential coping mechanisms of exercise, eating right, access to mental health services, and so on.
It starts by considering that most physicians, nurses, APPs, PAs, and others are hardwired to sacrifice themselves for the good of others. It’s in their DNA. Individuals who embody high levels of altruism are disproportionally attracted to healthcare, and the cultures of healthcare amplify their tendencies to self-sacrifice.
The unwritten, unspoken messages are subtle but persistent; you’re a good nurse if you’re selfless. You must put your own needs in the back seat if you’re a good doctor. Your family comes second if you’re going to be a successful surgeon. Taking vacations is selfish. Fear and sadness are signs of weakness, and so on.
In the case of physicians, the trauma that residency often provides only drives the ethos of selflessness deeper. Not only will you work hard, but you are often required to martyr your physical and psychological wellbeing. For many, subsequently, the ego becomes enmeshed with self-sacrifice and perseverance. Instead of having your altruistic strengths, your strengths begin to have you. (“I have the ability to endure” becomes “I am my ability to endure.”)
One could go on and on, but banging our heads against the wall trying to get the healthcare system to confront its own dysfunction will only produce cracked plaster and bruised skulls. No one is going to do it for us. No one is going to stop us from burning ourselves out.
So, it is incumbent upon us to change, and that is where Adaptive Development comes in. The required development takes methodical, systematic work.
The first step is to take ownership of the subtle agreements we make with the dysfunction. (This may sound like blaming the victim, and it is, of course, easy to say but hard to do.) Many of the psychological and emotional pressures carried by physicians are socialized. In other words, without realizing it, we look to others as sources of internal validation, orientation, or authority. We get our ego needs met by working ourselves to the bone. We shy away from setting, holding, and maintaining boundaries because we’re afraid. We neglect our relationships, our families, and our own health so we can measure up and belong. We feel wrong or shameful for being depressed or for having anxieties.
These are all ways we make agreements with dysfunction, and they’re all based in hyper-socialized ways of making sense. Something we Adaptive Development professionals refer to as the “Socialized Mind.”[4] About 47 percent of the college-educated population use the Socialized Mind to navigate relationships and the complexities they face at home and at work, and most of us don’t realize we’re doing it.
To liberate from hyper-socialized thinking, we must as noted, own the agreements we make, and then we must do the work to trend ourselves toward higher levels of Adaptive Development. In other words, we are required to use a more-nuanced way of sense making we call the “Self-Authoring Mind.”[5]
When we make sense of the world using the Self-Authoring perspective, we set, hold, and maintain boundaries. We define success for ourselves and set our own standards for personal integrity. Our work becomes part of our world, not our reason for existence. And, while we can indict ourselves when appropriate, shame plays a very minor role in our psychological makeup.
As leaders, we create “terrariums in the weedy garden” for our reports, and we do that without forming fiefdoms or demonizing superiors. When we trend ourselves to higher levels of Adaptive Development, we take vacations and truly relax. Our loved ones can feel our emotional and psychological presence because we have the emotional bandwidth to include them. Sustainability becomes a priority. We are passionate, grounded, and present in our work because we set psychological and emotional boundaries and limits, not just logistical ones.
Antonio Machado says:
“Beyond living and dreaming, there is something more important . . . waking up.”[6]
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Brad Fern is founder and president of Fern EPC, the Adaptive Development fast track for physicians, executives, and entrepreneurs.
[1] Wikipedia.
[2] Paul Keckley’s The Keckley Report.
[3] AAMC , March 21, 2024.
[4] Minds at Work, mindsatwork.com
[5] Ibid.
[6] Antonio Machado.
