Photograph by Davide Baraldi on Pexels

In the earliest stages of my training, I used to pass out on a semi-regular basis. It wasn’t the sight of blood that did it, just a combination of naturally low blood pressure, early mornings without breakfast, and long periods of standing in operating rooms or on rounds. I would always feel it coming: a little wave of nausea lapping over me, some black spots floating across my vision, a yawn I couldn’t suppress as my body tried to take in more oxygen. Standing there, knowing I was about to lose consciousness, I would discreetly rock on my heels, trying to pump the blood back up towards my brain, hoping to avoid a humiliating display of weakness. It never once worked. Inevitably, I would have to step away, mumbling an embarrassed apology, before sinking to the floor as soon as I was out of sight.

I remember sitting on the ground with my head between my knees on numerous occasions, unable to get up but unwilling to call for help. One such occasion sticks out in my memory. As I sat slumped over in the hallway of the NICU I had recently rotated on to, a nurse passed me and paused. I looked up gratefully, thinking here was someone who could help me up or get me some water. “You can’t sit there”, she snapped before turning on her heels and walking away.

What strikes me about this scenario is that I used to tell it jokingly, a funny story at my own expense, just another one of the little absurdities of hospital life.

Normalizing Unhealthy Work Cultures

As physicians we are socialized into normalizing unhealthy work environments. It’s not just the physical stressors: the shift work, the sleep deprivation (as I wrote about in Why We Can’t Sleep), the countless exposures to infectious diseases, the constant cortisol surge that comes with high stress environments. We also learn to normalize the mental stressors of an unhealthy work culture.

There seems to be this notion that because the hospital is an inherently fast-paced, high pressure environment, doctors must not only be impervious to unhealthy workplace conditions, they must also be excused when they perpetuate them. I’d like to posit the opposite. The naturally high pressure, high stress environment of the hospital makes deliberately creating and maintaining a healthy work culture all the more crucial.

In the wake of quiet quitting and The Great Resignation, there has been an increasing awareness around recognizing and addressing toxic work cultures. Unfortunately, as is so often the case, the medical world has lagged behind other industries in acknowledging the need to improve working conditions.

Three Predictors of Toxic Workplace Behavior

In their publications on attrition and toxic work environments, researchers Donald and Charlie Sull identified three predictors of toxic workplace behavior: toxic leadership, toxic social norms, and flawed workplace design. I’ve been thinking lately about how these patterns have played out in the hospital environments I’ve encountered. Some of them are obvious once you know how to label them. But there are other, more subtle ways in which a toxic work culture reveals itself that may be harder to recognize and subsequently root out.

Let’s start with leadership. Many of the issues that create toxic work environments are top-down issues. Leadership styles have a huge impact in generating work cultures that are then propagated down the ranks and take on a life of their own. Here are some of the ways I’ve seen toxic leadership show up in the hospital, although they are certainly not unique to the medical field.

Breaking confidences

I once had a supervisor routinely share with me the details of private conversations they had with other members of the team. I always felt a bit uncomfortable at being taken into these confidences, but at the time I thought this person was using me as a sounding board to help with their decision making. In the moment, being made privy to information that should really remain confidential may feel like our counterpart is simply asking us to weigh in, soliciting our advice. And I have yet to meet the person who doesn’t love to give advice (It’s not me, as you may have noted from reading this blog).

This can feel especially compelling coming from a superior, since it implies an elevation in our rank. But the net result is always a loss of trust. When things that were discussed with leadership under the presumption of confidence don’t stay in confidence, it undermines team members’ willingness to exchange important information going forward. It also breeds divisiveness among team members, further contributing to toxic social norms such as clique building.

Lack of accountability

Perhaps you’ve experienced this as well: One or more members of a team or department refuse to operate within agreed upon directives. They won’t follow internal best practice guidelines or standard operating procedures because it they prefer ‘the old way’. Or they refuse to adhere to certain safety protocols, dismissing them as unnecessary. Or they don’t attend important team meetings as a form of protest. Or they consistently show up late to their shifts, costing everyone else valuable time. Or maybe they repeatedly undermine colleagues in front of patients and families. But rather than hold them accountable, leadership looks the other way or, even worse, openly acknowledges the behaviors as problematic while declaring their inability to do anything about it.

When rules don’t apply equally to all team members and there is a lack of accountability, the message to the rest of the team is a.) bad behavior will be tolerated and b.) leadership does not have enough authority to ensure integrity within their own department. Again, the net result is a loss of trust because there can be no trust without accountability. It also signals a lack of respect for the team members who are working to uphold those same standards. And of course, it opens the door for all kinds of subsequent bad behavior when it becomes clear that boundaries will not be enforced.

Unclear chain of command

I once worked in a department in which the chain of command was very much in dispute. There were complicated inner political workings with multiple people at the top who did not communicate with each other. As a result, it was almost impossible to obtain guidance and support from leadership when the need arose. Issues were easily punted from one supervisor to the other, with no one ultimately assuming responsibility.

An unclear chain of command results in chaotic internal structures, ineffective communication both internally and externally, and uncertainty and frustration among team members. Leadership structures such as these make it nearly impossible to move forward and implement constructive change. They also prevent the necessary accountability mentioned above. The downstream effect is that team members start to feel resigned and demoralized as their efforts consistently dissipate along the fault lines this ambiguous system creates.

Volatility

I’ve worked under more than one supervisor whose leadership style was characterized by its unpredictability. The constant tension that their erratic responses generated was even more exhausting than being confronted with predictably bad behavior. Working with people who are easily triggered by an ever-changing set of reasons is a recipe for burnout. It doesn’t have to be screaming or verbal abuse, sometimes it’s enough for leadership to openly signal their frustration or malcontent. The inability to foresee what will activate those responses can leave team members feeling like they are navigating a minefield of ill-defined expectations.

Emotional volatility is the opposite of psychological safety, and team members may suffer from disengagement, an unwillingness to share ideas or problems, or to take risks for fear of failure, and of course, are far more likely to resign. 

When Leaders Are Screamers: How To Coach A Volatile Executive, Forbes July 28, 2020

I’ve seen this pattern of behavior erode even the most engaged colleagues’ motivation. The unfortunate end result is often high turnover rates that cost departments in more ways than one.

Toxic leadership sets in motion a cycle that is amplified the more people it reaches and thus becomes very hard to break downstream, which makes it a particularly powerful driver of toxic work cultures. The current approach to leadership in medicine all too often consists of promoting doctors to leadership positions based on their clinical abilities and hoping those somehow extend to the ability to lead effectively. But excellent diagnostic skills or procedural capabilities have very little to do with the qualities required to provide the support, nurturing, and guidance teams need in order to thrive. If we want to become intentional about creating a healthy work culture in the hospital, we must first become intentional about training physicians to lead.

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In Part Two next week, I’ll be looking at the subtle signs of toxic social norms and flawed workplace design. Stay tuned!