Show Richard Gunderman a radiologist whose job performance is largely gauged by how completely she complies with top-down initiatives and directives, and Gunderman will show you a radiologist who is either burned out or getting there.
Speaking at RSNA in Chicago Nov. 28, Gunderman, the forthright Indiana University radiologist and researcher who holds faculty positions in pediatrics, medical education, philosophy, philanthropy and liberal arts, suggested “cultures of compliance” can spread burnout like a contagion.
“Someone who is compliant is obliging. In fact, compliance really means obedience,” Gunderman said. “Is obedience, in fact, the virtue of the day in American healthcare or healthcare worldwide? I have my doubts, and one of the reasons is because it contributes to burnout.”
Defining burnout by the increasingly accepted triple markers of exhaustion (feeling worn out), depersonalization (sensing you could be readily replaced) and lack of efficacy (doubting you’re contributing anything meaningful), Gunderman traced the roots of the problem in the U.S. to 19th- and 20th-century efficiency experts such as Frederick Winslow Taylor, Henry Ford and Alfred Sloan.
The latter, he pointed out, came up with the concept of getting each worker at General Motors to perform one tightly ordered function—put a particular nut, for example, on a particular bolt.
“That turned out to be very effective in cutting manufacturing costs, but it also turned out to be quite dehumanizing for the people who do the work,” Gunderman said. “It caused a profound de-skilling of the American workforce. And that tide is beginning to lap the shores of American medicine—and, in particular, American radiology.”
Compliance vs. conversation
Gunderman encouraged attendees to push back against that tide by, for one thing, seeking out opportunities to help develop a vision for what the radiology profession could be.
“Do we make our numbers? Do we comply with policies? Or do we strive to be something more than that?” he asked. “Whom do we serve—the people watching the dashboards or the people for whom the dashboards exist in the first place, namely our patients and our communities? We need to think at work not just about what we are trying to do, or what we are being held accountable for doing, but in fact what we are striving to become.”
He urged the audience to help transform their respective cultures of compliance into “cultures of conversation.”
To that end, he recommended the viewing, or close re-viewing, of two films: Stanley Kubrick’s "Full Metal Jacket," which dramatizes how “humanly disastrous” a culture of compliance can be, and Louis Malle’s "My Dinner With Andre," which shows a culture of conversation ennobling two people by the simple acts of talking and listening.
“What have you learned over the last week, last month or last year in conversation with your colleagues or perhaps even patients and families?” Gunderman said. “If we want to overcome the problem of burnout facing radiology, we need to shift the needle away from a culture of compliance and toward a culture of conversation.”
A challenge for hospital leadership
Following the presentation, an attendee asked what role hospital and health-system leadership can play in bridging the gap between the potentially competing cultures of compliance and conversation.
Gunderman replied that the “most real and, in a sense, most important” thing going on in radiology at the present moment wasn’t happening in any hospital C-suite or even at RSNA in Chicago but, instead, in countless unseen encounters between particular radiologists and their referrers and patients.
“We need leaders whose style of leadership, whose vision of the organizations they lead, is aligned with that kind of an account of radiology,” Gunderman said. “There are some things we need to do at a corporate level to enable our people to perform at their best, but there is a great deal that our people need to do to perform at their best that only they can know.”
That’s because patients and referring physicians aren’t in conversation with radiology. They’re in conversation with radiologists.
“This is very uncomfortable for people who would like to adopt a top-down model of leadership, where compliance is king,” Gunderman said. “But our mission is not to make the top-down leaders comfortable or rich. Our mission is to do right by our patients—and our children and grandchildren who will someday follow us into this noble field of radiology.”
This message dovetailed with a point Gunderman had made earlier in his talk.
“There is a word very rarely heard echoing through the hallways of McCormick Place, at least during the annual RSNA meeting,” he said. “That word is courage.”
“You and I need to know what we stand for, about what it means to be a good radiologist, what it means to cultivate a good community of radiologists at the department level, at the national level,” he said. “We need to talk about that vision. And when push comes to shove, we need to be prepared to stand up for it.”