Why external rewards undermine internal motivation

In my last post, I mentioned the issue of lack of trust in institutions. It appears that our world is increasingly running on financial incentives and regulation. Psychologist Barry Schwartz states that this undermines our will to do the right thing.

This week Dr Todd Cameron, GP and practice owner in Victoria, posted an excellent four-minute LinkedIn video about why financial incentives are not as effective as we sometimes think. He mentioned the following issues with financial performance systems:

  • They assume people are lazy
  • They are not supported by scientific evidence
  • They ignore activities that are difficult to measure
  • They reduce the flexibility of organisations
  • They take away resources for system improvement
  • KPIs often work against each other or against other goals, values or purposes
  • KPIs can undermine collaboration.

Research confirms that incentives, big or small, usually backfire. Like punishments, they affect internal motivation and creativity. Social scientist and author Alfie Kohn wrote about the ‘bonus effect’ in Psychology Today:

“When people are promised a monetary reward for doing a task well, the primary outcome is that they get more excited about money. This happens even when they don’t meet the standard for getting paid.”

Kohn states that rewards not only make people lose interest in whatever they had to do to get the reward but incentive systems also reduce the quality of their performance.

I believe Todd is right, money should be the byproduct of doing a great job. Pay is clearly not a motivator to improve performance. Most people get out of bed in the morning because they want to do the right thing – this is usually something we’re good at or passionate about.

Great examples and a work environment that gives people freedom and sets a clear direction at the same time are more powerful than monetary bonuses. Todd recommends that KPI funds should be used to improve systems and collaborative platforms and that targets should not be tied to financial rewards.

What happened to common sense

Last week, at the final meeting of the My Health Record Expansion Program steering Group, we spoke about trust. Or better, the lack of trust people have in big databases, governments in general and many other institutions.

This global trend is described by psychologist professor Barry Schwartz, who says:

“(…) the disenchantment we experience as recipients of services is often matched by the dissatisfaction of those who provide them. Most doctors want to practice medicine as it should be practised. But they feel helpless faced with the challenge of balancing the needs and desires of patients with the practical demands of hassling with insurance companies, earning enough to pay malpractice premiums, and squeezing patients into seven-minute visits – all the while keeping up with the latest developments in their fields.

Schwartz says that we seem to respond to any problem with the same answer of sticks and carrots. There is a widespread belief that more and better rules and incentives will solve our woes. There is one issue. Rules and incentives deprive us of the opportunity to do the right thing. They undermine empathy, creativity and the will to figure out what moral right means.

The My Health record offers great opportunities for healthcare in Australia. However, even though 90.1% of Australians now have access to the My Health Record, this cannot be the end of the line. A system that is responsive, has means to listen to users and learn from errors, mistakes and imperfections, is key to an effective and trustworthy digital health solution into the future.

Kindness, care and empathy are an essential part of my job – and everyone else’s. But it’s unlikely that this will ever be translated into key performance indicators or expressed in My Health Record upload percentages, practice incentive payments or MBS fees.

People are inspired by great examples, not by incentives. Above all, most people want to do the right thing. Trust may be a rare commodity these days but it remains an essential ingredient of effective healthcare delivery. It’s common sense, really.

How many days start with the letter T?

The other day I attended a leadership event at our local hospital. One of the speakers asked us “How many days of the week start with the letter T?”

The obvious answer is of course two, Tuesday and Thursday – but he said there’s another answer someone once gave him during a workshop, which is also correct: Tuesday, Thursday, today and tomorrow.

The point he made was that together people often solve problems in ways they wouldn’t have thought of on their own. Transformational ideas and break-through inventions are usually incremental processes that occur when different minds work together or build on each other’s work.

Steve Job’s iPod was based on existing mp3-players. Thomas Edison didn’t invent the lightbulb but improved it. The invention of the automobile and the airplane was the work of many; Henry Ford and the Wright Brothers just refined the ideas.

It never ceases to amaze me how people in a group – when the circumstances are right – develop creative ideas to solve challenging problems.

That evening, during dinner, I asked my children ‘Who knows how many days of the week start with T?” We had a bit of a discussion as a family until my 10-year old daughter said, “Seven days dad, because I always start my day with a tea.”

Why our opinions get us in trouble

“The history of human opinion is scarcely anything more than the history of human errors,” Voltaire said a long time ago.

Health professionals are trained to give opinions. It’s what we do every day in caring for our patients and leading our teams. Sometimes, however, it’s better not to give an opinion – or at least sit on it for a while.

Admittedly this is not always easy to combine with busy clinics, fast-paced lifestyles, opinion-based social media and rapid news cycles.

Nobel Prize winner Daniel Kahneman described two ways of thinking in his well-known book ‘Thinking, Fast and Slow’.

The first method, which he called system one, is fast, intuitive, runs automatically and cannot be switched off. It generates first impressions and intuitions based on experience. It is however subject to errors and biases and is poor at performing statistical estimates.

The second way of thinking, referred to as system two, takes more conscious effort and time. It is normally in low-effort mode but when system one runs into difficulty, system two will be engaged.

The two systems can work effectively together, as long as we are aware that our first guess, based on system one thinking, may not always be right and that we need to verify it by applying more analytical system two thinking.

The challenge, as I see it is, to have an opinion and an open mind at the same time.

This is an edited version of an article originally published on NewsGP.

Decluttering our homes and lives

Accumulating possessions is not always associated with an improvement in wellbeing. It can actually lead to stress and health issues.

On the other hand, giving, donating and getting rid of stuff are usually described as positive experiences. Decluttering homes even has health benefits.

A new Netflix series, Tidying up with Marie Kondo, brings a powerful message across: organising our homes and offices comes with rewards.

Marie Kondo, dubbed the Japanese Mary Poppins, creates happiness by helping people throw away stuff they don’t need and organise their belongings. As a result relationships seem to improve and families live happier together.

The concept is of course not new, as professional organisers, unclutter clinics and clean-up blogs have been around for a while. But there is something appealing about watching this show.

Whether it is a desire for simplicity, a need to create organised spaces to think, work and live, or just guilt reduction, the slowly disappearing clutter towards the end is satisfying.

Marie Kondo makes decluttering homes, and lives, a fun activity. But she does something else. By asking whether objects spark joy she reminds us about our priorities and what life is all about – something we occasionally forget.

Knowing what life has in store for us

Living with uncertainty is not an easy task. It can be the source of many anxieties.

I often go through this with my patients, for example when we may have found something sinister but more time is needed to confirm the diagnosis.

Yet, when it comes to our lives and deaths, we always live in uncertainty. But what about the opposite: what if we knew what life has in store for us?

Chloe Benjamin deals with this theme in her book The Immortalists.

At the beginning of the story four young siblings visit a fortune-teller who gives them the dates when they will die. This knowledge influences the rest of their lives and the choices they make. It becomes a self-fulfilling prophecy. Three of the four siblings die on the predicted date, largely as a result of their own doing.

I wonder if the information increasingly available through genetic testing will influence our lives and deaths in a similar way. Would we live our lives differently knowing what may be ahead of us? Could this knowledge also create its own anxieties and problems?

Here are five things to consider before ordering a genetic test.

Doctors from overseas

“G’day doc, I’m right off me tucker and crook azadog. Yesterday arvo me neighbour said it’s just the collywobbles but crikey, he’s mad as a cut snake so I thought I’d better find out what the doc has to say. I know youse are flat out but waddaya reckon, she’ll be right? I feel weak as a wet whistle. Not droppin off the perch yet am I? Probably just old age. Howyagoin anyway, settlinin all right? Gotta love the top end mate, heaps better than the big smoke.”

When I arrived in Australia – in Cooktown of all places – one of my biggest challenges was understanding the accent and the slang. I also struggled with basic expressions. I remember being invited ‘for tea’ one night – so after dinner I went over expecting a cup of tea or coffee only; to my surprise our host had prepared a delicious roast. On another occasion I was asked ‘to bring a plate’; I took a few plates and, just to be sure, some cups and cutlery too.

I thought the communication was problematic because I come from a non-English speaking country. It turned out that most immigrants struggle with language, communication and the often slightly different meaning of common expressions, not to mention the bureaucratic jargon. For example, as doctor Jennifer May wrote in the Medical Journal of Australia, a term such as ‘reciprocal recognition of qualifications’ has a different meaning in different jurisdictions.

The first six months were a crash course in ‘Strine’. The patients were wonderful and seemed to strangely feel sorry for the new overseas doctor in town. They taught me all the basics; some gave me Australian slang dictionaries and Indigenous Australians told me stories about their culture. Still, it took a few years before I could fully understand most conversations.

The preparation

For most immigrants the challenges begin long before entry to Australia. The paperwork and background checks required by the Australian government and healthcare organisations – which can take one to two years to complete – are only a small part.

Croc drama: A crocodile dragged a fisherman from his tent on the riverbank and a woman jumped on its back in an attempt to stop the giant reptile. Source: Cooktown Local News

Even though the decision to emigrate is mostly a voluntary one, and it is a privilege to be welcomed to Australia, it doesn’t mean that there are no downsides. Emigrating doctors and their families have to give up their lives in the home country and say goodbye to loved-ones, familiar neighbourhoods, cultures, customs and careers.

It is not uncommon for overseas doctors and their family members to experience some adjustment problems. Many tears have been shed when settling in a remote Australian outback town or new suburb. It can be stressful when a spouse struggles or the children have problems at the local school.

Often well-established and respected at home, immigrant doctors start all over again. They are initially temporary residents with limited rights and no access to Medicare. Their medical registration is conditional, they have to work in places where many Australian trained health professionals don’t want to work, and their future is uncertain and dependent on passing health checks, police checks, language tests, assessments and exams.

My arrival in Cooktown reported in the local newspaper (2004). Full story below.

It can be difficult to negotiate employment conditions or discuss real or perceived injustices – as a conflict may lead to cancellation of sponsorship or visa. Financial challenges are common as starting over in a new country does not come cheap. There are all sorts of legal and tax problems, such as dual taxation. I had to give up my Dutch citizenship when I became an Australian citizen.

For the immigrant there is always ‘the other world’ of their home country. They often use the holidays to fly ‘home’ and visit family and friends for a few weeks, which is joyful but can be intense and emotional. Migrants may never feel one hundred percent part of the Australian society and at the same time they often don’t fit in anymore in the home country, which can affect their sense of belonging and create feelings of loneliness.

Rural medicine

For me another culture shock was rural medicine. The contrast with Amsterdam, where I trained as a doctor, could not have been greater. I quickly had to learn about tropical diseases, snake bites and Irukandji – just to name a few. Shortly after I arrived a 4.2 meter saltwater crocodile dragged a fisherman from his tent on the riverbank when a woman jumped on its back to stop the giant reptile; the story appeared in all the newspapers.

Although many of the medical textbooks back home were written in English, learning to speak the medical jargon in another language was yet another challenge. Names and doses of commonly used drugs differ between countries, not to mention the different guidelines.

I was able to do a few up skilling courses including trauma and emergency medicine and with assistance from helpful and skilled colleagues – sometimes over the phone – and a great nursing team, we were able to manage many problems locally. I am grateful for all those who have welcomed and taught me over the years – patients, staff, nurses, fellow doctors and others.

Not unique

For a long time I thought my ‘adventures’ were unique but over the years I learned about similar stories, not only from overseas doctors but also from Australian graduates, all struggling during their first placements in rural and regional hospitals and GP practices.

These stories are often tales of incredible resilience and courage and what always amazes me is to hear how valued health professionals are in their communities – even though we may often feel ill-prepared or have doubts about our skills and knowledge.

The demands on doctors in small towns can be high, not seldom 24 hours per day. Working towards another degree or fellowship is taxing for anyone, but for international medical graduates coming from a different background there are many extra challenges. The working hours and fatigue don’t go well with training and exam preparation.

The workload and the tyranny of distance can make supervision suboptimal; there is often limited support and the amount of bureaucracy can be perceived as overwhelming.

On the bright side, there are many people who warmly welcome and support the newcomers. Professional bodies and colleges offer introductory, support and exam preparation programs, but often the local and individual initiatives make the difference. An example is Dr Farooq Ahmad who, after passing his Australian fellowship exam, decided to support others and has helped hundreds of doctors pass their exams.

In the video below Kenyan born Dr Ken Wanguhu describes the importance of being welcomed by a community as well as the rewards of contributing and ‘giving back’.

Concerns

Although many areas of Australia are relying heavily on international medical graduates, not everyone is happy with the influx of doctors from overseas. Critics of the Australian skilled immigration policy have often mentioned the ‘brain drain effect’ on developing countries: the recruitment of healthcare professionals compromises the, often already struggling, healthcare systems in the developing world.

Concerns have publicly been expressed about doctors from non-Western training backgrounds and the uncertainty around standards and relevance of knowledge and skills to the Australian situation.

The regulation changed in the aftermath of the Dr Jayant Patel case. Dr Patel, nicknamed ‘Dr Death’, was permanently barred from practising medicine in Australia in 2015. Legislation introduced in 2009 now protects patients by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner can be registered.

This example is not unique to Australia nor to international medical graduates. Many countries have similar stories, think for example about Dr Harold Shipman in the UK and Dr Christopher Duntsch in the US.

Although there is anecdotal evidence that patients sometimes avoid seeking treatment by international medical graduates, research indicates that there is no difference in patient satisfaction with, and acceptance of, care by Australian and international medical graduates.

Diversity

The ‘doctors from overseas’ bring diversity, expertise, experiences, cultures, innovation and stories to Australia. Cross-cultural experience appears to be valuable in many ways; some have argued that immigrants are more entrepreneurial, resilient and creative. Whether this is true or not, one thing is for sure, starting a new life in a different country takes courage and perseverance.

My wife Nancy and I have never looked back. Although we miss our family and friends in The Netherlands, we’re grateful for the opportunities Australia has given us. I can only hope I am able to give back what I have received.

Source: Cooktown Local News (2004).

5 ingredients for effective collaboration

Collaboration can be very rewarding. It is often talked about but not easy to achieve, and it doesn’t always make the top of the priority list.

Although it’s not the solution to everything, effective collaboration can be a source of satisfaction and has the potential to make work, and life, more fun. Of course, collaboration does not mean that we have to agree on everything.

I’d like to share some thoughts on the ‘ingredients’ of successful collaboration:

#1: Letting go of control

No one is as smart as all of us, said Ken Blanchard. It’s ok to not have all the answers. In collaborative cultures outcomes are largely dependent on organic group processes. It is important to empower others and trust in the wisdom of the group and diversity of thought.

#2: Celebrating diversity

Interesting things happen when people bring different backgrounds, disciplines, skills and ideas to the table. We need to be open to a dialogue that celebrates differences. This is not always easy as our tendency is to engage with like-minded people.

Diversity improves decision-making as it stimulates critical evaluation and prevents groupthink. Diversity also means accepting that we can have differences of opinion.

#3: Aiming for mutual benefit

In collaborative cultures mutually beneficial solutions become more important than winning and personal gain. We need to attend to the needs of all parties and not just our own.

Consensus improves the quality of decision-making through genuinly addressing individual concerns. Asking questions and finding out what outcome the other party needs is key to finding common ground for agreement.

#4: Formulating shared values or goals

Often we want to jump to the ‘how’ without having explored the ‘why’. Universal values are motivating! They answer the why question and are the reason we get out of bed in the morning. Providing excellent care to our patients is an example of a universal value/goal most of us share.

#5: Building relationships

If we focus on outcomes without investing in relationships, there is a good chance that we will fail. Building trust and relationships are key components of effective collaboration. This is never a once-off tick-box exercise but should be an ongoing activity.

This post was originally published on BridgeBuilders.

How to upgrade an organisation’s tribal culture

Immature tribal cultures create silos and distrust, and sustain undesired behaviours. How can we change a dominant culture and become more effective?

My mother spent years of her childhood in Tjideng, a Japanese internment camp for women and children run by the cruel Captain Kenichi Sone.

She was born in the former Dutch East Indies, now Indonesia. The Dutch occupied and exploited the country for over four hundred years, but in 1942 things changed dramatically as a result of the Invasion by the Japanese imperial army.

The women in the Japanese internment camps are sometimes called the ‘forgotten women’ of the war in the East. These camps, as well as Dutch colonialism, are some of the worst examples of tribalism.

Tribalism comes of course in many shapes and forms including, as we all know, in the medical world.

Tribes & organisations

Most leaders know that tribal cultures are a key factor in the performance of organisations. Some leaders are experts at creating close-knit cultures, but only a few can change a culture that doesn’t perform optimally.

Tribalism is the natural way we organise ourselves into social groups. Our ‘tribes’ are part of who we are. They offer support, security and a sense of belonging an there’s nothing wrong with that.

However, tribalism can also refer to a false sense of superiority, sometimes leading to exclusion, bullying and discrimination.

We can change a dominant tribal culture and upgrade our organisations to more collaborative, healthy stages. History shows that goal-oriented groups and organisations that work well with others are more successful.

5 tribal cultures

In the book ‘Tribal leadership’, Professor David Logan et al describe five stages of tribal culture. As he points out, the medical profession is only half way, at stage three of five.

Five tribal cultures
The five tribal cultures. Source: Tribal leadership. David Logan, John King, Halee Fischer-Wright 2011

Logan’s tribal stage one is the mindset of gangs and war criminals – people who come to work with weapons. There is hostility and violence and no cohesion.

People working in a stage two culture may have coffee mugs with slogans like: “I hate work,” or “I wish it was Friday”.

There is often a high suspicion of management and authority in general, and team-building efforts are not effective in this culture.

Stage three is the dominant culture in almost half of all organisations, including many professional workplaces. Quite often doctors fall into this category. In stage three it is all about personal success and being the smartest. Stages four and five are the collaborative cultures.

Let’s have a closer look at the most common culture, stage three.

I’m great (and you’re not)

The mantra of stage three is ‘I’m great’, often followed by the unspoken words ‘and you’re not’. There’s a long history in medicine of stage three cultures with a strong focus on individual expertise and success.

Anatomy lesson
The Anatomy Lesson of Dr Nicolaes Tulp, by Rembrandt. Source: Rembrandt Huis.

One of the earliest examples I could find is this well known Rembrandt painting titled, ‘The anatomy lesson of Dr Nicolaes Tulp.’

Dr Tulp was a highly respected surgeon in Amsterdam in the seventeenth century; he is clearly the central figure in this painting. He’s the only one wearing a hat. Sadly but not surprisingly there are no women present.

You could argue that this scene demonstrates the dominant culture of the exclusive Amsterdam Guild of Surgeons. These days, almost four hundred years later, the dominant culture in medicine hasn’t changed all that much.

Professionals working in a stage three culture are often very good at what they do as individuals but what they don’t do is bringing people together.

They may think they are. Interestingly people in stage three often think that they are at one of the collaborative stages. They may talk about collaboration and teamwork – hallmarks of stage four and five – but their actions firmly put them in stage three.

The issue with a stage three culture is that it cannot be fixed – it can only be abandoned. The solution is to move your tribe to the next stage, stage four.

How to upgrade

People working in a stage four culture don’t talk about themselves. They first start listening. It’s no longer about being the smartest or about personal success.

There’s a move from ‘expert’ to ‘partner’. The language used is not “I’m great” but “We’re great”. There’s tribal pride.

Eventually, later in stage four, organisational boundaries become less important and cross-pollination between organisations may occur.

So how do we upgrade our culture from stage three to the more collaborative stage four? Logan describes several principles, including:

  • Focus your team on tribal success instead of personal success
  • Point out the superior results of stage four tribal cultures
  • Describe role models in the organisation that show stage four behaviour, for example people who are talking about ‘we’ instead of ‘me’
  • Encourage transparency and sharing of knowledge & information as much as possible.

There’s one main problem with stage four, reflected in the unspoken sentence that often follows “We’re great,” and that is: “… and you’re not,” referring to other groups or organisations. That’s where stage five comes in.

Stage five is the dominant culture in two percent of work places. In this stage there is no ‘they’.

‘Them & us’ thinking has gone out of the window and there is a focus on inspiring purposes. These are often universal values, taking away the need to compete.

People working in stage five cultures can work with any group that has a commitment to universal core values – even if these values are different from their own.

Effective followership

More collaboration in medicine has many benefits, including for direct patient care, mental health of doctors and healthcare reform.

We always talk about leadership but effective followership is just as important.

Effective followers don’t blame their leaders when things don’t go as planned; instead they offer support and gently, but persistently, steer their leaders in the right direction to help them achieve the organisational goals.

What the medical profession needs is people who build bridges.

I’d encourage you to review your own organisation(s) and look for opportunities to collaborate. Don’t accept non-collaborative cultures.

Find role models and like-minded people, people who talk about ‘we’ instead of ‘me’, and together take your dominant culture to the next level.

This is an adaptation of a presentation given at GPDU18.

Tribes, tribulation and the elephant in the room

If we want to change bullying and abuse within the profession we have to move our tribal cultures to the next level.

The medical profession has come a long way in the past 25 years, but sadly seems to have difficulties eradicating issues of humiliation and abuse of colleagues and medical students.

One option to fix the problem is to make junior doctors and students more resilient, which seems like a good principle that is currently being applied by other organisations in other areas. Fore example, Beyond Blue has released a practice guide for professionals to help children deal with the adversities they experience early on to prevent mental health conditions later in life.

But teaching resilience alone is not enough.

Another option is to increase awareness and understanding among senior doctors and educate them about bullying, discrimination and sexual harassment. A good example is the mandatory education module, ‘operating with respect’, from the Royal Australian College of Surgeons (RACS).

Elephant in the room

The elephant in the room, however, is our culture – or at least certain aspects of it.

David Logan, a professor at the University of Southern California, said it a few years ago in his New York Times bestseller ‘Tribal leadership’: on the tribal culture scale of 1-5, most professionals around the world score a meagre three. This includes lawyers, doctors and professors.

According to Professor Logan and fellow authors John King and Halee Fischer-Wright, a stage-three culture or tribe is built around knowledge, personal accomplishments and individual expertise. The emphasis is often on winning. Although there may be talk of teamwork, the group interactions usually resemble those of a master-servant relationship.

The mantra of a stage-three culture is, ‘I’m great’. The language used is often along the lines of, “I’m good at my job,” “I try harder than most,” “Most people can’t match my work ethic,” and key pronouns used are ‘I,’ ‘me,’ and ‘my’.

This creates several problems. Professionals operating in this type of culture often feel unsupported, undervalued and frustrated, and those around them feel like a support cast.

Stage-three cultures cannot be fixed, but they can be abandoned. The answer is to upgrade the culture and move away from the ‘I’m great’ mantra to ‘We’re great.’

The next level

Instead of relying on personal achievements and expertise, at stage-four it becomes all about the accomplishments of the group. Partnerships, communication and transparency are recognised as essential ingredients for success. This is a healthier environment, in which people feel more valued and supported.

Professor Logan’s top level is stage-five. Highly functioning teams focus on maximising achievement – not in competition with other groups or tribes but with what’s possible. Stage-five teams can work with anyone.

Australian research has shown that hierarchical and stereotype behaviours largely dissolve when health professionals are working in a more collaborative, multidisciplinary environment.

Resilience training and anti-bullying education are essential, but if we really want to make a difference we have to move our tribal cultures to the next level.

This article was originally published in newsGP.

New skills, fewer scripts and less screen time: 3 resolutions for the new year

Richard Branson said we should put our resolutions in black and white, because that helps us stick to it. Just in case he is right, I wrote down 3 professional & personal resolutions for the new year.

1. Learn a new skill

Rightly or wrongly, one of my fears is deskilling – at a personal level, but also at a macro level as a profession. As Dr Margaret McCartney wrote in the BMJ, the enterprise to streamline medicine by outsourcing certain tasks to protocol-driven non-doctors, runs the risk of deskilling generalist doctors.

There are probably other reasons for losing our skills, such as policy changes and the costs of consumables and maintaining skills. But we can’t always blame others for everything, so I have decided to learn at least one new skill every year.

2. Change prescribing habits

I have made a conscious effort over the years to reduce unnecessary antibiotic prescriptions. I am doing the same with opioid analgesics for chronic non-cancer pain, in line with new RACGP guidelines.

In the case of antibiotic prescribing I had to overcome a few hurdles, such as the fear of not meeting my patients’ expectations or leaving a serious infection untreated.

Talking to colleagues was helpful and I found that – after a careful history, examination and explanation – most patients accept a ‘watch & wait’ approach, with appropriate safety netting.

I feel better for practising less defensive, ‘play it safe’ medicine, which in the end may not be as safe as we’d like to think.

There are parallels when it comes to prescribing opiates. After the GP17 Conference in Sydney I took the RACGP’s 12-point challenge to GPs (see image) and found that I am now spending more time talking with patients about the pros and cons of opioids.

Yes, it is easy to slip up, especially under time pressure and just before lunch or closing time. However, by perseverance the snail reached the ark. I find every small successful dose reduction or non-pharmacological intervention satisfactory. I hope this will be a drive to continue the conversations with patients.

12 point challenge
Image: The 12 Point Challenge to GPs. Source: RACGP

3. Spend less time behind screens

Excessive screen time for children may be linked to several adverse health outcomes, so at home we use an app to limit the recreational time our children spend on their devices – making sure they have opportunities to learn, create and connect in the digital space. This sounds great but in reality it is a never-ending balancing act. It also made me realise that I may not be the best role model here.

It turns out most adults spend more time on their digital devices than they think, which was certainly true in my case. Some of the time behind screens, such as in the consulting room, is difficult to cut back but not all screen time is essential.

I took a social media ‘holiday’ during the month of December and it felt good. So this year I will unplug more often from the social media fire hose. I may even read a book.

This article was originally published in newsGP.

Same-sex marriage and the role of the GP College

During my medical training in Amsterdam I witnessed many of the effects of the Dutch liberal policies such as the legalised practice of euthanasia and their model on cannabis. The Netherlands was also the first country in the world to legalise same-sex marriage over 15 years ago.

When it comes to same-sex marriage I support this. Not so much because of health reasons but simply because I believe it is fair.

I acknowledge that LGBTIQ communities (Lesbian, Gay, Bisexual, Transgender, Intersex and Questioning) have had a lot to endure. I also respect that there will be people who disagree with me here and may have other opinions.

In Australia we now have the odd situation of the voluntary Australian Marriage Law Postal Vote, where we are asked to vote on the question: Should the law be changed to allow same-sex couples to marry? 

The RACGP position

The postal vote has created healthy debate but also vigorous campaigns by the ‘yes’ and ‘no’ camps. Organisations and businesses are being asked by their members and customers to take side and the health sector is no exception.

Unfortunately there have been inappropriate and hurtful comments on social media and elsewhere. It seems to me that these unintended consequences of the postal vote are doing more harm than good.

The Royal Australian College of General Practitioners (RACGP) has a diverse membership of more than 35,000 GPs with a range of views. The RACGP Council believes that members should make their own, personal decision about marriage equality.

This position does not imply that the RACGP is against same-sex marriage, or for, and it does not mean that the College or general practitioners do not acknowledge the many challenges facing the LGBTIQ community.

It also does not mean that the RACGP president is personally neutral on this topic – I know that he supports same-sex marriage.

The background

To better understand the position of the RACGP Council it is good to look at the history and the role of the College. For many years the organisation has mainly focused on training, education and quality standards. In recent years the RACGP has moved into advocacy to improve support of and recognition for the provision of quality general practice care.

The RACGP has invested heavily in a large database of guidelines, standards, policies and position statements driving general practice care. However, there has not been a demand from members to advocate on public policy issues such as climate change, sugar tax, alcohol sale, refugees or marriage equality – as a result the College has not developed a position on many of these topics.

The RACGP recently sent out a poll asking members if they would like the RACGP to advocate on a wider range of public policy issues, and one of the examples given was marriage equality. The response: One hundred members participated and one third stated that they did not think this was a role for the College.

This is only a very small sample and clearly more debate is required. The direction of the College will ultimately depend on what the membership wants. Traditionally the Australian Medical Association (AMA) has been doing this kind of advocacy very well, but perhaps there is a role for the Colleges?

Social responsibility 

An important argument for change is that it would increase the College’s social responsibility. As family doctors we come in contact with all of life’s challenges so we may as well participate in the various debates.

On the other hand, it will be difficult for the College to be everything to everyone. It may create more disputes.

Lastly, various RACGP sources including the Standards for General Practices affirm and underline respectful and culturally appropriate patient care and, in accordance with the law, strongly condemn discriminatory treatment of people based on their personal characteristics.

I’d urge everyone to be kind and considerate and show respect for others in this important debate.

Addendum 02/10/2017: RACGP Council has issued a statement in support of marriage equality.

At the time of writing Edwin Kruys was vice-president of the Royal Australian College of General Practitioners (RACGP).

Effective feedback

Giving effective feedback in the digital age: 10 do’s and don’ts

Giving feedback is of course best done in person. However, in the digital era this may not always be practical or possible and a lot of feedback already occurs via email, text messages or social media.

There are many ways to give feedback, some more effective than others. I have probably made every mistake possible. I’ve also seen really good and some not so good examples, including on this blog.

Giving effective feedback requires more than stating errors or shortcomings. Problem identification, clarification and advice or suggestions for improvement are useful parts of the feedback process.

Respectful communication

To make feedback acceptable and useful for the recipient, it is best delivered in a supportive way, including both positive and negative observations. We all know this is not always happening on social media, comments sections and blogs. Sometimes basic elements of respect and dignity are forgotten, which may undo the positive effects of feedback.

Effective feedbackMost doctors and other health professionals are passionate about what they do, but we also experience excessive occupational demands and sometimes lack of personal support. Electronic means of communication can play an important support role, but can also be a source of stress.

Some research suggests that doctors have high expectations of self, are achievement-oriented and have a tendency to self-blame. Together with the often non-disclosure of personal distress, this makes the profession vulnerable for burnout. Let’s be kind to ourselves and our peers.

Consequences & effect

We all appreciate helpful and constructive feedback, so it is good to think about the way we give feedback to others and the consequences our comments may have in the digital space.

The Medical Board’s Code of Conduct mentions ‘communicating respectfully’ and ‘behaving professionally and courteously to colleagues and other practitioners, including when using social media’.

An honest, well-formulated feedback message can be powerful and may have a positive impact. To achieve this I recommend the following 10 do’s and don’ts:

10 Do’s

  1. Be kind & respectful
  2. Help create positive, safe environments at work and in the digital space
  3. Base comments on direct observations and facts, not rumours or hear-say
  4. Be specific and to-the-point (and try to separate multiple issues)
  5. Apply the feedback rules of constructive criticism (e.g. include positives and negatives)
  6. Try to use positive words such as appreciate, suggest, improve, assist, solution, like, right, thanks
  7. Before posting on public forums try to give direct feedback first
  8. Only say things on social media you would be prepared to repeat face-to-face
  9. Be prepared to listen and examine your own actions and behaviour
  10. Always keep the social media policies and code of conduct of your organisation or profession in mind.

10 Don’ts

  1. Don’t just list problems, propose solutions too
  2. Don’t psychoanalyse or judge people, instead focus on actions & effect
  3. Don’t give feedback before fully understanding the issues (there are always two sides to every story)
  4. Try to avoid using words such as should, never, always, why, you(r), but – and especially the stronger ones like dumb, fail, ludicrous, crazy, farce, ridiculous, shambles
  5. Don’t press the send/post button when you are upset, angry or tired
  6. Avoid using exclamation marks and capital letters midsentence (comes across as shouting)
  7. Avoid giving the same feedback multiple times
  8. Avoid irony and humour as it may be misinterpreted
  9. Don’t phrase feedback as a question
  10. Don’t speak for others unless you are a representative.

What is your preferred method of giving effective feedback?

Video: 10 Common mistakes in giving feedback (Source: Center for Creative Leadership):

No new governance model for GPs yet – Just what the doctor ordered?

A majority of members of the Royal Australian College of General Practitioners (RACGP) voted against the proposed modernisation of their 16-year old governance structure.

As the saying goes, in the end we only regret the chances we didn’t take – I sincerely hope this will not be one of them.

At yesterday’s RACGP member meeting 45.87 percent voted for, and 54.13 percent voted against the resolution. As a result the College will continue with its 13-member representative Council model.

The modernisation proposal was the result of a member-initiated governance review process that started 3 years ago. The proposed model would have introduced skills-based board positions and a representative council that would have better reflected the membership.

The two GP-led governance structures were set up to hold each other accountable. The model was designed to create a greater diversity of voices and thinking within the College.

But it wasn’t to be. Some of the arguments against the proposal were that the board of 7 members was too small, would contain non-GPs, and that the Board-Council model was wrong.

In the end RACGP members have decided and that needs to be respected. It looks like College records have been broken with regards to voter turnout which is always a good thing – and possibly the result of the technology which allowed members to participate in the online member meeting and vote from their digital devices anywhere in Australia.

I thought it was great to see so many GPs participating in the various discussions about governance and I’d like to thank everyone for their input.

The current model has served us well. It has allowed the RACGP to grow successfully over the past years – even though it has its flaws. At some stage the College engine will need replacement, but for now we’ll continue to drive with the old one. Time for reflection.

For the Doers of Deeds

A wise quote, one of my favourites, for all decision makers, leaders and ‘doers of deeds’:

“It is not the critic who counts; not the person who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the person who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly.

(Theodore Roosevelt)

Image source: Gladiator (2000 film), Dreamworks.

Talking governance: Getting rid of the disconnect

As the Royal Australian College of General Practitioners (RACGP) has been growing rapidly to 34,000 members, one of the big issues the College grapples with is the perceived ‘disconnect’ between the College and its members. A new proposed governance model aims to better connect the membership with College leaders.

Every organisation needs to review itself once in a while. The RACGP last did this 16 years ago so it’s about time for an organisational update. The proposal includes a GP-led, partly skills-based Board and a larger representative Council. The two structures would be set up to hold each other accountable.

Conflicted

One of the reasons behind the proposed governance model is that the old structure is somewhat conflicted. The problem all Councillors have had up to now is that they represent a group or state within the College on the one hand, and are directors on the other.

This can lead to Councillors having to take a position such as this: “The group I am representing wants A but, putting my directors hat on, I think we should do B in the interest of the organisation” (excuse the simple example to illustrate the point).

In other words: Council, at present, may be faced with situations where it is not able to represent the membership well because directors’ duties, by law, take priority. We can’t be good directors and good representatives at the same time – but are probably managing ok overall. However, this is one of the reasons why there is a perceived structural ‘disconnect’ in the organisation.

Fresh approach

The proposed new governance model splits these two functions (representation vs directorship) between a Council and a Board which will hold each other accountable. This is an essential, but much overlooked, purpose of the new model.

It will improve the representative function of Councillors by freeing them up to work purely on behalf of our members, while Board members (directors) will mainly look after the business side of the RACGP. This model is not new and is used in other colleges and not-for-profit organisations to manage this very issue.

I believe the proposed model breathes new life into the RACGP and general practice by creating a Council that will better reflect its membership. The model creates places for New Fellows as well as Registrars and will foster new leaders with a greater diversity of voices and thinking.

Over to members now – please vote on May 30.

Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

Talking Governance: Why board diversity is important for success

Should the Royal Australian College of General Practitioners (RACGP) be lead by GPs only or a more diverse mix of directors? In the lead up to the College’s general meeting on May 30 board diversity has been one of the topics of debate.

The composition of boards and councils of other Colleges has been used as an example but, more important than what has been happening so far, is where we will be in 5, 10 or 20 years time. A new Governance Model should prepare the RACGP for future challenges. This requires more than just looking at what other Colleges do today.

The Trump response

When President Donald Trump ordered a closure of the US borders to prevent Muslim refugees and visitors entering the country, the Scientific American republished How Diversity Makes Us Smarter by Katherine Phillips, Professor of Leadership and Ethics and senior vice dean at Columbia Business School.

“Simply being exposed to diversity can change the way you think”

Professor Phillips argues that diverse teams are more innovative than homogenous teams, referring to a body of research by organisational scientists, psychologists, sociologists, economists and demographers.

“Diversity enhances creativity”, she says. “It encourages the search for novel information and perspectives, leading to better decision-making and problem solving. Diversity can improve the bottom line of companies and lead to unfettered discoveries and breakthrough innovations. Even simply being exposed to diversity can change the way you think.”

Not-for-profit boards

Vernetta Walker of BoardSource, an organisation based in Washington supporting nonprofit board leadership, says that achieving diversity on a nonprofit board is a challenging but doable and essential task.

“Don’t assume everyone agrees about what diversity and inclusion mean for the board,” she says. “Before asking ‘How do we become more diverse?’ boards must ask ‘Why do we need to become diverse?’

“Boards with a good gender balance perform better”

The evidence to answer that question is coming largely from the field of gender diversity. Louise Pocock, Deputy Executive Director of the Australian Governance Leadership Centre says that several studies have shown that boards with a good gender balance perform better.

Although board diversity often refers to gender, momentum is growing that diversity is also about other aspects such as ethnic and cultural background, age, education, skills, experience and boardroom behaviours and attitudes.

“A board comprised of diverse individuals brings a variety of life experiences, capabilities and strengths to the boardroom,” she says. “There is greater diversity of thought and a broader range of insights, perspectives and views in relation to issues affecting the organisation.”

“Diversity of thought may, in turn, encourage more open-mindedness in the boardroom, help generate cognitive conflict and facilitate problem solving, and also foster greater creativity and innovation. It also reduces the risk of ‘group think’ – where board members’ efforts to achieve consensus overrides their ability to identify and realistically appraise alternative ideas or options in relation to the organisation.”

Reluctance to adapt

Sally Freeman and Peter Nash from KPMG Australia state that boards of tomorrow need to be nimble, and responsive to the rapidly changing environment.

The authors say that, in order to create board diversity it is important for boards to recognise their conscious and unconscious biases. The key to good diversity is getting the mix right to achieve a shared purpose – overcoming biases and assumptions – and then, how that mix is managed, which requires a chair who is adept at facilitating open and robust discussion. Boards don’t make a huge number of key decisions but the ones they do make need to consider the breadth of challenges and opportunities faced by the business.”

“Sometimes boards are reluctant to adapt”

“However, sometimes boards are reluctant to adapt. These are the boards that struggle to see how current social, environmental, geo-political or technological issues could impact their business – at times only recognising the consequences once it’s too late. There is further evolution required for those boards who take the view that these issues are ‘not real’ or do not impact their organisation. Diversity can assist with surviving this evolution.”

Long-term success

Suzanne Ardagh from the Australian Institute of Company Directors (AICD) says that board diversity is a component of a strong performing board and that research now shows that high performing boards are very much aware of how their board composition could contribute or detract from robust discussions, decision-making and ultimately, performance.

She says that a mindset shift is required to create more diversity on boards and that this is essential to set up an organisation for the future and for long-term success. “I would urge Chairs and Directors to make that change which society is seeking. Boards need to become more inclusive of the wide and diverse community that we are – it is an imperative that becomes more acute every day.”

“A mindset shift is required to create more diversity on boards”

Vanetta Walker advises boards to expand diversity, but limit board size. “Many organisations identify their needs for inclusiveness and diversity only to confront the biggest challenge of all: how to fill all those needs without weighing down the board with too many members. When a board is too large, some members may feel disengaged, and decision-making can become cumbersome.”

“Diversity really impacts decision-making, and good decision-making is good governance,” says CH2M Hill board member Georgia Nelson (see video). “Having diverse folks around the table really drives you to let go of conventional thinking. You get out of traditional boundaries and you begin to think about things in a different way, and by doing that innovation grows and prospers.”

Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

Sources:

Speak out!

I like North Stradbroke Island. Under the smoke of Brisbane lies this beautiful island with a lovely rural feel to it. At Straddie you can also swim with dolphins. My kids love it.

During our last camping trip, just as the children had come out of the water after a beautiful close-encounter with a dolphin, four women marched on to the beach, the leader of the pack carrying a bucket full of fish. They walked straight past the please-do-not-feed-the-dolphins sign, into the water, and began to draw the attention of the dolphins.

My children were watching, initially surprised. “Dad, what are they doing?”

“It looks like they’re hoping the dolphins will come.”

“But dad, they are not allowed to feed the dolphins!” My son became angry and suggested to kick the bucket over which was standing on the beach behind the women. Then the dolphins came. Followed by the spectators.

“Dad, tell them to stop!” This was the point where the situation became tricky.

While I was thinking of the social psychology experiments by Latane and Darley about the innocent bystander effect (the probability of help is inversely related to the number of bystanders) and Milgram (participants administered electric shocks without protesting), I realised that I needed to act soon to save the dolphins and my reputation as responsible parent.

But instead I said: “Ok kids, let’s go.” I started to pack our gear and walked back to the car, feeling really bad and trying to find excuses; it wasn’t my job after all to look after these dolphins and besides, feeding them a few fish more or less wouldn’t matter anyway.

In the meantime a crowd of about thirty people had gathered around.

While I opened the trunk of the car, I noticed the sign. It wasn’t one of those ‘Don’t feed the animals’ warning signs you see in the zoo; this was a friendly educational post with pictures and background information. It said that feeding dolphins changes their normal wild behaviour and turns them into beggars – which puts them at risk. This made a lot of sense of course, but it also triggered something inside of me.

“Maybe I should say something,” I said. This was received with a cheerful “Yes daddy!” by my kids, who suddenly saw a glimmer of hope: maybe dad wasn’t a typical scared grownup person after all!

Fuelled by a sense of righteousness I walked towards the group. But, as I passed the bucket, I noticed it was empty. A little voice in my head said: “You see, what’s the point? The damage is already done. You’re too late,” but as I looked over my shoulder I saw my children watching in the distance, jumping up and down with excitement. There was no way back.

With a loud voice I informed the group that their actions were illegal and that they could be fined, pointing out the big sign. The responses were quite interesting: some people immediately walked out of the water, a few in the direction of the sign. Others – with the bait still in their hands – looked at each other, unsure what to do next. Some chose to ignore my clearly unwelcome message.

On the way back to the camp my action was abundantly celebrated on the back seat. I realised that it had been a close call. A quote from Pam Brown crossed my mind: “Dads are most ordinary men turned by love into heroes, adventurers, story-tellers, and singers of songs.”

Are you a leader, a follower, or both?

To lead people, walk behind them ~ Lao Tzu

When talking about the success of organisations, businesses or political parties, we often focus on leaders and leadership, but what about the followers? I’d argue that followers are just as important. There are no leaders without followers, and good leaders often have great followers. Yet, followership is an undervalued concept.

Robert E. Kelly was one of the first researchers who pioneered the theory of followership. He proposed 5 categories of followers:

  1. The sheep, who are passive and look to the leader for directions and motivation.
  2. The yes-people. They are more active and positive, but still look to the leader for direction and vision.
  3. Alienated followers think for themselves, but lack positivity. They often come up with many reasons why their leader or organisation is going in the wrong direction.
  4. The pragmatics are fence sitters. They will follow, but only if others follow first and it is clear where the leader or organisation is heading.
  5. Star followers are positive, independent thinkers. They are effective followers who will support their leaders if they agree, but will also challenge leaders if they disagree, offering constructive feedback.
Followership matrix
Followers in the upper right corner of the matrix are just as valuable as leaders. Source: In Praise of followers (Kelly, 1988)

Are you a good follower?

The success of an organisation depends partly on how well its leaders lead, but partly also on how well its followers follow. Most of us spend the majority of our time following others in one way or another. But we’re not always good at it. So how do you know if you are a good follower? And can we become better at it?

Star followers are sometimes viewed as ‘leaders in disguise’. According to Kelly, effective followers share the following qualities:

  • They think independently and can work without close supervision
  • They are committed to their organisation and to a purpose, principle, product or idea
  • They build their competence and focus their efforts for the greatest impact
  • They are courageous, honest, and credible.

Effective followers keep their leaders honest. Yet, followership has a negative connotation, almost to the point where it is seen as a weakness instead of a strength. But being a follower is more than just doing what you’re told. Kelly: “(…) our stereotype is ungenerous and wrong. Followership is not a person but a role, and what distinguishes followers from leaders is not intelligence or character but the role they play.”

Followers are leaders

In addition to the many available leadership courses, we should consider creating more followership training opportunities, focussing on topics like:

  • Improving independent, critical thinking
  • Self-management
  • Disagreeing agreeably
  • Building credibility
  • Aligning personal and organisational goals and commitments
  • Acting responsibly toward the organisation, the leader, coworkers, and oneself
  • Similarities and differences between leadership and followership roles
  • Moving between the two roles with ease.

If an organisation does not succeed, often its leaders are publicly criticised or changed. But there are alternatives. Having read Kelly’s classic publication ‘In praise of followers‘, it seems that becoming a better follower is an empowering experience.

Online therapy? It works.

Mental health care is not accessible to everyone. It’s a fact that less than fifty percent of people who need treatment actually get it. But access to an internet connection is available to most people. So it makes sense to offer more health services online.

Although the opinions are divided about Dr Google, health experts now agree on one thing: internet therapy for many mental health problems works.

5 benefits

E-mental health is a broad term used for mental health services delivered via internet programs, telehealth, mobile phone applications and websites. There are five benefits:

  1. It can be accessed anytime and anywhere
  2. There are no or low costs to patients
  3. It fills service gaps
  4. It reduces wait lists
  5. It’s cost-effective to the health system.

Some patient groups will benefit less from online therapy, such as people with complex or severe mental illness, personality disorders, substance dependence, or people who have a higher risk of self-harm or suicide and need urgent clinical management.

Who is it for?

E-mental health probably works best for people at risk of illness or people with mild to moderate symptoms. It is used in many ways including first-line treatment and relapse prevention. Evidence shows that it can be as effective as face-to-face therapy. Using the services in combination with regular visits to a doctor is ideal.

If you want to know what e-mental health services are available and how reliable they are, click here (free registration). The site uses a smiley system to show how much evidence there is that a service works.

More information and free e-mental health training for health professionals can be found here. The RACGP has published a handy e-mental guide for GPs.

Have a look at the video as well. Before you use any of the online services it is recommended to check the terms and conditions so you know what happens with the personal information you provide.

Sources: