Psychological Fitness Foundations, Part 5 - Autonomy of Team

Continuing our series on psychological foundations for physician mental fitness (autonomy, connectedness, and competence) via self-determination theory (SDT), we are rounding out the final domain of physician autonomy this week – Team. Interestingly, over the past two weeks, many of my examples demonstrated ideas for autonomy of time, task, and technique actually involved team. Teamwork is interwoven into medicine, so it makes sense that it would impact the other three arenas.

There are top-down organizations that give little say to physicians in forming their team, how their team operates, or what the team has control over. As a result, those types of organizations miss out on harnessing the power of a physician's sense of ownership and all the amazingness and creativity we bring when we are "all in." And ultimately, they create atmospheres for physician disengagement and the detriment it brings. SDT involves understanding that autonomous motivations (healthier and more effective internal and intrinsic motivation) are supported when autonomy, competence, and relatedness are supported. It's a well-known fact that the carrots and sticks approach to motivation produces lower quality motivation for complex situations like patient care and graduate medical education. It can lead to compliance (which often breeds resentment) but it doesn't often lead to engagement without individuals sensing a source of autonomy as part of the team. 

Autonomy in this realm can look like having input on hiring, firing, and promoting; choosing a team for a project, shared decision making on delegation; and empowering the team to make real change. You know by now that I like to offer examples, not to set some kind of standard, but to get your own brain ideas flowing of how to find your own agency. (After all, it is a psychological foundation for mental fitness.)

In week 3, we looked at an example of support for time-autonomy -a healthcare system left local decisions of office hours and call coverage to our medical director. He was skilled in a collaborative leadership style, and we would meet together to discuss the pros and cons of details such as staggered lunchtimes, start times, and Saturday coverage. And we worked together with a common purpose as a supportive team to make the office run well, maximizing everyone's personal desires while balancing the group's needs as a whole. It fostered a sense of collaboration instead of toxic individuality - which is the predictable outcome when the physician feels more like a cog in the wheel without any say.

It was similar to the example in week 4 of our academic department, as an example of task-autonomy - our PD gave us the ability to shuffle roles/hats to better align with our passions. It also allowed for the realization and great conversation that there were roles that everyone wanted and ones that really no one wanted and how to make that equitable. Morale was improved.

Also in week 4, we also looked at an example of a healthcare system leaving decisions to the local office regarding staff utilization. In addition, our local medical director and office manager invited all the providers' voices in staff change decisions. As a result, we were as involved with the interview process for the back-office staff. We each hired our own MA. By doing so, it improved our sense of ownership and engagement and teamwork.

I don't believe every physician must have complete autonomy with every decision regarding hiring/firing/remediation, forming or choosing a team, or even having control of how a team will function. In the academic setting, the scheduling and residency support staff worked closely with the medical director to set up the four patient care pods. I didn't get to choose my pod mates, but we were given time with the strategic design – 2-3 attendings, 3 R3s, 3 R2s, 3 R1s, 3 MAs, and a scheduling support staff for regular meetings. We chose the agenda, had some level as a team of how our pod functioned, and modeled for residents skills in team building, having difficult conversations, and responding well to feedback. In other words, no autonomy in forming the team but a modest amount of how it functioned and a modest amount of empowerment to make decisions. And it was largely very successful and rewarding.

Now for the thought work:

Where do you already have autonomy in your team, even if at first glance you see none? Think carefully. Be the detective – thinking this way puts your brain on task, and it likes to give you answers if you support it in its mission. That, alone, can ease some frustration. If you find you’re resistant to this exercise, pause and figure out why? What is in it for you to not find the areas that you control? Are you afraid that means you’ll be endorsing the lack of agency that does exist? Is that really true? Are you just wanting to stay closed off because it’s easier to villainize everything rather the see the full truth - the good, neutral, and the bad? How does that position affect your emotions and your experiences of the day and job? What is it costing you?

Now, where might you get to have some say that you're not taking advantage of the opportunity? Will it come with more responsibility, effort, or not? Do you have the bandwidth or not? Weigh all the options before going through a door that might add more to your plate than you're willing. If you want it, then do what it takes and remember that you are choosing what comes with it.

Where do you want some control or ability to choose teams, staff, how they function, the power they have, but it's not available? Brainstorm without judgment ten potential ways to get that. This will help uncover some limiting beliefs if you can then look at them one by one and ask, "How can it be possible?"

And last, where can you find appreciation for the way things are in which you don't have control, even if it's not preferred? Maybe you can appreciate that in a residency program, with nearly 48 part-time providers made up of primarily learners, that no scheduler could manage so many individual preferences? Or acceptance that it's this way for now? The hospital system is inflexible in how many days I must work. I don't like it. I think they could be more open-minded to a 4-day workweek AND I accept that it is this way for now. What are the reasons I choose to stay in this system? I love the staff, the patients, the location, etc. I choose to accept to work here, this is what it looks like currently. This is how you find agency in such a setting. It's over the perspectives you choose. 

One last tool for offices and health care organizations is Dan Pink's autonomy audit. 

Okay, residents and fellows, I have not forgotten the issues surrounding autonomy or gaining agency in your setting. I will follow through with my promise and attempt to tackle it next week.

Have a joy-filled week! Tonya

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