Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice
Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice
Elizabeth A. Rider
MaryAnn C. Gilligan
Lars G. Osterberg
Debra K. Litzelman
Amy B. Weil
Dana W. Dunne
Janet P. Hafler
Natalie B. May
Arthur R. Derse
Richard M. Frankel
Ph.D. 6 12
William T. Branch Jr
0 Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin , Milwaukee, WI , USA
1 Institute for Professionalism & Ethical Practice, and Division of General Pediatrics, Department of Medicine, Boston Children's Hospital , Boston, MA , USA
2 Center for Bioethics and Medical Humanities, Institute for Health and Equity, Medical College of Wisconsin , Milwaukee, WI , USA
3 Department of Pediatrics, Harvard Medical School , Boston, MA , USA
4 Department of Internal Medicine, University of North Carolina School of Medicine , Chapel Hill, NC , USA
5 Division of General, Geriatric, Palliative and Hospital Medicine, Department of Medicine, University of Virginia School of Medicine , Charlottesville, VA , USA
6 Department of Medicine, Indiana University School of Medicine , Indianapolis, IN , USA
7 Department of Medicine (Teaching), Stanford University School of Medicine , Palo Alto, CA , USA
8 Department of Pediatrics, Yale University School of Medicine , New Haven, CT , USA
9 Department of Internal Medicine, Yale University School of Medicine , New Haven, CT , USA
10 Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine , Atlanta, GA , USA
11 Department of Emergency Medicine, Medical College of Wisconsin , Milwaukee, WI , USA
12 Education Institute, Cleveland Clinic , Cleveland, OH , USA
CONCLUSIONS: While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.
humanism; organizational culture; faculty development; burnout; leadership; values; compassionate healthcare
BACKGROUND: Changes in the organization of medical
practice have impeded humanistic practice and resulted
in widespread physician burnout and dissatisfaction.
OBJECTIVE: To identify organizational factors that
promote or inhibit humanistic practice of medicine by faculty
DESIGN: From January 1, 2015, through December 31,
2016, faculty from eight US medical schools were asked to
write reflectively on two open-ended questions regarding
institutional-level motivators and impediments to
humanistic practice and teaching within their organizations.
PARTICIPANTS: Sixty eight of the 92 (74%) study
participants who received the survey provided written
responses. All subjects who were sent the survey had
participated in a year-long small-group faculty development
program to enhance humanistic practice and teaching. As
humanistic leaders, subjects should have insights into
motivating and inhibiting factors.
APPROACH: Participants’ responses were analyzed using
the constant comparative method.
KEY RESULTS: Motivators included an organizational
culture that enhances humanism, which we judged to
be the overarching theme. Related themes included
leadership supportive of humanistic practice, responsibility to
role model humanism, organized activities that promote
humanism, and practice structures that facilitate
humanism. Impediments included top down organizational
culture that inhibits humanism, along with related
themes of non-supportive leadership, time and
bureaucratic pressures, and non-facilitative practice structures.
One of medicine’s great traditions is humanistic care of those
who are suffering.1–6 Deep-seated personal commitment to
incorporate human values like caring, compassion, and respect
into every health care relationship defines medical humanism
and is imbedded within the fabric of medical
professionalism.2–4,7–15 Yet, while remarkable technological advances
have influenced what we can do to patients, much of what
patients want and expect from their doctors remains within the
humanistic realm of being with patients when they are
suffering. This includes listening, helping with difficult decisions,
and navigating their illness trajectories.1–15
Healthcare has evolved rapidly, resulting in significant
changes in organizational and practice environments.
Economic forces and commercial interests now drive the
healthcare industry to focus on clinical productivity,
efficiency, performance metrics and regulations, pushing physicians
to see higher volumes of patients with less time for each.16,17
Time spent in meaningful interactions with patients has
diminished, compromising the traditional patient–doctor
Over half of US physicians now experience professional
burnout.18,19 Healthcare professionals’ stress and burnout
inhibit forming therapeutic relationships and detract from the
patient experience and quality of care.20 Incongruence
between personal and health system values and work overload
contribute significantly to physician burnout, whereas value
congruence significantly predicts professional efficacy in
addition to well-being of physicians.18,21
Medical educators’ efforts to counter the decline in
humanistic care have largely focused on cultivating humanistic
attributes in individual physicians.22,23 Such efforts have included
curricular and programmatic interventions, such as courses
teaching ethics and professionalism, mindfulness, and
wellbeing and group support.24 At the same time, it is clear that
organizational factors play a central role in physician stress
and the development of burnout.21,24 Organizational factors
influence how individuals act, their responses to new
situations, what they pay attention to, and significantly impact
patient safety and quality of care.25,26
For these reasons, we studied factors at the organizational
level that may be key to either promoting or impeding the
compassionate, humanistic care that most physicians strive to
deliver. In this qualitative study, we asked physicians at eight
medical schools (Box 1), who had participated in a one-year
small-group faculty development program in humanism,27–31
to identify organizational-level factors that either promoted or
impeded their ability to practice humanistically. We chose to
study physicians who were promising and respected teachers
with an interest in humanism, whom we expected would have
insights into achieving humanistic practice.
Box 1 Institutions Participating in Program and Survey
Harvard Medical School/Boston Children’s Hospital, Boston, MA
Indiana University School of Medicine, Indianapolis, IN
Medical College of Wisconsin, Milwaukee, WI
Stanford University School of Medicine, Stanford, CA
University of Colorado School of Medicine, Denver, CO
University of North Carolina School of Medicine, Chapel Hill, NC
University of Virginia School of Medicine, Charlottesville, VA
Yale University School of Medicine, New Haven, CT
PARTICIPANTS AND METHODS
We surveyed all graduates of our one-year faculty
development program at the eight schools and received responses
from 68 of 92 faculty members (74% response rate). We
designed the program to enhance their humanistic teaching
and role modeling.27–29 Site leaders at each school (who are
also authors of this paper) selected the participating faculty
from a pool of applicants whom they judged to be promising
clinical teachers and practitioners.27–29 Program participants
attended twice-monthly experiential and reflective learning
sessions for one year.27–29 All consented to the qualitative
study, which was exempted and/or approved by the
Institutional Review Board at each institution.
The 68 respondents included 40 (59%) women, 46 (69%)
people under the age of 45, and 58 (85%) junior faculty
members (instructors or assistant professors). About half of
the respondents were primary care internists, pediatricians, or
family physicians with the remainder being clinical specialists.
The response rate was 11/16 from school #1, 10/10 from #2,
15/17 from #3, 10/10 from #4, 10/12 from #5, 2/17 from #6,
3/3 from #7, and 7/7 from #8. The low response rate from
school #6 likely reflects the fact that reminders were not sent to
that school’s participants, and the low total number for school
#7 reflects a leave of absence by the site leader.
Program participants at the eight schools were provided a
working definition of medical humanism taken from the
Arnold P. Gold Foundation2 on which to base their answers to
our survey. Medical humanism was Bcharacterized by
respectful and compassionate relationships among physicians, their
patients, and other members of the healthcare team that
flourishes within a humanistic culture.^ Humanistic healthcare
professionals were described as those who Bdemonstrate
integrity, excellence, compassion, altruism, respect, empathy,
and service.^ Program participants were asked to provide
written reflective responses, preferably a paragraph in length,
to two prompts: (a) What institutional or specific
organizational unit-related factors promote humanism for you and
others? and (b) What institutional or specific organizational
unit-related factors inhibit or pose barriers, to humanism for
you and others? Word counts of the reflective responses
averaged 69.6 words (95% confidence 62.6–76.6 words), median
66.0 words, range 3–189 words. Rapid scan of responses by
two investigators (WTB and RMF) revealed insightful data
worthy of analysis.
We employed the constant comparative method32–35 to
analyze the 68 program participants’ responses. Four investigators
(WTB, MAG, LGO, EAR) met on six conference calls to
analyze responses. Each respondent’s reflection was read
aloud on the call, after which the group discussed and reached
consensus on the major theme(s) of that reflection. The
investigators kept track of themes, and iteratively revised,
combined, and/or refined them by consensus as they compared
additional sets of writings to those previously analyzed.
Illustrative quotes were also identified and grouped under each
Investigators agreed that they were coding the themes
consistently after comparing their interpretations by the third
conference call. By the sixth call, all participant responses had
been analyzed and no additional themes were identified. The
investigators concluded that they had reached thematic
saturation and consensus agreement on the themes. Another author
(JPH) independently reviewed and agreed with the choices of
themes and related quotes. Final themes are listed in the
Motivating Factors for Humanism
Organizational culture was the overarching theme that unified
the motivating factors within institutions. Four additional
themes were related to, or influenced by, organizational
culture: leadership supportive of medical humanism; the
responsibility to role model humanism; organized activities designed
to promote humanism; and practice structures that facilitated
humanism. We noted that many statements pertaining to
motivating factors described individual acts and relationships, or
participation by small groups of study physicians in activities
designed to shore up humanism:
An organizational culture of humanism: Respondents
described humanistic culture as being maintained by
caring relationships that reflected the study physicians’
values. Relationships were about how colleagues
treated one another and how they were treated by
administration. For example, study physicians described
having Bcolleagues who are interested in discussing
humanism in medicine as a way of supporting each
other,^ and Bcolleagues [with whom] I can be
vulnerable^; another described a Bprofessional culture
which supports respect, collaboration, and
compassion among professionals working together. This
culture then hopefully Btrickles down^ to the doctor
Respondents described a level of trust in relationships
that encompassed mutual compassion and acceptance
of vulnerability. The high level of mutual support
between individuals within this culture was illustrated
poignantly by the practice described at one institution
of calling B… a ‘code lavender’ that we can call where
the chaplain comes to deliver a message, a cup of tea,
or just some peace for a particularly challenging day.
We debrief every death at the time of the event with all
staff involved.^ The sum of these individual
relationships characterized by humanistic values 2,12
contributed to the culture. Wrote one participant, BI am
fortunate that humanism and professionalism are core
values in my department.^
Leadership supportive of humanism: An illustrative
quote described a division chief who exemplified the
qualities that study participants associated with good
BHumanism is promoted within my division by our
division chief. She treats all faculty fairly and with
respect. I believe that she sets the tone for our entire
division. Because of this, we are better able to work as
a team within my division—we support each other
through difficult times and cover for each other’s
patients whenever necessary. We are given a reasonable
amount of time to see patients and a reasonable
number of clinic sessions per week. It is my goal as a
clinical chief to maintain this degree of supportive
environment for all staff who work in our clinic.^
Responsibility to role model humanism: Faculty
members reflected that they were always role modeling
humanistic qualities for learners. One participant
wrote, B… words and actions, be they large or small,
are often being viewed under a microscope by learners.
[We have] many young and impressionable learners
and it is [our] responsibility to teach them how to
provide compassionate care in even the most difficult
Another participant described characteristics of a good
humanistic role model: BThe best physicians were
those that not only had extensive knowledge and
experience, but also those who were humble, listened to
everyone’s input, and were comfortable seeking others
advice when needed. Role modeling such behavior is
Yet another reflected that good role modeling could
create a ripple effect throughout the organization: BAs a
leader, when I show humanism to my faculty, I realize it
makes them more likely to show the same to their
patients, learners and colleagues … When those to
whom I report show humanism to me, this helps me
feel that my values are shared with them.^
Organized activities designed to promote humanism:
Study physicians believed that some humanistic
educational programs helped shape the organizational
culture because they, Ballowed for deeper discussions with
colleagues,^ and Ballowed the formation of a
community of professionals that would reinforce the
importance of treating others with respect.^ Examples
included a residency curriculum on humanism, programs
for underserved populations, reflective writing
exercises, regularly scheduled interdisciplinary forums
(e.g., Schwartz Rounds), medical student electives
fostering compassion and self-knowledge (e.g., The
Healer’s Art, Reflection Rounds), and our humanistic
faculty development program.27,36–40
Practice structures that facilitated humanism: A
workflow structure that allowed adequate time to build
relationships with patients was judged essential. A
participant opined, BPatient workload that is
reasonable and conductive to spending the time you would
like with each patient rather than always being in a
Policies creating structures that facilitated humanistic
practice also provided protected time for teaching,
adequate staffing to assist physicians with their work,
and adequate support available from social workers,
case managers, behavioral health professionals, and
Elements of the physical environment that facilitated
humanistic culture included co-location of practicing
faculty members near their medical assistants and
social workers; having a clean and quiet team room;
ample chairs; and, in one instance, art work and music.
Barriers to Humanism
An inhibiting organizational culture disrupted humanistic
practice. Additional themes contributing to an inhibitive
culture included the following: unsupportive leadership;
inadequate time with patients; bureaucratic pressures; and
nonfacilitative practice structures. Some barriers resulted from
individual actions, but often barriers reflected system-related
factors, business practices, and bureaucratic requirements.
Inhibiting organizational culture: An inhibiting
organizational culture was described by two participants as
occurring when, Bcolleagues treat patients or patient’s
concerns with disrespect or interact…in an arrogant or
dismissive fashion,^ or where Bthere is not much of a
culture of sharing personal stories and recognizing the
humanity of colleagues.^
Sustaining humanistic culture required unified efforts
from faculty members, leaders, and staff that often did
not occur. One participant put it this way, B[It is…
difficult for me to gain trust when some members of
my team are uncaring.^ Behavior that overtly impeded
humanism was sometimes described in terms of,
Bdisruptive personalities that bully colleagues and
Several respondents pointed out that maintaining a
humanistic culture was an ongoing process that should
Bnot be taken for granted^ and required unremitting
efforts. Leaders should, Brecognize that we need to be
nourished in mind and spirit.^
Unsupportive leadership: For leadership to be out of
touch with the day-to-day struggles of physicians, or to
make productivity the overriding focus, impeded
humanistic culture. One participant summed it up this
way: BI think leadership…do[sic] not always listen to
what a provider requires to be humanistic when it may
compete with another goal such as efficiency or
increasing the number of patients that are seen,^ and
when the leadership is Bprioritizing RVUs over patient
centered care.^ Thus, excessive focus on productivity
was of special concern when done at the expense of
physicians’ ability to deliver humanistic care. As one
writer stated, BWhen the focus is on productivity, when
the institution provides no tangible value for taking the
time or initiative to be humanistic, a barrier is slowly,
but inevitably built.^
Participants identified unrealistic expectations and
inadequate support personnel as creating an unsupportive
environment. For example, one participant stated, BAt
times, the administration of the hospital doesn’t have a
thorough understanding of the struggles that are going
on in various care settings of the institution. Physicians
can be asked to adopt too many initiatives at once
leading to frustration and negativity. In addition, some
treatment areas receive less support/resources in terms
of nursing or administrative personnel. Being
understaffed can create an environment of stress and
negativity—leading to a less humanistic culture within
Unsupportive or out of touch leadership was resented.
One study participant wrote that it was, B… about not
being respected—not understanding or realizing the
stresses I am going through.^
Time and bureaucratic pressures: Many respondents
mentioned Btime^ as a barrier. Workflow that provided
insufficient time with patients and pressure to generate
RVUs often drove dissatisfaction as reflected in the
BTime and bureaucratic pressures are important
factors. Adequate time needs to be given for patient
contact, record-keeping, ancillary contact, consultation,
self-care (meals, breaks) and breathing space between
times of patient-contact.^
BThe whole approach to reimbursing physicians using
RVUs, a system that is biased toward doing procedures
and not spending time with patients…I think this is the
biggest barrier right now to treating people
Non-facilitative practice structures: The study
physicians lumped together bureaucratic pressures, out of
touch leadership and poorly structured practice
workflow as producers of stress, frustration and
dissatisfaction. One writer commented, BToo many
responsibilities, no admin support, disconnected units, parts
that don’t communicate with others.^
Physical space was sometimes viewed as
nonfacilitative. A participant identified, Bsmall hospital
rooms, no family rooms, team rooms that are away
from the patient care areas.^
The EMR was often singled out as a barrier. BOur EMR
does more to retard humanism than any recent change
in practice, from the mere reality of looking at a screen
rather than the patient in the room, or knowing you’ll
spend twice or 3 times the time documenting as you
could possibly spend caring for or ‘hearing’ the
Our study’s results highlight the effects of organizational culture
on humanistic medical practice. We know that organizational
culture influences patient safety, quality of care, medical errors,
patients’ and families’ experiences of care, physician
satisfaction, and burnout.21,24,41–43 Our qualitative study adds real life
meaning to these reports by linking them to the lived
experiences of its study physicians. Study physicians named
supportive colleagues, influential role models, engaged leaders, and
adequate time to build relationships with their patients as factors
that sustained their medical humanism. Because it highlighted
discordances between individual physicians’ goals to build
therapeutic relationships with their patients, and prevailing
system barriers and bureaucratic requirements, the study suggests
the need for transforming organizational culture to make it more
sustaining of humanistic practice. Strategies to reinforce the
humanistic and relational aspects of care and their alignment
with an organization’s values12,23,27,38,39,41,42,44–46 are needed if
an organizational culture of humanism is to flourish.43,47–49
Although often assumed to be important in shaping
performance, organizational culture can be difficult to define.48 One
widely shared viewpoint defines organizational culture as a
pattern of shared assumptions and correct ways to perceive,
think, and feel in relation to problems.47,48 Our study
physicians added that culture reflected the qualities of their
relationships with colleagues and patients. Relationships operated
through people within their organizations to shape and
influence the other factors, such as workflow designs, and the
alignments of leaders’ and physicians’ goals and values.49
Figure 1, reflecting the themes expressed by our study
physicians, provides a graphic representation of positive
components in organizations that were identified as contributing to an
organizational culture of humanism. Our study suggested
ways to achieve this humanistic vision, but it also implied
blind spots and inadequacies that must be overcome by
physicians and leaders who wish to change their organizations for
It Is Time for Organizational Change
The study uncovered high levels of physician dissatisfaction
with a number of health care systems. We attribute the
dissatisfaction to incongruence between the study physicians’ core
humanistic values and the current business climate and
bureaucratic requirements to which they are subjected.45,46 The
study physicians described a clash of disparate cultures.50–53
These included the tone and attitude of some administrators,
the metrics used to judge physicians’ performance and, most
of all, the pressures of time and numbers of patients seen.
Resultant stress, frustrations, dissatisfaction, and burnout call
for major change.21,30,43–45,53
Leadership is Key
Supportive leaders should effectively model change-behavior
and/or articulate a clear vision of necessary changes.47 Study
participants described good leaders as Bwalking the talk,^ by
treating people fairly and respectfully, promoting and valuing
humanism in patient care, and advocating for adequate time
with patients, better use of teamwork, and sufficient support
staff. Good leaders protected faculty members from unrealistic
or intrusive requirements and productivity pressures. Not all
leaders were described this way; some were Bdisengaged^
from the physicians’ struggles.
We also think that more is required of today’s leaders than to
bolster equanimity within an apparently unsatisfactory status
quo. Experts on organizational behavior identify leadership as
a crucial element to create, sustain and, at times, change
organizational culture24,47 If elements of a given culture
become dysfunctional, B… leadership has to surmount culture
and speed up the normal evolution with forced cultural change
It Is Not All Up to the Leaders
Study participants identified their individual role modeling as
an effective way to foster humanistic practices.54–56 They
participated in educational programs with like-minded
colleagues designed to enhance humanism, strengthen resilience,
and promote well-being.6,27,36–40 Less formal activities
included family conferences, multidisciplinary case
conferences, check-ins, and opportunities for story-telling. As an
additional example, Indiana University School of Medicine
employed multiple small steps that called attention to
respectful, collaborative relationships as the foundation of humanistic
interactions.57,58 These are downstream activities that may
assist physicians in dealing with the stress without altering
This leads to the observation that physicians, like those we
studied, were acting individually to be humanistic but were not
joining collectively with their leaders to create system changes
and an organizational culture that delivers excellent, safe,
efficient care and preserves humanistic values.46 Physicians
may be overlooking the basic principle of working together to
create organizational change.
Complex organizational cultures are co-created by
administrative and managerial leaders, physicians, and other healthcare
professionals, staff, and stakeholders. We will focus here on
organizational change strategies as a prelude to changing
practice structures. The first step in positive change is for
physicians, leaders, and all stakeholders to reach a consensus
on the organization’s mission, strategy, and goals.47 The
challenge begins with each organization’s leaders. Our study
physicians described some leaders as good role models and
supportive advocates, and others less so, but strikingly absent was
language describing the leaders as change agents, articulating
a clear vision for how to reshape and improve the
organization.12–15,41,42,59 Our observations of study physicians’
responses to our survey lead to a related question. Although
the study physicians identified individual relationships as well
as programs and practice structures that promoted humanism,
they never mentioned sharing a common vision. We suggest
that a shared vision of the practice is a necessary first step to
bring the elements of Figure 1 into being. Faculty members,
leaders, other healthcare professionals, and staff may then
collectively shape their organization and its culture to achieve
their vision, which ought to encompass a community of
practice congruent with professional values and maximally
beneficial to patients. We judge our study physicians to be deeply
engaged with their individual patients and humanistic
relationships with learners and colleagues, yet potentially missing a
strategic organizational focus. This applies equally to leaders.
Both groups need to build their relationships and work
together to effectively produce desirable structural changes that
create and preserve humanism in organizations. In the
Appendix online, Table 1, we describe attributes and best
practices that might characterize a humanistic organization.
Our recommendations are based on this study’s results and our
collective experience as medical educators. Specific details for
re-structuring medical practices to enhance physician
satisfaction are being tried and studied.60,61 We thought it premature
to propose concrete changes in the workflow, team
functioning, and other practice structures in Table 1 in the Appendix,
online. They are important subjects for continuing research.
Because the study participants were volunteers who completed
a year-long program in humanism, they may not represent all
faculty members within or outside of teaching institutions.
Health care organization was not a topic in our faculty
development course on humanistic role modeling and teaching.
We doubt that our course primed our study physicians’ views of
organizational motivators and barriers to medical humanism.
This was a qualitative study subject to selection bias. However,
as promising and respected teachers with an interest in
humanism, we expected the study physicians to have insights and to be
humanistic leaders who could suggest the way forward for their
organizations. Although some of our conclusions may be less
generalizable to practices and physicians outside of teaching
environments, we believe that our findings, including, for
example, the importance of working together to establish a culture
of humanism, explicitly role modeling humanistic practice, and
providing supportive practice structures, should be applicable to
a variety of patient care settings. Our qualitative approach
uncovers root causes and processes, a necessary step for
improving practices. To confirm our results would require a larger
study using quantitative methods.
Efforts to counteract physician dissatisfaction, burnout, and
other negative consequences of recent changes in medical
practice have largely focused on supporting and cultivating
humanistic attributes of individual physicians.62 Our study
findings suggest that addressing organizational factors is at
least equally important. Without positive organizational
changes, actions focusing only on individuals are unlikely to
achieve physician satisfaction, resilience, compassion, and
well-being along with optimal patient care.
Corresponding Author: William T. Branch, Jr, M.D.; Division of
General Medicine and Geriatrics, Department of Medicine Emory
U n i v e r s i t y S c h o o l o f M e d i c i n e , A t l a n t a , G A , U S A
Funding Information The authors are grateful to the Arnold P. Gold
Foundation [grant number FI-14-008] for generous support of the
Compliance with Ethical Standards:
Prior Presentations: None to date.
Conflicts of Interest: The authors declare that they do not have a
conflict of interest.
IRB Approval or Exemption: Yes.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license, and indicate if changes were made.
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