Motivation and Emotion, VoL 19, No. 3, 1995

Satisfaction in Generalist Care: A Systems Approach

Michael E Slag 1 The Duluth Clinic

By understanding that community benefits are the aim of the health care system it is possible to markedly increase the professional satisfaction of physicians. The principles of continuous quality improvement are especially helpful and include (1) understanding the interdependencies in a system of care, (2) understanding methods of knowledge and prediction, (3) understanding variation, and (4) understanding individual and organizational psychology.

In recent years, generalist physicians have often felt frustrated and unsat- isfied with the role that has developed for them in the current U.S. health care system. The value and desirability of the work of generalist has become overshadowed by the perceived values and contributions of specialists and subspecialists, both internally within the field of health care and as per- ceived by those external to the health care system.

The dissatisfactions in primary care as practiced by generalists stem from many disjunctions in the way current health care is delivered. There seems to be less extrinsic reward for the generalist. The heroes in health care seem to be the daring proceduralists with their high-drama rescues. Financial resources go to some of those same people. Even patients some- times want to "see the specialist." The rewards and value placed on the generalist's knowledge and skills regarding human function and disease, along with his or her knowledge of human interactions, seems to have slipped. For some doctors, this causes their own sense of intrinsic reward for their work to be challenged.

1Address all correspondence to Michael F. Slag, M.D., Duluth Clinic, 400 E. 3rd Street, Duluth, MN. 55805.

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0146.7239/95/0900.0211507.50/0 @ 1995 plenum Publishing Corporation

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How can the satisfaction that was once present for the generalist be rekindled? The basics have never changed:

• The potential to make a significant positive impact on the lives of others

• The potential for personal and intellectual growth • A depth of personal and social interaction uncommonly available

to most individuals in society • Significant societal respect • Significant financial rewards when compared to the rest of the

working world

The aim of this article is to show how the principles of continuous quality improvement (CQI) may contribute to greater satisfaction for gen- eralist physicians.

The theories of continuous quality improvement may offer a way of change for the better. These theories have several core tenets (Deming, 1993).

The first is an awareness of the community need. By this we mean that the health care profession exists to serve needs in the community, which include receiving information, reassurance, and assistance with re- storing or maintaining health. These needs have led to health care in all of its forms.

The second major component is the appreciation of a system. This means that individuals who function as a part of the health care delivery system need to understand that they are interdependent upon each other. It is exceedingly unusual for a single individual to be able to dramatically impact the health status of another individual without interacting with many other aspects of health care delivery, such as other providers of health care, institutions that deliver components of health care, and the members of an individual's family.

The third major component of CQI is theory of knowledge. A theory of knowledge is an understanding of how individuals in organizations learn, and then knowing how to address your actions in ways that make it likely that learning can happen at every level, from interactions between two peo- ple, up to and including interactions between many people.

The fourth component is variation. The concept of variation is simply to understand that in all biological systems, including most social systems, no single measurement remains steady over a significant period of time. However, it is also clear that whatever is being measured typically will fall within a common range of variation. This range of variation then describes the normal pattern for whatever factor is being observed. The concept of statistical thinking is based upon the fact that decisions are best made when

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data are available and analyzed to their most useful resolution. This sug- gests that decision making, either at an individual level or at an organiza- tional level, occurs after the study of facts and application of theories that allow predictions of an outcome.

The fifth major component of continuous quality improvement phi- losophy is a theory of individual and organizational psychology. These con- cepts ask one to understand how and why people are motivated, whether at a personal level or at an organizational level. For effective interactions to occur, there must be a knowledge of this important component.

The generalist is ideally trained to think in these ways. By becoming refocused on the concept of being a coordinator and a communicator, the generalist is able to take a central position in the health care delivery sys- tem. This is in addition to already having a basic skill set that allows the possibility of dealing with a very large number of human maladies.

Early in our training we are taught to think of systems. There is a wonderful interrelationship of all of the human body's subsystems, each highly interrelated and interdependent. As time goes on, however, many physicians, unlike the generalist, become so subspecialized so as to lose sight of this. The focus becomes narrower, and the larger systems are not seen or are relegated to a more secondary status: "My system is the most important."

We often also fail to see that other systems in which we work have the same interdependence and interrelatedness. For many reasons, physi- cians do not see their day-to-day work metaphorically as the functioning human body, no part of which functions for long without the health and support of other parts.

In addition, we can expand our knowledge of the scientific method and apply it to the systems we work in. As an end result, not only is there an opportunity for our patients to get better, but we also have the ability to work on the system that provides those results and improve it also (Ber- wick, 1989).

How can this transformation occur? The first way is to become aware of the systems that we work in. Who do we rely on in order to get our work done? Who relies on us to get their work done?

By asking these fundamental questions, we open the door to a new concept of understanding what information and services we need in order to accomplish our goals. Are the people who supply us with the materials that we need to do our work providing what we need? These things could include patients and their abilities to provide a history, health care financ- ing that allows us to finance the care that we feel is indicated, and infor- mation systems that allow us to have at our fingertips the data required

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for decision making. Many more examples of providers and suppliers exist in this complex health care system.

We can now also begin to see that we as physicians are also critical suppliers to those individuals who receive the results of our actions. For example, is our handwriting legible so that our orders can be read without wasting the time of others? Are our instructions to patients and their fami- lies clear enough so that mistakes aren't made in the administration and use of medications? Once again, there are many examples of people who receive our work. Have we learned who the people are who receive the output of our work, and do we know if we are meeting their needs?

As we bore deeper, are we clear about the purpose of our work? Is it to have an exciting career, or to cure or modify existing disease? Or is it the prevention of diseases? Until we know what the aim of our work is, we may be at odds with each other. Only an open dialogue will allow us to come to understand the breadth of our aim. As we look deeper into the aim of our work, it usually becomes clear that we exist as a function because there is a strong societal need for our efforts. When our purpose is aligned with the stated (and unstated) societal needs, some of the dis- content that exists in health care may dissipate.

Variation is a concept we understand well. In the human body we know that a normal hemoglobin measurement may range anywhere from 12.5 to 17, a sodium measurement may range from 135 to 150, and that there is normal variation in its day-to-day temperature. We've learned that it is rare for any two or more sequential measurements to ever be the same. We've learned when to be comfortable with a stable amount of variation within acceptable guidelines, and we've learned when to pay attention to a meas- urement outside the realm of the expected. How often have we failed to consider this same concept in the day-to-day activities of delivering health care? Someone becomes concerned if the number of visits goes up or down. Another becomes concerned if the collection ratio is up or down, or if the number of staff employees per physician changes this month compared to last month. If we are willing to expand our knowledge of variation into our day-to-day work life, it will be easier for us to accept a range of events or activities that may have caused us concern in the past, while at the same time we become more attuned to the times that we must study an event that truly is unusual and must be understood.

Returning to our metaphor of the human organism, we know that com- munication between subsystems is elegant and effective. One muscle con- tracts, another simultaneously relaxes. Blood sugar starts to rise and insulin rises right along with it in order to limit the degree of elevation of the blood sugar. Then the sugar starts to fall and simultaneously the insulin drops off in order to prevent the sugar from dropping too far.

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That level of communication skill seems impossible to many in our day-to-day functions. However, with our existing knowledge of how systems interact and the feedback that may occur, we have the mental model we need to think about our everyday communication. When we plan a com- munication, we need to ask who the recipients of an action plan may be. Have we thought of their responses to our initiatives, and do we know who the responders will be? What will we do when they respond to our planned actions? Chess players use this way of thinking as a matter of necessity. How close can we model it? Will such forethought reduce unexpected vari- ation in our activities? It is likely.

In our training we learned about the psychology of individuals. We learned to dig deep, to find out what motivates an individual. We learned that once we have an understanding of the mind set of an individual we are with, we have a chance for real communication and a jumping off place for change. The current reality can be understood, and a potential future reality can be described. The gap can be gauged and a plan for narrowing that gap can occur. Organizations also have psychologies and emotional histories. The people in an organization adapt and adopt a set of rules in how they behave and how they are managed. These ways become embed- ded in the group activity as a culture. They are not easy to change. How well have we made an effort to know the psychologies of our own organi- zations? Have we thought to apply our knowledge of individual psychology to the organization we work in?

So, how do we proceed to regain our personal sense of satisfaction in the work we do, while at the same time being aware of the others impacted by our work? The theories of continuous quality improvement as taught by W. E. Deming, J. M. Juran, and others are an excellent starting place. If we start to become aware of the reason for our own work as a need of society, we can get beyond the arcane squabbles and comparisons that oc- cur between specialties as to "who is most valuable." The answer is simple: "No one and everyone." Our systems of health care are highly interde- pendent. Even the most seemingly independent solo specialist is often in- exorably wound into a system. Try to think of a complicated surgery procedure that could be done without the benefit of the anesthesia staff, the operating room staff, or the recovery room staff; there are many other examples. Once we can see that each individual has a place in a system, we can begin to value that place in the system and become aware of the multiple interactions that each individual may be a part of. Generalists are taught first to be systems thinkers, to notice the subtle and then to bore down when the situation requires it.

Once we have learned to be.observers of the web of systems we work in, we can begin to understand their intricacies, and focal points become

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obvious. With a system vision in mind we can find the leverage points that can lead to improvements which will benefit not only our patients but also ourselves and all others who work with us interdependently. Our knowledge of the scientific method can be applied to the theories we devise once we have knowledge of our systems. In continuous improvement, the Dem- ing/Shewhart cycle of Plan-Do-Check-Act is nothing more than a simplifi- cation of the scientific method. George Box called it "the democratization of the scientific method."

We have all learned that data are required before we make serious clinical treatment initiatives. Now we need to think the same way in our organizations. We need to make decisions using data whenever we have such information. We also need to recognize when we lack data and knowl- edge of a process in coming to critical decisions. Only then will we be al- tering our organizations in ways that are nondestructive.

As these concepts coalesce, a pattern emerges. To be able to do mean- ingful work and, therefore, have personal satisfaction, we must have an understanding of the aim of our efforts. Our systems of work must be in alignment with our aim, and the aim must be in synchrony with societal needs.

If we are aware of the interdependence of the components of the sys- tems we work in, we are more likely to be able to foster positive change and growth.

The generalist has the potential mind set to view systems in this way. If we can see the value of that ability and apply it to improving the or- ganizations we work in, we may regain a central integrative position in health care that has been perceived to have been lost. Not only can our systems of work benefit, but the most important recipient of the outcome of our system, the patient, will also benefit.

REFERENCES

Berwick, D. (1989). Continuous improvement as an ideal in health care. New England Journal of Medicine, 320, 53-56.

Deming, W. E. (1993). The new economics. Cambridge, MA: Massachusetts Institute of Tech- nology Center for Advanced Engineering Study.

Batalden, E B., & Stoltz, P. (1993). A framework for the continued improvement of health care. The Joint Commission Journal of Quality Improvement, 19, 424-452.