Back in 2018, we reached a significant tipping point in medicine. For the first time, physician practice owners were not in the majority. Instead, most practicing physicians reported being employed, with family medicine having the highest share of employed physicians.¹

Loss of autonomy is a major frustration for many employed doctors, particularly those who used to practice independently. Suddenly, you are not “the boss” or “in charge” because this is not your practice. The practice exists inside an organization that is a vast bureaucracy, and you are smack in the middle of the org chart with several layers of bosses above you. These individuals often are not doctors, but they have the power to dictate the specifics of your practice and possibly decrease your job satisfaction unless you figure out a way to have some influence over their decisions.

For example, let's say you are spending one to two hours each night doing pajama-time charting at home, and you would like to try working with a scribe to ease your documentation workload so you don't burn out. You make a great case to your administrator, who shoots down the idea, saying, “If I give you a scribe, I have to give everyone a scribe.”

Here's another example: Your organization uses centralized scheduling with inflexible templates, and you are wanting some control over your schedule. You would like to be able to schedule two 10-minute walk-in visits after lunch each day to unload your afternoon. It would be good for patients too, but your boss says no.

In both examples, you disagree with the decision and feel your organization's bureaucracy is causing harm. It's not a matter of life and death, such as a pandemic, where you might be asked to do things that put your life in danger and need to say “No!” In this article, we're not talking about crisis or emergency situations. We're talking about routine circumstances, but there's still real harm involved — inefficiency, overworked doctors, unhappy patients, etc.

So what should you do?

A. You could leave the organization and go work somewhere else, but you'll likely encounter a bureaucracy wherever you go.

B. You could say nothing, keep your head down, and accept the bureaucracy, which will eventually lead to job dissatisfaction, resentment, burnout, or worse.

C. You can learn how to navigate the bureaucracy and gradually take back some control over your practice.

Option C involves developing two essential skill sets: 1) managing your boss and 2) maintaining a position of influence in your organization. Here's how to do both.

THREE KEYS TO MANAGING YOUR BOSS

Why is this important? Your boss is your support inside the organization — the source of the “yes” you will need to move from “the way we do things around here” toward your ideal practice. Like it or not, the quality of your relationship with your boss is a huge factor in the quality of your life. A good relationship can boost you to a thriving practice. A poor relationship can lead to burnout and is one of the top reasons employed physicians quit their jobs.

If you don't know who your boss is, your first assignment is to figure that out. This may be a challenge in your organization, especially if the structure has changed recently. Is it your chief medical officer, someone in the administration area, your practice manager, the chairperson of your executive committee? Who does the organization see as your immediate supervisor, or who in your organization sees himself or herself as your supervisor? If the position of your boss is missing or vacant, that is not a good thing because there is no one to represent you, no one who has your back, and no one to advocate for your requests. It is in your best interest to clarify this role. Then, you can proceed with the following steps.

1. Understand your boss. It is vitally important to understand your boss on several key levels. First, know your boss's personality, communication style, and decision-making style. Is your boss an action-oriented person who wants the bullet points and then makes a quick decision, or is your boss a detail-oriented, introverted “engineer type” who takes time to make decisions — or something completely different? Study them and their communication style carefully. Pretend you are an anthropologist, carefully observing your boss as a key member of your “tribe.” How do they schedule their days? How do they prefer to be contacted — by email, text, phone, in person? How do the people who have the best working relationships with your boss relate to this person? What success factors can you identify and emulate?

Next, practice the “Platinum Rule”: Treat people the way they want to be treated. Match your boss's communication style and personality when the two of you are together. Give them the information and time they want, just the way they want it, especially when you are making a request for change to your work structure.

Get to know your boss as a person too. Do they have children, outside interests, or hobbies? Where do the two of you have common ground? Take great notes, just like you would with a patient. Always be adding to your knowledge base and building your relationship.

Finally, you need to know their goals and priorities. Your boss almost certainly has a boss. They have their own goals and orders from above. Do you know what their key objectives are for this quarter or this year? The easiest way to find this out is to ask them directly. Then ask how you can help. What role do they see you playing in reaching these goals? It will be much easier for you to get what you need from your boss if your request aligns with one of their own goals. This is the essence of a win-win solution.

2. Understand yourself. You must understand yourself on these same levels. What is your personality, communication style, and decision-making style? Notice the way you communicate naturally and how that either matches or conflicts with your boss's personality and style. In most cases you will need to modify the way you communicate to connect effectively with your boss. Remember you are striving for the “Platinum Rule”: Treat people the way they want to be treated. So if your boss likes all the details and time to consider a decision, give them just what they want — details and some time.

You also must understand what your own goals and needs are, as well as your ideal job description. If you're continuously trying to improve your practice toward the ideal, you will probably have requests for your boss every month. Winning your boss's support is often key to making the practice changes you require. Know exactly what you want from your boss. Do your best to align your needs with one of your boss's goals, and create a win-win that pleases both of you. Then ask for what you want. You may need to negotiate back and forth and be willing to compromise, but do not let that stop you from getting clear on what you want and asking for it.

3. Manage your relationship. Let's face it, you can't actually manage your boss. You are not in the position on the org chart for that. What you can manage is your relationship. Most physicians miss this point altogether. They see their boss only a couple times a year, and most often that is when their boss stops by to tell them there is a problem. That is the absence of a relationship. You can't manage a vacuum. The chance of you getting something you need from your boss when this is the nature of your relationship is close to zero. You must manage the relationship proactively.

Think of it this way: Your relationship is like a bank account. Every positive interaction makes a deposit of goodwill into this account. You can draw on this balance of goodwill if there is a conflict or problem. If the only time you see your boss is when there is conflict or a problem, you have no goodwill to draw on. It will drive the two of you even farther apart.

The solution is simple: regular collegial meetings with your boss to make sure you are on the same page. You will need to schedule these meetings. Arrange this meeting as a regular get-together in the absence of any problems or crisis, by saying something like this: “I would like to buy you a cup of coffee and get to know your goals for me — and the larger organization — so we are always on the same page.” Then, make a habit of scheduling your next visit with your boss before this one is done so you always have a relationship-building meeting on the books with them. Quarterly is great. Monthly or every other month is better.

Here are some initial questions to ask at your meetings:

• What are your goals for this quarter and this year?

• What role do you see me playing in those goals?

• How else can I help you get there?

• How do you evaluate my performance, and what are the most important numbers for you?

• How am I doing at this time?

• How can I improve?

• What is something you see on the horizon that I can start preparing for now?

Down the road, you will also use these conversations to ask for what you need to keep creating your ideal practice. But early on, keep working to make deposits in your relationship bank account with your boss. Shoot for a ratio of 5:1 — five positive interactions for every negative or uncomfortable interaction. This way, your balance will always be in positive territory.

Once you've built a positive balance in your relationship bank account, it's time to ask for what you need. Pick the highest priority change you want to make to your practice. Look at it from two perspectives — yours and your boss's. Put yourself in their shoes now that you know more about them and their situation. Create a solution that will be a win for both of you, and prepare to present this request at your next meeting. It's a good idea to rehearse your presentation with someone you trust. (Your significant other is a great person to play your boss; they usually participate with gusto.) Never go in cold. Expect the best, but prepare for the worst. Be flexible and willing to negotiate.

If you meet resistance and you know your request is a good thing for the practice, try using these three magic words: “innovation pilot project.” Bosses love being able to report innovation in their area to the higher-ups, so propose an innovation pilot project. This can be a powerful way to get permission to try out your idea and, eventually, expand it if it's successful.

FIVE POWER TIPS FOR MAINTAINING A POSITION OF INFLUENCE IN YOUR ORGANIZATION

As you relate to your boss or others in the organizational hierarchy, keep these tips in mind.

1. Stop acting like a doctor. When you're trying to get what you need from your boss or your boss's boss, resist the urge to act like a doctor. Doctors give orders, expect compliance, and demand urgency. Instead, ask questions, observe carefully, make requests, and be patient.

2. Know when to ask for forgiveness vs. permission. Administrators have several concerns you must honor: money, staff, policy, and mission. If you need something that does not require more money or more staff, does not violate policy, and is consistent with the mission, just do it. If anyone objects later, beg forgiveness (or ask to be an innovation pilot project).

3. Don't be a whiner. The typical employee will point to a problem and ask their boss “What are you going to do about this?” This will destroy your relationship and make you adversaries immediately. Instead, any time you bring your boss a problem, bring a solution too. Ideally your solution is a win-win that accomplishes two things at once: It gives you more of what you want, and it meets one of your boss's objectives. You do not want your boss to see you as “just another whining doctor.”

4. Remember the “continuation rule.” Every interaction you have with your boss sets the stage for your next encounter. If you end on a positive note, your next meeting will continue on that same positive trajectory — even if your discussion is about a problem. If this meeting ends badly, you will start the next one in the pits as well. Do everything you can to avoid ending any meeting in a negative fashion. Never storm out of a meeting with your boss.

5. Avoid the “disruptive” label. Never lose your cool. When you feel negative emotions rising up inside you, use your mindfulness skills — breathe and release — or table the conversation until you can gather your thoughts and emotions. When you need to point out a problem or hypocrisy, don't accuse or assert. Instead, channel the 70s-era TV detective “Columbo,” and use phrases such as “I'm curious …,” “I'm confused …,” “I was wondering …,” or “Maybe you can help me out here.” This is where it is helpful to know the mission statement and use it to your advantage, showing how a current process or policy is incongruous and should be changed. For example, “I was wondering … The mission statement says X, but we're doing Y. Maybe you can help me out here.”

A SURPRISING RESULT

When physicians I coach apply these skills, they are often surprised at the flexibility, support, and positive working relationships that result. In many cases, things they thought were impossible — such as going to a part-time schedule, getting additional clerical support, or getting needed equipment — were immediately made available when they presented a reasonable request to their boss. What requests should be at the top of your list? In an upcoming issue of FPM, we'll delve into the process of creating your list of what you need or want, which starts with identifying your ideal job description.