Leadership Lessons from the End of Life
The end of life and the journey through serious illness can teach us a lot about leading in high-stakes situations.
Dr. Michael Fratkin was a burned-out palliative care physician in an under-resourced clinical setting. Fed up with the way things were going, he “had enough crazy or coffee” in him five years ago to step out of the typical healthcare box and build something new. The result was Resolution Care Network, a palliative care organization that seeks to bring “capable and compassionate care to everyone, everywhere in the face of serious illness.”
Fratkin’s job as a clinician can only be successfully accomplished through carefully listening to and understanding who his patients are, what they want out of life, where the gaps or challenges have been in the past and then creating a plan with them that takes into account both their personal and medical situations. He’s helping people make decisions at perhaps the most vulnerable time of their life, helping them live as well as possible during their remaining days.
In addition, as the leader of a healthcare organization designed to carry out a profound mission on a shoestring budget, Fratkin has had to build and maintain a team united on common goals. Here are some of his insights on listening and stories that apply to any healthcare leader.
Read it all or simply expand the sections that interest you.
Start with similarities, not differences
Successful listening begins with acknowledging common ground. Fratkin enters every conversation with a new “patient” by telling them that, well, they’re not a patient. “We let them know we don’t take care of patients,” he said. “We only take care of people. And we do it with an extraordinary team of other people.”
We’re not here to quibble about semantics and labels, so don’t get hung up on what the person in the bed – or across the desk – is called. Fratkin’s point was that only a quirk of timing separates the care team from the people they care for.
“The only difference is that they’re in a moment in their life where they need help, and we are in a moment when we need to offer help,” he said. “That’s a phenomenon of the calendar. It’s not a substantial difference between us and them.”
When soliciting feedback or getting to know a situation, leaders shouldn’t begin with, “I’m the doctor, you’re the patient” or “I’m the CEO, you’re the manager” (either explicitly or implicitly). Instead, set a comfortable tone that will allow for a deeper, more honest conversation by focusing on areas where the field is level. Even something as simple as coming out from behind the desk can help highlight the similarities.
Respond in kind
Don’t be afraid to offer relevant pieces of yourself. It’s Empathy 101, but something that is easy to skip over because a leader (or clinician) may feel that their job is to collect information, not offer it. As Fratkin listens to his patients, he gives them bits of his own story.
“I say, ‘I am a father and a husband and a brother and a son,” Fratkin explained. “And I also happen to be this thing called apalliative care doctor, but we’ll get back to that.’”
Because his approach revolves around listening to stories, Fratkin thinks about everyone as a character in the patient’s story.
“I very intentionally offer fragments of the character of me. When I walk into this person’s life, I need to sketch out who I am. They say, ‘I’ve got a daughter,’ and I say, ‘I’ve got a daughter.’ They say, ‘I came from New York.’ Well, so did I.”
This is the type of thing we tend to do naturally at social gatherings. But it’s much harder when there’s hierarchy in place. Leaders should shift their mindset to think less about the superficial conditions (in this case, rank and situation) and elevate the interpersonal connection.
*Note: This is in no way to dismiss the very real and important role that position/rank plays in a business setting. As we note elsewhere in this volume, a leader must lead, and that may mean “pulling rank” in one way or another.
Acknowledge your bias
Bias is a strong word, but it doesn’t have be dangerously negative. We all have a unique way of looking at the world based on our own experiences. Our training and roles affect this perspective, too. Successful listening depends on learning to think from the other person’s point of view.
Fratkin teaches his team to collect all the necessary medical information, listening from the perspective of their role as a nurse, doctor, social worker, etc. But he doesn’t let them stop there. While he certainly reviews reams of medical records before walking into the room, he’s aware that he could spend six weeks with that data and not have a clue who they are as a person.
“Sometimes by the time my initial encounter occurs, others will have gathered a ton of data, the team will have met and I will have created a sense of this person in my mind,” he said. “I can absorb a story from others.”
That’s fine, he cautioned, until it clouds his ability to look past the impression and see the reality.
“My role as the physician is to bring the gravitas of that role and extract actionable understanding of this person [but] sometimes that initial sense gets in the way of discovering things that were not gathered by the team,” he said. My challenge is ensuring I’m receptive to whatever comes my way and remembering that I really don’t know, no matter what I’ve heard beforehand, what their story is.”
Don't expect technical details to save you
Listening and storytelling are two sides of the same coin. Part of successful listening is encouraging the other person to tell a clear story that reveals relevant details.
As above, this is a place where Fratkin noted the limits of medical data when it comes to working with seriously ill patients. And, by extension, a healthcare executive may run into challenges if he doesn’t go past data and analytics.
Fratkin said that at Resolution Care, clinicians try to flip the equation by thinking of the person first and the medical condition second. If they focus on the medical side, there will be no way forward if the patient resists advice – or if non-medical decisions need to be made.
“We know a lot about medicine but if people we care for don’t trust us, they won’t ever really reveal the stuff that we need to know to guide them,” he said. “They won’t reveal what’s most important to them. They won’t reveal how they’ve made tough choices in the past. They won’t trust us because they would see us just as a part of the same healthcare system they’ve been alienated from.”
It’s a particularly stark issue when dealing with seriously ill individuals and those making decisions about their end-of-life wishes. However, the same can be said for a leader working with her staff. “Our numbers aren’t good enough,” one could say at an employee gathering. “Work harder. Do better.” But why aren’t the numbers good enough? Knowing that is the only way to identify what to change and how to change it. And the only way to know is to provide plenty of room for the people involved to tell their stories.
Ask, ``What don't I know?``
Once you’ve reviewed the data and heard the story, add it all up and see if the math works. Look for the gaps. Fratkin said, “The trick is to shift your focus away from what you know and continuously ask, ‘What don’t I know? What doesn’t add up here?’”
Often, data that accumulates around a medical problem gives a false sense of understanding the breadth and depth of what a person needs, Fratkin pointed out. But data is only part of how we make decisions. “We like to think our very rational, left-brain, Western model of analyzing problems is the way to manage huge and sometimes conflicting data sets,” he said. “But that’s not the way decisions are made by people.”
Sure, some people are very analytical and like to focus on data. However, we depend on our ability to tell stories to make decisions, develop social norms and teach critical lessons that groups need to succeed. Listening to stories and processing the information passed through them will reveal material that may not be reflected in the data. Fratkin pointed to a frequent occurrence with Resolution Care: An individual under their care declines an evidence-based intervention “because there’s a story in the way.” A high percentage of Resolution Care’s patients are young and poor with a host of challenges around social determinants of health. As a result, the “story in the way” is often significant mistrust of the healthcare system, leading to resistance against medical advice.
*Note: While we’re talking about the importance of giving people room to tell stories, it’s worth adding that people who can tell good stories do have a social advantage (see that first link above). Want to get ahead? Take all those numbers that people say they want – and, ok, that they need – and learn to wrap them up in a good story.
Reframe the story
So, if a physician is encountering resistance to medical advice, or a hospital executive to a new program, what do they do?
Assuming they’ve listened well and uncovered the story that’s getting in the way, the next step is to reframe that story. Adjust it slightly to guide the other person towards a resolution. Whether a person is analytical or intuitive, we all see ourselves within “the arc of our lives,” as Fratkin put it. We all have a beginning, middle and end. A leader’s job is therefore to understand how a person sees herself – “What character has she created for herself? What beliefs has she gathered together? What matters most to her?” in Fratkin’s framing – and then offer solutions that take her worldview into account. Fratkin said that he tries to “reframe the story in a way that allows people to step forward towards things that I think are evidence-based and likely to bring them benefits.”
Instead of saying “do this,” it becomes, “here’s how we can accomplish our goals together.”
Don’t (necessarily) take the trendy approach
Or pursue the trendy people.
This isn’t so much about listening specifically. But it does inform the entire concept of the art of change, and it helps create an environment that allows for effective communication, setting vision and being authentic.
Fratkin spoke about the challenges he faced as he left his previous clinical role and started Resolution Care. It was a great concept, but to grow and succeed he needed much more than just an idea. And so, he told a story. It’s that story we started this article with: We’re all pretty much the same.
“I drew people together through the story that the individuals over there who are moaning and writhing and suffering and oozing and messy and full of chaos in their lives are no different than us,” he said. “And we are no more important than them.”
He used that story to run a successful crowdfunding campaign and obtain a donated office. Then he used it to build a team, but not out of the people you might expect.
“I didn’t gather the 20-something, Silicon Valley startup-obsessed, entrepreneurially-trained MBAs,” he said. “I was working with social workers and nurses who were burned out and I had to draw them together.”
There’s been turnover, he said. Not everyone lasts because, well, that’s true with any organization. The people who do stick around, though, challenge each other. They bring ideas – and critiques to Fratkin. But the shared vision is “the rudder that points us forward,” he said. And it’s also the ideal they all work to live up to. They all understand the story of Resolution Care, and the stories of the individual people who come to them for help, and the stories of each other. “That’s why they’ve stayed,” said Fratkin. “They get that we honor them and respect them and are interested in their development as much as we are in the wellbeing of the people under our care.”
Leaders of all stripes can take this from Fratkin and know that it may not always be the obvious people who will drive the organization to new heights. Attracting those people and keeping them requires an intense amount of engagement – listening, vision, authenticity and responsiveness – from leadership. But the return on that investment is a workforce that will be deeply motivated and will move mountains to accomplish the shared goals. In this case, improving lives of the people they serve.