I worked 40 years as an employed clinician, but I always feared losing my job. There were many reasons to be scared: mergers, acquisitions, downsizing, and potential conflicts with new bosses, to name a few. However, the primary reason I feared for my job was for speaking my mind. Existing in a constant state of anxiety due to job insecurity is a terrible way to live. But, as the sole earner for a family of four children and a spouse, I felt I could not afford to take any chances, and the greatest risk I perceived was voicing my opinion about something negative at work. Let’s face it: nobody likes a whiner or a whistleblower. The problem is, the less you say, the more you enable others to define your voice and your identity.
Had I owned my practice rather than worked for health care organizations all my life, things might have been different. Nowadays, however, more than 50% of physicians are employed, so my experience is quite relevant. I worked at academic medical centers and pharmaceutical and health insurance companies. Clinicians working in the industry are considerably outnumbered by the “suits” and must conform to business values that may clash with patient care values. Sometimes, for example, business dictates that the truth be hidden, like refraining from publishing the outcomes of negative clinical trials. Clinicians working in-house for large corporations also walk a fine line when organizational demands intrude on obligations to individual employees. Companies may try to downplay clinicians' opinions that employees’ illnesses are work-related.
When I was 41, I was approached by the CEO of a psychiatric hospital where I was CMO. They told me they were about to default on a substantial loan that could bankrupt the hospital and allowed me to listen in on a telephone conversation between himself, the chief financial officer and the bank loan officer. The CEO fabricated an excuse why the hospital was in default, and he promised to satisfy the payment if the loan officer granted him a two-week extension. The loan officer agreed. The pair smiled smugly and chuckled after the call, leaving me tangled in their web of lies. Somehow, they made the payment, but soon after, the hospital was again on the brink of bankruptcy. It was acquired by another healthcare system, proving the adage that you can call yourself an “acquired health care company” and be correct half of the time. I saw the handwriting on the wall after that call, and I changed jobs before the acquisition.
I’ve felt muzzled throughout my career due to the fear that my opinions might not sit well with individuals who rank above me in the organization.
Many well-intentioned bloggers have shared their tips for speaking your mind at work. They tend to frame the issue in terms of courage rather than fear. They ask, “What’s the most courageous act you ever did at work?”
Employees’ responses are remarkably consistent, such as, “I stood up to my boss,” “I shared truthful information no one wanted to hear,” and “I argued an unpopular point of view.”
However, none of their answers speak to the nuanced practice of a physician.
In the world of medicine, opinions can be dangerous and politicized. Holding a controversial opinion can damage your reputation; stating a belief that contradicts the medical establishment can leave you vulnerable; voicing your opinion at the wrong time can make you appear foolish. The axiom attributed to Abraham Lincoln goes: “Better to remain silent and be thought a fool than to speak and to remove all doubt.” One can easily see how this mantra may inhibit physicians in their practice of medicine.
My first week into a job with a renowned pharmaceutical company, I challenged the senior vice president (a clinician) regarding the feasibility of conducting a clinical trial in depression — I was in favor of the trial, but the senior vice president was not inclined to fund it. I argued my rationale to them, and the next thing I knew that my boss was calling me advising me to back off. He said he had just saved my hide, as the senior vice president was disposed to firing me — simply for speaking my mind in opposition.
Another time, while working in the health insurance industry, I outlined a comprehensive plan to manage mental health benefits for the company’s insureds. I suggested that the company carve in mental health benefits rather than carve them out, as was the prevalent arrangement at that time and still is today. A couple of weeks later, the CMO told me he was eliminating mental health benefits, a euphemism for eliminating my job rather than the benefits per se. The back-to-back blows I suffered while working in the industry further silenced me and curtailed any aspiration for a position in the C-suite. I figured I was still capable of leading by example. Why should I risk putting my neck on the chopping block by gunning for an executive position of authority? To quote Jimmy Cliff: “The harder they come, the harder they fall.”
I retired when I reached full retirement age, as defined by the Social Security Administration and when my return on lifetime investments provided sufficient income. To help pass the time, I began consulting from home for a few companies. My consulting business has now grown to 30 hours per week. But the important thing is I feel I have nothing to lose by speaking my mind because if a client were to drop me today, I would still be financially independent. My clients seem to like me and appreciate my openness, directness, and honesty. My retirement had allowed me to speak my voice — ironically, at a time when I was not expecting to work anymore. If your workplace would support firing you because you voiced an unpopular opinion, you shouldn’t be working there.
How have you handled difficult workplace confrontations? Help your colleagues with your experiences in the comments below.
Arthur Lazarus, MD, MBA was a 2019-2020 Doximity Community Fellow. He is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry in the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.
Illustration by April Brust