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Every organization has a culture, either by default or by design. Why not cultivate one that helps people thrive?

Fam Pract Manag. 2018;25(4):11-15

Author disclosure: no relevant financial affiliations disclosed.

Copyright © 2018 Mark H. Greenawald, MD.

It’s Monday morning, and you roll out of bed ready for another day at work. As you anticipate your day ahead, what emotions are you experiencing? Excitement? Worry? Dread? What emotions do you think your practice team is experiencing? As you walk through the door of your practice, what expressions do you see on everyone’s faces?

Today, many physicians and health care workers are feeling worn down. Professional burn-out is at unprecedented levels, particularly among family physicians.1 Even if you are not feeling burned out, you may be living in what I call “survival mode,” simply trying to get through the day.

That was me a few years ago. I was suffering from sheer exhaustion, isolation, and unresolved grief and shame from the loss of a patient, but I didn’t realize how bad things had gotten — until I found myself in tears after a minor traffic stop and my wife insisted it was time to get help. When my therapist asked if this stressed-out life was the life I wanted to live, I realized I had to make a change. I altered my practice to find balance and improve relationships and developed a framework that I now teach to other physicians.

I’m proof that you can create a different future, one in which you and your practice team regularly and honestly say, “I love my work.” Imagine a practice like that, one in which everyone consistently felt energized and glad to be part of the health care team, helping to contribute to the important work of patient care.

Too often when faced with such a vision, our minds immediately decide it’s impossible because we feel so many of our challenges are caused by things “out there” that we can’t control. You might find yourself thinking, “My work life won’t get better until ___.” Often, what fills that blank is something that may not happen for some time, if ever. I’ve heard many colleagues fill in that blank with “retirement,” for example. This stance forfeits the power you have over your professional happiness, and that of your team. Before your mind immediately goes to “yeah, but” and you start listing all the reasons a thriving practice culture can’t or won’t happen, stop and consider the possibility of a better future.


  • Building a deliberate practice culture starts by asking the simple question, “How do we want to be together?”

  • A practice culture that focuses on service, teamwork, attitude, reflection, renewal, and self-care will help its members thrive.

  • To change the culture of your practice, you must intentionally do something different than what you are doing now.


Culture is simply the way a group thinks, acts, and interacts. It is composed of the behaviors, beliefs, values, and symbols the group accepts, often without thinking about them. They are passed along by communication and imitation from person to person over time.

Let’s return to that positive vision of your practice. How could such a life-giving practice culture come about, particularly in the midst of all the present-day hassles of providing health care?

A practice culture develops in one of two ways: by design or by default. It is either by choice or by chance, by intention or by accident. If you don’t know how your culture developed, then you probably have a culture by default. That doesn’t mean it’s an unhealthy culture. It simply means that when things aren’t going well, your practice has no standard to help you recalibrate and no target toward which you are moving.

The good news is that creating a more life-giving practice culture is within your power, regardless of what’s happening “out there.” Even in our present health care environment, there are practices already achieving it. And your team is likely looking to you to be the catalyst to help build and support such a culture.


To provide a map for creating a practice culture that has the potential to be life giving, I like to use the “STARRS” acronym. It emphasizes the six qualities by which teams can experience high levels of well-being while together doing the important work of providing patient care. It is not a substitute for the important operational, structural, or process changes involved in practice transformation.2 Such changes are necessary for creating a more efficient practice but in and of themselves are not sufficient for creating a thriving practice culture. Following the “STARRS” will take you the rest of the way.

Service. Did you ever stop to think that our work in health care involves not only providing services to our patients but also serving each other in the process? Service to one another involves how we look out for each other in the process of doing our work, and how we recognize and uplift each other for that work. Robert Greenleaf, who coined the term “servant leadership,” describes the potential impact of this type of service: “Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?”3 As physicians, leaders, and “culture catalysts” in our practices, we need to set the example and serve not only our patients but our team as well.

What you can do now:

  • Regularly check in with each other to ask how things are going.

  • Look for opportunities to personally point out a job well done by individual members of your team.

Teamwork. We commonly think of teamwork in the context of care delivery, or what we do together for our patients. Teamwork also refers to how we connect with each other as coworkers and teammates. It requires presence and awareness, not only knowing each other by our titles and roles but also knowing about each other — our strengths, limitations, challenges, joys, motivations, goals, and dreams. All of these things affect, positively or negatively, our ability to be fully present and energized to perform our work. This approach to teamwork reminds us to be certain we are connecting with each other as fellow humans, rather than simply as “functional units” trying to get work done.

What you can do now:

  • Ensure you are present when interacting with your team, and not distracted by other concerns.

  • Get to know your teammates and the joys and struggles they are experiencing.

Attitude. Have you ever noticed that emotions can be contagious? One person comes to work with a bad attitude, and soon the whole team is on edge. Social science describes this phenomenon as “emotional contagion.” Fortunately, we don’t have to let others dictate our emotions. We can, in fact, choose our attitude, often by reframing our thoughts or beliefs. Psychiatrist and Holocaust survivor Viktor Frankl wrote that “Everything can be taken from a man but one thing: the lastof the human freedoms — to choose one’s attitude in any given set of circumstances, to choose one’s own way.”4 Choosing to have a positive attitude even in the midst of great stress can help create a positive, encouraging environment for others and help advance the kind of practice culture we all want.

What you can do now:

  • Check your own attitude regularly and reflect on its impact on the team.

  • Regularly look for opportunities to see challenges in a positive light, and express this perspective.

Reflection. In the busyness of our work and the hassles that can accompany it, we tend to forget why we were called to health care as a profession in the first place. Deliberately carving out time, as an individual and as a team, to reflect on our work and reconnect to meaning, purpose, and professional identity are important ways to stay calibrated and grounded. Reflection reminds us that the work we do every day matters greatly and that through it we have the incredible opportunity to positively affect numerous lives on a daily basis. We should reflect not only on the medical care we provide but also on our patients as people and the joys and challenges of caring for them, celebrating their successes, and grieving with their sorrows.

What you can do now:

  • Remind each other regularly of the mission of your practice, and share stories about how this is being lived out.

  • Provide opportunities, perhaps during team meetings, to share with each other your reasons for doing this work and examples of the positive impact it has.

Renewal. The work we do is often challenging, tedious, and exhausting. Without recharging on a regular basis, we risk depleting our physical, mental, emotional, and spiritual reserves. Too often, we think of “renewal” in the context of taking a vacation, but it should be a daily process of staying energized and connected with our work and with others. Research suggests that it takes between three to six “uplifts” for a group to overcome every hassle they experience and achieve optimal performance and team success.5 Given all of the hassles that are part of our daily work, deliberate, regular uplifts are essential to creating a positive, thriving practice culture. These can include simply taking a work break, eating a good lunch, having fun while you work, celebrating team successes, or getting enough sleep at night.

What you can do now:

  • Schedule regular times of recognition and celebration with your team.

  • Create rituals to encourage each other during the day, perhaps something as simple as a “high-five” or “thank-you.”

Self-care. As physicians, we talk to our patients daily about following healthy lifestyles, but we don’t always follow our own advice, which takes a physical as well as emotional toll on us over time. The science of change indicates that the most successful change occurs as a team sport, with mutual support, encouragement, and accountability being essential ingredients. A key part of creating a thriving practice culture is to live (and encourage others to live) a healthy lifestyle. This includes attending to how you eat, move, sleep, relax, and stay present and connected. Too often we physicians act as if carving out time for self-care is selfish, when in reality it is insanity not to do this.

What you can do now:

  • Model self-care in your own life by following recommended guidelines.

  • Create a “culture of health” by talking about its importance with your group and sharing helpful articles or ideas.


To change the culture of your practice, you and your colleagues must intentionally do something different than what you are doing now. It will be an ongoing process, not an immediate event, but you get there by taking small, deliberate steps.

The first step is deciding what you want your culture to look like by asking “How do we want to be together?” In addition to the STARRS attributes, what other qualities do you think would help create a thriving practice culture? Write them down, and then discuss your ideas as a group. These qualities might be things you are presently doing that need to be accentuated or things you are not presently doing but need to begin.

Next, assess the current state of your practice culture and identify opportunities for improvement. This includes identifying any parts of your practice that are draining the life from your team. You can use the five-minute STARRS assessment tool to guide this step. Distribute it to your colleagues and staff, and have everyone complete the first part, “The State of the YOUnion,” for their own self-reflection and the second part, “The State of the Union,” to anonymously assess the group.

Part one: The State of the YOUnionNeverRarelySometimesOftenDaily
I recognize my teammates for their good work.12345
I give small gestures of kindness to my teammates.12345
I focus on my teammates when they are talking to me.12345
I check in with my teammates, and know about their joys and struggles.12345
I enjoy coming to work.12345
I help to create a positive and encouraging team culture.12345
I know and embody the mission of our practice.12345
I regularly connect with those things that have meaning in my work.12345
I have fun in my work environment.12345
I take time to celebrate my/our successes.12345
I follow and encourage a physically healthy lifestyle.12345
I take time for stress reduction/relaxation.12345

Then, meet as a team to discuss the results and identify where you want to focus your initial efforts. Don’t try to implement multiple changes at once. Instead, choose one item, initiate the necessary changes, and once that item becomes a routine part of your practice culture, add another. Be patient but persistent with the process, remembering how long behavioral change can take and how easy it is to get distracted by the busyness of our day-today work.

Finally, to maintain momentum, include “practice culture” as a discussion item during your regular practice meetings. Consider completing the STARRS assessment quarterly to monitor progress, and feel free to add questions that are relevant to your evolving practice culture.

For more resources on improving physician well-being, visit the AAFP’s web portal Physician Health First.


As you implement this more deliberate practice culture, monitor your internal dialogue on Monday morning as you roll out of bed, preparing for another week at work. If the STARRS are aligned, your attitude will be quite different than it is now, and you won’t look back.

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