Small Changes Big Impact

Leadership transparency and the approach to feedback with Dr. Allan Grill

February 19, 2020 University of Toronto - Department of Family & Community Medicine Season 1 Episode 15
Small Changes Big Impact
Leadership transparency and the approach to feedback with Dr. Allan Grill
Chapters
Small Changes Big Impact
Leadership transparency and the approach to feedback with Dr. Allan Grill
Feb 19, 2020 Season 1 Episode 15
University of Toronto - Department of Family & Community Medicine

In studio today, we have Allan Grill, family physician and chief of family medicine at Markham Stouffville Hospital, physician advisor for the College of Family Physicians of Canada and associate professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on leadership transparency and the approach to feedback.

Show Notes Transcript

In studio today, we have Allan Grill, family physician and chief of family medicine at Markham Stouffville Hospital, physician advisor for the College of Family Physicians of Canada and associate professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on leadership transparency and the approach to feedback.

Dr. Rezmovitz:

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Allan Grill, family physician and chief of family medicine at Markham Stouffville Hospital, physician advisor for the College of Family Physicians of Canada and associate professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on leadership transparency and the approach to feedback. I hope you enjoy the show. Welcome.

Dr. Grill:

Thanks Jeremy. It's great to be here.

Dr. Rezmovitz:

Thanks Alan . I'm so happy that you're here today. You know, we have a history together. You were once at Sunnybrook. I'm still affiliated with Sunnybrook. We've done some excellent work together in the past. You were my preceptor once actually.

Dr. Grill:

Yep. Division of Long Term Care.

Dr. Rezmovitz:

Division of Long Term Care. So we go way back. So thank you for coming on the podcast today. Why don't you tell me about what drew you to the podcast?

Dr. Grill:

So I think what drew me to the podcast was you approached me and asked me to be honest.

Dr. Rezmovitz:

Oh.

Dr. Grill:

And because of our friendship together and my respect for your career and professionalism, I said, why not? I think it's a great thing. To be honest, I think it's great you've started this and I'm always supportive of innovative ideas in the department and I figured this would be a lot of fun.

Dr. Rezmovitz:

Awesome. So as chief of Markham Stouffville Hospital now - or I guess chief of family medicine in Markham Stouffville.

Dr. Grill:

Yeah, let's not make it bigger than it is.

Dr. Rezmovitz:

No, no - but you are an associate professor. Congratulations.

Dr. Grill:

Thank you very much.

Dr. Rezmovitz:

That's awesome. I saw that. So what changes have you started making?

Dr. Grill:

Well, I thought that today we could talk about maybe one or two small changes that - as it says, small changes, big impact - that had a significant impact on my professional career in medical leadership. And maybe we could start off with a very small one, which was me just saying yes to somebody at my office asking me a question. It was a few years ago when H1N1 hit - that flu outbreak that scared a lot of people in - pretty much around the world, but specifically in Toronto and Markham where where I work. There were a lot of unanswered questions, a lot of nervous people. And at the time in my family health team, believe it or not, I had no leadership role whatsoever. I was just sort of an associate physician there. I would come in, see my patients, leave, payment, overhead check. I didn't go to any meetings. I didn't really have any say in how the office was being run. And the lead physician, Bill Newton approached me and asked me if I would co-chair - I think they called it the pandemic H1N1 committee. And I think he approached me because I was working for Toronto Public Health at the time and I have a Master's in Public Health that I got after residency. And he figured I may have known more about H1N1 than other people in the office. And it was the first time in at least two or three years that I'd been working there, that anyone had really asked me to get involved in anything and I said yes. And just by saying yes to that, it actually had a significant impact on my career path, both at the family health team and in leadership in general.

Dr. Rezmovitz:

Well obviously begs the question how? How did it have a significant impact?

Dr. Grill:

So what we ended up doing on this pandemic committee was we were just asked to make some decisions. So like one example would be: would our family health team actually vaccinate our own patients? If you remember at the time there was a shortage of vaccine. Not everybody wanted to vaccinate patients. Public Health was trying to put out all of these clinics. For some reason there was this myth that it was difficult to load the vaccine. It was complicated. Anyway, our nurses looked at the situation and said, how can we not vaccinate? And so, the first decision was how involved were we going to get in collaborating with York Region Public Health. So we ended up vaccinating about 5,000 people, which we were told was a lot of people at the time, just given the fact that there was somewhat of a shortage. And we also had to tell our patients that we were going to focus on the high risk patients, not vaccinate everybody because everybody wanted to get vaccinated and it's hard when you're dealing with scarce resources. But it really brought the family health team together because we needed everybody's help. We needed our admin staff to sort of ask some screening questions at the door. We needed our doctors to double up on call because of all the people that were coming in with sort of influenza like illness. And we even, we even stopped periodic health exams if you can believe it temporarily because we just needed more spaces to deal with sick people. And it really brought everyone together and everyone was very supportive and they look to me for some of the knowledge I had been learning about H1N1 at my job at Toronto Public Health. And I thought it was a really successful endeavour. We got through the pandemic. And after that experience, I sort of got the leadership bug and I decided to explore other opportunities where I could engage in what I now call medical leadership.

Dr. Rezmovitz:

You're just leading us down a pathway today. So tell us about these other leadership opportunities.

Dr. Grill:

So I would say the next small change that I made was how I viewed what I think some people call continuing professional development or some of us still call it CME - continuing medical education. Instead of just taking my CPD in something clinical, I actually started to look for leadership courses where I could get credits towards the CFPC license that we need - that five-year of credits, the Mainpro+ credits. And I looked at the Ontario Medical Association, so they were offering this intensive one year physician leadership development program course. It was six weekends. You had to apply. They were looking for new leaders and also established leaders within Ontario who were all doctors - it was totally doctors. And I think they were looking for 30 people. There had one cohort already and I had heard some good things about it. And I'll be honest, I just - I threw an application and I had no idea if I was going to get accepted or not, but I did get accepted. And I have to say, and I still talk about it now - in fact, I've been invited back to be on a panel to speak about my experience with the OMA - but that leadership course, it changed my professional career. It changed my life. And I can go into those details if you want me to elaborate further, but it just gave me a lens to look at my career. It was a very different lens than the one we had used in medical school and residency. It taught me things like self-reflection, the ability to sort of open yourself up to constructive criticism. There was another great term I learned in that course called creative destruction, which sounds like a paradox, but it's the idea that every organization and every person has to go through sort of like a change life cycle . So you get your training, you start working, you do your thing, you think you're pretty good at it, but even if you think you're great at it, there should be room to change. And you almost have to reinvent yourself every so often or do a recheck. And it's creative in that sense. And it's destruction because you try to get rid of the stuff that you can improve on and then you add in sort of that quality improvement angle to it. And you know a lot about quality improvement of course. So that course really - it just changed my career in the sense of how I looked at even my clinical practice. And it really influenced me to try to look for other leadership opportunities within primary care that I thought were fun and that would help me earn a living.

Dr. Rezmovitz:

So you mentioned a couple things actually that make me reflect on what you said. The creative destruction process sounds like Tuckman's stages of group formation. Do you know about forming, storming, norming, conforming?

Dr. Grill:

Sure. Yes, I've heard that . Yeah .

Dr. Rezmovitz:

Yeah. So it just sounds like that's what someone's doing at their own self level, right? Their own system level is you're going through these cycles yourself because you're forming, you're starting, you're realizing there's something that I need to change, right? When you finally get over the storming and the conflict, then you start norming and then you start performing. So it sounds like they've adapted that for leaders, which is amazing. You mentioned that - would I like you to elaborate? Anytime anyone says it changed my life, I want to know about the impact - that it changed your life professionally and if it had any consequences personally. But not just with you and your connectedness with the people in your clinic or your patients. I'd love to hear a patient story also, but maybe if someone reflected back to you and said, here's actually something that I got from you that has now impacted other people down the line.

Dr. Grill:

And I like the fact that you want me to comment both professionally and personally because I do want to share a personal story with you today about how this has impacted me. But let me just start with the professional. So after my experience helping out my family health team a little bit with H1N1, and then I took this OMA leadership course - around that time my family health team was going through some changes. They were going through some staffing changes , some changes about how the place was being run. And you know, I tend to voice my opinion when I feel strongly about something. And so I started, I guess you could call it complaining. I would maybe say I was giving some positive feedback or some constructive feedback.

Dr. Rezmovitz:

Is it a leadership quality you learned in the program?

Dr. Grill:

I think the leadership program helped me sort of fine tune the way I express my opinions about things, which is also really important. So some of the board members at my family health team said, "Alan, if you've got all these ideas, why don't you step up and be on our board?" And I said, "okay, I'll do it." And I had never sat on a board before - I hadn't even volunteered on a board in my life. And so I got involved with the board and we had some tough decisions to make about who was going to lead the organization and how it was going to be organized. We got through it and then I just started to get more and more involved in the way the fit was being run. And I started to like it. And eventually it led to me becoming lead physician of the family health team. I'm in my second term now and I think I got the confidence to even take a shot at that from the OMA leadership course. And while that was happening, I started to look around for other opportunities within leadership outside the practice. So as you know, we can spend seven days a week seeing patients, learning more about clinical cases - we could dedicate our whole career to just that one on one interaction. I think when I did my Masters in Public Health down at Harvard, I got more interested in population health, and I tried to figure out if there was a way I could sort of mesh that into my career. So when I got an email around the same time from the Ontario Renal Network where they were looking for a family physician to help with early detection and prevention of chronic kidney disease, I thought, "hey, that sounds like a fun idea." And by the way, I didn't know much more about chronic kidney disease than any average family physician and I really had no idea what I was getting into. But I applied, I interviewed, I got the position. And the reason why that's had a huge impact on my career is number one, I know more about chronic kidney disease than I think I'll ever even want to know. And two , I was able to work with some great nephrologists and some great admin staff and we actually created a toolkit - you know about that toolkit it's called KidneyWise - you can find it at kidneywise.ca. And it's an algorithm that basically empowers family physicians to figure out who to screen for chronic kidney disease, what tests to order, how to make the diagnosis and how to manage those patients. And it actually - it empowers them in the sense that you actually have to refer very few patients to nephrologists for CKD. So by learning about that and creating this algorithm, we published a paper about it in Canadian Family Physician, which was great. So I felt that I was contributing academically. I was able to give a ton of talks at conferences. I was able to educate my peers, which I find very fun. Like I think it's great when family doctors can educate other family doctors. We're not always hearing from specialists. And it was just -

Dr. Rezmovitz:

We are a specialist.

Dr. Grill:

Fair enough.

Dr. Rezmovitz:

We're generalists.

Dr. Grill:

We are generalists. That's an excellent point. And you know what, it was fun. You know, I got to meet new people and network. So professionally , all of that training and just me putting myself out there has led to these career opportunities that has really given me a lot of job satisfaction and I think they've also helped me in the office because I can apply some of those population health principles to the patients I'm seeing.

Dr. Rezmovitz:

So saying yes, got you there. You took the risk.

Dr. Grill:

I took the risk. Yeah.

Dr. Rezmovitz:

Would you say that you are 100% qualified for the -

Dr. Grill:

I would probably say no. At the time I probably thought no. I mean, you go into these interviews and most of my mentors have told me over time that if you're willing to put yourself out there and you're willing to be honest sometimes you get an opportunity and then you make that opportunity - like you sort of - you make the best of that opportunity. And I can tell you that - and I still remember I went to Josh Tepper, who's now the CEO of North York General Hospital, a family physician, colleague. He's been one of my mentors over the years. I remember going to him after the first three months at the ORN and I said, I need some help figuring out how to navigate this job. And he gave me some really sound advice at the time. And then, you know, things got more comfortable and I was able to use the skills that I had to make the job work. And I'm really proud of the work that I did at the ORN.

Dr. Rezmovitz:

That's awesome. So then - you go ahead.

Dr. Grill:

So now you want to hear about the personal side?

Dr. Rezmovitz:

Yeah. Okay.

Dr. Grill:

So one of the things that you learn about in leadership courses, but until it sorta hits you, you don't appreciate it, is the idea of self reflection. And I'm a firm believer that not enough leaders in the world, even some of the ones I've come across have really opened themselves up to reflecting on their performance , their skillset , et cetera. And it's really interesting Jeremy because, as you remember - because I don't think we'll ever forget - in medical school and residency, it was all about feedback, right? It was constant feedback. Some of us have stories of it being a positive experience and other people have stories of it not being a positive experience. And yet when you move out into practice, I find that this sort of a performance review or evaluation, it kind of disappears, right? Like if we get into trouble with the CPSO, that's one thing. But if we're doing our job and we're competent, there's actually not that many opportunities where you get feedback from colleagues. I can tell you in my office , we don't do performance reviews for colleagues. We just assume that everybody's competent, they're doing good job. If there's no complaints, you sort of move on. And I wonder why we lose that when we go into independent practice. So the leadership courses really stressed a lot about self-reflection - ongoing reflection as we talked about earlier. And where it hit me the most the first time was I had a 360 degree review when I was working for Toronto Public Health. And this was even before I took some of these leadership courses. And you know, for people that don't know what a 360 review is, it's basically where you get people who report to you, who are on the same sort of work level as you, and the people you report to and they evaluate you and they evaluate you on your job description, on your personality, on your qualities, et cetera. So I went through this 360 review and I got one piece of feedback that at first was really surprising to hear. So I think it was something like, you know, "Dr. Grill when he sometimes is speaking to some of the inspectors, he speaks in a very authoritative tone that can sometimes be interpreted as almost demeaning." And when I got that from my 360 review, I almost couldn't believe it. I thought it was an outlier - like Alan Grill doesn't do that. He's a nice guy. He would never do that. And so I kind of put that aside. And then a few weeks later I was on call at Sunnybrook and Long Term Care and I was having a discussion with one of the nurses and I probably wasn't having my best day. And I had an interaction that left me frustrated with the phone call. And when I got off the phone call, my wife turned to me and said, "how did you think that phone call went?" She was in the room. And I said, "well, what do you mean?" She said, "well, you were a little bit hard on your colleague on the phone." And I sort of thought about it for a second and then she said, "you remember when you shared with me that comment on the 360 review? Do you want to maybe re-examine that comment?" And I'll be honest, Jeremy, that was a big aha moment for me because I realized that I had an area I needed to work on. I clearly needed to focus on how I was sort of interacting with colleagues, especially in a situation where I was being asked for my help and if my colleagues were feeling that way, after that type of interaction, I needed to change. Now I could've ignored it. But it meant a lot to me to come to that realization - that was kind of like an aha moment. And it's been something I've continued to work on over time. I try to keep a positive attitude. I try to remember that when someone's asking me for help, I need to be there for them. Just like when I go to other people for help, I want them to be there for me. And it's this whole idea of self reflection. When I ended up learning more about it in these leadership courses, it brought me back to that feedback that my wife had given me, who knows me very well. And I've really made that sort of a project over time to - and I've tried to teach other people as well. We have to be collegial. And if we work together as a team, we get a lot more things done.

Dr. Rezmovitz:

I think a lot of the time the reason people don't want to hear certain feedback is because it will fracture their egos. And as we go further and further in our careers, the ego grows. And it's really hard to hear that you've been doing something that hurts somebody else when we know that there's no intention to hurt someone else. If we could change the semantics of the term "feedback," because I think there's a post-traumatic stress of getting feedback from - there's so much feedback and constructive criticism, and how we view that, to something simple like information. Hi, here's some information for you. I've noticed this. Here's an observation, here's some information. You get the choice of what you want to do with it. And then I think people might be more susceptible to change than being told "here, we observed you. Here's some feedback. We think you need to change." Who wants to hear that?

Dr. Grill:

No, I agree. And you know, I think - I'm not an expert on human behaviour by any means, but I think just as human beings, we have a tendency to just get defensive when we start to hear things we don't like. And I couldn't agree with you more. You know, we're starting - there's all these - we're teaching residents now - sorry, we're teaching each other on how to talk to residents and medical students in terms of delivering feedback. I mean we're going to lectures on how do you actually give - we're getting feedback on how to give feedback. But you know, I find that in some of the leadership courses I've taken, they've actually given some reasonable advice on how to do that. And I think you hit the nail on the head in the sense that, first of all, if you develop a good relationship with somebody - like a good friend, I find that accepting feedback is much easier. You know, you can always couch it. I want to have a conversation with you. I feel comfortable talking to you. Can we talk about this as opposed to just bringing someone to a room, sitting them down, telling them what you didn't like about them and telling them to improve. So I agree with you. The approach is important. I think building those relationships over time so that you're open to feedback. But when it comes to leadership, I would say that I think you actually get more respect when you're open to feedback and you're open to change. I mean how many times - I guess I'm turning it back on you - how many times have you been in a situation where you thought you had a great idea about something, you shared it with someone and it went nowhere. And people may not even h ave a cknowledged that it was a good idea? I'm not so sure the next time you're g oing t o even want to go up to that leader and give them that idea or you're g oing t o even feel part of that team. So -

Dr. Rezmovitz:

You're talking to the wrong guy. I come up with like a hundred ideas a day. You know, if you say no, it's just getting me closer to the next idea. I take the Mel Brooks approach to generating ideas, right? Carl Reiner kept Mel Brooks around. They said, "how many ideas does Mel Brooks have in a day? Like how does that relationship work?" He's like, "Oh Mel Brooks comes up like a hundred ideas a day and they're all terrible." "So why do you keep them around?" "Because one Mel Brooks idea, you know?"

Dr. Grill:

Right. So what's interesting about that comment is you have an ability to self reflect on the fact that you don't take it personally and you just come up with the next idea. There's some people out there, it takes a lot of courage to go up to whoever's leading their group and actually express how they feel. And if they have one bad experience, they may never want to express it again. And I think that's a missed opportunity. So I would argue that strong leaders are always open to feedback because they're accountable. And accountability is all always about improvement. It's about being able to ask yourself questions - why are you doing things a certain way? And to be honest, like for myself, I ask a ton of questions all the time and I ask questions about myself too, and I'm open to them. Now, if there's an idea that comes up and I don't think it's the right direction, no problem. But I'm always open to hearing what other people have to say. That's how we get better.

Dr. Rezmovitz:

That's how we get better. Yeah. I couldn't have said it any better. So then what's the metric that you're using on how to know that you're making progress and getting better?

Dr. Grill:

Yeah. So I'm glad you brought that up because I have two answers. So going back to Sunnybrook - now, maybe it's just me drinking the Koolaid - but I actually feel that - and I still am affiliated, I still do call for the Long Term Care group at Sunnybrook on weekends, every once in awhile -I find that when I walk down the halls, I feel good when I bump into nurses, and nurses are saying hi to me. "How's it going, Dr. Grill?" I feel that that's gotten a lot better over time and I'm hoping it's because I've worked on that relationship in terms of being there for them on call when there's a situation that they're feeling stressed about, I'm there to support them and help them as they do for me all the time by the way, it's a two way street. So on a personal level I actually feel that it's had an impact. But you're right. What are the other metrics? So one of the things that I did at my family health team after thinking about this for awhile, and it's the first time my family health team has done this is I went to the executive director, which is kind of like the CEO of the family health team. It's a non MD. And I said, "I think we need to bring something up at our governance committee." I said, "I think I need a performance evaluation and I think we need to make it 100% transparent." And at first they were like, "so tell me more about this. Why do you want to do it?" And I said, "well, you know, first of all, I want to be evaluated because I want to know I'm actually doing a decent job." I mean I'm getting paid a bit of money for this. I'm leading a group. I need to know of how I'm doing. And I said "secondly, I need the group to know what other people are saying about me and that I can come up with a personal learning plan at the end of this. So that in a couple of years from now, if I don't meet those goals, either they're going to kick me out or they're going to say, 'why haven't you met those goals?'" So they were totally open to the performance review. They were surprised I wanted to make it transparent. And by transparent, what I mean is that we didn't have the entire organization evaluate you. We have like 80 staff. So we picked certain people that I work with closely that knew about my role, et cetera . We got them to do like - not a full 360, but something similar. Like a 180. Very good. Very good. Touche. And once the information was gathered , the governance committee looked at it confidentially, then they shared it with the director - the chair of our board who I report to. He met with me. And then I took that feedback and I kind of made a road show with it. So I put together a PowerPoint presentation with one of the members of the governance committee, Parm Singh , who is a wonderful colleague who has been very supportive of my leadership over the years. And her and I put together this presentation and we talked about how we put together the - how the whole process went. So it started with an idea. It went to governance. Here's how we pick the people to evaluate. We made that totally transparent. Then we put down some of the comments that I got in feedback - both positive and constructive. I won't say negative - constructive. And I talked about what I thought about those things. And then I even talked about what I was going to put in my learning plan to address that feedback. And we presented it first to the governance committee. Then we presented it to our board. We presented it to the interdisciplinary healthcare provider groups like the non MD clinical providers. We presented to the admin staff and I was fully transparent about what I thought of the evaluation and how I was going to move forward. And then we agreed that three years later we would do another one. So we're just at the time where we're going to repeat the evaluation. And in fact, just to add to that, we then started applying to give these talks at conferences. So the first place we presented it was that the Association of Family Health Teams of Ontario conference. And I'll never forget Jeremy, when we gave the talk and we got to the Q&A, people in the audience were like "I can't believe you're telling us about what your organization -" First of all, they said, "I can't believe you got evaluated, but I can't believe you're telling us what they said about you." And I said, "I will be fully transparent about any of this." And some of the people came up to us after. And then - when you're talking about impact and they said, "you know what? Can you send me your personal learning plan template? Can you send me the slides? I'm going to try to implement this in my group." And I've had people both in Ontario, because that's where family health teams are - and we've presented this nationally as well, that have actually written us back and said, "you know what? We've implemented something similar. Thank you so much. We never thought we could do this. And it's been very positive." So indirectly I had an impact even though I was just happy to tell the story. I thought it was a good story.

Dr. Rezmovitz:

It's direct. I don't think it's indirect. I think you've had a direct impact. Being vulnerable - allowing yourself to be vulnerable in your organization because of the goal of being better has made a serious impact in your organization. Your commitment to scholarship has improved others, right? Because you're going and presenting on this stuff. My question is how do we get this at every single academic teaching site at the Department of Family and Community Medicine in Toronto?

Dr. Grill:

I know it's a great question. And -

Dr. Rezmovitz:

And then beyond DFCM, how do we get it at the Faculty of Medicine so we can start evaluating the leaders but in us in the exact way that you described it from a transparency standpoint to allow improvement and to keep transparency?

Dr. Grill:

It's a wonderful question. So I think my first answer is maybe some people just haven't given it enough thought. You know, people are busy, they're doing a lot of different types of work - especially in academic centres. You're being pulled in a million different directions. My understanding - because I do get emails about this, like our chiefs - even when I was at Sunnybrook, I got emails saying, can you fill out this evaluation for the chief? But I never heard back about it. I never heard what came out of it. Was there going to be a change in direction of the leadership - whatever it was, how was it gonna impact me as a clinician? So the first thing I would say is that I think sometimes it takes one strong leader to go through this and that influences others. So, I don't look at myself as some huge influential person. I'm just - I'm one chief at one hospital. But maybe if we got a couple of chiefs at some of the bigger academic teaching centres - or maybe if the chair of our department decided to get an evaluation of that magnitude, maybe other people would follow suit and say, "well, if that person's doing it and it was a positive experience, maybe we should do it." And I think me telling this story, it was a painless experience, Jeremy. Like I wasn't hurt by the evaluation, my feelings weren't hurt. You know, listen. Some of the feedback, we improve the process in the sense that there were some people that would, there was a numerical score and there was a comment area, right? And some people put some low scores numerically but gave no comments. So when we do the evaluation this time around electronically, we're not going to let people move on unless they put something in the comment box because a number doesn't mean much. But you know, it was a painless experience. And I think maybe if some people realize that their professional growth is almost dependent on this type of feedback, they'll actually want to do it. You don't have to force them to do it. So part of it is, could we get the right influential person to do it and then tell their story. And I tried to do that in some of these conferences, but again, like I'm not putting myself down, but I'm just - I'm one small cog in the wheel, if you know what I mean.

Dr. Rezmovitz:

You are one small cog in the wheel. I'll confirm that. I'm kidding. No, this was brilliant. Absolutely brilliant. I guess the questions I have are, what barriers stood in your way to do this?

Dr. Grill:

So that's a great question. So first of all , I needed volunteers at my family health team to help me out. And again, I don't want to make myself sound like the model leader out there, I just happened to really like it. But you know, our colleagues are working very hard. There's been some political issues that they've had to deal with, with the OMA and the government. The work environment isn't the greatest right now. And so our colleagues are doing their best to manage their patients and I think a lot of them are saying, I don't know how much time I want to give outside of that. I mean you just did a podcast on work-life boundaries. I think a lot of people are looking at that very seriously these days. So we had to find some volunteers to help us out. And again, I was able to get my executive director on board . I mean it's part of their job so that wasn't so tough. The governance committee, I needed one volunteer to help me move this forward because if it was just me doing it, there's obviously a conflict of interest, right? The guy who's being evaluated setting the questions? I'm not sure that's the best way to do it. And again, Parm Singh was, was outstanding in giving her time. And then once we convinced the governance committee to go ahead with it, we made it easy, right? So we said, "I'll tell you what. We'll come up with the questions - the three of us. And once we come up with it, we'll let our IT person whose job it is to just put it in an electronic format" - so that that wasn't too much of a stretch. We got another volunteer who happens to be a community member on our governance committee who has expertise in evaluations collate all the information. So she was happy to do that. She was already volunteering. And all the board chair had to do was carve out an hour of his time to meet with me and I was flexible. I was willing to meet with them first thing in the morning, at lunch, after work. So I had to be flexible too . So once you actually put - it's like baking. I'm not great at baking. I bake cookies the other night with my daughter. Once you have the ingredients list and you have a willing party, it's actually not that hard. And once the process was put in place , it was just a matter of replicating it. So the boundaries was getting the volunteers. I think the other boundary is these things had to be sent out by email. Right? How many emails are we getting these days? So does everybody answer it - what, right away? No. So we have to bug them a bit. That's always a barrier. And then finally, I guess I had to carve out some time to present this stuff, but I was happy to do it. So when you find somebody who's passionate about something and you feed that passion, people tend to do it.

Dr. Rezmovitz:

Alan , I'm going to feed your passion right now. I'd like to challenge you. I'm the lead for CPD in this department and I'd like to work with you on how we can implement this in the Department of Family and Community Medicine for leaders and how we can push this to the Faculty of Medicine through the office of CPD, Continuing Professional Development because I think it is a brilliant idea. I think you've done the groundwork. I think we can create a package, the ingredient list, and I think we can package it out and make excellent scholarship for the Department of Family and Community Medicine to set the tone to set the road, the set the path, if you will. Do you know about the rider, the elephant and the path?

Dr. Grill:

I don't think I know that one .

Dr. Rezmovitz:

You don't know that story? So there's the rider who's on top of the elephant. There's the elephant who's, you know, a thousand pounds obviously or more. How much does an elephant weigh? Depends if it's a baby elephant, obviously. And there's the path. The first thing is to convince the rider which direction. The rider represents the logic. Where do I want to go? The rider decides I want to go somewhere. The elephant represents emotion. Even if you want to go somewhere logically, sometimes you lack or you have a hard time convincing the motivation or the emotional component of yourself to move. That is the elephant. If you put up the rider against the elephant, the elephant always wins. Always. If there's going to be a conflict. But let's assume for a second that people actually buy into this idea. Actually beyond buy-in. Brenda Zimmerman's frontline ownership is way better.

Dr. Grill:

Take ownership.

Dr. Rezmovitz:

Take ownership on this, right? Create the transparency, create the opportunities to be better. Role model being better from the top. So the rider aligns. The elephant aligns because we have the passion enthusiasm to do this. But we have to make sure the path is clear. And it takes the environment and the context to make sure the barriers are free so that we can move this elephant and the rider in the right direction. And my challenge to you is let's do this.

Dr. Grill:

I am happy to work with you on this. We have the - how did you put it? Like we have the groundwork and I think Parm Singh and I would be more than happy to share all of the information.

Dr. Rezmovitz:

Champion it.

Dr. Grill:

We could champion it. And again, I think it would make our department stronger. I mean everybody has an opportunity to get better. And the best way to get better is to have the people you work closely with give you some feedback. And by the way, the other thing I'll just say is that - and I want to take this back to patients because you said to me, can you give me an example of where it's impacted your patients? So I'll give an example. Early in my career when I would have an interaction with a patient that I didn't think would go well, my first reaction would be that patient doesn't know what they're talking about. It was the patient's fault that they reacted this way. It wasn't me. I did everything I thought was professional. It's an outlier. And then over time, what I've come to realize is that there are some situations where you get feedback from patients and you would have done everything - if you had a second chance, if you had a magic wand in a second chance to do it again -

Dr. Rezmovitz:

It's family medicine. You always have a second chance.

Dr. Grill:

Exactly. But if you had a second chance to repeat it, you might do everything exactly the same. But here's the difference. There was always a nugget in every piece of feedback you get - even the feedback where you're 99.9% convinced that person on the other end of that conversation got it wrong. There was something to be learned about that. And here's one example. I remember that there was one time where I think I phoned a patient about some information that I got. It wasn't urgent, but I didn't phone right away after I got the result , I think I waited a few days or maybe I read it, thought I was going to do it and then remembered a few days later. And I remember the patient saying that they would have appreciated hearing it earlier because they were sort of nervous about it. And you know, I could have said, "well, why didn't you call the office" or "it takes a few days to get that report back." But I acknowledged that even though I didn't mean to make them feel that nervous, I acknowledged their feelings. And since that time I have tried my best - as I'm sort of wading through all of the EMR reminders that we get - I've made a conscious effort that if there's a certain test or report that I think a patient wants to hear back relatively quickly, I make that effort to call them quickly. So even that piece of feedback where I didn't think I necessarily did anything wrong, it has impacted my approach to those situations.

Dr. Rezmovitz:

That's amazing. We have time for one more comment and my comment to you is going to be. if they only knew, I'd like you to finish the sentence. If they only knew. And it can be any system. You can speak to any system that you want. It can be a patients , it could be to colleagues, it can be the leaders, it could be to your kids, any system.

Dr. Grill:

I'm going to answer that with a piece of advice that one of my profs gave me years ago. It doesn't matter where it came from. Do you remember when we were kids and - well, at least in our house - every once in awhile we'd get a box of those sugar cereals - the ones that are really bad for you?

Dr. Rezmovitz:

They're fantastic for you - acutely. Chronically - I think they're really - if we're going to speak in binary comments, then yeah, I think chronically they're poor. They're poor for you. But acutely they raise your blood sugar and you feel invincible.

Dr. Grill:

Right. It's temporarily.

Dr. Rezmovitz:

Yeah, it's acute.

Dr. Grill:

But you know why I really liked those cereals? It wasn't necessarily the taste of the cereal.

Dr. Rezmovitz:

It was the marshmallows?

Dr. Grill:

Nope, it was the prize. It was the toy that you sometimes got. And I still remember there would be mornings where my older sister and I would run down to the kitchen to try to see who could get their hands on the box first to rip it open and get the prize. And looking back, the prize was always - it wasn't a great prize, right? Like it was sort of cheap. It would break. It might last a day then you wouldn't even care about anymore. But one of my profs finished a course by saying - I think the quote was, "life is like a box of cereal. Never stop searching for your prize." And I have to say that the excitement I had as a kid towards that prize, it would be nice if we all kept that type of excitement towards our personal lives, our careers. And in order to do that, like I said earlier, I think we have to work on reinventing ourselves and finding things to do. So my advice 20 years ago would be Alan , keep an open mind, try new things and it'll probably work to your advantage moving forward.

Dr. Rezmovitz:

I definitely agree. And I want to thank you so much for coming in today and having this chat.

Dr. Grill:

Thanks Jeremy. It was my pleasure.

Dr. Rezmovitz:

Take care. This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullen , Ryan Silva , and the whole podcast committee. Thanks for tuning in. See you next time.