What Healthcare Leaders Will Take Away
This episode is for healthcare executives, clinical leaders, physicians, and nurse leaders who would say, sincerely, that they would never exclude anyone. Natalie Holder, Esq. SPHR, is an employment lawyer, executive coach, and the founder of QUEST Employment Initiatives. She is the author of Exclusion: Strategies for Improving Diversity in Recruitment, Retention and Promotion, which she now describes as a field guide to the top ten indicators of a broken workplace culture. In conversation with Dr. Lillian Liang Emlet, she makes an argument that lands harder than a discrimination claim: intent is beside the point, because the damage comes from patterns nobody names.
Listeners will take away four things. First, why well-meaning clinicians make biased decisions under pressure, and Holder’s own family’s story of what that cost. Second, the in-group/out-group dynamic that sits underneath every indicator she studies. Third, six of those indicators, described concretely enough to recognize on your own unit. Fourth, her answer to where a leader should start, which is not a values statement: “There’s nothing like making decisions that are based on data.”
Holder is not asking leaders to feel guilty. She is asking them to look at what their own numbers already show, and then to look at their own story.
Can a Leader Who Would Never Exclude Anyone Still Be Running an Exclusionary Culture?
What closes that gap, in her account, is pressure. Under a full load, people reach for a story. Faced with competing exigencies, she says, “we immediately go to the story, the narrative, whatever is our understanding that helps us to cope in that moment.” She gives clinical examples of what those stories sound like from the inside, assumptions that a community will not follow directions, cannot get to the office, or does not care about its own health, and describes care being administered accordingly.
Dr. Emlet adds the clinical version. Anyone can walk through the door, so “you will always get a zebra,” and a brain running on pattern recognition under load is exactly the brain that misses one. Her read is not that clinicians are careless but that “we are so overtaxed and the system is all built against us, against the clinicians and also against the patients.”
How Does a Leader’s Bias Actually Reach a Patient?
Her grandmother had sepsis. She was admitted only because her mother knew the system and knew who to escalate to. Holder is direct about the counterfactual: “but for my mother’s advocacy,” her grandmother “would have died.”
The physician later called and apologized, explaining that he had not understood what was happening. Holder’s mother’s reply is the line the episode turns on: “No matter what was happening in that moment, you did not see your patient. You instead saw a statistic, and you treated her as one.”
Dr. Emlet’s response is worth sitting with, that most people in healthcare have a version of this story about themselves or someone they love, and that needing advocacy and health literacy simply to access care is itself the first problem.
What Are In-Groups and Out-Groups, and Why Do They Matter So Much?
She defines the in-group by affinity rather than intent. “In-groups are the groups in where I see myself in you. I feel some sense of affinity. I feel comfortable around you.” The basis can be almost anything, shared pedigree, the same schools, the same race, the same cohort, the same gender. And the consequence follows automatically: everyone she does not feel that affinity with “they’re now in my out-group.”
Holder does not ask leaders to eliminate this. She treats the inclination as natural and asks a narrower question: “how do we make sure that even when we do have that natural inclination to create an in-group versus an out-group, that we’re not working against each other?”
The reason it matters beyond fairness is her central claim, and she states it as a spillover rather than a moral: where these indicators are showing up, most likely “it’s not just impacting these out-group members, but it’s also impacting your customers, your clients, your patients. It really, once again, is the ecosystem.”
She illustrates the spillover with a store. Watch how a manager treats their people and you can predict the service you are about to get, because “it oftentimes comes from who that leader is.” Her work with healthcare teams moves the same lens from the microscopic view of disparities to a macro one: how a team treats each other shows up in what patients receive. Episode 112 takes the same systemic view of a team from the coaching side: how teams think within the system.
When the numbers have not moved
If your culture scores or retention numbers have not moved in a year, that is the signal Holder is describing. Book a clarity call and we will look at what your data is already telling you.
What Are the Signs of a Broken Workplace Culture?
- A lack of informal mentoring. Mentoring, in her definition, is “that ability to give someone real-time feedback that can either help identify where their strengths are or identify where their weaknesses are.” The problem is who receives it: there is a “higher likelihood that you are going to provide informal mentoring to that person who’s in your in-group.” Her clinical example is a colleague tipping you off about which question to raise at grand rounds, and what that does for how you are then seen. Without it, “this is someone who flounders because they have to basically figure out all on their own.”
- Bullying. Not shouting. “Bullying is intimidation that is meant to denigrate another individual,” and today it shows up as not being invited to meetings you should be in, as “the meeting before the meeting or after the meeting that doesn’t include you,” and in the wording or tone of an email.
- Dual identity. “It’s the fear of not being able to be yourself in the workplace”: pretending in order to belong, and weighing whether a cultural element that is part of who you are will be teased. Her example is deciding, as she puts it, “maybe sometimes,” not to bring a certain meal to work for fear of the question that follows. The cost is having to “traverse two different worlds.”
- Isolation. The experience of “feeling as though you don’t really have anyone to identify with,” which she ties to being the first of anything, the first in a practice area, the first woman, the first African American, and to whether real supports exist for that person.
- An inability to recover from mistakes. In-group members get grace, often in the form of a leader saying “I made a mistake like that when I was your age.” Out-group members are treated “as though they are persona non grata” for the same error. The distinction she draws is that “their mistakes are not who they are.”
- Insensitivity, and the inability to engage in civil discourse. Comments, images, and depictions of someone’s culture or identity delivered as a joke. When that becomes the texture of a workplace, she counts it as an indicator.
She also gives a worked example of how bullying gets disguised. A quality-assurance clinician stepped in where a physician’s team did not feel safe and resolved it; the physician responded with a nasty email that copied her boss and told her she had failed at building cohesion. Holder’s reading: “You didn’t allow him to be the hero of the story. That’s what he’s upset about.” The email was not feedback. It was a message that she was not competent. Naming that kind of exchange out loud is its own skill, and it is the subject of our conversation on difficult conversations in healthcare.
Where Does Accommodation Fit, and Why Is Healthcare Harder Than She Expected?
Her example is a nurse with diabetes who needed to eat periodically to keep her glucose up, and colleagues who read it as favoritism: “No one else is allowed to eat on shift. Why is she allowed to eat on shift?” Holder’s answer is the legal definition, plainly stated, that an accommodation means “providing the opportunity for this person to work in your environment with an accommodation that allows them to do their job,” and that colleagues with questions should take them to a supervisor rather than to the employee.
Dr. Emlet extends it past the clearly physiologic case to cognitive processing and workplace adjustments, where the need is less legible and the accommodation conversation is correspondingly harder.
When the same people go quiet
Leading a team where the same people keep going quiet? Our coaching for healthcare teams and leaders is built for exactly that conversation.
Where Should a Leader Actually Start?
Her standing instruction to prospective clients is a filter: “Don’t call me until you’ve looked at your data.” Her reasoning is unsentimental about how change actually survives contact with a working week. If someone calls while the motivation is a feel-good impulse, then “when I provide you with the hard work it takes, priorities now take place, and you don’t have the time or the interest or the passion anymore.” A real number, patient-care metrics off target, culture scores off target, psychological safety off target, supplies a why that outlasts the impulse. She acknowledges the objection directly, that we should want to change for humanistic reasons, and answers that change costs financial, emotional, and time commitments that other priorities will otherwise preempt.
Then she turns the lens on the leader:
- Ask how you were trained to lead. Many people are handed leadership because they were good at the work, and organizations “conflated being good with your job with being a good manager.”
- Ask what training you have actually done to lead across not just demographic diversity but geographic and cognitive diversity too.
- Ask what your own story is. “Where did you develop your understanding of other groups, heterogeneous groups? Where did that come from?” And then: what are you telling yourself about the people on your team?
Her stated goal for any leader is generative rather than corrective. She quotes a saying, “Leaders who don’t create new leaders haven’t led,” and defines success as the people on your team being able to see what a real leader looks like and wanting to become one. For a companion route into the same self-examination through a team lens, see what team personality differences reveal.
What Should a Leader Do Once They Can See the Pattern?
Her claim for what naming does is modest and worth keeping modest: “sometimes just saying it is enough.” Being able to tell a colleague that you did not feel a certain way but their action landed that way, and hearing it acknowledged, can be the opening for a different way forward.
Holder’s closing addition is about the signal that started it. Whether it came from data or from something “gnawing at you a little bit” more internally, the discipline is the same: “it’s not ignoring the signal and doing something about it.”
Key Takeaways for Healthcare Leaders
Frequently Asked Questions
Can a leader with good intentions still create an exclusionary culture?
What are the indicators of a broken workplace culture?
What does workplace bullying look like if nobody is shouting?
How does excluding staff affect patient care?
Where should a healthcare leader start if they want to change their culture?
Who is Natalie Holder?
Keep listening
Prefer to keep listening? More on leading clinical teams is in the Leadership Collection.
Episode Transcript
Download transcript (.txt) ↓︎Segment 01
The ecosystem, not the exception (From 00:00)
Cold open: Holder names her own bias toward people getting the care and help they need, calls coaching an investment in the relationships around you, and states the claim the episode builds on, that where these issues show up they most likely reach past out-group members to patients and clients.
Segment 02
Meet Natalie Holder (From 01:00)
Dr. Emlet finishes the hook, an employment lawyer who has spent two decades inside healthcare systems, federal agencies, and law firms and found the same pattern everywhere, and introduces her guest and QUEST Employment Initiatives.
Segment 03
The book, and why this conversation (From 02:00)
Holder’s background across human resources and law firms, her discrimination litigation, and her thought leadership on culture and harassment-prevention training, plus her work on recruitment and retention barriers. Her book Exclusion is named, along with the plan for the episode: how subtle bias erodes engagement and innovation, and why the work is unfinished even though most people believe things are improving.
Segment 04
From physical therapy to journalism (From 03:00)
Holder’s path: a physical-therapy start in a family full of nurses, a work-study student who skipped showing her work because classroom minutes cost money, a chemistry professor who wrote that she did not have the methodical mind to be a scientist, and the switch to communications.
Segment 05
The clipping that changed the plan (From 05:00)
A Newsday clipping of a mother and son facing the legal system, and the question that redirected her, who had the greater ability to help this family, the journalist or the lawyer. She chose advocacy, and Tulane Law over journalism school.
Segment 06
Intent is not the test (From 07:00)
Holder grants the sincerity first, most people will say they are equal opportunity and that they love people, and extends that good faith to clinicians, describing the heart and desire to relieve suffering that draws people into the profession.
Segment 07
You did not see your patient (From 08:00)
What the work takes, a grounded person with real empathy, and then the gap Holder names between intent and the background, motivations, and history that shape decisions. Her grandmother, an immigrant with sepsis, sized up on socioeconomic grounds and left unattended; her mother’s advocacy as the reason she survived; and her mother’s reply to the physician’s apology.
Segment 08
The stories we reach for under pressure (From 10:00)
What the coping narrative sounds like clinically: assumptions about which communities follow directions, which can reach the office, and which are presumed not to care about their own health, with care administered accordingly.
Segment 09
You will always get a zebra (From 11:00)
Holder frames her aim as getting people to stop and examine how and why they are deciding, especially where the stakes are life and death. Dr. Emlet on how common this experience is even for people inside the system, and on pattern-recognition under load: anyone can walk through the door, brains get lazy, and a system built against clinicians and patients alike makes biased mistakes easy. Holder agrees that something in the healthcare system needs to change, and names her own role: helping clinicians see how their decisions reach colleagues and patients alike.
Segment 10
From disparities to team dynamics (From 13:00)
Her store analogy: good service or shoddy service oftentimes traces back to who the leader is, and how that leader treats their people.
Segment 11
Why leaders first (From 14:00)
The macro lens, how teams treat each other feeding the care patients receive, and Dr. Emlet on why Transforming starts with leadership and wellbeing coaching before systemic team support, so that well leaders have capacity to give to their people.
Segment 12
Coaching as an investment (From 15:00)
Holder on her mother’s nursing team, where so much of the pressure, dysfunction, and conflict rested on the individual and services like this did not exist. Dr. Emlet on how hard it still is for people in healthcare to believe they deserve this kind of support, and Holder’s own stated bias: coaching is an investment in yourself and in the relationships around you.
Segment 13
Belonging, and the study behind the book (From 17:00)
Dr. Emlet on loneliness, social connection as a social determinant of health, and why understanding belonging means understanding exclusion. Holder answers with the conference research that shocked her: two case studies presenting with the same symptoms, a Black patient and a white patient, drawing markedly different proposed care, which sent her to propose a healthcare-disparities conference viewed through a workplace-dynamics lens.
Segment 14
In-groups and out-groups (From 20:00)
Affinity, shared pedigree, schools, race, cohort, gender, forms the in-group, and everyone else becomes the out-group. Holder’s question is not how to eliminate the instinct but how to keep it from working against the team.
Segment 15
The first indicator: informal mentoring (From 21:00)
Why a lack of it signals a broken culture. Mentoring is the ability to give real-time feedback that identifies someone’s strengths or weaknesses, and there is a higher likelihood you extend it to the person in your in-group, the person you feel safe with.
Segment 16
An ecosystem question, not a review question (From 22:00)
What happens to the person who gets no informal mentoring: they flounder, figuring it out alone, while a colleague’s tip about which question to raise at grand rounds quietly shapes how someone else is seen. Then Dr. Emlet on how the annual review reduces all of this to one question about your boss, when the real subject is the whole team’s peer support, and on having felt both in-group and out-group herself. Holder answers the request for the list by naming bullying, and by noting how much more subtle these behaviours have become.
Segment 17
What bullying looks like now (From 24:00)
Bullying without shouting: the excluded meeting, the meeting before the meeting, the tone of an email, plus the quality-assurance clinician whose success was met with a message undercutting her competence, and Holder’s reading that she had not let him be the hero of the story. Then dual identity: the fear of not being able to be yourself in the workplace, and pretending in order to belong.
Segment 18
Isolation, mistakes, and insensitivity (From 26:00)
The cost of traversing two worlds, one at work and one at home; the isolation of being the first of anything and what supports exist for that person; the grace extended to in-group members after an error but withheld from everyone else; and insensitivity, identity delivered as a joke, as the last indicator Holder names here. Dr. Emlet then leaves the rest to the book as a teaser.
Segment 19
What people hesitate to ask for (From 30:00)
Dr. Emlet on how hesitant people in the out-group feel about asking for what they need, accommodations for religious holidays, time off to celebrate, being able to dress and show up as their full selves at work, and on how often this comes down to simply not understanding another culture. Holder names healthcare as one of the most surprising areas she has found for how difficult the reasonable-accommodation conversation becomes.
Segment 20
Accommodation is harder here than you would think (From 31:00)
The nurse with diabetes and colleagues who read her accommodation as special treatment, plus Dr. Emlet extending it to neurodiverse conditions, where the need is less legible, and asking what self-examination a leader should do first.
Segment 21
Start with your data (From 33:00)
Holder’s answer: evidence over sentiment, her don’t-call-me-until-you’ve-looked-at-your-data filter, and the honest reason why, that motivation without a number does not survive competing priorities. The signals she names are patient-care numbers, culture scores, and psychological safety.
Segment 22
How were you trained to lead? (From 35:00)
Whether being good at the job was conflated with being a good manager; what training you have actually done across demographic, geographic, and cognitive diversity; where your understanding of other groups came from; and the saying she offers, that leaders who don’t create new leaders haven’t led. Her stated goal is that the people on your team can see what a real leader looks like and aspire to it, which Dr. Emlet ties back to awareness as the very first step.
Segment 23
Awareness, and the neutral outside voice (From 37:00)
Dr. Emlet on running the race without stepping back, on metrics that will not budge year after year, and on why external people can surface franker conversations, and on what a frank conversation can surface about how people are actually making each other feel.
Segment 24
Do not ignore the signal (From 38:00)
Dr. Emlet’s modest claim that sometimes just saying it is enough, that naming how something landed can itself open a new way forward. Then Holder’s closing discipline: whatever prompted the impulse to change, whether a number or something gnawing at you more internally, the work is not ignoring the signal and doing something about it.
Segment 25
Where to find her (From 39:00)
Dr. Emlet on why this work needs someone trained to hold the space and who knows what everyone’s rights and options are. Holder points listeners to her website and its resources, including her work on Gen X employees approaching pre-retirement, and makes the case that helping one heavily-impacted segment lifts the whole organization.
Segment 26
Closing (From 41:00)
Dr. Emlet thanks Holder for a topic that rarely gets discussed, and invites listeners to send topic ideas and to pass the episode on by liking, subscribing, and forwarding it to leaders in their own ecosystem.
Read the full transcript
Transforming Healthcare Coaching Podcast — Episode 116: Exclusion and Belonging in Healthcare Leadership. Host Lillian Liang Emlet, MD MS CHSE CPC ELI-MP in conversation with Natalie Holder, Esq. SPHR. Published July 6, 2026.
Natalie Holder: I'm highly biased in terms of people getting the care that they need, people getting the help that they need. And there's nothing wrong with investing in yourself. Coaching is an investment, not just in yourself, but it's an investment in the relationships that surround you. The reality is that if these ten issues are showing up in your workplace most likely, it's not just impacting these out-group members, but it's also impacting your customers, your clients, your patients. It really, once again, is the ecosystem.
Lillian Liang Emlet: What if the thing quietly fracturing your team isn't about workload, pay, or the pace of medicine? What if it's something so subtle, so invisible that most leaders never see it? Not a policy violation, not a dramatic incident, just a slow accumulated experience of not belonging in the room. My guest today is an employment lawyer who has spent two decades inside healthcare systems, federal agencies, and law firms, and she has found the same pattern everywhere she goes. The thing that's actually quietly costing your team isn't what anyone talks about. It's what no one talks about. This is the Transforming Healthcare Coaching Podcast, and today we're talking about what it actually takes to build a team where every single person can do their best work and have belonging. So Natalie, it's so wonderful to have you here with us.
Natalie Holder: Thank you, Lilly, and it's a pleasure to be here. Thank you.
Lillian Liang Emlet: So I just want to introduce you to everyone. So Natalie Holder, Esquire, is the founder and president of Quest Employment Initiatives. It's a firm dedicated to helping organizations build cultures grounded in respect, accountability, and belonging. As an employer lawyer, she's graduated from NYU. she's been in both, human resources and also, legal firms, and she served in the New York City, mayor's office. She has litigated cases on discrimination. She has provided context, culture, thought leadership about how culture and harassment prevention training really can work. And she really has been one of the key people helping behind the scenes to help dismantle barriers for recruitment and retention of various different underrepresented minorities, in the workplace in many different healthcare and public sectors. And so we're really lucky to have her. She's also the author of Exclusion: Strategies for Increasing Diversity in Recruitment, Retention, and Promotion. And we're going to talk today about how subtle bias erodes the engagement and innovation in the workplace. And it's something that we all think is getting better, and yet there's still so much work to be done. So thank you, Natalie, for being here with us.
Natalie Holder: Thank you, Lilly. And I'm looking forward to this conversation
Lillian Liang Emlet: And so you came up through journalism actually before you pivoted to law. And so I'm curious at what point did you realize that law was probably the most powerful vehicle, law being more powerful than journalism, for the communities that you want to protect and help and serve?
Natalie Holder: So when I started my career in undergraduate, I decided that, "oh, I'm actually going to start off as a physical therapy student." So Lillian, I don't know if you know this, but I initially went to college to become a physical therapist, and it wasn't a stretch for me because everyone in my family was in healthcare. My mom was a registered nurse. All of my aunties were registered nurses. my uncle was a neuro, was a neurologist, and so everyone was in some way involved in medicine. And so I figured, "Oh, I'll be a physical therapist." And, that very quickly just flamed out when I took my first chemistry course and the chemistry professor was adamant about showing your work. However, I was a work study student, and so every minute I was in class it was costing me money, if that makes any sense. And so I felt like if I know the answer, I'll just put it on the paper and I can get back to work. had books to pay for, had a dorm to pay for, all the things, right? this professor wrote on my paper, "You do not have the methodical mind to be a scientist." And I thought, "Okay, you know what? Yeah, I'm good. I'm done." And, I decided to, switch into a different, major, which was communications. I loved it. It was a natural fit for me, and I enjoyed telling stories. I enjoyed crafting the stories. I enjoyed, where the story came from, and really digging into the who, what, when, where, and why of an issue. did wonderful internships. To this day, Scholastic was one of my best internships ever, writing for one of their professional magazines. when it came time to graduate from undergrad, when I was getting ready to graduate from New York University, I realized, "Do I really want to be a journalist, though?" There was a story at the time that, I can't remember all the details, but it was a very heart-wrenching case that involved a mother, a son, and the legal system. And I had the clipping from Newsday. I grew up in Long Island, and so Newsday was our newspaper, our local newspaper. And I remember cutting out the clipping of this mother and son who were holding each other- the face of this major legal criminal issue that they were about to face. And I thought to myself, who has the greater ability to help this family right now? it the journalist or is it the lawyer who's going to potentially represent this young man? And once again, I can't remember all the details, but I do remember I clipped out that story. me in that moment, I realized that I enjoyed also being an advocate. So not just telling the story, but also being the advocate for the person and also being that person who could help to change someone's trajectory. And journalists do that all day, every day, don't get me wrong. But I wanted to do it from an angle in where I was also interfacing directly with our legal system. And so instead of going to journalism school, I decided to pack up and go to Tulane Law School
Lillian Liang Emlet: Amazing, right?
Natalie Holder: Louisiana.
Lillian Liang Emlet: Yeah. you know, it's such a powerful thing, like how we communicate and how we share the stories and how are we thoughtful in that process really is a great foundation for going on to your legal career. And so to get into it, the reality is a lot of times I hear from other healthcare leaders, "Well, I would never intentionally exclude anyone." and I believe them. I don't think any of us ever intentionally mean to exclude someone on our team or in the workplace or with our patients. But your work suggests that the intent is really beside the point. And so I guess I'm curious from your perspective, having worked in the healthcare sector, and being a lawyer and seeing how the cases come up and seeing the stories evolve on both sides, how do well-meaning leaders end up creating really exclusionary cultures without even realizing it?
Natalie Holder: most people, yes, will say, I am not someone who engages in any sort of bias against anyone. I am equal opportunity. I love people. And please understand that as someone who has a lot of family members who are in the healthcare professions, I know that healthcare professionals go into that profession with a heart and a desire to see human suffering from a very different angle, to be in a place in where you are helping to make sure that human suffering does not occur. that takes a very grounded individual. That takes a person who has a great deal of not just sympathy, but empathy for pain, for suffering, and even diagnosing someone's issue. However, I have also seen in where one's intent is not necessarily aligned with what their true interests are or what their background and what their motivations might be, or even the history that shaped them and their understandings of other people and how they see other people. I remember my grandmother was, very ill at one time, and my mom, who was a registered nurse, brought her to, the, the healthcare, facility. And the doctor, who was very, overwhelmed that day, at my grandmother, who was an immigrant, not from this country. she immi- immediately sized her up on socioeconomic basises and determined, "I just don't have time for you today," basically left my grandmother there to not be attended to. And but for my mother's advocacy and my mom understanding the system and understanding who next-- who she had to speak to, my grandmother would have died because she had sepsis. so she was immediately admitted into the hospital, that doctor called my mom and apologized profusely and explained, "Oh, I'm so sorry. I didn't understand what was happening." And my mom in that moment said, had a greater duty. No matter what was happening in that moment, you did not see your patient. You instead saw a statistic, and you treated her as one." so that's how sometimes we allow our of this world to impact the decisions that we're making. We're not really intending to necessarily mistreat someone. But when we are faced with, a number of other exigencies, we immediately go to the story, the narrative, whatever is our understanding that helps us to cope in that moment. So if it's that "Oh, I have a greater priority of, looking after a patient who has greater means because I'm concerned about a lawsuit for not being able to attend to that patient," that might be what shows up in someone's care. If it's that, "I understand this community a little bit better, so I'm going to administer care that is aligned with what I understand this community is needing. I'm going to provide it." If I don't feel that this community is going to listen to me because, typically this is a community that doesn't follow directions. This is a community that doesn't have the resources to get, to, to get to my office. This is a community that I don't believe even cares about their own health care. I am going to administer care accordingly. as I looked at healthcare disparities, this was something that I wanted to make sure was making sure that people actually stop themselves and really understand how and where and why are they moving forward with the decisions that they're making, especially when we're talking about life and death.
Lillian Liang Emlet: Wow. One, that's a really powerful story, and I think unfortunately, all of us in healthcare have either experienced something similar or have a friend or a colleague or a loved one who also has experienced maybe something similar. I think that's what's scary, that happens even if you are inside the system and you know what's, what needs to happen and to have the advocacy and health literacy just to survive being a- able to access care, in general is problem number one. And then problem number two is I would say the system makes it so hard that depending on where you work, if you don't have diversity and awareness of the other ways anyone can walk through your door. So you have to keep an open mind, even if 90% of your, community is one potential, socioeconomic factor or, things that you would tend to see over and over again. You will always get a zebra. And so we always have to train to be ready to be able to handle anything. And I think we often, we get lazy. Our brains get lazy. And if we don't have the advocates to be able to partner with to be able to not make those mistakes, it's really easy, is what you're explaining to us, to make those biased mistakes without even realizing it, because we are so overtaxed and the system is all built against us, against the clinicians and also against the patients.
Natalie Holder: Absolutely. And, there needs to be something that changes in our healthcare system. And I mean, look, that could be a two-hour show
Lillian Liang Emlet: You're right.
Natalie Holder: of the different areas of our healthcare system that really do need to be refined, that need to be updated, that need to have more of a humanistic approach to it. absolutely. However, my job and my goal is to be that person who helps clinicians how and where their decisions impacting not just their colleagues, but also the care that they're giving to other people. Because that... There's something that, there's something, in the research that I did that shows that, seen it, Lillian. When you walk into a store, let's take a store as an example. When you walk into a store and you can see how a manager is dealing with their people how their people then impact you as the customer, you can tell really good service versus really shoddy service, and it oftentimes comes from who that leader is. Because if that leader is the person who is denigrating their people publicly, or if that person doesn't have any sort of, demand for good customer service, it shows up in how the customer is receiving that service. And so similarly in healthcare When I've worked with teams, it's helping them to understand that this is also not just about looking at what are the healthcare disparities and looking at healthcare disparities from this very, microscopic lens. It's now looking at it more macro and understanding how do all of us, how do our teams impact how we're working with each other and how does it then lend to the service that we're giving to our patients.
Lillian Liang Emlet: So key. And I really love the business analogy because the reality is, when we see a good business, we also become loyal to them. And I love what you mentioned about the, when the managers care for their teams, then it just, it trickles down and s- and becomes evident. And that's actually part of the reason why we started transforming was because we feel like leadership coaching, leadership plus wellbeing coaching for the leaders then translates into our systemic team support that we also provide. Because it really is about making sure once the leaders are well, you can embody and have capacity to be able to give to the people on who you're working with, and then they get empowered, and then they give to your end result, which is, in business it's the client or the customer. in healthcare, it's the patient and their families. I mean, part of the reason, it's just that we don't have capacity often, that whether that's from leadership or that's the front lines, it's just so challenging. and so it...
Natalie Holder: wish that
Lillian Liang Emlet: Yeah.
Natalie Holder: knew about your ser... So my mom is long retired now. My
Lillian Liang Emlet: Oh
Natalie Holder: almost 20 years now. However, she and her team so could have used services like yours because at least back then with nursing, so much of the pressure, so much of the dysfunction, so much of the conflict of a team rested on the individual. being able to actually sort through those issues, being able to understand and ha- and actually just even articulate those issues, not in a sense of, a therapy session, but instead of a ses- in- instead of in a sense of how do I now take the tools I know and do something different with it? How do I take action, the action that I know lives in me and doing something better with it? Coaching, I can only imagine, has really probably, greatly impacted healthcare in a positive way.
Lillian Liang Emlet: we hope so. I think what's interesting is that the penetration of coaching services for different people right when they need it is still a really hard thing for people to recognize. And in the end, I think a lot of times in healthcare, people don't think that they necessarily deserve to have something like this, and they don't seek it out. there's something about just always just shouldering on and being tough, and it's, it does, it's a big culture change in general.
Natalie Holder: very necessary, culture change. I high- so I'll admit, now this is my bias. I'm highly biased in terms of people getting the care that they need, people getting the help that they need. And there's nothing wrong with investing in yourself Coaching is an investment, not just in yourself, but it's an investment in the relationships that surround you.
Lillian Liang Emlet: Right. Right. Well, I think, I just wanted to, transition a little bit away from the coaching and instead focus a bit on your book. So your book is called Exclusion. And I think what I really love about that title is because, we think so much about, at least I do, about how can we have increased belonging? How can we combat loneliness? How can we change, really society where we are now so very individualistic to instead realize the greatest power is when we're together or we're in community, which is a social determinant of health, right? The more social connection we have and the more feeling of belonging is really important. And so to understand belonging, you do have to understand exclusion. And so I'm wondering if you could share with us a little bit about, the book, a- about thinking through that it's really not about overt discrimination. you're really just talking about everyday little things that actually shows a culture of exclusion that may be operating in most organizations. And so I'm just curious about, like, what the central argument is about your book and why does it matter in the healthcare organizations?
Natalie Holder: When we started this conversation, you spoke about the provider who will say, "I'm not someone who discriminates. I'm not someone who has any biases. I took a Hippocratic oath. I do believe in providing the same care to everyone." know through research, we know through studies that's not true. When I wrote this book, was at a time when I had launched, a healthcare disparities conference at the Yale Smilow Cancer Center in New Haven, Connecticut. And there was a study that really just shocked me, and it was about, a conference, a medical conference in where these professionals, these doctors were, presented with two different case studies, different patients, but they both presented with the same symptoms, the white patient and the Black patient. the Black patient, they immediately thought, well, they had very, I would say, non-aggressive ways of looking at helping this patient. they provided, the thought of, "Okay, we'll do something that will basically patch this person up and move him along." when the white patient presented, that's when there was like an explosion of ideas and thoughts and very aggressive care and the tests and the studies that we want to engage in. And I thought, "Oh my gosh, is scary. This is frightening to me." The whole idea that based on the way that I look, that might impact the care that I get from my provider. so that's when I reached out to Yale Smilow Cancer Center, and I said, "Hey, would you be interested in putting together a conference that looks at healthcare disparities?" Because they were interested in that, but we're going to look at it from- perspective of an employment, a workplace dynamic. As an employment lawyer, being able to help your providers, whether they're doctors, nurses, other staff members in the hospital, helping them to understand that they're a cohesive unit, how well they work together impacts how well the institution is going to be able to deliver good care. And it's all based on the tenets of my book, which basically looks at what are the top ten indicators of a broken workplace culture. So workplace cultures exist to reproduce themselves. The whole idea is that you do have norms and that you do have in-groups and out-groups. In-groups are the groups in where I see myself in you. I feel some sense of affinity. I feel comfortable around you. Now, it might be because we share pedigree. We went to the same schools. It might be because we're the same race. It might be because we're in the same, cohort. It might be because we're the same gender. it might be, that's what helps me to create my in-group with you. else who I don't feel that affinity with, they're now in my out-group. the question is, how do we make sure that even when we do have that natural inclination to create an in-group versus an out-group, that we're not working against each other? Because sadly, is our out-group members that are impacted by these ten indicators of a, broken workplace culture. reason why, I could stop and just say, "Oh, well, these in-group members are impacting these out-group members by, just naming these ten issues." The reality is that if these ten issues are showing up in your workplace most likely, it's not just impacting these out-group members, but it's also impacting your customers, your clients, your patients. It really, once again, is the ecosystem. And so it isn't just breaking the out-group, it's breaking your culture. And so let's take, for example, "informal mentoring". Informal mentoring, if there's a lack of it, in your organization, that's an indicator of a broken workplace culture. How and why? mentoring is that ability to give someone real-time feedback that can either help identify where their strengths are or identify where their weaknesses are. And there's a higher likelihood that you are going to provide informal mentoring to that person who's in your in-group, that person who you feel safe with, that person who you feel that sense of affinity with. What happens with the person who doesn't get the informal mentoring? This is someone who flounders because they have to basically figure out all on their own. Can they? Sometimes they do, but it's just that much more difficult. Think of it this way, Lillian. If I'm able to tell you, "Hey, you might want to raise this question during grand rounds tomorrow morning with that particular, physician because this is something that they focus on." How do you think that's going to impact how you're now seen with your coworkers and colleagues and with that, physician who's running ground, grand rounds versus the person who has to basically watch and observe and figuring it, figure it out all on their own? That's just one example that I found during my research that identified these indicators of a broken workplace culture.
Lillian Liang Emlet: and I would say that probably there's so many places where when they think about does my boss or superior or team lead actually help me? That's the only question you get at the end of your annual reviews. You don't really think about it's actually the entire ecosystem of the team. And what you're talking about really is so much of the peer supports, and it is very easy to feel like you're in the in-group or even the out-group. And I have definitely felt that in the different, organizations I've been in. I'm curious, so what are the 10 things that people should be looking for to see if they have a good culture or not, to help people feel like, "Okay, I'm not crazy. I might have some issues at-"
Natalie Holder: So another indicator, it's bullying. So once again, going back to your great opening of this conversation, there's such a thing called cancel cal- cancel culture. So you're not going to engage in overt discrimination or harassment today. It is going to be so much more subtle. Similar to bullying, you're not going to engage in the yelling, the screaming for the most part because we understand that there is, know, there's decorum in the workplace and people are watching. However, bullying still exists. What is bullying? Bullying is intimidation that is meant to denigrate another individual, and that bullying can show up by not being invited to certain meetings even though you should be a part of those meetings. Bullying could be that person who, has the meeting before the meeting or after the meeting that doesn't include you. You know what that one looks like, right, Lillian? bullying can also be the way in which an email is worded. It could be the tone that someone's using. recently I, came across a situation where There was a clinician who was helping out a doctor with his team, the doctor wasn't really understanding that his team didn't feel safe about a certain issue. And so this clinician stepped in and, because she was quality assurance, she did provide the right elements to make sure that the team felt safe. Well, instead of this physician, thanking her for the wonderful outcome that the group had, he instead sent her a very nasty email. And the email, copied her boss and basically said... And basically took away the credit that she was due, told her that she didn't do a good job of creating cohesion and collaboration. And the coach in me, once I heard, and also the employment lawyer, when I heard this situation, I said, "You didn't allow him to be the hero of the story. That's what he's upset about." And basically what he was doing, he was bullying her into believing that she was not qualified and competent to do her job. what bullying can look like today. dual identity. It's the fear of not being able to be yourself in the workplace. Fearing that you have to basically pretend to get along, to go along, and to be a part of that in-group. It is that fear that if you did bring in cultural elements that really are a part of who you are, you might in some way be teased or ostracized or bullied by your coworkers, by your colleagues. It's maybe sometimes deciding I'm not going to bring a certain meal into the workplace because I fear someone asking me about it, and I fear someone making fun of something that is a part of who I am. So dual identity oftentimes is creating that feeling of being an out-group member in where that person feels as though they have to traverse two different worlds, one in their workspace and one in where they're allowed to be themselves at-" home. Isolation is another of a broken workplace culture. of feeling as though you don't really have anyone to identify with. Oftentimes, it's when you are the first in your group. You may have been, the first of a particular practice area to join a practice group. You might be the first woman to join a practice group. You might be the first African-American. Whatever that experience is it's a question of, all right, so you are the first, and what sort of supports and mechanisms are there to ensure that you will be successful in not fighting the current that, once again, is the norm for how this organization has run itself for years? The inability to recover from mistakes. So we find that when individuals are on the out-group,
Lillian Liang Emlet: It's
Natalie Holder: they have a much harder time helping the in-group members and often leaders, who are often the leaders of the organization, to understand that their mistakes are not who they are. That just because they might have gotten a note incorrect, that they are not all of a sudden, this employee who is not capable or competent of doing their work. And so we often find that when people are in the in-group, have an easier time of getting over the mistake because that leader who identifies with them will say, "I made a mistake like that when I was your age. I made a mistake like that when I first started practicing, it happens versus that person who's on the out-group as though they are persona non grata for the mistake that they've made. Insensitivity and the inability to engage in civil discourse. right now we are living in a time in where people may feel as though they have license to say and do what they would like to, and they frame it as a joke, right? and this is a nonpartisan conversation. There was a situation recently in where there was a graphic that came out of our White House that positioned one of our former presidents as a monkey, and the former First Lady as a monkey, And it was all done as a joke. That graphic was taken down because someone finally eventually said,
Lillian Liang Emlet: We can't
Natalie Holder: do this. "This is really offensive to not that former fam- not just the former family, but also to everyone who might identify with that former family as being African American." And so when you find that you're in an environment in where there are comments, there are pictures, there are depictions of your culture, your race, anything that you feel is an identity factor for you. When that becomes a joke that is offensive and that becomes your workplace, that's an indication of a broken workplace culture.
Lillian Liang Emlet: I'm going to leave the rest to be a teaser for other people to get out there and read your book, because I can tell you all of us have experienced the bullying, the dual identity, all of these things in terms of having subtle jokes made in the workplace, in healthcare, and even in diverse environments. I mean, at least I think we're lucky in healthcare that we do try our best to be able to recruit a relatively diverse workforce across the organization in general for the places that I've worked. and there are obviously employment laws, and there's policies that support diversity in the workplace. And yet at the same time, these things are very subtle when you're in the out group. At some point, you're not sure. You always feel hesitant about how much you should share, right? In terms of I sort of-- I do need the accommodations for different religious holidays, for different, accommodations for, being able to celebrate, have time off, and be able to express my full self at work, and it's okay to wear certain pieces of clothing, even, at work. so I think it's definitely one of those things where a lot of times people just don't understand other cultures, and then also people become afraid to even talk about these things, and then it just spirals. And then next thing you know, you're down this deep path of all of the things that you've talked about.
Natalie Holder: Even people with disabilities within healthcare, can I tell you that healthcare is probably one of the most surprising areas and where I found that the conversation around reasonable accommodations very difficult. There was a nurse who was, diabetic, and she needed to actually, eat a candy bar every few hours just to make sure that she kept her, her sugar le- levels up. And her coworkers would say, "Oh, well, she gets special treatment. No one else is allowed to eat on shift. Why is she allowed to eat on shift?" And I said,
Lillian Liang Emlet: Because
Natalie Holder: she requires a reasonable accommodation." That is the definition of a reasonable accommodation, that you are providing the opportunity for this person to work in your environment with an accommodation that allows them to do their job. I mean, it wasn't my case, it wasn't my workplace, but when this person told me about this, I thought, "Tell your colleagues at work that you are entitled to a reasonable accommodation, and if they have a question, they need to speak to their supervisor, not you, it to get a better understanding of what does define a reasonable accommodation and why as an employer they have to provide one to her."
Lillian Liang Emlet: I mean, is this crazy? Because that's obviously, like a, a physiologic fact, right, in terms of, glucose metabolism. And I just think about the fact that's a medical condition. There's so many other neurodiverse conditions where it is cognitive processing and workplace adjustments to be able to, think and do the tasks that are necessary at the pace that we need to do. That's also challenging in terms of, But we won't get into all these rabbit holes. Now, I'm curious, though. So leaders that are listening to this podcast are just like, "Great. Well, maybe I do have some things I-- we need to work on." But how? A leader wants to shift, for example, the culture of their team. They recognize that, okay, maybe we do have a couple problems, and I've recognized and I've felt it inside, and I really want to help things be different. And so what kind of self-examination things should leaders do, first? Like, how do they work with themselves first so that they have the ability, capacity, sensitivities to be able to make meaningful change about the in and out groups to prevent some of these symptoms that you're talking about?
Natalie Holder: There's nothing like making decisions that are based on data. Evidence that is backed by data oftentimes gets people to make the moves and the transitions that they otherwise wouldn't make. I mention this because sometimes people will think, "Oh, as a feel-good, I want to make change on my team." I always say, "Start with your data. Don't call me until you've looked at your data." Because if you call me before you've looked at your data, when I provide you with the hard work it takes, priorities now take place, and you don't have the time or the interest or the passion anymore. But when you have a data point that shows that, for instance, patient care numbers aren't where you want them to be, or your, cultural scores, the scores around your organizational culture aren't where you want them to be, or psychological safety isn't where you want to be in your organization, that's when you call someone like me to actually start doing the deeper work of understanding, okay, so now you have your why. You understand, what's occurred. Now you have your why as to why you want to change it. And I would say that is oftentimes a really good driver. cynical in where people think, "Well, shouldn't we just be looking to make change for, a humanistic stake?" That would be wonderful, but the reality is that making change does require financial, emotional, and time commitments may sometimes become preempted by other exigencies in the workplace. To be committed to this work, to be committed to change management work when it comes to organizational culture really sticks when you're talking about evidence-backed data And so I would say start with those numbers, and then ultimately, you start- Really taking a look at you as a leader. How did you even get trained to become a leader? Were you someone who was thrust into a leadership role because you were really smart, you were really talented, someone thought that you were really good at what you did? So automatically they conflated being good with your job with being a good manager, which we've seen happen over and over again in different industries and in different professions. from there, it's what have you tapped into in terms of making sure that you truly have the training and understanding of what does it mean to run an organization that has not just demographic diversity, but also, all other elements of diversity, geographic diversity, cognitive diversity, all the diversities that people bring into your organization. What training have you really taken to make sure that you are that person who can lead in that environment? And then also looking at what is your own story? Where did you develop your understanding of other groups, heterogeneous groups? Where did that come from? are you telling yourself about the different people who you have on your teams? all about tapping into that self-awareness first before you start looking to make changes with any other parts of your team, because I'm a believer that when you lead a team, goal should be to, create other leaders. There's a wonderful saying, "Leaders who don't create new leaders haven't led." And so if you really are about leading a team to success, your goal should also be, how do I make sure that the other people on my team can see what a true leader looks like and also aspire to do that, not just for themselves, but for our team and for our customers and clients and patients
Lillian Liang Emlet: I love that. I mean, really at the end of the day, we're all just trying to make the next generation better, and that includes leadership. And so I think obviously we're both coaches because we like to make, the very first step to be awareness. Self-awareness, self data, really drives everything else. Because if we're not aware, we don't even know our own story. We really haven't taken the time to re-reflect and reconsolidate. And it's always amazing to me, you're just doing the race, right? and you just realize I'm just doing the things I'm supposed to be doing. If we don't take a step back and just get a sense of where we are in our values, where am I in my own story, where am I in my team, my organization story, it's no wonder that things can devolve over time. and I also think you, you bring up a really great point that sometimes when every single year internally, your data metrics, right, for those things that really matter the most just won't budge, and the internal group, change management groups from internal just really keeps trying all kinds of projects. Well, it's time to find people like us, the external people, to come and do neutral work because we are not part of the organization, and so we can allow more frank conversations to come forth about really what's happening and how are we really making each other feel, and what are the human interactions that are accidentally causing this. Get it out in the air and then be able to move on, because sometimes just saying it is enough. And be like, "You know what? I don't... I actually don't feel that way, but you made me feel this way. And now that I said it, I feel a little bit better, and maybe we can find a new way forward."
Natalie Holder: Exactly. It is that self-awareness piece. It is that signal. And I would-- I'd even say tap into the signal. What was that moment that made you say, "You know what? I do want to change something on this team. I do want to see some improvement." Like I said, it may start with your data. It may start with something that's gnawing at you a little bit, more, more internally. But whatever it is, it's not ignoring the signal and doing something about it.
Lillian Liang Emlet: I love that. So, we're going to come to a close for this podcast, but we obviously could keep on talking about all kinds of things. And so for everyone listening, could you share how they can work with you and how can you go to their organization? What can you provide and how to continue the conversation with you?
Natalie Holder: Lillian, first off, thank you for having me on your show, and it's been a pleasure chatting with you. for anyone
Lillian Liang Emlet: Awesome.
Natalie Holder: I would say start with going to my website, natalieholderspeaks.com. On the website, I have a number of resources that you can even start to look through. For instance, anyone who is working with Gen Xers right now, Gen Xers who may seem as though they are tapped out and they're just not focused, what? There are three questions that they're asking themselves that you need to also be asking yourself as a leader before you actually lose your Gen Xer employers, sorry, your employees. there's a term, Lillian, right now called pre-retirement that's applying to Gen Xers, right? The people who are just a little too young to retire, but closer to retirement than they are to the beginning of their careers. I've got a, a great paper on that on the website that'll help you understand, okay, if we're working with helping out our Gen Xers, guess what? We're not just focusing on them. We're also looking at our entire organization. I'm a big believer in that saying, "A rising tide lifts all boats." If you are working to help a segment of your population that is being heavily impacted by any of the top 10 indicators of a broken work cl- workplace culture, you are helping the entire organization. so yeah, I'd say check out natalieholderspeaks.com some resources, continued reading, and reach out to me to book a call.
Lillian Liang Emlet: Thank you so much for coming on the show, and it's been really such a delight to really think about, a little more deeply about how all of these little hidden cultures actually are the issues that may face your organization and your teams. And they're not easy to talk about, and they're not easy to surface, and it really does take someone who's trained, have heard other stories, can hold the space, and also know what everyone's rights are and what their options are in terms of how to resolve these things. So thank you so much, Natalie, for coming on to really talking about a topic that really isn't get talked about that often. and so for everyone listening, thank you so much for listening this far. If you have other topics you want us to cover, please email us at podcast@transforminghealthcarecoaching.com and continue the conversation with us by liking, subscribing, and forwarding this episode on to your leaders, your other people in your ecosystem that needs to, maybe get a hint that it's time to change for the better. Thanks everyone for listening.
Connect with Natalie Holder
References & Mentions
Your Host
Dr. Lillian Liang Emlet
Physician · Executive Coach · Founder, Transforming Healthcare Coaching®
Lillian is a practicing physician, certified executive coach, and the voice behind the Transforming Healthcare Coaching® podcast. She works with clinicians, clinical leaders, and healthcare executives leading through role transitions, seasons at capacity, and culture change — helping them lead with clarity, intention, and sustainability.
Learn more about Lillian →