Lost in the Health Care System?

Jack Cochran

“As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

“I’ve lived in the hell that is American health care…”

A devoted physician wrote these words in reaction to a recent blog post we wrote. And he is clearly not alone.

In our new book The Doctor Crisis, we report on the widespread unhappiness, frustration, dissatisfaction, and anger of so many American physicians.

We believe this crisis is real and growing; that it is an impediment to providing the care the American people need; that dealing with the doctor crisis is fundamentally patient-centered; and that the crisis has not been recognized for the fundamental threat it poses.

Our recent feature on The Health Care Blog elicited some powerful reaction:

Rob: ”In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership…”

Jeff: “Can validate what Rob has said. I’ve spent the last three years listening to physicians about the possible alternative futures for their profession, and the overwhelming desire was exactly as Rob said- an overwhelming impulse to flee…”

Some commentators wrote that doctors shouldn’t complain because they earn a lot of money, drive fancy cars and own nice homes. But that theme – accurate in many cases but certainly not all — gets us nowhere.

We think the rubber meets the road with this warning from Dr. Rob, ”…As a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored.”

Is Dr. Rob overstating it? We don’t think so. In fact, we think he has it exactly right. How can our system function properly if the level of job satisfaction among doctors continues to spiral downward?

Harris Interactive research describes the profession as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’ Has such extreme language ever been used to characterize the medical profession? Have doctors ever faced a time as turbulent as this?

Doctors are certainly not blameless as both Brian and Rob noted in their comments:

Brian: “…I’m concerned that you have framed your argument as though physicians are victims of the system rather than partial drivers of its characteristics …”

Rob: “…physicians as a group have been complicit in building this system, and so should bear a lot of the blame…”

So what needs to be done?

A crucial first step is for health care stakeholders to recognize and acknowledge the existence of the crisis. Doing so will get the doctor crisis on the national health care agenda. Unfortunately, the matter is  not currently a priority for many, if not most, provider organizations. That needs to change.

When it does, there are some powerful solutions out there. There is no doubt, in fact, that the building blocks for a better future are out there. They are found in many provider organizations that have improved both physician and patient satisfaction while improving care.

Important progress can be seen at many organizations including some we write about in our book: HealthPartners (Minnesota), Atrius Health (Massachusetts), Virginia Mason (Washington), and Kaiser Permanente (nine states).

We draw inspiration from the work of Drs. Christine Sinsky, Tom Bodenheimer and their colleagues who identified 23 high functioning primary care practices. Their findings and recommendations, if spread throughout the country, could help transform primary care in our nation. [Annals of Family Medicine (May/June 2013) In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices.]

We’ll be writing much more about these solutions to the doctor crisis in the weeks and months to come.

What ideas do you have for improving both physician and patient satisfaction?

The evolution of the physician role seems to accelerate daily. In our new book, The Doctor Crisis, we characterize the expanded role for physicians as that of healer-leader-partner.

Many physicians are adapting beautifully to this shift. Others struggle mightily. Some angrily. A number of doctors consider the change fundamentally unfair – a kind of bait and switch. We got into medicine to take care of patients, and now we’re being asked not only to heal but to become effective leaders and partners, as well. It’s too much.

No question – it is a lot to ask. But how can we turn back? Unless doctors step up as healers-leaders-partners, we can’t deliver the kind of care the American people need and deserve.

We defined what we mean by the terms healer and leader in our last two posts, but what do we mean exactly by physician as partner? We write in our book “physician as partner means being a great team member and recognizes that the surest route to sustained quality care is through effective teamwork.”

We’re talking about pulling a team together to do great population health management; working across siloes to team up with nurses, pharmacists, techs, and administrators. Great physician partners are collegial, approachable, and always respectful of other team members.

Some examples include:

  • Partnering with patients on shared decision making.
  • Partnering with nurses in clinical teams and on a larger scale when necessary.
  • An example of the latter is the partnership between the Colorado Permanente Medical Group and Exempla Healthcare to establish an accelerated nursing degree program and skills lab at Metropolitan State University of Denver.
  •  Partnering with physician colleagues by listening – as Dr. Cochran did in his listening tour (detailed in our book) where he sat down to talk with all 500 KP Colorado doctors to fully understand how best to fix a dysfunctional situation.
  • Partnering with clinical pharmacists so that everyone is practicing at the top of their license.

An outstanding example of a physician as partner is Dr. Paul Grundy, the director of health care transformation at IBM. Dr. Grundy and his IBM colleague Dr. Martin Sepulveda partnered with a wide variety of primary care organizations to build the Patient-Centered Primary Care Collaborative – a powerful partnership for the patient-centered medical home.

We quote Dr. Grundy in our new book:

“If you put resources upstream – if you manage aspirin, blood pressure, and cholesterol upstream you have a third less need to do cardiac intervention. If you don’t manage those things, you see more cardiac disease. This isn’t rocket science!”

This is exactly what we do so well at Kaiser Permanente – manage member health upstream. A major factor in our success in this area is our physician as partner culture. Just as Kaiser Permanente embodies physician as partner, so too does the patient centered medical home. Both rely upon physicians as partners with one another as well as with administrators, health plan partners, nurses, medical assistants, clinical pharmacists, behavioral health specialists, schedulers, receptionists and many more – all partnering in the cause of great patient care.

If Kaiser Permanente is in some way a model for the patient-centered medical home that will grow in importance in the future, then Dr. Grundy is in many ways a model for the healer-leader-partner that physicians must aspire to. His portfolio is global, as befits a global company such as IBM. He is as likely to be in Beijing, Zurich or Wellington as he is in Charlotte, Chicago or Los Angeles.

The essence of what Dr. Grundy does – especially his role as a leader and partner to many organizations seeking to improve – shows the pathway forward for other doctors. The geography doesn’t matter. Whether a doctor travels the world or remains in a small clinic in a rural area, the essential ingredients for success in the new age remains the same: Physician as healer-leader-partner.

What does effective partnering look like in your organization?

Jack Cochran, MD, FACS(@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.

Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States. 

Cochran and Kenney are authors of The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. Both write about physician leadership at, where this post originally appeared.


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The world of healthcare is changing. If you are not ready to change, thousands of us toiling in med schools are willing (since we may not know how it was 20 years ago).

I don’t see this any different than any other industry. “This is how we used to work twenty years ago” doesn’t work in other industries as well.

For those who complain about it, take a look at “Who Moved My Cheese” book.


The world of healthcare is changing, but one wants the change in the right direction. Top down control is not the way to go. So far top down control has increased bureaucracies, increased the number of businesses feeding off the healthcare dollars, increased total healthcare costs, reduced access and is negatively affecting quality.

I hope future medical students learn how to evaluate problems and not just rely upon committees to tell them how to think and act.

Granpappy Yokum
Granpappy Yokum

So young, so wet behind the ears, so smug, so wrong.

As you’ll learn one day, practicing physicians eat a big bowl of change for breakfast every morning. That’s how wesurvive.

What we object to is change that is not based on evidence, but that is intended solely to deliver physicians and the health of their patients into the control of corporate greed. if you want to be part of that process, be my guest.


Granp…, don’t forget the young have to pay for the change they vote for and right now the total bill is nearing the $100Trillion level. Of course much of that has to do with the actuarial cost of entitlements and things like Obamacare, so they will be left with the problem of financing an impossible debt or getting rid of the programs. The greed of incurring debts hoping they may never have to be repaid eventually catches up.

You won’t be around to remind them of their early smugness and lack of common sense.

Paul Grundy

the Whole Country has thousands of empty primary care physician slots not just limited to the VA for sure. We have under invested in primary care. We have over 20,000 die because they can not access car,. The Vets seem to bother us when they need to to lack of access and it should but what about the rest of our citizen what are they just part of the 47%.