How To Discourage a Doctor

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I stared and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a healthcare consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said.

“The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff.

“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff.

“Transforming previously independent physicians into employees has increased hospital influence over their decision making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic initiatives. But physicians have invested many years in learning their craft, they hold their professional autonomy in high esteem, and they take seriously the considerable respect and trust with which many patients still regard them.

As a result, the challenge of managing a hospital medical staff continues to resemble herding cats.

“Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus.

“How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following:

“Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently.

“Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation “at risk,” so that physicians begin to feel beholden to hospital administration for what they manage to eke out.

“Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass.

Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidence based. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures.

“Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher, from the 75th.

“Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness,” a growing sense among physicians that whatever they do, they cannot meaningfully influence healthcare, which is to say the operations of the hospital.

“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control.

When physicians think about the work they do, the first image that comes to mind should be the hospital, and when patients realize they need care, they should turn first to the hospital, not a particular physician. One effective technique is to ensure that patient-physician relationships are frequently disrupted, so that the hospital remains the one constant. Another is. . . .”

The sound of a door roused me again. The man in the three-piece suit emerged from the office, he and the hospital executive to whom he had been speaking shaking hands and smiling. As he turned, I looked about. Where was “How to Discourage a Doctor?” It was not on the table, nor was it on the chair where I had first found it. “Will he think I took it?” I wondered. But instead of stopping to look for it, he simply walked out of the office. As I watched him go, one thing became clear: having read that document, I suddenly felt a lot less discouraged.

Richard Gunderman is Chancellor’s Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, Philanthropy, and Medical Humanities and Health Studies at Indiana University

151 replies »

  1. This is what the private sector hospitals are doing to their employes.They have made the life of their employes miserable ,they recruit more and more physicians and always give them impression that u r not important ,u can be replaced any time.Simple email that your services are no more required is usually generated by high adminstrative authority….

  2. You Hippocratic oath replaced by hospital policies and administrative choices. Profits over patient care. Welcome to hospital employment.

  3. More relevant than ever it’s the world in which we live today. Freedom was destroyed amongst fanfare and celebration. 1984 is here people and we all consented. If you ever wonder why your EMR is such a piece of junk (100% guaranteed it is, eClinicaldoesn’twork is what we use and by far the worst software, all the others are even more terrible than that) this is why.

  4. This is a ridiculous take. How about the sixth amendment and the right to representation. Are criminal defense attorneys slaves? If you have a right to healthcare you don’t have the right to force any individual doctor into doing stuff they don’t want to do. People in favor of this just want everyone to have insurance to pay for their healthcare. And the current mainstream democrats are so far from actual leftists or socialists. They have basically done everything the same as trump outside of their social beliefs. Bigger military, police, and ice budgetSs. Still not back on the Iran deal. Still pro Israel and against Cuba and Venezuela and everywhere trump was. Haven’t rolled back tax cuts…like literally are you just complaining about being socially liberal?

  5. RICHARD GUNDERMAN, MD wrote it in 20214 but these words are in fashion.

  6. Can ‘someone’ please put this ” How to discourage a doctor’ online and make it public access. You can put it anywhere , it just needs to be downloadable.
    I am an anesthesiologist. The description of meeting with CEO is eerily accurate and reminiscent of how I met my hospital CEO.

  7. Yes and the latest assault is the “Right” to Healthcare. Our natural rights are all “freedom froms…..” eg. unlawful search or seizure. Once someone has a “Right to” a good or service, the provider of that good becomes their slave. NO ONE has the RIGHT TO the labor of another person. We must be careful to guard our freedoms and watch our language lest we become powerless puppets in a socialist/communist regime. Yes it could happen here.

  8. I came across this article by googling, “Hospitals screwing over Physicians” and it was the first to come up. I am not a physician, but my husband is. The hospital he is currently working for is going through a restructuring in which they just formed a separate physicians’ group. The same tactics described in this article are being used. I think anyone who has commented against this article and deeming it rubbish, either has not experienced this (yet), or they are a part of the administrators/consultants using these, “methods.”

    As I was reading this, I could not believe it as it seemed all of our assumptions and speculations were correct- that nothing they (administrators/consultants) were saying or the reasons they were giving were making any sense other than it appearing to, ultimately, be one big mind-game. This particular hospital has hired 2 different consulting companies in the past year alone. The purpose has been rather unclear other than scheduling several meetings per month telling the physicians how poorly their productivity has been (even if the numbers show otherwise), and doing some silly team exercises. All these meetings really have done have given poor morale and actually created a wedge between the physicians. They recently offered some silly term sheet with the intent/promise that new contracts would be presented. This presentation of new contracts also will double as the notice to all of the existing contracts and will be handed with a, “take it, or leave it” attitude. At this point, all of the physicians have been waiting for this alleged contract that they keep saying will be completed shortly and presented on such-and-such day, only to be told the same thing once that day arrives. I am convinced that this is all part of the game. My husband and I have come to the conclusion that they either want the physicians to quit or to get down on their hands and knees.

    I worked many years for a very large Main Street USA restaurant chain and I constantly compare the similarities in the way that company was run to the way my husband’s hospital is being run. I know there should in no way be any similarities to a hospital and a restaurant, but somehow, the new vision of today’s hospital administrators have not proven otherwise.

  9. Richard,
    LOVE IT. I have got my hands LEGALLY on some internal hospital documents that show the deliberate assassination of an MD’s career for speaking up against bullies in an administration. If interested, contact me at kstrong@dunkthejunk.org. We need help getting the truth out. The lower courts in the state have ruled even if the statements about an MD are known to be false, they are protected by professional immunity. So for example, if I wrote on an internal review that I knew of a malpractice suit against you and THERE NEVER WAS ONE, I am protected by professional immunity AND your career is permanently damaged. For anyone who reads this…remember you could be next.
    Kevin Strong, MD and Founder of the nonprofit Dunk the Junk

  10. I am one of the MDs that has a solo practice in Maryland who does not bill insurance at all. Started the clinic with zero patients 8 years ago before the crash, still exist, thriving, seeing patients, addressing concerns, using nutrition and functional approach to patient care, and surviving. It is not easy but neither is the BS of insurance based medicine. I am not rich but I am very happy…… I would NOT EVER work for a hospital or large group….ever.

  11. We have only ourselves to blame. Imagine all doctors opting out of all insurance before it is too late. Too late is either working for a hospital, company or government where THEY dictate whether or not we dance with the devil (use therapeutic guidelines or deny care). We are losing all power to protect
    our patients from rationing and misguided choices based solely on cost.
    Lyndon Johnson will be known as the worst president ever. He placed government between the doctor and the patient. The insurance companies followed suit. Now we have to get permission from a relatively mindless bureaucracies to deliver the best possible care. We need the leadership to “JUST SAY NO,” quit insurance, the government or is it too late?

  12. When I married a physician in 1989, I told her about how the tactics used frequently in other industries would eventually turn to the medical profession. One of the posts above places blame on the ACA. How naive!

    As a soon to be retired Corporate Executive, my suggestion to future physicians is to circle the wagons. In other words, support your profession by voicing your expectations at the public policy level. Physicians are a scarce resource, do you agree?

    Imagine this scenario . . . 1 million white coats standing on Capitol Hill.

  13. What a condescending article. I hope you lose your job and find some humility before you find another handsome man to hire you.

  14. I work in community adult learning disabilities. I instantly recognise all of the approaches advocated in this piece. From the local authority commissioners through to my immediate supervisor I am being directed to view my ‘service users’ as problems to be solved rather than as people with problems. I even had my immediate supervisor describe a service users mother as an ‘unknown variable in the equation’
    I believe the whole of NHS and social services to be infected with this type of ‘I’m alright Jack’ thinking from the top.

  15. Having worked in Portugal and the abroad it is certainly true that this happens to a greater extent in Portugal. The propaganda has already damaged the patient doctor relationship and many colleagues unfortunately opt to leave the country. One suspects the final goal is not even to undermine our work but to simply put an end to the national health service.

  16. Why the hell am I subjecting my self to self-flagellation of medical school, learning ddx’s and tx that will be substituted by a “therapeutic guideline” …

    I want friggin out.

    Someone give me back 4 yrs of my bloody life 🙁

  17. May we have real names please. If not then it just shows how we have been cowered by administrators. Yes we are smarter than administrators and should be involved in decision making but are not. The costs of medicine is caused by insurance coma ones and greedy hospital owners period. Take for instance the company that was hired by an insurance company to track doctors billing practices. I called the CEO and politely asked, ” is there an inducement clause in your contract with the insurance company” …………… There was a long pause before he answered. I then told him, ” thank you your silence has answered my question” he then went in to say in such a pathetic but guilty voice ” you had better get that information from the insurance company” is it not illegal and a crime for us doctors to practice what has been termed “inducement” by CMS if we happen to show compassion to a patient and not charge them or assist in some small way. So why is the insurance companies and every other Tom Dick and Harry on this medical band wagon making all the money at the expense of ourselves and our patients.
    I am still waiting for the admi starter SM to give us his full name. He called angry and vulgar for expressing my distaste of how e are been screwed and lead like sheep to slaughter. If we are going to start to man up and unite let’s have real names. This is America is it not. Lastly does anyone know a good investigator reporter to follow up on my story just elaborated above. I also have a good one on this so called patient satisfaction rubbish survey that they maybe interested in. The Internet is full of evidence of high corruption by fellow doctors who are profiteering and who should be exposed.

  18. Just prior to reading this, I was reading a blog on a nursing website. The comments for both columns are amazingly similar. Physicians and nurses both want nothing more than to care for patients in the best way possible. Both feel demoralized by the increasing emphasis on profits over people. As Heart Surgeon notes, healthcare providers can–and should–be the ones working to lower costs while maintaining, or even improving, quality. Leaving this to non-clinical administrators leads to cost cutting done based on where administrators ‘perceive’ there is waste instead of based upon thoughtful consideration and innovation coming from those actually caring for the patients.

    There are some hospitals and hospital systems where physicians fill many of the administrative and even executive positions (e.g., the Cleveland Clinic Health System). From what I have seen, clinical professionals in hospital leadership positions translates into higher quality in patient care.

    Many nurses have started to realize that getting an MBA allows them to fill positions where they can have a voice for nursing at a higher level. I am starting to see more physicians taking that route as well. It is my hope that this trend will lead to more clinical professionals in administrative and executive positions, replacing those who have little knowledge of what it takes to care for patients.

    Nurses and physicians are the two largest groups in healthcare. If they can find a way to band together to demand that their knowledge and clinical expertise have a greater impact upon how healthcare is changing, perhaps the tide can be turned from profits back to patients.

  19. Hi to every body, it’s my first pay a quick visit of this webpage;
    this blog consists of awesome and really fine information in support of visitors.

  20. Watching this over the last few years.. wringing my hands over the destruction of the doctor patient relationship.. thinking wish we could Unionize !!! Wish we had a voice.. like a bad dream where you are screaming but nobody can hear you.
    Proud of all of you who have commented.. we are NOT stupid, We are NOT faceless… Many of us have become depressed, hopeless. Please speak up and gather support. We are also human. There is strength in numbers.
    Please lets keep the dialogue strong. Reach out. Even those of us who have been isolated- surrounded by admin and NP.. please keep the communication and support strong on purpose. Nothing Will change until patients WAKE up and smell the coffee.
    The Race Does not go to the Swift – It Goes to Those that Keep Walking!
    Important to take care of yourself and stay healthy, stay safe.
    PS: Important – please pass along.. if any of You have a big white envelope from the NIH/CDC asking for you to fill out questionare and return.. PLEASE DONT fill it out. It is registering.. similar to a draft of sorts- throw it in the Trash. Tell your friends.

  21. Union, its a must! Either be employed as a high paid wal-mart employee pushed around by administration or leave the hospital…its happening and the state medical associations do NOTHING, nor the national ones…! Doctors don’t speak up because of retaliation & loss of privileges, by CMOs –non practicing CMOs!!

    there should be a law that mandates that CMOs see a % of patients to be CMOs!!

    needless to say, glad to be out of medicine in my 40s!! And, hope NPs & PAs take more of the market, maybe then will doctors unite…

  22. Thanks for your comments
    Unity and public support is the key
    Early this year Queensland were to implement draconian contracts which were awful. Through a strategic series of campaigns and is going public plus the threat of 1500 public health doctors ready to resign over the contracts they changed them. This was very hard professionally and emotionally but there was a reasonable outcome
    As a result we have incorporated an independent senior medical staff association which advocates for clinical decisions and patients. So far it has worked. The administrators hate it as it exposes the hidden agenda time and time again

  23. Having a forum in which to be heard is vital – yes we are grieving over the loss of what we did know.. how we were taught. It is time to get mad, to get strong, to be creative. Think as if we are a crew going into a new country, having to abandon prior rules and think of new solutions. We dont have to abandon our goals and principals. We do need to find a new way to achieve them. We have to stop being naive. By the way, has anybody gotten the CDC mailing asking doctors to register.. sounds like we are being asked to register for some big doctor DRAFT

  24. Hi – Reading your comment, there is a lot of hurt and anger in what it being done to us. We are the care providers. We now need care. I wanted to reach out to you, let you know you are NOT alone. There are many of us, all standing together. Please stay connected and stay in the fight. You are important.

  25. this plus george orwell’s 1984 must be the manifesto our state in Australia uses
    We have an unworkable electronic medical record system
    25% of our wage depends on achieving key performance indicators
    Our hospitals average length of stay is best in the state but we are constantly told we are inefficient
    And lastly, despite being director of one of the major medical units I have been suspended from work over a trivial matter and this was reverberated by the faceless beuarocrats to show what they can do

  26. I just don’t get why people often look down Medical Professionals like Doctors. Yes, there might be a few of them but still their perspective on what Doctor’s do should be something that builds them up. I guess people is entitled to their own opinion but it doesn’t mean to say that it’s gonna make a bad publicity.

  27. Administration has no medical back ground. Then they will have a CMO who joined them put your back against the wall and against your colleague.
    That sucks in its own..

  28. I have heard this statement before – “If physicians don’t control healthcare, the MBAs will.” That is exactly what has happened to this country’s healthcare system. It is time for physicians to reassert themselves in the political, economic and regulatory processes…the alternative is a continuation of what has happened over the last several decades – the physicians’ vast intellectual capital will continue to be hijacked by hospital execs, MBA consultants, insurance companies, private equity, etc., for their benefit and to the detriment patients and physicians.

  29. You have just described Canadian Healthcare. The handbook was written up here. This is exactly what has happened here, and things have only gotten worse. The practice of medicine has become rife with “clinical guideline” being the gold standard and the feeling is that Nurse Practitioners can do most of the work of FP’s—just follow the guidelines. Incentive funding is also tied to outcome and billings are directly tied to charting and writing complicated justifications, just to get paid. On top of that, we are being told that “patient satisfaction” is more important than good care. By the way, healthcare executives have burgeoned in numbers up here to make sure that doctors aren’t overspending. The executives, who “monitor” doctors’ performance will be paid handsomely, even in a single-payer system, because Doctors need to be controlled, no matter who pays the bill.

  30. It is high time for a physicians bill of rights to counteract administration bullying.

  31. Hollywood helped create our modern day worship of the Medical Fields
    with whats now more than a lifetime of High Drama . Maybe the term “Cutting Edge” was re-coined if not originally coined in modern day
    use because of countless re Runs and re Do’s of Young Dr.Kildare
    starring Lionel Barrymore and Lew Ayres all the way back to 1938.
    They did 15 Movies in 9 years and then re Runs and then the 1961 Tv Series.

    I have 2 points to make. The first being the pedestal society places on the Healing Arts is near a religious reverence which Numbers crunchers play like a violin like Politicians spin the truth while trapping the Human Being in a role nobody can maintain. And to admit the manipulations taking place
    would shatter the illusion the public has been taught since childhood and the Role playing embedded in the soul of those called into true service.

    They do the same manipulation on charitable work and teaching if you
    will reflect upon it. As long as you serve the Medical Industrial complex they will call the shots. Systems follow the Constructal Law of thermodynamics and Medicine has turned into a money game
    like Wall Street loves.

  32. My summary document is a 5 pager. Seriously. The reason why we (Physicians) are “content,” rather apathetic, is that we are very tired. We have no time for family and fun let alone wanting to organize. We have organizations, the AMA, and all the individual societies we are members of. We believe those organizations will help but they do not. They comply. Of course, if physicians complain it is whining because we are “overpaid” and are the “root of the issue” which, of course is BS and used as a red herring in every way possible. We expect the administration you refer to to help us with the gov-empl-insurer complex but they do not and in fact they contribute heavily towards the misdirection we find in our system. It is a mess. Sounds like we should talk sometime…….

  33. It’s terrible. The ACA was sold as a way to a) insure the uninsured; and b) lower costs. It does neither. And I’m sometimes astonished by the apolitical nature of many physicians who seem content being blown wherever the political winds take them. Frankly, I think a lot of the anger I see in comments here being directed at administration would be better directed to what I call the larger government-employer-insurer complex. I truly believe the entire system could be overhauled toward lower costs and greater access to insurance in a summary document of about 10 pages.

    I don’t know you but I wish you more success and luck than you can even imagine.

  34. Thank you. It is not easy. I will not last as a solo doc in the current environment. Primary care solo docs are going away. We educate our patients concerning insurance in the Affordable Care Act environment we are now succumbed to. I felt the same as you concerning this article. Tried contacting the author with no success as of yet. But I have seen the actions described first person. There is some truth to the mess written. And you are right, it is creativity that prompts change, I am hoping, before my current life goes away that innovation in what I am currently planning will provide at least some, if not all, answers to a bleak future health care and medicine are headed towards……

  35. First, I LOVE that you opted out of the insurance morass. We need to go back to the very model you’re adopting. Direct purchase of a service by the health care consumer from you the provider. Full price disclosures, prices that can be lower due to the elimination of insurance transaction costs, etc. It’s where ALL of most medicine needs to go with insurance being for catastrophes. I envision a system where all prices for the majority of visits are disclosed in a menu, price competition happens, and consumers can make choices without being in the dark on costs. What other industry gets to treat their prices as “trade secrets” like hospitals do? It’s insane. You, Dr. Gonzalez, are a light in the void.

    But regarding this article, I’m going to go so far as to say I *know* the article he cites is not real. There’s no way. Every meal I’ve had in the past 25 years was earned by my writing and I can spot a tongue in a cheek a mile away. And as a brand and communications consultant, I know there’s no way anyone would street a document like that. So if it isn’t real, then it’s axiomatic that this is satire. I mean, it’s GREAT! It’s biting, skewering, effective, and ultimately very serious and thought provoking satire that shames administrators and provides a glimpse into physicians’ minds. It is creativity that should prompt thoughts of systemic change.

  36. Scott, I am not so sure. I agree we do not really know if it is real but I do not believe it is satire, that is for sure. I believe it is real simply because i have seen this personally at many different levels and I have lived it as a physician. As a previous department chief, assistant chief and as a “workerbee” to a helish system with more focus on useless EMRs and policies that eliminate the focus of patient care. I have left the hospital setting, founded my own medical center, and left the “middle Man” by eliminating insurance based practice. It is not easy surviving but I get to practice medicine the best way possible and have very happy patients.Patients who are healthier in the short and long run…..

  37. SM. Let’s have your real name so we know where you work. It will reveal what side of the fence you are. I am afraid you are wrong doctors here are fed up. You probably sit in your ivory tower and probably have never walked onto the wards or outpatients and asked the simple question. How can I help to make your work more efficient and effective doctor? Until you come clean I suggest you diagnosis yourself and not me. I donot partake in political correctness for the simple fact that’s what’s happened here in the USA. Everybody appears to be scared to say how we are being screwed by the likes of you. Angry of course I am pissed off as are over 70 % of medical professionals in this country who see their profession having been hijacked and become one large bureaucratic machine mostly to pander to the needs of insurance companies and adminstrators such yourself and where patient care and the doctors needs come last. Until your reveal who you are SM you voice has no representation on this forum.

  38. The author did not actually find a document titled, “How to Discourage a Doctor.” Rather, this is a provocative piece of fiction and satire that sheds light on what the author believes is happening. Something that attempts to speak the unspoken reasons. From the comments, I’m surprised by how many people think he really found this document. Maybe it’s physicians’ lack of business training and acumen attained through experience but even the shrewdest healthcare consulting company isn’t going to describe the process of breaking a doctor like you break a horse. But well done on the provocative blog, doc.



    This is an AMAZING article. The C suite typically comprises of d grade average poorly educated, on line MBA’s who are simply street smart (and exist to destroy physicians. They are typically jealous of the respect physicians garner and think that the hospitals earn revenue due to them..Sorry..but the revenue comes from the work of brilliant doctors who have an average of 14-17 yrs additional education and training after 12th grade.not a GED…The C suites are posh, preferred parking, stocked refrigerators while the doctors are on 36 hour call, stressed due to fear of lawsuits..trying to do their best in this awful political hellhole…


    ALL PHYSICIAND UNITE…don’t call it a union..meet every week in your hospitals and clinics, GET AN MBA>>RUN THE HOSPITALS as CEO/CAO/CFO/CMO.. OUST ADMINISTRATORS..let them starve.. I am getting an MBA and .u should too.

  40. Well said Joni SCultz. But trouble is wheelers & dealers are so engrosed with the business model largely unaccountable lot that it will generation to put back the man in white coat incharge . Politiicians realized it too, albeit belated. Meanwhile some thousands will unnecessarily loose lives before there is u turn.

  41. The tactics employed to discourage doctors seem like a wonderful way to encourage epidemics such as Ebola, especially by dependence on confounding patient information systems. Makes someone like me, a former medical system PR person, wonder if this is perhaps why the doctors didn’t know the Ebola patient’s status in Texas even though the nurses did. A broken health care model cannot fix the simplest broken patient without a tragedy of errors, much less the threat of a deadly global epidemic. I am afraid for our physicians, all healthcare staff and the population at large. I fear we’ll witness the same scrambling to correct myopic and dysfunctional systems as we did in response to Y2K, but with far graver results if the medical delivery system does not change from one of a business model back to one of healing, before managed care disempowered doctors. Power to the healers, not the wheelers and dealers. Put the white coat back in charge, not the stuffed suit.

  42. This is no surprise as physicians continue to be divisive figures. We have not recognized the strength in unity and allow ourselves to be divided and effectively conquered. The future is truly bleak.

  43. Brilliant. Bureacracy at its finest, only this time affecting the health of millions. So happy to be based in my own private practice and not reliant on administrators one bit

  44. Kitty,
    Well said, we do need to band together and form a revolt of sorts to expose these glutenous health care/hospital administrators for what they are…parasites on the countries health care system who offer no value or return on investment their 6 figure positions fetch. I also agree with the internet being our proverbial soap box in this war of salvaging what is left of the physician’s avenue to express their growing resentment towards these useless administrators and hopefully still have an impact.

  45. Anyone actually promoting the ideas in “How to Discourage a Doctor” is contributing to the demise of the American hospital system in my view, because it’s creating exactly the wrong culture – one of backstabbing and CYA versus teamwork.

    Hospital administrators should instead take a long-term view of their organization’s future survival and understand the sources of new innovation and competition. Start by reading about the many Healthcare MiniTrends (http://www.mhealthtalk.com/101-minitrends-in-health-care/).

    There are two basic ways to improve profitability – lower costs or increase revenue – but while one (lowering costs) is relatively easy in the near term, it can come with dire consequences. The danger of discouraging doctors and other short-term tactics is that the good ones leave, along with the hospital’s reputation and ability to compete.

    The other option (increasing revenue) has more upside potential in the long run, because doctors (and consumers) are smarter than you may think. With new incentives from high-deductible insurance policies, consumers are taking a more active role in health decisions, making healthier lifestyle decisions, focusing more on wellness, comparing prices, and considering alternatives like retail clinics, concierge services, and medical tourism. The challenge is to make your hospital the go-to place for care when people have a choice.

    Attracting and retaining top talent is key to future success in any business, so administrators should also focus on building a more beneficial corporate culture that inspires workers and gets them striving for excellence and working towards the same goals. A good place to start is by following Brett Hurt, founder of Bazaarvoice, which was named as one of the best places to work in America. Read his blog at http://www.lucky7.io.

  46. whew this is absolutely true,i have had direct experience when i worked in a major corporate,there were a slew of ceos the one who had brought me in was gone in 6 months,and the rest were hardly there for 6 months ,the one who finally did stay for 3 years had probably his own agenda,or there are petty politics and vested interests working in unknown ways….the learned helplessness of doctors is compounded by the management staff by fabricating and projecting wrong info to suit the needs of the local authorities,the doctor has little option but to toe their lines or quit
    and start their own.
    but i have learnt from the experience and devised better strategies,it is like bacteria and antibiotic resistance scenario,doctors have to come out of their helplessness and innovate .Only this never say die attitude can help better the scenario,doctors should also take interest in management and learn administration,otherwise parasites will overrun!the system and the collapse is inevitable

  47. I do understand the layers of sluggish and useless middle management that can exist between the doctors and the key people who can make decisions to improve the situation for the doctors and the patients. Right now though is the time to call them to account and take away their “well” of doctor waste that they keep going back to for another bucket opportunity. Doctors need to be pro-active, develop plans for improving the bottom line through streamline lower cost care and prove they understand that best practice saves lives and money. Yes, it is the job of some to count pennies and whittle costs. It is the job of others (doctors) to provide excellent care and be conscientious with respect to the money they freely spend. As for poorly performing Chiefs of Staff, I have never understood how they last a day, but I am aware of institutions cursed with them. The only choice there is mutiny or desertion. There is no positive effect with an ineffective leader.

  48. I agree with your conclusions if the presuppositions hold true:

    1) We should be looking for ways to cut costs, track those cost savings and then take credit for it. The doctors need to find the path to cost savings without reduction in quality of care, before the administrators do. Only then will we be the masters of the “new” system. It is so easy, but we refuse to do it.

    It should work except that the Chief of Staff has to be working for you, the clinician, and have your best interests in mind for the good of the dept and your pts. You can be the best at what you do and pts can truly appreciate their outcomes and still be disappointed at budget time mainly due to other non-clinical depts getting the bonuses and raises and extra funding as a consequence of your efforts to save the hospital a lot of money. It is not always that the logical and the best practice will get you the dollars at budget crunch time.

    2) Often, doctors don’t want to be bothered with participating in the committees that hold the purse strings.

    The presupposition may be true but it is a reality that some of us clinicians are kept away from such committees and told that our Chiefs of Staffs will handle it. My point is that what seems logical and just is at times unjust and self-serving when the people on these committees do not have the pts or the clinicians at the center of their agendas but only the bottom line in self-serving and selfish behaviors that are aimed at their pocketbooks be it through salary incentives or bonuses.

    I wish it were not the case and, perhaps, in select hospitals it is as the heart surgeon suggests.

  49. This is interesting, but also annoying. I am tired of doctors whining about being pushed around. We created much of this mess by not implementing best practices, not avoiding unnecessary tests and not just being good stewards of healthcare dollars. Yes, we have to do some things as “protection” against lawyers, but most of what we waste is just out of laziness or the “I do it this way” attitude. We should be looking for ways to cut costs, track those cost savings and then take credit for it. The doctors need to find the path to cost savings without reduction in quality of care, before the administrators do. Only then will we be the masters of the “new” system. It is so easy, but we refuse to do it. Doctors are only 8% of the cost. If we reduce the overall costs by 10%, billions are saved. If we manage to come up with the means of achieving the cost reduction and take credit for it, we can ask for a raise. Believe me, when our administration wants to reduce their spend on something that affects us, we trot out the enormous cost savings we garner with the lowest price on tissue valves in the nation, elimination of the use of albumin, reduction of OR “glue” use by 80%, an incredibly low transfusion rate and switching every patient to generic medications on the way out the door. All of which we continue to track. We did these things before someone told us to, so we get to take the credit. The same goes for when we ask to spend more for a device. We explain the long term financial implications and the problem being solved. Often, doctors don’t want to be bothered with participating in the committees that hold the purse strings. If that is the case, then they have no claim to their complaints. Oh, poor doctor that was up late last night is being pushed around by “the man”. Give me a break. We are owed nothing. We choose our jobs. If we are not smarter than the administrators, then healthcare is really in trouble.

  50. I think doctors should form unions.
    Today doctors and patients, and in fact other clinical personnel
    are fighting the sam evil in the face of the administration that factory workers faced one hundred years ago in the face of factory owners – all superseding and all dehumanizing GREED!!

    There is only one way to fight it – we must all speak together and stand together : Only if the administration knows that by ‘firing a few of us’ – the rest : (all as one) will stop working and shut down the hospital that this process can be stopped and may be even reversed !!!

    Until then just like child laborers were doomed 100 years ago, so are doctors are doomed today!!!

  51. Nico chill out! You’re a vulgar and angry man who does not represent the majority of American healthcare providers. Your complaints represent the problems with American healthcare, not individual administrators.

  52. We should not be using pseudo names. It means we are afraid. I come from ZImbabwe where speaking ones mind gets you in prison or killed. This is America is it not. Are we not allowed freedom of speech.!! To hell with administrators, bunch of self propheced idiots who would not have a job if it was not for us. It’s very simple we all give them notice that in six months we are downing tools. Get real come and talk to us with respect and that goes for adminstartors and insurance companies. Hey SM where are you? Still hiding behind your initials you coward!!! as doctors we need to stand together and tell these idiots where to go and fly a kite.

  53. Not entirely irrelevant, though, sad to say, there are those who will accept subpar standards, and deliver subpar care in turn, and not all of them will do so out of indifference to patient outcomes. While honorable and admirable, altruism can create its own negative feedback loop. Then discouragement sets in, to the providers who burn out battling to preserve their idealistic expectations, and to patients who are failed because they entrusted their well being to an institution that developed clay feet.

    You hit upon the “secret weapon” that healthcare providers have in this war of ethics and resource allocation. Our knowledge, skill, and experience are THE commodity that drives this industry. Healthcare executives are marketing US. Their power and income depend on our performance.

    Before we pronounce time of death on the remaining elements of a free economy in health care, it would behoove us to take charge of running this code and outwit the business persons of medicine at their own game. We need to play into their incentives, and there was never a culturally more appropriate time to do it. A recent study showed that on line consumer reviews significantly impact parents’ choice of pediatrician. Even if a neighbor spoke highly of said pediatrician, negative reviews swayed parents against entrusting him/her with their children’s health.

    The internet is a persuasive player in our culture. And for those of us who spent high school proms doing our homework, a resourceful tool to augment our hard won social skills. We should turn the tables and be the reviewers, instead of the review-ees. The internet has given everyman a voice. And created a forum for collective voices to stand up.

    Most of us will never have the time or means to be a lobbyist, but we can log in and make ourselves heard. We are forbidden from collective bargaining lest we become a monopoly. But, that does no preclude our right to freedom of speech (at least, for now, I think, no one has found a loophole that pertains only to doctors. . .) We’re consumers and we’re entitled to review the businesses that contract with us. We should publicly critique the business practices of medicine that negatively impact us and our patients. We should do this as a group and capitalize on the relative anonymity of the internet to protect us from risk to our livelihood. As a matter of fact, we’re doing just that, courtesy of Dr. Gunderson’s clever anecdote.

    And one other thing on my mind. . .

    If universal healthcare evolves into a “one payer system”, i.e., the federal government, who is answerable to none because the purse strings it controls are not impacted by performance, then all our handwringing will be for nought–and that “nought” includes healthcare executives. One size fits all will rule the day, and those six figures salaries will disintegrate into a pile of irrelevant dust. So will medical ingenuity and the ideals set forth in the Hippocratic Oath.

    Ah well, I hope I don’t find myself saying “Take a number.” I don’t even like it at the deli counter.

  54. I totally agree with it and can feel it too. Beautifully described in words. Hope there is some solution to it.

  55. We just have to say NO!, together….. the latter being hardest thing for medical professionals to do.

  56. This is exactly what is happening in my hospital… and it is not only in the US, I work in Europe. It is so sad to read that everything that is going wrong is being done on purpose. What we need to know now is how to react against this threat in our everyday working enviroment.

  57. How did C Business Majors become A Science Majors Boss -Because We Allowed it to happen !!!

  58. This is yet another reason to leave your AMA membership and join AAPS. AAPS is actively bucking these dangerous trends…while the AMA lines up at the trough to feed. The only way to organize is to get organized. It’s $350 well spent! I recently joined. Unity is the only way out.

  59. This is exactly what we feel like in our hospital, and is exactly what they are doing. Electric medical records- the worse, non intuitive program on the planet, forcing us to be billers and clinicians to be pharmacist, you have to read articles on the computer if you don’t pick the antibiotic they want you to use. And ya, fire ya, usually with little or no warning…

  60. I am a retired audiologist with 28 yrs in the VA. The VA is comprised of administrators that truly believe that they are the reason why we get paid and that without them we are in the breadlines. The catch phrase was ” clinical vs administrative” and was no different than the long-standing phrase, “Union vs Administration”. It is the adversarial position that views “winning” in dollars and cents, NOT in favorable outcomes whether you are treating patients or students.

  61. Sadly, Kitty, whether you accept them or not is irrelevant. If you do not accept the fact that the machine of of medicine ultimately controls how healthcare is delivered, they will find someone else to accept it, its that simple. Its unfortunate that healthcare executives see doctors as a way to control expenses, contrary to helping patients live, get better, improve quality of life, which is the basis of our fundamental training. In spite of this unfortunate commentary on our system, I still believe that doctors play the biggest role in ensuring these healthcare executives have their six or seven figure paying jobs. Without physicians, what is healthcare? Can healthcare executives deliver it? They might want to rethink this type of strategy.

  62. a nice article capturing the war on doctors by the big management groups and hospital along with medicare/obamacare. Doctors need to wake up and say enough is enough and fight for our right. Other wise as stated n this article we will be treated like assembly line workers in a factory soon. They can even lobby for getting thousands of foreign doc by waivering the need to do a residency training all over again in the US. mark my word this will happen if we don’t start caring about our profession and future

  63. Why are we being cowered by adminstrators. Why not name and shame them for their astronomic salaries impunity of layering regulation after regulation aligning themselves with insurance companies and their attitude of “to heck with doctors”. It’s obvious to me we are being screwed. Without us there would be no Insurance companies and no administrators. Why are we not in control of our own destinies. Those few doctors who are found to be messing it up for us, the majority who practice ethically should have the book thrown at them and never allowed to practice again. That will put a stop to the nonsense that these regulations are to stop abuses by doctors. We are being abused by the system to our detriment. Let say it as it is. I have not seen one supportive postive comment on this forum from a practicing physician saying the way medicine is going is positive. All I see is dissatisfaction. I wonder why?

  64. Thank you Rick. This isn’t going to make you popular with any hospital administrators, but is greatly appreciated by your peers. Fight the good fight. Sam

  65. Excellent article & so familiar all round. Irony is that those who unleashed this culture ie. political masters are the least qualified ones but all the same they play with the health care all the time.

    Problem with medical profession is that doctors are disunited lot – an opportunity the unaccountable bureaucrats / managers never miss.

  66. By the end of reading this piece to my partner, and grinning knowingly as each stratagem outlined in “the manual” struck a familiar chord, I realized that what Dr. Gunderson shared with us is his allegory, and a well done one at that.

    Oh, the manual is out there, though perhaps not in so many pages, linked by a staple. It’s wishful thinking on my part to conjecture that what binds the economic incentives undermining the doctor-patient contract is something as flimsy as a staple. If only this were a matter of battling windmills. . .these are real dragons. . . they are organized. . .and they are not hindered by pesky matters, such as human suffering.

    As Dr. Gunderson’s piece implied, these are times of dealing with the devil, and the arrogance that comes with knowing that the terms will be accepted–no matter how audacious. After all, the cards are laid out on the table. It’s on our conscience if we accept them.

  67. Mark
    I really like your article. It does imply that you have a copy of the “HOW TO DISCOURAGE A DOCTOR ” consult which would be a great piece of evidence to prove that this is actually going on. Certainly it seams that this is a trickle down consult already in use by the government as well as the insurance companies. If such evidence could be produced it might help polarize the physicians to become more active as a cohesive group to combat what is going on in the health care industry.

  68. this is very true, the hospital administrators have been bullying doctors for far too long, promoting a a culture of lack of security of tenure. saying every patient complaint or mistake or what they deem to be a mistake can result in firing, when the hospital administrator does not even have a medical background!

  69. A “Union of Suing Doctors” with a focus on protecting the doctor – patient relationship is not “socialist”.

  70. This is exactly what’s happening in my country (Portugal) where we have (or had?) a quite good health care system (clearly better than other systems in richer countries). Thanks for putting it in words. The general population should be aware of whats going on, but unfortunately they aren’t
    José Loureiro

  71. This is why I am coming up with a plan to quit being a doctor. I spent my entire life to become one and have a huge student loan debt. Its to the point that I have considered leaving the country. I am tired of being told that my pay is based upon how many patients I see. The other doctors order a million dollar work up on everyone and then don’t bother to see them until the tests results are back (in the ER). I refuse to pass out percocet and dilaudid like candy, so my satisfaction scores suffer. It breaks my heart that something that I have worked so hard for has become such a burden. I have realized that continuing in my profession is not worth the stress and worry. I wave the white flag. I quit.

  72. Speaking of cost, what about this: Medicare paid the physician $318.00 for a pacer implant, and the hospital $62,000.00 – a same day procedure.

  73. I am so glad somebody is saying what I have been saying: without the doctors, there is no healthcare, therefore no hospitals. As a nurse, and wife of a doctor, I wish more of you will find time to defend your supposedly self-regulating profession. You are one of the prime movers of the world…Atlas.

  74. Thanks for the article Dr. Gunderman. My wife and I (physicians from iusom) have been struggling with the ancillary aspects of healthcare, her much more than me as she is primary care. As a resident, she is still double booked at times, has to fill out superfluous paperwork, etc. She only enjoys family medicine when there is a personal connection and service rendered. Even paperwork isn’t bothersome if its necessary, but insurance companies, Medicaid being one of the worst, know that more obstacles and red tape mean lower costs for them. I’m disappointed that the recent healthcare overhaul did not address this, to my understanding. We both gained valuable insight from your article, so if you read the comment section (often the most entertaining part of online blogs, no offense intended), thanks.

  75. I know. It sucks. I’ve had to go to therapy to deal with all the anger related to being victimized by my employers. It only gets worse if we do not stand up for ourselves.

    How much worse can it get? One doctor told me she’s no longer allowed to ask open-ended questions to patients. Wastes too much time to ask, “How are you feeling today?” She explains:

    We are now to be double-booked [two patients per appointment slot] to ‘make our production quotas.’ Our regional director (not a doctor) reinforced the decision by our medical director (an MD under the thumb of the regional director) that we are NOT to ask open-ended questions in our visits but to let the medical assistants who room the patients identify the SINGLE issue that they are coming in for and THAT’S IT. So we basically need to shut down to whisk them through the door.


  76. We respond this way because we are treated like children. Last year, our hospital implemented a bump policy, aka, you can make no changes to your schedule for any reason without managerial permission. Even for emergency surgery, that’s right, running out the clinic door to get to the OR to save someone’s life while my secretary yells after me, “you need to fill out the bump form!” If you treat me like a professional, I promise I was trained to be one and have always acted like one. If you micromanage me and hover over me like a child, I will eventually learn the game and start playing.

  77. If the document you describe is a real one, the concerted effort to destroy physicians and the profession of Medicine is even more diabolical and conspiratorial than I had thought. If it is allegory to mirror what you’re seeing in daily practice, it is an absolutely brilliant, BRILLIANT, analysis of what hospital-based medicine, particularly that which is enforceable by the strong-arm of an EMTALA-controlled environment, has become.

    As I read it, it jolted me over and over again with truth. Reading this article reminds me joyously of the fact, and reminds me of why I praise God frequently, that although I still practice Medicine, I haven’t set foot in a hospital in over 2 years. Praise God, and Hallelujah. Medical students, pre-meds and residents, read this article and know this now:

    If you’re going to become, or remain a doctor, please, please do yourself a favor and make sure you have a skill that allows you if needed, to earn a living, providing non-hospital based, and non-EMTALA governed, elective outpatient care.

    Either that, or make the decision that at some point you’ll have to either revolt, or resign to being soul-crushed. Everyone that hasn’t lived this already, needs to print it out, study it, and contemplate what this will mean for your life. For those that have lived it, realize you still have a choice. You still have the choice to stand up, say no, and remain an independent physician. Break the chains, my friends. Break the chains.

  78. Excellent response Ben. You are absolutely spot on. In all the rubbish that is being foisted upon us, never has it to do with patient care, but regulations regulations that stifles our art of practicing medicine. I salute you. I did the same in my country and my passion for being a physician was restored. At the moment we are all robotic and clones derived from bureaucrats delusion minds. The back lash is coming and it’s coming fast.

  79. There is too much to say about this subject to post on a simple comment section. I am a solo actively practicing physician I quit the insurance system, I refuse to be an employee of a hospital or insurance company. I listen to my patients. I shun politicians and politics. I make recommendations to my patients based on both evidence based and experienced based medicine. I firmly believe in the art of medicine and the sanctity of the doctor-patient relationship. I honor and respect it. Unless physicians begin to believe in this, we will go away. We are going away. Our current health care system is set up to be found in Walmart and Kmart and in a big operating room in a big hospital. With no doctor.

  80. Income soaring but cutting jobs? Actively seeking to undermine physicians in favor of strengthening the corporation?

    Sounds like some other health systems. I can name at least one. *UPMC*

    We have to take our profession back and show them that we can care for patients without them, but they can’t earn their millions without us.

  81. SM and others who support his/her views, here is a challenge. Now that SM feels ever so powerful by doing some simple google search and found out who I am, what about giving us your full names so I can search you too. Its interesting that most of the names of the contributors in this forum are NOT searchable. My my, you are so courageous, to hide behind your agendas, without telling us who you are and what you stand for.
    I am for dialogue but not when its all one sided. Have you heard of the Six Hats method of getting to solve a problem, run a meeting, make decision Mr or Ms SM. I challenge you such a meeting in a public forum, and lets see what transpires. Who knows you might come out on top, now wouldn’t that be just fantastic for you and your side. I very much doubt it my friend, because the hidden bulk of the iceberg of resentful physicians will reveal itself, I have absolute no doubt.
    If you are not aware of the Six Hats method, you need to get current and look it up “on google of course”. So how about this, I am offering the fairest way to have such a discussion, in a public forum and we get an independent moderator who wears the White Hat. Look it up, I am not making this up. I await your reply. If you agree, I would kindly ask Pamela Wible to see if with her experience of publications and radio interviews if she would like to take this project on.

  82. Sorry I am on vacation until 6 th of October. Give me a call and we can discuss. It’s all about taking the first step, it was not easy but the best thing I ever did, because there was no abuse. I charged patients exactly what their insurance companies would pay choosing the median payment by the few insurance providers. Retired folk were given a 10 % discount and the indigent I did not even charge, and that was not often as most people have pride and would pay the basics. Patients hardly came for frivolously visits, there was mutual respect, patients knew up front of the costs and they could budget. I never had one disgruntled patients because I went out of my way to provide top service and hence had patients visiting me from surrounding countries and from overseas with clients who needed my services when visiting their families. Believe it or not it was civilized. We each played our role physicians and insurance companies but without the prescriptive nonsense. Because of what I had started, the numbers of physicians doing similar grew to a point that the insurance companies actually started having meetings with each other to have a more uniform price system. Guess who pushed for that, patients thousands of them complaining to their insurance companies to come clean and perform their duty and serve their clients instead of some board and their share holders.

  83. It’s happening every day and you know why? Because we are scared to say anything, speak up. This is America, freedom of speech, if I wrote like I do here I would been shot or imprisoned by the dictator government for speaking my mind. I am shocked at the level of fear by doctors in this country. I am living in the USA am I not. Have the rules changed and there is no freedom of speech? They want quieten us into submission. I say NO. You work with us or we will work against you, very simple. At this time it’s all one way, their way and nobodies else’s. What do you say SM. May we have your full name?

  84. Nico ~ I beg you to write your story of how doctors took back their profession in you country and post it on KevinMD and other sites like this one so we can learn from the successes out there. I favor positive learning strategies over fear-based education so often used to control those who must be free. I tried to call you a few days ago but it was after hours and your derm clinic was closed. Please contact me via my website if you need any help writing your story. I’m a good editor.

  85. Here is a true story:
    I just got out (Sunday) of the annual meeting of our state medical association. The officers are planning to give Trustee seats to corporate medicine “leaders”. The organization promotes the interests of corporate medicine and physician bureaucrats rather than working doctors. Sad and scarey.

  86. I speak what I feel. Instead you have what we call passive aggressive behavior , controlled anger, frustration, etc brain washed into you by your superiors. As I have said before read the book “the India way ” and you might come up to this century. I have no MBA but have started 3 businesses in my life all very successful. I had to abandon them because my country was taken over by a dictator. Have you started, planned, borrowed money, sacrificed time and energy to start any business of your own SM. I doubt it. That’s why you are an administrator, sheltered employment . You have no idea how to run a business, and realize your employees are your life blood. They we physician are being treated is absolute pathetic. I had biggest practiceClinical the country I come from, I went cash and became self reliant and had the insurance companies coming to beg me to go back with them. Witting 3 years of me starting the ball rolling over 50% of the doctors in the capital city went cash. There was no abuse of patients, but the ball was in their court to deal with the insurance companies. They, the insurance companies had to start sending thousands of checks to their clients instead to a few of the providers. Guess what happened SM, doctors took back their profession and insurers came back with their tails between the legs making offers that some of the cowards returned to the fold but the majority stuck it out. That’s what I propose we do here. I am 61 years old and to be treated by a bunch of useless so called business me who only think of one thing massive profit and treat us all in a prescriptive, patronizing and paternalistic manner is nauseating. There is no respect for is as a profession, they want to control outright, abuse us and then expect to work hard. Go read the Indian way and you might just to keep your job. As to my. Anger I vent it and for me it’s healthy

  87. SM probably doesn’t want to publish his name because he doesn’t want to get schooled like you just did by some skillful Google searches! Thanks SM for sheding some light on the slant of the author and his colleagues.

  88. Why do not do the deed SM and send this to IU. I am sure you will have an orgasm doing so!!!!!!!

  89. Don’t even know who Dr Gunderman is! It’s obvious we are voicing what most of our colleagues probably think! I do not think we are isolated phenomenon. The intrusion of lawyers, MBA’s administrators, insurance companies telling me how to practice is absolute rubbish. On top it when they cream the the money that us physician create it’s nauseating. SM are you scared to reveal your full name. Have you been cowered by your hospital. Tells us your name or get off this forum, we interested in moles who come and look for dirt of their colleagues. My views speak of the truth as experienced by the majority of physicians on this country. We need to stand up and not hide behind two letters SM

  90. Just so anyone that reads this article has the full story of the environment that IU boasts, looks like 12 months ago they cut 800 employees. Probably has not been a happy place to work since then, and Dr. Gunderman and Dr. Mousdicas are the products of that. We need to find a solution where doctors and administrators voices are heard and they work together in a collaborative way. But the anger that is being spewed on this feed will never accomplish the healthcare system we all envision.


  91. Wait a minute. Now it’s all coming together. The author Dr. Richard Gunderman is from Indiana University (IU) as well, and Dr. Mousdicas is one of his angry followers there. Sounds like the C Suite of IU needs to read this article. They have some disgruntled employees!

  92. Nico, your CEO at IU isn’t even an MBA, he’s a lawyer. Do you hate lawyers too?

  93. Never mind Nico, you’re a dermatologist and your this angry?!?!? I’ve never met an angry dermatologist. Any of the ones I know deal in cash, and are rolling in it. IU is either being mean to you, or you’re an angry person who hates anyone with an MBA!

  94. Nico,

    You sound so angry. You’re clearly not happy at your current hospital. If you want to bring your passion to a happy place to practice medicine, give me a call!

  95. It’s happening. Trust me.

    Akin to the civil rights movement of health care. There are many docs out there leading the way & liberating their peers. We can always use more station masters at the underground railroad. Join us.

    We certainly do NOT need any more physicians who are willing to prey on each other. Not the way to salvation my friends.

  96. Fantastic. Reminds me of when I walked out of a hospital in 2006, after being lectured to by the ICU Chief (about how not to upset ICU nurses by my detailed orders; we docs were expendable, he said). So I walked, and sure enough the CMO called me the next day asking me to stay on for another 6 months, since I was the only one of my specialty on staff! Guess what, a colleague took my spot within 3 months…who needs enemies, when we have such friends?

  97. You bet. But when will the trickle begin? Who will lead the exodus? What will it take for a sizable minority of docs to simply decide to slip out of the paper chains, sometimes set up by their own colleagues?

  98. I love this bumper sticker:

    TRUTH: THE NEW HATE SPEECH – Political correctness is destroying the very fabric of society. Never before in history have people been so afraid to stand up against absurdity for fear of being labeled a racist, a homophobe, or a bigot. Get rid of political correctness and let’s get people talking again.

  99. Beckygee, let’s have your full name. And before you hide behind your MBA , and pretending not to have opted out of medicine and call me not professional, answer me one thing. What have you done to support your physician colleagues . Tell me why have you not stood up and see the deceit persuaded by the se so called patient surveys. You are part of the problem as you sit in your smart office, and pretend to know what is going on I the clinics when you have no damn clue. Read the book the India way and see what progressive Companies are doing. You and your colleagues with MD come MBA are just perpetuating the parasites that you are. The new paradigm is employees first, and if you so not know this you are behind and need to go for a refresher course and be more professional. Counterintuitive is not but it make sense, when employees are looked after and feel valued guess what you MBA Idiot people actually feel valued and work and hive what you administrators want good service. You are part of the problem and only now are you commenting because doctors are starting to stand up. I will never be politically correct and you and you co administrators and your buddies the insurance companies need to be brought down to your knees because all you are parasites. So let’s have your full name mr MBA .

  100. I do agree. Slander never appropriate. I do think that those who injure others are just injured themselves which is why I think anyone who displays sadistic tendencies should receive mental health care.

  101. It is sad but at the same time we cannot afford yo sit back and just take it

  102. This is indeed a sad reality. I spent many years caring for patients, and then decided to join administration (yes – got a MBA) so I could be helpful to the process of running hospitals. The challenge for physicians and administrators is that neither professionals control the industry, and both are struggling for stability. I cannot imagine what is to be gained by stereotypes and slander (“MBA idiots, mind-fucking”), but it certainly is not professional or honorable as mentioned in the article.

    Truth is that these responses represent behaviors usually reserved for lesser trained professionals. Physicians are better than this we all hope, and will never accomplish your goals of respect, autonomy, and “senior leader” role by these means.

  103. PTSD. Fear.

    Physicians are the primary generators of revenue in health care. And look at all the parasites we support.

    Big box clinics know we are their only competitors. So they keep us in survival mode in paper chains. Control by fear tactics as noted in the above essay.

    Hint: Slip out of your paper chains. You’ll be happier and yes, you can make more money on your own when you stop giving 74-90% overhead to the parasites.

    I could go on . . .

  104. Dr Wible, well said. We need to stop this political correctness that is going on and being perpetrated by the very people who run the AMA and other so called speciality boards. They have done squat to protect physicians. We want the patient physician relationship to mean something.
    I have approached 3 vendors who conduct these so called pathetic unrealistic patient surveys to provide me with the studies that show validity and reliability of these generic surveys. They cannot, because they do not exist. Therefore they are perpetuating deceit in connivence with CMS in purporting to getting valid information. Now if you put the word deceit and profiteering in front of a lawyer what does they equal = FRAUD. that is a felony I believe!!!!!One of these vendors capital value just went up by a few hundred million dollars. Amazing, making money by deceiving doctors and patients alike and nobody says anything. Unbelievable!!!!!! And what of the insurance company that says it will allow for Isotretinoin (for severe cystic acne for 20 weeks) only irrespective of the fact that evidence says that relapse are common if one under doses. The mind boggles what will be coming next! I have no sympathy at all for physicians on this blog that support the status quo. You simply do not have guts to stand up and be counted!!!! We are been screwed and you want to play footsie footsie with these MBA idiots.

  105. Fact: Doctors can’t be victims and healers at the same time.

    Solution: DISINTERMEDIATION = removing the middleman.

    Time to remove no-value added intermediaries and while we’re doing that, let’s get the sadists in power positions into the therapy they need. It is not normal to treat other human beings in the manner described in this essay. An MBA does not give anyone the right to perpetuate an assault on humanity.

  106. If the writing is on the Wall,be it graffiti or Neon sign, does it matter
    who wrote the script? Medical Industrial Complex was spoken of by Dr. Benjamin Rush when he wanted Medical Freedom included in the Constitution.
    And George Washington would not support him.

    May I suggest Unionizing? Being called a Socialist and Communist in the same breath only humors me. The Constitution is a SOCIALIST CONTRACT that has barely been honored.

  107. What do you then suggest? You have obviously contributing inletting the profession be governed by MBA’s , probably you are one yourself!

  108. SM must be a administrator bureaucrat. He is talking absolute nonsense. We are being abused by a bunch of MBA’s who think they know how to practice medicine. SM I suggest you go and become a communist

  109. There is only one way to stop this rubbishing of our profession. We all agree country wide that on a certain date we hand in our notices giving the hospitals 6 months notice that we are withdrawing our services. No physician is to accept s any jobs from any hospital or University and lets see who comes crawling. We then make our demands. It is a no brainer

  110. I have been a physician for 34 years and during that time I have seen physicians change from being ‘Doctors” to mere “Medicocrats”. This has happened not only becuase of the hospitals, but because of the health care industry (Medical Industrial Complex) as a whole.

  111. The control of Health Care has been out of the Physicians guidance for some time. The specific tactics may differ based on venue but the strategy is universal for those who herd cats. Sad as that awareness is ,it is accurate and being practiced by the “Money” Managers. I am glad to see it discussed.

    The Money Managers are first cousins of Actuarials.

  112. The answer is simple but at the se time very difficult. To counter this effective and more physicians need to go back to private practice and go cash only. That is where we need to go.

  113. Having sat in many C suite meetings, I can tell you right now no hospital executive team consciously thinks this way. The reality is, our actions sometimes cause these environments for physicians, and result in these feelings. Physicians are the life blood of the hospital. We provide the space for your art and profession to be practiced, and it’s an honor to do so. We live in a very symbiotic relationship. The minute one party thinks it’s more important than the other, both die.

  114. Who wears three piece suits and why would a hospital executive listen to a consultant who is?

  115. This is an accurate description of what’s happening in our hospital system, but I did not suspect a conspiracy by administrators. Is Dr. Gunderman’s essay a satirical description of a reality that exists because of a series of random events, or is this a true description of a reality that exists by design i.e. is this for real?

  116. We have built a world of complexities thinking that quantitation will answer everything and it’s not. Insurance companies, where so much of it began and some what spread have highly trained quants now, many of which used to work for hedge funds creating models. Some of them are nonsense and insurers are driving themselves off a cliff with the time, expense, etc. in thinking more data is always good. Not the case as too much non relevant data to giving good care is taking a lot of time and money and those models are failing. Same thing with hedge funds if you notice as they are not having great years here and the models are failing there as well.


    Now we have Medicare Advantage MDs being fired and given no reason so we know it’s more quantitated madness, working a model that will eventually fail for care but will show a profit so we have “The Secret Scoring of America’s Doctors” and that’s a huge discouragement.


    Now folks are over working population health models, again with way too much non relevant data not related to good care, i.e. the hospital in North Carolina who thinks they need all patients credit card data to mull through for better care. The tech person there got sold a bill of goods as MasterCard and others are out actively marketing selling that data to any vertical they can make a case for. So yes, a doctor has to listen to some admin wanting doctors to rummage through patient Acxiom and credit card records now? Indeed a good way to discourage doctors with quantitated nonsense.


    Again it’s interesting to see how far folks will push the population medicine algos as there’s already hints of that out there. Population medicine is an old United Healthcare model that I saw on an MD’s desk around 8-9 years ago when I was developing. I had just finished creating a registry module and saw the brochure with the pitch and promotion to the MD about “neighborhood doctors” , “compare yourself with peers” sign up on website, enter data. So again many of these models crept on over to CMS as there’s been a very heavy reliance with HHS and CMS on using the United technology arm for yeas to help them with models, a former CMS person informed me of that one.

    Problem is no matter who’s models they are, too many are failing and you can’t expect a model not revised to exist for years, doesn’t happen but I see a bunch of that out there and yes indeed it frustrates doctors as we all know there’s flaws. Doctor work in the real world every day and there’s a name for that, patients. Others with building statistical models live in the virtual world of values, which we need some of it of course for measurement, but they are getting out there being way too non linear and they are failing. The CMA is a a good example with their recent efforts on rating doctors as Untied is pushing, model fails.


    So quantitated madness certainly is driving doctors crazy and this is not a myth. We also saw this with the recent VA OIG report to where quantitated madness was used to play down that people died and then of course the VA doctors came right out to dispute as they should have by all means.


    It’s very scary out there as everywhere we are seeing a big problem with people not being able to determine what’s a virtual value and what’s a real world value and we see it outside of healthcare too, very scary indeed. It’s pits battles where they need not be.


    Couple years ago I crated the Killer Algorithms page with videos from folks smarter than me, many of whom are quants that write these models so they know and can tell you the truth for anyone that wants to listen to the absolute core of the problem which I now call blatantly “code hosing”. Funny as even Nanex who does the stock monitoring got into to that one too as that’s what he does, identified code hosing on the markets, same thing, different industry and people who write models move between industries frequently as well. If you listen to Quant Cahty O’Neill, she tells you exactly that in one of her videos on how the modeling is the same and they try to find value and use models in different industries.


    By the way her PBS interview has a bonus point I call it when they ask here about her exit interview with Larrry Summers from DE Shaw, no words required, a bit roll of the eyes:) So there you go, quantitated madness discouraging doctors when the system is rigged with broken models that go no further than a proof of concept and yet become adapted for use and they just don’t work.

  117. To have real life situations complete with dialogue really paints a picture
    As a layperson I would assume that many times an initial so called diagnosis of symptoms by the patient shows other more serious problems diagnosed by a physician
    By not asking open ended questions I would think this secondary diagnosis will
    not reach the primary diagnosis stage due to production quotas
    I feel sympathy for physicians who wish to utilize their gifts talents and abilities and are stymied by pencil necked superiors
    Don Levit

  118. None of what has been described is a solution. It will all cost more but without delivering more care.

    The complexity of gov’t transformation in health care is so huge, nobody can ever be expected to understand its real cost. Instead the focus is on how much MDs get paid. It isn’t going to help in the long run due to increasing complexity issues.

  119. If you look at the health care cost curve, change was inevitable. I think we spend too much time worrying about the current changes and need to look at the real long term trends. I don’t know if we have the solutions to make things turn out the way we want, but I am not gonna just fold up and not try.

  120. Parable or not….true, true, true and true. And gunderman has job because he is a physician, and the guy in the suit has a job because gunderman is a physician. While you dont have to rub it in anybodies face but in a loving way we need to make sure management understands that principle.

  121. Thanks for describing exactly what is happening in the current “health care transformation”.
    We can expect the unintended consequences to start oozing out all over….

  122. And if doctors ever wonder what happens when you FINALLY stand up for yourselves and stop taking this shit. Here is a TRUE story from a physician friend this week: http://www.idealmedicalcare.org/blog/why-an-abusive-marriage-is-better-than-your-shitty-job/

    E-mail from my psychiatrist friend:

    Pamela, get this—after saying that I’d need to make up for my ‘lost time’ on production since I’m quitting my job, the Head Suit calls me today and begs me not to quit. I’m talking shamelessly groveling, tail-between-the-legs PLEADING in this phone call:

    Suit: “Don’t leave. Please. I don’t want you to go.”

    Me: “Um, okay.” Wasn’t sure what to say to that. Totally different attitude than when we were talking 3 days ago about my subpar “production.”

    Awkward silence.

    Suit: “Is there anything that would keep you here? Anything?”

    Me: “Well, um, honestly?”

    Suit: “Of course! I want you to be totally honest.”

    Me: “Okay. Then no.”

    Pamela, this whole process is crazy-making. I feel like I’m in my abusive first marriage all over again! But at least I got nice flowers and makeup sex out of that!

    After reading her above e-mail, I reply: “Can I publish this?

    Her response: “Oh HELL YEAH!!!! I would be completely and utterly honored. But please include one final note:

    Dear Suit:

    Word to the Wise:

    Don’t ever try to mind-fuck a psychiatrist.


    Dr. Out-The-Door”

    Get it docs? You really, really, really don’t have to take this shit.

  123. Yes. Doctors need to stop taking this shit: (full blog excerpt below)


    Another indication that health care is sick—doctors are being told to stop asking patients open-ended questions like:

    “How are you feeling?”

    “What worries you?”

    “What’s on your mind?”

    Today a physician just e-mailed me:

    “I am really, really overwhelmed right now. What happened to me at work this week was grim, even before our dreaded production meeting. I can feel tears welling up. Reason: Many times I have tried to incorporate friendly pick-me-ups like a smile, a handshake, a ‘thank you for coming in to see me today,’ an ‘it was wonderful to see you today’ at the end of patient visits. My standard opening line has always been some version of ‘What brings you in today?’ I’ve always felt a source of pride that I can ask open-ended questions and still get to the bottom of most issues in a short visit. My production meeting yesterday pretty much squashed all those niceties out the door.

    We are now to be double-booked [two patients per appointment slot] to ‘make our production quotas.’ Our regional director (not a doctor) reinforced the decision by our medical director (an MD under the thumb of the regional director) that we are NOT to ask open-ended questions in our visits but to let the medical assistants who room the patients identify the SINGLE issue that they are coming in for and THAT’S IT. So we basically need to shut down to whisk them through the door.

    You know as well as I do how ridiculous and futile that is and how fast care like this destroys what’s left of the therapeutic relationship. I now have to figure out a way to work even faster while still being caring and compassionate. I am in a really shitty position.”

    My plea to doctors: please stop taking this shit.

    Pamela Wible, M.D., is a family physician and founder of the ideal medical care movement.

  124. Wow, thanks for writing this. To me it doesn’t even matter if the particular document is a parable or not. You just described nearly verbatim what my previous (hospital) employer did. I’m so glad I got out quickly. Doctors (and other providers) need to remember that without them, there is no health care. We need to stop ‘taking it’ and instead stand up for ourselves and our patients.

  125. Immoral profiteering social engineering, preying on physicians and patients alike, in the tangible form of a physical “how-to” pamphlet…..medical plutocracy given form. If legitimate, I’ll bet they don’t want a copy of that to get out! (It very much should – somebody obtain and publish this, please).

  126. So maybe this is why hospital and clinics need to institute physician wellness programs—to counteract their own bullying and abuse.

    I just wrote the author to confirm this is real. I feel certain it is. I survived some of these shenanigans.