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
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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….
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.
Thanks for finally talking about > How To Discourage a Doctor – The Health Care Blog < Loved it!
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?
All under the auspices of the US government.
RICHARD GUNDERMAN, MD wrote it in 20214 but these words are in fashion.
This aged VERY well.
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.
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.
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.
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.
Sincerely,
Kevin Strong, MD and Founder of the nonprofit Dunk the Junk
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.
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?
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.
What a condescending article. I hope you lose your job and find some humility before you find another handsome man to hire you.
I could not agree more. In fact, I’ve written an entire series of novels that bring to light much of this type of controlling and discouraging behavior that goes on “behind the scenes’ every day. http://www.asurgeonsheart.com
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.
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.
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 🙁
SUCH AS OBAMA. OUT with OBAMACARE!!!!!!!!!!!!!!!!!!!!!
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.
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.
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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.
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…
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
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
Yes WE Do need a union
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.
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
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.
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..
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.
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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.
It is high time for a physicians bill of rights to counteract administration bullying.
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.
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…….
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.
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……
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.
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…..
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.