OP-ED

How To Discourage a Doctor

Screen Shot 2014-09-18 at 2.28.53 PMNot 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 started 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.

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tryslamdunkPaulGlenmike Recent comment authors
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try
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try

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… Read more »

slamdunk
Member
slamdunk

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… Read more »

Ben Gonzalez, MD
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Ben Gonzalez, MD

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.

Paul
Guest
Paul

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… Read more »

Glen
Guest
Glen

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.

RW Sewell, MD
Guest

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

MedStudent
Guest
MedStudent

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 🙁

Nico Mousdicas
Guest
Nico Mousdicas

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,… Read more »

MMK
Guest
MMK

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… Read more »

clinics
Guest

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.

Dr Lovejoy
Guest
Dr Lovejoy

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… Read more »

The suspended one
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The suspended one

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

The suspended one
Guest
The suspended one

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

Dr Lovejoy
Guest
Dr Lovejoy

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.

Vincent Farell
Guest

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.

ER, MD
Guest
ER, MD

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..