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The Winter of Our Discontent

Posted Jan 06 2010 3:47pm

by Jeff Brown, MD

Health care is in great ferment. The organizational side is particularly not much fun right now, but upheaval is too often the only way that we can get to a future of better possibilities. Congress' current meddling is rattling everyone's cage to get used to the idea of change in our business-as-usual thinking, which might in the end be the most lasting benefit of it. Just like the shift to managed care did.

And the key to that change is that we have to rethink how physicians and hospitals work together to manage what we do to help people. To do this, we need to realize that hiding behind the burgeoning problems of spiraling cost and inefficiency and blocking optimum solutions to those problems are the differing basic assumptions from our training that physicians and administrators bring to the table.

If you haven't thought about this before in these terms, just think how many misunderstandings in hospital boardrooms and offices everyone reading this can recall about the 2 groups as "2 ships passing in the night" spoke around and past each other, interfering with physicians' and administrators' goal of serving the sick and injured.

Many practicing physicians think that administrators, while individually able and sincere, are too focused on bean-counting and bureaucracy. They sometimes "don't get it." Conversely, executives too often see physicians, sometimes their social friends, as professional prima donnas who "just don't understand" the operational and regulatory complexities of running a modern hospital. And you all know what I mean when I say that I am phrasing this delicately. And, of course, both groups are right, up to a point.

I have often witnessed the stylized minuet between these disparately trained groups that goes on over budgets, policy and a myriad of details that are involved in running such a complex organism as a hospital. It's a wonder so many of them function as well as they do.

But intelligent players and shared good will alone can only carry the organization so far if the system they function in is not designed to accommodate the basic disparity in training and thinking between the 2 groups. If the people involved at all levels don't have the background to understand what is driving the other players and where those driving ideas came from, only frustration will ensue. And that's a very expensive luxury in healthcare, frustration.

In an effort to bridge the gap between administration and physicians in a rapidly changing, increasingly complicated hospital environment, there has been a movement in recent years for hospitals to hire a medical director or vice president of medical affairs. The idea is common sense; hire a (historically rare) doc, who by design, or talent, or chance has acquired some ability in administration and could help improve inter-group understanding and function.

Initially, as this idea took hold, there were a lot of missteps jumping on the bandwagon, in job description and identifying a suitable person, particularly with a limited, untrained talent pool. But it's proved to be a useful idea if done properly and the situation has improved with time and experience. Physicians and executives have both gotten more used to the idea and more physicians are getting MBAs and CPEs (Certified Physician Executive, from the American Academy of Physician Executives), so the pool of trained talent has enlarged somewhat.

But one individual, no matter how knowledgeable or charming, can't do it alone. It's really a time-buying band-aid, a first step, until there is inclusion at the physicians' training level of business and organizational education.

Hospital administrators come from a variety of backgrounds; law, accounting, public health, and business. They select themselves out by experience, interest and aptitude. Practicing physicians, on the other hand, have a common point of view in their training, but there are visible generalities on both sides to compare that can help our understanding.

Historically there has been a conceptual disconnect between these 2 groups. Regardless of background, administrators commonly are taught to work in teams, as part of a system, sharing responsibility and employing consensus decision-making; physicians are bred to be the Lone Ranger, solely making important decisions for our patients and assuming personal responsibility for them.

Administrators are resource oriented for group benefit while physicians are dedicated to what is best for specific individuals. Administrators tend to think inductively, emphasizing forward planning, while physicians' methods are deductive and largely reactive to events. In fact, our society's model of a "deducer", Sherlock Holmes, was modeled after a doctor, Sir Joseph Bell, author Arthur Conan Doyle's Professor of Medicine at Edinburgh.

There are many exceptions to these broad ideas that may spring to mind for each of us. And smart professionals are adaptive, often creatively so. We do all work together as best we can and things do get done. But too often this is in spite of our trained mind-sets, not because of it.

Hospitals have and will continue to evolve. Already their purview has extended across legal, economic, functional and geographical lines unimaginable just a few decades ago. And we pesky physicians will always be integral to the core mission. But to optimize efficiency, cost control and patient welfare, organized medicine needs to understand that administrative and organizational savvy is not "for them," but for us.

The practice of medicine does not exist in a bubble outside of society's functioning and physicians need to be trained from the beginning to understand and master the systems that we operate in to be the best physicians for our patients. As in so many other areas of human endeavor, Walt Kelly got it right for healthcare when he had Pogo say "We have met the enemy and he is us."

Jeffrey Brown, MD, CPE is a practicing physician whose writes the blog Take As Needed for Physicians Money Digest. A partner on the Stanford Graduate School of Business Alumni Consulting Team, he also consults for the California Medical Board. He can be reached at

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