Motivation for employed physicians to serve the health system

[nexus73]

I complain on here in various posts about hospital administration. There's just this clear disconnect between the administrators, who do no patient care, are paid well, and are fully aligned with the hospital and/or health system, and the physicians who provide the actual care that makes the business functional and are focused on best patient care and less so on systems level care issues.

From a simplistic standpoint, it's obvious that administrators are completely bought into the system. They are paid by the system and their work has no other outlet than to make the system "better", which in turns pays them, which in turn gives them opportunities for professional advancement within the system or the option to jump to better pay/prestige in another system.

As a physician, we give excellent patient care. But we don't get paid more if the system does well. There are no promotions with sweet compensation increases. We have some BS metrics that don't really align with hospital profitability. I have really zero motivation to go above and beyond for the system. I'm not eyeing the next promotion or trying to become the CMO at a competing health system. I have a job that pays well for providing patient care.

All this to say, whether it's asking/telling physicians they must supervise midlevels for zero pay, or cover extra shifts instead of getting locums, or whatever other nonsense admin is asking for, why in the world would I choose to do any of this? Sure the administrator asking gets cost savings, and can go into their annual review and argue for better pay because of how "effective" they've been, or add this to their CV to secure the next bigger job opportunity. But for physicians, what is the benefit?

If non-profit, hospitals don't have stocks, they can't give me options or special stock units, I don't do better if the hospital does better. Admin doesn't get this either, but they do get better promotions and bonuses if the system does better.

Just some rambling thoughts. Maybe I'm looking at this all wrong and if so happy to hear others' thoughts.

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[Sushirolls]

Shush. Knock it off. You looked behind the curtain. Don't tell all the new docs wrapping up PGY-IV this. Who will fill these positions?
It's supposed to be a secret!

I signed up for one of these after residency because I was home sick. Had student loans. And just wanted a pay check. Was too nervous to 'close doors' and wanted a job that still allowed me to do more, C/L, OP, IP, ECT, etc etc

I would spend time in the Doctor's Provider Lounge and would listen to the reasonable gripes and issues of other specialties within the system. I would routinely ask the others, why are you here, why do you stay? The answers summed up were its the devil they knew, their kids are entrenched in the local schools and not wanting to move. One doc finally listened to me and changed jobs (stayed in touch) and has since thanked me for finally leaving and wished (s)he had sooner. People get complacent. Or just want a simple pay check. Or they want to mentally check out, and that job allows them, too. Or they climb up to physician admin levels and they drank the same koolaid as the admin and are now ... one of them. Assimilated by the Borg...

I did briefly try to get my own promotion and expand my ECT service, and even open up an addiction department - both were met with a no. Even tried to set up a PCP friendly pseudo/CL clinic to be the benzo bad guy, to get the referrals to taper people off benzos that PCPs lack the know how or drive to initiate. Even the PCP dept head was lack luster to support this endeavor, and I continued to hear the grips of PCPs in the lounge.

Non-profits are all about the profit. Removing the pastors, priests, nuns, etc from the religious hospital systems ruined them.

 

[PikminOC]

I complain on here in various posts about hospital administration. There's just this clear disconnect between the administrators, who do no patient care, are paid well, and are fully aligned with the hospital and/or health system, and the physicians who provide the actual care that makes the business functional and are focused on best patient care and less so on systems level care issues.

From a simplistic standpoint, it's obvious that administrators are completely bought into the system. They are paid by the system and their work has no other outlet than to make the system "better", which in turns pays them, which in turn gives them opportunities for professional advancement within the system or the option to jump to better pay/prestige in another system.

As a physician, we give excellent patient care. But we don't get paid more if the system does well. There are no promotions with sweet compensation increases. We have some BS metrics that don't really align with hospital profitability. I have really zero motivation to go above and beyond for the system. I'm not eyeing the next promotion or trying to become the CMO at a competing health system. I have a job that pays well for providing patient care.

All this to say, whether it's asking/telling physicians they must supervise midlevels for zero pay, or cover extra shifts instead of getting locums, or whatever other nonsense admin is asking for, why in the world would I choose to do any of this? Sure the administrator asking gets cost savings, and can go into their annual review and argue for better pay because of how "effective" they've been, or add this to their CV to secure the next bigger job opportunity. But for physicians, what is the benefit?

If non-profit, hospitals don't have stocks, they can't give me options or special stock units, I don't do better if the hospital does better. Admin doesn't get this either, but they do get better promotions and bonuses if the system does better.

Just some rambling thoughts. Maybe I'm looking at this all wrong and if so happy to hear others' thoughts.

My friend works for a hospital. She gets more pay the more rvu she does so it incentivizes her to do more work.

 

[Celexa]

I more commonly give this advice in the context of academia and it's incredible ability to induce guilt and self-sacrifice, but it has its applicability here....

The institution will never love you back.

Can substitute any other number of verbs. The institution will never sacrifice for you. The institution will never return a favor. The instition will never care how much you tried. The instition will never be grateful. The institution will never feel guilt. The institution does. Not. Care.

What actually matters is who you work with in the day to day and whether you are able to take care of your patients in a way that you can feel at peace with.

 

[comp1]

If you conceptualize everything as you, the provider, being in opposition to this gigantic faceless institution...there is indeed no reason to do pretty much anything. However, that is not the day to day of our jobs. Heck, it's not the day to day of an administrator's job. Everything you do should be viewed through the lens of relationships. There should be a constant give and take. The "institution" may not care about you, but that's not really relevant. It's just a concept. It's like saying the earth or the universe doesn't care about you. You do things for other people, to help other actual real, breathing people. They might be patients, they might be other clinicians, heck they might even administrators, but you do things for people and they do things for you in return because you've built a relationship with them. This is how humanity became the dominant species on the planet.

 

[nexus73]

If you conceptualize everything as you, the provider, being in opposition to this gigantic faceless institution...there is indeed no reason to do pretty much anything. However, that is not the day to day of our jobs. Heck, it's not the day to day of an administrator's job. Everything you do should be viewed through the lens of relationships. There should be a constant give and take. The "institution" may not care about you, but that's not really relevant. It's just a concept. It's like saying the earth or the universe doesn't care about you. You do things for other people, to help other actual real, breathing people. They might be patients, they might be other clinicians, heck they might even administrators, but you do things for people and they do things for you in return because you've built a relationship with them. This is how humanity became the dominant species on the planet.

I certainly don't conceptualize it as nonstop opposition and never said that. My point is that doctors get paid what they get paid for being doctors and they do not have the carrots that administrators have for bonuses and promotions as motivators. It's more to highlight the discrepancy between job structure and path between doctors and admin, to explain why doctors and admin are often at the same table but not able to hear each other.

This idea of -they help you out, so you help them out- doesn't resonate with me. I don't see the hospital helping me out over and above what my compensation is for the agreed upon work. The problem with viewing things as building relationships through helping out is that in my experience, the more helpful you become, the more is asked of you, typically without further compensation, and often no expression of gratitude. The universe not caring is different than humans choosing to deliberately ask more of you with nothing in return.

 

[Merovinge]

I certainly don't conceptualize it as nonstop opposition and never said that. My point is that doctors get paid what they get paid for being doctors and they do not have the carrots that administrators have for bonuses and promotions as motivators. It's more to highlight the discrepancy between job structure and path between doctors and admin, to explain why doctors and admin are often at the same table but not able to hear each other.

This idea of -they help you out, so you help them out- doesn't resonate with me. I don't see the hospital helping me out over and above what my compensation is for the agreed upon work. The problem with viewing things as building relationships through helping out is that in my experience, the more helpful you become, the more is asked of you, typically without further compensation, and often no expression of gratitude. The universe not caring is different than humans choosing to deliberately ask more of you with nothing in return.

This is exactly how capitalism works. The goal is to pay every employee as little as possible to maximize revenue for the stakeholders. Because in large organizations it can be very difficult to quantify or feel the cost to productivity/quality of any cost cutting measures and because executive bonus is tied to this, you absolutely get the system you are describing. This is a natural consequence to having a capitalism directed healthcare system.

I largely agree with both your posts and think you are looking at it right, but this is not some shocking conclusion, this is exactly what you would expect if you look at how modern corporate structure in capitalistic societies is currently playing out. We have many systems in the country in which the incentives are poorly or oppositely aligned from what would be optimal for the population, this is far from unique to healthcare (although we may be the largest gorilla in the room). Given the state of congress, I would not expect anything to change anytime soon.

 

[Sushirolls]

I'm fine with PE and other for profit entities doing them, chasing dollars. I get that.

One of my unexpected beefs, was discovering that non-profit health entities really aren't. They behave just like a for-profit entity, and being a non-profit is just a checklist to maintain that tax status.

The hand off of pastors, priests, nuns, etc of some of the religious non-profits to pureblood suits, essentially gutted those organizations from having true community orientation. This is a travesty, and skewed the healthcare market drastically.

 

[comp1]

Maybe the OP would be happier in government work? The admin bonuses for cost savings definitely aren't as direct there. It can even be a little inverse at times. And relationships definitely are the way to get through a bureaucracy. If not that, I'd recommend trying out the admin work, at least for awhile. It can be perspective widening and help a clinician get a feeling for why a system works the way it does and where small changes can be made for improvement.

 

[clozareal]

There are RVU targets and bonuses if you go above them. The hospital is a big system so building a compensation model that aligns more closely with the hospital's performance is tough because even though it might create more engagement from physicians, your actions might not have any influence to the performance at large. It also might not have any influence on public perception of the quality of care since that depends on marketing, profitability of the hospital system since you don't control expenses, or morale of the employees since there's so much turnover in staff and you can really get into trouble if you say or don't say something in the workplace (standards of communication have gone way up in recent years).

It used to be that you could get put on probation, suspended, or fired because of egregious patient safety issues. Now it's if you don't speak up if a problem arises, use the wrong tone of voice, use a word in a patient note that has a negative connotation, or look at someone the wrong way, you are guilty until proven innocent in the eyes of administrative law of the hospital and medical board system. I've heard of people being suspended, made to do the physicians health program, etc for things that would have been excused many years ago such as yelling in the operating room when a tense situation arises. That really doesn't motivate physicians to work in the system.

I would definitely work within the system if it was easy for me to utilize hospital resources to create a program that would benefit the community and specific patient populations. I would love to leverage the academic assets to create CAP programs that would help those with eating disorders, autism, tourette's/tics, neurodevelopmental conditions, a treatment-resistant ADHD clinic, or whatever but after being in talks with a few academic institutions in my area, it was not a near-term or financially worthwhile possibility.

 

[comp1]

Oh yeah, if you try selling an institution on launching a whole new program as an outsider or past grad...it's going to lead to disappointment. That's something that the system develops some sort of organic internally grown interest in and then seeks out people to help shepherd it into existence. You have to be part of the system before becoming the driving force for a new program within it, usually for many years.

 

[clozareal]

Oh yeah, if you try selling an institution on launching a whole new program as an outsider or past grad...it's going to lead to disappointment. That's something that the system develops some sort of organic internally grown interest in and then seeks out people to help shepherd it into existence. You have to be part of the system before becoming the driving force for a new program within it, usually for many years.

This is what they said to me. "You should be part of this existing clinic for years and maybe you can think about starting a program outside of work hours. You'll have to fit meetings into your work day outside of your regular duties to gather the resources and if you come up with a good business plan that's approved, you might be able to get half a day for this."

 

[PikminOC]

There are RVU targets and bonuses if you go above them. The hospital is a big system so building a compensation model that aligns more closely with the hospital's performance is tough because even though it might create more engagement from physicians, your actions might not have any influence to the performance at large. It also might not have any influence on public perception of the quality of care since that depends on marketing, profitability of the hospital system since you don't control expenses, or morale of the employees since there's so much turnover in staff and you can really get into trouble if you say or don't say something in the workplace (standards of communication have gone way up in recent years).

It used to be that you could get put on probation, suspended, or fired because of egregious patient safety issues. Now it's if you don't speak up if a problem arises, use the wrong tone of voice, use a word in a patient note that has a negative connotation, or look at someone the wrong way, you are guilty until proven innocent in the eyes of administrative law of the hospital and medical board system. I've heard of people being suspended, made to do the physicians health program, etc for things that would have been excused many years ago such as yelling in the operating room when a tense situation arises. That really doesn't motivate physicians to work in the system.

I would definitely work within the system if it was easy for me to utilize hospital resources to create a program that would benefit the community and specific patient populations. I would love to leverage the academic assets to create CAP programs that would help those with eating disorders, autism, tourette's/tics, neurodevelopmental conditions, a treatment-resistant ADHD clinic, or whatever but after being in talks with a few academic institutions in my area, it was not a near-term or financially worthwhile possibility.

The problem I see is that there are ever increasing regulations on small businesses. So imo it's not that easy to set up and maintain pp

 

[SmallBird]

I think there are some layers to this - perhaps an uncommon opinion, but I believe that many individuals working in hospital administration want to support excellent patient care and would like physicians to be happy. There is an overall bias towards growth as being important which can work against these goals at times, and there is very little incentive for most systems to try and contain costs when they are so easily passed on to consumers. I remember talking to a retired health insurance executive and how that industry was actually invested in things being expensive as if healthcare was delivered much more efficiently than health insurance would be a small industry not a large one, and they can maintain profits even with it being so expensive by raising premiums. The ACA actually exacerbated this dynamic as the federal government now subsidized purchasing of private health insurance as well.

And then, I think psychiatrists have done a bad job of describing our role in a way that is digestible. By going along with the idea of us being 'prescribers' it is of course hard for an administrator to understand our needs and why we aren't replaced. If we were more consistent in explaining the standard of care as drawing on neuroscience, psychology, general medicine, etc., and actually practiced to this standard as well, I think we would be less pressed to make some of the compromises we have to in terms of patient time, volume etc. One setting I work where this has been achieved is in the army where the role descriptions say for NPs/PAs are quite different from psychiatrists and we have different expectations as a result

 

[Merovinge]

I think there are some layers to this - perhaps an uncommon opinion, but I believe that many individuals working in hospital administration want to support excellent patient care and would like physicians to be happy. There is an overall bias towards growth as being important which can work against these goals at times, and there is very little incentive for most systems to try and contain costs when they are so easily passed on to consumers. I remember talking to a retired health insurance executive and how that industry was actually invested in things being expensive as if healthcare was delivered much more efficiently than health insurance would be a small industry not a large one, and they can maintain profits even with it being so expensive by raising premiums. The ACA actually exacerbated this dynamic as the federal government now subsidized purchasing of private health insurance as well.

And then, I think psychiatrists have done a bad job of describing our role in a way that is digestible. By going along with the idea of us being 'prescribers' it is of course hard for an administrator to understand our needs and why we aren't replaced. If we were more consistent in explaining the standard of care as drawing on neuroscience, psychology, general medicine, etc., and actually practiced to this standard as well, I think we would be less pressed to make some of the compromises we have to in terms of patient time, volume etc. One setting I work where this has been achieved is in the army where the role descriptions say for NPs/PAs are quite different from psychiatrists and we have different expectations as a result

Can you post the difference in the job descriptions? I'm curious how the army does it.

 

[PikminOC]

I think there are some layers to this - perhaps an uncommon opinion, but I believe that many individuals working in hospital administration want to support excellent patient care and would like physicians to be happy. There is an overall bias towards growth as being important which can work against these goals at times, and there is very little incentive for most systems to try and contain costs when they are so easily passed on to consumers. I remember talking to a retired health insurance executive and how that industry was actually invested in things being expensive as if healthcare was delivered much more efficiently than health insurance would be a small industry not a large one, and they can maintain profits even with it being so expensive by raising premiums. The ACA actually exacerbated this dynamic as the federal government now subsidized purchasing of private health insurance as well.

And then, I think psychiatrists have done a bad job of describing our role in a way that is digestible. By going along with the idea of us being 'prescribers' it is of course hard for an administrator to understand our needs and why we aren't replaced. If we were more consistent in explaining the standard of care as drawing on neuroscience, psychology, general medicine, etc., and actually practiced to this standard as well, I think we would be less pressed to make some of the compromises we have to in terms of patient time, volume etc. One setting I work where this has been achieved is in the army where the role descriptions say for NPs/PAs are quite different from psychiatrists and we have different expectations as a result

In a hospital system you can't say that theres a difference as then you are called disruptive

 

[clozareal]

In a hospital system you can't say that theres a difference as then you are called disruptive

If you're disruptive, then you get reported to the medical board and NPDB. It'll always be a stain whenever you try to look for a new job. If you leave, you'll never get it resolved. If you stay, you'll be out of pay on suspension/probation for months-years. Then you will be out of work for 2 years trying to fight it relegated to working lousy jobs hours away from where you live.

The difference has to come from someone whose not a physician. Administrators aren't held to the same standard and handcuffed to the whims of the state medical board (or whoever has a grievance against you to make a report) on whether you can work to make money or not. It takes 100,000 hours to get our license but 1 minute to lose it.

 

[PikminOC]

If you're disruptive, then you get reported to the medical board and NPDB. It'll always be a stain whenever you try to look for a new job. If you leave, you'll never get it resolved. If you stay, you'll be out of pay on suspension/probation for months-years. Then you will be out of work for 2 years trying to fight it relegated to working lousy jobs hours away from where you live.

The difference has to come from someone whose not a physician. Administrators aren't held to the same standard and handcuffed to the whims of the state medical board (or whoever has a grievance against you to make a report) on whether you can work to make money or not. It takes 100,000 hours to get our license but 1 minute to lose it.

So there won't be any change...the system works too well for the hospital...

 

[splik]

Well there is obviously exploitation of physician good will and "professionalism" but I am a bit confused about the idea that employed physicians have no incentives. Many settings have incentives for productivity, patient satisfaction, attracting patients w/ good insurance, meeting quality measures. Many settings provide bonuses if the system is doing well (but this is less common because physicians don't want to share with others). Employed physicians can be promoted to various leadership and administrative roles which come with reduced patient care time and better compensation. Physicians like to hate on administrators, but administrative roles are also essential to the running of larger organizations and it is precisely because few physicians take up such roles that we get screwed over! Physician led organizations tend to be better run. If you don't want to advance within such a system, just want to see patients, and don't want people profiting off you - then don't be employed! It really is that simple. Physicians as employees is a very, very recent phenomena in the history of American medicine and psychiatry remains the easiest field to avoid being a cog in the system.

 

[PikminOC]

Well there is obviously exploitation of physician good will and "professionalism" but I am a bit confused about the idea that employed physicians have no incentives. Many settings have incentives for productivity, patient satisfaction, attracting patients w/ good insurance, meeting quality measures. Many settings provide bonuses if the system is doing well (but this is less common because physicians don't want to share with others). Employed physicians can be promoted to various leadership and administrative roles which come with reduced patient care time and better compensation. Physicians like to hate on administrators, but administrative roles are also essential to the running of larger organizations and it is precisely because few physicians take up such roles that we get screwed over! Physician led organizations tend to be better run. If you don't want to advance within such a system, just want to see patients, and don't want people profiting off you - then don't be employed! It really is that simple. Physicians as employees is a very, very recent phenomena in the history of American medicine and psychiatry remains the easiest field to avoid being a cog in the system.

My friend got promoted to med director. Her patient load and hours didn't change. Just more responsibility

 

[SmallBird]

Can you post the difference in the job descriptions? I'm curious how the army does it.

A more illustrative example is something I was able to achieve for a program I led at a medium-box shop. We were starting a new IOP and there was going to be a psychiatrist and an NP involved. In the program description I described the psychiatrist as responsible for crafting the initial biopsychosocial formulation, and that ongoing treatment would involve managing biological aspects of care and supervising the other aspects of care delivery. The social worker was responsible for implementing psychosocial aspects of care. The NP did NOT have the same role in formulating, but would manage the biological aspects of care ('med management') for a case that was initially formulated by a psychiatrist. I feel this worked very well in practice, was easy to understand, and nobody complained. It also meant that the psychiatrist in the program was billing a lot more and it worked well from that perspective. The previous director had tried to get the psychiatrist more money by loudly shouting that NPs were terrible and that was less effective.

 

[Stagg737]

Some of these points are also dependent on the system. Yes, many are terrible. There are ones that aren't as bad or offer more freedom though. Where I'm at they're pretty flexible about allowing you to create a clinic with a specific target and will accommodate (to a certain extent) with lightening other job responsibilities to develop other clinics or settings.

 

[clozareal]

A more illustrative example is something I was able to achieve for a program I led at a medium-box shop. We were starting a new IOP and there was going to be a psychiatrist and an NP involved. In the program description I described the psychiatrist as responsible for crafting the initial biopsychosocial formulation, and that ongoing treatment would involve managing biological aspects of care and supervising the other aspects of care delivery. The social worker was responsible for implementing psychosocial aspects of care. The NP did NOT have the same role in formulating, but would manage the biological aspects of care ('med management') for a case that was initially formulated by a psychiatrist. I feel this worked very well in practice, was easy to understand, and nobody complained. It also meant that the psychiatrist in the program was billing a lot more and it worked well from that perspective. The previous director had tried to get the psychiatrist more money by loudly shouting that NPs were terrible and that was less effective.

I feel like this is how NPs and PAs were originally supposed to function in the team.

 

[PikminOC]

A more illustrative example is something I was able to achieve for a program I led at a medium-box shop. We were starting a new IOP and there was going to be a psychiatrist and an NP involved. In the program description I described the psychiatrist as responsible for crafting the initial biopsychosocial formulation, and that ongoing treatment would involve managing biological aspects of care and supervising the other aspects of care delivery. The social worker was responsible for implementing psychosocial aspects of care. The NP did NOT have the same role in formulating, but would manage the biological aspects of care ('med management') for a case that was initially formulated by a psychiatrist. I feel this worked very well in practice, was easy to understand, and nobody complained. It also meant that the psychiatrist in the program was billing a lot more and it worked well from that perspective. The previous director had tried to get the psychiatrist more money by loudly shouting that NPs were terrible and that was less effective.

When I was hired at my second job in 2010, I asked about the np at my office working like that. Admin looked at me like I was cray and said they don't use midlevels as physician extenders...

 

[whopper]

Only once did I see an administrator have that balance between good patient care and profit. This guy was an MD and had an MBA This was THE ONLY TIME I saw that balance well-done.

E.g. If a patient could be taken out of surgery inpatient earlier due to better psych treatment cause the post surgical patient was depressed he knew that should be added to the profitability of the psych department in terms of money saved vs money generated.

Due to the above he was able to add several treatment-effective measures that added to cost-effectiveness, but like I said he was the only guy I ever saw that was able to do that well.

 

[nexus73]

It seems to me the physicians who move into admin almost universally shift into a system aligned mindset. And they end up rationalizing selling out the doctors they oversee little by little. They accommodate changes that enable unreasonable admin decisions. Doctors end up with worse jobs and get nothing out of it. And if you are able to push back on admin and they realize they don't have leverage (i.e., you're not easily replaceable), they come to really resent you because you're not drinking the koolaid.

I suppose Splik's comment is right. If you don't want to work in this system don't be employed. It's just frustrating to me that it almost feels like once employed the system is your master and resents any opinions not in lock step with what administration wants.

 

[SmallBird]

It seems to me the physicians who move into admin almost universally shift into a system aligned mindset. And they end up rationalizing selling out the doctors they oversee little by little. They accommodate changes that enable unreasonable admin decisions. Doctors end up with worse jobs and get nothing out of it. And if you are able to push back on admin and they realize they don't have leverage (i.e., you're not easily replaceable), they come to really resent you because you're not drinking the koolaid.

I suppose Splik's comment is right. If you don't want to work in this system don't be employed. It's just frustrating to me that it almost feels like once employed the system is your master and resents any opinions not in lock step with what administration wants.

It is also possible that they are asked to do even more nonsense that gets passed on to us but ultimately try and be strategic in maintaining a balance between the demands of the senior administrators and the satisfaction of their providers. I do agree that too often it seems they are more interested in how they are perceived by senior management than our satisfaction but a good number of administrators try and maintain a slightly balanced mindset.

 

[Candidate2017]

The problem I see is that there are ever increasing regulations on small businesses. So imo it's not that easy to set up and maintain pp

Complying with every single regulation is at least one or two fulltime jobs. Just pretend you're a roadside fruit vendor or MBA. Make sure to pay your taxes though.

I think there are some layers to this - perhaps an uncommon opinion, but I believe that many individuals working in hospital administration want to support excellent patient care and would like physicians to be happy.

Lol!

It's just frustrating to me that it almost feels like once employed the system is your master and resents any opinions not in lock step with what administration wants.

Choosing to be an employed professional (which is an oxymoron), in exchange for an "easy" paycheck, means you are obligated to serve many masters in pursuit of profit: The Man first and foremost and by extension third party payors, patients a distant second, and then medicine last. You are not a professional in any sense of the word, other than for liability purposes, because you do not practice independent judgment.

Your plumber or electrician is more professional than your average employed physician. They tell you what they can and will do, based on their training, and will tell you to GTFO if you argue with them about how to do their job. Meanwhile, I have to listen to patients tell me how weed is good for them, I don't understand "adult" ADHD, etc.

 

[VA Hopeful Dr]

Only once did I see an administrator have that balance between good patient care and profit. This guy was an MD and had an MBA This was THE ONLY TIME I saw that balance well-done.

E.g. If a patient could be taken out of surgery inpatient earlier due to better psych treatment cause the post surgical patient was depressed he knew that should be added to the profitability of the psych department in terms of money saved vs money generated.

Due to the above he was able to add several treatment-effective measures that added to cost-effectiveness, but like I said he was the only guy I ever saw that was able to do that well.

I've had 2 physician administrators directly over me in the past. The MD/MBA one sucked. Not long after I left they had to close the urgent care I worked in because it was losing money. It was a single physician seeing 60+ patients per day. I have no idea how they lost money on that.

The one I have now is MD only and, while he can be a jerk at times, really fights for primary care. I've been here 5 years. My income has gone up every year with the same (or sometimes lighter) work load. We have metrics, but because of him we have a whole department designed to help us do that. They call out medicare patients and do the AWV questions before visits. They monitor med compliance and work directly with patients to improve it. Stuff like that.

 

[erg923]

It seems to me the physicians who move into admin almost universally shift into a system aligned mindset.

Look, physicians alone do not keep hospitals financially solvent. Especially not psychiatrists. Not even close. You want to work at a hospital? You best thank a hospital administrator MD or Ph.D. Someone has to count the sausage or else you won't have a job.

If you would prefer to practice clinical psychiatry in a physician lead, unregulated, overcrowded, and dangerous inpatient warehouse asylum as they did 50-60 years ago...be my guest! But the outcomes sucked.

 

[SmallBird]

Look, physicians alone do not keep hospitals financially solvent. Especially not psychiatrists. Not even close.

If this was true there would be no need for managed care orgs, UM departments, or admin departments of any sort. Someone has to make the sausages here.

If you would prefer to practice clinical psychiatry in a physician lead, unregulated, overcrowded, and dangerous inpatient asylum as they did 50-60 years ago...be my guest! But the outcomes sucked. The whole reason for the payor oversight movement in the late 70s and subsequent movement for ROI oversight of psychiatry in general. No one can do it alone.

always just two options with you.

 

[FlowRate]

Your plumber or electrician is more professional than your average employed physician. They tell you what they can and will do, based on their training, and will tell you to GTFO if you argue with them about how to do their job. Meanwhile, I have to listen to patients tell me how weed is good for them, I don't understand "adult" ADHD, etc.

I'm sure there are employed jobs where you're able to practice independent judgment.

The people "telling" us what to do the most often are insurers in the sense that most patients can't afford to pay out of pocket for interventions we recommend if the insurance isn't covering most of the bill.

I'm in low-level admin (clinic medical director) and I look at it as an opportunity to support my front line docs (I'm front line as well, 0.8 clinical FTE) and get involved in improving systems issues.

 

[erg923]

always just two options with you.

Exactly! Very simple. Thank you.

 

[nexus73]

It is also possible that they are asked to do even more nonsense that gets passed on to us but ultimately try and be strategic in maintaining a balance between the demands of the senior administrators and the satisfaction of their providers. I do agree that too often it seems they are more interested in how they are perceived by senior management than our satisfaction but a good number of administrators try and maintain a slightly balanced mindset.

I think this is true and probably the best that can be hoped for.

My personal experience has been that admin requests are unreasonable overall. It's not like half the requests make sense so you can compromise on some of them. It's all irrational stuff that is either unsafe for patients or staff, or it makes the job so much worse docs will leave and they won't be able to hire more when they find out what the job requires. So you have to tell admin no and that doesn't make things more fun.

This is usually stuff like why won't MDs supervise midlevels for free?
Or why won't docs come in at 7am to see ED boarders (when patients are still sleeping usually), waiting to see them at 10am after staffing and unit discharges isn't good enough?
Why won't psych take the violent psychotic guy to a low acuity psych bed when the high acuity psych beds are full? You have beds open on the tracker.
You know the ICU doctors can see 30 patients per day (and then leave to see clinic patients), psych should be able to see at least that many.

 

[PsyDr]

I’ve started saying “Administrative work is not within the scope of my practice”.

 

[vanfanal]

Such a coincidence that I was reading this article that heartbreakingly illustrates the incompetence of admin when it comes to medical matters, and the fatal consequences of ignoring and bullying docs.

As I was reading it, I was thinking about this thread. I guess we can’t say that admin problems are all related to private equity, or corporations or capitalism, as this was in England. Admins universally just plain suck.

Hospital bosses ignored months of doctors' warnings about Lucy Letby

Hospital bosses failed to investigate allegations and tried to silence doctors, BBC investigation finds.

www.bbc.com

 

[mistafab]

Such a coincidence that I was reading this article that heartbreakingly illustrates the incompetence of admin when it comes to medical matters, and the fatal consequences of ignoring and bullying docs.

As I was reading it, I was thinking about this thread. I guess we can’t say that admin problems are all related to private equity, or corporations or capitalism, as this was in England. Admins universally just plain suck.

Hospital bosses ignored months of doctors' warnings about Lucy Letby

Hospital bosses failed to investigate allegations and tried to silence doctors, BBC investigation finds.

www.bbc.com

This highlights one universal temptation for all admin. No matter how many ‘Swiss cheese model’ lectures they give practitioners… when they are on the hook for a mistake, they are tempted to blame, shame, or hide the facts instead of objectively looking at the potential ‘root causes’ that they love to harp about. They are just humans, after all.

You have this disgusting CEO/admin lecturing MDs about openness and sensitivity, meanwhile they are literally letting an employee kill babies. The Swiss cheese model finally worked, yet when the issue was caught, it was willfully ignored. Terrible shame.

 

[Dr.MONO]

The answer is always private practice.

 

[calvnandhobbs68]

This highlights one universal temptation for all admin. No matter how many ‘Swiss cheese model’ lectures they give practitioners… when they are on the hook for a mistake, they are tempted to blame, shame, or hide the facts instead of objectively looking at the potential ‘root causes’ that they love to harp about. They are just humans, after all.

You have this disgusting CEO/admin lecturing MDs about openness and sensitivity, meanwhile they are literally letting an employee kill babies. The Swiss cheese model finally worked, yet when the issue was caught, it was willfully ignored. Terrible shame.

Yeah now that the sentencing is over the NICU doctors can finally let it rip (rightfully so) and going full blast against the hospital. They made the NICU attendings write her a "I'm sorry" letter and attend mediation sessions with her. It took them 3 months to even HAVE A MEETING about this ****.

 

[Mad Jack]

Something must be wrong- I'm employed and like my job. I focus on the day-to-day and have a great and supportive inpatient unit. Leadership is (mostly) willing to listen to staff physicians, as a lot of hospital leadership is composed of physicians. Incentives are pretty well aligned with my daily work, and are reasonably easy to achieve.

Perhaps I just haven't been doing it long enough. Perhaps I'm a masochist that is oblivious to the painful parts of my job. Or perhaps I've just found a good job, idk

 

[Merovinge]

Such a coincidence that I was reading this article that heartbreakingly illustrates the incompetence of admin when it comes to medical matters, and the fatal consequences of ignoring and bullying docs.

As I was reading it, I was thinking about this thread. I guess we can’t say that admin problems are all related to private equity, or corporations or capitalism, as this was in England. Admins universally just plain suck.

Hospital bosses ignored months of doctors' warnings about Lucy Letby

Hospital bosses failed to investigate allegations and tried to silence doctors, BBC investigation finds.

www.bbc.com

The problems are those of incentives, and those incentives are just of varying intensity/degree/flavor in different systems or parts of the world. Admin job is to make a place run "smoothly", if this is maximizing prestige, revenue, or just lack of effort for the rent seeking administration class it really doesn't matter. They don't take care of patients and largely don't spend any time with patients, they simply call the shots and respond to whatever incentives are offered for them. We all know how that system ends up working.

 

[PikminOC]

The problems are those of incentives, and those incentives are just of varying intensity/degree/flavor in different systems or parts of the world. Admin job is to make a place run "smoothly", if this is maximizing prestige, revenue, or just lack of effort for the rent seeking administration class it really doesn't matter. They don't take care of patients and largely don't spend any time with patients, they simply call the shots and respond to whatever incentives are offered for them. We all know how that system ends up working.

Physicians are incentivized too with certain numbers they have to hit for patient satisfaction tied to their bonuses at some of the hospitals I see

 

[Sushirolls]

Physicians are incentivized too with certain numbers they have to hit for patient satisfaction tied to their bonuses at some of the hospitals I see

That incentive has the opposite effect. To hasten burn out. To either realize working for Big Box shops is too much of a grind and not worth the squeeze. Or, simply check out and become the perfect wRVU miner, who leaves that nice bow tied xanax on the counter with a quaint card, "thank you for your visit, may health be with you."