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How hospitals discourage doctors: A step by step guide

How hospitals discourage doctors: A step by step guide


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 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 health care 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 health care 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 health care 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 health care 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 health care 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.

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 health care, 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 a professor of radiology, Indiana University School of Medicine, Indianapolis, IN. This article originally appeared in The Health Care Blog and is reprinted with the author’s permission.
 
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willabeast

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//Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass.// agree admin wants sentence #1. sentence #2 is simply not going to work well for admin. If a doc is not confident in prof judgement, that is a very costly doc. that would be the one who orders multiple tests, has longer hospitalization times, and longer procedure times.
 

algosdoc

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Or try this- Cerner favorite orders in a hospital erased by IT for no apparent reason....takes 5 times longer to enter preop and discharge orders. New Cerner EMR program going into effect in 3 months (to replace the current Cerner) requires 5.5-8 hours of mandatory training. The first two hours of training is online- the training program rejects the physicians ID repeatedly even after being reset several times by IT. The hospital dictation system changed one week ago and all physicians were assigned new dictation ID numbers but the hospital forgot to send out these new IDs to everyone that was not a hospital employed physician, making it impossible to dictate an operative report. The new dictation service does not have any published number available to physicians having difficulty or to medical records. Medical records closes at 5pm and no help is available after hours for determining the ID for dictation. Physicians are penalized for not getting timely dictations on operative reports. Hospital parking garage mandates physician's park in the physician parking structure, then changes the door codes so they no longer work the the physician electronic badges, without notifying physicians. The call box for security has no one on the other end. Cell phone calls to security through the hospital operator go unanswered. After hour physicians must crawl over concrete barriers at the other end of the garage then drop to the floor, walk to the other end of the garage and down stairs to reach their cars at night. All this occurs in a 5 hour period, and physician finally able to leave the hospital one and a half hours after finishing surgery due to all these snafus that to hospital administration are all just minor annoyances.
 

bronchospasm

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Hospitals want ancillary services that the physician can order, facility fee, labs, MRI , UDS etc. They have NO interest in physicians.
 
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Ducttape

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First part is just bad IT support. Happens to anyone.

Just ask the millions of Time Warner customers.


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drpainfree

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hospitals are no friends to doctors...they use doctors to make profit and dump you whenever you're no longer a profit-generating widget.
 
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jonnylingo

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Or try this- Cerner favorite orders in a hospital erased by IT for no apparent reason....takes 5 times longer to enter preop and discharge orders. New Cerner EMR program going into effect in 3 months (to replace the current Cerner) requires 5.5-8 hours of mandatory training. The first two hours of training is online- the training program rejects the physicians ID repeatedly even after being reset several times by IT. The hospital dictation system changed one week ago and all physicians were assigned new dictation ID numbers but the hospital forgot to send out these new IDs to everyone that was not a hospital employed physician, making it impossible to dictate an operative report. The new dictation service does not have any published number available to physicians having difficulty or to medical records. Medical records closes at 5pm and no help is available after hours for determining the ID for dictation. Physicians are penalized for not getting timely dictations on operative reports. Hospital parking garage mandates physician's park in the physician parking structure, then changes the door codes so they no longer work the the physician electronic badges, without notifying physicians. The call box for security has no one on the other end. Cell phone calls to security through the hospital operator go unanswered. After hour physicians must crawl over concrete barriers at the other end of the garage then drop to the floor, walk to the other end of the garage and down stairs to reach their cars at night. All this occurs in a 5 hour period, and physician finally able to leave the hospital one and a half hours after finishing surgery due to all these snafus that to hospital administration are all just minor annoyances.
This. The summary of my life.

Might I add: Time out on computers changed from 60 min to 5 min. So now I get to log in multiple time MORE than before.
 

SSdoc33

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Ligament posted the exact same article in 2014. Old news.

Yet, both are in private practice.... buyers remorse perhaps? Why don't you let the hospital-based docs bitch about their hospital-based professional lives?
 
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drusso

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Ligament posted the exact same article in 2014. Old news.

Yet, both are in private practice.... buyers remorse perhaps? Why don't you let the hospital-based docs bitch about their hospital-based professional lives?
They do. I hear it from my hospital-based colleagues all the time. Unfortunately, they are also made professionally vulnerable by their Admins. I know many who are even fearful about posting their grievances on this forum because they fear that they being monitored by IT department personnel. Recently, a couple prolific posters have stopped posting here out of similar concerns. I think that independent physicians have a duty to stand up to professional injustices regardless of W-2 status.
 

SSdoc33

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They do. I hear it from my hospital-based colleagues all the time. Unfortunately, they are also made professionally vulnerable by their Admins. I know many who are even fearful about posting their grievances on this forum because they fear that they being monitored by IT department personnel. Recently, a couple prolific posters have stopped posting here out of similar concerns. I think that independent physicians have a duty to stand up to professional injustices regardless of W-2 status.
how very altruistic of you. who knew that PP docs cared so much about the hospital-based peons working for the man?

look, i agree with a lot of your thoughts on this, but most of it is >2 std. devs from the norm for a hospital based doc. kudos if you are doing well in PP. thats great. but i really dont understand why you are so worried about the hospital docs. they are grown-ups. they can take care of themselves....
 
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nvrsumr

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We are concerned because the deck is stacked against private practice and most will have to join the collective eventually.
 

Ducttape

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We are concerned because the deck is stacked against private practice and most will have to join the collective eventually.
the way to reduce that likelihood is to have a successful private practice that encourages all doctors to go in to private practice. there is a fundamental difference between "You HOPD must have it bad, ive heard rumors about x happening" vs "PP is great, I love it, no hassles, money is easy, living is easy, who wants a margarita!!!"

as someone who works in the hospital system, seeing non-hospital based doctors pontificate how badly the hospital guys (ie me) must have it, when nothing intolerable has happened to me - yet, primarily makes me more defensive and makes me wonder if there is jealousy involved...
 
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lobelsteve

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the way to reduce that likelihood is to have a successful private practice that encourages all doctors to go in to private practice. there is a fundamental difference between "You HOPD must have it bad, ive heard rumors about x happening" vs "PP is great, I love it, no hassles, money is easy, living is easy, who wants a margarita!!!"

as someone who works in the hospital system, seeing non-hospital based doctors pontificate how badly the hospital guys (ie me) must have it, when nothing intolerable has happened to me - yet, primarily makes me more defensive and makes me wonder if there is jealousy involved...
Scraping by as a hospital owned, predominantly outpatient guy. But ive always been an employee and never an owner. So no millions for me in PP. But no risk either. Hospital has been mostly kind and Im enjoying working for them. My docs loungs has a nut dispenser on the wall. Deluxe mixed, honey peanut, and shelled pistacio. And Monster energy, a selectomatic Coca-Cola machine, and coffee bar.
 
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drusso

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the way to reduce that likelihood is to have a successful private practice that encourages all doctors to go in to private practice. there is a fundamental difference between "You HOPD must have it bad, ive heard rumors about x happening" vs "PP is great, I love it, no hassles, money is easy, living is easy, who wants a margarita!!!"

as someone who works in the hospital system, seeing non-hospital based doctors pontificate how badly the hospital guys (ie me) must have it, when nothing intolerable has happened to me - yet, primarily makes me more defensive and makes me wonder if there is jealousy involved...
Well, I guess at its core, it is my personal conviction that it is ethically wrong for hospital systems to direct and control doctors. I think that it is morally hazardous to be in such a relationship when they've stacked the deck against our profession with bloated facility fees, site of service differentials, ancillary revenue streams, etc. I suppose the emotional obverse to my personal conviction would be, "Why would anyone WANT to be directed and controlled by a system or a less educated manager? Who would accept that deal?" "Why not just be an independent contractor and hire your own billing company?" It elicits a sense of disgust.

...Yet, intellectually, I realize that people take that deal all the time...everyday...for all kinds of reasons...

Still, I think that as a society we should keep it simple: Hospitals are in the hospitality/cruise-ship/lodging business...doctors are the educated professionals who actually diagnose, treat, and care for patients. I won't tell hospitals how to run their business and they shouldn't tell me how to run mine (practice medicine or see patients). In other words, you don't tell doctors what to do.
 

nvrsumr

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Solo PP would clear 2+ million a year on hospital rates. Let's all advocate for an even playing field and get all the employed docs back in the private sector just like 75% were just 9 years ago and have the rising tide lift all boats.
 

Ducttape

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If one views that, as a physician, I can focus on the medical management and spend 90% of my time on that aspect, and not have to devote more on business...

I became a doctor to do medicine, not worry about salaries, A/R, co-pays, personnel retirement plans (outside my own).

If I wanted to do the rest, I would have gotten an MBA.

Frankly, when medicine became all about making the big bucks, that's when medicine turned for the worse.

(FYI, out of curiosity - Look at the big pill mills like in Fla. How many were HOPD salary employed docs?)


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neutro

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My HOPD contract ends in a few months.
The above is very true.

Its interesting you guys talk about EHRs causing daily frustration. Well in my case, we got an email from a CEO that no one can take time off from mid-october to mid-november because of 3 day EPIC training because they arent sure when we can be scheduled. So instead of giving each physician a scheduled date and time, they block ALL of us.
I had time off scheduled and CME during that time which I am not scrambling to adjust.
When you join a hospital, you give up control.
To me that is far more important than any $ amount.
 

Ducttape

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a lot of the angst I think that HOPD have is that they did not choose the health care system that they worked with wisely.

indubitably, there are a lot that are horrific and demanding.


when I joined my current job, the admin was very physician friendly, and focused primarily on making sure that I was happy. they let me run the medical side of the clinic, but was very clear about the financial side and its structure and support.
 

lonelobo

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Scraping by as a hospital owned, predominantly outpatient guy. But ive always been an employee and never an owner. So no millions for me in PP. But no risk either. Hospital has been mostly kind and Im enjoying working for them. My docs loungs has a nut dispenser on the wall. Deluxe mixed, honey peanut, and shelled pistacio. And Monster energy, a selectomatic Coca-Cola machine, and coffee bar.
That decides it for me! Hospital employment here I come
 
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Ducttape

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I don't have any of that.

had a water cooler until they took it away.

but im learning on being more mindful (and I complained, and it came back).
 

SSdoc33

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Solo PP would clear 2+ million a year on hospital rates. Let's all advocate for an even playing field and get all the employed docs back in the private sector just like 75% were just 9 years ago and have the rising tide lift all boats.
not if they saw 50% medicaid.

lets call a spade a spade.

an "even" playing field means no SOS differential AND a single payer system. that is the only way it is even. if you equalize the SOS differential, the tide in PP will rise, but the hospital based boats will sink.
 
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drusso

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not if they saw 50% medicaid.

lets call a spade a spade.

an "even" playing field means no SOS differential AND a single payer system. that is the only way it is even. if you equalize the SOS differential, the tide in PP will rise, but the hospital based boats will sink.
Food for thought: Who's entitled to SOS differential? How should it be negotiated and for whom? Why aren't people at the table bargaining over it?
 

drpainfree

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The above is very true.

Its interesting you guys talk about EHRs causing daily frustration. Well in my case, we got an email from a CEO that no one can take time off from mid-october to mid-november because of 3 day EPIC training because they arent sure when we can be scheduled. So instead of giving each physician a scheduled date and time, they block ALL of us.
I had time off scheduled and CME during that time which I am not scrambling to adjust.
When you join a hospital, you give up control.
To me that is far more important than any $ amount.
give me freedom, or give me death - William Wallace (braceheart)
 
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drpainfree

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a lot of the angst I think that HOPD have is that they did not choose the health care system that they worked with wisely.

indubitably, there are a lot that are horrific and demanding.


when I joined my current job, the admin was very physician friendly, and focused primarily on making sure that I was happy. they let me run the medical side of the clinic, but was very clear about the financial side and its structure and support.
Just wait until the admin personnel get swapped out, you might have to think again. It might never happen, and it might happen tomorrow without you knowing. You have no control of it. In my experience, it happens way too often to rely on a "physician friendly" admin to risk my lifetime of investment in an organization.

What's the "lifetime of investment"?

It's the time you spent to build your practice.

When you find out you are no longer on a good terms with a new group of admin, you realize you already lost control of your practice (if it was ever yours), and too late to start on your own.
 
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drusso

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Just wait until the admin personnel get swapped out, you might have to think again. It might never happen, and it might happen tomorrow without you knowing. You have no control of it. In my experience, it happens way too often to rely on a "physician friendly" admin to risk my lifetime of investment in an organization.

What's the "lifetime of investment"?

It's the time you spent to build your practice.

When you find out you are no longer on a good terms with a new group of admin, you realize you already lost control of your practice (if it was ever yours), and too late to start on your own.
In other words..."New boss, same as the old boss."
 

Ducttape

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ive seen administrations come and go. I am aware how the ebb and flows can work - both harmful and to our advantage.

on only 1 point will I take you to task, and that is that it is never too late to start on your own (barring losing DEA or state licensure of course)