How To Discourage a Doctor

Discussion in 'Allopathic' started by PamelaWibleMD, 09.24.14.

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  1. PamelaWibleMD

    PamelaWibleMD Banned Banned

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    RICHARD GUNDERMAN, MD

    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 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.

    From: http://thehealthcareblog.com/blog/2014/09/18/ho...

    I e-mailed Dr. Gunderman: "Is this a parable or true story?"

    He replies, "I would feel more comfortable describing it as a parable, though it contains large elements of historical truth."
     
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  3. type12

    type12 2+ Year Member

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    So, I'd love to hear your opinion on physician oversight and regulation. Should physicians be autonomous in the wake of the Wall Street bust (bankers self-regulating, lobbyists and special interest groups being one-in the same)?

    To be frank, the perverse strategies presented here are just par for the course in any other field. If employees were treated better, the job satisfaction rate would be much higher.
     
  4. Kaustikos

    Kaustikos Archerize It 7+ Year Member

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    Barriers between physicians and patients? Ok, just have the patient email me their problems and cc the hospital. Problem solved
     
  5. PamelaWibleMD

    PamelaWibleMD Banned Banned

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    Physicians by nature are humanitarians who want to serve their communities-especially in primary care. They need to be able to serve their communities without the burden of supporting no value-added intermediaries whose primary interest is not patient care or physician wellness, but their own job security.

    How many people do you need between your physician and your vaginal speculum? You don't need a team to perform a Pap smear (or most other primary care). I've been a solo doc for 10 years. No staff. I do surgery. I can provide 99% of what my patients need. Without committee meetings. Without getting permission from the clipboards.

    Disintermediation = removing the middle men.
     
    Last edited: 09.24.14
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  6. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu... Lifetime Donor 7+ Year Member

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    It is good, and sadly true, satire. I'll be looking for jobs with independent groups and paying my professional society to fight against regulations that are bad for docs and patients...and I'll pay my other professional society to fight against the policies supporting nonindependent groups that the first society produces.
     
  7. DermViser

    DermViser 5+ Year Member

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    Which ironically enough, the federal government is actually making primary care (General IM, Peds, FM) even harder for physicians. Funny you mention teams, bc that's what is the goal with the Primary Care Medical Home. So now on top of the long hours, squeezing 8 medical problems into a 15 min. visit, increasing documentation and preauths, etc. we're going to increase all that and make them responsible for a team.

    It seems like the goal is run physicians out of primary care and have it done by NPs and PA instead for cost savings. Getting a physician to see you in primary care will be a luxury.
     
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  8. FiveOClock

    FiveOClock 2+ Year Member

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    To me, this is exactly why physician-owned healthcare MUST be a goal of physicians across this country. We cannot afford to cede anymore control to hospitals or government. The Obama administration and his healthcare corporate cronies know the threat that physician owned facilities poses to their control and revenues; that's why they've done as much as possible to quash all entrepreneurial endeavors by physicians. Heres some insight into how well your government is working to help patients.

    http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Physician_Owned_Hospitals.html
     
  9. @JackShephard

    @JackShephard

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    I wish this were a simple problem and we could solve it by eliminating the middle man. We can't.

    Unfortunately, this is a complex problem and it's dynamic. Because of that, we'll need dynamic solutions and great minds attacking this. Eliminating the middle man may make many physicians happy and save on costs, but it's not a panacea for our current ills.

    There are large hospitals that need to be managed by competent individuals. I've yet to meet the surgeon who has time to round, operate, see follow ups, deal with complications, and run the day to day operations of a hospital.

    Someone will need to "be the middle man". I'm not even sure if that's an appropriate term. We need people to run and organize healthcare full time, not as a part time hobby. In today's world, maybe the how is wrong... maybe our administration is bloated, inefficient and greedy. But that's not a criticism on the system as much as the workers or philosophy of those running it.

    If we are to survive the great challenges of our nation's future, we will need to work together.

    The idea of us vs. them will only create more divide and chaos in a inexplicably fragmented and overly complex system. The renegade independent physician will likely be happier but that won't help us solve the biggest healthcare issues of the next few decades.

    I'm hopeful. But we'll need incredibly smart people dedicated to solving problems, who are willing to compromise and cooperate. Our nation's existence hangs in the balance.
     
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  10. type12

    type12 2+ Year Member

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    While I see the value in @PamelaWibleMD 's view and outlook on a physician's motivations and care, I think I'm a little more pessimistic about this, and agree with your sentiment. It's probably not going to be easy to figure out, but yeah, everything you said resonates with me.

    In an ideal world, though, no oversight would have been awesome. :-(
     
  11. @JackShephard

    @JackShephard

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    NPs and PAs have become a necessity.

    Put aside our profession as physicians - by examining the need in primary care and the low # of medical students pursuing it (likely because of design - we've incentivized students to become specialists), it becomes clear that there need to be more players in primary care. If there were viable solutions to get more physicians practicing this, then that would be great. It takes 7 years to train these primary care physicians and not enough medical students are choosing primary care.

    If you have any better solutions it would be great to hear them.
     
  12. DermViser

    DermViser 5+ Year Member

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    You realize that there are physician owned hospitals right? Have you heard of this hospital called the Cleveland Clinic, as an example?

    Read this: http://www.kevinmd.com/blog/2013/04/health-reformers-learn-doctorowned-hospitals.html, and there are many articles showing that physician-owned hospitals are doing better both for patients and employees.
     
  13. DermViser

    DermViser 5+ Year Member

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    Except most NPs and PAs are NOT in primary care. They are in specialist care. They ain't no fools either and find primary care just as frustrating.
     
  14. DermViser

    DermViser 5+ Year Member

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    You realize it doesn't matter how many US MD medical students fill primary care spots, when IMGs and DOs are filling those spots right? At the end of SOAP, all spots are filled. It's the same number of spots, the only difference being who is filling them.
     
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  15. @JackShephard

    @JackShephard

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    So there are 238 hospitals that are physician run out of 5,000. You plan to just have 4,700 hospitals switch over to doctors? I know many doctors who are excellent business people. Then there are many who are terrible with finances and business. You've given an example of what < 5% of our healthcare system is doing and think it will automatically work for everyone?

    A smart doctor and business man obviously has an advantage over a person who only knows business without medicine. But I don't think it's a serious solution to restructure 95% of the hospitals in America like that. It's more likely that we will need to find a way to improve our current system.

    Furthermore, a quote from your post:
    It is true that these doctor owned hospitals are able to pick better patients. Part of having an efficient and profitable system is having the right customer base.

    I would love to compare the socioeconomic landscape of the physicians owned hospitals - I would guess that have prime locations in nice areas, allowing them to deal with great patients.

    This isn't to say I disagree with the idea of physician run hospitals. They probably have more potential than many of our current models. It's just not a feasible solution for the entire system.
     
    Last edited: 09.25.14
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  16. @JackShephard

    @JackShephard

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    I realize this, but not all of them will do specialist care. They still fill some spots.

    This doesn't change the fact that there aren't enough primary care physicians.
     
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  17. DermViser

    DermViser 5+ Year Member

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    You realize that medical schools have MD/MBA programs and many MDs in practice go back and get their MBAs, correct? Who do you think are the CEOs that run most of those hospitals now? They're MBA onlys. How is that turning out for you? It's not a full, all out "restructuring".

    The facts and data don't lie. Hospitals run by physicians (who also likely have an MBA as well) do better on many objective metrics and their employees are happier. Why you argue this simple, basic point is beyond me.
     
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  18. DermViser

    DermViser 5+ Year Member

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    And again, I'm telling you that PAs and NPs go in droves for specialty care, JUST LIKE PHYSICIANS. They don't go into primary care in any greater numbers or percentages than physicians do. They have the ability to flip between different fields.

    You said American med students aren't going for primary care in enough droves. What I am telling you is that it doesn't matter whether they are or not, bc IMGs and DOs are filling those gaps that would normally go unmatched. Those spots are eventually filled by them.
     
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  19. @JackShephard

    @JackShephard

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    Still, there aren't enough residency programs training enough primary care physicians.

    Here, let's use real data (if you provide response, please leave links)...

    http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/
    Anyway, there is a problem and the residency slots aren't being increased. It needs to be solved.
     
  20. @JackShephard

    @JackShephard

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    All we know is they performed better in this last metric - and they have potential to do well. There's no way to compare that small 5% with the larger aggregate. It's a select group of hospitals in select locations. Also, I would like to know what percentage of physicians have MBA's? What percentage of physicians have the time and skills to step up to leadership positions in the other 95% of hospitals? It's one thing to say, "Wow, it would be cool if ________." And another thing entirely to propose a workable solution.
     
  21. DermViser

    DermViser 5+ Year Member

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    One could make the argument (and they have) that we have enough physicians it's the DISTRIBUTION that is messed up. Ezekiel Emmanuel, the architect of Obamacare has said exactly this in his article.

    You are correct, residency slots aren't being increased bc the govt. feels there are enough spots for all US medical graduates in terms of numbers and they would be correct.

    One UCSF family medicine academic has even advocated medical assistants doing primary care: http://archinte.jamanetwork.com/article.aspx?articleid=1868539, although I don't think the solution to a shortage is having ****tier providers.
     
  22. DermViser

    DermViser 5+ Year Member

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    No. They performed better on OBJECTIVE patient metrics as well as employee satisfaction. Comparing physician run hospitals to non-physician run hospitals. That is a fact. You can deny it all you want and obfuscate, but it is fact. That is why they're getting back more in Medicare payments, bc of their better patient outcomes in comparison to teaching hospitals. Which is why teaching hospitals are now complaining about it and making excuses and screaming it's not fair. See the link that I posted earlier that addresses that.

    If you think there aren't enough MDs with MBAs then you aren't looking hard enough. Not every MD just wants to practice medicine. You think an MBA only has the time and skills but MDs with MBAs don't? This isn't some made up pie in the sky scenario.
     
  23. @JackShephard

    @JackShephard

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    Stop turning this into some giant partisan debate.

    I'm not denying anything.

    I'm talking about finding solutions. I hold no ideology.

    I agree that < 5% of the hospitals outperformed the others on objective merits. I never denied that (read my post). I'm stating that what works for 5% may not work for the whole.

    If I think there aren't enough MDs with MBA's I'm not looking hard? I asked what % of them are and what % are ready to run a hospital. If you have data or some type of research showing this is a viable solution, then present it.

    I'm done for now with this thread, as I'm busy, but I think a few take home points are: If we're going to solve this problem, we'll need to think about solutions more than holding ideological stances or attacking others. #2, if people are serious about this then find real data, real solutions and create real proposals at the state and federal level. I don't agree with you right now Dermviser because you've given me no real reason to support your stance, I would gladly if you had some proof of what you're saying. And please, stop trying to polarize my stance. I didn't deny anything, I questioned if they had the same population as the other hospitals and payer mix. If you have data to show this then present it, but don't write off my objection as ideological obstinance when I have an honest objection.
     
  24. DermViser

    DermViser 5+ Year Member

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    There are more than enough MDs with MBAs. You don't get "practice" in running a hospital. You learn by doing it just like the MBA only people do. It's irrelevant whether physician run hospitals are <5% of total, when laws have been passed to limit physicians owning things bc of Stark laws, etc. Even then they are still doing better on objective measures than those that are not.

    Point is that that is one way for doctors to be less discouraged, when doctors take back their own profession. nothing is ideological here and no one has attacked you.
     
    Last edited: 09.25.14
  25. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    It would be a viable solution if we started selecting more entrepreneurial physicians. Oh yeah, and if Obama hadn't outright banned them despite their excellent outcomes. This generation of physicians is largely a group of followers, selected for their hoop jumping abilities and tendency to cede to authority. The medical student selection process makes such traits a near-necessity. This is why we have spineless representation, physicians that are generally awful when it comes to business and finance, and entire cadres of newly minted doctors that want to work for the man rather than themselves.

    Medicine has a culture problem that is going to destroy us from the inside out, mark my words.
     
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  26. DermViser

    DermViser 5+ Year Member

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    Yes, funny how if they aren't the solution, Obamacare pretty much banned any new ones from being started. Lobbied for by the American Hospital Association. I wonder why?

    You are correct. The medical school selection process very much capitalizes on being a follower and staying a follower (while asking for ECS that demonstrate being a leader ironically enough), in med school, residency, etc. So then no surprise, other people take it as their own, and we willingly let them, all in the name of "professionalism" of course.
     
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  27. Mad Jack

    Mad Jack Critically Caring Gold Donor 2+ Year Member

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    Ugh, I hate he who must not be named so much.
     
  28. Dral

    Dral 7+ Year Member

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    Thanks for posting! Get that information out there!

    We as a profession have sat on the sidelines too long. I actually enjoy administrative work, but that stuff has got to go.
     
  29. PamelaWibleMD

    PamelaWibleMD Banned Banned

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    Incredibly smart people do not seem to always come up with incredibly smart ideas. Here are a few ideas worthy of discourse:

    1) Primary care is significantly different than tertiary care & specialty care. My disintermediation discussion focus is on primary care which can not be lumped in with tertiary care. It is a different animal. Delivery, cost, funding strategy completely different. Pap smears and lung transplants can not be lumped together.

    2) Let's stop listening to experts, consultant, and politicians. Showcase the many docs in the country who are happy with happy patients. They have figured something out. But they do not have the time or the media power to get their amazing solutions out there.

    3) Why don't med schools allow these inspirational, smart, innovative docs to teach. Why keep hearing from the cynical burned out ones who are toxic to themselves, their patients, and the next gen of docs.

    Heck, some of this stuff just seems so basic. I could go on . . If we really wanted to solve our health care woes we could have easily done so already. Too many talking heads.
     
  30. PamelaWibleMD

    PamelaWibleMD Banned Banned

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    @calvandhobbs68 ~ That is funny because I just got publicly flogged on Sermo by docs who were just outraged by my insensitivity to abused women. Don't kill the messenger. I can't tell you how many docs have made the same abusive marriage analogy over the last 10 years.
     
  31. Psai

    Psai ヽ(´ー`)ノ Account on Hold 2+ Year Member

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    They need to get over themselves
     
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