The eternal fight between doctors, insurers, and hospital administrators

[amestramgram]

---

Members don't see this ad.

Hi, does anyone in the United States know any hospital in which doctors and their administrators get along fairly well with each other? I've only ever witnessed combative relationships and doctors being denied what they want for their departments, so I was curious to see an example in which this relationship has been done well. Thanks.

 

[Perrotfish]

Hi, does anyone in the United States know any hospital in which doctors and their administrators get along fairly well with each other? I've only ever witnessed combative relationships and doctors being denied what they want for their departments, so I was curious to see an example in which this relationship has been done well. Thanks.

As a general rule, the harder a physician is to replace the better the physician will be treated by administration. The administration is more accommodating in a community hospital than in a tertiary care center, is more accommodating in the Midwest then in southern California, and will always treat the pediatric CT Surgeon with much more deference than the Hospitalist. The administration also isn't always wrong. They don't have a bottomless pile of money and sometimes physicians are 'denied what they want for their departments' because what they want would cost way more than its worth in terms of patients care and safety.

Some administrators are also just better at being administrators. Leaving the balance of power aside, some bosses are better than others at understanding what it and isn't important for patient care and physician satisfaction. There are studies that suggest that physician administrators are more likely to be good administrators but its a weak correlation. Mostly its something you have to feel out one job at a time.

 

[nimbus]

Hi, does anyone in the United States know any hospital in which doctors and their administrators get along fairly well with each other? I've only ever witnessed combative relationships and doctors being denied what they want for their departments, so I was curious to see an example in which this relationship has been done well. Thanks.

Yes.

 

[mimelim]

I generally side with administrators over physicians. They tend to be more reasonable. Certainly not always, but I find their positions much more realistic and thought out on average.

 

[Tenk]

My hospital CEO and I are chill af.

 

[VA Hopeful Dr]

I generally side with administrators over physicians. They tend to be more reasonable. Certainly not always, but I find their positions much more realistic and thought out on average.

Ha.

My only general complaint is that things aren't always explained. I've yet to have an interaction with admin where, if they explain why they are doing something, I can't see where they are coming from and if not agree at least be OK with it.

Its the dictates from on high with no explanation that irritate me.

Oh, and being lied to. That makes me see red.

 

[mimelim]

Ha.

My only general complaint is that things aren't always explained. I've yet to have an interaction with admin where, if they explain why they are doing something, I can't see where they are coming from and if not agree at least be OK with it.

Its the dictates from on high with no explanation that irritate me.

Oh, and being lied to. That makes me see red.

I have found that the larger the system/hospital the more things a) aren't explained, b) dictated from on high. Big academic centers with multiple bosses/levels of bosses are the worst when it comes to this kind of stuff. I won't name specifics, but it isn't exactly hard to figure out... There was a vascular surgeon I know who left a job because there was a bishop in significant control of funding and they kept making all sorts of changes that didn't make any sense. Bishop mind you...

But, for every gripe that I hear physicians make, 50%+ are based on not understanding what is going on around them. The classic line I hear is, "I just want to go and operate." Well, that isn't how the real world works, you don't just get to go to your little hole and do the little thing that you want to do with no regard for anything else. Part of that means running the hospital and keeping the other hundreds of employees set as well.

 

[VA Hopeful Dr]

I have found that the larger the system/hospital the more things a) aren't explained, b) dictated from on high. Big academic centers with multiple bosses/levels of bosses are the worst when it comes to this kind of stuff. I won't name specifics, but it isn't exactly hard to figure out... There was a vascular surgeon I know who left a job because there was a bishop in significant control of funding and they kept making all sorts of changes that didn't make any sense. Bishop mind you...

But, for every gripe that I hear physicians make, 50%+ are based on not understanding what is going on around them. The classic line I hear is, "I just want to go and operate." Well, that isn't how the real world works, you don't just get to go to your little hole and do the little thing that you want to do with no regard for anything else. Part of that means running the hospital and keeping the other hundreds of employees set as well.

It's why a good local level manager is worth their weight in gold

 

[Neopolymath]

It's why a good local level manager is worth their weight in gold

Good luck finding one that doesn't leave or get promoted (also see Peter Principle). Nursing is a great example of this very thing.

 

[nimbus]

Good luck finding one that doesn't leave or get promoted (also see Peter Principle). Nursing is a great example of this very thing.

I’ve been working in one hospital for 16 years and the CEO has been in his position since before my arrival. He’s been working in the hospital system for over 30 years. I know a few other similar situations in my city.

I would call it an eternal, ongoing negotiation which is a part of life in any large enterprise. I wouldn’t call it an “eternal fight”.

 

[amestramgram]

I'm in my last two years of fellowship.
How do I start out on the right foot in the admins eyes when it's my first month as a real doctor? I just picture myself in some CEO meeting and they dictate that you will spend 10 hours doing more documentation - period, no questions asked. They get to take away my family time with impunity.

Am I not allowed to tell the administrators that I don't want them pushing more and more non-clinical duties on me?

 

[raiderette]

I would love to hear from Kaiser, Mayo and Cleveland Clinic employees.

 

[libertyyne]

I would love to hear from Kaiser, Mayo and Cleveland Clinic employees.

Cleveland and mayo both have doctors as CEOs.

 

[amestramgram]

I'm fully aware that administrators are charged with ensuring the overall financial health of the hospital, and if that involves pissing off your employees, that is an acceptable cost. What I strongly object to is:

- administrators failing to value the experience of senior clinicians and then making schedules that put inexperienced team members on tough cases, without supervision, and then letting things fail when the senior clinician could have easily avoided a bad outcome
- administrators forcing more and more documentation and required courses down my throat
- administrators not listening to physician advice on how to improve the hospital, and instead catering to metrics, lawyers, the media, and patient satisfaction scores. Case in point - failing to provide the resources for a surgeon to increase his case load (mainly expand an ICU), and the resulting 50% cancellation and rescheduling rate because the surgeon feels like his team is unprepared to pick up more patients. This results in severe patient dissatisfaction, moving to competitor hospitals, and decreased staff morale. Admin didn't care. Another case in point - administrators decreasing the number of rooms allotted to our clinic, regardless of the fact that we have potential 4 hour total patient times in a cardiology clinic. Admin again dictated the rules with no recourse for alternative action.

How can I do my part to allow my admins to stop doing this nonsense? Or at least agree to work with me when it's my time to be a first year attending? I'm adult enough to realize that my boss will not always agree with me but what I've seen is a blanket no at every turn, almost like democrat vs republican dogfighting.

 

[nimbus]

Case in point - failing to provide the resources for a surgeon to increase his case load (mainly expand an ICU), and the resulting 50% cancellation and rescheduling rate because the surgeon feels like his team is unprepared to pick up more patients. This results in severe patient dissatisfaction, moving to competitor hospitals, and decreased staff morale. Admin didn't care.

That surgeon must not be a money maker for the hospital. I’ve seen administration bend over backwards for the ones who are. Literally provide every single thing they request. Multiple NP’s-yes. Latest $2mil davinci-yes.

 

[managedcarefin]

Of hospitals that have been clients of ours community hospitals and smaller hospitals are often much more in lock step with their non administrative doctors.

 

[Perrotfish]

I'm in my last two years of fellowship.
How do I start out on the right foot in the admins eyes when it's my first month as a real doctor? I just picture myself in some CEO meeting and they dictate that you will spend 10 hours doing more documentation - period, no questions asked. They get to take away my family time with impunity.

Am I not allowed to tell the administrators that I don't want them pushing more and more non-clinical duties on me?

"As a physician you can have anything that you want, but not everything that you want". Its a saying used mainly by financial planners, but it also applies to your negotiations with your employer.You can say no to anything that the admin asks you to do as long as its not explicitly in the contract you signed. The question, then, is whether you are still valuable enough to employ despite saying no to those things.

Did you land a Rad/Onc or pediatric infectious disease job with Kaiser in San Diego? Those guys are making great money, in professions that often can't find work at all, in one of the most desirable cities in the world. In that case the job is the job and you either do it or they will find someone who will.

Are you willing to be the one OB or general surgeon who will work in the community hospital in my small town? Then you could say no to anything, and honestly they would never ask you in the first place.

Did you take an academic cardiology job in a semi-desirable mid-sized city? Now its a balance: most people would probably suck it up and work hard for the first few years, and then start pruning some of their more obnoxious admin tasks after establishing a good reputation for clinical abilities and academic productivity. It would depend on the exact dynamics of the group and how much extra work they are asking you to do, though. 30 minutes a week dealing with the immunizations committee is very different from 15 hours/week dealing with precepting medical student small group learning.

 

[Mr.S]

I generally side with administrators over physicians. They tend to be more reasonable. Certainly not always, but I find their positions much more realistic and thought out on average.

LOL this is a joke right?

 

[Perrotfish]

How can I do my part to allow my admins to stop doing this nonsense? Or at least agree to work with me when it's my time to be a first year attending? .

1) I think pretty much everyone would advise you to keep your head down until at least your second year as an attending. Unless you think that you are seeing/doing something that will kill a patient wait until you have both a full year's experience and board certification before you start making suggestions.

2) When you are ready to make suggestions, remember that you need to sell them on your ideas. Going to your administration and saying "I need 10 more ICU beds" is very different from saying "here is the time I project it will take us to recoup the expense from a 10 bed expansion of our ICU".

3) Take some time to study actual negotiating skills. I like "crucial conversations" , though there are other good programs. You could just read the books, but if you are still in fellowship they may even pay for you to go to a course or two.

4) Remember that the administration is made up of people. Foster some human connections there. If the only time the management sees you is when you are shouting demands at them they are going to be less likely to give you the response you want regardless of the merits of your case. You might also learn the context to decisions that previously didn't make sense to you. For example if the reason they won't expand the ICU is because they haven't been able to hire an intensivist in 2 years and now half of their existing staff is threatening to quit then you might need to adjust your request (could post surgical cases be managed by a hospitalist with ICU nursing staff ratios?) or even just realize that what you want isn't practical.

 

[CherryRedDracul]

LOL this is a joke right?

Well, it depends. Perhaps he has better administrators at his hospital.

There are other hospitals where administrators are mediocre and don't realize how much money they're making the hospital system lose until someone bright steps in and fixes it up.

 

[RNthenDoc]

Hospitals need the evil doctor Kelso, and they need the snide doctor Cox.

The departments I’ve seen run the best had ex clinical staff in management. The trend is to replace them with MBAs, though.

I left nursing in part due to the fact that the main career move was to go deeper into hospital management, and even where I was the expectation was to tow the company line. As a nurse I actually wanted to be a nurse, not a “provider” or CRNA or something that really has nothing to do with nursing.

They just built a physician-run hospital not too terribly far from my Med school, so it will be fascinating to see how it fares vs. the HCA monster in town. I hope I get to rotate there!

 

[droliver]

I generally side with administrators over physicians. They tend to be more reasonable. Certainly not always, but I find their positions much more realistic and thought out on average.

Agree. I hate this is true, but there’s a lot of our colleagues (particularly in orthopedics and neurosurgery) who are entitled and disruptive A-holes to the effective running of the OR and constantly throw tantrums about how the hospital is run. Drives me crazy

 

[Psai]

Agree. I hate this is true, but there’s a lot of our colleagues (particularly in orthopedics and neurosurgery) who are entitled and disruptive A-holes to the effective running of the OR and constantly throw tantrums about how the hospital is run. Drives me crazy

If I was earning millions for the hospital and they weren't catering to my whims I'd probably be throwing a tantrum or two myself