I ended my last post ("Royal Pains") with a promise to revisit and further explain my statement that the lack of alignment between physicians on a hospital's medical staff and the hospital administration is well known. Some experts refer to this lack of alignment as "Blue Suits versus White Coats", referencing that administrators frequently wear blue or black suits, while physicians frequently wear white lab coats. Unfortunately, negative stereotypes only make this lack of alignment worse. As Deane Waldman and Kenneth H. Cohn write in The Business of Healthcare, "The manager sees a doctor who has no understanding of, or interest in, resource constraints or proper organizational behavior, even if the doctor has an MBA and manages a successful multimillion-dollar division. The doctor sees a heartless bean counter who cares nothing for patients, despite the CEO spending seven hours before a state oversight committee aggressively seeking support for the doctors’ medical programs."
The management expert Henry Mintzberg suggested that there are four different "worlds" or subcultures that exist in hospitals today (see his article, "Toward healthier hospitals"): the hospital trustees (or Board of Directors), the physicians, the managers (i.e. the hospital administrators), and the nurses. Mintzberg also noted that these four worlds rarely talk to each other, nor do they attempt to solve problems by collaborating together. Each world has its own language, which makes it even harder for the "citizens" of each of the four worlds to collaborate and communicate with each other. Mintzberg wrote his article in the late 1990's, and while the communication and collaboration between the four different worlds has certainly improved, I will admit that there are still four distinctly different subcultures in most hospitals today.
The divide (some would call it a chasm) between physicians and administrators is compounded by the fact that the growth in the number of healthcare administrators has far outpaced the growth in the number of physicians. Between 1975 and 2010, the number of physicians in the U.S. increased by 150%, roughly proportional to the growth of the U.S. population as a whole. In contrast, the number of healthcare administrators increased by 3,200% (see the graph that is frequently shown on social media below):
Most experts defend the tremendous growth in healthcare administrators by citing the tremendous growth in complexity of the U.S. healthcare system due to advances in technology in general (and in information technology in particular), as well as the greater scrutiny from regulatory agencies and payors. Unfortunately, the imbalance in growth between physicians and administrators has only further escalated the tensions between the two groups. As Pooja Chandrashekar and Sachin Jain write (see "Understanding and fixing the growing divide between physicians and healthcare administrators"), "Physicians blame managers for creating administrative hurdles that diminish autonomy and increase workload. Administrators blame physicians for failing to comply with resource complaints."
Some of the reasons for this growing divide between physicians and administrators is historical. It was not all that long ago that most physicians were independently employed (rather than being employed by hospitals), working mostly in a private practice setting and rounding occasionally at the hospital whenever one of their patients was admitted. There was very little regulatory or administrative oversight of physicians, which has largely changed in recent years. While both physicians and administrators are often following a call to serve, they differ in how they approach that calling. For example, while physicians focus on improving the health of their individual patient, administrators focus on improving the health of the population. While an individual physician may feel justified in expending all the available resources for one patient, an administrator often has to balance resource expenditures to serve the needs of all the patients who seek care in their organization.
One potential solution to this issue is to develop physician executives who can bridge the divide between their colleagues and the hospital management team. There has been a virtual explosion of physician leadership programs in the last several years, including dual-degree (MD/MBA) programs, postgraduate certificates, and graduate (e.g., MHA, MBA, MMM) programs tailored specifically for physicians. Hospitals and health systems have developed specific executive-level leadership roles for physicians, with a number of different titles (Chief Medical Officer, Physician-in-Chief, Chief Clinical Officer, etc). These physician executives must balance reading the New England Journal of Medicine with the Wall Street Journal, speaking both the "language" of their physician and administrator colleagues. What frequently happens (based on surveys of physicians in executive positions), however, is that the physician executive is never fully embraced by the administrators ("You're still a physician!") and can find themselves alienated by their physician colleagues ("You've gone to the dark side!"). It can be difficult to balance this reality that they may no longer be viewed as physicians by their colleagues, while at the same time never be fully trusted by the hospital management team.
There are certainly other ways to bridge the divide between physicians and administrators. There are countless articles and books written on this very subject. Admittedly, however, despite the growing literature on this subject, the divide between physicians and administrators remains. What has worked well in one organization may not necessarily translate to another organization, as a lot depends on the history, culture, and leaders of an organization. Regardless, here are some high-level, general themes (from the Chandrashekar and Jain article, as well as the Institute for Healthcare Improvement's (IHI) white paper, "Engaging Physicians in a Shared Quality Agenda"):
1. Unite around a common, patient-centered vision. What's generally not very controversial, even between physicians and administrators, is that the care that is provided in an organization should be of the highest quality. I've found that physicians and administrators can and often do unite around the common goal of providing safe, effective, timely, efficient, equitable, and patient-centered care.
2. Improve mutual understanding of roles. Administrators need to understand the physician experience, but just as important, physicians can benefit from looking at a problem through the lens of an administrator. Executive rounding (using Lean/Six Sigma concepts, "going to the gemba", a Japanese term for "the place where value is created") and clinical shadowing programs are two commonly used techniques to help administrators gain a better understanding and appreciation of what physicians do. Conversely, leadership training and teaching physicians "the business side of medicine" can help physicians better appreciate and understand what administrators do.
3. Increase transparency and provide opportunities to collaborate. To increase trust between physicians and administrators, organizations should increase transparency around how and why certain decisions are made. Better yet, having members of the medical staff participate in those decisions helps to increase trust and collaboration. Importantly, these physicians shouldn't be viewed as the token physician representative, but rather as active participants in the decision-making process. A number of organizations have adopted so-called leadership dyads (physician/nurse, physician/administrator) or triads (physician/nurse/administrator), whether for service line leadership or leadership of organization-wide change initiatives. Importantly, make physician involvement in these initiatives clearly visible to the rest of the medical staff.
4. Remember that respect is as important as autonomy. Administrators can preserve both autonomy and respect by engaging physicians in "active problem-solving, rather than passive rule-following". Administrators should take physicians' concerns about administrative burden, workplace culture, and burnout seriously. Initiatives that are co-led by physicians and administrators (see the "dyad model" above) and that focus on reducing hassles and wasted time can go a long way. The IHI white paper "Engaging Physicians in a Shared Quality Agenda" recommends changing the narrative by making physicians partners, not customers. Having administrators treat physicians as partners, collaborators, and colleagues will go a long way towards building trust and collaboration.
The leading healthcare organizations have figured out how to narrow the divide between senior management and physicians. It's not easy. But it's important for physicians and administrators to be on the same page when it comes to the goals of the organization.
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