A member response.

Making Change Happen

by Toni A. Mitchell

The Ties that Bind

This issue of The Physician Executive examines how to build effective organizational structures in a health care industry burdened with a bureaucratic culture. How can physician executives help lead the way in creating more productive and harmonious organizations that maintain the physician's role as patient advocate? Should physicians be employees of hospitals, and how does this affect the physician-patient relationship? How can physician executives apply a new model of mergers to create more truly integrated health care systems? What are the common roadblocks to change? These questions are addressed in the lead articles. ACPE members Toni A. Mitchell, MD, MBA, CPE, FACPE, and John M. Ludden, MID, CPE, FACPE, were invited to share their thoughts on these articles and how they might apply the information to their organizations.

The famous anthropologist Margaret Mead is often quoted as saying that change occurs only through people who are committed to making it happen. Physicians have experienced a great deal of turmoil over the last several years, but, as the lead articles in this issue indicate, we are at the beginning of a new revolution. The theme that runs through these articles is that physicians will need to learn to view themselves differently in relation to their profession and to society.

The socialization of physicians begins with education and training that seems to have changed little in the 20 years since I finished. This process leaves young physicians ill-prepared to address the consumer-driven health care model predicted by Regina Herzlinger, DBA; to possess the business savvy needed to succeed described by Ken Baskin, Jeffrey Goldstein, PhD, and Curt Lindberg; or to understand the importance of the organizational politics portrayed by Elliott Jaques, MD, PhD, and Richard Thompson, MD.

Perhaps the medical schools offering an MD/MBA have the right idea--students learn the art and science of medicine, while gaining the basics of management, accounting, and marketing. The critical first steps for implementing change must begin in medical school to prepare physicians for the world envisioned by these authors.

As Herzlinger notes, the health care system is designed for the convenience of clinicians. The system will be transformed by patients who are knowledgeable about their diseases and demand better data in order to make informed choices. While Jaques is correct that physicians who work in a federal system are employees of a bureaucracy, patients benefit because information about their outcomes can be collected in a systematic fashion and of sufficient size to meet the "good, solid, and transparent data" Herzlinger believes patients want and need.

The other critical element that Herzlinger identifies is the need for an expanded safety net for the uninsured and underinsured--a serious deficiency that is not addressed by our system. Arguably, this situation has been made worse by increased managed care penetration, and the solution may entail greater government oversight.

In any system physician executives have a vital role to play. They have the perspective of the clinician and his or her confidential relationship with each patient, but a good physician executive also understands the organization's needs in delivering quality medical care. As Baskin, Goldstein, and Lindberg clearly articulate, trust is the key. Patients must know that whatever system of care evolves, high quality clinical care is the linchpin and physician executives are in the best position to assure that their trust is well placed.

Toni A. Mitchell, MD, MBA, CPE, FACPE, is Chief Consultant, Acute Care Strategic Health Care Group at Veterans Health Administration in Washington, D.C. She can he reached by calling 202/273-8530 or via email at toni.mitchellmail.va.gov.

The Tentacles of Bureaucracy

by John M. Ludden

In Lilliput, Gulliver (a surgeon) awoke to discover himself completely bound down by myriad tiny ligatures. At 16 percent of the GDP, the institutions of the health care industry can feel the same way. This time the ropes are the tentacles of bureaucracy that inhibit change, stifle honesty, and obscure medicine's caring potential. All of us who have worked in organizations know that the details of bureaucracy are most often individually desirable and reasonable. It is when they are twisted together that they become the ties that bind.

In the lead articles, there are very different responses to this leviathan and much to argue with and about. Each of these articles essays to strike though the mask of bureaucracy. These attempts must be made because it is intensely frustrating to feel unable to act effectively and reasonably. In the end, it may be that each physician executive will need to craft his or her own response to the dilemma of organizations and the insights provided in these articles may help. There is no general or universal solution to these dilemmas because they are rooted in human relationships of power, authority, aspiration, competition, and collaboration.

Elliott Jaques, MD, PhD, incises the debate about physicians' roles and management's designs by posing a clear version of the "state of nature" in which the physician is bound to confidential service of the patient and the patient has a kind of natural law right to such a relationship. Management, on the other hand, operates in a defined authority structure. In his state of nature, the two roles are immiscible.

As professionals we are often "accountable" to one another for the nature and quality of our work, even when the lines of authority are absent. As physician executives, we participate in what Alice Gosfield has described as the "clinical culture' which is an essential feature of the caring institution and is the raison d'etre of its organizational structure.

As physicians and physician executives graduate from parental and apostolic relationships to their patients, their institutions, their peers, (and themselves!), the supportive fiction of the state of nature will be questioned and perhaps even attacked. The still inchoate authority of the customer continues to rock the organizational boat. In describing the difference between bureaucracy and association, one might wish that Jaques had begun his analysis by characterizing the doctor-patient dyad, then worked to describe the surrounding structures of bureaucracy, caring, information exchange, and professional colleagueship that empower it.

Would Jaques' clarification have helped the process of the Deaconess Billings Clinic? It might have induced an earlier recognition of the issues. But the inherent creativity of the DBC "solution" seems a powerful example of the value of the small sailboat response to a confusing wind: loosen your grip on the mainsheet and the tiller, let the boat come into the wind, then plot an integrated course. The practical lessons of the DBC story are many and powerful, but the central thrust involves strengths that are, or should be, common in physicians: heightened attention coupled with careful listening that does not presuppose conclusion but guides the direction to a somewhat unpredictable conclusion. When physician executives think they know the answer at the beginning of the story, the potential for disaster will be greatest.

And some of the most important traps in our thinking lie behind Richard Thompson's "Ten Roadblocks." He goes beyond invective to insight debates about regulation are really about ethics; documented legal contracts undermine mutuality; audiences for good news need to be cultivated. Our inertia resists change; we fight for the sake of fighting; and most of all, we don't act in a trustworthy manner as an effective initiative.

These lead articles inform each other. They provoke. They inveigh. They tell stories. In the long run, Gulliver (a surgeon) did make it to the land of the rational Houyhnhnms.

Reference

(1.) Gosfield, Alice. Quality and Clinical Culture: The Critical Role of Physicians in Accountable Health Care Organizations, Chicago, Illinois: AMA, 1998: (available at [e-mail].)

John M. Ludden, MD, CPE, FACPE, is an Associate Clinical Professor in the Department of Ambulatory Care and Prevention at Harvard Medical School in Cambridge, Massachusetts. He serves on the board of the National Committee for Quality Assurance and is past President of the American College of Physician Executives. He can be reached by calling 617/421-6219 or via email at [e-mail] .