Developing loyal physicians: a five-point plan.

By 2001, the question in organizations of physician loyalty should be resolved. Physicians and health care centers will be intimately related through some version of managed care plans, effective regionalization, and capitation payment. However, predicting the future does not resolve today's dilemma. Executive staff, governing board, and physician leaders must cultivate physician loyalty, while at the same time avoiding a hornet's nest of possible problems. For a moment, don't even think about possible antitrust problems, such as with joint ventures designed to tie physicians and their patients to this health care center. And forget, for a moment, that ignoring Medicare fraud and abuse statutes and "safe harbor regulations" could lead to fines or prison terms. Rather, step back and consider the physician loyalty question from a broader perspective, including an expanded 1990s notion of "quality" and "medical ehtics."

A commonly asked question is, "To attract and keep loyal physicians, should we buy physician's practices, offer practice perks, or both?" But will long-range goals be met by throwing money at physicians? Or, as so often happens, will conventional wisdom turn out to be folly? Can loyalty really be bought? Or might those who will "sell" their loyalty, sell it again when a higher bidder comes along? It's true that spending money is necessary to develop a nucleus of loyal physicians. There's a big difference between attempting to buy the physician's loyalty directly, as opposed to investing wisely in efforts designed to win the physician's loyalty.

The ethical consideration comes in when one starts to consider the professionalism, dependability, and integrity of a medical staff built with this strategy. Will the best qualified and most committed physician really be attracted? In addition, think of the message being sent to the nucleus of careful and caring physicians currently on the medicaal staff. That clear message is, "We overgeneralize about physicians to the point of thinking that all physicians are agreedy and arrogant. Those who might think, "Well, not too far wrong," should think through the medical staff roster again. Think, perhaps, of the characteristics of the physicians chosen to care for them and their families. Many physicians, contrary to public opinion it seems, preserve values of professionalism and dependability. It would be a mistake for the health care center to lose the respect of these individuals.

Next, shouldn't one think carefully abouit joint ventures with physicians? A joint venture is an excellent idea if it makes business sense. Perhaps the joint venture is in a focused clinical area, such as an MRI unit with radiologists. Or perhaps the availability of joint venture capital makes it possible to provide a medical service previously lacking in the community. Or perhaps costly duplication of services can be avoided. But, joint ventures entered into for the expressed purpose of tying physicians and their patients to the hospital may run afoul of more than legal traps related to antitrust and other relevant legal issues. What about the impact of such ventures on clinical decisions? Surely every physician, except a superhuman moralist, might be influenced to order a certain diagnostic test, or admit the patient to one hospital instead of another, if increased income is a factor. Care must be taken that a specific joint venture is not feesplitting raised to a sophisticated level. This is the basic concern of "safe harbor" regulations.

There is another troubling and commonly asked question. It's usually asked by a member of the governing board. "When physicians admit patients, they use our equipment, and we pay for it. They use our nurses, and we pay nurses' salaries. So, physicians just owe the health care center their loyalty, don't they?" Theoretically, yes, in the best of all possible worlds. And some physicians see this altruistic point. But, usually, as in any human relationship, the physician's loyalty must be earned and deserved.

Let's take a fresh look at the physician loyalty question, starting at square one. What is it we expect of the physician? What does it mean to be "loyal"?

According to Funk and Wagnall's New Standard Dictionary: Loyalty = Devotion = A strong attachment or affection expressing itself in earnest service.

Affection? Emotional attachment? These are unrealistic expectations. Better to remember the physician who said, "If the hospital wants loyalty, tell 'em to buy a cocker spaniel." John Gardner points out that, "The loyalty of the professional man is to his professional and not to the organization that may house him at any given moment." [3] A few physicians, mostly in the general community hospital tradition, really love their hospitals. But hardly any physician anywhere feels affection for today's multilayered "health care organization."

But it is reasonable to focus on "devotion and earnest service" as reasonable goals. These can be earned, in any relationship, by:

* Demonstrating interest in the other's ability to achieve reasonable goals, instead of always demanding that the other person (or organization) show interest in one's own goals.

* Being upfront and honest with each other.

* Developing loyalty through a track record of actual decisions and actions, as opposed to lip service and promises left unfulfilled.

This perspective suggests a five-point plan:

1. Ask the physician! How can you help, from their perspective? Of course, beward of some physicians' notion of "input," which is, "If you ask my advice, I expect you to take it!" And be careful to sift the wheat from the chaff. Clarify that not all ideas can be implemented. And, when you judge a suggestion impractical, don't just ignore it. Prepare and give an explanation of why the suggestion cannot be implemented. Believe it or not, reasonable physicians will accept a well-documented, logical explanation and will make their next suggestions more practical.

2. Evaluate the services you presently offer physicians, and consider new ones. Conventional wisdom says a physician referral service is a big help to your medical staff. Is it, or isn't it. Ask. Meanwhile, offer new services. How can you help the physician with office paperwork? Do you provide a "beeper" service, and computer time, free? Some hospitals provide a convenient means for physicians to dispose of harmful waste products from their offices. Conduct "personnel skills" seminars. Most physicians can't hire, fire, establish salary scales, and evaluate employees worth a darn.

3. Don't overlook or abandon traditional physician concerns. Most physicians still talk about being attracted to a medical center by good nursing, readily available subspecialty consultations, and a medical staff office that is more than just leftover space from marketing and risk management.

A caveat: Requests for expensive equipment are, of course, traditional. Here, being upfront and honest pays off. While a physician's idea of "adequate equipment" may be too rich for the blood of today's budget-conscious health care center, that may be obvious only to the board and executive staff. Have enough confidence in your physicians to share honest financial performance figure and projections with them. Plus, be honest with yourself. You don't have enough money to fill each physician's toy box. You may gain respect (and loyalty) by explaining that you will not be exploited; gaining physician loyalty does not mean you should be expected to play Santa Claus.

4. See that loyal physicians have the biggest say in the organized medical staff. Membership and political privileges are still as important to many physicians as clinical privileges. Be sure the medical staffbylaws give membership privileges (voting, holding office, being selected department chairman, influencing surgical suite and intensive care polities, etc.) to staff members who frequently bring patients to the medical center.

5. Finally, or perhaps first of all, ask physicians, "How are we doing?" That is, in the eyes of reasonable staff members, are the executive staff, governing board, and physician leaders earning physician loyalty by being straight and upfront? Are negative "surprises" being avoided? Do grassroots physicians feel that asked-for input is considered? When the CEO or vice president for medical services tells the staff something is going to happen, does it really happen?

Deliver on promises, and avoid the mistake of thinking secrets can be kept from the medical staff. Otherwise, efforts to develop physician loyalty, however heavily funded and in spite of short-term success, will probably fail in the long run.

References

[1] Johnson v. Misericordia Community Hospital, 301 N.W. 2nd 156, Supreme Court, Wisconsin, 1981.

[2] Minimum Standard for Hospitals Chicago, Ill.: American College of Surgeons, 1919.

[3] Toffler, A. Future Shock. New York, N.Y.: Random House, 1970, p. 146.

Richard E. Thompson, MD, is President of Thompson, Mohr and Associates, Inc., Dunedin, Fla. This article is based on a chapter in his book Keys to Winning Physician Support, an ACPE monograph.