Friction points!

"I work among the driven and I am fascinated by them.... My goals are to provide excellent patient care, not hate my work environment, and get home in time to play with my kid before bedtime....

"The whole thing makes me ache for my boss, who must manage this group of insanely competitive, fairly narcissistic beings. His job, I imagine, must be agonizing. I want to lead, sure, but never by being the official boss. In fact, I hereby declare it my goal to never, ever officially manage anyone."

So writes BigMamaDoc, a family physician who maintains a Web log self-deprecatingly titled "Fat Doctor" (http://fatdoctor.blogspot.com). And yet, in a subsequent post, she acknowledges another reality:

"The basic message we all got out of our emergency clinic meeting was that we are in trouble, big trouble, and we need to see more patients. From now on, anyone who wants to be seen will be seen whenever he or she wants to be seen. Procedures will be done immediately instead of rescheduled for a more convenient time. Amen and The End.

"There is a small panic growing in me as I start to worry more about the business of our practice. I never studied business, I don't like business, and I don't want business to be a part of my life. But I can't take care of my patients the way I want to if the clinic goes under."

Ground down

Not all physicians, of course, share BigMamaDoc's aversion to personal managerial responsibility. But then, not all are as empathetic with those who shoulder administrative burdens. An inherent tension exists between the people who shape and enforce organizational policies and procedures and the people who are governed by them.

And without question, observed former New England Journal of Medicine editor Jerome Kassirer, MD, in 1998, "many doctors are disturbed about the limitations on their capacity to make independent clinical decisions."

They are ground down, he explained, by "frustrations in their attempts to deliver ideal care, restrictions on their personal time, [and] financial incentives that strain their professional principles.... [Their] time is increasingly consumed by paperwork that they view as intrusive and valueless, by meetings devoted to expanding clinical-reporting requirements, by the need to seek permission to use resources, by telephone calls to patients as formularies change, and by the complex business activities forced on them by the fragmented health care system."

For a classical take on the labor-management struggle as it plays out on the contemporary clinical shop floor, who else to talk to but a union guy?

"We have idiot administrators who are unlicensed--whose only responsibility is to the employer, with no obligation to serve the public good--administering to licensed personnel," rails San Jose, California, neurology and pain management specialist Robert Weinmann, MD. On the side, Weinmann is president of the 5,000-member Union of American Physicians and Dentists.

[ILLUSTRATION OMITTED]

"Nothing is more destructive to health care than these renegade HMO managers and hospital executives," he fumes. "And yet they get to call physicians, dentists, nurses and other professionals 'disruptive' when they object to, contravene and defeat the stupidity of the regulations these ignoramuses try to shove down their throats!"

Weinmann, not surprisingly, can stuff your e-mail inbox to overflowing with horror stories of managerial misfeasance. Still, in most health care organizations, fortunately, the atmosphere is far less charged, far less polarized, than in his worst-case scenarios.

That's not to say that cooling systems at hospitals, clinics and group practices everywhere aren't turned up high to dissipate the heat generated by daily frictions between medical staff and administrators.

What are the issues that tax organizational thermostats in 2006?

Interviews with physician executives, non-MD administrators and front-line clinicians yield remarkably similar lists. Here, they say, are some of the principal sources of conflict.

Internecine competition

"The most emotionally charged issues," according to Terence Pladson, MD, CEO of CentraCare Health System in St. Cloud, Minnesota, "have to do with overlap of clinical privileges, where one specialty views everything related to the heart, for example, as their domain, while another specialty has some involvement too and wants to expand.

"Typically," he says, "we get twice as many requests for capital equipment as we have dollars available." So administrators start from the unenviable position of having to disappoint every medical constituency. "And it's only exacerbated," he says, "when the same equipment is requested by different departments."

[ILLUSTRATION OMITTED]

A 64-slice computed tomography scanner was the prize that set cardiologists and radiologists at each other's throats at his institution most recently. Both listed the state-of-the-art device in their capital budget requests. CentraCare could hardly afford to spring for two of the $1.1-million machines.

"The number of meetings required to make the decision, and to communicate why it was going to be the way it was," Pladson sighs, "was a very time-consuming process."

Allyson Pitman Giles, president and CEO of Catholic Medical Center in Manchester, New Hampshire, and chairman-elect of the American College of Healthcare Executives, also lists "rivalry among different specialties and subspecialties" as her major organizational headache. Bones of contention range across allocation of capital equipment to space and nursing resources, she says.

"Cardiac is the biggest margin producer at most hospitals," she says, "and we're the home of the New England Heart Institute. But general and vascular surgeons want to have the same access to operating rooms and equipment. And physicians in every specialty want the same opportunities to be lifted up as champions (by being featured in hospital ads, for example)."

[ILLUSTRATION OMITTED]

And then there is contention between employed physicians and those in private practice. "You have to make sure there's a fair and equal allocation of resources among them all," says Giles, "that you neither take advantage of nor favor the doctors you employ."

No matter how much explaining you do, though, says Pladson, the two groups often view an administrative decision as "paternalistic and unfair" from one perspective and "not supporting the system" from the other. "So there are," he concedes, "some no-win outcomes."

Competition between physicians and hospitals

"Cost pressures on practices have really escalated, and because of reduced reimbursements and difficulty maintaining income, physicians are looking for other revenue streams," says Kevin Mosser, MD, CEO of WellSpan Health in Gettysburg, Pennsylvania. "Often these come in businesses that are profitable to hospitals."

[ILLUSTRATION OMITTED]

So, he notes, when various specialists consider taking on such sidelines as outpatient surgery, imaging, physical therapy or laboratory services, "that's very threatening to hospitals, because those things pay for all the rest of the stuff we do."

Keith Noll, Wellspan's vice president in charge of cardiovascular services, remembers the bitter response of one health system CEO when Noll was the practice administrator for a group of orthopedists who proposed a joint venture with the system to open a surgical center attached to the physicians' office building.

"From our standpoint economically, we never meant to earn a large amount of money," he says. "We hoped it would be profitable, but nobody expected to become a millionaire. The aim was really to make things more efficient."

Invited to discuss the matter, the CEO strode into the physicians' offices, refused an invitation to sit at the conference table and, still standing, menaced that "if we chose to go on [with the proposal] he'd make it extremely hard for us to operate in any hospital in his health system. That was the old-school approach," says Noll. "We saw it from a quality-of-life standpoint; he took it as a threat."

In his role as a hospital administrator, Noll is more accommodating. "When we work with physicians," he says, "we take into account the impact a decision will have not only on us, but on our doctors as well."

So, Wellspan's York Hospital has an exclusive provider contract with a single cardiology group. That's a big draw in recruitment of top heart doctors to the area, says Noll; it's also a defense against competition that might siphon business from the hospital. At the same time, the hospital has joint-ventured with radiologists to award them half of all new cardiac MRI and CT scans.

"Finding enough readers is a challenge in today's market," explains Noll, "so not only do we get the best qualified readers, but collaboration helps with the workload. And since both groups want volume to go up at our center, this is a situation where everyone wins."

Many administrators have taken similar tacks to reduce internal friction--albeit at a certain cost.

"We've partnered with our physicians on two outpatient surgery centers, and the economic return has been very good," reports Steve Sanders, DO, chief medical officer at Carondelet Health in Overland Park, Kansas.

"Of course," he adds, "we've lost some revenue we could have captured if we'd kept the business in house."

Taking call

"Physician practice styles are changing, and a lot of work is outpatient-based now," Mosser says. "So physicians are beginning to question the time-honored practice of staying up all night and taking call [at the hospital] after working 12-hour-plus days. That's resulted in a growing reluctance and resentment at the requirement to cover the ED and some other functions. They feel they need to be paid. The hospital doesn't want to go down that path. It's a big issue in trauma."

Hospital administrators are divided in their response. In some markets they're hanging tough, adamantly maintaining that taking a turn on call is a traditional quid pro quo for hospital admitting privileges. Moreover, they argue like Mosser, paying for call "only adds to the expense for the hospital and limits our ability to do other things, like invest in new facilities and technology."

In many markets hospitals have been forced to accede to demands for call pay by doctors in critical specialties like surgery, neurosurgery and orthopedics. That, of course, only incites jealousy from colleagues without the clout to insist on similar reimbursement. And, of course, the level of the stipend, which usually starts out low, remains a source of grumbling, Pladson says.

"When I entered health care 30 years ago," recalls William Schoenhard, executive vice president and chief operating officer of SSM Health Care in St. Louis, "doctors really wanted to be on call because that was a way to build a practice. But today, because of the fact that so many patients present without previous care, in acute stages and in need of complex services and follow-up, doctors want to be compensated."

[ILLUSTRATION OMITTED]

Not only will his practice end up with every uninsured patient he treats while on night call in the ER, points out Michael Chapman, MD, professor emeritus of orthopedic surgery at the University of California, Davis, but these will be the most difficult patients--in poor general health, with a history of non-compliance, a high propensity for suing.

Chapman tells of an increasingly common scenario: "A guy on staff at the hospital, as his practice matures, decides to focus on total joint replacement. As time goes on, he gets pretty uncomfortable dealing with general orthopedic problems. So he goes to the administration, and says he doesn't want to take call anymore. That causes friction both with the hospital and with his colleagues."

To union leader Weinmann, the arguments for and against call-pay are basic: "Docs usually will not compromise on the level of care," he notes, "so if you [as an administrator] know that, why would you pay them? Well, if you want to build high morale, a solid medical staff, all pulling together with the hospital for the same things ... that's why you might do it."

Standardized materials

"Orthopedics used to be a cash cow for most hospitals," says Chapman. "That's changed. The only two bottom lines that are in the black are sports medicine and spine. Total joint replacement is now a money loser. Everybody's paying Medicare rates, and the prosthetics are eating up the entire margin."

Titanium ball-and-socket sets ... polyethylene kneecaps ... implantable pacemakers ... drug-eluting stents ... nylon or vicryl sutures ... the array of products a hospital must stock for its physicians--in multiple variants according to manufacturer, model, indication and clinical preference--represents a staggering investment.

For health care organizations struggling to improve financial performance, an obvious cost-cutting tactic is to winnow that inventory. And that requires coaxing a consensus from all the physicians to decide which items will be selected and which rejected.

Good luck.

"The hospital," says Chapman, "wants to get all the surgeons to use the same implants. Those trained in certain systems are going to be reluctant if they have to make a change. It feels to them as if it affects the quality of care, the way they do surgery, the outcome for the patient...."

Cut to Carondelet Health.

"In our [two] hospitals," Sanders says, "we wanted to standardize suture materials. We could purchase a certain brand for a substantial discount. But most of our surgeons weren't used to that material, they hadn't been trained in it, and they were adamantly against the proposal. It caused a huge rift.

"We were trying to be flexible," he sighs. "We certainly didn't want them to pack up and go to other hospitals. So we had to back off."

One of the first questions posed to her when she's recruiting for the New England Heart Institute, says Giles, is, "Are you going to tell me what I can use?" Her reply: "It's not the purview of anyone in administration to tell any physician what materials or procedures to use."

Indeed, when expensive drug-eluting stents were introduced, Catholic Medical Center agreed to absorb the huge extra cost even though insurers were denying reimbursement--simply because, says Giles, "our physicians said it was the right thing to do."

Limited physician autonomy 

Another friction point is virtually any mandate that curbs the independent judgment of physicians.

"Physicians tend to desire autonomy to control their practice style, pace of work and the way they manage patients," says Mosser. "So conflict arises primarily when physicians feel as though the administration is more concerned with the bottom line than with patient care. It's a matter of nuances. Tension will be created when physicians don't believe the administration has the patient's best interests at heart."

Since reporting in compliance with the new Centers for Medicare & Medicaid Services' emphasis on quality indicators falls to the hospital, not the physicians, says Theodore Dyer, vice president of medical affairs at Hendrick Health System in Abilene, Texas, "that puts hospitals into a quandary, forcing them to get into the physicians' chili more than the physicians would prefer."

As for his own efforts to promote clinical protocols as a foundation for the practice of evidence-based medicine, Dyer admits, "to the majority of the medical staff it's still cookbook medicine."

And if medicine can be reduced to following recipes, they argue, "then maybe we don't need doctors."

Physicians also complain that administrators are "harassing" them when concerns arise about extended lengths of stay, Dyer says. "The driver is not so much a health issue as it is a financial issue," he concedes. "But the amount of money coming into hospitals is pretty fixed, so the only way to increase the margin is by bringing in more patients through efficiency. Taking 24 hours to get a report done rather than two hours has a significant impact."

Conflict cures

"Sometimes issues percolating around the country seem to arrive later in Minnesota," jokes Pladson. But there would not appear to be any lack of the most widely cited physician-management conflict points at CentraCare.

On the other hand, his organization may be well out front in dealing with them. For the past year, he says, every meeting of the senior management team has wrapped up with this standing agenda item: "Are there areas of conflict with physicians that any of our policies, procedures or decisions have created? And if so, how can they be eliminated or modified to reduce the adverse impacts?"

The most effective grease for squeaky interactions between doctors and managers, proposes Peter Cardinal, MD, former vice president of medical affairs at Pennsylvania's Gettysburg Hospital, is "communication, communication, communication. That's the key to leadership.

"It's hard as an administrator to get away from your inbox," he acknowledges, "but you've got to do that. Conversely, physicians have to be willing to go out of their way a little bit to make a point of communicating with administrators. Too often they come in the back door, do their thing and go out the back door."

Paradoxically, regular rubbing of elbows with one another actually reduces internecine friction, according to Giles. She dons scrubs and observes doctors performing a variety of routine and not-so-routine tasks. "It diffuses a lot of issues," she says, "and it makes my job fun. Put on an apron and go help in the food line; pretty soon people will tell you everything that's going on in the organization!"

Enlightenment--that too is generated by friction. "Some of it is healthy, I think," says Schoenhard, who is the current chairman of the American College of Healthcare Executives. "Doctors have to advocate for patients, for new technologies, for new facilities--we need that."

Ultimately, though, the problems that set physicians and administrators against each other stem from one misshapen root, he says: "lack of access to health care in the United States. It plays itself out in weird, unintended consequences"--namely, each of the friction points noted above.

"The solution," he proposes, "begins with ensuring that everyone in the country has a provision for preventive care and at least basic catastrophic hospital care. That is not going to happen if we just work incrementally around the edges. Although, realistically, that's probably all that will happen given the present political climate.

"But one day," he exclaims, "I believe there will be a sea change--and a Big-Bang solution. And then maybe doctors and administrators can work together to take care of our communities. Because the current system is unsustainable. If we just keep beating each others' brains in, we're only going to make everything worse."

David Ollier Weber is a freelance health writer and frequent contributor to this journal. He can be reached by e-mail in Mendocino, Calif., at [e-mail].

RELATED ARTICLE: Through each other's eyes

Physician view:

* Administrators are insulated from the real pressures of patient care--taking call, scrambling to meet productivity demands ... and they're not at risk under the contract terms they negotiate, while the physicians they employ are.

[ILLUSTRATION OMITTED]

* Administrators don't understand how hard the doctors are working.

* Administrators are paid for non-productive work, like sitting around in meetings.

* Administrators are always worried about how much things cost.

* Administrators only focus on problems.

* Administrators don't get out from behind their desks often enough to see what's really going on.

Administrator view:

* Physicians lack a big-picture mind-set. They see things from their own perspective, or even from their own personal perspective.

* Physicians don't have time or don't want to make time to accomplish administrative tasks. But they don't trust others to do them either. They just want to veto whatever does get done.

* Physicians are unwilling or uncomfortable when it comes to peer confrontations.

* Physicians in the front lines often have a hard time coming to a group decision. There is no leadership.

* Physicians function as if other health care workers are less valuable.

Meanwhile, another influential eye--that of the television camera--plays an under-appreciated role in determining how doctors and administrators look at each other, suggests Keith Noll, vice president and administrator of cardiovascular services at Wellspan Health, in York, Pennsylvania.

"You watch TV," he says of the many popular shows with medical themes, "and hospital administrators and doctors are stereotyped. And their relationship too is stereotyped--as confrontational."

When an image floats so ubiquitously through the social ether, even clinicians and managers absorb it as a paradigm of normal behavior.

--David Weber