Service and collaboration keys to physician control. (Big Business/Noble Profession).

PHYSICIANS ARE NOT adapting well to the forces transforming health care.

They're on the defensive, experiencing less joy and feeling victimized by forces seemingly beyond their control. They're experiencing:

* Less autonomy

* Increased costs of practice

* Expanded regulatory overlay 

* Threats of litigation 

* Loss of respect

* Time pressures

* A diminished sense of collegiality (1)

In his book It's Not Luck, Goldratt describes with elegant simplicity an approach to understanding the causes of these undesirable effects. (2) It represents an outline for determining the root or primary causes.

* Make a listing of all undesirable effects that are related to a given situation.

* Place each of these effects in a separate box and draw an arrow from each effect to another box that contains a causal explanation.

* Continue to link boxes until they end at a box that appears to be the primary cause of the antecedent manifestations.

You essentially keep asking the question "why" until you identify the primary cause. Goldratt teaches that, in any listing of as many as 10 to 15 undesirable manifestations attending a given situation there are usually only 1 or 2 primary causes.

Applying this analysis to current manifestations of physician discontent leads me to conclude that there are indeed two primary causes:

* Physicians still place themselves at the center of the health care universe.

* When together, physicians behave as a town hall democracy.

Consumers in control

Consumer attitudes and expectations are clearly changing.

Every day consumers experience an ever-improving quality of product and quality of service as producers compete for their attention and loyalty. The focus on continuous quality improvement and six sigma initiatives continually raises the bar of expectations.

Experiencing high service excellence in many facets of their lives creates expectations that a similar level of service exists in all others. More important than increasing expectations, ability to easily access health care information has put the consumer in control of the health care industry.

Historically, there was an immense gap in knowledge between the physician and patients. This knowledge gap generated patient dependency and placed the physician in control.

Now, the patient can access more information than the physician can recall. The knowledge gap has narrowed and physicians are threatened by an apparent loss of control.

This predisposes physicians to become defensive in response to the assertiveness of consumerism and leaves them vulnerable to competitors who are willing to adopt a more expanded view of their customers.

In today's world of easy access to information, all successful business enterprises place the customers' needs at the center of their considerations.

Physicians, because of the historical emphasis placed on the doctor-patient relationship, generally refuse to refer to those who potentially may benefit from their services as customers, preferring to call them patients.

The concept of customer is viewed as demeaning. While understandable, this preference actually reinforces the perception of the patient as one who is dependent, perpetuates a sickness model of interaction and limits the potential of viewing the patient as a partner in managing their health.

It precludes expanding into a wellness model with its extended range of opportunities. In addition, this traditional view is based on an acute illness model of health care intervention. When people are sick, they require access to physicians and hospitals.

However, today the majority of encounters with the health care system are for chronic and not acute problems. When people are chronically ill, what they require is not access to doctors and hospitals, but access to information.

There are many examples that document how a motivated and informed person can self-manage their illness and produce outcomes superior to those of the traditional model.

Nevertheless, the dominant physician metaphor continues to be that of the all-knowing ship's captain.

The pressures of time and shrinking margins, together with the growing sub-specialization of medical practice, are causing physicians to see patients as outputs of production, further compromising physician adaptability.

If your underlying belief is that the unit of production in health care is created one doctor to one patient at a time, when profit margins decline, the only apparent solution rests in creating more units of production--generating more patient encounters.

As a result, many physicians come to view patients in transactional ways, sacrificing the doctor-patient relationship in deference to a doctor-disease or a doctor-technology relationship.

At the end of these impersonal encounters, I believe that both the patient and the physician are left feeling cheated and unfulfilled.

Almost all physicians chose the profession because they wanted to help people. Yet, too often, the means has become the end. This additionally contributes to consumer dissatisfaction with traditional medical care.

Failing to personalize health care interventions risks transforming the practice of medicine from a profession into a trade.

Town hail democracy

The other primary reason that physicians are adapting so poorly is that, as a group, they practice town hall democracy--one person and one vote.

Physicians comprise what is referred to as an expert culture where a person's success and reputation are a direct result of individual skill and effort. (3)

Experts characteristically assess situations from the perspective of "how will this affect me personally?" In expert cultures, an individual member's contribution to the overall success of the group is defined in terms of an individual performing at his or her isolated best. The whole is the sum of the individual parts.

This cultural predisposition significantly inhibits adaptability and renders physicians vulnerable to the dictates of more organized constituencies. There is limited capacity to lead and a predisposition to defend the status quo.

Because of these cultural characteristics, physicians are organizationally impaired.

Physicians have no frame of reference that allows them to understand how to work together. The only times they get together in a setting away from the patient's bedside is at medical staff meetings.

Anyone who has tried to conduct business at a medical staff meeting will appreciate how difficult it is to accomplish anything meaningful. Physicians are reluctant to speak on behalf of other physicians because they would resent others presuming to speak for them.

This same attitude precludes followership. There is an overriding concern to manage for consensus--of finding solutions that are the least objectionable to the most persons.

There is no collective identity, no formal acknowledgment of leadership roles beyond what is ceremonial and representational, and there is no commitment to followership around issues of common interest. (2)

Paradoxically, the only thing that unites physicians is the mutual commitment to the preservation of individual physician prerogative.

Collaboration navy

The Institute of Medicine reports challenged the provider community to demonstrate measured accountability for the outcomes of health care interventions and to begin to organize itself in response to the needs and values of patients.

These reports directly challenge the existing physician paradigm that emphasizes physician autonomy and personal accountability. That paradigm focuses on the adequacy of individual performance with a failure to appreciate the many systemic interdependencies that exist and the critical contribution of process design flaws to compromised outcomes.

When adverse outcomes are retrospectively analyzed, it always becomes apparent that if only someone would have been appropriately vigilant, the adverse outcome would have been avoided.

The culture then assigns blame and seeks to prevent recurrence through additional training. This blame and train approach arises from a culture that uses measurement for judging individuals, rather than for improving processes of care.

It is also quite apparent that most health care organizations are structured in deference to the needs of the providers rather than the needs of patients and their families.

Excessive wait times, disregard for privacy and confidentiality, redundancy and poor integration and communication of information are just some of the inadequacies that too often permeate our health care "non-system." Patients are progressively less willing to accept these inadequacies. Ignoring their expectations invites the superimposition of regulatory and legislative solutions.

Town hall democracy forces physicians to always be reactive.

It is only the perception of a shared threat that prompts them to gather in the first place. They are constantly reacting rather than anticipating, or better yet, creating positive change.

Without acknowledging representational democracy and legitimate leadership, there is no capacity to act creatively.

Efforts to unite physicians often fail because of the lack of a common group identity. If physicians are to become successful and capable of asserting a collective influence, they will need to accept leadership and demonstrate followership within the context of a unifying and collaborative identity.

It is difficult to predict whether physicians can move beyond the overriding commitment to individual autonomy towards collaboration, where individual success becomes a derivative of collective success.

If physicians could accept the leadership of representational democracy, those representatives could:

* Advocate for the shared goals of their constituency

* Have a frame of reference from which to make decisions

* Allow for some consistency of direction

In this way, physicians could become proactive and begin to help shape the future of their work environment.

Attempts by health care organizations to unite their medical staff primarily reflect initiatives focused on the organization's mission. There is a great reluctance to divide the physician staff.

Metaphorically, organizing around shared mission represents an attempt to build an ark on which all can sail. The key to making an expert model work is the time spent engaging the experts in the creation of a vision that serves their personal interests.

Vision, not mission, is what unites experts. (3)

Because different segments of the physician community value some goals higher than others, it is clear that there can be no single way to create a unifying consensus. It's not an ark that's needed, but of a flotilla of ships, with each designed to achieve the ends of its respective crew.

While it is possible to orchestrate these ships into a navy that can effectively pursue an overarching and shared goal, each ship will decide issue by issue whether or not to participate.

Individual physicians will segment into groups comprised of individuals who similarly prioritize what they personally value. Experts respond well to change processes where they feel in control of the decisions that most affect them and feel professional respect throughout the development and implementation of the process.

Experts do not make shared mission a prerequisite for commitment.

If physicians are to become more adaptable, they must first focus on the customer and then stop managing for total group consensus.

Subgroups of physicians, united around shared interest, must acknowledge representational leadership and define specific measures that will assess their progress towards successfully achieving their shared objectives.

If physicians can successfully influence these two root causes, they will become more adaptable and better able to play a creative role as architects of their own future. In addition, they will ameliorate many of the undesirable effects that frustrate them and compromise their sense of joy, happiness and satisfaction in their professional lives.

References

(1.) Bujak, JS. "Recapturing The Joy in Health care." Health Forum J. 1999, Nov-Dec., 42(6): 42-4.

(2.) Goldratt, E. It's Not Luck. Great Barrington, Mass., The North River Press, 1994.

(3.) Atchison, T and Bujak, S. Leading Transformational Change: The Physician-Executive Partnership. Chicago, Health Administration Press, 2001.

ACPE Resources

Bring Joseph Bujak to your organization for an OnSite Educational program. Call Lou Ellen Horwitz at 800/562-8088 or visit www.acpe.org/onsite for more information.

Joseph Bujak, MD, FACP, is vice president of medical affairs for Kootenai Medical Center, Coeur d'Alene, Idaho. He focuses on the reorganization of the provider community and the redesign of health care delivery. He can be reached by phone at 208/666-2014 or by e-mail at [e-mail].