Trouble brews between medical staff and management: if you must blame someone, blame Herbert Spencer.

  The average medical man is an educated gentleman, a delightful
companion, a man of parts, and many such are our best friends; but
doctors, when associated in corporate matters, are oftentimes too
self-seeking. With an eye out for their profession, they are inclined to
be aggressive, and naturally, under such conditions are not a gracious,
peaceful, easily cooperative body of men.
--George H.M. Rowe, MD
Association of Hospital Superintendents
1902

Conflict management consultants abound, but there are no conflict avoidance consultants because conflict cannot be avoided. The natural elements of life are air, water, fire, earth, and conflict.

In organizations, factions fight over power and money, and they fight because either they do not understand each other's language and problems, or else they do not communicate at all. (1)

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There is nothing new about physician/management conflict. However, new causes and expressions of conflict arise continually, keeping pace with sea changes in medical technology, organizational structure and health care financing.

Conflict is especially intense in the hospital component of health care organizations. That's where health care costs are highest, where there is still some physician control of patient care matters, where the biggest legal liabilities are and where the general public's attention is focused.

In the 1930s, when my father was superintendent of Dimmitt Memorial Hospital in Humansville, Missouri, hospitals were simple and run informally. Communication was good. Little money was at stake, comparatively speaking.

Dad wrote out patients' bills in longhand (see Figure 1). Insurance was available, but was not the norm. Board members wrote checks to cover the expected annual deficit. Dad's hospital board minutes and correspondence indicate that the medical staff had the last word in most matters. Indeed, the hospital was sometimes called "the doctor's workshop."

Then in the 1960s, simultaneous growth of expensive high-tech medical care and third-party payment (insurance companies and Medicare/Medicaid) changed hospitals forever.

First fight

The first big fight of this modern era was a battle between medical staff and board; both groups claimed ultimate authority. Remember, back then physicians did not understand how organizations work. Physicians gave orders in the context of caring for a hospitalized patient.

Why, they thought, should we not give orders to the board? Factions debated the real meaning of a "self-governing" medical staff, and whether medical staff bylaws are or are not a contract.

Active medical staff members wanted to elect new staff members, rejecting few. The board wanted to select and appoint staff members. It was no contest. The board won hands down. On a scale of 1 to 10, physician resentment rose from near zero to 6.

In the 1970s came the malpractice crisis. Plus, medical staff cooperation was required to meet increasingly complex hospital accreditation standards of the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

Physicians complained, "Management tries to get us to do what they want by saying the Joint Commission requires it, and if we don't do what they want we will all get sued. Whatever happened to patient care reasons for changing?"

The 1980s saw the joint venture era in health care. Hospital executives sought to tap physicians' deep pockets by establishing joint ownership of some health care services. One result was a version of fee splitting. Also, executives incurred the enmity of physicians not asked to participate.

Furthermore, physicians asked to participate did not trust executives to be fair and square. "I'll tell you why you're here," said one chief of staff at a conflict resolution retreat. "A guy opened a restaurant and advertised rabbit fajitas.

"The health department came around and said, 'Where do you get all the rabbits?' Owner says, 'Tell you the truth there's a little horse meat in there but not enough to hurt. It's fifty-fifty, one horse to one rabbit.'

"That's management's idea of going fifty-fifty with us."

Also in the '80s, hospital medical directors became commonplace. The original idea was that the medical director would be a statesmanlike individual with both clinical expertise and business acumen, as comfortable in the doctor's lounge as in executive offices and the boardroom.

If successful, this person would occasionally make the medical staff forget that he was an executive and occasionally make the executive staff forget that he or she was an MD or DO. One task of the medical director was to be a big help to elected medical staff leaders, practicing clinicians with little time and often little taste for assuming organizational responsibility.

The initial medical staff reaction to this idea was to perceive it as a threat. First-generation medical directors were local practicing physicians about ready to retire, far more physician than executive. Even so, the doctor's lounge scuttlebutt was that the new medical director had "gone over to the other side."

By the end of the 1980s, as a result of all that had happened, the indicator on the virtual physician resentment meter hovered just above 8.

Managed care

In the 1990s came managed care, the compromise result of President Bill Clintons' failed reform efforts--just as Medicare/Medicaid is the compromise proposed by Lyndon Johnson's, when he saw the futility of seeking uniform health care coverage for every citizen. (2)

One feature of managed care policy is encouraging health care companies to maximize investor profit in the face of ratcheted down revenues. The struggle for control of the order sheet in each hospitalized patient's medical record--begun as utilization review in the 1970s--intensified.

Once the mighty captain of the ship, so powerful that jokes likening doctors to God were commonplace, doctors found themselves increasingly second guessed by people who did not hold a license to practice medicine.

Today, with patient care managers, utilization reviewers and quality control officers in place, it would be more accurate to call the order sheet a suggestion sheet.

Physician/management conflicts next focused on whether health care conglomerates should adopt the professional ethic, serving each patient, or a utilitarian ethic serving the common good.

The obvious answer, an Aristotelean blend of concern for each patient and concern for the big picture escaped the attention of conflicting groups who were busy battling over ... guess what ... money and control.

As in the battle with the board for hospital control, doctors lost. However, the loss was more devastating. Then, doctors only lost organizational control. This time, they lost one of the main reasons for justifying their existence, the state-given right to dictate the care plan for each individual patient. Physician resentment index hits a 9.

It appeared then that things could not get any worse. But they have. Why? The invisible and so far largely undiscovered troublemaker is a little known and long dead British philosopher!

Ironic, isn't it. Philosophers are usually thought of as peaceful people urging calm reason rather than constant conflict.

Herbert Spencer (1820-1903) was a British philosopher and sociologist greatly influenced by the utilitarian views of Jeremy Bentham. Spencer and others reasoned that Charles Darwin's principle of natural selection (survival of the fittest) is as applicable to the development of societies as it is to explaining the origin of species. (3)

According to this theory, societal change over time is actually the accumulated result of individual adaptation and the need to compete. Some individuals adapt and compete better than others. These, the fittest, survive. The weaker individuals do not survive. By this process of natural selection, societies gradually improve over time.

Spencer followed a basic rule for philosophers, avoid polemics. That is, do not say you are going to talk philosophy then subtly switch to suggesting political policy. However, in subsequent years others applied their own interpretations of Spencer's theory to politics, a school of thought known as Social Darwinism.

The idea is: We are obliged to favor the strongest members of a society. Assisting the weak only wastes available resources and does not contribute to social progress. At various times, Social Darwinists have used their theory to justify social inequality, imperialism, elitist economic policies and even eugenics. Others have used the concept to accuse imperialists and dictators of being ruthless and inhumane.

In Germany in 1904, Social Darwinists formed the Monastic League, a forerunner of the Volkisch movement and ultimately, of the National Socialist German Workers Party (Nazi party).

Another example of a Social Darwinist policy is imposition of gag orders in managed care. (4) Other examples are downsizing and outsourcing, cutting nursing staff in the face of high executive compensation, and dropping emergency services.

No wonder the physician resentment meter now registers 9.9.

Richard E. Thompson, MD, is former vice president of the Illinois Hospital Association, taught ethics at St. Petersburg College and Missouri State University, and is author of Think Before You Believe, Xlibris, 2005. He can be reached at [e-mail].

References

1. Neuhauser PC. Tribal Warfare in Organizations: Turning Tribal Conflict into Negotiated Peace (The Business Strategist Series). Ballinger. New York. 1988.

2. Thompson, RE. Health Care Reform as Social Change. ACPE. Tampa, Fla., 1993.

By Richard E. Thompson, MD

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