Using an old tool to create a new compact in health care.

Help your brother's boat across and your own will reach the shore.
--Hindu proverb

In today's challenging health care environment, physician executives need all the management resources and tools they can garner. As you work to strengthen your relationship with physicians, consider how you can use an ages-old "tool" you may have overlooked.

Anthropologists studying cultures around the world discovered that exchanges in societies that don't use money are often based on the principle of reciprocity. In these small groups, the important dynamic is the relationship between the two parties to an exchange. When an even exchange of goods or services occurs between two parties, balanced reciprocity is said to be operating.

Balanced reciprocity characterizes many of the exchanges between hospital administrators and physicians as well. Although we in industrialized societies usually determine the equity of such exchanges by affixing dollar amounts to the transaction, the principle is the same as when a member of the Kikuyu tribe exchanges a goat for a neighbor's assistance in rebuilding a dwelling.

Here are a few examples of balanced reciprocity--not all of which include the exchange of money--that administrators will be familiar with:

* A cardiovascular surgeon agrees to perform all of his cases at a medical center that agrees to purchase an expensive surgical robot for his use.

* Members of the medical staff enter into a joint venture with hospital administration in a medical office building construction and rental.

* Medical staff members agree to take ER calls if the hospital covers their malpractice costs for all uninsured patients.

* Medical staff members agree to dictate their history and physicals within 12 hours of patient admission if the hospital will have the dictation transcribed and delivered to the chart within two hours.

In these exchanges, both hospital administrators and physicians have given something tangible--funds to buy a surgical robot or submitting to a temporal deadline, in order to get something from the other party. Assuming that both sides believe the exchange is equitable, they will be satisfied with their agreement and both will benefit from the exchange.

Search for equity

Not all exchanges, however, even in small, close-knit societies, are equitable or fair. Anthropologists have found that even when relationships are very important, one party to an exchange sometimes will attempt to take advantage of the other. When this happens, it's negative reciprocity.

Just as relationships are damaged in small societies when negative reciprocity predominates, so too do the relationships between hospitals and physicians suffer when one party takes advantage of the other.

An example of negative reciprocity in the hospital setting is the physician who threatens to take his admissions to a rival hospital when he is asked to follow evidence-based guidelines. Similarly, the hospital administration may try to punish one of its surgeons by withdrawing the surgeon's credentials because she has partnered with other surgeons and a national franchise to establish a surgicenter.

In these examples, the exchange is between one physician and the hospital. But the consequences of these actions affect many more on the medical and management staffs.

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Both the physician who threatens to defect to a competitor and the physician who loses her privileges will influence colleagues' opinions of the hospital and may even solicit support in the form of a boycott or censure.

Obviously, good administrators will eschew engaging in negative reciprocity as much as possible. And while balanced reciprocity may be the desired norm in most situations, wise health care managers also need to understand and become adept at using a third type of reciprocity known as generalized reciprocity.

Generalized reciprocity is the type alluded to in the Hindu proverb at the beginning of this article. It involves doing something for another person or group because you realize that in the long run you will benefit, too.

Generalized reciprocity is difficult for those of us accustomed to a quid pro quo system to embrace.

In health care organizations, as in other enterprises, managers, physicians, and staff constantly weigh--consciously or unconsciously--what each is getting out of the business relationship.

As long as a physician knows he will get a better schedule in the operating room next week, for example, he may be willing to acquiesce with a colleague's request to trade for a choice time slot this week. That's balanced reciprocity.

But what if the first physician knows that the operating room schedule is finalized for the next several weeks and he probably won't be "paid back" for his generosity. Will he still trade time slots with a colleague?

If the professional and/or personal relationship with that colleague is important, the answer is yes; the physician in this example knows that sometime in the future, he can call on his colleague to return the favor. Or, he may never ask for a similar favor but instead be satisfied with having fortified the relationship.

As the opportunities for balanced reciprocity between hospitals and physicians diminish, managers will need to rely more and more on generalized reciprocity in their relationships.

Increasingly, physicians can dip into revenue streams that have been traditionally controlled by hospitals. For example, hospitals are no longer creating as many free-standing clinics in partnerships with physicians. Instead, large national corporations are building these clinics with physician partners. Because these corporations are for-profits, they can be more selective of which patients they will treat, leaving the underinsured and uninsured to the hospitals.

To offset these diminished opportunities for balanced reciprocity, managers--and physicians--need to search for opportunities to practice generalized reciprocity in their exchanges.

The following conversation between an influential member of the medical staff at All Saints Hospital and the vice president of medical affairs illustrates a missed opportunity for generalized reciprocity.

"And another reason I don't introduce more colleagues as potential staff members," continued Dr. Zacharias, "is because the physician lounge is crowded, dark, and often dirty."

"How can that be such a deterrent?" asked Dr. Jonas, VPMA at All Saints Hospital. "Our surgical suite is one of the best-equipped in the city and our staff nurses are excellent. Surely those are more important than the appearance of the physician lounge."

"Of course they are more important," said Dr. Zacharias, "but the lounge is also important. I often get here as early as 5:00 am and I like to have a cup of coffee and talk with colleagues before my first surgery. Just last week, Dr. Barrett shared a surgical technique that he had read about, and I had an immediate application for it in a surgery I performed the next day. The opportunity to exchange information with other surgeons like Dr. Barrett is one of the main reasons I value a comfortable lounge."

The VPMA in this apocryphal exchange has a valuable opportunity to earn a lot of goodwill from the medical staff--not just one physician--if he heeds and acts on what Dr. Zacharias is saying.

Physician lounges are not only a place to drink coffee, chat with colleagues and enjoy a respite from the frenetic pace of modern hospitals; they are also a symbol to many physicians of the regard which the hospital's administration has for its medical staff.

A lounge that is, in Dr. Zacharias' words, "crowded, dark, and dirty" suggests a low degree of respect for a hospital's physicians. Moreover, a lounge like this is hardly the type of place one would want to bring a potential medical staff member.

If All Saints Hospital's administration allocates the funds to upgrade the lounge, they will ultimately benefit from increased goodwill and possibly even better clinical results.

Physicians, too, can and do engage in generalized reciprocity in their exchanges with administration. Physicians who volunteer their time to engage in philanthropic efforts on behalf of the hospital's foundation don't expect an immediate return on their "investment."

At some point in the future, they or one of their colleagues may receive research funding from the foundation but there's no guarantee. When cardiologists agree to limit the number of vendors from whom they will request endomechanical devices, they may be rewarded indirectly by the hospital's investing a portion of the savings in new equipment or procedure rooms for their department.

Recent research reveals that much of the unwritten compact that has served for decades as the reciprocal link between medical staff and hospital administrators no longer holds. Payer, regulatory and medical-legal pressures, in addition to the technology that has moved care out of the hospital setting, have all made it necessary for physicians and administrators to create new forms of reciprocity.

Generalized reciprocity can be a powerful tool for hospital administrators who are asked to accomplish many aspects of their jobs through influence, rather than by the exercise of formal authority. Implementing generalized reciprocity requires a leap of faith by the one who initiates the exchange and a realization that there is no guarantee the gesture will yield tangible or intangible rewards.

The potential for rewards in the form of enhanced professional relationships and greater productivity, however, is tremendous and justifies taking the leap.

James Tucci, MD, MMM, is senior vice president and chief medical officer at St. John Health, Warren, Mich. He can he reached at [e-mail]

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Linda Catlin is an organizational anthropologist and principal in Claymore Associates, Inc., in Colorado Springs, Co. She can he reached at [e-mail]

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Resources

* "Recovering Physician Loyalty: Lessons on Crafting a True Hospital-Physician Relationship," The Clinical Advisory Board, Washington, D.C., 2002.

* "Renewing the Partnership: Establishing a Shared Physician-Hospital Ambition," The Clinical Advisory Board, Washington, D.C., 2002.

* "Breakthrough Physician Strategy," The Clinical Advisory Board, Washington, D.C., 2003.

* "Physician-Hospital Relationships: The Empty Clubhouse," VHA Research Series, 2003.

* "Physician-Hospital Relationships: Forging the New Covenant," VHA Research Series, 2004.

* "The Search for Strategies to Improve Physician-Hospital Relations," The Governance Institute, Winter 2003.

By James M. Tucci, MD, MMM, and Lina B. Catlin