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Reader feedback.

Dear Editor.

Harvey Dershin's article in the May/June issue of The Physician Executive (volume 25, issue # 3) is well done and long overdue. Large dysfunctional organizations will never achieve lasting success. For a long time, I have felt that systems theory was under-applied In medicine. I try to approach the patient from a systems framework, but they call It "holistic." The real problem is that most of the current managers in health care don't understand the business they are in.

Ted J. Stuart Jr., MD, MBA, ABFP


Northwest Family Physicians Ltd.

Glendale, Arizona

Adapting to the health care climate

I just finished reading Harvey Dershin's article, 'Nonlinear Systems Theory in Medical Care Management, in The Physician Executive. Since I "do" medical management for a living, I found his article stimulating and of potentially great usefulness in educating physicians to adapt to life in the current health care climate.

I would also like to comment on the interesting interview with J.D. Kleinke by Richard Reece, MD.

Mr. Kleinke has made a fundamental error: When the conversation turns to risk-bearing, he remarks that "the risk-bearer ultimately lives or dies by his ability to manage the train wrecks or the high cost catastrophic cases. Inevitably those involve the hospital." This thinking supports his thesis that physicians must align themselves with hospitals in order to most effectively deal with these cases and manage risk successfully.

The truth is that many of these train wrecks and catastrophes can be avoided by improving the delivery of care outside the hospital, starting years before the patient ever slides down the slippery slope of catastrophic illness. Physicians can be morally and financially motivated to promote wellness. illness prevention. screening. and aggressive management of chronically 111 patients. They should be trained in fostering patient compliance with treatment plans and physician compliance with the latest treatment modalities. All this is well within the purview of the physician community and can be brought to bear on patient populations to improve their lives and reduce their disease burdens.

Sadly, the incentive for hospitals is to provide more and more services, not fewer and fewer. There really is no rationale for hospitals to be brought further into the revenue stream, which should belong to those physicians who have the opportunity. through risk-bearing, to earn it.

Harvey L Kaufman, MD

Chief Medical Officer

Valence Health

Trevose, Pennsylvania

Ambiguous, poorly accessible analogy

I have just finished reading the May/June issue of The Physician Executive (volume 25, issue # 3). I feel compelled to comment on "Nonlinear Systems Theory in Medical Care Management" and "Culture in Chaos: The Need for Leadership and Followership in Medicine." The conclusions reached in each article are logical and likely quite valid. My concern is the method by which the conclusions were reached.

There seems to be increasing use of cross-specialty terms. such as chaos and complexity. The use of metaphor is valuable to allow analogies to be drawn and simplify understanding by using cross-specialty terms and concepts. The use of complicated, arcane, scientific subspecialties such as complexity. chaos, and other nonlinear dynamic theories as analogy does little to aid understanding. In the strictest lexical sense, most health care organizations and delivery systems. as well as most disease states, are complex, occasionally to the point of chaotic. In the strictest mathematical sense, however, I doubt that any system or patient meets the criteria of nonlinear, deterministic, aperiodic behavior with exquisite sensitivity to initial conditions. In short, even if system or patient behavior could be expressed mathematically. the result would likely remain something other than chaotic (in the mathematical sense).

Could the same conclusions have been drawn without reference to complexity? Almost certainly. Established principles of Bayesian analysis and quality Improvement would allow the same conclusions as 'Nonlinear Systems Theory In Medical Care Management" to be reached--but without irrelevant analogy and graphics. Standard management principles would serve likewise for "Culture in Chaos: The Need for Leadership and Followership in Medicine.

As managers. we need to make information and ideas accessible. Attempting to achieve scientific credibility by introducing jargon is not helpful. Our colleagues and subordinates are unlikely to take us seriously If we use an ambiguous, poorly accessible analogy to help bring their understanding in line with ours.

Yours truly,

John K. Hall, MD, FRCPC

Chairman Department of Anesthesiology and Critical Care Driscoll Children's Hospital Corpus Christi, Texas

More on the dance of anger

I am deeply disappointed with Charles Dwyer's views about physicians in his article, "More on the Dance of Anger" (May/June, volume 25, issue # 3). Dr. Dwyer has portrayed physicians as a group of uncooperative and egoistic individuals. I believe that physicians' frustration and anger is neither Imagined nor due to ego, but rather to the unethical expectations within some managed care systems-inappropriate early discharges, denial of necessary tests or admissions, restrictions on referrals to appropriate specialists. etc.

Does he advocate that physicians adjust their ethical values and accept these changes? Does he believe that the physician should remain silent when managed care denies appropriate treatment? If he were the patient, would he really wish his physician to take such a passive role?

Dr. Dwyer's advice is inappropriate for professions such as medicine where human lives are at stake. I would assure him that most physicians will not change their ethical values as long as they are responsible for someone ehe's life.

Sincerely yours,

Farr Ajir, MD, MBA, CPE, FACS

Neurological Surgery

Westlake, California

Not adapting harmoniously

When Charles Dwyer. PhD, (volume 25, issue # 3) asks physicians to adapt harmoniously with changes imposed upon them by managed care, he presumably does not refer to well documented activities for which more than one HMO has been later indicted for fraud or illegal denial of services. And to be perfectly frank, a more even-handed discussion would have included a cost-benefit analysis of the hundreds of millions of patient care dollars that have been shifted to legions of consultants such as the author. Many physicians and much of the public perceive this group of professionals to be, at best, marginally productive and, at worst. instrumental in fostering the very discontent about which he so amusingly writes.

Very truly yours,

Ali J. Naini, MD

Los Angeles, California

Coping with grief and loss

I want to congratulate the editors of The Physician Executive for recognizing and confronting the painful emotions all in health care are struggling with through our evolution/revolution. The many strategies promulgated by the authors in the various articles in the March/April issue represent pieces of the puzzle one could name as the solution to coping with these emotions. I believe there is another piece that we should add-transition management, a term coined and written extensively about by William Bridges.

Transition management is a set of tools designed to help people through the emotional journey that is the natural reaction to any and all change processes. This journey occurs with all change; positive, negative, planned, and unplanned. Change is an event that is external to a person. Something stops and another thing starts. Transition is the internal psychological reorientation necessary in human beings for the change to occur successfully. Organizations don't change. people do! Transition management may work as a parallel process to change management. It therefore does not impede or slow change. it facilitates it.

The transition journey has three phases, each of which can be recognized and the human movement through them facilitated. The first is an ending phenomenon. People must give up some of themselves in order to move to something new. The change might precipitate the loss of identity, friends or colleagues, a sense of competence. etc. Robert Klint refers to these emotions of the grief process, the natural response to loss, in his article.

We can help ourselves and others understand and catalogue what we are truly losing and what is continuing for us. Inevitably there are things we must let go of. Let's recognize them and as leaders support our colleagues through the loss and the grief. Ceremony helps to mark endings and brings closure. The simple public acknowledgement by leaders that there is loss lets those we support know that we are sympathetic to their grief and that we care. These tools and others (that we use everyday in our work with patients) are critical to move people out of the ending phase.

People then move into an "in-between" time. The old is evaporating and we are not yet comfortable with the new. This phase, defined as the neutral zone, is chaotic, anxiety provoking, and results in a breakdown in consensus with a concomitant Increase In discord. We must be at our best as communicators in order to show a sense of connection and concern. More importantly, we must encourage and teach entrepreneurship and creativity to help solve many of the real practical work Issues that suffer in this chaotic "wilderness" time.

Finally we move people to the beginning phase, the time it takes to understand and become comfortable with the change. (This is different from starting, which occurs at a single moment In time, the day the risk portion of our compensation goes from 10 to 15 percent). Leaders need to "add glue" to reinforce the change as we move through the beginning. Tools include a focused effort, as leaders, to be consistent in our messages, behaviors, and the rewards we provide to others as they change their behaviors. Simultaneously celebrating successes in the organization occurring during the transition and "spreading the word" is an effective way to support the "new." It reinforces those who believe in the change, it convinces those who sit skeptically on the fence, and it confounds those who continue as critics.

Adding transition management strategies to our strategic planning and change management initiatives will help keep the heart and soul in our organizations by supporting those we often refer to as "our most precious resource"--our people.

Gregg Broffman, MD


Transition Concepts, Ltd.

Medical Director, HealthCare Plan


Dear Reader:

"We are changing the concept of an article. Heretofore, most articles that you read anywhere are a self-contained look at a particular topic or issue. We want to change that traditional view of an article and expand it so that people who have an interest in the topic will find it to be a more complete resource.

--Roger Schenke Executive Vice President

The Physician Executive has been redesigned to bring you expanded editorial content in a concise, easy-to-read format. The key concepts are bulleted and the abstracts have been expanded to help you quickly decide whether the article is of interest to you. Articles will include more case studies, stories, and applications to theories being explored to give you hands-on examples of how ideas can be implemented in your organization. Author book picks and recommended resources, such as related books, articles, and websites, will also be provided.

Each issue will present a mini-theme with several articles focusing on different aspects of a key medical management issue. This issue's theme of conflict management provides an overview by David O. Weber to give you the background and facts, as well as several articles presenting differing views, tools, hands-on strategies. case studies, and approaches, such as mediation, for dealing with disputes. Interviews have been introduced, for example this issue's talk with Leonard Marcus, PhD, noted conflict resolution expert, author, teacher, and Director of the Program for Healthcare Negotiation and Conflict Resolution at the Harvard School of Public Health.

The Pej Journal club has been launched to give you a way to further explore themes and articles. Please log onto to participate in an online discussion about conflict management facilitated by Cathie Siders, PhD, and Carol Aschenbrener, MD, authors of "The Conflict Management Checklist" in this issue We invite you to participate in this CyberFoum and others to ask questions and discuss articles and concepts with other interested colleagues. Highlights will be reported in subsequent issues of the Journal.

Please let us know what you think of the new editorial format. You may contact Susan Sasenick, Managing Editor, by calling 800/562-8088 or via email at We look forward to bringing you a more lively and varied Journal that addresses the issues that are important to you.


In April, the American College of Physician Executives sent a flashmail to members asking them if conflict resolution was a part of their management activities and, if so, to what extent it consumed their time. One hundred and fifteen members told us that they spend, on average, approximately 20 percent of their time dealing with some form of conflict resolution--involving disputes between physicians, patient-physician, patient-hospital. physician-hospital physician-staff, and hospital-managed care organization. All agreed that conflict management skills are an essential part of their physician executive toolbox.

Here's a sampling of what other physician executives said:

* The percentage of time one spends is hard to gauge since most of decision-making involves conflict resolution.

* If interpreted broadly (to include helping people with different ideas reach consensus in policy development, for example) 'conflict resolution" consumes a substantial chunk of a physician executive's time--probably in excess of 25 percent.

* I spend at least 50 percent of my time on conflict management or negotiation, if you use the broad definition of "conflict resolution." I define it as anything that prevents me from getting the optima! results from a group of individuals.

* It is a small part of my job that elicits about 75 percent of my anxiety.

* I sometimes feel like I spend 100 percent of my time with conflicts, but that is probably an illusion. Conflict is like the hot stove in Einstein's analogy of relativity. A few seconds can feel like an eternity. Nowadays conflict is inevitable, as managers want more and more productivity for less and less money.

This special issue on "Conflict Management--When Cooing it Gets Hot" brings together experts on conflict resolution from the health care field to provide some answers on how to deal with this inevitable phenomenon--One that is accelerating in an industry besieged by relentless change. From a diagnostic conflict management checklist, to pearls of wisdom from colleagues on how they've addressed conflict, to assessing conflict in your organization through a grief budget, the articles provide hands-on strategies and case studies to help physicians executives manage conflict.
COPYRIGHT 1999 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Publication:Physician Executive
Date:Jul 1, 1999
Previous Article:Addressing medical errors: the key to a Safer Health care System. (Health Policy Update).
Next Article:Medical society opposes mandatory use of "hospitalists". (Short Takes).

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