Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institute for Medical Humanities at University of Texas - Medical Branch at Galveston, and blogger at Hooked: Ethics, Medicine and Pharma. 

Danielle Ofri, a prominent internist/author at Bellevue in New York, started a recent op-ed piece, “Last week I was ready to quit medicine."

She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.

Ofri’s plaint caught my attention because I had recently put up a guest post on Health Care Renewal about another highly skilled, caring physician who was seriously considering quitting practice. This led me to write a column for some of our local newspapers about demoralized doctors

In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.

We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.

There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.

Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports either quality care orefficient resource use?

If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look here - Ed]  . And we know that at least at the high end, these managers are paid munificent sums, and are lauded for their supposed genius (look here for example). 

So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.

All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.

This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I explained some time ago, most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or economism. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look here.)

Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look here), or "financialization." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this generic management. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now.

Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "learned helplessness." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.

After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, “when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”

Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means? 

Dr Howard Brody

GUEST BLOG - What Can Doctors Do to Combat Business Malfeasance in Health Care?

Dr Gene Dorio is a an internist and geriatrician in California, described in the Los Angeles Times as an "old school physician."  He would welcome discussion with anyone interested in his proposal.  Please email him directly at grd51 at aol dot com, or email me for forwarding.    

As a Health Care Renewal reader, learning of medical business malfeasance irritates my moral conscience, yet lack of legal intervention frustrates my inner core.

I am chairman of the Department of Medicine at a small community hospital in Southern California, and as I battle the Administration during Medical Executive Committee meetings, I am a lone voice. Some of my colleagues nod their heads, while others later tell me of their support, but few vocally nor in writing openly give their opinion. Why?

Most fear hospital financial retaliation, but I also know they don’t have time to formulate an opinion. You would think well-educated doctors who daily advocate on behalf of patients would be better attuned to being involved in our great medical debate. Because they have remained silent, “big business” jumped in and took over financial medical decision-making.

Using our medical license is the business scheme they use to make their money. With sophisticated business techniques, they have shut out doctors and dangled dollars as we all jump for their “carrots.” That successful business model and attitude is outside the realm of doctor’s poor business and public relations sense, with the noose continually tightening.

Realizing business would be nowhere without our medical license is our trump card...which we haven’t played yet!

What can we do? Logically, bring their business malfeasance forward on blogs (like Health Care Renewal) with the hope physicians and the public will be upset. It does stir the pot for some of our colleagues, but for the most part, doctor attention is now focused on just trying to survive. The public is rendered helpless by the continually confusing medical legalese by the well-financed business propaganda machine. This is where our frustration arises, as the backlash-opinion tsunami of their business outrage never materializes, especially from doctors.

Therefore, my first thought for a possible solution is focus on the public, clarifying the legalese, and use abhorrent stories of business abuse and patient care sacrifice for business profit. We must make them the villain.

Secondly, organize physician writers into a small group launching a “counter offensive” against their propaganda. The public still highly respect physicians and gravitates to their opinions and stories. With the right motivated people, they would think-tank refined opinions for the national spotlight.

Thirdly, network with national blogs and magazines, and city-printed newspapers for article publication as op-eds, letters to the editors, journal articles, and personal stories.

Fourthly, and probably the hardest, not get discouraged.

Health Care Renewal defines the problem, but not always the solution. Even when there might be solutions, they must be broadcast and directed at a higher level to ignite public opinion.

If you think this might be worthy for 2013 (as if we aren’t all busy enough!), I will be happy to spearhead this project with those advocate colleagues and idealists who might be interested.

Our profession is under assault from big business, and finding clarity is the shield we need to defend society and our patients.

Dr Gene Dorio