Saturday, September 20, 2008

A Cultural Chasm

Kevin, M.D. recently highlighted an article in the Washington Post by a physician which outlines the difficulties faced when physicians and hospital administrations collide. It is an interesting take on things, and is, on balance, rather balanced. While pointing out the problems administrators face from a financial standpoint, it also describes the vexing issue of striking the right balance with a hospital's physician workforce. Appropriately, the author draws out some key distinctions between the physicians and administrators involved:

It's a basic cultural divide, says David Nash, a physician who is chairman of the department of health policy at Thomas Jefferson University Hospital in Philadelphia. Doctors, he told me, have a "single-patient worldview with a focus on clinical culture which emphasizes autonomy," while administrators have a "management-culture focus that emphasizes teamwork and integrated worldview."
OK. I can buy that. There is no question that physicians are taught from an early stage to emphasize that the care of their patient(s) is paramount. And when push comes to shove, that is where my allegiances always will stay. I think patients probably want us to act that way, but I also understand that sometimes this can be taken to extremes --- fighting to keep outdated medications or equipment when other, more cost-effective alternatives are available, because "I have always had success with this" is an anachronistic attitude in today's cost efficient hospital. However, I would argue that many times administrative decisions adversely impact patient care, and it is my responsibility as a physician to fight against those decisions.

What to do? The article proposes that physicians bear the brunt of the responsibility here.
The solutions to these kind of problems are not taught in medical school. Physicians have little training in management and teamwork skills, says Kenneth H. Cohn, a practicing surgeon and an author of "Better Communication for Better Care: Mastering Physician-Administration Collaboration." He says that strategies such as structured dialogue and inquiry that avoids finger-pointing can help.
In a word, bullshit. I am sorry, but I do not think that "structured dialogue and inquiry" means anything other than sitting in meetings with administrators on my time while they decide whether or not my opinion is worth listening to. Sorry, been there, done that, have the bald spots and gray hair to prove it. Going to meetings is what they do, it's what they get paid for --- it's all a donation of a (large chunk of) my time without reimbursement, and in my experience my input gets relegated to the circular file. And why is this only our responsibility; don't administrators need to move a bit as well to achieve harmony? We don't have a cultural divide, we have a chasm the size of the Mariana trench.

IMHO, one of the most important differences between the physician and administration cultures is one of commitment. I tend to view top level hospital and hospital system administrators as a series of revolving temps; at times it seems that our top management is nothing other than a bunch of Kelly girls. It is hard to have a "structured dialogue" about plans for a big institution with people who have been here a short time, and who will be looking to leave before the next new moon. One hospital nearby me is getting its fifth CEO in 14 years. That's not the type of long-term commitment that is exhibited by the physicians and staff at that facility, those that have a stake in its long-term viability and quality of care delivery.

Here is my terribly biased and profoundly unfair portrait of this type of hospital system administration:

OK, I know, that's simply ridiculous. But I use it to make a point. If administrators are interested in having a "structured dialogue," and want physicians to undergo "training in teamwork," perhaps it would behoove them to take some of their unpaid time to do a few things that would open their eyes a bit:
  • Spend every Friday night with the 11PM-7AM shift in the ED for a month
  • Follow a patient from the ED waiting room, to the ED, to the CT scanner, to the OR, and then to the ICU
  • Show up at the scheduled "start time" in the OR, and then spend a few days sorting out why "start time" is always in quotes
  • Stay up most of the night with a physician on call, receiving all of the same pages, getting out of bed to go see patients, and then go to that "dialogue" meeting at 7AM.....and then to the office to see a full day's load of patients
  • Go to one of the wards at 2AM to find out where the nurses get something to eat on a dinner break when the cafeteria was closed at night due to budget cuts
  • Make rounds in the ICU, and find out how many nurses don't always get a meal break, as they must cover more than their own patients as other nurses cart the critically ill down to radiology
The administrator who does some of these things gains a perspective that cannot be gleaned from reading or listening to reports in the comfort of a boardroom. He also gains something far more important, I would hope --- the respect of the staff working at the hospital, and an understanding that a long-term commitment to success is a better approach to make a hospital (or system) successful for the long haul. That guy I would "dialogue" with.