Medical organizations have never needed leadership from their physicians more than they do today. I started my consulting service to help physicians and their organizations provide this leadership, since excellent patient care depends upon it. Why is there a problem? There are two related problems. First, many medical organizations don’t think they need their front-line clinicians involved in “the business.” Second, many physicians don’t know how to be helpful even if they do have opportunities to be involved.
I think the best mental model for a healthcare organization of any size is triangular with three boundary conditions for failure: clinical, financial, and human. The successful organization will find a way to maintain a dynamic balance of forces that keeps the organization functioning in all three domains with sufficient resilience to overcome the inevitable jolts. Physicians must be involved in defining clinical success and failure and must be involved in leading their particular clinical microsystem. Physicians are the only ones, for instance, who can decide when a patient should be “off protocol.” They are the ones who must decide when standard care should be provided and when personalized, non-standard, care is appropriate. They are also in a good place to measure stress in the clinical support staff if workload exceeds capacity or training is not sufficient. After all, few of us practice without help from a virtual army of nurses and technicians. Yet few physicians receive any training in these issues during medical school and residency and there are fewer opportunities for on-the-job training with effective mentors. I have also spent many years leading courses and seminars designed to teach the basics of leadership to physicians and have incorporated many of the things I have learned from doing so in these articles. But leadership is not a skill obtained in a vacuum—it always occurs in a specific organizational context. Consequently, I have also tried to distill insights into the increasingly bureaucratic large organizations within which physicians now practice to help guide their education. Finally, no organization exists in a vacuum. Trends in medical practice, changes in the way health care is financed and organized impact everyone, so physicians must stay abreast of these changes. I contend the central challenge in the practice of medicine today is keeping an eye on the patient’s needs. It may seem obvious, but the competing priorities of different organizations and the influence of money makes it very hard to keep patients at the center of any organization. Frontline clinicians must do so if organizations are to succeed. Some organizations recognize their issues, but it can be helpful to bring in an outsider to say the things that need to be said. After all, the consultant goes home and does not have to live in the daily politics of the organization. If that is your situation, I am available for talks, seminars, and individual coaching for physicians attempting to provide clinical leadership in their organizations. Contact me and we can discuss your needs. Other organizations are not sure of their issues, so it can be helpful to bring in an outsider to establish a “diagnosis” and recommend various treatment options. Just like in clinical medicine, though, it is up to the patient to accept the diagnosis and follow through on the treatment plan. If this is your situation, contact me and we can discuss your needs. Even if you don’t need a consultation, I hope you find the articles on this website informative, provocative and helpful as you think about how you can help your organization provide high-quality medical care in today’s complicated environment. You can sign up for email notification when new articles are posted or follow me on LinkedIn or Facebook and receive notification that way. It is only together that we can improve the care of our patients, so learning how to work together in our organizations is truly a matter of life or death. |
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May 12, 2025 On the Social Contract, Part 1 Critics of Big Medicine cite mortality statistics where the US is worse than most other advanced countries. We often blame diseases of despair, but a recent retrospective analysis shows survival in the richest US quartile is about the same as the poorest Northern and Western European quartile. February 3, 2025 Seasons Seasons are a part of life and we seem to be in both astronomical and sociological winter, so we should expect hazardous driving conditions in both areas. December 16, 2024 War Stories Research shows children who grow up hearing stories about their family are more resilient. Would promoting telling of "war stories" among physicians have a similar effect?" September 22, 2024 Humility A new paper found literature supporting a pivotal role for physician humility in five domains: learning and professional growth, preventing and managing error, tolerating uncertainty, trust, and teamwork and communication. Three other studies from the same journal show how this might work in practice. July 25, 2024 Bandwidth Bandwidth, the mental and emotional capacity to handle information flow, is routinely ignored in healthcare. We need to rethink when, and for what, we really need the overloaded clinician's attention. April 16, 2024 Reducing Hospitalizations A recent report by Vazquez and associates failed to show an impact of two population health processes on hospitalization rates at one year. What can we learn from this study. January 23, 2024 Fighting the Last War When I was in the Army, one criticism was we were always training to fight the last war, not the next. Ironically, the Army has an entire system designed to study and evolve tactics as dictated by combat experience anywhere in the world, but health care organizations do not. What might we learn from our current situation in health care? December 9, 2023 Redesigning Medical Care in Hospitals Implementing changes designed to improve teamwork are hard and resource-intensive, and may not be as complete as desired. Supporting the effort must be, and must be seen to be, a top priority in these difficult financial times or staffing problems will get worse. November 9, 2023 Primary Care Like Mom and apple pie, primary care medicine is more honored in principle than in practice. September 19, 2023 Disruptive Innovation Paying for value does not seem to be working and making the patient the center of the enterprise seems unlikely to outrank minding the money. Anyone have another idea? July 16, 2023 Is My Hospital Going Broke? I was visiting with a friend the other day who said “60% of hospitals in this country are losing money.” I decided to see if I could find some of the data underlying his statement. May 17, 2023 Replacement Theory AI is not going to replace medical clinicians, but used properly, it can free them to do the tasks only people can do. April 7, 2023 Measuring Social Determinants of Health We can define poverty and discrimination in medical terms and in terms of impact on individual health, but does it help or distract from our historic task of trying to improve physical and mental health in ill or injured patients? I don’t know, but I fear it only serves to make a difficult task impossible. Eye of the Tiger KKR has described structural workforce changes that bode ill for health care organizations. If the challenges are not viewed with the "eye of the tiger," organizations are likely to be eaten by that tiger. January 24, 2023 High-Cost High-Need Patients A small number of patients use a disproportionate share of medical resources—the high-need, high-cost patient. If you can identify such patients prospectively, care management resources might be deployed cost-effectively, as most studies of care management methods yield disappointing results. Can this approach work? January 9, 2023 A Way Forward on Public Safety? Recently, a group of thought-leaders in the field of patient safety have considered the rather alarming slippage in patient safety results related, in part, to the pandemic stress test. November 29, 2022 The Costs of Leadership Part 2 I wonder if the excessive reliance on metrics is so leaders can say the “numbers made me do it.” Is this just a modern, secular version of “the devil made me do it?” November 7, 2022 The Costs of Leadership It is tempting to assume that the “younger” generations are unduly cynical, conditioned as they are by advertising and social media, but staff in all organizations have a “B. S. meter,” and it is usually both sensitive and specific. October 18, 2022 The Future of Health Insurance The impact of U. S. Supreme Court decisions on healthcare has rightly focused on the reversal of Roe v. Wade, but another decision may be an omen of future developments. September 13, 2022 The Doctor Patient Relationship 2022 Today in the United States, the physician—patient relationship may be more fraught than ever, challenged as it is by greater emphasis on patient autonomy in the context of widespread misinformation and by external forces, constraints, and incentives not aimed at patient benefit. August 16, 2022 Advisory Report on Burnout, part 2 We are in a time of “bowling alone,” “working from home,” and other trends that result in a general stretching of the social bonds that hold our communities together. This means organizations must be intentional about creating healthy communities within the walls if they want to create healthy communities outside the walls. July 26, 2022 Advisory Report on Burnout, part 1 Health care worker burnout has become so prevalent, the US Surgeon General has issued an Advisory Report on immediate steps needed. July 7, 2022 The Repair Shop Sinsky and Panzer argue for rebalancing medical practice between solution shop (repair shop) work and production work. June 18, 2022 Repeating Arguments Does Not Make Them Sound When it comes to saving money in the care of end-stage kidney disease patients there are a number of oft-repeated statements that may not be true. This will nullify CMS's goal for 80% of new starts to be either at home or transplanted. May 23, 2022 Clinical Reasoning A new computer program has been developed to help trainees learn clinical reasoning, but the challenges remain large. April 20, 2022 Linking Guidelines and Process Improvement I fear working on the difficult issues of improving health care delivery and linking guidelines and process improvement won’t stop us from ramming the iceberg created by current economic realities of high inflation, low unemployment, wage growth, lack of qualified applicants for positions requiring credentials, and pent-up patient demand that was deferred by the pandemic. March 28,2022 Understanding the Patient Experience Perhaps it is the ability to see an individual, not a group that counts. March 13, 2022 Balancing Money and Mission The expose in USA TODAY March 11th of the excess COVID 19 mortality in Trilogy nursing homes is yet another example of the need to address the imbalance between money and mission in healthcare. February 24, 2022 Ensuring Resilience Unintentional injuries during hospitalization have reverted during the pandemic to levels not seen in years. Authors from CMS and CDC opine about what should be done about it. January 30, 2022 Staff Shortages When there is no room at the inn due to staff shortages, the standard of practice will have to change. We need to think about what this might mean. January 17, 2022 More Encouraging News Are we on the verge of Clinical Guidelines 2.0? January 4, 2022 Encouraging Signs How do we deal with the shortcomings of industrial medicine? December 15, 2021 Value-Based Dialysis Care A recent flurry of reports describe real-world results of the paying for value trend. What conclusions can be drawn? December 1, 2021 Continuity and Fragmentation in Health Care Dr. Linda Rourke has written a thoughtful piece about the challenge of maintaining continuity in patient care November 9, 2021 Addressing Health Care Culture A contrary view of the culture changes needed in healthcare. October 25, 2021 The Profit Motive The American College of Physicians has published a new position paper on financial profit in health care. October 11, 2021 CQI - The Good, the Bad, and the Ugly Are the uses and misuses of the continuous quality improvement method emblematic of our times? September 21, 2021 Staff Shortages and Health Care Reform Persistent staff shortages may force care re-design in ways healthcare organizations have previously resisted. September 8, 2021 Pandemic Psychology The psychological stress test posed by the pandemic has ramifications for the future of population health efforts. August 23, 2021 Update on Value Based Purchasing Three articles this week provide a useful update on value based purchasing. August 10, 2021 More on Variation - Part 2 Malpractice and restriction of hospital privileges represent extreme variation, but remain thorny problems. Jul;y 25, 2021 More on Variation - Part 1 Variation is not peculiar to healthcare, but is a general issue with the way the people think, and occurs whenever judgment is needed and the data are fuzzy. July 13, 2021 Adding Versus Subtracting A recent study suggests people favor additive rather than subtractive solutions to problems. June 28, 2021 Social Determinants of Health Social determinants of health trump many medical therapies, but can changes be made that result in better health? June 12, 2021 Getting Excited Watching people think constructively is exciting, but rare. May 28, 2021 Paying for What We Don't Want Do you believe the proverb "you get what you pay for"? What if you pay for what you don't want? May 17, 2021 How Did We Get Here? How did the health care payment system become such a mess? May 3, 2021 Individual and Organizational Stress During the Pandemic April 20, 2021 The Stress Continuum The stress continuum was developed by the military, but is applicable to all healthcare organizations. April 6, 2021 Post-Pandemic Leadership Challenges I see four lessons and challenges for medical leaders post-pandemic. March 22, 2021 Déjà vu All Over Again Yogi Berra reportedly said "It seems like déjà vu all over again," which is apt for describing private equity investment in medical practices. March 9, 2021 Another Case Study An effort to redefine corporate purpose offers a parallel to efforts to reform healthcare. February 24, 2021 Vaccine Hesitancy Vaccine hesitancy is a case study with implications for what we can expect from current efforts to create "good healthcare". February 9, 2021 Swimming Upstream Our current cultural norms make following traditional medical advice, like eating less and exercising more, difficult for most people to do. Improving health may have more to do with modifying these forces, which is beyond the competence of health care providers and organizations. January 25, 2021 Numbers Numbers are everywhere, but we need to be conscious of both the uses and the abuses of them. January 13, 2021 Cathedral Thinking What lessons does building cathedrals have for healthcare reform? December 28, 2020 Optimism or Hope "Hope is optimism with a plan." December 10, 2020 Reliability or Dependability Is reliability too narrow a goal? Shouldn't we strive to be dependable, with its connotation of both reliability and trustworthiness? November 22, 2020 Individual Resilience Fear is a normal response to threat, but how do some people develop resilience in the face of it? November 9, 2020 Managers or Operators Physicians often blame the "suits" for their problems. Maybe medical organizations need more operators and fewer managers. October 26, 2020 Standardization Versus Innovation Two recent articles present starkly different approaches for healthcare organizations dealing with the stresses of the pandemic and healthcare reform. October 13, 2020 Fusion Cells Fusion cells aren't a new form of fuel, but a method designed to break down institutional rigidity. September 28, 2020 Physician Leadership 2020 Lee and Cosgrove identify six challenges in the decade ahead for physician leaders, but many organizations currently lack meaningful physician participation. September 16, 2020 Necessary Conversations Conversation is an essential step if we are to overcome the problems with our current dysfunctional health care system. August 30, 2020 Quality Improvement 3.0 Is it time for clinical quality improvement 3.0? August 18, 2020 Agility "Agile managment" is a business term akin to what I have called resilience. Are we at the point of a conversion experience? August 4, 2020 Strategic Questions for Physicians Part 2 Specialist physicians also face strategic choices and no matte which is made, the future will bring major changes. July 20, 2020 Strategic Questions for Physicians Part 1 Several trends are making it imperative for physicians to re-examine their idea of what effective practice of medicine entails. July 6, 2020 Answering Strategic Questions Part 2 What happens if hospitals think of themselves as cost centers, not revenue centers? June 22, 2020 Answering Strategic Questions Answering strategic questions is hard work and also uncertain, but these are not reasons to avoid asking them. June 7, 2020 Uncertainty “It is time…to realize that changes in culture, investment, leadership, and even the distribution of power are more important for progress toward the Triple Aim than measurement, alone, ever was or ever will be.” May 26, 2020 Risk As Michael Tackett put it, we are experiencing a historic referendum on risk. How should we think about it? May 12, 2020 Concordat The pandemic is a time of disruption. Can it be chance to "push the reset button? April 29, 2020 History Lessons If the public response to an epidemic is a play in three parts, we are currently in Act 2 and Act 3. April 13, 2020 Spending Wisely Are we spending our health care dollars wisely? March 30, 2020 Crisis To paraphrase Donald Rumsfeld, you fight coronavirus with the healthcare system you have, not the one you might wish you had. March 10, 2020 Rushing to a Solution? Does our rush to solve organizational problems make them worse? February 26, 2020 Care Management Transitional care management seems likely to be good for patients, but costly to hospital-based organizations. A recent study illuminates the challenge. February 5, 2020 Asking the Right Questions Solutions for problems in health care abound, but are we asking the right questions? January 21, 2020 "Hotspotting" "Hotspotting" is a new term for an old idea, but it usually means identifying and intervening on patients who are, or at risk for becoming, superutilizers. But are we asking the right questions? January 7, 2020 System Failure Medicine has adopted the language of manufacturing with terms such as efficiency, reliability, and “lean processes.” An unintended consequence may be increased risk of system failure. December 16, 2019 The Doctor-Patient Relationship The doctor-patient relationship is central, but is threatened by excessive focus on productivity. But is the productivity-driven payment system corrupt? December 3, 2019 Virtual Integration Platforming is a new buzzword for an old idea--successful organizations put the customer at the center of the business. What does that mean for healthcare organizations? November 18, 2019 Getting the Tempo Right Effective doctor and patient communication requires getting the tempo of the conversation right, not speed, but the current production system makes this a rare event. November 5, 2019 Experimentation Experimentation may seem risky, but is essential for progress. How do we do it safely in challenging times? October 23, 2019 More on the Quality Paradox The quality paradox is the number may improve while the experience of care worsens. What's new? October 8, 2019 Playing it Safe? Many health care organizations have become frightened—so much change is being forced upon them it seems insane to voluntarily try something different. But what it it is essential? September 18, 2019 The Work-Around A work-around get past a problem with addressing either the root cause or a solution. Health care abounds with work-arounds. September 3, 2019 More on Money in Healthcare Hospitals account for the largest fraction of the healthcare dollar, but are usually hegemonic if not monopolies in their communities. Can Trustees call them back to their mission of patient care? |