Assumptions

             I recently tripped over my assumptions. We often assume that those we talk with share our assumptions, even though we know that is rarely the case. The reason I bring this up, of course, is that many of you do share my assumptions, even if you do not draw the same conclusion from those assumptions that I do. Let me enumerate some of them for your consideration and future discussion.

                    First, I assume that people will want medical care for the foreseeable future. Second, I assume the way we get paid to provide that care will change, probably in important ways, in the near future. Third, I assume that fee for service practice is on life support and its survival is problematic. Fourth, I assume that if fee for service survives, the reimbursement rate per unit of service will go down. Fifth, I assume that all hospitals must learn to break even on the Medicare book of business to survive, and that means most of them must wring at  least 35%  out  of  their  current  COST  structure.  Sixth,  I  assume that  hospital administration cannot get a 35% reduction in real costs without real pain and without real changes in the way physicians practice medicine. Seventh, and last for this discussion, I assume that it is in the best interests of our community, including us, that we continue to have a vibrant, growing, high quality health care system.

                    These may not seem unreasonable assumptions to you, so why did I trip on them? Primarily, I forgot two things. First, the problems of today are easier to see and more certain than the problems of the future. This is why patients sometimes hesitate to take the risk of aggressive therapy for bad disease when they don’t feel like they are dying just now. Of course, by the time they realize they are dying, it is too late to make the change. Organizations and the people who work in them have the same problem. For patients and organizations alike, there is an optimum time to take drastic action, but timing is important. The second thing I forgot is that people and organizations both have histories that influence what seems proper.

                    At the risk of being improper again, let me suggest that our hospital culture defines proper as a strict separation of the medical and management spheres of concern and a strong preference for operating “behind the screen,” meaning that all public utterances are bland and uninformative.  Yet at the MEC meeting this month we had what diplomats would call “frank and candid” discussions about how to deal with meeting a Joint Commission requirement.   Management had considered this as in its responsibility, and set about to resolve the problem in its own way, perhaps without  realizing the negative downstream impact on patient care.  Now that we have had that “frank and candid” discussion, I suspect that the resolution of the problem will be different from the one first envisioned.  A lot of time and energy might have been saved if we had a new culture that saw that the previous paradigm of separate spheres and secrecy as obsolete.  What is needed now is transparency, cooperation, and lots more “frank and candid” discussion about our problems and what we need to do about fixing them.  Or at least that is my conclusion.  What do you think?

Written 16 September 2010. Updated 1 May 2014.

 Further Reading

Leadership Lessons From the Military
Lessons from leading the military in Afghanistan have implications for which medical organizations will thrive in the current turmoil.

Leadership Skills
A short presentation about medical leadership grafted onto a presentation.

New Leadership Skills for Physicians
David Brooks has identified highly valued skills in the modern world.  The good news is that physicians already use three of them.

Paradoxes for Physician Leadership
I started this website to share some notions about physician leadership. I have also reviewed many other people’s ideas about these subjects, some of which I have shared in other articles. What strikes me about much of the “literature” on physician leadership, though, is how they fail to grapple with the inherent paradoxes of the role of physician leader. Here are some that I think matter, with some links to other articles on this site, which develop the ideas in more detail.

The Case for Physician Leadership
Why the successful healthcare organization of the future must find a way to create physician leadership if it is to achieve the IHI Triple Aim.