Physician Leadership 2020
Lee and Cosgrove have outlined six areas in which physicians and their leaders will be tested in the coming decade. These core considerations are 1) putting patients first; 2) creating super-teams; 3) plunging into competition; 4) reducing costs; 5) embracing innovation; and 6) grasping the nature of leadership. Five of these six areas have been core areas I have focused upon in these articles—the exception being “competition.” While this may be a consideration in some large metropolitan areas, I suspect many areas are already at the point where there are only one or two providers, which is monopsony, not a competitive marketplace. Perhaps disruption will be provided by non-traditional providers, but there is some evidence that health care, like politics, is extremely local.
However, on the five areas where we agree our attention should be focused, I really want to ask the question “why is it the exception rather than the rule that physicians are involved in these areas already?” I do not intend for this to be a “blame game” nor do I want to suggest this is an issue that can be solved without cooperation from both physicians and management. Rather, I am operating from the perspective that medical organizations will not survive and meet their healthcare missions without both groups actively collaborating as a matter of routine. The pandemic has shown the groups can collaborate during an emergency—the challenge is to make this the “new normal.”
Based on experience in several different medical organizations and conversation with people in others, I suggest there are several challenges to overcome. First, physicians typically see the exceptions, where managers typically look for the rule. Said another way, physicians encounter patients one at a time where managers see them as a group. So, one of the first problems is to recognize this difference in orientation. As I see it, the goal is to decide how much “special cause variation,” to use the language of process control, should be built into the system. As I have said previously, patient-centered care means there must be more variation than medical science alone would predict. Given the lack of good evidence on appropriate variation, the answer should be local and negotiated, not dictated.
Second, physicians are accustomed to taking in “data,” although a lot of data is really just opinion, and making a decision quickly and alone, where managers tend to arrive at decisions slowly and more by consensus. Depending upon the problem being addressed, either style may be preferable, but recognizing the strengths and weaknesses of both approaches is paramount. Again, deciding which style should dominate requires a local decision on the nature of the problems—is it clinical and urgent, or is it managerial and such that delay will not aggravate the issues?
Third, both physicians and managers are subject to the “tyranny of busyness.” For physicians, the fee for service world rewards speed, so seeing a lot of patients is best financially, although not necessarily best for patients or quality outcomes. But managers can be dominated by the agenda for the next meeting in the effort to build consensus. Both need dedicated time to think, reflect, and converse. (And I suspect these conversations need to be in person, not by ZOOM.)
Fourth, and perhaps the most difficult, physicians need to link their individual and collective decisions about patient care to costs, while managers need to link their financial decisions to the impact on the care of individual patients. This is a glib formulation that hides a difficult reality—making good clinical decisions is hard work and time-consuming. So, if we need physicians to understand the financial implications of their decisions, they need good data. Simply saying “no” to ordering a test or procedure will reduce direct costs, but may well result in longer lengths of stay or worse outcomes. The more expensive antibiotic might often be the better choice both at the individual and at the organizational costs. Again, the financial decisions may not be evidence-based, but are being made anyway.
Early efforts to tackle this problem have been hampered by the lack of specificity in hospital cost-accounting systems and the difficulty in assessing the utility of clinical interventions, which always take place in multifactorial situations. I have seen both physicians and managers make glib assumptions about the “cost-effective” course of action, but rarely are there data to support any decision. The flip side of this dilemma, though, is to refuse to take action until good data arrive, which results in paralysis by analysis. Good data is a generational problem—we are going to have to change the assumption underlying most medical literature, which focuses on the scientific issues, and look instead at the global impact of the decision. The clinical utility of an intervention is important, but rarely studied, and the methods for studying it, such as “QALY” are currently at the policy level, not the patient level, of analysis.
For physicians, the primary challenge is to realize our current “pathway” for managing any given clinical problem is a complex combination of science, art, and habit. One physician myth is that these decisions are “evidence based.” Most aren’t. Just because we have always done it this way and our results have been acceptable does not mean we should dogmatically resist any effort to change the pathway as unwarranted interference that will “hurt the quality of care.” For managers, the challenge is to recognize that the current way of doing things is indeed complex and reflects a combination of science, art, and habit rather than physician obstreperousness. Thus, pathways needing change must have a compelling narrative behind them. The best, of course, is that current outcomes are below standard, so change is needed to catch up. The worst is that current processes are “too expensive.” Remember, both “too” and “expensive” represent value judgments. It may well be correct, but not self-evident, so the first step is always to get clinician backing.
So why do most organizations fail to get this level of cooperation and conversation? I suspect the real challenge is a mutual lack of trust. Physicians have been slow to recognize they need managers to keep the infrastructure intact and managers have been slow to recognize they need physicians to keep the business intact. Both sides have shown a strong preference for circling the wagons and hurling names at the other side, rather like our national political debates, instead of recognizing their mutual dependence. In today’s world, and in any reasonable future, medical organizations are going to need strong physician leaders and strong administrative leaders who can cooperate to solve patient problems and keep the organization solvent. My hope is the challenge of the pandemic will make it clear to both sides that this is the true state of affairs.
28 September 2020
 Lee TH, Cosgrove T. Six Tests for Physicians and Their Leaders for the Decade Ahead. NEJM Catalyst Innovation in Health Care Delivery 2020(4); doi.org/10.1056/CAT.19.1045.
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