By Manoj Jain
Special to The Washington Post
Tuesday, September 16, 2008
From the patient's point of view, doctors and hospital officials can seem to be a monolithic medical power structure. But in fact, physicians and administrators often do not see eye to eye.
Take the case of the hospital in Tennessee where I work as a consulting physician. Over the past eight years, several small outlying hospitals have had no overnight on-call surgeon in their emergency departments, and they started funneling their patients -- some of whom were uninsured -- to us. Three or four years ago, the general surgeons began demanding payment for the extra on-call responsibility. The hospital refused: If general surgeons got on-call pay, the administrators said, next it would be the neurosurgeons, then the interventional cardiologists and so on.
It was a standoff. As time went by and resentment hardened, the frightening possibility arose that somebody would need an emergency appendectomy one night and no surgeon would arrive.
That never happened, but the dispute made one thing clear: The disagreement might be between the doctors and the hospital, but the party most at risk was the patient. In the ER and beyond, such conflicts can have a serious impact on quality of care.
Several sources of frustration underlie doctor-hospital disputes. One is financial: Many physicians, including myself, are earning less these days as a result of diminishing reimbursements from health insurers, more uninsured patients, the high cost of medical liability insurance and the rising costs of maintaining a private practice.
Administrators, meanwhile, face their own budgetary problems. Needing to keep the hospital solvent, they push doctors to be aware of cost when ordering tests and to reduce the length of hospital stays. Each extra day I keep a patient in the hospital costs the hospital $600, on average, but the hospital doesn't necessarily receive any extra money. Medicare and some private insurers pay a fixed price for a hospitalization for a particular diagnosis, while physicians receive a fee for each daily visit.
Another sore point is the challenge to a physician's traditional autonomy. In an attempt to measure the quality of care, for example, Medicare's Web site reveals the percentage of the time that doctors at a given hospital ordered the right antibiotics for a certain condition. The definition of the "right antibiotic" is derived from evidence-based guidelines, an approach some doctors describe as "cookbook medicine." As one doctor told me, "I know how to practice medicine, and I don't need some administrator telling me what to do."
Administrators point out that professional medical societies developed the guidelines, and the hospital is just implementing them. Meanwhile, they know that Medicare payments may soon be based on this kind of performance data. So administrators think that their hospital's financial stability, as well as its reputation, are at the mercy of individual doctors.
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."
Do conflicts between doctors and administrators harm patients? "Look at the epidemic of medical errors," Nash said without hesitation. "Cultural strife leads to errors, and the number of errors shows the size of the cultural rift." (The most commonly cited study of medical errors, done by the Institute of Medicine, says that they lead to as many as 98,000 deaths in hospitals a year.)
The balance of power between administrators and doctors partly depends on the number of doctors available. In rural areas, hospital administrators know that the hospital's very existence may depend on being able to recruit and retain physicians. Stones River Hospital in central Tennessee, which has 70 beds, was crippled when two of its five primary care physicians left in 2006 and 2007. The patient census dropped by 50 percent, and the hospital went into the red. Stones River has found one physician and is still urgently recruiting another.
In other settings, where doctors are plentiful, administrators are in more control. A few years ago, the management of a major Tennessee hospital planned to close a large campus; a key surgeon there told me he didn't learn about it until the decision was made. "As the president of medical staff, I was never consulted or informed, and I found out when everyone else did," he said. "That makes the medical staff disenfranchised and without influence."
In the case of the angry on-call surgeons at my hospital, the eventual resolution left a sour taste in a lot of mouths. The administration went to open bidding for the contract, and last year a practice across town was selected for on-call duty. The administrators described it as "fair competition." My colleagues, as one surgeon put it, felt "stabbed in the back." Trust and mutual respect were both lost.
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.
At Kaiser Permanente, senior fellow and physician Jay Crosson says the doctor-administrator conflict is addressed "through hundreds of committees and leadership councils that jointly manage the organization on a daily basis." He also points to alignment of mission and strategy as well as management training for physicians as factors that make a difference. But Kaiser is operating on a different model than most medical facilities: It owns many hospitals, and it pays doctors a salary.
Many hospitals, including my own, are seeking to eliminate conflicts by hiring or contracting with hospitalists, physicians who see patients only in the hospital setting. Today there are more than 20,000 hospitalists, compared with a few hundred a decade ago. Having a salaried staff of doctors gives administrators better control over physician quality measures and length of stay. This shifts more of the focus of private physicians to the outpatient setting. Unfortunately for the patient, this means two primary care doctors: one for when they are in the hospital, the other for the rest of the time.
Quick and easy solutions to conflicts may not be on the horizon. But they have to be reached, because doctors need hospitals and hospitals need doctors. And patients need both.
Manoj Jain is an infectious-disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:firstname.lastname@example.org.