Why physicians are susceptible to hardball tactics

I was invited to a medical staff leadership conference sponsored by our hospital. A company specializing in training physician leaders ran the meeting. The topic was healthcare reform and its effect on hospitals and physicians. Included were discussions on patient-centered medical homes, accountable care organizations, bundled payments and physician integration and alignment with hospitals.

The course director made it crystal clear that there will be no place in the future for physicians who do not buy-in to the idea of population-centered, cost-effective medical care. Physician leaders will take corrective action to eliminate dissident physicians from the medical staff.

One of the cases we discussed was this (my abstraction):

“A hospital has a orthopedic-neurosurgery spine service line, headed by a physician-manager dyad and having a steering committee composed of physicians and managers. Several neurosurgeons want to do minimally invasive surgery while the orthopedists want to do surgery the old way. The orthopedists said there was not enough evidence to warrant change. Hospital administrators want minimally invasive procedures because these surgeries use less expensive hardware and have higher margins. One orthopedic surgeon, employed by the hospital, and who has a long history of disruptive behavior, refused to attend meetings where the issue is being discussed.”

We were asked to draw an organization chart, indicate who was accountable for what, suggest a plan of action regarding the surgeon’s continuing disruptive behavior, and recommend another plan if the orthopedic surgeons continue to perform the higher cost procedure.

I doubt that anyone else at the meeting had my perspective on this case, as I have been brought up 3 times for disruptive behavior, nearly a 4th. A psychiatrist, who I had thought was a friend, was at each meeting. At the last meeting, he ventured I had a psychiatric diagnosis where I liked being brought up for disruptive behavior. And I’m at a top 100 hospital.

With that background, here’s my analysis: (1) “Disruptive” is vague and could cover a variety of actions. It could mean abusing nurses. Christensen thinks disruption is a good thing. He uses the term to describe innovation that improves efficiency or lowers costs. The term “disruptive” is recommended by law firms popular with hospitals, which is why it is used. (2) We are not given any information about the surgeon’s prior disruptive behavior. It may or may not be relevant. (3) Medical staff disciplinary procedures do not provide due process protection, but I still think we have to assume that the surgeon is innocent until proven guilty. (4) There’s conflict between hospital administration and the orthopedic surgeons. It’s possible that the charges of disruptive behavior reflect an ongoing management campaign to bully the orthopedic surgeons, the employed one in particular. (5) We don’t have enough information about the surgeries to make an intelligent comparison. The only data that’s presented is financial and that’s not enough.

The point of the meeting was that hospitals need to control physicians’ decisions. The problem for physicians is that they have no Plan B if they can’t be a doctor. They are locked-in to their profession and therefore susceptible to hardball tactics. Physician leaders will use the medical staff disciplinary process to prosecute charges of disruptive behavior (and do sham peer review as well). They only need 1 or 2 successes to get staff physicians to cooperate with management recommendations for change.

This is not my idea of leadership.

Bradley Evans is a neurologist. 

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  • athelas314

    You’re right, “disruptive” is a useful weasel word.  ”Professionalism” is another one.  I’ve heard the word slung around 20 years now.  It means exactly what those in power want it to mean, nothing more, nothing less.

    • http://www.facebook.com/people/Karl-Hafner/100001398635141 Karl Hafner

       unfortunately experience has taught that anyone no matter where if you do not agree with the majority will be considered disruptive.  We only need to look in our own history books.  How did hand washing come about? Most truly new ideas are considered disruptive. 

  • Sophie Zhou

    Pressuring a physician – a trained professional whose decisions are based on health – to follow the directives of a hospital with an economic mission is disrespectful and dangerous. A poor working environment will only push talented individuals away.

    - alittlehappi.blogspot.com

    • Bradley Evans

       It’s not just hospitals. It’s insurance companies, governments, pharmaceutical companies. They see that controlling the pen that writes the prescriptions can provide great economic benefits.

    • buzzkillersmith

      These folks don’t want talented individuals. That’s the last thing they want.  That’s kind of the whole point, Sophie. They want providers they can control, so long as those providers are not so incompetent as to attract multiple malpractice suits.  

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This is why, folks should stop selling their practices to hospitals. The only hope to balance what’s coming is to maintain viable and sustainable independent practice. It’s imperative for both physicians and patients alike.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      Hospitals can charge more for the same service. My primary care practice, if hospital-owned, ends up adding on facility fees that outweigh the reduced physician reimbursement, adds bloat, and the cost of medical care is that much higher.

      Contrary to the blather you hear about more efficient practice in large organizations, in reality they are less efficient. They prosper because they are able to extract higher payment from government and insurance.

      Then they impose noncompetes on individual physicians……..contract clauses that would be void and unethical in law firms, everywhere in the country……so if a physician leaves that organization, the doc has to leave the area.

  • buzzkillersmith

    A lot of docs are stuck between a rock and a hard place.  It’s easy to say, “Don’t sell your practice,” and that’s certainly great advice if you’re in ophtho or derm, but in family medicine you often have a choice between selling your practice to a larger entity or closing up and moving on down the road.  Moving the kids out of their home town.  Taking the wife away from her friends and family.  It’s not that fun or that easy.
    This situation is not our fault.  It is the economic circumstances, created by this society, that we find ourselves in. 
    Most of us would love to work in a thriving single-specialty group practice with other family docs, without the need to kowtow to MBAs with dollar signs in their eyes and no knowledge of or interest in how medical care should  be  delivered.  Maybe the direct primary care model is the future. Things have gotten desperate.  I think the PCMH is self-delusion on the part of PCPs and will be an economic and lifestyle boondoggle (and the early research seems to suggests as much), and accountable care organizations are yet another idiot idea that has now morphed into a scam by hospitals hoping to enserf us. 
    The players here want us as sheep in the pen.  What they might get instead in primary care medicine without the medicos.

  • CorpAvenger

    To start with I just want to say that I whole heartedly agree with the basic facts and sentiment being conveyed here and that large organization like primary care, with more layers and more staff still attempting to divide the patient up is insane. So is this concept that some have bought into of allowing the Insurance Carriers whose really one and only job is to Assume the Risk in exchange for a specific fee, should be allowed to ever “Cost Shift” that risk and expenses upon the providers of the care that are supposed to get paid appropriately for their knoweldge, training and hard work, investigative work…. Cognitive Medicine which is WAY under valued by all of the Stakeholders and Powers that Be…. Gov’t, Insurance, AMA & RUC, Hospitals and the like.

    The real way to solve this mess is to allow doctors PCP’s to scatter back out into small private practices where they can be paid and compensated much better, Fairly for the Great Understanding and Mangment of the entire patient who hoppefully they can provide more care for instead of farmed out to this great new System which only serves to divide the patient up more and more, and still Nobody has a real personal human relationship with that patient, who is a real person and human being… And will usually respond best to someone who they feel cares about them, knows them personally and that the patient feels some human skin in the game, disappointing their nice caring hard working doctor if they don’t try to comply by taking somewhat better care of themselves…. Like Daaaahhhh.

    BTW, one of the best ways to try to fight this behavior is to have more Americans in all walks of life learn about the specific kind of “Bullying” that this kind of controlling behavior is…. And the need to control and manipulate can come from many origins, in this example, some new power broker whose agenda is to force a new poor model of care upon the employees mainly to prove their own worth and advance their own careers as much as many of them claim to have some positive motive at the helm of their behavoirs and goals….

    We call this organizational destruction of another human being, “Mobbing” and if you bother to google it and learn a bit more about it, there actually has been many years of Valid Social, Psychological research applied and brought to bare on this all too neglected and over looked topic. As you said many times the Victim is portrayed as the problem and blame is projected upon them, it is really a very facinating phenomona if it weren’t so gosh darn destructive and hurtful to both the victims and their organizations. And that of course if the long term hook to help sell this better understand with in the long term, that it is actually hurtful and harmful to the entire company, academic dept, college, hospital or dept. I have even seen and personally experienced in volunteer youth organizations such as many of the places I have coached or officiated at…  It’s all too real and all too pervassive….

    In part of Scandinavia and up in Canada there are actual workplace laws in place about Mobbing and Bullying and the result is much improved productivity, lower healthcare costs, better employee retention, and even at times properly punishing and weeding out the worst of humanity or getting them help to get them to stop engaging in this Traumatising, hurtful, destructive behaviors…. These Mobbing Bullies are very good at gaining and recruiting, misrepresenting and twisting things around… And in not much time, the person who has been targeted starts to behavior irradically, inappropriately, strangly, more defensive and hostile, and less cooperative… And understandably so too. Being open, guard down, cooperative and helpful has only helped to lead to their harm and trauma and so 1) they are wounded and acting from the place of that trauma with the symptoms of that collective trauma 2) they are learning from their experiences to keep their guard up and watch out because their workplace really is a dangerous place that protects and condones the harmful behaviors that they have been personally harmed with….

    It is high time that we here in America start to clean up our act in our schools, workplaces and the halls of academia (where at times mobbing is a practiced blood sport, much like the Hockey Organizations I have been at previously) and properly start to tag the bullies and harmful hurtful people who destroy others for their own gain or in protection of their own fraigile egos for what they really are…. Hurtful, harmful, traumatizing Mobbing Bullies, Abusers who either need to be given help, accept help and change or be shown the door for their truly destructive behaviors…. They are “Toxic” and their Toxicity can and does spread and make ill the entire organization and the people that they interact with.

  • Laurence J Sloss

    Unprofessional, disruptive, outlier, dinosaur, impaired, troubled…  managerial suitocracy bafflegab manipulated to smother individuality and dissent from the corporate value system of greed and power.  Bottom line: live in the system, conform, submit or be crushed (or maintain your own practice, serve your patients and community, uphold your oaths of service and integrity, be an example of excellence and hard work, and content yourself with the intrinsic rewards of a life of worth, and well lived)

  • SidewaysShrink

    I am refusing to go into a multi-specialty practice. I wasn’t “there” but I have read that this same thing happened in a lot of places with the advent of HMOs. Docs sold and joined because, as in the current environment, they felt the economic were too tight or too complex, but by the early 90′s (?) private practices were thriving again because patients and providers refused to play the insurance companies game of restricted access.
    My rates have been cut by 15% this year by 2 payers–1 of whom I am dropping. But I have too many loans to trust my ethics and income to a group practice’s administrative whims. Psychiatry is a throw away specialty in multi-specialty groups because the insurance reimbursement can be so poor. If your specialty is the same, that group will expect you to see patients with every kind of insurance and it will come out of your “productivity bonus”–well there won’t be one. Or the formulary will be so restrictive it will make you feel like you’re practicing medicine from when you were in elementary school–whatever that was like.

  • Suzannegordon

    My question in response to this story is ” what is the meaning of disruptive behavior?”  This term is often used euphemistically to discuss physicians who are abusive to nurses, physicianss-in-training, and lower level staff.  This behavior should be called what it is –”abusive” — and should not be tolerated.  In this case, both the hospital and Dr. Evans use the term with the same imprecision. In Dr. Evans’ story, the primary issue is one of dissent from a managerial decision.  But is that all there is to it?  What about the orthopedist’s “long history of disruptive behavior.?”  How can we evaluate this story if we do not understand what “the a long history of disruptive behavior means.”  Was it a long history of being rude, abusive, screaming, throwing tantrums, injuring someone?  Or was it a long history of dissenting from administrative decisions?  Similarly, how can we evaluate Dr. Evans’ own behavior– which is also labeled “disruptive,’ if we don’t know what it alludes to.  Did Dr. Evans scream at nurses, or did he dissent from a managerial decision?
    All the comments that follow seem to suggest that everyone responding to this story are doing so under the assumption that disruption now means dissent?  But is that the case?  Shouldn’t we find out before jumping to conclusions — which may be right or may be wrong?

  • http://twitter.com/gcgeraci Gaspere (Gus) Geraci

    You have to fight with data! Not going to the meeting doesn’t work. That’s removing your input and surrendering. New is not always better, but if it is, then you should get on board. But better needs to defined by clinicians, not just bean counters. There’s fault on both sides if you don’t go the meeting with data, and if administrators are allowed to use finances to define better. If the clinical outcomes are identical, then $$$ should be considered more strongly.