Would a Hippocratic Oath for health care executives make a difference? Probably not. Nonetheless, there is ample evidence that the organizational cultures of too many hospitals are not conducive to physician well-being.
In a provocative blog posted on May 2, 2019, emergency medicine physician Mark Borden indicated a Hippocratic Oath was urgently needed for administrators.
Dr. Borden wrote: “Physician employment was, and is, obviously an intrinsically flawed structure that was considered absolutely unacceptable for obvious reasons for the entire history of medical practice!” Later he stated, “We have been rendered impotent and stripped of the prestige that a ‘higher calling than profit’ previously conferred upon us.”
Echoing Dr. Borden’s concerns, psychologist Jodie Eckleberry-Hunt posted an August 19, 2019 blog saying physicians “have been stripped of decision-making duties, relegated to worker bee status on the production line. The System dictates schedules, workloads, and access.” Subsequently, she indicated, “The System is a taker and is holding physicians hostage.”
Pediatrician Christina Dewey likewise condemned the “system” and particularly railed against administrators “dictating how and what we physicians may or may not do within a hospital system — all in the name of cutting costs, often to the detriment of our patients. We now spend more time worrying about how many patients we need to see in designated time slots, checking boxes, running behind, doing never-ending non-physician required tasks than we do on patient outcomes…”
Dave Chokshi, MD, Chief Population Health Officer at NYC Health + Hospitals, the largest public health care system in the U.S., and Stephen Swensen, MD, Professor Emeritus at the Mayo Clinic College of Medicine and Senior Fellow at the Institute for Healthcare Improvement, reported the August 8, 2019 findings of a leadership survey by the NEJM Catalyst Insights Council.
- They noted clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet respondents to the survey indicated nearly half of health care organizations (47%) are not very effective or not at all effective at clinician engagement.
- This same survey documented the disparate views of clinicians and executives. Far more executives (55%) than clinicians (26%) said their organization had a formal strategy for clinician engagement – a disturbing and revealing dissonance.
- Dr. Chokshi acknowledged that “many clinicians are suffering from professional distress and organizational distrust.”
- Dr. Swensen stated, “Allowing clinicians to be disengaged with the organization is the opposite of the Triple Aim. You wind up with poor patient experience, higher costs, and worsening outcomes.”
Respondents to the survey were asked to offer their responses to the question: “What are the biggest contributors leading to disengaged clinicians?” Five representative replies are particularly informative.
1. “EHR inefficiencies, regulatory compliance burden, time-based work restrictions causing a mad dash to finish tasks regardless of patient needs, bureaucratic barriers to providing care, reimbursement denials that generate more clerical burden, focus on revenue over patient and provider satisfaction.”
2. “Feeling of insignificance. No feedback. No recognition of good work.”
3. “Burnout, administrative burden, loss of autonomy, and failure of leadership at the highest level to promote a culture of caring, respect, and inclusiveness.”
4. “Respecting time (weekends, holidays, meeting times). Choosing things that affect every clinician, not just the ones bringing in the highest revenue. Resources (e.g., social workers, nutritionists, psychologists) to help us help our patients in the ambulatory practice, not just inpatient. Truly including clinicians in the field, not just administration, in decision-making.”
5. “Inviting them to the table and then not listening or offering them the opportunity to contribute.”
These survey results clearly demonstrate that a sizable divide still exists in some institutions between administrators and clinicians.
Daniel Marchalik, MD, Medical Director of Physician Wellbeing at MedStar Health, made the astute observation in the March 2, 2019 issue of The Lancet that “A successful approach to addressing burnout must be preemptive — a mindful modernization that considers the well-being implications of technological, economic, and administrative changes before they are implemented.”
On July 31, 2019, the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience released case studies on initiatives that reduce clinician burnout and support clinician well-being at organizations across the country. “Although there is no one-size-fits-all solution for clinician well-being, techniques and resources described in the case studies may provide a useful starting point for other groups,” the Collaborative said. Earlier in the year, the American Hospital Association, which is a sponsoring member of the Collaborative, produced a playbook to help hospital and health system leaders address burnout in their organizations.
We don’t have a reliable barometer to measure the validity of Dr. Borden’s rationale for advocating the development of a Hippocratic Oath for executives, but administrators who disregard the serious concerns underlying his admonition do so at their peril. Developing a Hippocratic Oath for them would not make difference. Instead, the American College of Healthcare Executives (ACHE) must continue to regularly review its Code of Ethics, ethics self-assessment tool, and numerous ethical policy statements.
In addition, the ACHE must remain dedicated to providing leadership and educational resources to enhance the ability of its 48,000 affiliates to recognize and address the legitimate expectations of clinicians who have every reason to presume they will be working within a supportive organizational culture — one which demonstrates daily an unassailable commitment to truly caring for staff, not just patients and their families. By empathizing with physicians and accelerating the adoption of evidence-based best management practices, executives should take action to make sure these expectations are met much more consistently.
Paul B. Hofmann is president, Hofmann Healthcare Group.
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