I remember when I tried to make colon cancer, and really solid tumor screening, a major priority at my former academic institution a few years ago. I was tired of the broken system that was in place, the patients who were getting deferred care, and the failure of leadership on this issue. With my altruistic mentality, dogged stubbornness, and help from a few colleagues I thought I could overhaul the entire system.
I soon had a target on my back from innumerable employees of the institution, who were furious at me for ruffling proverbial feathers.
I eventually achieved some victories, but lost the overall mission. While I became dejected and jaded about the role and purpose of healthcare organizations, I received a real life MBA in power politics, leadership, how to communicate with non-clinicians, and how to (not) innovate. And that is almost as valuable.
In nearly every doctor's lounge in the country, physicians complain (often rightfully so) about how "they" don't get it - "they" being the army of administrators, consultants, patient experience managers, clinical directors, practice managers and more.
In this post, we will talk about this phenomenon and what can be done about it.
First, the scope of the problem. Since 1970, the number of physicians have increased 150% (though by some estimates, there is still a shortage). During that same time, the number of healthcare administrators increased 3200%
This means this problem, a function of our broken insurance based system, is not going away. We can complain all we want as physicians, but we need to find a way to collaborate effectively with administrators.
Next, understand that administrators have a fundamentally different worldview than clinicians. Working with them is predicated on understanding them. Much like the earlier post on the business v medical mindset, there is a similar corollary on the administrator v medical mindset.
Here are some of the key take-ways:
Guardians (aka Administrators)
- Administrators are top level, physicians are ground floor. This is not a reference to rank or hierarchy, but rather scope of practice and view. Physicians because they serve patients will immediately feel every nook and cranny of a clinic or healthcare organization because it is their day to day job. I remember once I get upset at the call center because I got too many referrals for large hiatal hernias into my general GI clinic. These are patients best seen by interventional endoscopy or surgery for reduction. Patients were upset at me for their three month wait time only to be told that I don't have much to offer them. I got upset and found some relevant administrators who not only not been aware of this brewing problem (in all medical specialties, not just mine) but had no clue what it meant. I realized this major patient routing problem was not even on the radar of administrators.
- Administrators have more diverse professional backgrounds. Doctors are fairly similar in their socialization, belief systems, and world-views, if only by dint of fairly uniform medical training. Coming up through the ranks allows us to innately understand one and another. Administrators, on the other hand, often come from a variety of professional training backgrounds - operations, sales, marketing, communications, legal, commerce and more. This means we as physicians cannot immediately assume we have a shared language of understanding of a situation. That can lead to creativity but also conflict.
- Physicians who are executives or administrators are a somewhat unique breed. However, they tend to become more admin like in their behavior and worldview than pure clinicians. The reality, and the overall message of this post, is that physicians and administrators respond to different incentives as part of their job requirements. The farther away someone is from the bedside and closer to the boardroom, expect their incentives and attendant behaviors to change correspondingly.
- Administrators see physicians as sources of patients. We may or may not be respected as professionals, but our primary value to healthcare administrators is in the clinical foot traffic - and the attendant money via insurance and Medicare - that we bring with us. The second that diminishes or there becomes a cheaper way to get that same revenue (AI, mid level practitioners etc), watch out if you're an MD or DO. More foot traffic we generate- especially with superstar physicians - the more leverage we have in a traditional medical system.
- Administrators have a top down approach. Physicians are generally more collaborative. There is a clear line of command in healthcare administrator because it mirrors the corporate world directly. Mandates, memos and metrics of evaluation are how that world operates. Physicians, once out of training, are largely deferential or collaborative with each other (at least publicly) because we all need each other as sources of referrals. Hence the letters we write to each other - "Dr. Smith, it was my esteem pleasure to see your patient Ms. Johnson in my clinic for congestive heart failure..." Administrators don't realize that a significant part of their clinical delivery apparatus, namely doctors, don't respond to mandates and don't like to see themselves as part of the "worker bee hive mind."
The metaphor I offer is that of the airline. Physicians are pilots and administrators are flight traffic controllers. Both are needed to collaborate effectively or customers don't get where they want to safely.
What is the biggest message I can write about this topic. The enemy is NOT them - either white coats or gray suits. It is the dysfunctional healthcare system we operate in.
Until physicians and administrators can fully develop their leadership, the system won't change.
And that is something we should all truly complain about.
