A call to arms: on the need for clinical leadership

Holding the key

By Richard F. Belloff, D.B.A., FACHE, PAHM, and Pamela Raye Bostwick, M.S.O.D.


A just machine to make big decisions
Programmed by fellows with compassion and vision
We’ll be clean when their work is done
We’ll be eternally free yes and eternally young.
“I.G.Y. (What a Beautiful World),” 1982, by Donald Fagen

Life in the U.S. health care sector has never been dull, but the pace of change in the years since the passage of the Affordable Care Act (ACA) has been frenetic. Major changes seem to come monthly, under an umbrella of impressive sounding names like:

  • Accountable Care Organizations (ACO)
  • Medical home
  • Population health management
  • Electronic medical records
  • Big data
  • Value-based purchasing
  • “The triple aim”
  • Bundled payments
  • Pay for performance
  • Capitation
  • Health care system transformation

This list could be longer, but you get the picture. At the core of these initiatives is the promise that health care providers will “put the patient first” and that the marriage of science, technology, systems thinking and, most of all, big data will produce a health care system with better medical outcomes, greater patient satisfaction and, of course, lower costs.

An interesting notion for sure, and who could possibly be against such an inspiring future?

The march of science and technology does not imply growing complexity in the lives of most people. It often means the opposite.
— Thomas Sowell, Hoover Institution

Not to be outright cynics, we urge cautious optimism. It just might be (or is likely) that the rhetoric of health care reform has gotten just a bit ahead of the reality. There is an old adage in business that suggests that one should “under-promise and over-deliver.”

We suggest that this is sound advice.

It is noteworthy that the impetus and design of these revolutionary programs are, for the most part, not a product of the physician/clinical community. Indeed, until the passage of the ACA, the average clinician would have been hard-pressed to define any of the programs from the list above.

Pay no attention to the man behind the curtain!
— The Wonderful Wizard of Oz, Frank Baum, 1903

So if these programs were not developed by your family physician, where exactly did they come from? The cast of characters include (Tillman, 2015):

  • Academia
  • Health care policy analysts/think tanks
  • The health insurance industry
  • The health care consulting industry
  • The health care information technology industry
  • The Department of Health and Human Services (Centers for Medicaid and Medicare Studies)

An impressive list, wouldn’t you say?

Now, you might ask why this is concerning. The professions listed are filled with some of the brightest minds available, motivated solely by a concern for the patient’s welfare. Surely they would never place their interests above that of the patient.

For the reasonable person, the nagging seeds of doubt remain. What other interests might be at play here, and why were practicing clinicians such a minor part of the brain trust?

We will leave you to speculate at your leisure. It could well be that clinical concerns, i.e., the relationship between physician and patient, was simply not that important in the overall scheme of health care reform.

Is the doctor-patient relationship dead?

A 2013 study published in the Journal of General Internal Medicine showed that interns spend 40 percent of their time at the computer and only 12 percent involved in direct patient care. (Siegal, 2015)

If you have been to your physician lately, you may have felt that the building was a bit crowded. At the front desk are any number of clerks shuffling forms, checking insurance cards and getting patient signatures.

Eventually, the CMA with no name (nurses apparently don’t work in physician offices anymore) walks you back, takes your vitals and asks you why you are here. He/she leaves the exam room, and you wait for the physician to arrive. When she does, she is carrying her laptop computer so that she can type into the office’s electronic medical record (EMR) system. The office visit goes by in a flash (18-20 minutes on average) with perhaps five to 10 minutes of real honest-to-goodness eye contact and undivided physician attention (National Ambulatory Medical Care Survey, 2010).

You may leave with a prescription, but alas, no piece of paper in hand. Your prescription has already been forwarded to the local Walgreens computer system. Then, there is the office visit co-pay to pay on the way out.

This, my dear patient, is the systems technologist dream office visit. In case you didn’t notice, there were others in the office with you (virtually) the whole time. These interlopers included:

  • the EMR and its users
  • the insurance company through its claims systems
  • the physician’s employer (most likely) though the EMR and the billing system (today’s employed physician has volume quotas to achieve and incentive pay that is at risk)
  • your pharmacy through its own computer system

With all of these fine folks “helping” the physician attend to your medical needs, today’s physicians must be a happy lot indeed!  Well, perhaps not.

In 1973, 85 percent of physicians had no doubts as to their career choice. In a 2008 survey of 12,000 doctors, just 6 percent of respondents reported having a positive morale. (Siegel, 2015)

A more recent survey of 8,000 physicians found that more than 77 percent were pessimistic or very pessimistic about the future of their profession. Fully 58.9 percent would not recommend a career in medicine to their children or other young people (Merritt Hawkins, 2012).

One might think that today’s patients want more technology and systems processes. After all, we have become a technological society, right? Interestingly, this is not the case (Stone, 2003). Instead, patients want a physician who:

  • makes eye contact
  • considers them a partner in the decision-making process
  • communicates well
  • doesn’t rush them through the office visit

Lead me, follow me or get out of my way.
— General George S. Patton Jr.

Finally, we come to the heart of the matter. The U.S. health care system is undergoing the greatest changes since the passage of the Medicare and Medicaid programs. This change is being led not by caregivers but by regulators, consultants and policy experts. Clinicians and their patients seem to have no role in this future save to be compliant, obedient and quiet.

A Chinese proverb suggests that “if we do not change our direction, we are likely to end up where we are headed.” This change of direction must be led by clinicians, the only individuals who have the requisite skills and who are fundamentally charged with the patients’ welfare.

I will be mindful always of my great responsibility to preserve the health and the life of my patients, to retain their confidence and respect both as
a physician and a friend who will guard their secrets with scrupulous honor and fidelity… (Osteopathic Oath, 1954)

You are the only true patient advocates left who can generate the conversation needed to change direction. To do this, you must grab the reins of leadership and begin to effect real and lasting change.

How can this be done? Well, the road to success is paved with knowledge. In this case, clinicians must begin by mastering the language and knowledge of leadership. You must understand how policymakers, bureaucrats and technologists think, their reasoning and their view of the world.

Then, in language they understand, you can begin to push back in the areas where clinician and patient welfare are being sacrificed for the sake of lesser considerations.

This will be a very long and involved process with no guaranteed outcome. However, if you don’t choose to act, who will?

Richard Belloff is an assistant professor in DMU’s master of health care administration program.
Pamela Raye Bostwick has a master’s degree in organizational development and is a former health care human resources professional. She currently conducts research in the health care administration field.


References

Tillman, K. (2015): Building the Infrastructure of the Affordable Care Act: Hillary Clinton, UnitedHealth Group/Optum, and the Center for American Progress, Journal of American Physicians and Surgeons, 20(4), 110-115.

Siegel, M. (2015): The Slow, Painful Death of the Doctor-Patient Relationship, Observer Opinion. Retrieved from http://observer.com/2015/07/the-slow-painful-death-of-the-doctor-painter-relationship/

National Ambulatory Medical Care Survey (2010): Time spent with physician (Table 27). Retrieved from www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

Merritt Hawkins (2012): A Survey of America’s Physicians: Practice Plans and Perspectives. Retrieved from www.merritthawkins.com/compensation-surveys.aspx

Stone, M. (2003): What Patients Want from Their Doctors. British Medical Journal, 326(7402): 1294. Retrieved from www.ncbi.nih.gov/pmc/articles/PMC1126182/

Richard Belloff, D.B.A., FACHE, PAHM

Richard Belloff is an assistant professor in DMU’s master of health care administration program.

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