Medical Unsustainability

I talked with a management team recently about the marital counseling that they asked me to do last year to keep their surgeons from fragmenting as the hospital negotiated insurance contracts.  In retrospect, problems began years before, when the hospital employed group members under a contract that measured and rewarded only individual productivity, to which I obtained the following response:

I don’t understand citizenship.  After all, why should we pay our docs to act like adults?

I empathized with the concern, which I have heard in many of the 42 states in which I have worked.  At the same time, I pointed out:

For the most part, doctors have done everything asked of them.  We studied hard in college to obtain admission to medical school, where we memorized and regurgitated facts on demand to become competititive for residency and then worked 100-hour weeks and did research on the side to be competitive for fellowship.  Those of us who trained in a previous century had no courses in communication, teamwork, win-win negotiation, or conflict management.  We learned informally from clinical role models, who also lacked formal training in these areas.  Hence the sins of one generation are visited upon the next.

As the authors of Crucial Confrontations wrote, the fundamental attribution error is to assume that people’s behavior stems from evil motives. Other variables involving ability and training, perceived differences in social status, and structural incentives or impediments also merit consideration.  When I worked at Dartmouth, I coauthored a study of residency education as a system that can be studied and improved (The odyssey of residency education in surgery: Experience with a total quality management approach. Current Surgery, 1997; 54:218-224) with Dr. Paul Batalden, who taught me:

Every system is perfectly designed to get the results it gets.

Incentives do matter, as my co-editor, Doug Hough pointed out in his review of pay-for-performance contracts in the US and the United Kingdom (Can Pay for Performance Really Pay for Performance? The Business of Healthcare. Westport. Praeger. 2008, 194).  Successful pay-for-performance programs have four characteristics:

  • A significant potential impact on provider revenue to make behavioral change worth the effort
  • A small number of metrics to make a clear connection between behavior and reward
  • Predictable payouts to reinforce the desired behavior
  • Sustainable improvement in clinical outcomes

As attention focuses on federal , state, and local deficits, medical unsustainability at the local level will become the subject of increasingly bitter conversations until we change our frame of reference from finger-pointing and blamestorming to empowering and rewarding dedicated front-line healthcare professionals who help us improve processes and reduce waste of time, materials, money (and lives).

In Charting the Course, which I reviewed last October, CEO Will Jenkins told his CFO:

… the front lines can find the 50% waste in our hospital better than you ever could…. we have to stop departmentalizing the budget because each department then seeks to maximize the performance of its own silo, thus submaximizing the whole (p.189-190).

This whole debate is about one thing and one thing only. Control.  And why shouldn’t it be? We’re the chiefs, and we’re all about standing on the bridge and commanding the ship… but if the crew can’t or won’t tell us that we’re hard aground on a sandbar, we’re wasting time and … looking silly (p.187).

As I wrote in The tectonic plates are shifting: cultural change versus mural dyslexia, (Frontiers of Health Service Management. 2007; 24(1): 11-26, 41-43), transformational change is simultaneously exciting and terrifying.  It requires a culture in which people feel safe speaking out on ways to improve care for our communities and a commitment to active listening.

For those who see my comments as young and naive, I reply, “Guilty, as charged, your honor.”  As I wrote in What Physicians and Administrators Can Learn from Nurses (Better Communication for Better Care: Mastering Physician-Administrator Collaboration, Chicago: Health Administration Press, 2005, 63), I take my inspiration from  my late father, a neurosurgeon.  When I asked him from whom his residents learn, he said:

Mainly from me. Only those who are smart enough learn from nurses.

Happy new year.  As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2013, all rights reserved


I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.



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