Service Fanatics

by James Merlino

  With these sacrifices, however, come great rewards. By their title alone, physicians are afforded tremendous respect and stature, and very few U.S. physicians are suffering financially. Becoming a doctor essentially guarantees lifetime employment at a reasonable salary—I say reasonable because while some specialties are very highly compensated, others such as primary pediatrics and adult primary care are not. With the United States and the world facing a physician shortage, doctors will likely never be under threat of unemployment.

  Patients recognize the sacrifice physicians make and hold them in very high esteem. Physicians remain among the most respected and trusted occupations in the United States.2 A recent Gallup poll ranked medical doctors the fourth most honest and ethical profession.3 These findings are anecdotally supported in my conversations with patients, who frequently remark how they respect what I do as a physician. Patients interact with me for a very short period of time without really knowing who I am, but because I’m a physician, I have instant credibility. I’m certain this is the experience of physicians throughout the world.

  Doctors Have an Ugly Side

  However, there is another side to physicians that the public rarely sees. Prior to applying to medical school, I was appointed to the board of a small community hospital in the city where I grew up. It was the early nineties, and hospitals were very different back then. They were more independent, as this one was, and community hospitals near large urban areas were not part of large systems as they are today.

  Most of my colleagues on the board were local businesspeople and community servants, as I was. The board also included a few physician leaders, including the president of the medical staff. All the physicians at the hospital were in private practice. It was a classic community hospital triad model, with three semiautonomous but symbiotic stakeholder groups: the administration operating the hospital, a board providing oversight, and a medical staff delivering care.

  Under this model, which is still very much in existence across the United States today, the true hospital customer was the physician, not the patient. A hospital CEO in Arizona once told me that the role of the hospital president was to ensure that physicians were happy, because they were the real customers. Physicians brought patients to the hospital; it was not the hospital that attracted patients for physicians. It was, and in many cases still is, a paradox. Many hospitals depend on private practice physicians to bring in patients, and those patients determine whether the hospital is successful. But hospitals are forbidden by federal law from doing anything to entice physicians to bring patients. So in these situations, physicians very much control the market.

  As a board member, I was in awe of the physicians, their knowledge, and the influence they commanded over the organization’s governance. It was fascinating to watch my board colleagues defer to physician opinions. When a physician leader spoke, it might as well have been written in stone. While our board included some very successful business leaders, they didn’t have the ability to effectively challenge a physician’s perspective. The physicians could quickly deflate any issue by questioning how it would impact the patient-provider interaction. You had little credibility to counter if you hadn’t been on the front lines of care. Physician omniscience often ruled on critical hospital decisions. For me, it was an early lesson in hospital backroom politics and the power wielded by physicians.

  Physician power plays were very much in evidence when our board became concerned with pregnancy-related outcomes. An important quality measure for obstetrical units is the vaginal birth after cesarean section (VBAC) rate, a marker of high-quality care. Pregnant patients who have had a previous cesarean section should be offered a vaginal delivery for their next pregnancy, when appropriate, rather than automatically defaulting to a C-section. Repeat C-sections pose significant risks to mothers and carry the possibility of surgical complications, a longer hospital stay, slower recovery, and ultimately greater expense.

  For the obstetrician, C-sections are more convenient (no middle-of-the-night hospital trips to deliver a baby) and lead to higher reimbursement, because doctors are paid more for a C-section than for a normal vaginal delivery. Many of our obstetricians at the time had very high C-section rates and had VBAC rates well below what was normal from a quality standpoint. But some of our competing community hospitals had physicians with rates much worse than ours, and the president at a competitor started to hold obstetricians accountable for poor VBAC performance. This obviously did not go over well with the physicians, leading to an influx of obstetricians applying for privileges at our hospital. During a board credentialing meeting, I asked some of these physicians why they decided to change institutions after so many years of practice at a competitor. One answered that he wanted to expand his practice, while another stated that she wanted to practice in what she considered a better hospital. When challenged about their C-section or VBAC rates, the physicians asserted their need for autonomy to “make the right decisions for my patients.” Nonmedical people simply cannot compete in such conversations.

  I think most of us on the board knew the real reason these physicians were leaving the other hospital. They had poor VBAC rates and were seeking to escape the increased monitoring at the competitor hospital. These physicians were exercising a very important economic and political trump card, arranging to take their patients to another hospital if held accountable to a higher-quality standard. Proving this is nearly impossible, and denying privileges to a qualified physician is risky business. But more important, we also wanted those physicians to bring us their patients, because it would make our hospital more successful. Remember, in this model, the physicians are the customers, and we wanted them to bring us their customers, the patients. These physicians were leveraging their power against us to get what they wanted, and it was wrong! But all of their requests for privileges were approved.

  My experience as a surgical resident and fellow also gave me firsthand exposure to the ugly side of medicine, which showed me just how far administrators and the medical leadership were willing to go to protect disruptive physicians. Most people have heard about the difficulty of internships and residency training—the exhausting hours and hard work of learning and taking care of patients. But much less discussed is the monstrous bullying that many medical trainees face under the tutelage of physicians. Bullying takes on many forms: screaming and yelling, calling people names, telling house staff that they are stupid, making fun of them excessively, and demeaning them in front of other residents and hospital staff such as nurses and, in the worst cases, in front of patients and families. Bullying can evolve to physical violence. Some surgeons throw things in the operating room and occasionally throw things at other caregivers. When I was an intern, a surgeon physically assaulted a chief resident by grabbing his shirt and shoving him against a door. Some of medicine’s best-known and well-published physicians are the worst behaved. The doctors in training are not the only recipients of this despicable behavior; unfortunately, it is often directed at nurses and other members of the healthcare team as well.

  Fortunately, I was never the recipient of physical violence, but the bullying behavior that my colleagues and I experienced at the hands of various “teachers” was well known, but simply ignored, by our departmental chairs. In my residency, the behavior was always brushed off with the comment, “But he’s such a good surgeon.” I witnessed nurses in the operating room and on patient floors excusing terrible physician behavior and rudeness toward patients with “But he’s such a good doctor.” The same was true in my fellowship. Trainee after trainee, nurse after nurse, had been consistently and repeatedly bullied by a member of the medical staff, yet the physician was allowed to continue to practice.

  Today I think—I hope—we are better at policing this and holding people accountable for bad behavior. Leaders are better at monitoring and policing these actions, and some hospitals have peer-based professional conduct committees to review incidents when they are reported. We know, however, t
hat not all acts of bullying are reported and many hospitals do not have these types of committees. All of us in physician leadership positions know that bullying absolutely still occurs.

  In January 2014, the Associated Press reported that a doctor in Shelby, Montana, had privileges suspended for disruptive behavior after allegedly refusing to delay a surgery, which caused an entire day of cases to be cancelled.4 He also allegedly threatened to kill an employee if she didn’t help him fix a problem with an electronic medical record.

  A recent study suggested that a majority of medical students were bullied in some fashion.5 Interesting, and more disturbing, is that bullying tends not to be overt, but what sociologists call “micro aggressions,” which are “subtle interactions that shame employees and undermine their confidence.”6 This is the worst kind of bullying because it’s very difficult to catch the perpetrators.

  These stories are all too familiar across healthcare. Bullying behavior by physicians toward colleagues and subordinates is well described. There can never be a circumstance where this is right. We should never excuse bad behavior with coworkers or patients in exchange for excellent physician skills. Both appropriate behavior and excellent skills are required to deliver safe, high-quality, and effective care.

  Physicians who bully or are abusive put patients at much greater risk than would be created by denying society their “good” physician skills. These behaviors cause unsafe environments for patients. A physician who has a reputation for bullying or angry behavior can undermine a healthcare team’s ability to speak up when a patient is at risk. One of my colleagues in training actually had the courage to walk out of an operating room during a surgery because he was being treated so poorly, despite there being no protections in place for him at the time. His willingness to stand up and take action was the right thing to do. In his words, “I was bullied to inaction. I could not function. It was bad for me and dangerous for the patient, and I had to leave.” Everyone in the department knew about this act of courage, but there were no consequences for the staff member. While we should all have the courage to stand up to bullying and abuse, all too frequently employees and subordinates fear coming forward, and healthcare leaders are reluctant to take decisive action. My colleague should be a role model for all of us in medicine to call out bad behavior and hold people accountable.

  I have met hundreds of physicians over the course of my career that are incredibly talented, dedicated team players focused on doing what’s right and caring deeply about their patients and colleagues. But my service on the community hospital board and my experiences in surgical training taught me very important lessons about the physician culture behind closed doors. It can undermine what is right and what most of us represent in healthcare.

  Patient Experience Cannot Be Fixed Without Addressing This

  “The problem with healthcare is people like me—the doctors,” states Thomas H. Lee, chief medical officer for Press Ganey Associates, Inc., and former network president for Partners HealthCare System in Boston. Lee is a world expert in understanding physician engagement. In his 2010 Harvard Business Review article “Turning Doctors into Leaders,” he describes some of the challenges that physicians face as they adapt to a new world of healthcare where we need their help to drive significant organizational change.7 He acknowledges that the fundamentals undergirding physicians are solid, but they need to think and act differently to become leaders paving the way for significant progress.

  Why are this background and the topic of physician engagement important in patient experience? Because it simply can’t be improved without physician leadership and involvement, and if the patient experience is to be fixed, we must recognize and confront this “other side” of physicians.

  People make significant sacrifices to become physicians and shoulder incredible responsibility and stress to practice medicine. These circumstances set physicians apart as unique, and they need to be recognized for it. However, we must call out the hypocrisy and mitigate the risks that a few rogues are placing on our efforts to promote the culture required to deliver effective healthcare. Beneath the dedication to care for people, there’s an occasional undercurrent of selfishness and greed and dangerous behavior. When combined with the unquestioning respect and admiration that patients have for physicians, these physician attitudes and behaviors can be hazardous to healthcare and are perverse. We also must recognize deficiencies in how physicians are trained and develop methods to enhance their capabilities to lead.

  Physicians Must Lead

  I’m frequently asked which was the toughest stakeholder group to engage in our effort to transform the patient experience. This is a loaded question with an obvious answer: the physicians. My response is always met with head bobs and comments like, “I thought so.” When I speak to hospital leaders, the question is always asked, and the audience response is always the same. Physicians should want to lead patient experience efforts, but the reality is that they’re not often involved or engaged.

  Physicians are typically revered by their nonphysician colleagues. So they proffer a range of excuses for physician disengagement on important patient experience initiatives: “Physicians are too busy and have more important things to worry about. Their time is valuable, and we shouldn’t burden them with this work. They’re smart people and know it’s important, but we have to lead it for them.” Others will admit that while physicians are at the table, they’re not really involved in helping to fix anything.

  These excuses are unacceptable. We can’t improve safety, quality, or the patient experience, or transform and develop the healthcare culture we need, without physicians at the table, engaged and helping to lead. The pressures on hospitals today are such that we simply can’t be successful without physician help. Regardless of the difficulty, the challenges to physician engagement must be met head-on. The impact that physicians can have on the patient experience is as powerful today as their influence on individual patients was 100 years ago.

  If you acknowledge that the patient experience is everything around the patient, and you accept the Cleveland Clinic definition—that the patient experience includes how we deliver safe, high-quality care, in an environment of satisfaction, to achieve value-driven healthcare—then you also must acknowledge that just as we can’t improve the patient experience without steadfast CEO leadership, it can’t be improved without physician involvement. Even if you believe that the patient experience is solely about satisfaction and making patients happy, the same holds true.

  Taking the position that physicians “have a lot to do” or that “they’re smart people who will understand the importance” is inadequate and diminishes the impact physicians can have on patient experience initiatives. Physicians carry tremendous influence on both patients and the organization’s other caregivers and are typically viewed as leaders by subordinates. Physicians hold a position of incredible respect, and patients and their families hang on to every word and action; their influence to individually impact the patient experience is unparalleled. They are the most powerful and effective drivers of patient perception and service. I have often argued that physicians are our most important service recovery tool. They can influence patients enormously. Another benefit of physician engagement is that once they’re engaged, they become powerful partners in ensuring the success of patient experience efforts.

  Getting to Leadership

  A critical component of engaging physicians is recognition of their importance to healthcare and their unique role in the patient relationship. I would never argue that what physicians do is more important than the care provided by other critical members of the healthcare team, but physicians deserve recognition that their role is different. Most physicians want to help, but they often are not asked or meaningfully engaged. Cosgrove and Lee argue that physicians need to engage “in a noble shared purpose”; in essence, get them to help “pursue a common organizational goal.”8 In our organization, I’ve personally asked nearly every key physician
leader to help me enhance the experience for our patients, and no one has ever said no. Some would argue that there should be no need to ask for help when it’s a requirement of leadership to participate. I disagree, because remember, we’re talking about a unique stakeholder group. Physicians are the engines of the clinical organization and deserve some deference regarding their time.

  A very good first step is making meaningful presentations to physicians to help them understand what the patient experience is about and how it impacts them. I initially joined small groups of physicians at department meetings to deliver a high-level stump speech explaining why the patient experience was important and ways we could improve it. These early talks, however, were not effective, because in actuality, there was no real meat to my presentation—no strategy and no recommended tactics. In addition, I had no hard data that supported what I was talking about. I just showed our overall hospital HCAHPS scores, and at the time we didn’t really understand how they applied to the local environment or how physicians could have impact on the scores.

  The physicians’ skepticism was palpable, and I could see lack of interest in their facial expressions. Most physicians were clearly just humoring me and paying polite attention. They would ask a few easy questions about the concepts and then inquire what exactly I wanted them to do to help. The doctors weren’t rejecting the message; they were simply applying their analytic skills against what I was saying to better understand it. Physicians are trained to interpret and understand important issues. I didn’t have any substance yet—the information I presented was just window dressing, and that won’t fly with docs. Their reaction taught me that if we were to engage physicians, we had to provide detailed information and convey exactly what we wanted them to do to help—a basic concept of change management.