Dr. Danielle Ofri - author of the book What Doctors Feel - wrote a groundbreaking piece in the New York Times this week entitled: The Business of Health Care Depends on Exploiting Doctors and Nurses
In the article she writes:
"Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine."
We couldn't agree more.
Unfortunately, her article then crashes and burns in an impossible recommendation that half of all US Healthcare Administrators be fired, because:
"If we converted even half of those salary lines to additional nurses and doctors, we might have enough clinical staff members to handle the work."
Duh! AND I think we agree no organization is going to take her up on that change in business model.
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In this post let me show you
- Why we agree with Dr. Ofri that physician exploitation is built into the industrial practice of medicine
- Some simple Case Study examples of exploitation from our thousands of hours of physician burnout coaching client files
- The Triple Competitive Advantage if your Leadership Team STOPS Exploiting the Doctors and begins to Practice the Quadruple Aim Instead
This is Blog Post #301
Complete Blog Library is Here
Let's start at the beginning ...
Does the US Healthcare Industry actually exploit doctors??
That is the very purpose of any business - wring every last drop out of all your limited resources to maximize the Return on Investment (ROI) to the organization. (It's what the shareholders expect!)
The primary limited resource to any healthcare organization are the things the doctors and other providers do with patients one-on-one - behind closed doors, pulled curtains and in Operating Rooms.
If you are an employee provider for a professionally managed healthcare delivery organization, you are putting yourself in a near 100% risk of this exploitation to some degree. This imbalance is extremely common, often invisible, not typically conscious on the part of your administrators and a major cause of our modern burnout epidemic.
In our experience with thousands of over-stressed and burned out doctors, we can say with confidence that 95% of US healthcare organizations carry out multi-level exploitation of several fundamental characteristics of a well trained physician:
- our sense of responsibility, lack of professional boundaries and inability to say NO
- our professionalism and work ethic - we have high standards and will adhere to them even if leadership does not care
- our work hardening and resilience - we are capable of superhuman extremes of stamina and sheer gumption (we survived residency after all)
- our naivete in communicating with "the boss" and understanding of how to navigate a bureaucracy - administrators will always have a political and cultural advantage over the workers inside the org chart
- our ignorance of the Profit and Loss statement reality that fewer workers, doing more work means more PROFIT - even in a "non-profit" organization. There is ALWAYS a powerful negative incentive to staff appropriately and provide adequate resources to do a good job
Realize this Exploitation -- is a major cause of the 50% physician burnout rates of the last several years
The rise of the employee physician and the massive merger and acquisition activity in the US healthcare system has fundamentally altered most doctor's day-to-day reality at work. The average physician has much less control over every aspect of their work environment than in years past.
If you are an employee, you are a worker bee. The odds of you being truly exploited are nearly 100%.
As an employee physician, this exploitation - is multifactorial - propped up by the business realities of ...
- the structure and performance incentives of most healthcare delivery organizations - administrators in charge, driven by numbers
- the leadership habits of healthcare administrators - physicians and non-physicians - who somehow never round on their providers (in our experience with over 170 organizations to date, less than 5% of senior executives ever round on a single provider in any given year)
- the massive merger and acquisition activity in the USA rapidly producing larger and larger delivery organizations...
- more and more out of touch with what doctors actually do with patients - in care settings strung out across multiple states and thousands of miles
- and run by administrators who's skills were honed inside hospitals and academic medical centers - not physician practices
And this Exploitation is - hopefully - just a phase in the development of the US healthcare system
- because it is NOT the best way to run a healthcare delivery organization
- especially in an era of physician shortage
Two Case Studies:
Case Study #1
The Hospitalist Department Launch
One of our physician burnout coaching clients came to us with this story:
She was hired along with a colleague to start a hospitalist department in a 40 bed rural hospital in Kentucky. "We will start with you two and staff up to a full four person department within a year", her administrator said ... four years previously.
The call schedule for the this two-person department is 7 on, 7 off - 24 hours a day. If one of them takes a vacation - which is rare - their partner is on service 24/7 for 21 days in a row.
Despite repeated requests by our client for a break and repeated assurances from administration that they have new hires in the pipeline, no additional physicians are ever added to the department.
The physician did not quit for four full years because the whole service is a "shit show" and she feels a professional responsibility to hold it all together. She is frozen with guilt whenever she contemplates "abandoning" the patients and staff to this whirlwind. The hospital administrator appears supportive, asks her how she is doing and how he can help.
No help arrives. Our client eventually quits - with coaching support - after an ultimatum to the hospital, "Hire two more doctors or I will be forced to leave." The hospital lets her go and uses a Locum Tenens service instead.
In a single move to a new job, our client's burnout resolves quickly. Her practice satisfaction goes from 2/10 - 8/10 when she joins a six person hospitalist team with an authentically supportive administrator in a similar sized hospital.
Take Home Points:
A two person hospitalist team looks REALLY GOOD on the Profit and Loss Statement. - - - You are doing the work of four
- For the price of two
There is a MASSIVE FINANCIAL DISINCENTIVE TO STAFF APPROPRIATELY here. This disincentive is always present for administrators. This is just an obvious example.
The administrator didn't care a bit about our doctor's health, wellbeing, burnout, or patient care quality, safety and satisfaction. He fundamentally exploited this doctor on a number of levels FOR YEARS paying only lip service to her consistent requests for support. Only her professionalism and personal work ethic maintained this house of cards.
Case Study #2
The Denial of Appropriate Requests for HELP!
This particular example is so common, most physicians can relate because they have experienced this exploitation first hand.
In fact, the only exception to this workplace scenario will be if you are personally a Power User of your EMR and a digital native. Even then, however, I would still argue your highest and best use is NOT farting around on the computer ... right?
No one can argue that the adoption of the modern Electronic Medical Record increased the work of patient care by 30 - 50% - much of it falling to the physician. In response, a majority of physicians in all organizations and settings are overloaded with charting tasks.
Studies show doctors spending 2 hours charting for every one hour of direct patient care and devoting 2 hours of "pajama time" each night charting from home.
EMR and other digital tasks - InBox work and Patient Portal inquiries and more - are always the number one stressor sited in physician burnout studies.
Despite all of this evidence that EMR burns out doctors, wastes time and gets in the way of seeing more patients, requests for documentation help is routinely DENIED by administrators. The usual refrain is, "If I got you a scribe, I would have to get one for everybody".
The request for documentation support is dismissed outright without even studying if it might actually increase productivity.
This is exploitation of the doctors in its simplest and most obvious form:
- We are exploited because we are responsible for the patient - not the administrator
- We are conditioned to get this work done even at the expense of our quality of life. If you don't supply additional resources I will get the charts done (at no additional expense to the organization) or burn out trying
- With the added pressure that ... if the documentation is not done properly, we could easily be liable as well
- ALL this additional work has been stacked on the backs of the providers
- The Result is our 50% Physician Burnout Prevalence
That is systematic physician exploitation, hard wired into the fabric of a system where the administration's only tool is to control costs, driven by evil industry data like the MGMA Staffing Surveys.
Doubling the workload should have driven staff increases to handle the workload and free up the doctors to see more patients.
But no ...
"... the doctors' will do it ... they always have ... why should we pay more ... they are just a bunch of whiners" ... and the exploitation feedback loop continues.
Fortunately team based care models like the APEX Project at the University of Colorado are showing that upstaffing is more profitable, with higher quality and less burnout and staff turnover.
We now have hard proof that exploitation is not the best course of action. In fact ...
This Exploitation is Short-Sighted, a Massive Waste of Your Most Precious Resource ... and Hopefully Just a Phase
If you want to burn out doctors ...
- Keep exploiting them, understaffing them, building systems of care that make no sense
- Keep making no attempt to understand what they do and the optimal levels of support they require - whatever you do, make sure you don't round on them ... ever!
- Keep hammering away at that Triple Aim
Just know there is another way
As leaders, our job is to take great care of the doctors and staff - so they can take great care of the patients.
We believe that the organizations who learn how to STOP EXPLOITING THE DOCTORS -- build systems that work and a more supportive culture (the Quadruple Aim) -- will derive a triple competitive advantage in the near future:
The Quadruple Aim's Triple Competitive Advantage
1) Better Patient Care ...
makes you the Provider of Choice in the eyes of the Patients & Payors
2) Healthier Culture …
makes you the Employer of Choice in the eyes of the Independent Doctors
3) Higher Levels of Trust …
make you more Nimble, Stable and Profitable than the Competition
... we invite you to join us at the Quadruple Aim Physician Leadership Retreat
Learn the skills and get the support to be a Physician Wellness Champion with elegance and grace
- 13 hours CME
- 12 weeks comprehensive follow up support
- 150 graduates doing great work on 4 continents
PLEASE LEAVE A COMMENT
Do you think the healthcare industry exploits physicians?
How have you see this exploitation in your job/career/institution?