Fixing the doctor

Not long ago, I overheard a frustrated hospital leader ranting about the poor performance of a physician.  It was not that the doctor was screwing up surgeries, ordering the wrong drugs or missing obvious diagnoses.  Actually, the physician was rather adept at healing his fellow man.

The doctor’s failures concerned length of stay (far too long), sloppy medical records (incomplete, loaded with cut-and-paste) and a temper, which while not directly abusive of staff, made the work environment tense, perhaps even hostile.  After months of trying to coral the doc into the straight-and-narrow, the administrator was maxed out. “For god’s sake,” he said, “Can’t we just throw him off the staff?”

Now, I get the point.  With all the complexities of running a modern healthcare organization, it is frustrating and wasteful when the best educated, best paid and most committed individuals, cannot carry out the most menial tasks.  Hand-holding physicians and correcting paperwork 101 is annoying, and can be expensive.  Isn’t time that docs step-it-up, put on their big-boy-pants and do their part? To get good, let alone great, we better get tough.

I mused on this and came to a revelation.  One may sympathize with that administrator wanting the best and blaming recalcitrant docs for low-hanging-fruit failures.  None-the-less, if we are going to build world-class systems, then the question is wrong.  Instead of asking how soon we can throw the flawed doc out the door, we should ask, “What can we do so that we never have to throw another doctor off our staff or take a physician out back for a talking-to?  How can we protect, encourage and support our doctors, so that they are not drowning in a torrent of e-paper, regulation and consumptive confusion?”  The doctor is the product and we should be lending support, not increasing her misery.

There are days when I would like to blame doctors for all the ills of healthcare.  Physicians have always had final control, deciding on the patterns and specifics of care, directing and implementing innovation, and whispering into the patient’s ear.  It is doctors who over-order, duplicate, overspend and run sloppy organizations without metrics or any obvious collaborative structure.  They could have maintained professional, fiduciary control of medicine for the past 50 years, and left nothing for CMS or the insurance industry to pre-certify, no gaps in quality or efficiency, no corrosive cost overruns and no sloppy vulnerabilities upon which politicians and malpractice sharks feed.  However, doctors failed. We did not maintain control, so it is being done to us.

The truth is that we cannot really blame the doctors.  Frankly, they did not know better.  Med schools selected students who cared about science and human service, not bookkeeping or the bottom line.  Then students, interns, and residents were promised that if they worked hard … really hard …. That all good things would follow.  Not a word about how to lead, structure or manage the system.

Med schools teach that a doc’s only responsibility is that one patient in front of you. That must be your entire focus.  You are the ultimate decision maker and completely responsible for each patient’s treatment.  Give great care, one soul at a time, and everything good will follow. Fail and everything will descend upon your head.  Ignore the rest. Ignore the realities of the real world.

Med schools taught medical ethics, not business ethics.  They taught how to balance blood pressure, not budgets.  They taught how to talk to patients about life and death, but not how to talk or guide an employee or co-worker.  It was never explained or even suggested that other professions have real value, and what that value might be or how to use it.  Lawyers are bad.  Insurance companies all greed.  Hospital administrators wanna-be B+ healers.  And the most the most corrosive lesson?  There is no “I” in team… you are alone.  God and Hippocrates have willed it.

So the doc “strays” because he does not understand his role in a modern, integrated, automated, politically correct, monitored, complex medical system. He or she was raised to believe that the system is strange and perhaps anti-patient … evil.  How can we assign blame when doctors were chosen and channeled for the role of lone hero and then, we attack, isolate, insult and underappreciate their decades of just trying to do the right thing?

Healthcare, and therefore the daily practice of medicine, are going through a cyclone of change.  No one feels this more than the physician who still needs to touch, understand and treat one patient at a time, even while they flap, grasp and flounder in the systemic storm.  While we might want to blame each doc for being a stubborn, archaic relic, the truth is each is motivated, caring, intelligent and deeply passionate about not only the patient in front of them, but the entire community around.

Physicians have not failed us.  We have failed them.  The possibility, the opportunity, the need, is that we must work together to teach and learn the requirements of integrated, global, team-based healthcare and the value each of us can bring.  We must build systems that support, not subjugate. We must not only direct, but listen. We must treasure the value and sacrifice of each clinician, each healer.  If we do not, then we will burnout passionate and skilled doctors, and it is patients who will pay the ultimate price.







  • Liz
    This problem is NO different than any other employee who is doing his/her job in a sloppy manner. Docs should get no more of a "pass" than any other employee if they refuse to do some of their job or decide to do that part poorly. They are NOT special just because they have an MD (although certainly there are a fairly large number of docs who seem to think so, but that is a separate issue). Yes systems need improved - but the medical system is not the only system out there that is screwed up. If the doc does not like the paperwork that goes with the job at one place of employment they need to find another employer or hang out their own shingle. A doc refusing to do a careful job in all aspects of their work does need fired (after counseled about what they need to do). Sloppy medical records, for example, put both the patient and the employer at risk. The way you present this case you are excusing someone who apparently is a lone wolf not doing his/her job because it comes with a lot of red tape and in med school they are told the red tape is not part of their job. Well med schools need to update what they teach then to make sure that they don't teach what is not true (that their only job is to take care of the patient - no another part of their job is to do the paperwork that now comes with the job. ALL of us out there have parts of our job we hate, that is a waste of time... Well we all know that red tape is part of their job, my job (ever try to design a course having to play the "Quality Matters" BS game? OMG it is a time consuming waste of time dreamed up by someone who had too much time on their hands and done an insufficient reality check), and a ton of other people's jobs (including people who are professionals) in a bunch of other fields. Does that make it right? Of course not. But it is reality at the moment and people need to deal with it. If they are hired by someone and are an employee their employer owns them while they are on the job, have the right to tell them what to do and that it has to be done to standards, and part of what they need to do is ALL of their job responsibilities well, not just some of them. Med school needs to also teach that this is now, unfortunately, part of life and that they will need to get with the program if they want to keep their job. The current paperwork heavy environment in health care not excuse the administrator from seeing if there are ways that someone else can pick up part of the job that is routine and mindless as that is not a good use of someone's skills. Can a PA, NP, secretarial type person do some of it to free up the doc to do more things in line with their training level and fewer things that can be done by someone else? If the answer to that is yes, then within the constraints of the budget, rules that they have no control over, etc. people should be hired to do that work. And the reality often is that often bosses can't do everything they want to do to improve the work place for a class of employees due to constraints beyond their control. Sure the system needs fixed, but that does NOT excuse a doc who is refusing to do part of their job, is doing a sloppy job on part of their job... Begin a doc is NOT does not excuse being a poor employee. In that respect docs are no more privileged, just because they are a doc, than any other employee.
    • Liz
      PS typo in the last paragraph - should be being not begin. And I don't agree with some of the rubbish docs and other professionals have to deal with, it is a waste of their time and training to do that work, however I do believe they are no more special than any other employee. If they refuse to do the job they were hired to do - all of the job - then they need a different job. That they were not taught about it in med school is no excuse. Most people leave school without knowing a lot of what they actually need to know to do their job in many professional fields. Maybe med school needs to offer a 'paperwork and politics hell' class that docs to be need to take to enlighten them. Maybe docs need to band together and get things changed. Maybe politicians need to think before they pass laws (good luck with that). Regardless of all of this, an employee is hired to do a job and it is their responsibility to do it. All of it. Whether or not they like it.
  • Larry Schouten MD
    Great commentary, Jim; however, the devil is in the details. Do you have any specific recommendations as to how to build such systems and, where needed, change culture?
  • This patient has seen endless problems that started and persisted not with a doctor, but with administration. I just don't want to hear about "like any other employee." A doctor may be ornery at times, but is not "every other employee." Let's hear who signed for the electronic records software that is often completely impossible - like the ones who ok'd the records it took a nurse and me an entire afternoon just so I could get in to get a cataract removed. And gag rules? Whoever allowed this software to be adopted and PAID FOR is the problem. For every rude doctor, I've found some I sometimes wish were my brothers and sisters. At the same time, I've suspected the administrators of putting my complaint in the wastebasket. And by the way, I've learned that a doctor I can't bear can be another woman's very favorite.

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