Why it matters - Next! - physician management issues

Physician Executive, March-April, 1998 by Joe Flower

I'm sitting in my four-wheel-drive at the edge of a redwood grove on a ridge top, looking down across tumbling hills of grass and forest to the distant sea. An intimacy of clouds boils up against the tall dark trees, whipping them with clots of windy rain that rock the truck. In moments they are gone, the sun is shining on Monterey Bay below me, and a rainbow appears over my right shoulder. The forces of change batter the mountain, and the mountain does what a mountain does.

Watching the rain and wind, pushed by the power of the storm, I can't get my mind off a conversation of the night before. At a gathering at a friend's big white loft, I was talking with a vascular surgeon and a neurosurgeon, both energetic men with beepers on their belts and little party pastries in hand. They had asked what I did, and I had mentioned this column.

The vascular surgeon was dismissive: "I'm sure that helps some people, but I wouldn't read it."

"Why not?"

"It's just not important for me. All this organizational change stuff is just make-work for consultants. It doesn't matter. It doesn't take us anywhere definite. When I'm scrubbed and have a scalpel in my hand, that's when I know what Jam after. I can tell you when I have succeeded. I know that it makes a difference in someone's life."

"But that's just the point," said the neurosurgeon. "Surgery takes great skill, and the patient's life is at stake. I am very proud of what I can do, and happy that I can make a difference--yet I know that I can do it, and I know what I am attempting. Personal change, organizational change, working with people--now that's really hard. There are no markers; no clear rules, it seems to go on forever--and the risks are enormous."

I was surprised. "More than the risk in surgery?"

He looked at the ceiling for a long moment, then said, "Look, surgery carries huge risks but mostly for the patient. If I were to make a really big mistake, my professional standing might he at risk, there might be legal problems, feelings of guilt. But in dealing with change, working with other people, what's at stake is who I am, I guess. What I might discover about myself How I might have to change."

"What about the risk of not getting involved in change work, not even thinking about it?"

"I don't know. It feels like that risk is just as great. Since everything around me changes, I had better know how to deal with change, or I'm stuck,"

That comment stuck with me the risk of not being able to change in a time when everything around me is shifting. If I am unable to change, unable to see things in new ways, to understand what I had not understood before, to renew myself I am taking part in my own slavery, selling myself down my own river.

Physicians facing change

Physicians everywhere are facing changes in the ways they are paid, and in their relationships with their patients. The United Kingdom wrestles with privatizations and new kinds of insurance. In Canada, restructuring commissions are closing and merging hospitals, and physicians face reductions in global spending caps, sometimes even retroactively applied. Similar arguments over service and spending cuts rage across Australia and New Zealand. In these and many other countries, physicians face their own decisions about how to alter their practices in order to survive financially, and how to deal with the uncertainty, the lack of information, and sometimes the loss of income and even social status.

In the United States, an increasing number of physicians are being confronted with the choice to join their practice to a physician service organization (PSO) or some other capitated financial structure in which they collectively put themselves at financial risk for the health of their patients. Experience shows that this can be a good idea. Physicians gain control over their cash flow, and can actually make more money. At the same time, they get more involved in their patients' lives, pushing preventive medicine and education in every way possible in order to avoid the costs and health risks of acute episodes of such chronic conditions as congestive heart failure, diabetes, and asthma.

The fear factor

In all these decisions, the biggest handicap is fear. Some physicians let fear keep them from changing. Others let fear drive them too quickly into change that turns Out tO be unwise. Many U.S. physicians, for instance, sold their practices or entered into binding contracts in recent years with physician practice management companies (PPMs) whose main source of profit turned out to be bargaining the physicians into accepting lower compensation-in return for stability, a guaranteed cash flow, and promises of future profits that have magically failed to show up.

The fear of change--the fear of the unknown, of things that, deep down, under the professional veneer, I wonder whether I can handle--is quite real. It is immediate and nearly constant.

In some ways, the large challenges are easier to handle. Can you remember how you first decided to go to medical school, what your state of mind was when you made that life-shaping decision? Or when you decided to go into your specialty, to join a larger practice, or to become a physician executive? Or when you decided to marry, or divorce, or move to another state?