Reclaiming physician power: your role as a physician executive

Physician Executive, Nov-Dec, 2006 by Edward J. O'Connor, C. Marlena Fiol

Dr. Schmidt, the newly hired vice president of medical affairs at a large Midwestern hospital, was charged with halting the decline in physician morale. He soon learned that things were worse than he expected. The medical staff seemed to have little in common beyond their opposition to administrative actions.

In addition, it appeared that he was now seen as part of the "them," someone who had joined forces with the dark side in order to wrest more power and control from the physicians. He was viewed as part of the problem.

Sitting in his lonely office, he pondered what role he could play in bringing physicians together to enhance health care in their community.

The challenge

Schmidt's situation seems pretty grim. And according to a National Survey on Physicians conducted by the Kaiser Family Foundation in 2002, the level of discontent of the medical staff at his hospital is not unusual.

When asked about the state of their morale, the majority of physicians reported that both their colleagues' and their own morale has been waning in recent years. Almost half are thinking about leaving medicine, and would not recommend it to a young person today. (1,2)

While physician satisfaction and medical school applications increased slightly in recent years, both are still far below levels reported during the good old days a decade or more ago.

The number one reason for dissatisfaction that physicians cite is administrative hassles. (1) As one physician's wife stated, "my spouse's judgment is constantly questioned by nameless and faceless corporate minions armed with the rule books." (2)

Physicians are feeling a loss of control and a loss of status. And information that used to be restricted is now available to everyone (RN's, patients, insurance companies), thus empowering others, seemingly at the expense of physicians. (2)

If that isn't enough, many physicians are facing increased workloads in response to higher overhead costs, decreased reimbursements, sky-rocketing malpractice claims, and more competition. (3)

Third parties and limited budgets seem to be controlling the direction of medical care, and this shift of power has left many physicians feeling a loss of both control and authority. (4)

In addition to these losses, physicians' collective voice seems to be weakening over time. Evidence of this can be seen in American Medical Association's declining membership, that dropped by almost 43,700 members--a decline of 15 percent--between 2000 and 2004. (5)

Moreover, a 2002 VHA study found that physicians lack responsibility for clinical care as a collective whole, there is a lack of respect for physician leadership, and health care organizations tend to avoid partnerships with their medical staff, even if they could potentially enhance quality and safety. (6)

Increased outcome measurement and a shift in control from providers to customers further threaten the physician's traditional identity as captain of the ship. The lack of a new, common, generally accepted group identity has contributed to making any efforts to unite physicians a risky endeavor.

Pressures to reform our health care system have led to even further constraints on physicians, requiring them to accept reductions in reimbursements and to alter practice styles. Many physicians find themselves in what has been described as a zero-sum health care system comprised of enemies, cost-shifting, declining trust, lack of standardization, quality challenges, skyrocketing costs and plummeting value. (7)

It is hardly surprising that a study by Archives of Internal Medicine showed that over 80 percent of physicians responding believed that their commitment to undivided patient loyalty had diminished. (8)

Bringing physicians' social contract back on track will require that the profession of medicine come together to reclaim its power. Bringing physicians together, however, has typically been a difficult hill to climb.

Opposing forces include the lack of explicit, shared mission, vision or values along with the fact that one of the few things that typically unites physicians is their mutual commitment to the preservation of their individual prerogatives. (4)

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Fighting for control

As physicians witnessed the rise to power of administrators and hospitals as institutions in their own right, they naturally fought to protect their control over medicine. But rather than fighting for a place at the table in the hospital of the future, battles frequently seem to be about bringing back what are considered to be the "good old days" of individualism, autonomy and escape from the influence of the bottom line.

Autonomy has been the rallying cry. (9) However, conflicts between clinical demands and limited budgets appear to be here to stay.

Physicians have tried to regain their autonomy and control in a number of ways. For example, many physicians learned the methods of the "enemy" by enrolling in MBA and MMM programs. The output of such programs is the physician executive with enough financial management know-how to be able theoretically to fulfill the role of translator between the clinical and financial domains of health care, (4) using the tools to protect physician rights in the boardrooms of management.