A NEW PARADIGM

 

HOW PHYSICIANS CAN TRANSFORM THEIR FUTURE

 

By HOWARD L. LANG, MD

 

Abstract:

To improve doctors’ professional future and garner power in the changing environment, medical staffs must cease to identify with hospitals and form regional physician organizations. Such organizations support the notion that the physician-patient interaction is the centerpiece of any healthcare delivery system.

 

 

The series of articles on medical staff self-governance in Southern California Physician aims to illuminate and alleviate the problem of strained relations between medical staffs and hospitals. To that end, I propose a different way of resolving the longstanding conflicts.

Given that the definition of insanity is to do the same thing over and over and expect a different result, my message is one of positive transformation, moving beyond conventional thinking to employ cooperation among physicians to drive progress.

To be clear, the medical staff is not merely another department of the hospital as many hospital advocates assert. It is a self-­governing organization, composed of licensed independent professionals possessing special expertise, knowledge and training that carry with them inherent—not delegated—professional responsibilities. With these responsibilities comes authority that is also inherent—not delegated. Self-governance is the exercise of this authority in a manner provided by and through an organizational structure consistent with the law.

 

In his book Mind Set, John Naisbitt writes, "You don’t get results by solving problems, but by exploiting opportunities." If the founder of FedEx had tried to fix the post office, he wouldn’t have created FedEx. The people who succeed in this world are those who look for the circumstances they want and if they don’t find them, create them.

We must create new circumstances for a new future. Trying to solve the conflicts between medical staffs and hospitals in a traditional manner is not enough. We can only create a new future by exploiting the opportunities that we have in dealing with the problems. The destiny of medical staffs must not be a matter of chance or something to wait for, but a path to be pursued. We must not let fear of the unknown prevent us from shaping our own future.

Transforming Powerlessness

One major reason for large-scale medical staff strife is disillusionment among physicians. One major cause of disillusionment is physicians’ sense of powerlessness—powerlessness in the face of crisis, powerlessness in the face of complexity, and powerlessness in the ability to direct their economic and professional future.

Feelings of powerlessness are cultivated by hospital advocates who want physicians to believe that hospitals will remain the centerpiece of the healthcare delivery system. Some have said that the American Hospital Association’s vision of a reformed health system features a network of local hospitals as the core architecture. I maintain that hospitals should not be at the top of the food chain. They’re not the leanest and most agile—they have the highest costs and least flexibility.

Instead of looking for opportunities to collaborate and cooperate, hospitals compete to be the "winner" within their market. Administrators may talk about values, but those values are often tied to the marketplace and based on how much money and leverage hospitals have. Productivity and efficiency are measured by the degree to which they increase the hospital’s wealth or power.

 

Most hospital managers and the majority of hospital board members have business backgrounds rather than clinical experience. They view patients mainly as "consumers" and the patient-physician encounter as a market arrangement. They see physicians and patients as cogs in the healthcare machine that can be substituted without consequence. Patients are either money-winning or money-losing biological structures.

Physicians are caught in the middle of this competitive process, with the hospital board and administration establishing the strategies and tactics—often under the banner of "community benefit"—and only later, if at all, asking the medical staff to be supportive in implementing the hospital’s plans. Consequently, physician interests take a back seat—if they get a seat at all.

The time has come, however, to reclaim the driver’s seat and some power in the changing healthcare system. To have negotiating clout, physicians can no longer be isolated and serialized. It is interesting to note that the word idiot comes from the Greek idiotes, which means a person who stands alone. Powerlessness and isolation go together. Even if people are powerless as individuals, they can become powerful by coming together to cause change. The sense of powerlessness survives only as long as people do not organize to take power.

 

One cannot refute the power that physicians have, if we will only use it! No healthcare delivery system can function without us. However, physicians widely think their profession is under siege—bound like Gulliver by a profusion of Lilliputian regulations, review panels and managed care networks.

Still, we have endured all manner of abuses in order to preserve the illusion of autonomy and authority. It seems that we would rather be ruined than changed. Yet the healthcare delivery system is experiencing continued and profound change. As John Maynard Keynes warns, the real difficulty in changing any enterprise lies not in developing new ideas, but in escaping from old ones.

 

Rather than acting as agents of change, physicians see themselves as victims of forces outside medicine that are reshaping healthcare. If we want to maintain the professional aspect of our profession and stop the industry from damaging the profession, we must become the architects of change. We must develop organizations that preserve physician autonomy in a world where medicine has come to be dominated by large corporations. In today’s environment, it is im­perative that physicians have the ability to band together to accomplish the goals of quality patient care and self-preservation, both psychologically and economically.

Developing Regional Physician Organizations

A fully integrated professional corporation is one vehicle that can accomplish these objectives. As a single legal entity, the professional corporation can act on behalf of its physician-employees without fear of violating antitrust, safe harbor and other regulations that limit independent physicians from planning and working together.

In September, the U.S. Federal Trade Commission provided a favorable advisory opinion for the clinical integration program of New York’s Greater Rochester Independent Practice Association, according to GRIPA officials. The FTC staff opinion indicates that the agency does not intend to challenge the program, including its plan to negotiate payer contracts on behalf of its members. GRIPA Connect Clinical Integration (www.gripa.org) is a strong example of what physicians can achieve with proper planning and organization.

With that as background, physicians can begin to change future ties with hospitals. We have the opportunity to recreate the relationships between medical staffs and hospitals. The new paradigm consists of removing the medical staff from the organizational structure of the hospital and declaring the entire organization independent of the hospital. This concept was first articulated in 1993 by Robert E. Toomey in an article in Modern Healthcare. He was the former president of the Greenville Hospital System in South Carolina.

I propose that we cease identifying ourselves with hospital medical staffs. We must identify with community or regional physician organizations. Because the centerpiece of any healthcare delivery system is the physician-patient interaction, physicians should form organizations that support those interactions and reject the notion of patients as money-winning or money-losing biological structures.

The regional physician organization would not be tied to any one hospital, but instead offers ownership and participation to physicians at any hospital within the relevant service area. It would be organized and operated with particular attention to antitrust compliance. Patients—and perhaps payers—would be on its board.

The hospitals in the relevant service area would contract for needed patient services with the regional physician organization. Those contracts would spell out the process for credentialing, quality improvement, utilization review and other medical staff functions to minimize the duplication of administrative services. The requirements of the Joint Commission would also be detailed in the contract.

In addition, the review of inpatient care could be merged with the review of care at ambulatory centers and other sites to achieve a broader focus on patient outcomes, rather than only the inpatient component of care. Depending on its contribution to hospital operations, the regional physician organization could negotiate a contract to provide hospital-based services such as radiology, pathology and anesthesiology.

The regional physician organization could offer other benefits and services for physician members. These could include legal services, negotiation services, group purchasing, assistance with personnel issues and purchasing of professional liability insurance. The organization could also establish community-oriented acquisition strategies for capital-intensive medical technologies or arrange expensive new medical and surgical services, such as ambulatory surgery centers, cardiac care services and comprehensive outpatient oncology services.

The regional physician organization would have meaningful involvement in bylaws (the bylaws become the contract between the physician organization and the hospital that chooses to utilize its services), strategic planning, resource allocation and governance (dealing with the owners and board).

Depending on the circumstances, the regional physician organization could provide consultation for individual hospitals in areas of structure, committee function, quality indicators and credentialing. In other words, physician guidance for re-engineering can be accomplished.

Regional physician organizations might take many forms, only limited by our imagination. Some of the medical staffs in a region may have more similarities than differences and could merge and become part of a larger corporation. Or the merged organization could incorporate and become part of a super-regional ­corporation.

 

This model is based on the theory that an organization is an aggregation of resources meant to satisfy the interests of the people within it. Every organization has one unifying reason for being—to garner power to put into practice or promote its common purpose. The organization is a tool to meet the needs of the individuals within it. The organization exists because the people involved in it perceive that their behavior within the organization is the best way to fulfill their personal values. These personal values are clinical authority, business autonomy and a core belief in the fiduciary responsibility in the ­physician-patient relationship.

Taking the Next Steps

At this point, I can imagine what you are thinking: "This takes a hell of a lot of work." True, but what valuable enterprise doesn’t? Thomas Edison once said, "Opportunity is missed by most people because it is dressed in overalls and looks like work." But a lack of action by physicians means a tacit acceptance of the status quo.

When physicians are seen as deliverers of a commodity—patient care—they have little or no ability to influence the administrative structures that outline what care is provided, the financing decisions that drive which kinds of care are offered, and the social factors that determine which patients receive care.

As physicians, we must ask ourselves five questions. What are we doing and why are we doing it? Why are we doing it this way? Does what we are doing correspond to what we believe? Is the medicine we are practicing congruent with the medicine we want to practice? If not, what will we do about it?

The world today is an arena of power politics moved primarily by immediate self-interest. We need to acknowledge that to maintain our legitimate role in the healthcare delivery system, we must acquire power. Power is the very essence of life. It is an essential force always in operation, either changing the world or opposing change. As St. Ignatius said, "To do a thing well, a man needs power and competence."

The reason an organization, medical staff, negotiating unit or cyberspace community exists is for the power necessary to put into practice measures that promote its members’ common purpose. Change comes from power and power comes from organization. Policy follows power.

 

Too many physicians are playing the role of the ingénue in the evolving story of American medicine’s corporatization. A combination of naiveté and apathy paralyzes our decision-making processes. We face difficult challenges, but our response has been inaction, inadequate defense or total passivity. Too many physicians demonstrate little interest in participating in the efforts to regain our rightful role in the healthcare delivery system. All of this has the makings of a Greek tragedy—a fall from grace accelerated by stubborn self-destructiveness.

 

The best way to predict the future is to create it. We must create a future that best serves the needs of patients and physicians. Physician passivity in the face of corporate and other cost-­containment pressures is neither desirable nor necessary. The anxiety that many physicians feel results from blind faith in the worst possible outcome. How can we create a future that allows for change, but still retains the core values of the medical profession?

At this point, I can imagine what you are thinking: "Physicians are so independent that they would never come together on such a large scale." It is unfortunate that aggregates of individuals who share a common way of life in a dispersed state—which Jean-Paul Sartre calls an aggregate series—show behavior in which they become enemies to one another and therefore enemies to themselves. In a panic to exit a collapsing stadium, for example, people trample, suffocate and kill one another, compounding or even creating a disaster which a reasonable evacuation of the premises would have controlled or avoided.

The same is true when workers remain isolated within their class so that their employers have every opportunity to exploit them. Each worker sees the next one as a competitor who is ready to accept slave wages to get hired, so he tries to sell his labor power at an even lower price. Does any of this sound familiar? For the demands of labor to become possible, groups have to be formed in which, on the contrary, each individual regards the next one as the same as himself.

Until now the culture of the medical profession has not been a culture of integration. We have been, by nature, serialized, and outsiders not as oriented to patient issues will use every method they can to enhance our serialization and thereby control us. For our interests and our patients’ interests, groups of physicians must be formed in which each individual physician regards his or her fellow physician the same as himself or herself.

We must create a future that will restore physicians’ professional as well as economic viability. Restoration of these will bring the restoration of our professional identity. With the return of our professional identity will come peace of mind. Peace of mind produces right values, right values produce right thoughts, and right thoughts produce right actions.

At stake is who will control patient care in the future. Now is the time to adopt a strategy of physician empowerment in implementing the economic and structural reforms necessary for excellent medical care in perpetuity.

Visions are values projected into the future. I have described to you a vision of the future and the values that provide the foundation for that vision. All that is needed for this new universe is a new mindset.

 

From a sign on the wall of a church in England:

 

A vision without a task is but a dream.

A task without a vision is drudgery.

A vision and a task are the hope of the world.

 

Howard L. Lang, MD, is a board-certified obstetrician/gynecologist who was in private practice for 26 years in Northern California. He received his medical degree from Northwestern University and completed his residency at UC San Francisco. He was president of the California Medical Association from 1991–92 and served as chair of the American Medical Association Organized Medical Staff Section from 1986–92. A champion of physician empowerment, Dr. Lang has extensive experience in medical staff-hospital relations and has written medical staff bylaws for staffs nationwide, including model medical staff bylaws for the Medical Association of the State of Alabama and the South Dakota State Medical Association. Since leaving private practice and relocating to Scottsdale, Ariz., he has consulted with physicians, physician groups and medical staffs throughout the United States. He has made numerous presentations regarding the principles necessary to preserve medical staff self-governance. He can be reached at drhlang@aol.com .