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One of the byproducts of Obamacare and its new set of incentives in healthcare is the shifting of all the power to the administrators. The hospital working environment has changed dramatically, with physicians and staff “feeling” the new-found power of administrators. The administrators now call most of the shots and frequently play rough-shod over the feelings and opinions of the physicians and experienced hospital staff. The mistreatment of physicians and experienced clinical staff by administrators is nearly universal, raising questions about the motives behind it. In this article, we discuss the various potential motivations for the administrators to keep the physicians and staff in state of constant fear.
A new reality for physicians in recent years is intimidation by the administration and creation of hostile work environment in which the physicians have progressively less control and predictability. Most physicians do discuss this in private ‘hushed’ conversations but are loathe to publically express their concerns because of fear of victimization and retribution from the hospital administration. There is new ‘fear’ amongst the physicians about saying anything that will not be ‘well-accepted’ or can be misconstrued by the administration and invite ‘punishment’. Everyone keeps reminding the physicians about “how things are now” and physicians now have to be extremely ‘careful’ while dealing with the hospital staff and also other physicians since everything that you or say can be ‘misunderstood’ or ‘misperceived’ and invite disciplinary action. The physicians are now advised to deal with the errant or irresponsible staff by “killing them with kindness”. However, the administration does not follow the same advice of “killing with kindness” while dealing with the physicians who fail to follow the administration’s advice of “killing with kindness”. Any ‘perception’ of ‘misbehavior’ by a physician invites a vicious attack by the administration often involving the hospital lawyers, peer review committee and medical executive committee, with the potential to destroy a physician’s medical career by declaring that physician ‘disruptive’ and reporting it to the National Practitioner Data Bank (NPDB).
Why and how did the physicians lose power and influence and become “hostages” to the whims and fancies of the administrators
Till a few years ago, highly skilled and experienced physicians used to attract business (patients) to the hospital with their professional reputation amongst their referring physicians. The hospitals had to depend on these high-quality physicians for business and the hospital administrators ensured that these physicians were treated well and their resource needs were addressed. Since a hospital’s success depended on treating the physicians well so that they brought their patients to that particular hospital, the physicians were treated fairly and respectfully. In the past few years with new regulations in healthcare, the hospitals have bought the primary care practices, hospitalist practices and ER physician’s practices, where the referrals for specialist physicians originate. Nowadays, the hospital administration de facto controls the patient referrals to the specialist physicians. With the use of the electronic health record (EHR), the administrators closely monitor that patients are only referred to specialist physicians who are ‘favored’ by the administration and are quick to ‘warn’ and even punish the ‘errant’ physicians who send the patient to high-quality specialist physicians who may not be in the preferred physician list. With the administration’s new found control over patients (‘business’), physicians have been rendered completely powerless and the administrators are now in the process of ‘putting the physicians under their thumb’.
Why do the hospital administrations want to intimidate and coerce the physicians?
Just because the control over business has shifted from physicians to the hospital administrators with the implementations of ‘healthcare reforms’, it might not seem to be a good enough reason for the administrators to intimidate the physicians, except in probably a few instances where some individual administrators may have a personal grudge against a particular physician. However, the intimidation of physicians by the hospital administrations is near universal and occurs in almost all hospitals. This raises suspicion that this systematic intimidation and coercion of the physicians by the hospital administrators has some hidden agenda and with secondary gains to the hospital. By creating an intimidatory and hostile work place environment, the hospital administrations have effectively ‘gagged’ the physicians who are afraid to point out or speak up against obvious problems and quietly acquiesce to ever increasing demands from the administration.
Potential reasons why the hospital administration would want the physicians to be afraid of speaking out
There have been lots of changes in the healthcare system in recent years that compromise the quality of care. The new mantra in healthcare is to cut costs in all possible ways. The physicians have little say in the functioning of the hospital and the hospital administrators are now in-charge of all decision making. On daily basis, I encounter fiascos or ‘goof-ups” due to ‘system failure” that jeopardize patient safety. Physicians are unhappy at the new work-place scenario and dismayed and sometimes angry with repeated ‘system failures’. To prevent physicians from going public with these issues, the hospital administrations come down very heavily on any physicians or even staff members who even raise issues about quality. In the following sections, we will discuss things/information that the hospital administrations would not like the patients to know.
Cost-cutting measures by the hospitals and their impact on quality of patient care:
There have been radical changes in the hospital ‘systems’ and ‘procedures’ that often result in fiascos that put the patient’s well-being at risk. On such example is the use of Just-in-Time (JIT) inventory management to reduce costs. Though JIT inventory management has been successfully used in industry to optimize inventory, it is being thoroughly abused in healthcare and is putting the patients at risk of sub-optimal care and physicians at risk of litigation. This is because when JIT inventory management is properly implemented, the size (or cost) of inventory held is optimized based on the cost of ‘stock-out’ (instances when the inventory runs out, preventing a sale transaction or stopping the production line). The cost of inventory and the cost of stock-out are both borne by the same party (business or factory owner). In contrast, in healthcare the cost savings from reduced inventory of medical supplies benefits the administration, the cost of the stock out is borne by the patient (who might not get the right device placed during surgery or appropriate equipment/tools not available during surgery/treatment) and to a smaller extent by the physicians who run risk of malpractice lawsuit if there is an adverse outcome resulting from ‘stock-out’ of essential supplies. The hospital administration institutes policies to ensure that the patients or their family members do not find out that a device or equipment required during their surgery or procedure was missing due to a stock-out. An intimidatory and coercive work environment ensures that the physicians are afraid to speak up even when they compromise the quality of patient care. Anyone brave or “dumb” enough to speak is dealt with very strongly by the hospital administration often with trumped up charges against that physician.
Hospitals are increasingly hiring inadequately skilled physicians just out of training to perform complex procedures/surgeries without supervision.
To capitalize on and monetize their new found control over referrals to specialist physicians, the hospitals are hiring physicians in procedure-intensive specialties/sub-specialties. This way the patient does not have to be referred ‘outside the hospital system’ for highly specialized surgeries and procedures and enables the hospitals to capture the revenue from hospital/facility charges etc. However, in several specialties/subspecialties the number of adequately trained and skilled physicians and surgeons who can perform these complex procedures safely and properly is rather limited. Consequently, less reputed hospitals have to compromise on the quality of the physician/surgeon they can hire. Because of the new ‘heavy handedness” of the administration, the credentialing committees rarely turn down hospital privileges for these hospital-hired physicians and ‘relax’ the credentialing criteria to accommodate them. Usually the hospital staff and other physicians are aware of and gossip about the sub-optimal outcomes in patients treated by these hospital hires. However, the fear and intimidatory work environment due to heavy handedness of the hospital administration ensures that no one has the courage to publically speak out about the grossly inadequate quality of care and surgical/procedural outcomes of these physicians hired by the hospital. And, if someone is ‘foolish’ enough to do so, the entire hospital machinery is activated to discredit such person(s) and often their careers are destroyed by performing sham peer review and labelling them a ‘disruptive physician’.
In order to maximize their profit margins, the hospitals are shifting more and more costs to the physicians.
Increasingly, the physicians are being asked to perform extra ‘unpaid’ duties and responsibilities by the hospital administrations. Such duties include taking mandatory ‘calls’ and taking care of uninsured patients for which the hospital does get paid or is obliged to commit resources. In addition, the electronic health record (EHR) has increased the burden of documentation for the physicians, so much so that large number of physicians now have to spend extra 2-4 hours daily (in the evening/weekends) to complete the medical records and are still able to see fewer patients. The hospitals have used the EHR to shift more and more work that was previously performed by secretaries, technicians and nurses to physicians. As the result, these processes have become very cumbersome, inefficient and a drag on a physician’s productivity besides compromising the quality of patient care. In the new healthcare work environment, the physicians have no good option but to acquiesce to these and other more unreasonable demands and cost-shifting by the hospital administration.
How are the hospital administrations successful in intimidating and coercing physicians?
In an era, where any kind of work-place hostility or abuse can land the employers in a lot of regulatory and legal trouble, it seems hard to imagine how highly educated, successful and fiercely independent physicians can be so thoroughly intimidated and coerced by the hospital administrators. An understanding of the physicians’ practice and work circumstances helps understand this apparent paradox.
- The hospitals and hospital associations have used their far superior resources and lobbying power to get rules/regulations which the hospital administrators can use against the physicians even to the extent of threatening a physician’s medical career. The peer review process which was originally intended to promote and ensure the quality of patient care, is now most frequently abused by the hospital administrations to intimidate the physicians. The provisions that were created to enable objective and constructive peer review process are now used as a smoke screen by the administration to avoid public scrutiny of their frequently malafide actions against physicians (sham peer review).
- The hospital administration can behave as a monolith against the ‘divided’ physicians who are too stuck up with old professional rivalries with fellow physicians and cannot come together for collective good. The physicians are perfect target for ‘divide and rule’ tactics of the hospital administrators. The hospital administrators do so by cherry picking ‘compliant’ physicians and showering them with special favors, titles and important committee memberships. These compliant physicians, usually are average or below average clinicians who are only too happy to accept the special favors and status from the hospital administrators in return for carrying out the administrators’ wishes and often act at their henchmen in various committees including the peer review committee, credentialing committee and medical executive committee.
- The physicians have everything invested in their clinical practices and it is not easy for them to leave and start afresh in another location. The administrators on the other hand are in a position for shorter time, can easily switch jobs and locations if needed. The physicians have much more to lose in their struggles with the hospital administrators. The physician’s career can now be destroyed by the hospital administrators after they get the physician declared a “disruptive physician” through a “sham peer review” proceedings. In contrast, the administrators do not have a ‘medical license’ to protect and even when involved in shady and unethical practices can at best be fired and can still easily move on to another job.
- The hospital administrations now have physicians entirely under their thumb as the administration now controls the referrals to specialists and can easily exclude an individual physician from receiving referrals. Several hospital administrations have already modified the EHR to control and regulate referrals to their ‘favored’ physicians and exclude more independent (and less submissive) physicians who are usually highly skilled and experienced physicians and had large successful clinical practices till recently. The administrators also can initiate “sham peer reviews” on individual physicians who do not ‘play along’ with the administration and completely ruin their medical careers. Lastly, the hospital employed physicians have ‘No-compete’ contracts that exclude that physician from leaving the hospital to join another hospital in town, further raising the stakes for the physicians as they have to relocate to another town if they get into the administrators’ bad books.
- The hospital administrators plant and politically support incompetent and often very opinionated nurses and technicians. These nurses and technicians are encouraged to file complaints against individual physicians often using “anonymous complaint lines”. They also test the patience of the physicians by their incompetence and voicing their opinions about physicians loudly and frequently. In the new reality in healthcare, most physicians have learnt to ignore these “moles”. But every now and then, when there is a slip on the part of physicians, the physicians are accused of and tried for mistreating the hospital employees. Very often the standard of guilt is set so low by the administrators that even though no angry words were used by the physician nor did the physician raise his/her voice, the perception by the hospital employee that the physician’s demeanor was angry and threatening can be used as grounds for disciplinary action against the physician. Any physician who reacts ‘like a normal person would react to incompetent staff’ risks being labelled a ‘disruptive physician’ through sham peer review process. In this new reality in healthcare, almost all physicians have to learn to deal with incompetent co-workers by ‘killing them with kindness’. Or else, the administration will ‘discipline’ the physician with a very heavy hand devoid of any kindness ……