We have a burnout problem in American medicine. Over 54% of physicians report a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. The number is up 10% from just three years ago.
Who is to blame? If you ask many physicians, the fault lies among leaders involved in healthcare finance, policy and clinical administration.
Why don’t business people get us?
Why are there so many administrators involved in the delivery of care now—when there were so few in the early days of my career?
This is the general sentiment I hear most frequently from physician colleagues. There is a real belief that everything would be better if my administrator colleagues just backed off and let them get back to taking care of patients.
We are amidst one of the most dynamic moments in healthcare delivery—and the relationship between those who deliver care and those who administrate it has never been more tense, challenged, or fractured.
Where did things go wrong?
The simplistic explanation is that change is hard—and the healthcare industry is changing more rapidly than anyone is able to keep up with. There is certainly some truth to this, but it misses a bigger—not to mention potentially fixable—problem. The relationship between those who administrate care and those who deliver care has never been more strained because at a very basic level, both groups don’t understand or trust one another.
Solving the challenges facing American healthcare will require a distinctly different type of relationship between physicians and administrators than currently exists in most health systems around the country.
Drawing on my experience leading change at CareMore Health System, and through discussions with my physician and administrator colleagues, I’ve come to believe that building a better relationship between physicians and administrators is a real possibility.
Four guiding principles can help jump-start the effort.
Unlock the Ingenuity of Physicians
The first is to formalize processes and structures to unlock the ingenuity and knowledge of front-line physicians. As health systems focus increasingly on maximizing value, physicians are dramatically underutilized assets. Systems build broad-based committees and coalitions, but the physicians sitting on these committees are almost always part-time administrators, and almost never true front-line clinicians. Even the best-intentioned clinician-administrators often lose sight of the micro-level insights that drive improvements in care or delivery. Sadly, I increasingly include myself in this category.
One of the fundamental cultural tenets at CareMore is that all physicians—in addition to being responsible for delivering care—are responsible for redesigning healthcare. This type of empowerment leads us to genuine insights that enable us to collectively improve care. A great example was the insight that providing free toenail clipping services to diabetic patients could improve the frequency of foot examinations, allow early intervention on ulcers and reduce amputation rates. Getting the culture of physician engagement right—and valuing all physicians for the special insights that they can bring to care delivery— is a critical foundation for value-based healthcare delivery.
Invest in Educating Physicians About the Financing of Delivery of Care
The second principle is to invest in educating physicians about the financing of care delivery. Most physicians complete their training with little or no knowledge about the financing or organization of healthcare. Nowhere in their premedical education, medical school, residency or fellowship do most physicians get a comprehensive education on healthcare policy, administration, finance or organizational behavior.
It’s no wonder that there is a world of suspicion between those of us involved in administrating and financing care and those involved in actually delivering it. When you are working with different understandings of how the world is structured and why, mistrust, misunderstanding and miscommunication are soon to follow.
Because of student activism, some medical schools and residencies have begun to more robustly incorporate some healthcare policy and finance into their curriculum, some going as far as to create management and leadership tracks. But as someone who worked to advance this cause within the walls of medical education, even these efforts often fail to reach the majority of physicians.
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Progressive health administrators must invest in preparing physicians to understand how healthcare is paid for and how payment informs the structure of care delivery. Absent this understanding, there will always be a layer of mistrust and confusion that gets in the way of true constructive dialogue and engagement about how to solve problems of healthcare delivery.
At CareMore, we have invested in building a CareMore Academy that is focused on educating physicians about many of the elements that they never learned in medical school—including how healthcare is paid for in our system. Members of our finance staff, health plan network operations and clinical analytics invest significant time delivering coursework to physicians when they are on-boarded. They also deliver refresher courses as physicians progress in their careers at CareMore.
How different would health systems be if administrators devoted 10% of their time to educating their physician colleagues on finance and administration of care?
Invest in Learning Clinical Medicine
The converse of teaching physicians about healthcare finance and administration is the need to teach administrators about clinical medicine. The very best administrators with whom I have worked have a deep, intuitive understanding of clinical medicine that enables them to speak the same language as their physician counterparts—and, in the process, build meaningful bridges that otherwise would not exist. As intimidating as this may sound to some, investing in gaining an in-depth understanding of both basic and clinical science (perhaps through a short annual review course in internal medicine) can create a powerful basis for collaboration.
At a minimum, understanding how care is organized and delivered on the front lines through intensive clinical shadowing can help create deep mutual understanding and genuine respect. What if rather than framing collaborations in terms of the buzzwords like “population health” and “value-based healthcare,” those involved in the financing and administration of healthcare delivery came armed to talk about details of improving the care of patients with diabetes, atrial fibrillation or COPD? Without a doubt, the types of solutions that administrators and physicians would design together would be more patient-centered and more likely to deliver value than those either side would develop alone.
CareMore’s CEO, Leeba Lessin, was a sterling example of this form of leadership. Over the course of her career, Leeba’s extensive clinical knowledge led countless individuals into thinking that she was trained as a physician. Leeba spent time understanding the nuance of how diseases are diagnosed and treated. In turn, she was able to contribute meaningfully to both the micro and macro design elements of healthcare. And she commanded ultimate respect from her physician colleagues. She pushed other business leaders within the company to improve their knowledge of clinical medicine by implementing structured clinical shadowing as a prerequisite for all senior executives.
The Importance of a Name: Physicians Are “Physicians”
The final principle is semantic—but nonetheless important. It relates to how we address physicians at the most fundamental level. Over the past decade, the healthcare industry has begun to refer to all clinicians—physicians, nurses, pharmacists and others—as providers. With that homogenization of all clinicians has come the increasing view of clinicians as widely interchangeable parts. While that view may make sense in some situations, it does not match up with the reality of how patients seek care. Patients do not seek a “provider,” but rather they want great clinicians who will care for them. When we only refer to physicians as “providers,” we inadvertently devalue their clinical training, the work that they do and their contributions.
These four guiding principles will not, by any means, altogether solve the problems of physician dissatisfaction and burnout. But I’ve seen them begin to reverse some of the smoldering tensions that have overtaken many healthcare organizations throughout the country. Physicians alone cannot solve American healthcare’s biggest problems without the help of talented, dedicated and multidisciplinary administrators. Nor can these administrators solve the same problems without the robust and thoughtful engagement of physicians.