The “white coats vs. blue suits” disconnect stems from differences in perspective and priorities. With physician leaders ideally situated to mind the gap — and mend it — here’s some food for administrative thought.
The growth of value-based payment programs, as well as the uncertainties of health care legislation, have heightened the importance of cooperation be-tween the leaders of health care organizations and physicians working on the front line. While clinicians and leaders agree alignment is more important than ever, they also say there’s a vast divide separating them.
The gap between administrators and physicians manifests as lack of understanding, lack of cooperation, lack of engagement, anger, frustration and, sometimes, disrespectful behavior. These slights, both real and perceived, between managers and providers are a source of underlying tension in many health care organizations.
Negative stereotypes simply widen the gulf. In The Business of Healthcare: Volume 3, authors J. Deane Waldman and Kenneth H. Cohn sum up the perceptions:
“The manager sees a doctor who has no understanding of, or interest in, resource constraints or proper organizational behavior, even if the doctor has an MBA and manages a successful multimillion-dollar division. The doctor sees a heartless bean counter who cares nothing for patients, despite the CEO spending seven hours before a state oversight commit-tee aggressively seeking support for the doctors’ medical programs.”
For leaders of health care organizations, recognizing the problem areas that frontline clinicians commonly face and addressing them proactively can improve care delivery, shore up organizational goals, and help prevent physician dissatisfaction and burnout.
Why It Exists
Health care experts frequently say the overarching reason the gap exists is the complexity of the health care system. As Waldman and Cohn write, “… the real enemy is not the so-called other — physicians or health care executives — but our dysfunctional health care system.”
Suneel Dhand, MD, a Massachusetts-based hospital internist, author and blogger, points to federal regulation in particular. “There have been huge changes in the past decade or two with greater need to control costs and more federal directives affecting care delivery,” he says. “These factors filter down to affect the physician.”
Others spotlight inherent differences between physicians and administrators in training, perspective and priorities. Even though physicians increasingly are making their way into the C-suite, many existing health care administrators hold traditional views.
They’re “business-oriented, focused on profitability, considering the big picture, and seeing physicians as sources of patients,” while physicians are “clinical, focused on income, patient by patient, and seeing other physicians (not the hospital) as the source of patients,” writes Atefah Samadi-Niya, MD, in a 2015 study of physician-hospital relationships in Canada.
These differences can result in conflicts about care delivery and the use of resources, which ultimately can lead to communication problems, suspicion, and “a cultural gulf … that is extremely difficult to bridge,” write Waldman and Cohn.
Erin DuPree, MD, FACOG, a physician executive with the Joint Commission Center for Transforming Healthcare, has observed a range in the degree of disconnect across health care organizations. “Today, there are many organizations where physicians and executives are working together effectively and have bridged the gap,” she says. “Yet there are many others where physicians are seen by administration as separate, almost enemies.” She says this led to her own career change. “I moved into administrative roles because of my anger with administration and the fact that I refused to be frustrated for the rest of my career,” she says.
She suggests the differences are because of a lack of understanding about each other’s roles. “The issue can stem from an administration’s fear of not really understanding ‘clinical speak,’ ” she says. “To administrators, it often seems as though physicians know all and that’s their world.”
Marc-David Munk, MD, chief medical officer of Iora Health in Boston, agrees. “Much of the clinical work that is required to be successful in a high-performance health care organization is squarely in the domain of the physicians,” he says. “Administrators get frustrated because they don’t really under-stand the work and don’t know how to impact performance.”
At the same time, he adds, physicians often lack an understanding of the operations and decision-making that comprise the administrator’s work life. “As the business of health care migrates toward risk, there is an interplay between the clinical and the financial to find a sustainable business model,” Munk says. “You can’t run a successful clinical business without physicians who are really driving improvement, yet many physicians lack a good sense of operations and a deep understanding of the financials of the business.”
Some observers identify less-than-ideal leadership behaviors as a contributor to the gap, particularly a reliance on top-down executive mandates. Says Dhand: “As physicians, we have a unique relationship with patients and feel we know what is needed at the front lines. It’s a problem if a lot of nonclinical leaders are trying to enforce mandates. Physicians will never take kindly to directives coming down from MBAs.”
Why It Matters
The gap has a chilling effect on an organization’s culture and overall functioning. Patients suffer when parties cannot over-come their differences to providing care without preventable errors, Samadi-Niya suggests.
It also has a direct influence on the enthusiasm of physicians to work collaboratively with organizational leaders. When a significant divide exists, leaders find it difficult to engage physicians in the challenging work of adapting care delivery to succeed under value-based payment models. Physicians who lack engagement or show burnout symptoms are likely to leave their organizations — and perhaps medicine entirely, studies indicate.
“If every day is a struggle and you’re not getting support from administration, if you’re feeling like no one has your back, it can definitely lead to burnout,” Dhand says.
Stephen J. Swensen, MD, the former medical director for leadership and organization development at Mayo Clinic, has studied the phenomenon. “Decisions made without clinician input can result in processes that are inefficient and frustrating, and that erodes the physician’s sense of autonomy, which is not good for physicians,” he says. “The gap between physicians and administration has an adverse effect on the human need for control and purpose in work. And the cynicism of burnout then fuels the divide.”
Strategies exist to mend the physician-administration gap and build alignment. DuPree suggests the ideal mechanisms for building a connection vary by organization. “What works best depends on the history, the culture, and the leaders themselves,” she says. Here, five steps for leaders to consider:Understand the physician experience. Listen to those on the front line to grasp the importance of why a physician’s daily work experience relates to the wellbeing and performance of the entire enterprise.
Karen Weiner, MD, MMM, CPE, chief executive officer at Oregon Medical Group in Eugene, Oregon, says it should be required of leaders. “If, in any other industry, we pointed out that our primary revenue generators were burning out faster than we could replace them, all senior leadership would be thinking about sustain-able models for these revenue generators,” she says. “Understanding physicians’ work experience is not a side thing or a feel-good thing. It is part of our job as leaders.”
She adds it’s important to use every possible avenue to learn about physicians’ work lives. “I sit in on all-physician department meetings and talk with physicians to clarify issues, either in one-on-one conversations or in evening phone calls,” Weiner says. “Many executives would cringe at these activities, thinking them a waste of time or just complaint sessions. But if you are there just to listen, you learn a lot.”
Taking face-to-face meetings one step further, administrators can learn plenty by observing clinicians at work. In the parlance of the Lean management system, such visits are referred to as “going to gemba” — a Japanese term for “the real place” or “the place where value is created.” “Understanding the work and the barriers is basic leadership,” Weiner says. “But visits to clinical sites must be authentic. If leaders are glad-handing and making the rounds, physicians can see it a mile away.”Create collaboration opportunities. DuPree says performance-improvement initiatives are ideal for this, because they help both sides learn about the roles and responsibilities of the other. “We found that, over time, the physicians saw and understood the administrator’s side and the system of care, and administrators saw and understood the physicians’ problems,” she says. “It does mean carving out time, but it also means being part of the change.” She encourages physicians to work with their direct supervisors to create weekly or monthly time in their schedules for improvement projects.
Munk suggests that an agreement about responsibilities can help bridge the gap as well. “It is easy as a physician to get cynical and paint administration with a broad brush, and just as easy for administrators to get cynical about physicians. Settle on a compact to outline mutual expectations,” he says. Having expectations delineated can help avoid misunderstandings down the road.Increase clinician leadership at all levels. Munk notes that many of the top-performing health care organizations are led by physicians. “If you have a physician administrator who understand operations and business, clinical work, physician culture and how to motivate physicians, it is a very powerful thing,” he says.
Mayo Clinic requires leaders in clinically related positions be practicing clinicians. Swensen says this helps minimize the gap between frontline physicians and administration.Evaluate your leadership behaviors. Leadership behaviors shape the culture, communication style and relationships throughout the organization. Swensen says Mayo Clinic leaders are evaluated in five areas: appreciation, interest in subordinates’ ideas, interest in subordinates’ careers, transparent communication, and inclusiveness to ensure feelings of respect.
The organization surveys all employees annually on the degree to which their direct supervisor displays these behaviors. Research shows lower levels of burn-out among physicians whose supervisors score highly in these behaviors.
Engage physicians respectfully. This means treating physicians as respected and trusted partners and collaborators rather than employees. Dhand suggests finding ways for physicians to retain some autonomy. “At the end of the day, it’s about feeling you’re in control of things, not controlled by someone else,” he says.
This requires leaders to use care when considering financial incentives for physicians. Munk says “alignment payments” rub physicians the wrong way. “It is cynical to assume that you can get what you want in clinical performance by motivating physicians financially,” he says. Instead, he suggests engaging physicians in problem-solving. “Appeal to their intellect and to their inherent motivation to do the right thing for their patients,” Munk says. “Share data and ask them to contribute to thinking through a problem.”
Diane W. Shannon, MD, MPH, is a freelance writer specializing in health care improvement topics, based in Massachusetts.