In a previous post, I discussed Drucker's concept of “knowledge workers” and how that
concept applied to psychiatrists and physicians. The basic concept is that
knowledge workers know more than their managers about the service they provide,
work quality is more characteristic than quantity, and they are generally
considered to be an asset of corporations. I pointed out that physician
knowledge workers are currently being managed like production workers and
referred to common mistakes made in managing physicians and psychiatrists.
Today I will tell attempt to describe how some of that mismanagement occurs
using examples that psychiatrists have discussed with me over the past several
years.
Inpatient psychiatry has taken a severe
hit over the past 20 years in terms of the quality of care. Many people have
talked with me about the discharge of symptomatic patients occurring in the
context of high volume and low quality. Depending on the organization, a psychiatrist
may be expected to run an outpatient clinic in addition to a busy inpatient
service or in some cases provide all the medical services to the inpatients
with minimal outside consultation. Most hospital care is reimbursed
poorly despite political suggestions to the contrary. Psychiatric DRGs are
typically 20% less than medical surgical DRGs and they are not adjusted for
complex care. Administrators generally "manage" psychiatrists in a
way to make sure that inpatient beds are covered. That frequently means that psychiatrists
who prefer practicing in an outpatient setting end up doing some inpatient
care. An outpatient clinic may be canceled so that a psychiatrist is available
to run an inpatient unit. There have been situations where inpatient beds or
whole units have been shut down for lack of psychiatric
coverage. The only explanation given is that there is a "shortage" of
psychiatrists.
I had the pleasure of running into one of my
residency mentors in an airport last May. I let him know that I was just
finishing up 21 years of inpatient work and moving on to something else. He
smiled and said: "Three months wasn't enough?". I always liked
his sense of humor but there is also a lot of reality in his remarks.
I don't mean to imply that it is any easier on
the outpatient side. If you are a manager, what could be easier than having a
unit of production that you could hold your employees to? It turns out there is
something easier and that is being able to set the value of that unit of
production. That is what RVU based productivity is all about. A standard
managerial strategy these days is to have a meeting with an outpatient
psychiatrist and show them how much they are "costing the clinic"
based on their RVU production. Spending hours a day answering phone calls,
doing prior authorizations, questions from other clinicians, curbside
consultations, discussions with family members, and documenting everything
doesn't count. I have had the experience calling a clinic at 7 PM and hearing
keyboards clicking in the background. I have asked outpatient colleagues how
they are able to produce outpatient documentation themselves and still get out
of clinic on time. Now that I work in an outpatient setting myself, I know what
they were telling me was accurate and that is the documentation gets deferred
until later.
The mismanagement does not stop there. At some
point in time medical schools decided that there were also going to start
basing faculty salaries on clinical production. I suppose every medical school
as a formula for converting teaching and research time into production units,
but until I see those formulas my speculation is that any activity that does
not result in billing leads to lower compensation. The days when physicians
were hired as teachers and academicians seem to be gone. Because of discriminatory reimbursement,
departments of psychiatry will be disproportionately affected.
Within psychiatry there used to be an
interest in organizational dynamics and how they impacted patient care. The
dynamics in most organizations today are set up to promote the business. That
has produced a focus on high volume-low quality or in some cases supporting the
specialty with the highest reimbursement and procedure rates.
Associated dynamics are in place to select and shape an idealized corporate
employee who will modify his or her practice according to the whims of the
Corporation. It may be hard to believe but large medical corporations
everywhere are trying to figure out how to recruit young physicians who believe
in their models. Physicians who don't accept these ideas frequently find that
the company is not very friendly to them. There are always various political
mechanisms for ousting any dissidents and there is minimal tolerance for
debate. The dissent can be as mild as asking why consultants with less
expertise than the physicians in the practice are being called in to critique
them and come up with a plan.
When it comes to physician mismanagement there
are few businesses that can equal the government. RVUs, the Medicare Physician
Payment Schedule, pay for performance, and various failed political theories
like fraud as the cause for healthcare inflation, and managed care amplifying
all of the above and focusing all of that irrational management directly on
physicians. The result is obvious as enormous
inefficiencies, job dissatisfaction, and demoralization. Governments partnering
with businesses and placing business practices like utilization review and
prior authorization in state statutes increases the burden exponentially. At
the heart of this conflict is a physicians training to be a scientific critical
thinker and function autonomously with the businesses interest of making a
buck. Despite all the lip service to quality, business decisions are always
made on a cost rather than quality basis.
It is often difficult to see any light through
the blizzard of government and business propaganda that passes for the management
of physicians and psychiatrists. Psychiatry has bore the brunt of
mismanagement over the past 20 years and that has well been well documented in
the Hay group study showing the disproportionate impact of managed care on our
field. Inpatient bed capacity has dwindled and the beds that have not
been shut down are managed for high-volume low quality work.
Outpatient clinics including those run by and nonprofits are managed according
to the same model. Businesses and governments have provided the incentives
for this type of practice. The available consultants in the field only
know an RVU based productivity model and nothing else. Rather than treating
psychiatrists as knowledge worker assets, the available jobs frequently reduce
us to micromanaged clerical workers utilizing about 10% of our knowledge.
It should be no surprise that the environment makes it seem like anyone can do
the job.
One of my favorite quotes from Peter Drucker was:
"More and more people in the workforce and mostly knowledge workers will
have to manage themselves". After all, only the
knowledge worker knows how to best complete the job. Every psychiatrist that I know, knows how to get
the job done and it is often at odds with what we are allowed to do. The best
pathway to do this is to optimize the internal states of the knowledge workers
and create environment where they manage themselves. There are very few
environments available where that can happen today for psychiatrists.
George Dawson, MD
