An Unpublished NEJM Letter

 

 I was notified this morning that a letter I sent in to the New England Journal of Medicine would not be published because they had limited space.  Anyone sending a letter is notified that if the letter does not respond to one of their articles you are limited to 400 words.  If your letter does respond to an article the word limit is 200 words.  I was responding to an essay by Lisa Rosenbaum, MD (1) and whether medicine is a calling or just a vocation and the implications that each of those categories have.   My first attempt at the 400-word mark (374 actual) is below:

 To The Editor:  The essay by Dr. Rosenbaum (1) highlights a critical issue in medical education, research, and practice.  Much of the analysis is dependent on the concept that medicine is either a job or a calling. The critical factor in all settings is the practice environment.  Over the past 30 years we have seen a severe deterioration in that environment and how it impacts physicians. 

Forty years ago – physicians were valued as knowledge workers.  Work quality was emphasized and teaching departments were run by senior physicians who emphasized teaching and research.  They were models for focused lifelong learning and were able to maintain interest and enthusiasm in their departments by balancing clinical demands and those learning tasks. Trainees in the department benefitted from identification with these physicians as well as learning clinical approaches in their specialty.  The department head often had a business administrator in the department, but there was no doubt that the focus was medicine first and business tasks were minimal.

Over the past several decades, business and political interests have changed the physician role to production workers. Physicians are now valued in corporations for productivity and all the administrative time that takes. Department heads are often more focused on business matters than teaching and research.  Meetings take on a business rather than academic orientation.  More time is spent learning about the business environment rather than learning medicine.  The administrative burden alone easily exceeds the time used in the past for teaching rounds and conferences.  This burden has also decreased physician efficiency and added hours per day producing documentation for billing purposes that is repetitive and excessive. It also detracts from the physician patient relationship that is further fragmented by physician extenders.

The modern practice environment is not conducive to producing and motivating physicians.  Rather than an environment where experts can have spirited exchanges about medical care – it is one where experts are second guessed by administrators with no medical training.  It is an environment that does not produce a calling.

Recognition of the severe deterioration in the practice environment is the first step in correcting the problem.  Steps need to be taken to restore practice environments to stimulating settings that can lead to a high level of expertise, quality, and humanistic care.    

 

George Dawson, MD, DFAPA

 

References:

1.  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

 

The final 200-word final submitted version is below:

 

Rosenbaum argues doctors' declining job satisfaction stems from corporatization, generational changes, and a shift to production-style management.¹ Traditionally, senior physicians oversaw the practice, fostering a learning and research environment. Forty years later, business managers treat doctors as production workers² in an increasingly inefficient environment. This clashes with physicians’ role as knowledge workers, requiring intellectual stimulation, collegiality, and patient-centered care.

That change is responsible for a marked deterioration in the training and practice environment.  Business practices have been emphasized to the point that there has been an adverse effect on physician time management for professional and personal activities. It is also a direct cause of burnout.³

Physicians function best as knowledge workers consistent with their training. Physicians have been forced into the role of production workers. The solution is not to develop a rhetorical response to being in that role. The solution is not an idealization of the “good old days” – but recreating and restoring the physician knowledge worker environment.  That is the first step toward making physician sacrifice meaningful again.

 

George Dawson, M.D.

 

1.  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

2.  Drucker PF. Knowledge worker productivity – the biggest challenge.  California Management Review 1999; 41: 71-94.

3.  Lacy BE, Chan JL. Physician burnout: the hidden health care crisis. Clinical gastroenterology and Hepatology. 2018;16(3):311-7.

 

It took me 5 rewrites to get to progressively less words.  When you tend to use as many words as I do that was a painful process.  If you are a blogger the pain is compounded by the fact that editorial control is lost and you cannot publish your comments anywhere else (including a blog) if you hope to get them published in a journal.  The NEJM has a 3-week deadline for letters based on their articles.  It took them 5 weeks to reject it. They obviously can publish whatever they want and provide whatever rationale that they want – but the space argument seems thin.

Let me suggest why I thought this letter – even pared down to 170 words was important enough for me to send.   A brief review of Dr. Rosenbaum’s essay is necessary and if you have access, I encourage you to read it.  The essay begins with standard blue-collar rhetoric rooted in reality – basically that the working man is subjected to the whims of corporations who rarely have their interests in mind.  A young physician from that family concludes that the idea of medicine as a calling is using that term “weaponized against trainees as a means of subjugation— a way to force them to accept poor working conditions.” 

The problem with that analysis is twofold.  First, trainees do not have a monopoly on subjugation by corporations or the government.  It has been a decades long process directed at practicing physicians.  Second, rhetorical “weaponization” of terms applied to the profession is unnecessary.  That battle has already been lost. The current work and training environment has been deliberately shaped by the managed care business and like-minded governments for the past 30 years. Businesses don’t have to use weaponized rhetoric.  All they have to do is replace physicians with non-physicians, tell them they can work somewhere else, or reduce their compensation or just not pay them if they don’t meet their productivity expectations. They can also use internal committees and business practices to scapegoat and gaslight physicians who they do not like.  There is essentially unlimited leverage to get what they want.  All those measures are far more powerful in getting physician compliance than suggesting they need to make sacrifices in the service of a calling.  Physicians today are expected to make significant sacrifices or else – all in the service of their business masters.  It is evident the young physician in the essay knows nothings about it. The only practice and training environment that he knows is the one that has been severely compromised.

From medicine-as-a-calling, Rosenbaum introduces us to workism.  This term was coined in an Atlantic magazine essay to suggest that somehow work is a central part of life, identity, and meaningfulness is life.  That author goes on to suggest that people born between 1981 and 1996 were encouraged in this attitude and found themselves instead in debt and with no meaningful life work.  That led to demoralization and nihilism about capitalism.  When I read these paragraphs, I had to wonder how naïve this generation could be?  How could they possibly think that American capitalism and the economy was good for anybody?  Don’t they read anything about the environment, pollution, climate change, environmental catastrophes, unnecessary wars, near economic catastrophes – all precipitated by American capitalism?  I don’t think the idealization of work or capitalism explains the lack of medicine-as-a-calling.

There is a glimpse of reality in the next section when we hear how of how a long-time residency director of internal medicine stepped down due to a misalignment of the missions of hospitals and training programs. That is really putting it mildly. In many cases that difference was all it took to destroy training programs.  It is common to hear how residents are just used as inexpensive labor – but that has always been the case. The real problem is that the quality of teaching is adversely affected when faculty are told that they must max out their productivity and at the same time – get no credit at all for teaching.  

Rosenbaum’s essay depends on generational stereotypes and barely touches the root of the problem.  I reference the work of Peter Drucker – widely considered a guru in business management.  He pointed out the differences between production workers and knowledge workers. Basically, knowledge workers are quality focused in areas that they have more expertise than the management does. They are generally felt to be critical to the business and the idea is to retain them and give them adequate resources. Establishing a culture of excellence in their knowledge base adds to the environment. Production workers are engaged in repetitive tasks.  Their supervisors generally have worked their way up from doing the same tasks and therefore know as much about their work.  Early experiments in mass production showed that analysis of the repetitive tasks by so-called efficiency experts could improve the overall production.

What has occurred in the past 30 years has been the mass conversion of physicians from knowledge workers to production workers. The associated practice and academic environments have suffered drastic changes. Academic physicians have found that a major part of their work – teaching and research has been devalued in many cases to nothing.  In the meantime, they are expected to see many more patients, often to the point that they find themselves in new clinics – just to increase the overall billing.  The electronic health record (EHR), billing, and coding, and maintenance of certification are all added time penalties with no associated productivity credit. They have little say about how they see patients or how many patients they see.

I will cite one of many examples to highlight these points.  Just 5 years ago,  an internist I know was audited by his managers who had him tracked from 8AM to 4PM by an efficiency expert. That time frame encompassed 90% of his patient contacts, but only 66% of his workload.  Every day when the efficiency expert left – he would ask: “Where are you going? I am here for another 4 hours.”  The managers wanted to use the efficiency expert report to suggest that he was not efficient enough in seeing patients – but the real problem was the lack of clerical support and the EHR. The exercise was enough for the internist to realize he was working in a hostile environment and he moved on.  A clear loss of a knowledge worker.  The corporate myth that everyone is replaceable missed again in this case. This internist had experience and skills that could not be duplicated by anyone else in that clinic. This cycle of corporate flexing repeats itself thousands of times per day.

There can be no calling to work in such an environment where your work is routinely denigrated and devalued.  It plays out as a personal attack. You will necessarily feel like a production worker and start to work on the goals of production workers like standardized working conditions, hours, and benefits.  When you come home at night – you will leave the job behind you and no longer think about the patients who have problems with no solutions or what you need to know to do a better job. There is no esprit de corps of cohesion, support, and invigoration necessary for a stimulating knowledge worker environment.

That is the recent attitude and it correlates directly with the business takeover of medicine – not the newest generations.  It also correlates with prominent editorials in the top journals of our field like the New England Journal of Medicine.  These editorials illustrate on almost a weekly basis that there is no end to the businessmen, politicians, and lawyers who want to run and ruin our profession.  To date – they have been tremendously successful.  There is also no lack of evidence that the medical profession has been completely inadequate advocating for a reasonable practice and training environment.

Medicine will never be a calling again until the work and practice environment has been repaired and removed from the complete control of businesses and governments.

And yes – it is that simple.

George Dawson, MD, DFAPA

 

References:

1:  Rosenbaum L.  On calling – from privileged professionals to cogs of capitalism?  N Engl J Med 2024; 390: 471-5.

2:  Drucker PF. Knowledge worker productivity – the biggest challenge.  California Management Review 1999; 41: 71-94.

Graphic Credit:

All details at this link.  Coming from 4 generations of railroad workers it was a natural choice:  

https://commons.wikimedia.org/wiki/File:Group_of_laborers_digging_through_dirt_pile_along_railway_bed_LCCN2016647134.jpg

Knowledge Workers

 

I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. Since then, things continue to go in the wrong direction.  Some knowledge workers get more recognition from the business managers than others but it is based on income generation rather than the cognitive aspects of the job. And of course, psychiatrists are managed as if there is no cognitive aspect as all.  In an interesting development at the time, I was contacted by Canadian physicians after this editorial was published in the newsletter, but no American physicians.

 

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise. In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems, we all encounter in our work environment on a daily basis I had the recent thought that this is really a management problem. Most of the management that physicians encounter is strictly focused on their so-called productivity. That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians. Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year. Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this

is always in the larger context of increasing RVU productivity. Internet searches on the subject of physician management gener­ally bring back diverse topics like "problem doctors", "managing physician performance", "disruptive behavior", "anger manage­ment", and "alcoholism", but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management, I encountered the work of the late Peter Drucker in the Harvard Business Review. Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".  He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager. Work quality is more characteristic than quantity. Knowledge workers typically are the major asset of the corpora­tion and attracting and retaining them is a corporate goal. Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers. It does not take an expert in management to realize that this is not an efficient way to run a knowledge-based business. Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines? Would you replace the engineers and architects by general contractors or laborers? I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions. The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists. The second approach is addressing the issue of RVU-based pay directly. I will address the commonly used 90862 or medication management code. As far as I can tell, people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects. I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic inter­vention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all a la carte items that need to be assigned RVU status and added to the basic code. Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines. The final solution looks ahead to the future and the psychiatrist's role in the medical home approach to integrated care. We cur­rently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall, these are political problems at the legislative, bureau­cratic and business levels. It should be apparent to anyone in practice that when political pressure succeeds in dumbing down the profession, it necessarily impacts adversely on work environ­ment, compensation, and most importantly the ability to deliver quality care. The continued mismanagement of psychiatrists by businesses and bureaucrats who have nothing more to offer than a one-size-fits-all productivity-based model, is the biggest threat to psychiatry today and a much more enlightened man­agement strategy is urgently needed. The Minnesota Psychiat­ric Society and the APA need a strong voice in that change.

 

George Dawson, MD, DFAPA

Happy Labor Day IV

This is my fourtth Labor Day writing this blog and it is my custom to summarize the work environment for physicians like I did in Happy Labor Day I, II, and III.  Things have not improved very much and there was a timely piece by an anonymous physician filed on another blog entitled Confessions of a Burnt Out Physician.  That post is full of anecdotes about physicians being managed like production workers and to the point of not even having an adequate work space to conduct work that requires focus and confidentiality.  Another key element of managing physicians is to make sure that their days and nights are filled with the modern equivalent of paperwork - e-mails and charting that is read by nobody except the occasional coding and billing staff.  If that is not demoralizing enough, there are always the suggestions that physicians are not doing enough, even though they are easily in the hospital for 4 or 5 hours after all of the business people are long gone.  This can all be handled masterfully.  As an example, the RVU productivity system was in many cases introduced to physicians as a system of "fairness".  That is - the idea that everyone has to pull their own weight.  That works very well in any environment of competitive physicians.  It was dovetailed in nicely with multimillion dollar lawsuits by the Department of Justice that were based on charting.  Now physicians could be fined or imprisoned if their documentation was not up to snuff.  And of course the Department of Justice wanted every physician in this country to know that any discussion of fees was a potential antitrust offense.  When all of that business rhetoric had settled out, the only things that really changed was how easily physicians could be manipulated and overworked while their professionalism was completely ignored.  Apparently none of us knew how to work or act before managed care came along.

There have been some additional business innovations in the last year to make physician's lives even more difficult.  I read another blog recently where the topic of physician managers affiliated with Big Pharma were desired to bring money into departments and how that and key opinion leaders (KOLs) from that field was a key corrupting influence in medicine and psychiatry.  That influence is trivial compared with the business influences on medicine and their adverse effects.  Excellent clinicians, teachers and researchers now need to get an MBA before they are considered as a department head.  A managerial class that is progressively less competent to manage may be an acceptable business standard but it seems like an extravagance in medicine and one that has cost us hundreds billions of dollars and untold unnecessary work for physicians.

Furthermore, we know what works in terms of physician management.  I worked in tens of departments where the department head was a physician who was in that position because of skills pertaining to clinical care, teaching and research.  That doesn't mean that they were necessarily easy to get along with, but in teaching institutions their skill set was on display every day.  That model transitioned to one where a physician and an administrator of some type both co-lead the department.  The physician leader was still affiliated with physicians in the field at that point and could feel their pain.  The next step was removing any physician with those alliances from an administrative position.  In many cases, this meant people who had no hesitation to manipulate physicians either by a "It's my way of the highway" attitude,  making the environment so hostile that they forced selected dissenting physicians to quit, or after pretending that the physicians had some input (usually through endless mind-numbing meetings about the business) simply telling them that no matter what their opinion was - this was what would be happening.  Throughout the process there was an endless stream of "Change is good", "Cost effectiveness", and "Managed care friendly" propaganda.  But it didn't stop there.  Managed care run institutions have an entire cadre of case managers whose primary job is to "manage" physicians and make sure they are discharging people according to the companies proprietary standards.  If there are any disagreements that low level administrator can easily go up the change of command to get decisions in their favor or identify physicians who are not in lock step with the company.  Everywhere within these organizations there are rules about identifying "disruptive physicians" and penalizing them.  I am not talking about doctors throwing scalpels across the operating room.  The threshold can be so low these days that a "disruptive physician" is anyone who gets into it with an administrator for any reason, including legitimate disagreements.

The effect on the psychological environment of physicians has been corrosive.  Within a generation we have gone from a training environment where medical students and residents could identify with senior physicians who embodied professionalism and an intellectual approach to medicine to managed care employees who use a business approach.  Instead of rounding on patients and learning the importance of medicine as a life-long intellectual pursuit, trainees are focused on the business manager's pursuit of getting patients out of the hospital so that corporate America can keep making money by easily beating the fixed reimbursement scheme set up by the government.   The business rationalization has always been "of course we need to make money to keep the doors open", but that never addresses the trade-offs.  In this case the trade-off is no relationship or plan to assist the patient.  In the case of patients with psychiatric disorders, there are inadequate inpatient and outpatient services, both due to business rationing to maintain profits in a rationed and cost-shifted world.  In many cases health care systems have carried these plans to their absurd conclusion - just close any inpatient beds, close the outpatient clinics, and hope that some taxpayer funded clinic or jail can pick up the slack.  The typical health care manager has an endless stream of bad ideas.

Are there any bright lights on the horizon?  I think that there are.  I would count the movements against the medical specialty boards and the proposed maintenance of certification (MOC) programs.  It is very positive that physicians are standing up and saying that they are unnecessary, not evidence based, and a tremendous waste of time, money, and resources.  More importantly all of that stress falls squarely on overworked physicians.  There is now at least one parallel certification organization that depends primarily on initial board certification and then continuing medical education courses - the historical standard.  It will take a significant commitment, especially from younger physicians to keep this movement alive because it is just a matter of time before credentialing committees for clinics and hospitals will be putting the squeeze on their physicians to use the labor intensive MOC programs.  There is also the question of medical boards.  Will they require MOC for maintenance of licensure (MOL)?  Only time will tell, but like all things American - the bet is on the oligarchs and that currently is everyone making a lot of money out of managing physicians.  At some level that includes professional organizations populated by members who are very friendly to the business world.  If anyone doubts the benefits to professional organizations, just visit the American Psychiatric Associations Learning Center and the MOC offerings.  If the monopoly can be broken, it suggests that physicians may have the ability to counter the business and government strategies that keep what is basically an anti-physician system afloat.  Business strategies have nothing to do with the practice of medicine.

Another bright light that I neglected to comment on initially is the young psychiatrists going into private practice.  At first I was reluctant to endorse this idea, primarily because it contrasts so starkly with my experience in community psychiatry, acute care psychiatry, and general hospital psychiatry.  I was concerned that there would not be enough psychiatric expertise to care for very ill people.  But in conversations with many young colleagues they are some of the brightest, happiest, and enthusiastic physicians that I have seen.  The reason I am given by these docs is that they decide who they are going to see and what their schedule is and not some administrator.  They decide what their clinic policies are and not some administrator.  Some of them have worked in managed care settings and had the courage to walk away after the standard "performance evaluation", especially when it had become an exercise in a loyalty oath to the company and trying to dredge up anonymous critical remarks from coworkers.  My opinion on this private practice trend is that it is a good one.  Any person consulting these folks is going to get recommendations based on quality psychiatric care and not proprietary managed care guidelines.  They will also be talking with a psychiatrist who has not seen ten other people before them and one who has the energy to focus on their problems and possible solutions.  Some of these private physicians also spend days in community mental health centers and on community support teams - treating patients with severe problems.      

So my fourth Labor Day message is slightly brighter than the last three, but not much.   I have to say that there are a few of us around yet who know exactly what happened and what is possible -  and I feel your pain.  If you feel up to it post your anonymous story here.


George Dawson, MD, DFAPA

How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped

The truth crops up in unexpected places.  A colleague directed me to an article is USA Today that I found to be very interesting.  It clearly describes the central problem with health care in America.  From that article (see reference for full text, clinic map and video):

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

The report details what happened when the Army's outpatient substance use clinics were shifted from medical oversight by the Surgeon General's Office to the Installation Management Command.  This change occurred in 2010.  Some of the changes noted are striking including a basic error in hiring an unlicensed counselor.  Since 2010,  90 soldiers committed suicide and 31 of those suicides occurred after reviewers concluded that there was substandard care.   They could not conclude that the substandard care was causal.  Review of additional data showed that 7,000 soldiers were identified as having a problem but not offered treatment.   Half of the 54 substance use clinics were rated as substandard, specialists identified "poor continuity of care" as a problem, and staff attrition as a significant problem.  Only 309 of 352 counseling positions are currently filled.  The same article estimates that 104,000 soldiers have drinking problems.

What is the significance of this report?  I don't think there is anything unique about what happened to the Army's substance use clinics when the management changed.  It has been happening everywhere else for at least 25-30 years.  Before that time, medicine and specialty departments were managed by senior clinicians based on merit.  The department heads were active clinically and they were valued for their clinical and research expertise.  Some of the most valuable teaching experiences I had during my training occurred due to direct contact with these department heads.  Reviewing brain and spinal imaging with the head of the Neurosurgery Department.  Doing rounds at night with the head of the Renal Medicine Department.  The list goes on.  The point is that all of these experts were engaged in treating patients and teaching medical students and residents.  They had an intimate connection with the provision of care and the profession.  Many of them also had great personalities.  So what changed?

They changes were subtle at first.  When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department.  The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital.  They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students.  These experts were consulted in complicated cases to back up the generalists who were now seeing their patients.  The next step by the managers was to suggest that productivity in the larger departments was uneven.  They suggested that they had a metric so that would assure that everyone in the department was pulling their weight.  When I first heard that explanation, I looked around and concluded it was a myth.  Everyone in my department was a hard worker and that was borne out by the actual numbers.  The numbers were the real story.  The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective.  But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager?  Well it seems like easy work if you can get it.  Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations.  If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring."  That may be applying a medical metric to business that could be far from the mind of managers.  Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2).  Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business.  Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers".  These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor."  He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302).  I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine.  In both cases, the managing class came about largely as an invention of federal and state governments.  The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money.  Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers.

When I try to talk with people about this problem their eyes glaze over.  Advantage to both the financial and business managers.

In the meantime, when you drive by your local hospital and it claims to be one of the "Top Hospitals in the US" - don't be surprised to learn that there are at least 600 hospitals on that list.              


George Dawson, MD, DFAPA


1:  Greg Zoroya.  Investigation: Army substance-abuse program in disarray.  USA Today.   March 12, 2014.

2:  Rakesh Kurana.  MBAs Gone Wild.  The American Interest.  July 1, 2009.

3:  Thomas Piketty.  Capital in the Twenty-First Century.  The Belknap Press of Harvard University Press.  Cambridge,  Massachusetts 2014.

A Toxic Work Environment For Physicians

I posted my opinion on burnout interventions for physicians on another blog.  That opinion was that mental health interventions to address the product of a toxic work environment that is increasingly toxic seems futile to me.   The author agreed with me, but stated that her program was designed to help residents survive their residencies and nothing more than that.  She pointed out and I agree that residents can't change the structure of their work environment and they can't quit.  That is one advantage that more senior physicians have - they can do both.   The additional rhetoric on the thread suggested that there was no definition of a toxic work environment.  Based on what I have posted here,  I thought it would be fairly easy to pull together a few elements of that definition.

Before I proceed there are a few qualifiers.  As a more senior clinician it is possible like other areas in life, that younger colleagues do not have the same experience and therefore do not relate to what you are posting.  In this case it would have to do with whether or not they worked and trained in managed care environments.  I think that it is entirely possible that if you have worked and trained exclusively in a managed care environment, that your experience is entirely different.  That could make it more difficult to identify the cause of distress or it might make it easier to tolerate all of the non-medical intrusions into the daily work environment.  There are documented personality factors and cognitive styles like perfectionism and obsessiveness that have been implicated in burnout, but they tend to be traits that are inherent in most physicians so I am focused here on immediate environmental factors that are the cause of this widespread problem.   They are really quite straightforward and they can all be attributed to mismanagement:

1.  Sleep deprivation:  The adverse effects of sleep deprivation on cognition and emotional health are well documented.  The expectation that physicians will be sleep deprived is a well known tradition.  While there have been some improvements with restrictions in residency training on the number of hours of continuous work, current practices have in many ways led to a worsening of this problem.  The hospitalist movement had led to the 7 days on and 7 days off schedule that creates fatigue and decreased work performance toward the end of that stretch.  I have interviewed hospitalists about their experience and they have told me that their work slows down, largely due to cognitive inefficiency the last two days.  That slowing adds an additional 2-3 hours of added time to complete all of the work.  It seems like a questionable practice to extend working hours to the point of cognitive inefficiency and fatigue for the sake of the administrative simplicity of not having to schedule cross coverage for weekends.  Outpatient physicians are no less immune when they are expected to sit in their clinics long after hours to complete what are essentially administrative tasks.  Many of these administrative tasks are unnecessary from a medical standpoint.  In both cases the electronic health record (EHR) places a large burden on physicians everywhere and access to it from home can create a 24/7 work environment.

2.  Excessive workload:  The invention of RVUs has given administrators unprecedented leverage in establishing a high volume, low quality production line of physician services.  Markedly different quality of service can be provided by different physicians submitting the same billing code, but there is an unquestionable race to the bottom from the administrative side.  There is no better example than the annual review conversation where physicians are told where they are on the global productivity scheme and one of two things happen.  They are told that they should target a higher decile (or two) next year or they are simply given an RVU expectation that they need to meet in order to "justify" their salary.  In some cases there is just an arbitrary expectation of a percentage increase in RVUs with no theoretical upper limit.

3.  Changing work load:  There has been no accounting for the fact that physicians have taken over more and more work tasks in the past thirty years that were previously done by other people.  Transcriptionists and billing personnel have been replaced by the hundreds of thousands.  The burden for generating detailed medical documents and accurate billings falls directly onto physicians and it is a heavy price.  After seeing all of the patients in a day, physicians generally settle down to do all of this documentation with the associated phone calls and billing.  The expectation that physicians need to know about matching their documentation to a purely subjective billing and coding scheme that can change from year to year within an organization is a reminder of the absurd administrative burden paid by all physicians.

4.  Uncertainty:  Medicine is a demanding field that is mapped onto significant biological variability that increases with the age of the patient.  Coping with that uncertainty is one of the baseline tasks of physicians.   The best way to cope with it is to stay current with the best diagnostic and treatment practices of the speciality being practiced.  Business and government intrusions into this field based strictly on cost and regulatory changes introduce much more uncertainty.  These intrusions take the form of case managers or external reviewers demanding that ill people be discharged from hospitals based on an arbitrary length of stay figure,  those same reviewers denying a recommended therapy by the physician who has seen and is personally responsible to the patient, denied medications based on expense or contracting, or treatment based on guidelines promulgated by business organizations rather than medical or professional organizations.  There is also a broad movement to train physicians as basically customer service representatives through the use of very basic interpersonal techniques.  Many organizations use "customer" feedback as another piece of the algorithm that determines compensation.  The  important physician task of telling patient what they might not want to hear is not "incentivized".

The other relevant dimension here is that the staff who are ordering the physicians around are frequently not physicians and have no real responsibility to the patient.  They are frequently working from proprietary guidelines devised by people who are also not physicians and have no direct responsibility to the patient.

5.  The expectation of free work:  There is no better example of free work than looking at all of the employees in health care organizations that physicians have replaced, but it doesn't stop there.  Teaching medical students and residents is another good example.  Lectures and lecture preparation is not only not reimbursed but there is usually the expectation that the same number of patients needs to be seen that day or made up at some point during the week.  The teaching tasks are typically unsupported and lecturers and teachers are responsible for the lecture content and even getting the necessary copyright permissions.  Before managed care, medical education was more of an integral part of the work and physicians typically got credit for it and department support.  The current work environment emphasizes RVU productivity as the sole measure of reimbursement.  This has become problematic in academic environments that are supposed to emphasize teaching.  In many cases those academic goals have become secondary to so-called productivity.

Managed care has added an immense amount of additional free work for physicians.  It comes in the form of all of the additional work due to utilization review, medication prior authorizations, and a blizzard of additional paperwork.  In the case of medication prior authorizations it takes a minimum of 35 minutes a day and additional staff to do all of the paperwork, but I am sure that most physicians have spent that kind of time on a single case.  The initial impetus for these measures was supposed to be cost effectiveness, but it should be apparent at this point that making money for managed care companies is the real priority and physicians are forced into the role of rubber stamping these measures.  That rubber stamping comes at a significant time cost.  Aggressively holding physicians to a productivity standard, while wasting significant amounts of their time is probably the single most toxic factor in what is already a toxic environment.

5.  Overt abuse: With the unprecedented leverage that business administrators have over physicians and the proliferation of administrators there have also been additional strategies developed to get rid of physicians who are dissenters or don't fit with corporate expectations.  A familiar one is the disruptive physician concept and its many forms.  The corporate interest is in taking any complaint about a physician whether it is substantiated or not and using it to manipulate that physician.  There are many possible sources.  The 360 evaluation solicits complaints from all of the coworkers in the environment where the physician works.  Making those complaints anonymous will predictably results in more significant and negative complaints.  These may be reviewed in an annual review and used for compensation purposes or disciplinary action.  There are variations within organizations like a "three strikes and you're out" rule.  In all of these procedures the physicians involved have no recourse other than filing a lawsuit or defamation suit.  These procedures become tools that can be used by any administrator against any physician who is viewed as a dissenter to the latest and greatest idea by that administrator.  I have seen physicians subjected to firing and onerous rehabilitation schemes like meeting with an administrator and the supposedly aggrieved employee to help them get along on an ongoing basis.  Those exercises in manipulation are superimposed on the physician who is already trying to keep his or her head above water in the sleep deprived assembly line environment.

6.  The not so covert war against the medical profession:  Let's face it - business administrators would obviously love physicians to act the way they treat them - like production workers rather than knowledge workers.  They would really like to replace physicians with less expensive providers or prescribers and will eventually make the argument that a corporate structure with various computerized whistles and bells will be superior to trained medical staff.  The only reason there is any tension at all at this point is that some physicians have skills learned in medical school and residency that have been codified to a certain degree in the legal and regulatory landscape.  The only reason that behavior inconsistent with corporate behavior is tolerated is that a particular physician probably has skills that nobody else does.  That does not prevent administrators from threatening entire blocks of physicians with either disenfranchisement or firing.  The disenfranchisement can occur along the spectrum of decreased reimbursement, additional work expectations without additional resources, or both.  Additional sorties include campaign to teach physicians basic interpersonal skills learned many times in medical school and residency.  Bringing in consultants to tell physicians how to perform their work in a manner more consistent with what administrators want and ignoring the often considerable internal expertise in the department is another familiar strategy.  The legislative front has been exploited to the maximum already with business tactics like utilization review and prior authorization included in many state statutes.  The resulting business friendly legal and regulatory environment leaves very little room for criticism by physicians or their patients.

These are a  few of the examples of a toxic work environment for physicians.  I realize that many are not unique and that other assembly line workers may be subjected to the same abuses.  The problem of course is that physicians are not trained to work on an assembly line.  They are trained to be scientifically inquisitive and intellectually active.  That dimension alone requires many hours apart from work.  In addition to family life that intellectual aspect of being a physician suffers the most from the currently toxic work environment.


George Dawson, MD, DFAPA

Supplementary 1:  This blog is full of posts on the mismanagement of knowledge workers and the abuse of physicians by business systems.  Here are a few examples:

Mismanagement of knowledge workers

Mismanagement of knowledge workers

Demoralizing micromanagement of physicians

Lessons From Google on How To Manage Physicians

This month's Harvard Business Review has an interesting article on managing technical professionals entitled:  "How Google Sold Its Engineers on Management."  One of the secondary goals of this blog is to point out how people who manage physicians are not only technically inept but in many cases openly hostile to the physicians they manage.  That is largely because the entire system is based on artificial productivity measures and practically all of the management is focused on how to get more artificial productivity out of physicians.  A classic example of this kind of management focuses on how many deeply discounted patient visits are seen per day.  Other tasks like chart checks, telephone calls, paperwork of various kinds, and the tremendous burden of managing the electronic health record and all that involves are not counted as productivity of any sort.  Physicians are basically expected to do all of that plus teaching and lecturing on their own time.  In one system where I worked you were given points for being a good citizen and eligible for some trivial reimbursement if it was apparent that you were doing more than cranking out RVUs (the standardized measure of productivity).

This whole system of management is archaic in that it is a system that was set up to manage production workers and not knowledge workers with technical expertise.  Physician managers seem oblivious to the fact that the product of their organization rests solely in the expertise of their doctors.  A healthcare organization will only be that good and it is in the interest of that organization to retain and develop the careers of the best physicians they can find.  That is not the prevailing way that employed physicians are managed.  In fact, physicians are micromanaged and their decisions are routinely second guessed.  In the worst case scenario, if the physician disagrees with the financially based decisions of their managers they can be fired or politically scapegoated for not being a team player.  Some physicians may be subjected to several of these confrontations per day often over trivial cost savings.  In psychiatry for example, the arguments often arise over length of stay considerations where there is a set reimbursement for a hospital stay and the manager wants the person out sooner so the hospital can make more money.  The patient care goals of the physician based on their technical expertise and the financial goals of the case manager are discrepant.  That conflict is compounded by the fact that the managers do not have the professional credentials or the accountability of the physicians they are literally ordering around.
    
How do they do it at Google?  I consider engineers and doctors to be equivalent professions.  They  both require years of study and ongoing study.  They both have professional codes of conduct.  If there is any management on the technical side, engineers and physicians both want those people to have the best technical qualifications.  In that context the HBR article was interesting.  At one point Google wanted to try a completely "flat management system" with no managers.  Many of the engineers thought that it might recreate an academic environment similar to graduate school and produce a similar level of excitement and creativity.  That model resulted in upper management being flooded with human resources issues.  They eventually developed a system of managers with few layers designed to reduce micromanagement.  The example given was that some of the managers have up to 30 engineers reporting to them.  According to the engineer interviewed for the article: "There is only so much you can meddle with when you have 30 people on your team, so you have to focus on creating the best environment for engineers to make things happen."  This is a foreign concept in managed care.  Not only are physicians micromanaged but their work environment if frequently manipulated by various managers to decrease both their productivity and work-life balance.  It is a set up for burnout and suboptimal intellectual performance.

The following table is a good example of the differences between how Google manages their engineers to remain a state of the art engineering company with an emphasis on technical expertise.  There are very few medical organizations that have a similar focus.  The ones that do are usually criticized by managed care companies and dropped from their networks for being "too expensive."  As a physician ask yourself which environment you would prefer to work in.  Imagine working on the most exciting and intellectually stimulating team you have ever worked on in your training compared with where you currently work.  As a patient, the question is no less significant.  Do you want a physician who is excited about practicing medicine, who is intellectually stimulated, and not burned out or do you want a physician as they are currently managed?

Google Managers	Physician Managers
Micromanagement is prevented	Micromanagement is the rule of the day
Work environment is optimized for engineering work	Work environment is optimized for managers
Respect for technical expertise and problem solving rather than title and formal authority.	Strictly chain of command often flows from people with no technical expertise.
Good manager empowers the team.	Good manager empowers themselves and their boss.
Helps with career development.	At the minimum does not care about career development and at the worst may try to actively interfere with professional career.
Has technical skills to help and advise the team.	Has no technical skills and often has no medical degree or license.
Productive and results oriented.	Productivity is measured in adjusting physician productivity units

I used to work in a clinic that was analogous to Google in that we were: "A clinic built by physicians for physicians."  Our mission was to provide care to all people irrespective of their ability to pay.  We did not have a lot of resources, but we were good at our mission.  The collegial atmosphere was excellent and we did not make a lot of money.  It was an incredible learning environment where psychiatrists routinely interacted with colleagues from all specialties.  It was acquired by a managed care company and was managed less and less like Google.  Today all of its management parameters rest fully on the right side of the table.

The best management for knowledge workers is known.  Why don't we see it applied to physicians?

And yes, that is a rhetorical question.

George Dawson, MD, DFAPA

The Dog Quadrant

Before anyone gets the wrong idea, this post is not about pet therapy.  It is not about the purported advantages of owning a dog.  It is not even about the new research on dog intelligence that I was frankly surprised by, especially the research showing how easily dogs can beat non-human primates on specific tasks.  So much for that massive frontal cortex conferring supreme advantage over the animal kingdom.  No - this is about managed care and using the term "dog" in its pejorative context.

Several years ago, I was burned out and suffering from the type of large scale mismanagement that is so common in organizations that run on managed care principles.  I attempted to approach the problem with humor by reading Dilbert cartoons.  Read the first few pages in the Dogbert Management Handout to see what I mean. I soon realized that this stuff was too close to the truth about health care management and decided to look for other management styles.

I happened across the work of Peter Drucker and his ideas about managing knowledge workers that were considered revolutionary.  There was certainly nothing like that going on in health care.  The managed care approach to managing physicians was to actually treat them like they were not knowledge workers but assembly line workers.  Drucker's stroke of genius was in recognizing that managers know much less about products and processes than knowledge workers and that the business was essentially the product of the knowledge workers.  Managed care techniques are diametrically opposed and are based on the fact that business guidelines are somehow relevant to medical care and even may actually be called medical quality.  There is no health care process more autocratic and primitive than managed care. I have reviewed how this bizarre set of circumstances evolved in several posts on this blog.

Along the way, I also interviewed a health care business management expert and asked him if there were any definitive texts that are used to train business people about managing health care and he referred me to the text Strategic Management of Health Care Organizations.   I started to read and study the text, initially trying to find out why Drucker was completely ignored by health care managers.  That was when I encountered the BCG Analysis for a Health Care Institution (p 254).   BCG is an abbreviation for Boston Consulting Group who came up with this technique for analyzing products and services.  In this case, there was a four quadrant graph that differences in market growth rate and relative market share position.  I don't have permission to reproduce it here so I will do my best to describe it briefly.  The high growth/high market share quadrant was termed "Stars" and contained services like orthopedics, cardiology, oncology, and women's service.  The medium/high and high/low quadrants were called "Cash Cows" and "Problem Children".  The lower right hand quadrant of the graphic were the "Dogs" and they included psychiatry, ENT, pediatrics and others.

I am no financial analyst, but what is wrong with this picture?  Let me give you a hint.  If you have a portfolio of medical services and one of them is selected for rationing and the others are not - it should easily end up in the Dog quadrant.  The selective rationing of psychiatric and mental health services is a known fact for the last 30 years.  When you ration a service you naturally slow its growth and reduce the market share.  The market share is reduced even more precipitously when you start shutting down bed capacity and hospitals.  Early in the course of all of these events some high profile teaching units in hospitals affiliated with prestigious medical schools were shut down and it was described as being secondary to a lack of reimbursement from companies using managed care models.  If you are in a business that severely distorts the market by controlling growth and market share it makes little sense to pretend that you can analyze portfolios across an imaginary market and make decisions about resource allocation in an organization.

If you were a physician unlucky enough to be trapped in this process it played out in several ways.  There were endless meetings that formed the base of misinformation.  There was the suggestion that productivity was the only fair way to reimburse physicians and the implication that some physicians were much less productive than others.  That was a good way to provoke the competitive, even though in practically all cases that was not true.  Then there was the usual barrage of financial information.  Overhead figures from who knows where.  The suggestion that physicians may need to cover the salaries of any physician assistants working with them.  It was an unending painful process designed to give the appearance that physicians had a say in the business, except at every critical decision they did not.  In the end all there were was a long series of Dogbert management PowerPoints.

I have not seen the latest edition of the book and I wonder if there have been any additional pejorative classifications for mental health or psychiatry.  One thing is for sure.  You don't end up in the Dog quadrant because of lack of real demand or free markets.  You end up in the Dog quadrant because of managed care and their supporters in the government.

And then they can use this analysis to remove even more resources.

George Dawson, MD, DFAPA

Happy Labor Day II - To All of the Docs on the Assembly Line

Last year I posted a Labor Day greeting to all of the docs laboring in American medicine.  I used the assembly line metaphor for obvious reasons - physicians were no longer being treated like knowledge workers but were being treated like assembly line workers.  Circumscribed patient visits were the widgets.  In the case of proceduralists the procedure was the widget.  One of my friends referred to himself as a "scope monkey" based on the expectation for the number of procedures he was supposed to produce every year.  Have there been any substantial changes in the last year?

The bad news is that there have not been. Managed care continues to consolidate its monopoly.  The final product under the Affordable Care Act (PPACA) will result in unprecedented leverage on the part of that industry over physicians and patients.  I often compare the healthcare industry to the financial services industry when it comes to an example of government determined monopolies.  The 401K is a great example of how this works.  The 401K was sold to the American public as a great way to save for retirement.  When the choices in 401K were limited it was sold as a way to simplify the 401K for most people.  The truth about 401Ks is that they have not been a very successful investment vehicle.  They put trillions of dollars of retiree savings at risk and the fees they charge are even more outrageous than medical fees.  I just looked at a bond fund prospectus this morning that shows on an investment of $10,000 I could expect to pay $1,000 in fees every 10 years.  Considering that there are about $9 trillion dollars in 401Ks and IRAs that generates about a trillion dollars in fees (about $90 billion a year) for the financial services industry.  Those fees are generated independent of the general goal of retirement funds - actually having money for retirement.  My prospectus has the usual disclaimer: "The value of your investment in the fund can go up or down.  You can lose money by investing money in the fund."  As many baby boomers found out that can be 30-40% of your principal.

How does managed care compare?  The most interesting game has been the idea that all fees will increase substantially with the implementation of the PPACA.  This bill allows for unprecedented merger and efficiencies.  It allows for only 80% of the health care premium to be devoted to the actual provision of health care services.  It is logical to assume that a greater percentage of the health care dollar devoted to health care would also decrease premiums.  There will be significant hidden savings associated with a model of care that is integrated and minimizes the amount of physician billing.  Insurance company rhetoric suggests that provided additional services to the uninsured with no limitations on pre-existing conditions will more than cancel out the monopoly advantages.  If that was true why lobby for large monopolies?

One of the indicators to me of just how much leverage the managed care industry has is the expected out of pocket costs for a retired couple on Medicare.   That number is currently $220,000 not including nursing home costs.  That is roughly more than four times the average retirement savings for most Americans.

The financial services industry and the medical industry are basically government mandated hidden taxes on the American people.  In exchange for that huge subsidy we get an industry that charges us significant fees to place our retirement funds at risk all of the time and another industry that rations health care and charges whatever they want in order to make money.  In the case of the medical industry the overriding philosophy is not consistent with an enlightened approach to employees that probably know a lot more about the provision of quality medical services than the administrators.

That conflict of interest is central to the deterioration of the practice environment and a diminished focus on quality care and a continued focus of the study and academic aspects of medicine.   Having medical care dictated by administrators using business guidelines or managed care reviewers using the same approach is demoralizing.  Unless this conflict of interest is adequately addressed - the focus of health care will be turning out widgets.  Only the widget producers will be valued.  Administrators making arbitrary decisions run the whole show.

All of this remains decidedly grim in terms of the practice environment where most physicians work.  It is only fair to consider some solutions.  I will try to avoid the political decisions I have advanced in APA and other medical forums over the past 20 years.  Physicians are uniquely oblivious to the fact that the science of medicine is routinely trumped by business and politics.  Are there any possible solutions?  For many years private practice was always considered an option.  With the PPACA that route will be more difficult because the solo practitioners and groups will probably be off the network and professionally isolated, but some will be able to practice in this environment.  There is still niche work where physicians can be paid professional salaries and still have adequate time to complete all of the administrative tasks and focus on quality work, but they are rare.

A single exciting model that I think can disrupt the usual managed care and government restrictions that I expect to flow from the PPACA comes from the University of Wisconsin and their Memory Clinics approach.  This is a statewide network of clinics focused on providing state-of-the-art and quality care across a number of settings.  Guidelines, continuing education, and consultation is provided from a University based department and there is a minimum requirement for for ongoing education every year.  I don't see why this model cannot be widely applied across psychiatry and all other medical specialties.  It brings the academic focus back into medicine instead of the current focus by governments and business.  The practice environment of medicine needs this academic focus and it would greatly enhance the practice environment and get us out of widget production.

That is my hope between this Labor Day and the next.

George Dawson, MD, DFAPA

Financial Blogger Gets It - Sort Of

I was buoyed to see this line as the title of a financial blog today:  "Coming Corporate Control of Medicine Will Throw Patients Under the Bus".  You don't usually see that level of insight into what is going on in medicine from financial people who have usually bought the "cost effectiveness" dogma, even at a time where middlemen are siphoning off hundreds of billions of dollars from the direct provision of health care and producing an inferior product.  I will say it for the thousandth time - what other industry can make money by selling you a rationed product and denying your access to that product?  Can you imagine what the automobile or cell phone market would look like with that guiding principle?

The article is  focused on two critical issues-physician management by people with no medical experience and the message from the top.  The first part of the article discusses the situation of a pediatrician who had successfully managed a clinic but found herself being managed by a non-physician who told her that she either had  to see very complex patients in a shorter period of time or not see them at all.  The second part of the article focuses on a blog post where a CEO/physician for a managed care company flat out encourages physicians to get rid of difficult patients to improve their managed care style performance measures.

The blogger in this case is Yves Smith.  I have been reading her blog for years.  She wrote the book Econned and takes a generally skeptical view of that way that financial markets are regulated and run.  I have seen her do commentary on some financial television but infrequently.  I would tend to see her commentary as legitimate criticism and welcome in the area of physician and health care management.  As a blogger she is highly successful.  This post alone has about 40 pages of commentary.

In this article she has some additional comments about what physicians face in the assembly line of today's managed care environment:

"As an aside, it's hard to stress enough that this sort of demoralizing micromanagement an unwillingness to listen and learn from workers is a weird shortcoming of management American style.  And it has been weirdly airbrushed out of the media."    

I can't agree more with the second comment in particular.  The American public gets a glimpse of how their health care management occurs only when Michael Moore makes a movie about it or they are confronted face to face with an impossible situation.  That happens all of the time in psychiatry with restrictions on treatment to the point that it seems like treatment has never occurred.  To get that accomplished takes both micromanagement of physicians and a general management style that greatly emphasizes profit margin over patients.  At the public relations level, physician opinion especially physician dissent is not tolerated.  The personal experience of the physicians in these systems is considered the property of the organization.  Any public disclosure of the severe shortcomings can be ruthlessly suppressed either by firing or a series of political maneuvers designed to force resignation at some point.  

There is a divergence of medical and corporate culture at the level of disclosure of errors or wrongdoing.  For most of my professional life I have been in monthly conferences - some type of mortality-morbidity conferences where real or potential errors were discussed on a department wide basis.  I don't think that happens in the corporate world.  I think that errors in the corporate world are acknowledged if they are widely known and there is an emphasis on public relations and maintaining an almost unrealistic positive light on the company.  That has been most evident in the past decade with an abundance of managed care public relations.  Wherever I turn it seems like I come across a hospital or clinic that is proclaiming themselves as the "best" - usually in the country.  That kind of advertising by physicians was widely viewed as unethical by state medical boards.  These ratings are usually based on a few process parameters that can be actively "managed".   Contrary to what health care management tells you the quality of any hospital or clinic depends on the quality of the physicians working there and the level of autonomy they have in their medical decision making.

You can have the best surgeons, internists, or psychiatrists in the world and if they are managed to see as many patients as possible and provide the care that will provide the best profit margin for the company - their medical and surgical care will not be appreciably different from a mediocre staff.

I wrote a piece several years ago about an informed approach to managing knowledge workers that originated with management guru Peter Drucker.  The details can be found in the original piece in this newsletter (page 3) and a earlier posts on this blog.  Everywhere I look in health care we are at the opposite pole from Drucker.  Managers are generally far too authoritarian in dealing with physicians especially in cases where (like the Yves Smith blog post) - the mangers know far less than the physicians.  This managerial style is also disruptive.  Many health care managers think that they can implement any idea they wake up with that morning if they accompany it with enough "Change is good" or "Cost effective" rhetoric. All of this micromanagement and mismanagement illustrates that Dilbert has changed professions.  He is currently wearing a white lab coat.

The other bad news of course is that corporate control of medicine is not coming - it has been here for years.  In the case of psychiatry it has been here for 30 years.  Anyone who wants to see how corporate control of medicine changes things only has to look at the state of current psychiatric services or their "shortage" for a lesson.

George Dawson, MD, DFAPA

Mismanagement of Knowledge Workers

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