OK, I Am Convinced; Where Do We Start?

Editor's Note: Last week's post, "Why isn't "Health" Practiced in Healthcare?" drew a lot of interest both here and on LinkedIn. And, because this subject is so broad and complex, this will be a three-part article.  Enjoy. As always, you can find all my blog posts from 2013 to the present on my website at http://stevemarshallassociates.com/steves-blog/

Why Are Doctor's Offices So Badly Run?
That's an easy question to answer - because physicians are not trained or prepared to run a business during seven years of medical school! As patients, many of us have picked up on the kind of tension that plagues doctors’ offices and hospitals—the tension between doctors, nurses, and administrative staff. There are horror stories about bully physicians who punish any questioning of their authority with verbal abuse, a dynamic that can result in deadly medical mistakes. But even conscientious doctors can be bad managers, and miscommunications and dissatisfaction in a medical context are bad for doctors, nurses, and patients. A recent Mayo Clinic study found that inadequate supervision in a medical setting is associated with burnout—which is related to medical errors and a lack of empathy with patients. Burnout also, unsurprisingly, leads to turnover, which exacerbates the national shortage of doctors and nurses.

Doctors “do very, very well independently, but we don’t know how to engage the people around us,” said Keith Gray, the chief of surgical oncology and the co-creator of a when about the average doctor’s management skills. “We don’t know how to delegate, we don’t know how to empower, we don’t know how to add value to others.”This is a problem whether a doctor runs an independent practice or is employed by a hospital system. Thanks to the increasing complexity of insurance billing and medical record keeping, physicians who work in small or independent practices are essentially, business owners, responsible for hiring, retaining, and managing a team of receptionists, nurses, and medical assistants. And running a practice has a particular challenge: In most businesses, bosses can delegate important tasks to underlings to make the organization run smoothly. However, in doctors’ offices, only the doctor can perform the central activity of seeing and diagnosing patients—which makes the hierarchy of a medical practice less like a pyramid and more like a wheel, with the doctor at the center.

American doctors are increasingly choosing to take salaried positions at hospitals or large health centers, in part to avoid the administrative headaches associated with running their businesses—but working at a hospital doesn’t get physicians off the hook when it comes to directing staff. In fact, the organizational structures of hospitals can make management even more complicated and frustrating than it is in private practice, since doctors, nurses, and administrators fall under different branches of the hospital hierarchy. "It’s just a series of silos that are not communicating well with each other,” says Gray of his hospital. In practice, this means that doctors are giving orders to nurses and assistants who officially answer to other people. “In fact, my medical assistant doesn’t work for me,” says M., a physician who works in a large urban health center—rather, the assistant works for the head nurse. “I am effectively managing her impotently. I can’t say, "If you come in late again, X or Y. There is no ability to discuss consequences.”

If almost every doctor needs to manage a team effectively, why don’t medical schools and residency programs teach students the skills they’ll need to oversee medical staff? For one thing, it’s hard to see where formal management training could fit in, since the four years of medical school and three years of residency are jam-packed with clinical education. But, according to Dike Drummond, a former primary care physician who now coaches doctors and blogs at the Happy MD, the problem goes deeper than that. “Why don’t they teach this in medical school?” he says. “It’s a blind spot.” Even worse, medical school and residencies can inadvertently teach doctors how to be bad managers.

What's worse is that there are few resources for doctors who need help figuring out how to manage their staff. Physician executive MBA programs and “physician leadership” training programs, such as the one Keith Gray developed in Tennessee, are intended for doctors who either are or want to be high-ranking executives in a hospital system. They’re not much use to doctors working in the trenches.

So what’s an average doctor—one who’s not angling for a “leadership” role in a hospital or practice group—to do? Drummond teaches his clients to recognize the difference between clinical contexts and administrative settings. In clinical settings, doctors have the expertise to answer questions—that’s what they went to medical school for—and it (usually) makes sense for them to expect their nurses and medical assistants to follow instructions. But in administrative contexts—billing insurers, maintaining electronic medical records, documenting visits, keeping medical supplies in stock, handling appointments—doctors have no special expertise. Drummond advises doctors to “take off the doctor hat” when they’re asked an administrative question. “Because it’s exhausting for the doctor always to think they have to have the answer always, and give orders and have everybody obey them. It’s just exhausting.”

Most physicians have to figure out how to manage their staff on their own—which is what M., the physician at the urban health center, did. “I remember my first medical assistant, who did absolutely nothing for me,” says M. “She wasn’t very interested in being helpful, and there was almost nothing I could do about it. And I didn’t know how to deal with it. I remember photocopying my stuff and writing all my referrals and watching her—it was before phones—read the newspaper.”

Eventually, M. figured out that she needed to giveher staff “as much authority as possible, so they feel empowered and feel good about what they do.” Now, when she teaches residents, “I say, ‘No one has ever told you how to manage staff. And that is something I am going to do for you.’ ”

Most medical students and residents still aren’t so lucky.

Next Week: Baby Steps First on How to Get Started.