Why is the common sense among front line providers treated as anything but by health care management professionals? Doctors are treated as experts when it comes to treating a patient, but they are treated like amateurs when it comes to thinking through health care delivery reform- even in their own hospitals or facilities. A recent study in the Harvard Business Review by Kaplan and Haas “How Not to Cut Health Costs” demonstrates this phenomena.
The report highlights five mistakes that hospitals make when they try to cut costs. The first mistake is cutting back on support staff. The article goes on to make very basic points about why cutting support staff is shortsighted in so far as it often fails to cut costs in the long run. For example, “It makes no sense to have physician and senior nurses perform tasks that could be done just as well by far less expensive personnel.” In short, decisions based on balance sheets from up high which are “uninformed by an awareness of the underlying clinical and staff resources needed to deliver high-quality outcomes” can lead to bad medicine and frustrated doctors.
The article also critiques the crass notions of productivity that are the bread and butter of the health care management consultancy world. “It would be absurd to try to increase the productivity of musicians,” Kaplan and Haas write, “by having them play faster.” Yet, doctors are continually being given new productivity standards to meet with little or no input.
As convincingly stated by Kaplan and Haas: “To make matters worse, clinical personnel—the people who actually treat patients—are seldom involved in decisions about how to achieve savings, which means that providers lose out on significant opportunities for benchmarking and standardizing medical practices in ways that could both lower costs and improve care.”
This has always been obvious to the doctors and care givers in the field. How, then, is it that the common sense of the front line is so easily rejected by management until it is repackaged and presented in management language by anyone but a front line doctor?
Perhaps one way to think about this is the different boxes put around expertise. Doctors are implicitly treated as experts when it comes to diagnosis and treatment but in questions of management and reform they are easy to ignore. When it comes to diagnoses and treatment doctors are trained to live in a world of logic, evidence, and science. But in the political word, while there is plenty of work to do on understanding how we should be changing the health care delivery system, doctors are excluded not because of their lack of evidence or because of their imperfect knowledge; doctors are excluded simply because they don’t have the power as a profession to be part of those discussions and decisions.
It is about power.
It is a strange time for doctors. In the privacy of their examination room evidence prevails, but in many of the decisions that control and impact the examination room power prevails. What is to be done?
Margalit Gur-Arie’s recent blog post “Why Physicians Must Unionize” is all about the failure of doctors to be effective in the political sphere (and at addressing issues where we work) and forwards unionization as the solution to that problem:
“Imagine a professional union fighting for the freedom of its individual members to exercise professional judgment for the sole benefit of individual citizens. Imagine a medical union fighting to provide the best care to ordinary citizens, free from the whims of the political and business classes.”
Obviously we agree, but getting doctors to that point is the real challenge.
As Gur-Arie notes “…by far the toughest barrier to creating such union consists of the physicians themselves…. As a group, physicians are largely conservative and not given to activism. And this is precisely why an American physicians union can become the most formidable social innovation of our times.”