7 Reasons Hospitals Struggle to Align With Physicians

Physician-hospital alignment is becoming more important as hospitals seek to lower costs, improve care and prepare themselves for payment models that reward collaboration. Kenneth Cohn, MD, MBA, FACS, a practicing surgeon and the author of Getting It Done, discusses seven problems that plague physician alignment attempts — and how hospitals can achieve integration in spite of them.

Dr. Cohn has written several books on collaboration in healthcare. His latest, Getting It Done: Experienced Healthcare Leaders Reveal Field-Testing Strategies for Clinical and Financial Success, is available at http://gettingitdonebook.com.

1. Physicians are trained to be individualists. Dr. Cohn says while collaboration is essential to the next wave of payment models in healthcare — bundled payments and ACOs, to name a few — hospitals may struggle to align with individualistic physicians. "I think the most glaring reason it's so difficult to align is the way we're all trained," he says. "Physicians have very different backgrounds and training and experience, and we tend to personalize our differences."

During his research, Dr. Cohn interviewed MBAs and physicians and asked them what percentage of their grade during training was based on team projects. The MBAs said 30-50 percent; the physicians said zero. "I don't think physicians in my generation ever had any formal lessons in communication or negotiation," he says. "When I talk about win-win negotiation with physicians, they say, 'If I have to give something up, the hospital should have to give something up, too.'" This combative attitude makes it difficult to involve physicians in hospital projects that require compromise or cooperation.

2. Employment may not be enough to spur engagement. Many hospitals are looking to physician employment to solve their alignment woes. Once the physicians are on the hospital payroll, administrators may believe they will readily engage in strategic initiatives and cost-cutting measures. But engagement may not follow employment quite that easily, Dr. Cohn says. "Physicians are a bit like tenured professors," he says. "I've heard a number of deans say that just because you pay somebody doesn't mean they put you at the top of their list."

In the era of healthcare reform, physicians are forced to juggle the needs of their physician colleagues, hospital administrators, patients and support staff. Employment may help hospital administration climb that priority list, but it is not enough to guarantee long-term engagement with operational planning. Physicians must actually care about hospital goals and projects to participate in them. This means involving physicians in a shared vision and meaningful work that makes a difference to patients and families — the number one priority of physicians, according to a survey conducted by Dr. Brian Wong and reported in Future Scan in 2009.

3. Physicians come to meetings as figureheads, not participants. Dr. Cohn says physicians often see meetings as a waste of time, a burden that cuts into their clinical duties. "You hear doctors talk about committees as a group of brain-dead people who take minutes and rob hours," he says. "Physicians say, 'They take me away from my office, and I'm not getting paid for it.'"

He blames this disillusionment on the fact that physicians are often brought to meetings to give their blessing on a decision rather than to provide input. "It's very important to invite doctors to meetings before a decision is made," he says. "In some places, physicians work in dyads together with a service-line administrator. In some places, the meetings use triads and include nurses in operational decisions." If physicians can work on problems with their administrative, physician and nurse colleagues, they will know they have a real impact on clinical operations, rather than acting as a "yes man" for hospital administration.

4. Physicians and administrators treat problem-solving differently. Physicians are trained to take a large amount of data and distill it into a single diagnosis, Dr. Cohn says. This problem-solving takes the shape of a V: a wide amount of information coming to a point. Many hospital administrators, on the other hand, are taught to take data and use it to create different options — a style of problem-solving that looks more like a W. "To a busy physician, the administrator will look like he can't make a decision," Dr. Cohn says. If physicians are looking for a single solution and administrators are looking for multiple options, meetings and problem-solving may be a struggle. Start the process by talking about each committee member's goals and thought process. The discussion may stop participants from confusing different viewpoints with malicious motivations.  

5. Definition of "long-term" varies. When Dr. Cohn asks physicians to define "long-term," the most common response is, "Forty-eight hours." For an administrator designing a new cancer center for the hospital, this viewpoint can be a challenge. Dr. Cohn recommends that hospital administrators use "chunking" to provide physicians with a 2-3 week roadmap of outcome measures for long-term projects.

"When we check these boxes off, all of a sudden, there's transparency, which can help build trust," Dr. Cohn says. "After a few months, you can look back and see how many boxes you've checked off." He says this documentation will help physicians understand that long-term projects are made up of many small, essential steps, rather than just hours of deliberating and wasting time.

6. Hospitals may not make expectations clear up-front. As a result, Dr. Cohn says some hospitals have started asking employed physicians to sign a compact when they join the facility. Mayo Clinic in Rochester, Minn., has a salary, incentive, and a physician-physician mentoring system that makes expectations clear from day one; Virginia Mason in Seattle and Gundersen Lutheran in La Cross, Wis., both use compacts that prescribe certain expectations of the hospital and the physician.

"They say, 'Read this compact over before you apply, and if you don't agree with it, chances are you'll be happier somewhere else,'" he says. Dr. Cohn has seen physician compacts do wonders for hospital-physician alignment and facility reputation; a few years after Wisconsin's Wheaton Franciscan Health Care implemented a compact, the system's main hospital joined the ranks of Thomson Reuters' Top 100. A compact can attract physicians who want to develop a shared vision with the hospital and dissuade physicians who do not, Dr. Cohn says.

7. Physician mentors are under-utilized. According to a survey on physician turnover by AMGA and Cejka Search, 74 percent of physician groups said they believed a mentorship program reduces turnover — yet only 56 percent of groups assigned a mentor. The same is true in hospitals, Dr. Cohn says. Physicians with mentors are more likely to engage in hospital initiatives, communicate well with administrators and stay with the hospital for a longer period of time.

Physician colleagues can be great mentors because "most physicians are suspicious of top-down edicts," he says. "You won't see the same thing at a hospital that you would at a company like GE, where a dynamic CEO changes the culture [single-handedly]." As Dr. Cohn wrote in the July 2009 Journal of Healthcare Management, when hospitals assign physician leaders to mentor new physicians, physician retention soars.

Related Articles on Hospital-Physician Alignment:
8 Choices Physicians Can Make in the Wake of ACOs
10 ACOs to Know
Virginia's Valley Health Acquires Cardiology Group

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