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The Physician Culture and Resistance to Change

Richard L. Reece, MD, January 3, 2008
"It's hard to imagine how unsystematic and data-free most healthcare is today and how hard the existing culture of care resists the intrusion of process-based data." George Halvorson, Chairman and CEO of Kaiser Foundation Health Plan and Hospitals, Health Reform Now! John Wiley & Sons, Inc, 2007

The physician culture resists challenges to its beliefs. But the challenges continue.

The beliefs include:

  • Medicine is a profession centered on the patient.
  • Money shouldn't be central in deciding what's best for the patient.
  • Data alone is insufficient to judge physician performance.
  • Physicians are a brotherhood and a sisterhood.
  • Medical practice is not "just another business."
Beliefs under stress
These beliefs have been under stress as Medicare and health plans have emerged as physician paymasters, as the for-profit "medical industrial complex" has grown explosively, and as claims-based data has been used to rank physician performance. These developments have transformed medicine along corporate lines. In business, the piper usually calls the tune. The physician culture resists this notion. Consequently, constant rearguard battles erupt to maintain the professional status quo.

I believe in capitalism, for-profit businesses' obligations to stockholders, "not-for-profit" health organizations' need to generate profits, the necessity to manage healthcare organizations, and the maxim "no margin, no opportunity."

This piece, then, isn't a screed against capitalism, greed, or profits. Instead it rests on the belief that many current healthcare efforts toward "responsibility" and "accountability" have gone astray because the health system's movers and shakers fail to take into account the physician culture.

I'm not saying doctors always react admirably to trends threatening their culture. I'm saying they act predictably.

Recent Developments
Today's recent efforts to change healthcare and the physician culture include:

  • Pay-for-performance (If only we can get doctors to do the right things with measurably better results, we could induce them to change by rewarding them with more pay.)
  • Physician rankings (If we could use data to cull bad doctors from the herd, we'll have a higher performing system.)
  • EMR implementation (If we would make medical record systems mandatory, we could avoid duplication, coordinate care, save money, and raise quality.)
  • Hospital/physician-integration (If only hospitals and physicians would integrate, join together in joint ventures, stop duplicative competition, get their computer systems to talk to one another, and otherwise coordinate care, patients and the system would benefit.)
  • Health 2.0 (If we could aggregate enough data, integrate EMR, PHR, and claims-based data, deposit the data in central data banks, bring data to bear at the point of care, predict and use data to indicate what works, and intervene with the latest, hottest, and best information, the system would take a quantum jump forward in reducing cost and lifting quality.)
  • Consumer-directed care (If we could raise deductibles high enough to sensitize "consumers" to cost and give them enough information, patients would become price and value savvy, and patients would become "health consumers" capable of negotiating with physicians on a more even playing field and of choosing higher value care.)
Why Recent Developments May Misfire
These are logical concepts to minimize costs, and to manage and rationalize care, but movers and shakers who put them into play may underestimate cultural barriers.

Here are a few examples of why these concepts may misfire.

Pay-for-performance: Most doctors think they're "performing" very well. They've done their time in pre-medical education, medical school, residency, and fellowship training--usually 12 to 16 years in all--and deem themselves autonomous professionals. They resist hectoring, lecturing, criticism, and data judging their performance. It's not that they perform equally well. It's just that each thinks their performance rests on their individual circumstances. Besides, these questions always arise, Based on whose performance? And on what basis? Standards set by health plans or Medicare? Or standards set by physician organizations? Also business-minded physicians know tracking their own performance in outpatient settings entails expense--buying and installing record systems, maintaining those systems, undergoing a period of reduced productivity, training staff, spending time and money generally not compensated for by the small bonuses that health plans provide. Some skeptical physicians are asking: Why should I be paid for what I'm supposed to be doing already? And why am I not privy to the criteria used to judge me, placing me in a "lower tier," even excluding me from networks?

Physician ranking: A national movement is afoot among health plans to rank physicians. Health plans are using retrospective claims data to rank doctors in terms of cost and "quality." Physicians believe rankings rest mostly on cost. They're incensed when the ranking criteria for exclusion are unknown. Physicians have rebelled in Washington, New York, Connecticut, Minnesota, and Massachusetts among other states. In Massachusetts, the dispute focuses on "tiered networks" covering state employees and a state commissioner's request for claims data from health plans. Under the commissioner's plan, patients pay more to see a lower tier doctor than a higher tier doctor. For doctors, the problems are two-fold: 1) doctors don't know how and why they are being ranked, and 2) patients may assume a low ranking means the doctor is incompetent, or even a quack. To show how fiercely physicians resist ranking and how complicated ranking can be, the Massachusetts Medical Society is saying tiered ranking should 1) strengthen patient relationships, 2) involve physicians in designing and implementing programs, 3) use clinically important and sound performance measures, 4) ensure adequate sample size, 5) rely on sound data analysis techniques, 6) share and review data with physicians, 7) guarantee transparent quality and cost data, 8) identify practice characteristics requiring special attention, 9) use uniform reporting formats, 10) minimize unintended harmful consequences of reporting to the public, and 11) be pre-tested before implementing. In other words, fight intrusion into the physician culture with counter-measures to make it a fair game.

Mandatory EMR Implementation: This has the earmarks of cultural dogfight. In this Internet era, IT enthusiasts and data aggregators are saying: Surely the time has come for a national computer system linking patients, doctors, hospitals, government, and health plans using data to cut costs, improve quality, coordinate care, and avoid duplication. For at least five years, IT engineers, managers, and thought leaders have been hard at work at all levels of the health system to make a unitary computerized national system a reality. HHS secretary Michael Leavitt has gone so far as to say Medicare payment cuts should go into effect immediately. If doctors and hospitals don't toe the line and install EMRs, then reduce their revenue streams. The trouble is that only 5 percent of hospitals and 15-30 percent of doctors have done so, and foot-dragging has been fierce in solo and small practices without the resources to make EMRs happen. Doctors say EMR implementation costs too much, disrupts practices, lowers productivity, interferes with patient interaction during the clinical exam, has no tangible return on investment, and shows no evidence of cutting costs or raising quality. Maybe sufficient government and health plan pressure will turn the situation around, or perhaps a federal program like Hill-Burton will turn the trick, but so far it's a bureaucratic, technocratic and physician cultural standoff.

Hospital-Physician Integration: This has long been a dream among hardheaded managers and healthcare leaders. For good reason. Hospitals and doctors share a common goal--getting patients well. But cultural disputes keep getting in the way. Hospitals believe they're the center of the healthcare universe. They're open 24 hours a day, legally obligated to take all comers, and offer comprehensive services with on-the-spot intervention in case of emergencies. But doctors may disagree as to who should be King of the Mountain, who should control clinical care, and who should reap rewards. Doctors know without physician services, hospitals would simply be empty buildings with mediocre food. Money factors are there too. Hospitals consume about 50 percent of all care monies while physicians take 25 percent. Previously I belonged to the integration crowd. Fifteen years ago, I co-founded the National Association of Physician Hospital Organizations, later renamed the National Association of Integrated Health Organizations. Both are history. Ten years ago it became apparent hospitals, given their administrative structures and controlling mentalities, were running most Physician Hospital Organizations (PHOs). The standing joke among doctors was that PHOs were really HPOs, meaning hospitals controlled them. In any event, neither hospitals nor physician organizations felt committed to financially supporting PHOs, which died from financial starvation. But before their premature death, at a hospital at which I was a PHO chairman, the hospital and its medical staff developed a hundred or so bundled bills, common hospital procedures, incorporating all hospital and physicians services and making them known in advance. This sort of price transparency will become common in consumer-directed care. What went around will come back around.

Health 2.0: Among IT visionaries, the belief persists that with dropping computer costs, widespread Internet use, ubiquitous Googling, ingenious algorithms, and aggregation of EMR, PHR, and claims data, a rational cost-efficient reform will rapidly come together. Comprehensive, at-your-finger tips, computer-based information will replace paper records. Some policy wonks and all-knowing pundits even believe computer-guided artificial intelligence can closely mimic clinical care, interpret nuances of patient-doctor interaction, select the best tests and proper procedures to perform, predict their relative effectiveness, and substitute or augment clinical judgment. That these functions can save money remains untested. In Minnesota, a state dedicated to creating a statewide record system by 2015, health costs are out of control-1.1 million Minnesotans expect to pay 10 percent of their pre-tax income for health benefits next year, and for a quarter of residents, the cost will be 25 percent of pretax income ("Healthcare Takes a Hefty Bite out of Minnesotan's Income," Star Tribune, December 20, 2007)

Consumer-Driven Care: The November 24/31 issue of American Medical News carries an article "Consumer-Directed Care--Culture Shock." It says both doctors and patients resist patients being defined as "consumers." This may be why consumer-directed care, defined as high-deductible plans paired with high-deductible or flexible savings accounts-are slow out of the gate. Of 150 million Americans with health benefits, only 2.7 million have enrolled. This may be a classic example of culture resistance. The American Medical News reporter explains it this way:

"The limited growth of consumer-directed health plan enrollment is in part due to the exam room taboo. A typical patient, sitting in an open-backed gown on top of an examination table doesn't much want to talk about money. And doctors don't want to be the ones to bring it up."

This open-ended image doesn't lend itself to price haggling. Neither does the gap between patient or doctor knowledge, nor the fact that vulnerable patients want to look good and not run the risk of looking impertient in the doctor's eyes.

Then there's the problem of data-gathering during the patient exam. The March 2006 issue of Family Practice Management gives these tips:

  • Listen to the patient before opening the computer screen and reviewing patient status
  • Let the patient see the screen as you explain what you're doing
  • Talk to the patient as you search for information
  • Point to the screen to explain what you're looking at
  • Learn to type, look, and listen to patients at the same time
Talking about price continues to be awkward, partly because many patients lack the knowledge to know what the physician is talking about. But it may be that economic factors-patients spending their own money or looking for a bargain combined with continuing unaffordable and escalating healthcare costs-will drive cultural change.

Summing up
Because of cultural factors--patients taking the doctor's word for granted, first-dollar coverage without discussion of money, freedom of doctors to order what they please based on clinical judgment, patient dependency and trust in physicians' superior knowledge, the physician's penchant for autonomy, clinical and monetary differences between hospital and physician cultures--transitioning to a more managed, monitored, and data-based system is fraught with obstacles. These barriers will not be easily surmounted.

Physicians have limited but real options: becoming employees, creating new practice models, pursuing non-clinical careers, retiring, not accepting new Medicare patients, owning facilities, undertaking entrepreneurial activities, ending health plan contracts, joint venturing with hospitals, joining large groups, entering academia, morphing their practices into collective organizations with more clout in the marketplace, or joining together to voice their vision of a better system.

Most physicians will simply go with the flow, resisting, adjusting, but bowing to the inevitable, even if the current runs against their culture. In the end, it's better to be mainstream than extreme. After all, we're all in this together.


Richard L. Reece, MD, is a pathologist, writer, editor, speaker blogger and consultant in Old Saybrook, CT. His latest book, Innovation-Driven Care: 34 Key Concepts for Transformation, was published in March. His blog may be accessed at www.medinnovationblog.blogspot.com. He may be reached at rreece1500@aol.com.
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