Royer, Thomas C. MD
Section Editor(s): Baker, Edward L. MD, MPH; Column Editor
On the basis of recent national polls, we would all agree that the support for the Affordable Care Act is certainly mixed among both legislators and the public sector. However, as noted in previous articles in this column,1,2 there is almost unanimous agreement among all stakeholders that the health system in the United States has some significantly broken parts.
In this context, it is clear that public health professionals are working more closely with partners in the health care delivery system to address major opportunities for health system change. In addition, and perhaps most importantly, we are seeing the medical profession, both individual practitioners and their associations, joining the other voices that have been saying for over a decade that there is significant overuse and misuse of health care procedures, both diagnostic and treatment, perhaps as high as 20%. Clearly, on the basis of these accounts, there is an urgent need for all health-related organizations, including physicians and their practices, to transform. Regardless of the degree of implementation of the Affordable Care Act, to be successful, physicians must enhance their focus on prevention, support the increase in primary care providers, and work with their colleagues to develop innovative approached to care delivery, including accountable care and medical home models. They will also have to do some serious reflection regarding their best practice style as a hospital employed or contracted physicians, in contrast to continuing as independent practitioners. Again, it should be abundantly clear to all the stakeholders in the health care delivery process that transformation must occur to address these challenges.
Why Are Physicians So Critical?
It is becoming increasingly clear today, then, that a successful and sustainable physician practice—individual or group, single, or multispecialty—will be one that can prove, by clearly defined and appropriate metrics, that they are delivering high-quality and safe care while reducing costs, improving accessibility, and promoting health. These goals must be embedded into the physicians' practice strategies and operational performance, both clinically and administratively. In many cases, this will require physicians to embrace a new roadmap for change since the achievement of these goals is predominately dependent on the physicians' practice style. Why?
Physicians, first and foremost, drive the quality and safety of the clinical outcomes in concert with the nurses and other members of the care team. To achieve quality, they must actively participate in care management processes and support the utilization of evidence-based medical diagnostic and treatment protocols. They must support population health and preventive medicine programs, move their services when appropriate to the often safer and cheaper outpatient or ambulatory surgery areas, and lead in the designing of pathways of care that improve accessibility and level of service satisfaction for their patients and their families.
But as important as they are to quality and safety quality improvement, the physicians are also a critical driver of the cost of the various health care products and treatment modalities. The number of staff the physicians require to assist them results in the magnitude of the labor costs, and their orders drive the costs of supplies and pharmaceuticals. And, finally, physicians significantly control the accessibility of appropriate care by the degree they limit their office hours, the number of patients they are willing to see per session, and the insurance types they will accept.
Because of the critical role that the physicians play, and will continue to play, in the health care arena, they will not only need to transform their processes and procedures but also have to take a leadership role in changing not only their culture but also the culture of the organizations with which they associate and do their work.
Fortunately, there is evidence from other industries, as well as from best practices being developed by physicians in collaboration with hospitals and health systems, that transformational leadership can be learned and transformational strategies are possible. However, one of the cultural changes these strategies will require is that all participants in the health care delivery process will have to work together in a much more coordinated and integrated fashion, with physicians taking a greater role in leadership.
Cultural changes are never easy for anyone or any organization, but they may be even more challenging for physicians. The medical school and residency training programs often foster independent thinking, fail to teach methods for strong teaming, and often offer little discussion about the development of strong interpersonal skills. In addition, the major tracts of postgraduate and continuing medical education programs exacerbate this polarity by often training physicians separately from administrators, nurse practitioners, physician assistants, nurse midwives, and support staff. Furthermore, physicians have little or no exposure to public health professionals with direct knowledge of population-based prevention strategies. As a result, these key constituents that must work significantly more collaboratively in the future have separate training sessions with agendas that even stress the need to compete to survive.
In addition, the physician educational process teaches the “scientific approach,” creating a level of discomfort with the “gray areas” that must be addressed in strategic and operational decisions. Also, physicians are usually not comfortable with learning and practicing effective conflict management, a key competency for successful change leaders. But, perhaps, even more significant and the greatest barrier is the realization of the significant polarity among physicians themselves, which only further impedes their collective, collaborative behavior. In contrast to earlier times, today there is “no common voice” among physicians. Varied positions on numerous issues are occurring between younger and older physicians, primary care and specialist, low-income–generating and high-income–producing procedural doctors, and even male and the growing number of female physicians who seek a different balance between their personal and professional lifestyles.
It is clear that physician transformation is critical but, for the reasons stated, hard to achieve. But if physicians are not successful working with their partners, the lack of reform will create sufficient opportunities for new players to enter the market, providing services once solely owned by the physicians and hospitals. This change is already being experienced in some parts of the country, and the new players include insurance companies, pharmacies, and large employers such as Walmart and Target.
The Key Physicians' Transformational Strategies
Having clarified that physicians are critical players in the new health care environment, what then are the key strategies that they must embrace for success? They include the following:
1. Accepting that the drivers of change articulated earlier are real, unacceptable, and must be reversed. The physician community must totally support the reality that their long-term survival is dependent on the creation of consistent, high-quality, and affordable care. Understanding their price and cost structures, and utilizing best practice in supply chain management, will be important.
2. Embracing evidence-based clinical protocols, incorporating them into their practices to ensure the best outcomes possible. Every physician should be “research oriented” by asking continually “why are we doing it this way and how can we do it better?”
3. Supporting total transparency of their clinical outcome data, identifying their negative variations from known best practices, and implementing documented improvement plans to change the negative to a positive.
4. Striving to lessen the dissatisfaction among their ranks and help to minimize the resistance for change coming from some of their colleagues who are “comfortable with the status quo.” Physicians, who have been trained to be individual thinkers, must now agree that the “collective team” success exceeds individual success. They must realize that solutions to the health care challenges we are facing will result from compromise driven from a strong desire to always create a “win-win” situation.
5. Demanding a “patent-centric” approach to problem solving. When the physicians and their colleagues are reflecting on various tactics to reach their new strategic directions, they must put the “patient's needs in the center of the room” rather than continuing to develop processes around the convenience of the providers. Although many physicians today are opposed to freestanding ambulatory and urgent care centers, fearing that they will rob patients from their practices, the physicians are not providing evening and weekend hours, which is the major benefit of the freestanding models designed around the patient's convenience.
6. Willing to express their opinions in a professional manner to their office colleagues, as well as to the hospital leadership teams with whom they work. They must actively participate in strategic planning, peer review, service line management, and supply and labor cost discussion.
7. Embracing health and wellness principles, incorporating them into their disease management activities. The physicians must agree that the time they are spending on coaching and mentoring their patients about the best practices they should incorporate into their daily living is a least equal to, and even more important than, the time they spend on disease diagnosis and treatment. This will undoubtedly require the greatest shift in the culture of the practice and the tasks performed during the routine clinic visit. While the development of a sound treatment plan for any illness is still critical, the physician must allocate sufficient time to educate patients and their families on the negative consequences of obesity, excessive alcohol consumption, use of tobacco products, and poor nutritional habits. It is hoped that the payers will increasingly see the importance of these interactions and appropriately reimburse for them, whether delivered face to face or over the phone. The Centers of Medicare & Medicaid recently indicated that it would start reimbursing for “phone-based” treatment discussions.
8. Accepting the reality that there is a critical need for additional primary care providers and that this shortage will not be filled in the short term by graduating physicians. Hence, they must work collaboratively with nurse practitioners, physician assistants, and midwives who are working appropriately within their scope of practice to fill this void at present. Again, many physicians oppose these groups, just as they oppose freestanding urgent care centers, stating that they practice poor quality medicine and steal their patients. Numerous studies have been conducted that negate these allegations.
These 8 strategies surely emphasize the critical importance of the physicians' role to ensure success in the new health care environment. In essence, they can be summarized for physicians, by stating that they must maximize collaboration with their physicians, support staff, and hospital leadership teams while minimizing competition and taking accountability for intentionally driving the cultural changes in attitudes and practice styles.
The 3 Key Leadership Qualities for Physicians Embracing Change
Making the necessary changes in their culture and practice styles will assuredly not be easy for physicians. However, they will have a greater chance of being successful if they consider the following 3 key strategies to enhance their transformational leadership skills:
1. Ensure that they have the necessary competencies.
2. Reaffirm their commitment to the health care professional team.
3. Reignite their passion in all that they do.
A competency is often defined as the observable and measurable characteristic of a person that people see each day. They result from a combination of one's knowledge, skills, abilities, behaviors, and attitudes. Today's important leadership competencies include operational focus, strategic and visionary thinking, being metric and outcome driven, accepting a high level of accountability, rewarding transparency and collaborations, and engaging and developing others. However, the critical competency for all health care providers, including physicians, is “being a change agent.” This requires one to accept the truth, present an understandable rationale for change, be open to push back from others, and support the consensus of the team once the road for change has been agreed upon. Also, helpful for physicians is to maintain a constancy of purpose, stay inventive during tough times, always live the mission, vision, and values of the physician individual or group practice, and never, regardless of how tempting, lose one's moral compass.
Because collaboration and integration are critical in the new roadmap, physicians must renew their commitment, strengthening their individual teaming skills and the teaming skills of their physician colleagues and support staff. They have to firmly believe that their outcomes are dependent on the quality of the team with whom they are working. The outcomes for quality and safety will only be as good as the “weakest link,” which can be eliminated by team members committed to doing their very best at all times.
Having Passion for Their Work
And, finally, physicians must reignite their passion for their work, if they are to be happy, believing each day that, regardless of how many challenges they face or how stressful it is, they can say affirmatively “it is worth it!” Many physician and health care leaders today are expressing just the opposite, deciding to retire earlier than planned and telling the younger generation that they should not pursue health care–related careers. By enhancing the passions of the practicing physicians, this negativity can, it is hoped, be reduced and even eliminated. Passion is the place where the love of your work lives, and without it, the roadmap for change might prove too daunting. So, how is passion developed and enhanced?
First, and foremost, all physicians must believe that health care is a sacred ministry, but not in a religious sense. Rather, it is as sacred ministry because each day people come through their office or clinic doors and turn their most precious gift over to them—their lives. This is an awesome responsibility for each and every physician and clearly is extremely special and unique for those having the privilege and honor of working in health care today.
Second, physicians must believe, in some way, that their work is a “calling” rather than a job or even a profession. People doing a job each day, can do satisfactory work, and people who believe that they are professionals clearly can do meaningful work. But with the degree of change that physicians must accept and their practices must undergo, it is possible that they will need to see what they are doing as a “calling,” for that degree of understanding may be necessary to do the transformational work required.
And, finally, passion is often reignited in physicians if they stop and ask periodically, as they are performing their daily patient-centered activities, whether in their offices, operating rooms, emergency departments, or hospital rooms, perhaps the most important question—Could this be one of the reasons I was put on this earth? I think regardless of the specialty, age, gender, or role any physician has, the answer to this question is always “yes.”
So, transformational changes in our US health system must occur. It is clear that the physicians' participation will be essential because of the critical role they play in driving health care outcomes. There are 8 important strategies that physicians should consider embracing and implementing, which would be made easier if they support the enhancement of 3 important transformation leadership qualities. Fortunately, with the right attitude and commitment from physicians all of this is possible.
© 2013 Lippincott Williams & Wilkins, Inc.