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Collaborative Fairness

“Where is the fairness?” asked an orthopedic surgeon with whom I will be presenting at the ACHE Congress March, 24, 2009 on adding new tools to your physician-hospital relations toolkit.  He has been Department Chair, so he understands the challenges that physicians pose.

His question related to issues regarding employment, i.e. how expensive it was for him to hire a new associate, provide him or her with office space and computer connectivity, and wait for a year till he or she generated enough income to offset expenses, compared to the relative expense of a hospital hiring a new orthopedic surgeon.  I chose not to argue with him about the fixed costs a hospital incurs with its property, plant, and equipment expenses, or the daily staffing challenges to be “right-sized.”

Instead, I recalled a conversation I had with my daughter in junior high school during a car ride from dance class.  As she sobbed, “It’s not fair,” a radio commentator said, “If life were fair, Elvis would still be alive and all the Elvis impersonators would be dead.” 
“Exactly,” I replied.  It was though NPR was connecting directly with us, or more accurately with me:
“Who’s Elvis?” she asked.

My favorite fairness test is, “If life were fair, people who snored would wake themselves up rather than their spouse.”  Robert Fulghum convinced me:

Life is lumpy.  And a lump in the oatmeal, a lump in the throat, and a lump in the breast are not the same lump.  One should learn the difference.
Fulghum R. 1991. Uh-oh: Some Observations from Both Sides of the Refrigerator Door.  NY: Villard Books,146.

If we have established that life is not fair, what do we do about it?  The best advice that I can offer, after traveling through over 40 states, is to reframe, changing perspective to see life as a learning journey rather than a conspiracy.  Dr. Abigail Zuger pointed out that the golden age, that lasted approximately two decades after the passage of Medicare in 1965, was an anomaly.  For example, she mentioned that in 1913, the American Medical Association estimated that no more than 10% of physicians were able to earn a comfortable living. (Zuger A. 2004. “Dissatisfaction with Medical Practice.”New Engl J Med 350(1):69-75.)

I have summarized below the article that I find the most uplifting (Marcus LJ, Dorn BC. 2001. Beyond the malaise of American medicine. J Med Practice Management;16(5):227-230.):

•  The chasm between physicians’ expectations and current realities is not due solely to managed care, which is a symptom of market pressures, that have forced unpleasant tradeoffs for patients as well as physicians
• Physicians mourn the loss not only of social interactions with patients but also with colleagues; business deals that have not achieved their goals have turned friends into enemies; for physicians and their families, medicine has become a financial burden rather than a predictable source of income
• Frustrated physicians seek to rekindle the personal qualities of medical practice that provide confidence, understanding, and reassurance:

Listen to patients talk about what was good about their healthcare experience. They will often express it in terms that describe how much someone paid attention to them, really cared for them, listened to them, or improved their life on a very personal level. There is no machine that can replicate that sensation.

The pendulum has swung far from the center.  What forces will it take to push it back toward a more balanced future for medicine and medical practice?
This is a time of opportunity, one in which we define a new mission and role for ourselves… Consumers want us to remain key to the workings of the healthcare system. 
When our patients are facing a frightening procedure or a discouraging diagnosis, it is common for us to comfort them by offering a course of action, something that can be done to offer them a sense of hope, and with it, a future.  This formula is what good medicine is about, and it is time we do the same for ourselves and for our profession.
Patients may be our strongest allies and advocates in this dialogue… because just as we value our relationships with patients, patients value their relationships with us.  Combined, there is a synergy of understanding that is at the core of what the physician-patient relationship is all about.

We will do what no machine can do: attend to the communication and interpret the information from our computers, translating it into human terms; help people to try to make decisions; and resolve the conflicts that emerge along the way… it will be up to us to attend to the uniquely human dimensions of what healthcare ultimately is all about.
We need to think creatively, we need to be willing to change ourselves, and we need to be willing to find a role for ourselves in a very different healthcare system.  Change is difficult , though things will not change for us unless we are willing to change ourselves. 
Is it possible to retain that thrill of being a physician?  Most certainly yes, since the essence of that thrill derived from the human dimensions of being a doctor. Change in and of itself can be exciting as we envision something new and being a part of making it happen.

 Dr. Zuger quoted a physician from Washington University: “One of the virtues of medicine … is its self-critical nature… Intrinsic dissatisfaction can lead to significant social good.” As a nurse executive counseled me, “It’s the sand in the oyster that creates the pearl.”

What do you think?

• What do you do to help employed and independent physicians that improves care for your community without playing favorites
• How do you deal with fairness issues
• Does creating a level playing field hinder, help (or do both to) patient care
• How would you complete the sentence, “If life were fair …”

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

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