I felt a little like tennis star John McEnroe as I read a comment from Dr. David Nash in Hospital Clash Puts Patients in the Middle by Dr. Manoj Jain, a special to The Washington Post, September 16, 2008:

Do conflicts between doctors and administrators harm patients? “Look at the epidemic of medical errors,” Nash said without hesitation. “Cultural strife leads to errors, and the number of errors shows the size of the cultural rift.” (The most commonly cited study of medical errors, done by the Institute of Medicine, says that they lead to as many as 98,000 deaths in hospitals a year.)

Like McEnroe, I shouted, “You can’t be serious,” as I envisioned a feeding frenzy of newspaper reporters and broadcast journalists at local hospitals, culminating in Congressional investigations of physicians and hospital leaders struggling to explain why differences in their outlook, background, and education lead to differences in priorities and actions.  Fortunately, that has not happened yet, perhaps because news of the financial meltdown took precedence.

I am not certain that physician-hospital administrator differences are at the root of 98,000 deaths per year.  I thought that the Institute of Medicine Report called attention to  multifaceted causes, such as systems that do not prevent error as well as they could.  In The Yin and Yang of Collaboration, I quoted Maggie Mahar:

The behavior of health care professionals is inextricably linked to the health care system in which they work. Granted, it’s not as though there’s a simple, direct line from institutional design to the hearts and minds of doctors; but systems set incentives and define interests that ultimately encourage, reward, or penalize certain behavior.

In “Mending the Gap Between Physicians and Hospital Executives,” (mentioned in The Yin and Yang of Collaboration) by Cohn KH and Hough D., The Business of Healthcare Westport:Praeger, 2007, Greenwood Publications, Inc.), Deane Waldman and I wrote that physicians and hospital leaders agree on the “who” because we care for the same patients and the “why” because we entered healthcare to make a difference in patients’ and families’ lives.  The “how” is an iterative journey, about which I remain passionate because I have seen dramatic improvements in clinical outcomes, revenues, and expenses when physicians and hospital administrators worked more interdependently:

•  A West-coast ICU Director enlisted the support of allied healthcare professionals in the clinical laboratory, pharmacy, and nursing to decrease turnaround time, make antibiotics readily available, and develop a mobile cart with necessary equipment and supplies.  These process improvements decreased mortality from life-threatening bloodstream infection (sepsis) from 46% to 23% in one year without any change in medication (Fried J. “Saving Lives by Improving Processes of Care,” in Cohn KH and Fellows S., eds. Engaging Physicians: A Case-Based Guide to Collaboration, in preparation)
• A Connecticut community hospital general surgery division went from whining, “It’s not fair,” (re: gastroenterologists referring patients with gastro-esophageal reflux to an academic medical center for laparoscopic fundoplication operations) to recruiting a fellowshhip-trained laparoscopic surgeon, whom the hospital hired as a part-time Surgical ICU Director, so that private physicians did not feel that the hospital was competing against them.  The new surgeon reversed the outmigration and proctored other general surgeons at the community hospital, so that they could become facile with advanced laparoscopic surgical techniques.  Discovering and meeting the needs of all stakeholders was a win-win situation for the hospital, gastroenterologists, surgeons, and patients and families by decreasing outmigration, increasing revenue, and allowing patients and families to receive care in the community (Cohn KH, Wise AS, Bellhouse DE. “What Physicians and Hospital Leaders Can Teach Each Other About Marketing,” in Cohn KH. Better Communication for Better Care: Mastering Physician-Administrator Collaboration, Chicago, Health Administration Press, 2005.)
• A CEO at a Rocky Mountain tertiary care facility asked the Medical Advisory Panel at his hospital for advice on how to cut supply costs. This panel of practicing physicians worked together with an interdisciplinary supply-cost-reduction task force to achieve over $500,000 in ongoing supply cost savings in the purchase and utilization of orthopedic implants, heart valves, radioisotopes, and anesthetic and cardiovascular medications. This task force represented the first time that physicians and administrators at this hospital worked together to achieve sustainable, long-term results (Cohn KH, Allyn TR. Making hospital-physician collaboration work. HFM. 2005. 59(10):102-108).

I felt flattered to be cited by Dr. Jain in his Washington Post article.  For more information on how techniques of structured dialogue, appreciative inquiry, and positive deviance can improve physician-hospital relations and patient care, please click on Cohn KH. Medical Staff Relations: A Practicing Physician’s Perspective. San Diego Physician. 2008; 95(6):24-32.

What do you think?

• Do patients, as well as nurses, get caught in the middle of physician-hospital administrator conflicts
• Are hospital leaders and physicians indifferent to the effects on others of their cultural strife
• Are conflicts inevitable as complexity increases due to government regulations, decreasing reimbursement, and rising expenses and consumer expectations
• How can we manage conflict to obtain more collaborative and interdependent care for our communities

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

Kenneth H. Cohn