Authors and reporters share an unspoken agreement. Authors provide content. Reporters provide exposure. Most of the time, it is a symbiotic arrangement. Some times, however, word limits frustrate both of us. For the Washington Post article,  Hospital Clash Puts Patients in the Middle, I provided definitions and examples of structured dialogue and appreciative inquiry in healthcare that unfortunately, never made it to the final article.

So, it should not be surprising that the one paragraph that made it into the article triggered an angry response in A Cultural Chasm from Aggravated DocSurg, a fellow practicing surgeon, who thought that I wrote that physicians bear the brunt of responsibility for the problem of physician-hospital communication:

Going to meetings is what they (administrators) do, it’s what they get paid for, it’s all a donation of a (large chunk of) my time without reimbursement, and in my experience, my input gets relegated to the circular file. And why is this only our responsibility; don’t administrators need to move a bit as well to achieve harmony? We don’t have a cultural divide, we have a chasm the size of the Mariana trench.

To Aggravated DocSurg, I agree that you are entitled to feel aggravated when people with whom you work do not respect your time, invite you to participate in meetings after decisions have already been made, and do not implement recommendations in a timely fashion. I wish that some of the examples I had mentioned to the reporter were mentioned in the article rather than just in my blog post, Collaborative Indifference, so that you could have seen the benefits to patient care when physicians and hospital leaders work more interdependently rather than independently, as you decry.

Finally, I agree with your efforts to encourage hospital leaders to leave their offices to witness eye-opening events that merit your, “That guy I would dialogue with:”

• Spend Friday nights with the ED shift for a month
• Follow a patient from the ED waiting room to the ED to the CT scanner to the OR to the ICU
• Show up at the scheduled “start time” in the OR, and then spend a few days sorting out why “start time” is always in quotes
• Stay up most of the night with a physician on call, receiving all of the same pages, getting out of bed to see patients, and then go to that “dialogue” meeting at 7 A.M. … and then to the office to see a full day’s load of patients

In “The Challenges and Opportunities of Collaborating with Creatively Abrasive Healthcare Professionals,” (in Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives), a full-time practicing nephrologist and “doctors’ doctor” wrote:

My frustration mirrored the frustration of physicians who work at hospitals and cannot influence scheduling, staff, equipment, policies, or procedures sufficiently to predict procedural starting times, room turnover, and training of staff assisting them with procedures. If you had told me then that I would be a member of the hospital’s strategic planning committee in 2005, I would have told you that you were crazy, since I never felt that any physician could really influence what a hospital was doing or where it was going.
In retrospect, my journey began late in 2002, when a medical colleague with whom I did my residency asked me to serve on what was called The Medical Advisory Panel (MAP) to evaluate and recommend clinical priorities for our community for the next three to five years.

I was skeptical and, not wanting to commit to attending weekly 7 AM meetings for the next six months, said that I would attend the first meeting and make a decision afterward. I quipped that for this process to work, the hospital would have to undergo a cultural enema, in that decision-making processes and operations would have to become significantly more transparent, efficient, and timely for physicians to feel that their ideas mattered.

I enjoyed the data-driven presentations, in which physicians from all major clinical areas discussed strengths, weaknesses, opportunities, and threats that they faced and proposed recommendations to improve care and to enhance physician-physician and physician-hospital communication. In addition, the MAP heard from the hospital CEO, Directors of Nursing and Finance, and the Chief Information Officer and obtained a perspective of the hospital and the complexity of its operations that we never had before.

During the presentations and the report writing that followed, the Medical Advisory Panel thought openly and frankly about new programs and measures to improve operational efficiency without being encumbered by the hospital system’s traditional business model and apparent “group think” approach to operations. Our report, presented to the Hospital Board of Directors in September 2003, represented the first time that the hospital received a consensus report from practicing physicians about what the hospital should do in the future. Before, the process involved squeaky wheels pursuing individual agendas.

We evolved from a self-interested view of what the hospital should do for us as physicians to a more empowered view of how the hospital could employ limited resources to improve care for our community. Through the process of discovery, we began to think and act more as long-term partners and co-owners than short-term customers and renters. The Medical Advisory Panel process allowed us to evolve beyond maintaining a level playing field for all physicians to leveraging hospital resources to meet community needs. That clinicians who prided themselves on patient care could come to consensus on long-term priorities gave the Board and hospital administration the confidence to accept the MAP recommendations.

As I travel around the country when I am not doing locum tenens surgical coverage, I am impressed that most physicians with whom I work are not cynics, but skeptics who respond favorably to hospital leaders who walk the walk.

Dale Carnegie is reputed to have said that anger represents the hope that by losing one’s temper, conditions will improve. We model behavior that we witness during residency from attending physicians who become our clinical and cultural mentors.

The challenge to all angry docs (and I admit falling into that category after being awake most of a weekend on call, when I feel that my best efforts to deliver outstanding patient care are being subverted by forces outside my control) is not whether our rage is justified, as much as how will we channel that rage to improve care for our patients?

What do you think?

• What events make you angry when you are caring for patients
• How do you handle that rage
• Knowing your hot buttons, have you become more proactive over time

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

Kenneth H. Cohn