By Allan Dobzyniak, MD

Doctor, if you have recently had occasion to be granted a visit with upper hospital management in the plush executive suite, most surely it was you who stood out quite conspicuously. Being greeted, hopefully politely, by one of the administrative secretaries, you were asked to be seated and wait along with others—consultants, lower-level management, salesmen, business associates, insurance executives, and maybe even golf buddies. Notable was that you, the physician, were the only one not appearing in tonsorial splendor, groomed to the hilt, well-rested, and adorned in a three-piece suit. You were the person blurry-eyed from the night shift or up all night with an emergency, dressed in a white coat with pockets full of papers and baggy greens, maybe blues. Curious though, it is you, the physician, who is responsible for all of their incomes.

Granted, as health care has become a complex, shifting, and regulatory nightmare with falling reimbursement rates and myriad payment mechanisms, hospital management has become more complicated. Looking for the easy way out of bottom-line revenue erosion, all of management’s expensive consultants have likely suggested cost reduction. And the most important driver of costs in virtually all hospitals is the medical staff. Even though physician compensation accounts for only 8 percent of health care spending, their decisions are estimated to account for up to 80 percent of the nation’s health care budget. Therefore, to cut costs, hospitals must either gain control of their physicians or collaborate with them to create value. With the ongoing obsession to employ physicians, it can be concluded that, in general, the approach preferred by the occupants of the posh offices of hospital executives is the former, control being the goal.

No matter how it is nuanced, the clinical decisions of physician employees are increasingly influenced by hospital management and its growing bureaucracy. How is it possible to transform an independent clinician with years of commitment to developing their craft, with the desire to hold onto their professional autonomy and who continues to cherish the patient-doctor relationship as foundational both to the very practice of medicine as well as its enjoyment, into a supplicant “worker bee?” Certainly, linking compensation to the egregious, impersonal wage equivalent of an hourly worker via some formulaic RVU (relative value unit) is a good start, but not enough. What must be done is to create circumstances that convince doctors that they are really not as important as they think they are—just another member of the team. That precious doctor-patient relationship must be relegated to peripheral importance or even of no importance at all.

Create physician dependency by introducing complex systems outside of their expertise and make them dependent on such. EMR, other IT, coding, and billing puzzles meet this goal. And remember to change these systems frequently—be sure they are costly, idiotically complex, quite unreliable, and, of course, user-unfriendly.

Physician confidence must be undermined. Confident physicians are comfortable and difficult to control. Undermine the independence of the Organized Medical Staff. Express irrelevance for the Medical Staff Bylaws. Hire a few competitors to the successful private practitioners. Fire a few of the employed physicians, not because of clinical incompetence but for not getting with the program and not acting as subservient team players. Absolutely necessary is designing a variety of schemes to put physicians’ compensation at increasing risk. Population-based, algorithm-driven decision-making according to “evidence-based” hospital guidelines must replace professional judgment, intuition, experience, and compassion that is individually patient-focused. No promotions, imperiled compensation, and any additional physician rewards must rely on these hospital mandates. Ah yes, just like assembly line workers, productivity standards must be unrealistically designed to be just out of reach if empathetic clinical care is not compromised. This may be the ultimate conundrum for physicians.

But this is the one I really love. Doctors, here, we administrators are going to give you physicians the responsibilities you have asked for; in fact, we demand you assume these. But then—ha-ha—no authority is allocated or tools provided. For example, physicians are made responsible for patient satisfaction scores but given no authority to control staffing, staffing attitudes, the workability or selection of IT, cleanliness, operating room efficiency, or even parking.

Also, there must be a hurried goal of driving a wedge between physician and patient. Create a design whereby the patients come to identify the hospital, not a particular physician, as their source of care. Centralized scheduling is one of the magic tickets here, among others. Phrases such as “refer to ortho,” “refer to derm,” “refer to peds” show the desired outcome has been met.

If any of this sounds familiar, do not be surprised. Such tactics are well known to those who seek to control health care, know virtually nothing about medicine, are sopping up ever more health care dollars, and are increasing in numbers far in excess of physicians.

If you enjoy economics, this might be of interest. Max Weber (1864–1920), a political economist, was a champion of hierarchy: “”Precision, speed, unambiguity, knowledge of files, continuity, discretion, unity, strict subordination, reduction of friction and of material and personal—these are raised to the optimum point in the strictly bureaucratic administration.” Then there is the view of the more contemporary Gary Hamel, who firmly believes that in order for organizations to prosper, bureaucracy must die and that it actually bears key blame for discord. He states, “By their very nature, bureaucracies are inertial, incremental and uninspiring. That’s a problem because today operational efficiency is just the price of entry, a necessary, but far from sufficient, condition for competitive success.” I choose Hamel, but surely, in many hospital executive offices, Weber is still their guy.

Allan Dobzyniak is an internal medicine physician.