I was invited to a medical staff leadership conference sponsored by our hospital. A company specializing in training physician leaders ran the meeting. The topic was healthcare reform and its effect on hospitals and physicians. Included were discussions on patient-centered medical homes, accountable care organizations, bundled payments and physician integration and alignment with hospitals.

The course director made it crystal clear that there will be no place in the future for physicians who do not buy-in to the idea of population-centered, cost-effective medical care. Physician leaders will take corrective action to eliminate dissident physicians from the medical staff.

One of the cases we discussed was this (my abstraction):

“A hospital has a orthopedic-neurosurgery spine service line, headed by a physician-manager dyad and having a steering committee composed of physicians and managers. Several neurosurgeons want to do minimally invasive surgery while the orthopedists want to do surgery the old way. The orthopedists said there was not enough evidence to warrant change. Hospital administrators want minimally invasive procedures because these surgeries use less expensive hardware and have higher margins. One orthopedic surgeon, employed by the hospital, and who has a long history of disruptive behavior, refused to attend meetings where the issue is being discussed.”

We were asked to draw an organization chart, indicate who was accountable for what, suggest a plan of action regarding the surgeon’s continuing disruptive behavior, and recommend another plan if the orthopedic surgeons continue to perform the higher cost procedure.

I doubt that anyone else at the meeting had my perspective on this case, as I have been brought up 3 times for disruptive behavior, nearly a 4th. A psychiatrist, who I had thought was a friend, was at each meeting. At the last meeting, he ventured I had a psychiatric diagnosis where I liked being brought up for disruptive behavior. And I’m at a top 100 hospital.

With that background, here’s my analysis: (1) “Disruptive” is vague and could cover a variety of actions. It could mean abusing nurses. Christensen thinks disruption is a good thing. He uses the term to describe innovation that improves efficiency or lowers costs. The term “disruptive” is recommended by law firms popular with hospitals, which is why it is used. (2) We are not given any information about the surgeon’s prior disruptive behavior. It may or may not be relevant. (3) Medical staff disciplinary procedures do not provide due process protection, but I still think we have to assume that the surgeon is innocent until proven guilty. (4) There’s conflict between hospital administration and the orthopedic surgeons. It’s possible that the charges of disruptive behavior reflect an ongoing management campaign to bully the orthopedic surgeons, the employed one in particular. (5) We don’t have enough information about the surgeries to make an intelligent comparison. The only data that’s presented is financial and that’s not enough.

The point of the meeting was that hospitals need to control physicians’ decisions. The problem for physicians is that they have no Plan B if they can’t be a doctor. They are locked-in to their profession and therefore susceptible to hardball tactics. Physician leaders will use the medical staff disciplinary process to prosecute charges of disruptive behavior (and do sham peer review as well). They only need 1 or 2 successes to get staff physicians to cooperate with management recommendations for change.

This is not my idea of leadership.

Bradley Evans is a neurologist. 

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