This article describes the tension that the coronavirus disease 2019 (COVID-19) pandemic brought up between administrators and physicians and offers a potential set of solutions to deal with it.
Am J Manag Care. 2020;26(12):In Press
This article offers 3 clear solutions for executives and leaders to help bridge the divide that the coronavirus disease 2019 pandemic revealed between administrators and physicians:
The coronavirus disease 2019 (COVID-19) pandemic did not create physician burnout, but it has certainly amplified it. Even before the pandemic, physicians were becoming increasingly vocal about their unhappiness with the state of affairs in modern medicine, ranging from performance-based compensation metrics to the arduous administrative burden on their practices. Now, during this unprecedented international crisis, physicians on the front lines are needing to say “yes” to extra shifts and unsafe working conditions, and to swallow the prospect of pay cuts and furloughs for their trouble. Recent proposals to combat a parallel burgeoning mental health crisis range from instituting greater emphasis on physicians’ intrinsic motivations to adopting wellness programs at the organizational level, instituting a chief wellness officer or other point person to coordinate these, and allocating federal funding to measuring and managing clinician well-being.1,2 Work done by Shanafelt and colleagues adds to the growing calls for reform by highlighting the need for clear messages and actions from leadership (who are often physicians themselves).3 These ideas are necessary but not sufficient; they will not address the deeper root causes of burnout that COVID-19 has laid bare before the nation.
The pandemic has shone a powerful light on an underrecognized source of physician dissatisfaction: Many physicians feel that their motivations and interests are increasingly divergent from those of clinic and hospital administrators, particularly in larger organizations. At its core, this divide is the result of rapidly changing structures and financing of health care. Recent years have seen a steady trend toward the consolidation of health systems, the decline of independent practices, entry of private equity into ownership structures, and value-based purchasing programs that distribute risk from insurers to physicians. Each of these iterations has led to more downward pressure on cost structures and a corresponding need to extract more value from physicians.
For example, top-down imperatives to expedite discharges or optimize clinic schedules are often viewed by physicians through a filter of distrust; they see such orders as motivated less by patient satisfaction and safety and more by the desire to maximize profit margins. These changes were meant to make physicians more efficient while improving quality; instead, they have had the unintended result of making them feel disillusioned, disparaged, and minimized. These days, medical society meetings and online discussion forums are increasingly dominated by requests for contract negotiation tips, nonclinical careers, “side gigs,” and advice on ways to retire early.4 Danielle Ofri, MD, PhD, in a widely shared New York Times article, ascribed the “exploitation” of physicians’ professionalism to holding the medical enterprise together, and writing in the New Yorker, Eric Topol, MD, wondered why physicians had yet to unionize and advocate for themselves.5,6
The COVID-19 pandemic has brought this tension to a boil. Now, as health care administrators scramble to create ad hoc sick leave policies, institute testing options, and procure more personal protective equipment (PPE) while safely reopening facilities, physicians are primed to view all of these actions with suspicion. A lack of PPE due to supply chain breakdowns has physicians excoriating their leadership on social media for treating them as disposable. Even as both hospital leaders and state governments were pleading for a volunteer force of physicians to help out in disease hotspots, many physicians, in online forums, were advising each other not to work for free during this surge. Some of this suspicion has been warranted, especially when news outlets carry stories of hospitals instituting gag orders on their physicians speaking to journalists, health systems firing physicians who protested against unsafe work environments, or administrators pocketing hefty bonuses in the midst of the crisis that has found 40 million Americans unemployed. Although these appear to be mostly exceptions to the rule, physicians for the most part do not seem to view their institutional leaders as comrades in the same fight.
What we can we do about this? We recommend a 3-part action plan to help align physicians and administrators in the fight of our lives.
First, leadership must aim for transparency even when the message is that of uncertainty or turbulence. Anecdotally, we have seen that at institutions where updates are frequent and dialogues open, feelings of being misguided or misled are minimized. Initiatives can be as simple as designating a clinical chief to send daily emails that provide all clinicians with a detailed breakdown of case number and trends, updates on management, a review of the latest literature, clinical guidelines, and candid memos on the status of supplies and testing equipment. Employees need to feel confident that their leaders are making decisions based on the best available evidence and supply and not by financial interest during this crisis.
Second, health systems can inspire confidence in their physician workforce by demonstrating that they are making substantive investments in community. The majority of hospitals and health systems in this country are nonprofit and enjoy a tax-exempt status in recognition for the benefits they provide, such as uncompensated charity care and medical outreach. However, not all hospitals are alike in their community investments, with research showing that only 62% of hospitals provide enough community benefit to warrant the amount they get in tax exemptions (with some egregious outliers).7 Meanwhile physicians, who increasingly are choosing to go into medicine while cognizant of declining reimbursements and diminishing financial security, are doing so with an arguably greater moral lens and sense of social responsibility than ever.8 The result is a fundamental disconnect between physicians, who increasingly view the patient-doctor relationship as representative of a larger social contract, and health care administrators, whom physicians view as being more revenue driven. The COVID-19 pandemic, which has shown a propensity to feed on and heighten existing weaknesses in our society, has hit safety net hospitals and community hospitals situated in economically depressed areas the hardest.9 These health systems often do not have the resources or well-connected board trustees to circumvent political gridlock in obtaining supplies for patients and physicians. Hospitals that have the means to help must help (and to their credit, many are already engaging in coordinating supplies). Doing so will not only save lives but also boost morale for a workforce that will be proud to be affiliated with such an institution.
Third, health care leaders must align with their workforce monetarily. No frontline physician is deaf to the news that their health system is hemorrhaging money due to the clampdown on lucrative elective and surgical care. But transparency on health care finances is largely lacking. Furloughs and pay cuts are hard to swallow if health care administrators do not face a financial pinch themselves, and such measures deepen the us-vs-them attitude among physicians. With no insight or input into how the budget is allocated and whether staffing and supplies are being prioritized, physicians are left to assume that the bottom line takes precedence over patient or physician well-being. Having an active and meaningful voice in financial decisions is key to rebuilding trust between physicians and administrators and likely leads to better clinical outcomes.
Divides between physician and administrative goals pose a threat to physician career satisfaction and longevity within the profession. These divides—like other weaknesses within our health system—have been exacerbated by the COVID-19 pandemic. Increasing alignment between the 2 groups, by taking both business and patient interests into consideration, will help physicians regain their sense of purpose and loyalty to their health systems.
Author Affiliations: Department of Medicine, Memorial Sloan Kettering Cancer Center (SM), New York, NY; Department of Pediatrics, New York-Presbyterian Hospital (RD), New York, NY; Columbia University Medical Center (RD), New York, NY; The Brookings Institution (KP), Washington, DC.
Source of Funding: None.
Author Disclosures: Dr Patel is a board member of SSM Health and Dignity Community Care, a health system that employs physicians. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (SM, RD, KP); drafting of the manuscript (SM, RD, KP); critical revision of the manuscript for important intellectual content (SM, RD, KP); administrative, technical, or logistic support (KP); and supervision (KP).
Address Correspondence to: Kavita Patel, MD, MS, The Brookings Institution, 1775 Massachusetts Ave, 8th Floor, Washington, DC 20036. Email: firstname.lastname@example.org.
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4. Physician Side Gigs. Accessed June 1, 2020. https://www.physiciansidegigs.com
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9. Mullangi S, Knudsen JL, Chokshi DA. Shoring up the US safety net in the era of coronavirus disease 2019. JAMA Health Forum. June 15, 2020. Accessed August 1, 2020. https://jamanetwork.com/channels/health-forum/fullarticle/2767380