BY: TIM PORTER-O'GRADY, EdD, PhD, and RICHARD AFABLE, MD, MPH
Dr. Porter-O'Grady is senior partner, Tim Porter-O'Grady Associates, Inc.,
and associate professor, graduate program, School of Nursing, Emory University,
Atlanta; and Dr. Afable is executive vice president and
chief medical officer, Catholic Health East, Newtown Square,
Physicians Must Play a Larger Role in Decisions Concerning Capital and
The age of the physician as customer is over. The notion of the independent
entrepreneurial physician whose relationship to the hospital and health service
setting is primarily that of a guest is an Industrial Age creation. In the 20th
century, professionals in all fields sought identity and role clarity. As a
result, they were anxious to establish a sustainable place for themselves. Physicians,
like members of other disciplines, were eager to position themselves as primary
decision makers projecting an image of independence and unilateral authority.
Physicians worked throughout the past century to codify a common and rigorous
curriculum and training program that would establish their primacy and independence.
This attracted single-minded, willful, purposeful people to the profession.
The physician's role in the health care system was established as one that was
controlling, directing, and decisive. Legal structures were created to protect
and ultimately promote that role.
However, the demands of the emerging 21st century require a different set
of values to sustain the work of health care and medical practice. The complexity
of clinical service and the application of advanced technology have created
a different professional and social milieu within which new relationships between
physicians, on one hand, and hospital and system leaders, on the other, will
unfold. The old alignments supporting physicians' independent behavior are now
dissolving. What is needed is a new configuration and affiliation that recognizes
and honors the complexity, alignment, and integration of roles in a service
agreement, thereby transforming the very nature of the clinical relationship.
The building of this new kind of relationship will be challenging, but it will
also be vital to those professionals who want to thrive in a new social construct
for health care.
Three Needed Things
Much of the negative fallout from 20th-century health care can be blamed on
the autonomy, compartmentalization, and polarization of many of its stakeholders.
From the division between nurses and physicians, on one hand, to the more general
conflicts between individuals and institutions, on the other, everyone involved
in health care is today caught in a pattern of behavior that is no longer sustainable.
Behavior that is mutually exclusive must change if health care is to thrive
in the new century.
Boards of trustees and administrators are, for example, finding it difficult
if not impossible to make capital decisions regarding new technology without
more clear and direct participation by physicians. In fact, it is becoming increasingly
clear that, if hospitals and health systems are to remain viable, physicians
themselves must provide strong leadership in the planning process. Gone are
the days when physicians were merely consulted about technology and nonphysicians
made the vital decisions concerning the hospital or system. Gone also are the
days when decisions concerning capital and purchase preferences could be based
on political jockeying. Today's health care environment requires consensus and
Three things are now needed to ensure the appropriateness and long-term viability
of health care technology planning and decision making.
Collaborative Structure To make the best possible decisions concerning
capital invested in technology, health care system leaders should establish
an organized process in which the system's physicians participate in assessments,
recommendations, and approval mechanisms.
Accountability Physician leaders must play a partnership role in technology
decisions in a way ensuring that they "own" and are accountable for the choices
Vision Decisions concerning the investment of capital in new technology
and information systems must always be made in a disciplined and systematic
manner. Plans should aim at the comprehensive use of technology that advances
both the mission and service viability of the health care system and its participating
Systematic Physician Involvement
Every health care organization has a technology and capital planning process.
Some work well; others do not. In an age in which technology has become a major
driving force in the transformation of U.S. health care, the critical factor
will be the ability of planners to anticipate the impact and availability of
a specific technology and fit it tightly with the health care system's resources
and potential future service configuration. Although some technologies (such
as information management and billing systems) are applicable to all health
care systems, each particular system will have a particular and unique relationship
to its community, as will be evidenced by the demographics and demands of those
the system serves. No one is closer to the service demands and needs of health
care consumers than physicians. Because they are oriented to both the economic
and clinical concerns at the point of service, physicians have a unique perspective
on the market. Taking physicians' personal practice biases (and such biases
are significant) into consideration, one must admit that their experience and
knowledge give them a comprehensive picture of current patterns of the behaviors,
needs, and demands of health care consumers. Because this is so, administrators
involved in information gathering and capital planning should seek input systematically
from practicing physicians. And that is just the beginning. Physicians should
be educated about the capital planning process and furnished with a better understanding
of how decisions are made based on clinical priorities and financial constraints.
Furthermore, because physicians will likely be the users of most of this new
technology, they must participate more fully in the decision-making process.
In the past, much of that process involved administrators' getting some sense
of what physicians wanted. Medical staff members rarely participated in weighing
cost against benefit, balancing one choice against another, and determining
the substantive fit between choices. Today, however, physician participation
in decision making is a critical part of new technology assessment and should
be included in the planning and selection process.
But how can physicians best participate in this decision-making process? The
medical staff structure at most hospitals does not lend itself to consensus
and collaboration, nor to an organizational mind-set. The criteria for medical
staff membership have traditionally been clinical. Because of this, medical
staff decision making is often deferred to an executive committee typically
made up of elected representatives, department chairs, and service line directors.
Such people may or may not have the facility's best interests in mind; loyalty
to the organization is usually not a prerequisite for election or appointment
to this group. As a result, medical staff members tend either to be excluded
from capital planning and decision making, or, at best, to play only an advisory
role. One way leaders could rectify this lack of meaningful physician involvement
is by forming a medical staff subcommittee or work group that would be specifically
involved in capital planning and decision making. Criteria for membership in
such a group would be:
- Commitment to the hospital or system
- Business acumen
- Clinical knowledge
- Understanding of community needs
- A demonstrated interest in the well-being and advancement of the institution
Appointments to the group should be made by administrators as directed by
the board of trustees, rather than by the general medical staff, for the reasons
stated previously. The political and financial challenges of such a move would
likely be significant, given the current dynamics of many medical staffs and
hospitals. But, given the importance of capital and technology decisions and
the many potential benefits gained from meaningful physician involvement in
this process, the risks seem to be justified.
Physician Competition Crisis
As clinical technology becomes more portable and flexible, health care delivery
becomes less dependent on institutions. Twentieth-century medicine was predominantly
manual and mechanical in its application. Twenty-first century medicine will
be different. Therapeutic interventions will increasingly be pharmacologic,
minimally invasive, genomic, and "chip"-based. These therapeutic approaches
will require hospitalization less frequently, and, because this is so, traditional
hospital-related care activities will become less important. The contemporary
increase seen in outpatient services presages this reality.
The "crisis" associated with this change is that, over time, hospitals will
become less relevant to the delivery of patient care. Much of hospitals' current
infrastructure is geared toward overnight stays and bed-based activity. Hospitals'
old dependence on bed-based activity has created a service and financial model
that may no longer be sustainable.
Physicians, too, are affected by increasingly portable clinical technologies.
Although they have the opportunity to embrace and take control of these new
techniques, their adoption of them is complicated by learning requirements for
clinical application and operational management. Unless physicians develop knowledge
of and experience with these modalities, they will find themselves in a disadvantageous
position—clinically, financially, or both. Significant variation in the use,
effectiveness, and efficiency of new technology can be expected until a critical
degree of experience and proficiency has been attained.
Medical groups are now taking steps to "own" many of these portable technologies
and services, providing them in their own clinical settings, often in competition
with hospitals. It is now possible for patients to return home after diagnostic
and therapeutic interventions that, until recently, would have required hospitalization.
New radiological techniques, cardiac procedures, cancer therapies, and minimally
invasive surgeries are among the innovations now commonly performed outside
hospitals. As many as 50 percent of curative breast cancer surgeries are now
done on an outpatient basis.1 In time, procedures such as electron
beam whole-body scanning may even supplant human diagnosticians. Indeed, these
procedures threaten to draw patients away from both hospitals and physicians,
thereby radically altering the financial and service landscape of health care
forever. The question for hospitals is: How can they remain relevant in a time
of dramatic transformation in service design and application?
A New Kind of Leadership
If hospitals and systems are to remain viable, their administrators must acquire
fluidity, nimbleness, and capacity for change. One key element of this leadership
is a total reconceptualization of the relationship between the hospital and
the medical staff. Although various laws and regulations may seem to limit or
even prevent the strengthening of such relationships, health care leaders must
be willing to test these apparent constraints.
If it is to thrive in the new century, U.S. Health care has an immediate strategic
and political obligation to address these issues. Several issues in particular
must be addressed.
Remove Constraints Twentieth-century laws and regulations that treat
physicians and hospitals as independent entities are no longer tenable. Although
society needs continued legal protection from profiteering and constraint of
trade, it must begin to recognize the interdependence of health care practitioners.
If practitioners are to have the opportunity to manage care across the life
continuum, they must be given the ability to integrate and collaborate on services
in a meaningful way. At present, such integration and collaboration are severely
limited by legal, structural, and financial constraints.
Build an Information Infrastructure Health care systems now have an
opportunity to create an Internet-linked information infrastructure involving
practitioners, services, sites, and health care consumers. Such an infrastructure
would go far toward changing the design of health care systems. It would establish
essential interdependencies between systems and practitioners, help consumers
evaluate the services available to them, and link financial and payment processes
in a coordinated model. Many health care leaders have taken a go-slow approach
to the creation of such an infrastructure, arguing that it is impossibly expensive.
However, the credit card and banking industries have shown that building an
effective and forward-looking clinical and financial information system without
the Internet is no longer an option. If Visa, for example, can build a network
that includes more than 350 million cardholders in every corner of the world,
coordinate the activities of four million vendors (with well over three million
transactions a day), and get the right information at the right time on an individual's
bill regardless of where in the world the transaction occurred, U.S. Health
care can do it too.2
Work Together Physicians and hospitals can no longer do much independently
to change health care's political, regulatory, and legislative landscape. Because
health care delivery itself has become so complex and interdependent, physicians
and hospital administrators must begin to recognize their own interdependence.
To collaborate effectively, physicians and administrators will have to work
for substantial adjustments in the laws and regulations in a variety of areas.
These areas include practice boundaries, business partnerships, clinical data
management, medical records, confidentiality, payment, quality improvement,
and "best practices." To make their collaboration work, physicians and administrators
must first change their view of each other, understand their mutual needs, develop
collaborative strategies for policy formation, integrate their data analysis,
and establish more direct leadership relationships in their boardrooms and executive
A basic tenet of quantum mechanics is that, at some level, everything is linked
in an inexorable dance of movement and resonance. Words sometimes used to exemplify
this circumstance are chaos and complexity. Although history shows
that physicians and hospital administrators have not always worked closely together,
the evidence indicates that such fractured and compartmentalized relationships
are no longer sustainable. However, a genuine relationship is not an accidental
or circumstantial occurrence; it requires concerted action.
U.S. Health care is approaching a seminal moment. Technology, which was once
evidence of change, has become the driver of change. Recognition of technology's
influence on structure and process is critical for the continued growth of health
care in this nation. Certainly, the complexities involved should prevent us
from continuing to operate as though the changes were simply incremental. Physicians,
nurses, hospitals, providers, payers, legislators, governments, and accrediting
agencies—all are today a part of the new health care mosaic, and, because this
is so, must recognize that fact and begin to work together.
- C. Case, M. Johantegen, and C. Steiner, "Outpatient Mastectomies: Clinical,
Payer, and Geographical influences," Health Services Research, vol.
36, no. 5, pp. 869-889.
- S. Davis and C. Meyer, Future Wealth, Harvard Business School Press,
Boston, 2000, p. 234.
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.