Monday, April 30, 2007

Knocking the Moose Off the Table: the Downfall of a Hypocritical Health Care Leader

A story that got prominent coverage over the last few days says something about the leadership of health care organizations, as long as one puts the information in a new sequence. So, starting with an article in the New York Times,
Mr. [Randall L] Tobias, 65, is a former chairman and chief executive of Eli Lilly & Company and of AT&T International. He served as the chairman of the board of Duke University from 1997 to 2000.
And per the Boston Globe,
Business Week called him one of nation's top 25 managers in 1997. His book, 'Put the Moose on the Table,' which advocates addressing difficult issues in a forthright manner, became a best seller.
Note that in the book, Tobias listed his "prerequesites for leadership," starting with "(1) inspires confidence, trust, and consistently displays the highest ethical standards...."

Back to the Times,
President Bush nominated him in July 2003 to lead a $15 billion program to fight AIDS worldwide.

At the time, some AIDS experts said Mr. Tobias did not have much experience with AIDS or Africa.

Then, as director of United States Foreign Assistance, he held the rank of ambassador.

In January 2006, Mr. Bush said he would nominate Mr. Tobias to be the administrator of the Agency for International Development. That position gave him the rank of deputy secretary of state.
The policies Mr Tobias pursued were often controversial. From the Boston Globe,
Bush persuaded Tobias to take charge of his five-year global AIDS initiative known as PEPFAR, or the President's Emergency Plan for AIDS Relief, which is now on track to spend $18 billion. During his tenure, AIDS treatment, care, and prevention programs were started, but there were also bruising battles with activists over policies relating to generic drugs and abstinence-only initiatives, as well as charges of favoritism in giving grants to evangelical Christian groups with little experience in Africa.

But [Harvard Professor Jim Yong] Kim, who formerly was director of HIV/AIDS programs at the World Health Organization, said that some of Tobias's policy decisions also had negative impacts on the fight against AIDS. 'I completely disagreed with their all-out attacks against making generic drugs more available' by refusing to use the WHO's system for testing the efficacy of medicines, he said.

Michael Weinstein , president of AIDS Healthcare Foundation , a Los Angeles-based group with extensive experience in treating AIDS patients, said that Tobias's policy to test all generic medicine through the US Food and Drug Administration 'meant that fewer people received drugs.'

[Furthermore,] The Bush administration's policy requires that groups receiving US money 'have a policy explicitly opposing prostitution and sex trafficking.' That policy, said [Center for Health and Gender Equity Executive Director Jodi] Jacobson and others, has led to the closure of numerous programs that had been teaching job skills to sex workers, forcing many prostitutes out of brothels and into the street.
Why was Tobias in the news lately? Back to the Times,
The head of the Agency for International Development, Randall L. Tobias, resigned abruptly on Friday for what he said were “personal reasons,” but an administration official said Mr. Tobias’s name had come up in an investigation of a suspected Washington prostitution ring.

On Friday night, ABC News said Mr. Tobias had confirmed on Thursday that he was a customer of an escort service.

A woman from Vallejo, Calif., Deborah J. Palfrey, has pleaded not guilty to charges that she operated a call-girl service in Washington, and has threatened on her Web site to sell her client list to raise money for her defense.

Mr. Tobias told ABC that he used the service for massages, not sex, according to the network’s Web site.
And back to the Globe,
Randall L. Tobias , the Bush administration official responsible for foreign assistance who resigned late Friday because of his use of an escort service allegedly involved in prostitution, was ridiculed as a hypocrite yesterday because he supported US policies that forced overseas organizations not to help prostitutes.

'I think it is somewhat ironic and hypocritical that he would patronize an escort service while he was denying funding to organizations who want to help prostitutes, and supporting a policy that obviously forbids fraternizing with prostitutes,' said Jodi Jacobson....
I am afraid that this case illustrates the psychology of all too many of the leaders of health care organizations. Tobias' downfall is ironic precisely because he failed to follow the rules that he, himself, set out, both in his leadership of the AIDS effort and in his best-selling management book. Too many health care (and other) leaders seem to think that they are not subject to the rules that apply to the ordinary folk, and that what they say need not be what they do. Thus the title and subject matter of Mr Tobias book now seem like something of a sick joke.

As F Scott Fitzgerald said, "the very rich are different from you and me."

As long as health care leaders feel no need to be do what they say and say what they do, and think they are above the common folk and that the rules do not apply to them, health care will be run for the leaders' benefit.

The need for representative, transparent, and accountable health care leadership has never been greater.


Anonymous said...

I see a common thread between Mr. Tobias' behavior and that of others such as Tom Foley (rail against child abuse while fooling around with child Senate pages), some church pastors (rail against sex while having a prostitute of either gender on the side), etc. I am sure there are other examples I haven't thought of.
Rather than thinking they are above the rules, it almost seems to be an inner psychological paradox - they know what they are doing is wrong, so they "compensate" by trying to make rules against it. Their very vociferousness smacks of a guilty conscience. I am not a psychiatrist, but I think it goes deeper than just thinking they are above the "common folk."

Jim said...

Help make May about health care ideas not empty attacks...

MedInformaticsMD said...

From the informatics perspective, I think a more relevant question is, when will physicians change and they and/or their leadership become strong political actors on their own behalf?

Physicians don't stand up to those non-medical business-oriented persons who have taken control of healthcare. Clinical IT might just become another tool of control.

This was recently on the HISTalk blog:

Re: claims data. Managed care organizations are using claims data as a proxy for chart review because it is cheap and available. One company released the data for our practice and subsequent chart review showed that most of the claims data did not correspond to data in the charts.

Per the JAMIA article "Comparison of Methodologies for Calculating Quality Measures Based on Administrative Data versus Clinical Data from an Electronic Health Record System: Implications for Performance Measures" it's clear that better clinical data is needed for quality assessment and that use of administrative data is akin to throwing darts (did we actually need a scientific study to know that?) However, with metrics controlled by payors, I'm not so sure even EMR's will help much. Payors will tilt the pinball machine towards maximum profits, and he who controls the data, controls the playing field.

Perhaps one has to ask a more fundamental question: do physicians deserve better?

A software engineering colleague of mine of Eastern European descent (i.e., grew up under repressive dictatorship and takes uncompromising views of defending one's rights) asked me the following questions:

"When you started writing about health IT difficulties in the later 1990's, did you receive support from physicians?"

I had to answer "no."

I had been writing for ten years that more attention needs to be paid to health IT project difficulties and failures, and just recently it seems these issues are finally being taken more seriously by the national informatics organization (e.g., a workshop last year on "avoiding failure.")

My friend also asked me: did any physician stand behind me when multiple actors interfered with and destroyed a Director of Clinical Informatics role I was to start in the Halls of the Ivy League?

My honest answer: no.

Next I was asked, did any physician stand behind me when I tried to fight for what was right, challenging the IT decisions in the non-academic hospital where I later became CMIO that stifled clinician empowerment and/or endangered patients?

Not a one.

I can only surmise clinician change agents in other settings experience that same physician indifference and unwillingness to stand up for the profession.

Perhaps physicians deserve the marginalization and de-professionalization that is well underway now?