Wednesday, June 26, 2013

Shut Up and Sell - the Corporate Physician's New Motto?

Evidence has been seeping into public view about the extent physicians who sign up to take care of patients as corporate employees give up their professionalism.

Shut Up...

In April, 2013, Medscape published an article whose striking title was "Can You Speak Out Without Getting Fired or Being Labeled a Troublemaker?"  The answer was basically "no."

Physicians often see problems at their workplaces relating to patient quality of care, financial practices, mistreatment of staff, and other issues. But as more doctors take jobs as employees of hospitals, medical groups, and other large organizations, they increasingly face the same dilemmas as millions of other working stiffs. When they come across actions or policies that they don't think are right, they have to decide whether it's worth it to speak out and get labeled as a troublemaker -- or perhaps even get fired.

 Across the country, a growing number of physicians are indeed losing their jobs -- and often their hospital staff privileges -- after protesting employment conditions. Such complaints may involve patient quality-of-care problems, short staffing, misallocation of funds, improper financial incentives, fraud and abuse, discrimination, overuse or withholding of medical services, or other misconduct, say organized medical groups, employment attorneys, and physician recruiters.

Of course, physicians swear oaths to put the needs of their individual patients first, and doing so within a large organization might well involve protesting conditions and practices that may affect the quality of care or even endanger patients.  But woe unto physicians who try to fulfill their professional responsibility when doing so goes up against the top executives to whom the physicians must now report.

'We were naive when we went into this,' says Maria Rivero, MD, who with her professional colleague and significant other Derek Kerr, MD, filed administrative complaints against their long-time hospital employer in 2010. 'We thought if we just brought it to people's attention, they would fix the problem and leave us alone. But if you blow the whistle on high-level executives, you need to prepare to be harassed and lose your job.'

Even working within the system to fix problems can lead to big trouble,

Still, the formal professional approach doesn't always work either. Cloyd Gatrell, MD, an emergency physician who was employed by EmCare, says that he and his wife Kathryn, a nurse, voiced concerns and presented data to executives at Carlisle Regional Medical Center in Pennsylvania in 2008 and 2009 on what they saw as inadequate nurse staffing levels that endangered patients.

After getting no results, Dr. Gatrell contacted the state health department, prompting a state inspection that found insufficient staffing. In 2010, he was fired by EmCare at the request of the hospital, according to his 2011 lawsuit against the hospital and EmCare claiming violation of whistleblower protection laws. His wife was fired earlier, and she sued separately. The hospital issued a statement declining comment on the litigation.

'We're supposed to be advocates for patients, but being employed puts us in a precarious position in taking a position on patient interests that's against what the hospital administration favors,' says Dr. Gatrell, whose suit is in the discovery stage. 'I think a physician still has that responsibility.'

Physicians who sign contracts with corporate employers, perhaps thinking that they will have less bureaucracy with which to contend and a more certain salary than they did in private practice, seem blissfully, or willfully unaware that those contracts may take away their ability to control their practices and stand up for their patients.

Still, federal and state whistleblower laws only provide protection from retaliation for physicians in certain situations, such as those employed by public entities or those who complain about civil rights violations or Medicare and Medicaid fraud and abuse. Otherwise doctors may have to rely on contract provisions or on state employment law, which may not offer much protection.

[An anesthesiologist on the AMA Board of Trustees and his hospital system's board,] Dr. Annis says that the AMA's new statement of principles for physician employment -- which asserts that physicians should not be retaliated against by their employers for speaking out on patient care issues -- provides support for doctors when they raise legitimate professional concerns with their employers. He says it's best for physicians to work through their medical staff organization.

But Dr. Gatrell points out that the AMA statement explicitly accepts that physician employment contracts may allow hospitals to strip doctors of their medical staff membership and clinical privileges at the same time they are terminated, known as a 'clean sweep' clause. 'If that's accepted by the AMA, the rest of the principles protecting physicians are meaningless," he argues. "If physicians can be fired without cause and then automatically lose their medical staff membership and its due process protection, how many will dare be a patient advocate?'

Some experts advise physicians not to sign employment agreements with such onerous provisions. But others say that physicians often have little leverage to remove them. 'It's not an equal negotiating table,' says Dr. Gatrell, who's now working for a small urgent care practice.

A May, 2013 article again in Medscape about the "4 Top Complaints of Employed Doctors," explained why physicians often see a lot they could or should protest to assure the quality of their patients' care,

 Some doctors report that hospital administrators treat them with a lack of respect. One female doctor said, also on condition of anonymity, that her biggest challenge on her job was 'how to handle nonphysician high school grads bossing you around when they function as your 'superiors' in your employer's organization. They manage their insecurities by bullying physicians and through passive aggressiveness, but always seem to gain the upper hand with those at the top.'

These are the sorts of brilliant administrators often hired by brilliant top executives, maybe at a cheap price to keep the bottom line and executive compensation healthy..  Furthermore, given that as we have discussed, "financialization" of hospital management often puts a bigger priority on short-term revenue than on quality care, as per one senior physician,

 'physicians are being increasingly targeted when they get in the way' of hospitals' agendas

To make more money faster, many hospital systems now seem to want physicians to only make referrals for lucrative tests and treatments within the system, even if some patients might be better served elsewhere,

The AMA recently issued guidelines for physician employment stating that 'a physician's paramount responsibility is to his or her patients.' Employers should not retaliate against physicians for asserting their patients' interests, according to these guidelines. 'In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority,' the AMA says.

The guidelines also call for employers and employed physicians to disclose to patients any agreements or understandings they have that restrict, discourage, or encourage particular treatment or referral options.

Nevertheless, employed physicians are often expected to refer patients within their own groups and send tests to a hospital laboratory or imaging center. Hospitals may tell employed surgeons which kinds of joint implants to use, and according to a New York Times article even whether to implant defibrillators in Medicaid patients. It's unclear how often any of this is disclosed to patients.

'What we doctors say is that we're ethically bound to our patients because we took an oath, and that's what our license is based on,' says Linda Brodsky. 'But many hospitals say, 'No, you're employed here, and what we say goes.'

Note that so far there seems to be little evidence that the AMA guidelines about physician employment are being honored other than in the breach.  It is also disappointing that the leadership of the medical society that represents internists seems so unworried,

 David L. Bronson, MD, President of the American College of Physicians, disputes Brodsky's assertion that hospitals tend to squelch doctors who criticize leadership for policies that they believe harm patient care. In fact, he says, healthcare organizations may identify outspoken physicians as potential leaders, 'as long as they're collaborative and trying to solve problems, and not just be a thorn in the side of everyone they know. Organizations are looking for physician leaders, and physicians who can collaborate and not just be adversarial can go far inside organizations.'

I would guess, having seen so many examples of generic management, mission-hostile management, management that seems more focused on the money than patient care, and management that seems to be able to make itself rich without evidence that it has done anything noteworthy to uphold hospitals' clinical missions, that hospital systems that promote physicians who are willing to speak out against hired executives are vanishingly rare.

And Sell

In June, 2013, Beckers Hospital Review published an article suggesting that now hospitals are going beyond just pressuring employed physicians to refer potentially profitable patients within the system, and now are pressuring physicians to act as salespeople to their colleagues,

 A few hospitals are beginning to train their employed physicians to "sell" the hospital, which involves asking referring doctors in the community to send patients their way....  the pressure to bring doctors into sales is mounting.

The author, the former publisher of Modern Healthcare, made a remarkable argument based on a definition that seems wildly optimistic,

 Customer service lies at the core of salesmanship. The Business Dictionary defines salesmanship as satisfying customer needs through a sincere and mutually beneficial process aimed at a long-term relationship.

Of course, skeptical physicians used to exposure to the sales tactics pharmaceutical and device companies use (look here, here, and here,  for example) might wonder why the author did not discuss such marketing tactics as the employment of half-truths and biased information, and the use of emotional appeals to trump reason and logic.

That the author was serious was shown by his list of seven pointers for hospitals seeking to transform its employed physicians into marketers.

Of course, physicians who are already "key opinion leaders" employed by drug and device companies, whose marketing executives may think. that "key opinion leaders were sales people for us," (see this post), might not be fazed by now being asked to market their own hospital.  Never mind about Principle II of the AMA Code of Ethics

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

The Moral of the Story

We have previously discussed various aspects of the travails of the brave new world of the corporate physician.  Physicians and other health professionals who sign on as full-time employees of large corporate entities have to realize that they are now beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation.  Physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.

It is disappointing that even medical societies that ostensibly support physicians' professional values have been afraid to warn against such employment, or do much to help physicians trapped within it.

Physicians who go to work for big corporations have to realize that they may be forced to put corporate executives' vested interests ahead of their patients.  Patients whose physicians work for big corporations must realize that their health care will now be corporate, with all that entails.

  As I have said before, we need to challenge the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.


Brad Evans said...

Albert Hirschman wrote a book "Exit, Voice, Loyalty." His idea was that, when you face a situation that you don't agree with, your options are (1) leave, (2) complain or (3) comply with that situation, even though you might not agree. Complaining in a medical situation is basically whistleblowing. Basically, whistleblowers end up ostracized and sometimes even blamed for the situation they complained about. You could say that a whistleblower might find a way to complain in such a way that his/her anonymity is preserved, but I don't think there are guarantees enough.

Your choice is leave or stay, I think. If you think being a "corporate physician" means you stay with the same company all your career, that's not the way that people look at being a corporate person nowadays. People switch jobs a lot. I don't know what job-switching means for medicine. My guess would be continuity of care would be lost and quality of care might suffer, but I don't know.

Roy M. Poses MD said...

That seems fatalistic, or cynical.

I have not read the book, but the list of options seems to leave something important out, like

4) Do something to change the situation (other than just complaining.)

Steve Lucas said...

The value of a doctor’s undivided loyalty to the patient is even found in science fiction. In the Dune series of books we find a doctor is a major character with an emphasis put on his conditioning to always act in the best interest of the patient. We may see this as a reference to the old Greek “first do no harm” or we can look at this as a reference to our modern society.

In the modern setting we see a passive/aggressive attitude prevailing in almost all fields. Doctors will say; your insurance demands this test, while the reality is they will pay for a test, and have no guidelines other than doctor determined need. This leads to the massive over testing in this country, and the resulting spending that is crushing our economy.

In Dune we see the doctors conditioning being broken and he is acting in the interest of others to protect his family. How different is this than the modern doctor accepting questionable practice decisions to provide an income for his/her family? That unneeded test becomes so much easier to sell if it keeps the business managers off your back. As noted, business managers are often chosen who lack the ability to review a situation so as to block any real discussion of need. This is a deliberate act by those in charge in an effort to improve financial results, not patient service.

I have been active in church affairs for a number of years. Today I am dealing with a number of clergy with business backgrounds who are taking graduate level business courses in order to “better manage” their churches. In full passive/aggressive mode they have explained how with their superior knowledge they are better able to expand the church while dismissing the current massive membership loss, and ever increasing salaries, as the price we pay for their presence in our lives. The parallels to medicine are striking as denominations respond like medical societies with soothing words of support, but no real action.

In the Jan. 5, 2014 Forbes article The Top 10 Jobs That Attract Psychopaths we find this list:

1. CEO
2. Lawyer
3. Media (Television/Radio)
4. Salesperson
5. Surgeon
6. Journalist
7. Police officer
8. Clergy person
9. Chef
10. Civil servant

While doctors ranked in the bottom ten we have to ask: Does their constant association with many on the top of the list force, or allow them, to behave as a psychopath?

The book Snakes in Suits makes clear the low level psychopath can make any employees life hell. As society accepts the passive/aggressive, pathological lying, self-centered nature of those chosen to represent us in the professions, how do we then respond when they act in their own self interest?

Steve Lucas

Judy B said...

This is so appalling that it almost leaves me speechless. For the time being, I will continue to avoid the medical industry like the plague....

Anonymous said...


Great job . . . and thanks for putting all this information into a single article. I think every reader should print this article and share it with his doctor(s). Doctors who look in the mirror and admit that their authority and livelihood has become subservient to corporate bottom lines should DEMAND change. Hopefully, those who are willingly blind (because their paycheck hinges on that blindness) will at least experience a twinge in their conscience or their gut that will grow into a nagging awareness that somehow this is NOT what they signed up for.


Anonymous said...

Healthcare is in severe disrepair. I am about to leave the healthcare industry so I may concentrate all my efforts to personally avoid it and protect my family members who need it. God help those who remain in healthcare and still care.

Mary Moore said...

Most medical societies have gone over to the dark side, and are now primarily after the money. The presidents of the Am Board of Int Med and the Am Board of Pediatrics make million dollar salaries. There is an automatic 25% fail rate for peds boards (more $$ in exam fees) and increasingly higher fees for MOC courses. Corporate medicine is here and has corrupted the entire system. Revenue enhancement is the order of the day.
Mary D. Moore, MD, Pediatrian

Steve Lucas said...

Dr. Moore makes an important point that medical education has been driven to the dark side. I feel we should also include academic medical centers in the discussion. In my state Big U has led the drive for increased CE requirement and even increased academic requirements for all those working at all levels in medicine.

Pharmacist now must have a PhD with the result that we now have a well educated young person who may have spent their clinical time working in pediatrics in a hospital setting, trying to figure out the Medicaid requirements for an 87 year old woman.

My eye doctor graduated from Big U and was a supporter until Big U proposed new CE requirements that would require essentially a semester a year of classes. Additionally, Big U was pushing for an insurance requirement that to be reimbursed for services a doctor had to meet these educational standards.

Doctors now find themselves not only dealing with the pressures of running a practice but with the drive of the medical schools they graduated from trying to maximize profit levels, often to support outsized staff salaries.

In my state all of the public university presidents’ salaries rank in the top 100 nationwide with Big U at the top.

Steve Lucas

Steve Lucas said...

Correction: One public university president in my state did rank 116th in nationwide pay.

Steve Lucas