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President's Message (A Cry for Help Unanswered?)

Howard Blumstein, MD FAAEM

Posted: 09/23/2011

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Dear Colleague

I recently received a message from a fellow emergency physician. The following is my response. The only edit I made was to remove his name. Enjoy.

I received your email, which was sent to the AAEM home office in response to an email sent out to folks who had not renewed their memberships. Yours seems to be the sort of tragic story we hear all too much from emergency physicians all over the country.

My job is pretty frustrating. We get calls for help on a regular basis from docs who, like you, get screwed somehow. What's frustrating is that most of the time there is little we can do to help out. Most of the time these doctors have gotten themselves into a situation in which they have signed contracts that give them no recourse.

We have offered support where we can. We suggest that the doctor (or doctors) appeal to the medical staff of the hospital, we sometimes write a letter to the hospital administration suggesting that their new contracts are not legal or are otherwise disadvantageous, we suggest that the doctor(s) contact their state chapter of the AMA. But realistically I have not seen that help.

We have, on rare occasions, gotten involved with lawsuits in which illegal contracts were challenged in court. We have had some success, but the most recent efforts fell victim to an incompetent judge.

You are not the first emergency doc to be disappointed by what they felt to be a tepid response to a call for help. But the fact is that when contracts give the employer the right to hurt you, they are nearly impossible to reverse and it is futile to try.

In truth, the best way to deal with the sort of situations you were in is to avoid them in the first place. That is why we place so much emphasis on trying to educate residents and members about the traps that exist in our specialty. I am on the road at least once a month to speak at residency programs about these issues. If you had a fair contract to start with, you wouldn't have gotten into the trouble that you experienced. Yet I am willing to bet that if you received any education about contracts and job hunting, it did not address the issues that allowed your situation.

I can assure you that I am not "on the take" as you say. I work at a university hospital (Wake Forest), I get paid by the university and made less than $5000 doing legal consulting last year, all for the defense. I get no money from contract groups and my university and my department make absolutely no money off of me except for my clinical activities. I get no time off for AAEM related activities and I get no bonus or additional financial consideration for being president, although it does reflect very well upon my department. About the only benefit I can see is that I have accumulated over 150,000 frequent flier miles related to AAEM activities.

I suggest that you contrast this with ACEP, where the President gets a handsome stipend for his/her activities.

I wish we had the resources to do more. Some members have contributed handsomely to the AAEM Foundation, which gives us a war chest that allows us to take action when the opportunity arises. But, unlike other organizations, we refuse to take donations from unscrupulous (and sometimes illegal) entities. That cuts off a big potential source of cash.

All this said, I am very sorry that AAEM was not able to meet your expectations when you were in trouble. You are not the first. I hope that physicians these days are more savvy and less likely to get into these bad legal situations. I know that our efforts already make it harder for unscrupulous and crooked business people and emergency docs to take advantage of our colleagues. I hope our continued efforts will continue to bear fruit. Only with the continued support of emergency physicians like you will we have the resources and clout to move forward.

Thanks for your consideration.

View From the Fishbowl

Joel M. Schofer, MD, RDMS, FAAEM

Posted: 09/26/2011

One of the members of the AAEM board of directors received the following email from a recent residency graduate. Identifying information has been removed:

Hey Dr. XXXX,

I hope all has been well in XXXX. My wife and I moved to XXXX, and things are going great (we have a 7 month old who is wonderful, also). I know senior residents are looking for jobs, and since I have worked for [a national contract management group] and now a democratic group, I just wanted to let you know you can refer them to me so I can let them know first hand what it is like working for each.

On top of what you and AAEM have been fighting for, the biggest thing for me is that hospitals [staffed by this contract management group] don't really let you practice EM the way it should be. None of the other departments respect the ED at all (how can they when no one sits on committees?) and problems in the ED don't get resolved. It is so difficult to admit problem patients because no one else wants to share any responsibility and the administration could not care less because we are just contractors. To be honest, it is even difficult to get a primary doctor to admit 80 year-old cardiac patients with chest pain unless they have positive enzymes or EKG changes.

Working in XXXX for my democratic group has been wonderful...I work a lot harder, but it is much more satisfying because the hard work is for patients and not haggling with consultants. Anyway, I thought you might like an update.

Please send my best to the others at XXXX.

Thanks!

XXXX, MD

I've been heavily involved in AAEM for years. During that time, I've been exposed to a number of opinions about contract management groups (CMGs) owned by lay people in violation of Corporate Practice of Medicine statutes. As a military physician, though, I've been relatively sheltered from their dominance of the EM marketplace. Recently I have emerged from my safe haven, and I can say that CMGs and their influence are everywhere.

When I finished my ultrasound fellowship and relocated to Virginia, I inquired about local moonlighting jobs. The most lucrative position was in an ED staffed by a national CMG. As a board member of AAEM, I cannot work for a national CMG. Well, I guess I technically "can," but that would be hypocrisy at its finest, so I guess I am "morally" prevented from working for a CMG. My conscience prevented me from taking advantage of this opportunity to maintain my skills and pocket a little extra cash.

I recently decided to get out of the Navy, and during my search for employment, I was looking for an academic position somewhere where I could play golf year round. I found two residency programs with positions I'd be interested in and climates that would benefit my golf game, but both were affiliated with national CMGs. Once again opportunities I was interested in were "off limits" because of their CMG affiliation.

After I found and accepted a civilian position, my wife and I started to look at places we could live. One area we are considering is a small town in the mountains of California. My wife is a pediatrician, and the town only has one other pediatrician who is approaching retirement age, so that would be a nice opportunity. In addition, they are planning on building a new hospital. Working part-time in their soon-to-be brand new emergency department (ED) could be a nice opportunity in the future... but it is staffed, once again, by a national CMG.

I've come to learn that not all national CMGs are the same. Some are owned by lay persons, "regular people" (not physicians), and Corporate Practice of Medicine laws prohibit "regular people" from opening up or owning a medical practice. There are some owned and operated by physicians that I could probably work for while serving on the AAEM board without feeling pangs of guilt. The email from the resident above, though, should remind everyone that the principles upon which AAEM was founded and the things we strive for are still relevant today, perhaps even more so, because, as I've come to learn, CMGs are everywhere.

(Contact Dr. Schofer with any comments at jschofer@gmail.com.)

*The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.

I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C 105 provides that 'Copyright protection under this title is not available for any work of the United States Government.' Title 17 U.S.C 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.

American Academy of Emergency Medicine. 2011;18(2):9 © 2011 American Academy of Emergency Medicine

Burnout and Career Satisfaction Among American Surgeons

Tait D. Shanafelt, MD; Charles M. Balch, MD; Gerald J. Bechamps, MD; Thomas Russell, MD; Lotte Dyrbye, MD; Daniel Satele, BA; Paul Collicott, MD; Paul J. Novotny, MS; Jeff Sloan, PhD; Julie A. Freischlag, MD

Abstract and Introduction

Abstract

Objective: To determine the incidence of burnout among American surgeons and evaluate personal and professional characteristics associated with surgeon burnout.
Background: Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work. A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among American surgeons.
Methods: Members of the American College of Surgeons (ACS) were sent an anonymous, cross-sectional survey in June 2008. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments.
Results: Of the approximately 24,922 surgeons sampled, 7905 (32%) returned surveys. Responders had been in practice 18 years, worked 60 hours per week, and were on call 2 nights/wk (median values). Overall, 40% of responding surgeons were burned out, 30% screened positive for symptoms of depression, and 28% had a mental QOL score > 1/2 standard deviation below the population norm. Factors independently associated with burnout included younger age, having children, area of specialization, number of nights on call per week, hours worked per week, and having compensation determined entirely based on billing. Only 36% of surgeons felt their work schedule left enough time for personal/family life and only 51% would recommend their children pursue a career as a physician/surgeon.
Conclusion: Burnout is common among American surgeons and is the single greatest predictor of surgeons' satisfaction with career and specialty choice. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the mental health of American surgeons.

Introduction

Despite its virtues, a career in surgery brings with it significant challenges that can lead to substantial personal distress for the individual surgeon and their family. Training for and practicing of the specialty of surgery are stressful endeavors.[1-3] A study of the graduates of a single academic medical center suggest that approximately one third of U.S. surgeons may experience burnout.[4] Similarly, national samples of member surgeons of surgical subspecialty societies suggest burnout rates ranging from 30-38%.[5,6] Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work.[7] Treating patients as objects rather than human beings and becoming emotionally depleted are common symptoms of burnout. Burnout can effect both physicians' satisfaction with their work and the quality of medical care they provide.[8-10] Additional data suggests surgeon distress may contribute to their plans to take an early retirement.[3,4] Studies suggest that difficulty balancing personal and professional life, administrative tasks, lack of autonomy, and patient volume are the greatest sources of surgeon stress.[2-5]

A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among American surgeons. The available evidence suggests that younger physicians[11] and female surgeons[4,6] are at higher risk for burnout than their older colleagues. Although trials in internal medicine related specialties suggest physicians in private practice may be at greater risk for burnout,[12,13] the available studies of surgeons have found no difference in burnout based on practice setting.[4,6] Although limited evidence also suggests differences in burnout may exist between different surgical subspecialties,[4] there are not adequate data to derive firm conclusions.

We conducted a survey of the membership of the American College of Surgeons (ACS) to determine the incidence of burnout among American surgeons and to evaluate personal and professional characteristics associated with surgeon burnout. The hypothesis of this cross-sectional study was that burnout is prevalent among American surgeons and that specific personal and professional characteristics may place surgeons at risk for experiencing the burnout syndrome. The specific objectives of this study were to: 1) measure burnout and quality of life among surgeons who are members of the ACS utilizing validated instruments; 2) evaluate the personal and practice characteristics of American surgeons; 3) determine the relationship between specific personal and practice characteristics and burnout among American surgeons.

 

Discussion

We report here a comprehensive, national study of the professional characteristics, career satisfaction, and burnout of American Surgeons. The responding sample of nearly 8000 surgeons represents the largest study of burnout among physicians ever reported. We found a high rate of burnout among American surgeons with nearly 40% meeting criteria for burnout. Consistent with this result, nearly 30% of surgeons had a mental QOL score more than a half standard deviation below the population norm, a decrement shown to be clinically meaningful.[25] Both personal and professional characteristics were associated with burnout on multivariate analysis. Younger surgeons were at higher risk as were surgeons whose compensation was based entirely on billing/productivity, those who worked more hours per week, and those who spent more nights on call per week. Area of subspecialization was also associated with burnout with higher risk among trauma, urologic, otolaryngology, vascular and general surgeons. Burnout was the single greatest predictor of career satisfaction among surgeons and accounted for more of the variation in satisfaction with career and specialty choice than any other personal or professional factor.

Despite a high frequency of burnout and low mental QOL, surgeons were generally satisfied with their career and specialty choice where approximately 70% would choose to become both a physician and surgeon again. While these numbers suggest American surgeons are personally satisfied with a career in surgery, only half would recommend their children pursue a career as a physician/surgeon and only one third felt their career left enough time for personal/family life. One interpretation of these findings is that although American surgeons generally enjoy the practice of surgery, their work loads are excessive, often leave inadequate time for personal/family pursuits, and frequently lead to burnout and poor mental QOL relative to the general population.

In addition to these potential personal costs of practicing surgery, extensive data suggests burnout among physicians may impact quality of care. Research has found strong associations between physician burnout/dissatisfaction with medical errors,[8-10,26] prescribing habits,[27,28] patient compliance,[29] patient satisfaction with their medical care,[30,31] and medical malpractice suits.[32] These findings underscore that surgeons' mental health and professional burnout matter not only to the individual surgeon and their family but to their patients, colleagues, societies, hospitals and government agencies tasked with promoting quality of care.[33] These physician societies and government agencies have a responsibility to recognize this issue, help identify its underpinnings, promote reasonable limits on work, and help surgeons develop strategies to prevent burnout and promote their personal mental health. In this respect, it is noteworthy that the present study was initiated at the request of and with the financial support of the American College of Surgeons who is using the data collected as part of their efforts to recognize specific challenges faced by surgeons, understand their impact on the profession, and advocate for the changes necessary to preserve professional integrity and promote quality of care by America's surgeons.

How does the prevalence of burnout among American surgeons compare with physician in other specialties and other studies of surgeons? Unfortunately, there is no good comparative data available for national samples of U.S. physicians in nonsurgical specialties. Most of the available studies from both the U.S. and abroad are limited by their small sample size and few represent national samples (Table 6). Crude calculations pooling the physicians from all the previous studies of nonsurgical specialties listed in Table 6 suggests the rate of emotional exhaustion and depersonalization for physicians in fields other than surgery are approximately 30% and 29%. These values are very similar to the 32% and 26% observed in the present study of U.S. surgeons and in previous publications of burnout among surgeons (Table 6). These results suggest the degree of distress and burnout experienced by American surgeons may be similar to their colleagues in other specialties. It is also unknown whether certain subspecialties that require treating patients with higher acuity or more complex health problems may place physicians at higher risk. Previous studies suggest that specialties in which physicians frequently deal with the chronically ill or incurable/dying patients may be higher risk than specialties that focus on curable diseases or conditions with a favorable prognoses.[34] In our study, we found higher rates of burnout among trauma surgeons, urologist, otolaryngologists, vascular surgeons, and general surgeons relative to other surgical subspecialties. Additional research dissecting the specific practice characteristics that contribute to burnout would be insightful.

Our study is subject to a number of limitations. First, although similar to national survey studies of the members of physician societies,[6,35] our response rate of 35% is lower than physician surveys in general[36,37] and could introduce substantial response bias. It is unknown whether physicians who are burned out are less likely to complete surveys due to apathy or more likely to complete surveys related to job stress due to greater interest in the topic. Second, our survey is cross-sectional and we are unable to determine whether the associations observed are causally related and the potential direction of the effects. Third, there are no doubt numerous important aspects related to both burnout and career satisfaction that were not measured by our study. No doubt some challenges vary by subspecialty, geography, practice type, and local practice environments, aspects that are difficult to address in a national study.

Our study also has several notable strengths. As noted, it is the largest study of physician burnout conducted to date. The survey included standardized instruments that are validated measures of burnout and QOL and facilitate comparison to prior studies of physicians/surgeons. The results of our study are consistent with prior studies of American surgeons from single specialty groups or specific regions which have found burnout rates between 28-40%.[4-6] The survey also included an extensive evaluation of personal and practice characteristics where the large number of responders allowed robust multivariate analysis with sufficient power to dissect complex associations and interactions.

In conclusion, burnout appears to be prevalent among American surgeons. A variety of personal and professional characteristics were related to burnout and burnout was the single greatest predictor of surgeons' satisfaction with their career and specialty choice. Given that extensive data indicates a relationship between physician burnout and the quality of care they provide patients,[8-10] these data have important implications for departmental, institutional, and national efforts to reduce errors and promote quality of care. The desire to satisfy the demands of patients and colleagues may subvert surgeon's self-awareness of a declining emotional state, and reduce the likelihood they seek help. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the physical and emotional health of American surgeons. We also encourage similar efforts by other physician specialty organizations.

Burnout and Career Satisfaction Among American Surgeons: Results

 

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Results

Of the approximately 64,300 Fellows and Associate Fellows (surgeons in their first year of practice) in the ACS at the time of the survey, 28,126 had an e-mail addresses on record with the college and permitted use of their e-mail address for purposes of correspondence. Of these 28,126, a correct e-mail address could be confirmed for ~89% (n = 24,922). Among these surgeons, 7905 (32%) returned surveys including 7112 Fellows and 769 Associate Fellows.

The demographic and practice characteristics of the study participants are summarized in Table 1 and Table 2 . Approximately 55% of the study participants were age 50 or older and 13% were women. Based on official ACS data regarding the demographics of U.S. members, 63% of all ACS members are age 50 or older and 8% are women. While women and younger surgeons were slightly more likely to respond, these demographics appear similar enough to allow generalizations to the entire ACS membership. Over 90% of responders were either married or had a partner. Approximately 21% of responders indicated that they had previously gone through a divorce, and 88% had children. Responders had been in practice a median of 18 years, worked a median of 60 hours per week, spent 16 hours per week in the operating room (OR), and were on call a median of 2 nights per week (Figure 1). Over half of the responders were in private practice, 29% in academic practice, and approximately 4% were retired.

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Figure 1.

Hours worked and call schedule of American surgeons. A, Distribution of average hours worked per week. B, Distribution of nights on call per week.

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Figure 1.

Hours worked and call schedule of American surgeons. A, Distribution of average hours worked per week. B, Distribution of nights on call per week.

Characteristics of responding surgeons with respect to burnout, depression, QOL and career satisfaction are summarized in Table 3 . Overall, 32% had high emotional exhaustion, 26% demonstrated high depersonalization, and 13% had a low sense of personal accomplishment. In aggregate, 40% of respondents had either a high emotional exhaustion score and/or a high depersonalization score and were considered burned out. Approximately 30% of study participants screened positive for depression. Given the sensitivity (96%) and specificity (57%) of the screening instrument used,[19,20] this finding implies that between 10-15% of respondents would have met the criteria for major depressive disorder at the time of the survey if they had undergone a full psychiatric assessment. The mean mental and physical QOL scores for surgeons participating in the survey were 48.8 and 53.5, respectively (the mean scores for the U.S. population are 49 ± 9 for both mental and physical QOL[18]). Overall, 28% of surgeons had a mental QOL score more than one half standard deviation below the population norm while 11% had a physical QOL score more than one half standard deviation below the population norm.

With respect to career satisfaction, the majority of the study participants indicated that they would become a physician again (71%) and, specifically, would become a surgeon again (74%) if they could revisit their career and specialty choice. Despite these high degrees of career satisfaction, only 51% of surgeons indicated they would recommend their children pursue a career as a physician/surgeon and only 36% felt their work schedule left enough time for personal/family life.

Factors independently associated with burnout on multivariate analysis are shown in Table 4 . Demographic characteristics associated with a higher overall risk of burnout were younger age and having a spouse employed outside the home as a nonphysician health care professional (eg., nurse, therapist, pharmacist, etc.). Having children was associated with a lower risk of burnout, however, among those with children, those whose youngest child was < 21 were at higher risk than those whose youngest child was > age 21. Professional characteristics associated with a higher overall risk of burnout included area of specialization (higher risk among trauma surgeons, urologist, otolaryngologists, vascular surgeons, and general surgeons), a higher number of nights on call per week, working more hours per week, a greater number of years in practice, and having compensation determined entirely based on billing. Having more than 50% of professional effort dedicated to nonpatient care tasks (administration, education, research) was associated with a lower risk of burnout.

Factors independently associated with career and specialty choice satisfaction on multivariate analysis are shown in Table 5 . Personal characteristics associated with a greater satisfaction with overall career choice (being a physician) were older age and the absence of burnout. Having a partner or spouse who works outside of the home was associated with a lower satisfaction with overall career choice. Professional characteristics associated with greater satisfaction with overall career choice were area of specialization (greater satisfaction among otolaryngologists, transplant surgeons, plastic surgeons, ophthalmologists, orthopedic surgeons, pediatric surgeons, urologists, trauma surgeons, neurosurgeons, and oncologic surgeons), having academic rank of full professor among academic surgeons, being in active military practice, having time dedicated to non-patient care activities, and spending more working hours in the OR. Having more nights on call per week was associated with a lower satisfaction with overall career choice. Similar to satisfaction with overall career choice, personal characteristics associated with a greater satisfaction with specialty choice (being a surgeon) were older age and the absence of burnout. Professional characteristics associated with greater satisfaction with specialty choice were area of specialization (greater satisfaction among transplant surgeons and pediatric surgeons) having higher academic rank among academic surgeons, and spending more working hours in the OR. Having more nights on call per week, being a vascular surgeon, and being in private practice were associated with a lower satisfaction with respect to specialty choice.

 
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  45. Arigoni F, Bovier PA, Mermillod B, Waltz P, Sappino AP. Prevalence of burnout among Swiss cancer clinicians, paediatricians and general practitioners: who are most at risk? Support Care Cancer. 2008.
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  48. Asai M, Morita T, Akechi T, et al. Burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients: a cross-sectional nationwide survey in Japan. Psychooncology. 2007;16:421-428.
  49. Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR, Montesanto B, Evans WK. Cancer care workers in Ontario: prevalence of burnout, job stess, and job satisfaction. Cmaj. 2000;163:166-169.
  50. Bressi C, Manenti S, Porcellana M, et al. Haemato-oncology and burnout: an Italian survey. Br J Cancer. 2008;98:1046-1052.
  51. Klersy C, Callegari A, Martinelli V, et al. Burnout in health care providers of dialysis service in Northern Italy-a multicentre study. Nephrol Dial Transplant. 2007;22:2283-2290.
  52. Viviers S, Lachance L, Maranda MF, Menard C. Burnout, psychological distress, and overwork: the case of Quebec's ophthalmologists. Can J Ophthalmol. 2008;43:535-546.
  53. Graham J, Ramirez A, Cull A, Finlay I, Hoy A, Richards M. Job stress and satisfaction among palliative physicians. Palliative Med. 1996;10:185.
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  55. Lloyd S, Streiner D, Shannon S. Burnout, depression, life and job satisfaction among Canadian emergency physicians. J Emerg Med. 1994;12:559-565.
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  58. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol. 2002;186:601-612.
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  72. Visser MRM, Smets EMA, Oort FJ, Haes HCJMd. Stress, satisfaction and burnout among Dutch medical specialists. Cmaj. 2003;168:271-275.
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Table 1. Personal Characteristics

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Table 2. Professional Characteristics

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Table 3. Career Satisfaction, Burnout, Depression, and Quality of Life Among the 7905 Members of the American College of Surgeons Who Participated in the Survey Study

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Table 4. Factors Independently Associated With Burnout on Multi-Variate Logistic Analysis

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Table 5. Factors Independently Associated With Satisfaction With Specialty and Career Choice on Multi-Variate Analysis

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Table 6. Burnout in Practicing Physicians

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Authors and Disclosures

Tait D. Shanafelt, MD,* Charles M. Balch, MD,‡  Gerald J. Bechamps, MD,§  Thomas Russell, MD,†  Lotte Dyrbye, MD,* Daniel Satele, BA,* Paul Collicott, MD,†  Paul J. Novotny, MS,* Jeff Sloan, PhD,* Julie A. Freischlag, MD ‡

*Mayo Clinic
† American College of Surgeons, Johns Hopkins Medical Institutions, Johns Hopkins University, Baltimore, Maryland
‡ Department of Surgery, Johns Hopkins Medical Institutions, Johns Hopkins University, Baltimore, Maryland
§ Winchester Surgical Clinic

 
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Annals of Surgery. 2009;250(3):463-471. © 2009 Lippincott Williams & Wilkins

 
 
 

Medical Serfdom

8 Reasons You Should Not Expect an Inheritance

Medical Justice Inc. vs. Frivolous Lawsuits

http://www.jpands.org/vol8no3/burr.pdf

http://www.jpands.org/vol8no4/burr.pdf

"I remember an internal medicine rotation in a wealthy private hospital, a satellite of the main teaching hospital, that was ruled by a greedy gastro-enterologist. He owned his own laboratory. Whether you were admitted for COPD or a splinter, you had serum amylase X 3, ultrasounds of liver and pancreas, and usually would have a colonoscopy and a variety of other unnecessary tests that enriched him and the hospital. Medical students and residents were required to order these tests on all comers, and woe to anybody who dared question the wisdom of this. In exchange, this doctor would ask esoteric questions designed to show he knew something you did not, then berate you for your ignorance. At the end of the rotation, I was asked verbally, by his serpent (I mean his assistant) to evaluate the rotation. I replied that, other than him being a proctoscope, it was tolerable. Needless to say, I did not get a good grade.
Eventually, the castle crumbled. I remember a neurology attending being admitted to this hospital with no GI complaints. He was furious when he learned the planned work-up. He refused. Medical students rebelled in the only way possible for them. At the end of the year, there was always a "Follies" assembly with jokes, funny stories, and satire. Having finished their rotation at this hospital, students showed the standard workup to the entire medical school class, most of the department heads of the main hospital, and various assorted faculty. They called it an "SMA Dr. X," actually using the attending's name. They identified it being done for a patient with no GI complaints. They diagnosed Dr. X as having a "stick up the ass" and showed an X-ray with a Cole bottle lodged in someone's colon. The next year, less than half of the residency spots at the satellite hospital were filled, the attending was relieved of his chairmanship, and the satellite hospital residency program was absorbed into the main teaching hospital.
I usually do not think of this experience. Talking to some medical students I know brought back memories of the old days of 100+ hour weeks, no days off for months, an accepted practice of attendings abusing residents and students, and continuous sleep deprivation. Those were the bad old days. I am sure others have their "House of God" stories.
I wonder if other docs had attendings who rated worse than this."

Doctors: The Truth About What Your Boss Wants From You

Shelly Reese

Posted: 11/17/2011

Introduction

You're expected to be a good clinician, but if you want to advance within your organization, you'd better be a lot more than that.

Healthcare organizations are evolving with unprecedented speed. Thanks to consolidation and cultural change, they're beginning to speak the language and adopt the tools of corporate America. They're using mission, vision, and values statements to define themselves and adopting sophisticated tools, such as personality profiling, probationary periods, and performance reviews to assess job candidates and physician employees.

In a world where medical care requires greater level of integration, healthcare organizations are demanding more than clinical excellence from physicians.

What exactly does the boss want? Here's a closer look.

Wanted: A Marketable Personality

A bit snappish before your first cup of coffee? Meetings make you impatient? No time to listen to Mrs. Jones drone on? The quirks that your colleagues learned to tolerate may no longer be so endearing to your employer.

"The old M.O. of an orthopaedic surgeon was: 'I'll show up when I want to and I'll use the device I want to and it's my way or the highway,'" says Brett Hickman, a partner with PricewaterhouseCoopers' Health Industries Advisory Group. "That's not sustainable."

Physicians have to find ways beyond their clinical expertise to engage patients.

Today's employers are looking for physicians who can relate to their coworkers and patients, says Tony Stajduhar, president of Jackson Coker, Permanent Division, a physician recruiting firm based in Alpharetta, Georgia. "Clients tell us over and over: 'We want someone who is going to be a good teammate. A good partner. Someone who works and plays well with others. Someone who is personable and will attract more patients.'"

Call it "charm," says Craig Samitt, MD, president and CEO of Dean Health Systems, a Madison, Wisconsin-based network of clinics, hospitals, and a health insurance plan. "Physicians have to find ways beyond their clinical expertise to engage patients. It improves patient satisfaction; it improves patients' adherence to the recommendations their physician makes; and it results in patient loyalty to the practice."

What's more, studies show patients don't sue doctors they like, notes Tommy Bohannon, vice president of hospital-based recruiting for Merritt Hawkins, an Irving, Texas-based physician recruiting firm. "Medicine is much more of a customer-service business than it ever has been," he says. "Going forward there is going to be more emphasis on things like interpersonal relationships and bedside manner."

Reviewing an evaluation form 1 hospital recently used as part of its candidate assessment process, Bohannon noted that 14 of the 17 questions interviewees were asked related to personality issues. It's not that clinical skills aren't important, he emphasizes: it's that they're not enough.

"Just because you trained at one of the top five programs and graduated top of your class isn't going to make you the best candidate for the job," he says. "Hospitals are employing doctors en masse and they don't want to upset the apple cart. If they can't retain, hiring becomes more difficult. They don't want a problem child."

Pit Crews, not Cowboys

When employers say they're looking for a good team player, they're not just spouting locker room platitudes. Employers want more than collegiality and being a team player is about more than meeting productivity goals, taking call, and serving on committees. It's about helping to bridge gaps in the care continuum.

If we brought a physician on board who wasn't receptive to modifying their practices, that wouldn't be an ideal fit.

"We're trained very much to be individuals, but the world is evolving in favor of teams," Dr. Samitt says. "Accountable care organizations, medical homes, integration of care: it's all about teams." That means physicians have to be innovative and adaptable. Part of being a team player, he adds, is demonstrating a willingness to adapt, grow, and innovate for the good of the patient and the organization. "If we brought a physician on board who wasn't receptive to modifying their practices, that wouldn't be an ideal fit."

During a recent commencement address at Harvard Medical School, Atul Gawande, MD, a surgeon and author of The Checklist Manifesto: How to Get Things Right, noted that the days of cowboys are over: healthcare needs pit crews. "Everyone has just a piece of patient care," he told graduates. "We're all specialists now -- even primary care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care."

Physicians interested in serving in leadership positions within their organization need an even greater understanding and appreciation for how the pieces fit together, says Brett Hickman.

"If you're a physician in the boardroom you need to understand the financials, but that doesn't mean you need an MBA," he says. The most valued physician leaders are those who can "build competencies across the continuum of care and understand the overall care delivery model." They're the kind of doctors who understand not only internal processes, but the value of nursing and purchasing and palliative care.

"Hospitals aren't looking for genius scientists," Hickman continues. "They're looking for someone who can work across the chasms of specialties."

That takes a skill set many doctors haven't cultivated, he says. "Physicians, especially those who are very procedure-based, are used to being the person to make the last call. That's effective in the OR, but in a team meeting or a boardroom, it's not." To be effective in the new environment, physicians need to know when decisiveness and execution are paramount and when introspection and listening make more sense.

Changes in Recruitment and Compensation

Employers aren't just talking about the qualities they want. They're revising their recruitment and compensation strategies to seek out and reward the doctors who have them.

Historically, Dean Health Systems hired physicians for clinical competence and fit vis à vis the other physicians in the practice, Dr. Samitt says. A number of years ago, it began using an outside vendor to conduct pre-interview personality profiles of candidates, making the process more thorough and less subjective, he says.

Employers are likewise revamping their compensation systems. Productivity is still vital, of course. After all, healthcare organizations need physicians to see a certain number of patients to justify their guaranteed salaries. But many are moving away from compensation models strictly based on relative value units (RVUs), Tony Stajduhar says.

Four years ago, Dean Health Systems moved from a reward system that was based entirely on RVUs to one that includes incentives for delivering value-based care, following meaningful-use criteria, attending meetings, and completing medical records. Today 12% of Dean's physician compensation package is incentive-based. Dr. Samitt says the goal is to bump that to more than 20% over the next 2-3 years.

Revising the compensation package "hasn't been a cakewalk," he admits, but it was the next logical step in a process that has included extensive communication and motivational physician-engagement activities.

At Samaritan Regional Health System in Ashland, Ohio, president and CEO Danny Boggs rewards physicians who help the organization meet its budgetary goals by supervising physician extenders. Entrepreneurial physicians -- like the internist who began offering acupuncture services -- are likewise rewarded, he says.

"The expectations in healthcare are evolving," Dr. Samitt says, "and we need to evolve our expectations of physicians."

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"No man is an iland, intire of it selfe; every man is a peece of the Continent, a part of the maine; if a clod bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as if a Mannor of thy friends or of thine owne were; any mans death diminishes me, because I am involved in Mankinde; And therefore never send to know for whom the bell tolls; It tolls for thee...."  John Donne

Public Key Encryption: Unsafe? The Center Will Not Hold?