AMA Journal of Ethics^®

Case

Dr. Gowen sighed as she sat down in the physician’s lounge to go through her accumulated e-mail. “Good grief, 50 unread e-mails in 8 hours?” she said to her colleague, Dr. Hassan, who was sitting next to her. He rolled his eyes.

“I know,” said Dr. Hassan. “I love this hospital but the number of ‘all-employee’ e-mails is overwhelming.” Suddenly he drew in his breath. “Have you seen this?”

Dr. Gowen peered over his shoulder at a spreadsheet sent out by the hospital’s CEO that listed the average monthly ordering costs for each physician on staff, by name, including lab requisitions, prescriptions, and diagnostic tests. She scrolled up to find a perfunctory introduction about trying to “do what we can” to cut costs. “Are they serious?” she said incredulously. “They’re trying to shame us into ordering less?” She flipped back to the spreadsheet and reddened when she saw her name. Her monthly costs were among the highest in the hospital.

“Looks like you’ve got some explaining to do,” joked Dr. Hassan. Dr. Gowen laughed, but her mind was racing. She didn’t think that her patients were sicker or had more complicated medical problems than the patients of her peers, and she trusted her clinical judgment—she had often been praised for her acumen in knowing what tests to order to clinch a difficult diagnosis. She certainly didn’t order tests that she thought were unnecessary or “just in case.”

She started to fire off an e-mail to the administration voicing her concerns, but then stopped. At her former practice, a physician-owned office, she would have brought the issue up with her partners and they would have discussed it together. But now, she was one of many salaried physicians on staff—did she want to come off as a difficult employee? Did she have the clout to refuse to comply? Uneasy, she signed out of her computer and packed up to go home.

Commentary 2

Dr. Gowen faces many ethical, behavioral, and attitudinal challenges, as do her colleagues. The first step in becoming an employed physician is to understand the “price of equity.” What is different about my expectations not just as a clinician but as a partner, business person, team player, and collaborator? How do I move from being the autonomous, 1-to-1, solo decision maker to a collaborative team player, 1-to-n, strategic thinker, and group problem solver? How do I make the transition from “owner” of my practice to “steward” of my hospital’s, patients’, and group’s outcomes both clinically and financially? At the end of the day, culture always eats strategy for lunch.

The following are differences between physicians and administrators/managers that both must learn to appreciate if situations like the one Dr. Gowen faces are to be handled successfully in the future.

As a physician, I have always been bound by the imperative “do no harm.” The financial pressures of the day must never persuade us to violate this principle. Being both a physician and a steward of resources is not an either/or proposition but rather an “and/too” one. It is about value—how to provide the best possible care and outcome at the most efficient cost—for everyone, because it’s the right and moral thing to do. It should not be about shaming physicians into ordering less, but about teaching physicians to understand, consider, and decide how best to utilize tests, supplies, drug choices, admissions, and other high-cost items in a smart, efficient, and clinically effective way that leads to the highest-quality outcome for the patient. The literature is rife with examples of how expensive implants and therapies actually lead to inferior or more dangerous results than older, more tested interventions. Demand-matching pharmaceuticals and implants to the specific condition of the patient is rather new but required of all of us.

Dr. Gowen should expect to receive more complete data than just a cost spreadsheet. Her quality outcome rating for this set of patients should have accompanied the cost analysis. She should expect to learn whether or not her patients’ clinical pictures were more complicated by seeing how her case mix compared to that of her peers. Improving care quality should be the driver, not pure cost benchmarking. How does Dr. Gowen know whether her test ordering is appropriate or “just in case”? Have standardized clinical guidelines been developed, and are they utilized both by her and the entire medical staff? Does a point-of-care ordering system exist as part of her EMR to allow her to see the cost consequences of her ordering decisions and how she might amend them? If the hospital CEO is going to demand new behaviors, he or she must provide all physicians with the tools necessary to allow for and incentivize change.

Dr. Gowen should take her concerns to the quality-of-care committee first. This committee should develop cost and quality guidelines, targets, pathways, and a comprehensive strategy for implementation and deliver it to the hospital’s chief operating officer. The COO’s span of control within the hospital typically includes service line operations, quality management, and implementation of cost-saving measures. This plan should include cost and resource needs. It should also include sample report formats that are doctor-recommended. The final recommendations should be presented to the full medical staff to obtain their buy-in. It is then the responsibility of the physician leadership to hold all physicians accountable for hitting the quality and cost targets.

Physician leadership in the hospital should consider developing a physician contract that outlines the expectations of all physicians at the hospital. Until everyone, including Dr. Gowen, truly understands the “price of equity,” change will be difficult and the knee-jerk reaction of “firing off e-mails” will remain the norm.