So, the other night, I’m listening to The archive of Dr A’s radio interview with Paul Levy, the CEO of Beth Israel Deaconess Hospital in Boston and author of the Blog “Running a Hospital“. And I’m really enjoying it.
“This guy’s great!” I yell to Mr TBTAM, who is reading in the living room. “Did you know he used to run Boston’s sewer system before he took over Harvard?”
Levy talked about how he had brought a new transparency to the Boston health care marketplace when he began to post Deaconess’s outcomes on his blog. I liked that. A lot.
Then he took on the technology must-haves, asking what data existed that robotic prostatectomies were better than good old fashioned procedures.
“Those machines cost a million two or a million five..When you consider that the margin on a prostastectomy… is $10,000 how long does it take to get a million and a half back?…Well, you never get it back… Those hospitals that have bought them have picked up market share from other hospitals in the field, and there’s just no clinical reason for this.”
And I’m thinking – this guy reminds me of Dr Wes. Looking for the evidence before jumping on the bandwagon and spending our healthcare dollars just to get market share. Great!
When Levy started to get on Dr A and his colleagues for not washing their hands, I was right there with him. After all, I’m an obsessive hand washer – always have been. I even began washing my hands in front of the patient years ago when a colleague of mine did a survey of adolescents, and discovered that the most important factor in their choice of doctor was whether or not she washed her hands before examining them.
So Levy and I, we’re simpatico, right? And I’m thinking – I’d like to work with this guy. Wouldn’t you, if you heard him say this?
“I never pretend to to practice medicine. They tell me what they need done in order to do their job and we do out best on the administrative side to get it done.”
Yes! Paul Levy! You are THE MAN! I begin imagining what it would be like to live in Boston…
And then he says it.
What He Said
It was a discussion he and Dr A were having about negotiation. About how docs don’t know how to do it very well, because it’s not a skill that mixes well with the quickfire decisions needed in the OR and in emergencies. I’m thinking “He really gets us…”
Dr A, who’s got an administrative position himself, joins in about how hard it can be to get consensus and change old ways. He asks Levy for his advice on what to do when a physician says “Do it this way or I’m leaving your staff and going to the competition.”
And Levy says this –
“My usual response to that is “Great. We need the office space anyway. And when will you be leaving?”
You could almost feel Dr A pull back from the mike. In fact, there was a massive shift in the universe as every one if us docs listening to the interview pulled back from our computers and began readjusting our position on Levy. (Okay, I’m willing to admit maybe this was just my own reaction.)
And I knew it, right then and there. He was not one of us. He was one of them. An administrator, not a doctor. Not getting that if a doc is threatening to leave, then maybe what you want him/her to do might be just a tad unreasonable. Maybe that EMR you are insisting he use isn’t quite ready for prime time. Maybe one can’t see a patient every 15 minutes without extra support staff that could have been paid for with just a minuscule portion of the ad budget. Maybe you’re not giving him the support he needs to make the change you want him to make. A change that may be good for the administration, but bad for the doc.
Easier and cheaper to let that guy go, rather than take the time to figure out just why he is so upset. Replace him with someone who is willing to play along without a fuss.
And it hits me. Again. The way its been hitting me for the past 20 years since I left residency.
We docs are really not in charge. The administrators are. Administrators who have never practiced medicine.
Why this is so hard for me
I have a confession to make. I became a doctor because I wanted to be in charge.
It was the summer of my junior year in college, and I was working full time in a nursing home, trying to find out a bit about this field of medicine that I was considering as a career. Trying to decide if I should become a nurse or a doctor.
I was doing private duty for a little old lady who had just moved into the home, spending the majority of her waking hours with her on the day shift.
She had Alzheimer’s disease. She figured that I was granddaughter, and that we were in a hotel. But she remembered that her son lived down the road (he did), and saw no reason why she shouldn’t be walking there whenever she wanted. And she couldn’t understand why, if I had a car, she and I couldn’t head over to the mall for some shopping. This made her mad.
As the days progressed, this little old lady got madder and madder, and it was becoming harder and harder to rein her in when she started to walk off down the driveway.
So they called in a shrink. A doc who she had never met. He came into her room and spoke with her for, maybe, 15 minutes. Never asked me a single question about her. Wrote a prescription for Haldol (an anti-psychotic) and walked out.
That Haldol dose was too much for her. She became lethargic, somnolent. Wouldn’t get out of bed. Began soiling herself. Lost all touch with reality. After a week, her brother, a retired doc, came to visit, assessed the situation and went ballistic. The Haldol was stopped. But she was never the same.
And I think – Wow. A doctor can come in, change a woman’s life in a really bad way. Another doc can come in and save it. And no one stops to ask me, the nurse who has been with her more than any of them, who knows her now better than anyone, what I think.
I want to be the doctor. I want to be the one in charge. No one is going to be the boss of me.
But I am not the boss of me
I know, I should just quit academic medicine and head out into private practice, where at least I will have some semblance of control.
But not really.
Because somewhere between the administrators, Big Pharma and the insurers, we gave away medicine. Gave it away because we were too busy taking care of patients to step up and fight. Gave it away because the battles were fought on such a large scale, and we were a bunch of unorganized small shops.
Some docs got smart and went back for their MBAs so they could talk the language and play the game with the suits. Some just became the suits.
But most of us didn’t go into medicine as a business. So as we were taking care of patients, those around us built up this huge business of health care around us. A business that is now turning non-profit medical centers into profit making enterprises. A business that is making insurance company CEO’s some of the highest paid CEO’s in America.
A business where the doctor, the one who is actually responsible for the patient, the guy who gets sued if anything goes wrong, the guy who that patient is coming to see in the first place, the guy who may not have taken Paul Levy’s negotiating class because he was too busy taking care of patients, that guy…that guy is as replaceable as a worker on an assembly line.
I get it.
I really do. I’ve been living it for 20 years, and I accept it. I know the rules and my place in the game, and I think I play it fairly well.
As for Paul Levy, CEO, well, you don’t just play the game fairly well. You play it really well. You’ve turned around a major medical center, which is no small feat. You know that. I know that. As good a doctor as I think I am, I could never accomplish something like that. I don’t have the skills you’ve got in this arena. Probably never will. And the truth is, I greatly admire you and what you have done. Heck, I even love your blog.
But I will ask you this.
The next time a doc threatens to leave, don’t be so quick to show him the door.
Stop and consider who he is and how he got to be in a place where he is willing to leave over whatever the issue is you are arguing about. Grant him the respect for what he does all day (and night). Remember what you said up there about never pretending to practice medicine, and how negotiating skills are not something we docs inherently have. Put yourself in his shoes. Go the extra yard to figure out why he’s so upset. Odds are, it’s because it’s going to effect how he practices medicine.
In the end, that’s really what this business is all about, right? Medicine.
And he is still, after all, the doctor.
___________________________________________
Levy responds in the comments below.
My Mom was a professor at Stanford, then a hospital administrator in San Jose, CA. She was and is a control freak, and she doesn’t get along with most people. Administrators are scary (even more so when she’s mommy).
Jeez, did you overact to an offhand comment. And you are very quick to judge. For the most part, I do exactly as you suggest, in that I view it as my job to try to make it possible for doctors to do what they want — and I defer to their judgment. But every now and then, there is a really, really stubborn and self-centered MD who does not understand that he or she is part of a larger group of physicians and a hospital. If he or she cannot accept the reality of that sitaution, he or she is likely to be happier somewhere else. Also, when someone STARTS a conversation by threatening to leave, it means someone very different from when they raise that possibility after a thoughtful discussion.
In short, your quick action to pigeonhole someone as an power-hungry administrator is way off base.
But … thanks for your nice comments about my blog. I like yours, too!
I didn’t read Mr. Levy’s comment before I typed my blog entry about your post, here.
Respectfully.
GruntDoc
I’ve read TBTAM, Mr. Levy’s and Gruntdocs thoughts — I have to say that I agree with Mr. Levy on this one. Using an ultimatum in a negotiation starts and ends the discussion because it leaves little room for compromise. It doesn’t just happen with doctors either — I’ve had the same “take it or leave it” approach from suppliers and with lease negotiations. There’s only one way to work with that type of tactic and the appropriate response is to let them know that you’ll consider it.
My impressions is that Mr. Levy did not suggest he wouldn’t consider other options. Rather, he won’t be bullied by an ultimatum (hope I’m not putting words in his mouth). If you read his blog, it’s hard to believe that Mr. Levy’s not open for thoughtful negotiations.
waittimes.blogspot.com
Paul Levy –
Thanks for your comments.
I think if your answer in the interview to Dr A’ question had been more along the lines of what you just wrote, than I may not have written this post at all. Because I completely agree with what you’ve just written.
But in the interview, you answer was so glib and without the same context, and took me quite by surprise. And while it may have felt like an offhand comment to you, it came across as much more than that to me. Sorry. It did. I cleary heard things differently than Grunt Doc did, and I listened to that section several times before I wrote this post.
Did I over-react? If describing my reaction, analyzing it and trying to give it context is over-reacting, then I am guilty as charged.
Actually, I was trying my best NOT t pigeon-hole you as power hungry administrator. As I said in the post, I admire you greatly, and think you are doing a fabulous job.
Thanks again for commenting.
Grunt Doc and Ian-
Thanks, too for your comments.
Dang. Sounds like you all did a great job negotiating this one! Loved the post and commentary. It resonates.
Dear tbtam and others,
Thanks for the back-and-forth. This has been good!
But, let’s go one step further, if I may — and I mean what I am about to say with great affection and respect. Why should it be acceptable to think that MDs shouldn’t be as good at negotiation and/or dialogue as anybody else? Indeed, a doctor often has to engage in very important discussions with patients and/or families and help them understand complex and difficult issues, e.g., when those patients and families tend to fall into patterns of denial.
It can be easy to stereotype MDs as not having good interpersonal skills. Some attribute this to self-selection, i.e., the “type” of people who become doctors. Some attribute it to the kind of training they receive, i.e., the need to be decisive and in charge.
You fall into that here in this post in a way by saying that the “take-it-or-leave-it” tactic is acceptable in some sense when a doctor uses it. And that administrators should know that and adapt to it. You are probably right in many cases.
But, what a sad statement that makes about some people in the profession! Why can’t part of the medical training include sessions in negotiation and empathy?
I actually conduct courses like this for our house staff and others, and they love it and find it a really useful adjunct to their profesisonal (and personal) lives.
Paul Levy –
Perhaps I and the docs I know have had different experiences with hospital administration than others. I have seen situations where what is being expected of a doc is just untenable, and where no support was being given for what they were being asked to do. In these situations, the doc made the painful decision to leave, communicated that, and miraculously, the support appeared, and ultimately, that doc stayed. Sad, but true, that this was what it took. Perhaps if those docs had done a better job at negotiating in the first place, things would not have gotten to that point.
I think this tactic is used more by docs who perceive themselves as powerless against administration than by those who are just being unreasonable. When decisions are made that affect them without their input. When they are invited to the table at the end of a process, not at the beginning. Again, learning how to negotiate would put these docs in a much better position.
I have found administrators to be most responsive to other administrators, not to docs. Their bread is buttered, so to speak, within their own hierarchy, and keeping their boss happy is more important to their survival than having a happy doctor. That’s just a fact of life, not a criticism. Getting docs into administration is the solution. Nursing realized this much earlier than we docs, and nurses are present at everywhere in hospital administrations I’ve known. Because the docs tend to be split into departments, they are often pitted against one another rather than working together toward a common goal. I don’t think the department structure has served us well in this regard. Instead, I think it has ghettoized us as the medical center business has evolved.
Where I work, docs are increasingly being appointed to administrative positions traditionally held by non-docs. And new positions have been created just for docs within administration. The result is an administration that is more responsive to docs, anticipates their needs rather than finding them out later in the process, and focuses primarily on issues that impact quality of care, which all us docs can get behind and that ultimately, are good business.
I personally would love to take your negotiating course. I know Dr A wants to as well. Hmm – maybe a little blogger road trip to Boston…
Thanks again for your thoughtful comments.
We’ll combine it with a Red Sox game . . .
GruntDoc has picked up this discussion. For ease of reference, I am copying a comment I just made over there in response to someone else’s:
Actually Nurse 1961, negotiation is not quite the art of getting what you want without giving away what you need: It is the art of reaching an agreement that increases the “size of the pie” so that both parties satisfy their interests better than they can without reaching an agreement. You should never make a threat in a negotiation unless you are prepared to carry it out — because a threat harms the underlying sense of trust that you need to stimulate the kind of creativity that produces ideas for joint gains. By making a threat, you have explictly said, “I can do better without making an agreement with you.” When someone does that to me, I do a similar evaluation. If I think I can do better for the hospital letting the person carry out his (it is always a “his”, by the way!) threat, then I will do so. If I think it is still worthwhile talking with the person, trying to find a negotiated settlement that works to everyone’s advantage, I will do so. But, as noted above, it surely poisons the well a bit to start out with the threat.
If you were to guess, which type of doctor is most likely to start off the meeting with a threat?
TBTAM – I don’t want to derail the discussion above – it’s excellent dialogue – but I did want to touch on your needing to be in charge topic further.
You can still be in charge, and have adminstrators like Paul Levy too. It all depends on how you define leadership.
In terms of patient care and the decisions you make, there may be outside influences that cause you challenge, but you are still the leader of the team at this point. However, at some point during the very complex transaction of providing care, others need to take charge. I am sure that you are grateful for others being responsible for certain parts of the process.
Try if you will to not view the world as us and them on opposite sides, but rather a team. A complicated, and difficult team, but a team none-the-less. Then decide for yourself where you can contribute as a leader and execute on it. If you do this, your need and desire to be in charge will be satified – perhaps not to the max, but if you are focused on asking yourself if you are leading where you want to be, you may find your values being satisfied more than a min. This perspective has worked well for me in the past.
We are all leaders if we want to be, and that is a good thing. You just have to think about what you want to lead. We will talk about HOW to lead some other time.
There’s an old maxim (I have no idea who said it, I just remember it from a leadership course or book or something).
Power is the ability to make people do what you want. Leadership is the ability to make people want to do what you want.
The training schedule is taxing enough without adding serious leadership classes to it. Having docs fill administrative roles is a good idea but a waste of valuable resource. If you have the doctor capacity (and finances) get them in the roles because it will make the leadership better/more involved. The opposite is true too however. Have the administrative staff work on the wards/ER/OR for a while especially late at night/weekends. It’s at those times that the dedication of clinical staff and teamwork really shine. The hospital has a very different atmosphere “after hours”.
Let me know when the Boston road trip is Paul — you’ve got some great ideas. Let me know when you’re in Toronto. Ian.
Thanks Mr. Levy, but I do think it is an art. If it were a science, then all you would have to do is go the statistical model for your answer. But because you are dealing with human emotion, you need to put it in the “art” arena.
Science is mostly dealing in the black and white, whereas in art can have many gray areas. In negotiation, you have to have some gray area that is your give and take. What am I willing to give up to get in return? Surgery times in return for more days of call in the ED? Specialty coverage without ED call? Working Thanksgiving to have Christmas off?
It is a lot like the dance of the tango. Sometimes the male (administration) leads and sometimes the female (clinical) leads. As it progresses it is obvious they can not do it alone so in the end the male (administration) takes the lead, but the spotlight ends on the female (clinical). Both win and both lose. But the partners stayed together for the entire dance, in the end they both could walk away. Just as in negotiations sometimes walking away is the right choice, but walking away before the negotiation begins will always be a lose-lose.
Forget attitude and good will and the like; it’s all about the power. If you are running Boston Deaconess and a doctor does the “I’m going to take my ball and go home” routine, sure you can give him the “Don’t let the door hit you in the ass on the way out” answer. More apropos to most people’s experience is the situation at my hospital (mid-size community/academic) where the administration took a hard line with the radiologists who then quit en masse and set up an outpatient radiology service (and is eating the hospital’s lunch) and then did the same to a neurosurgeon who was not signing his charts on time. He proceeded to take all his cases across town which resulted in a $1-2 million contribution to the margin loss to the hospital.
As most leadership/negotiation courses teach you have to accurately determine tow things before embarking on a negotiation: 1) whether you’re negotiating from a position of strength or weakness and 2) your “best alternative to a negotiated agreement” (BATNA) — which impacts on 1). My guess is that Mr. Levy is essentially always negotiating from a position of strength and that his BATNA is that he has to go find some new doctors, of which there are many.
The CEO of my hospital who THOUGHT he was negotiating from a position of strength and who THOUGHT he had a good BATNA is now looking for a job — any positions available?
And I LOVE the tango metaphor
Nurse 1961 gets it: It takes two to Tango.
until physicians assert their only power in the game, administrators and hospitals will throw them under the bridge for the greater good of the hospital and their own bottom lines. What is your power? your ability to care for patients. This is something no one else can do other than physicians. You have allowed insurance companies, the government and hospital administrators to divide you and put you on the sidelines begging for scraps. I guarantee the person at BIDMC who negotiates the contracts for the hospital negotiates on behalf of the doctors. This way they can throw you all under the bus to get higher reimbursement for the institutions. The harvard hospitals are all profitable. You the harvard md get paid way below national averages and live in a very expensive city. You are getting royally screwed 8 ways to sunday by these Harvard behemoth hospitals. You the doctor are not the brand and therefore have little to no value to them and can be replaced by the next fool who thinks it matters that you practice at a harvard teaching hospital when your colleagues around the country scratch their heads in disbelief over your foolish decisions. This is why MA is rated 47th out of 50 states in doctor job satisfaction. Take comfort it could be worse, you could live in mississippi, canada or england.
your only strength is collectively to tell the government yes medicare reimbursement is pathetic and we are not going to take your government run charity anymore as its not worth our time and heartache. The same holds true with the pathetic contracts that BIDMC negotiates for its physicians.
Your only stake in the game is your ability to take care of patients. Use it while you can as you are engine that makes the car move. stop letting them whip you like donkey.