Culture, Effect of - The Physician Culture and Resistance to Change Part I

Why Physicians Stick to the Status Quo

This originally appeared in HealthLeaders News, Apr. 7, 2003

In 1993, George Halvorsan, now Chairman and CEO of Kaiser Permanente, wrote in his book Strong Medicine:

"Rather than taking an overall leadership role in the continuous improvement of the health care delivery system, too many medical professionals either ignore the problems of the system in order to concentrate in their own specific practices or focus their energies and talents on protecting the status quo."

Today, 10 years later, health leaders still say physicians shun leadership and resist change. The following story illustrates one aspect of the problem.

Dr. Allen Wenner, a leader in persuading fellow physicians to employ electronic medical records, has introduced software to allow patients to record complete medical histories before seeing their doctor. The computer interview produces a structured history. This permits physicians to zero in on a patient's problem, freeing up large chunks of time to see other patients and increase revenues.

Yet most clinicians resist this breakthrough productivity tool. The thought of a computer interviewing patients simply runs against physicians' cultural grain. Physicians learn in medical school that personally interviewing patients defines a doctor. This ideal of what a doctor ought to be leaves a deep cultural imprint. Of this love affair with the past, Wenner says, "When we hurt enough, we will change. We're just not there yet."

I've told this story and others in my book, Managed Care Memoir: A Physician's Whistle-Stop Journey: 1983-2003.The book contains interviews with 12 healthcare experts. They discuss why physicians rebel against HMOs and why they cling to the status quo in face of Medicare, managed care, and malpractice squeezes.

Most doctors stick to the past by remaining in small practices: 80 percent are in groups of 10 or less, 60 percent in groups of 6 or less and 40 percent in groups of three or less. In addition, some physicians are bucking seemingly inevitable trends by withdrawing from hospital-sponsored organizations and canceling contracts with HMOs.

On the information technology front, less than 5 percent of doctors have converted to electronic medical records, barely 15 percent communicate routinely by e-mail with patients, and the percentage of small groups ready for full HIPAA compliance remains less than 10 percent.

What's the problem? Part of it is the conservative physician culture. This culture reluctantly shares decision-making and managerial power with outsiders. Also doctors avoid risks because they see nothing better on the horizon. For independent physicians, there are simply too few incentives, too little personal satisfactions, and not enough spare time and extra money to induce change.

Healthcare cultural problems exist at three levels:

1. The Culture of American Society
As J.D. Kleinke has written:

"Such is the culture of medicine in America. We demand the best, accept nothing less and reward lawyers handsomely for making sure we get it. Even the imminence of certain death does not attenuate this cultural fact, as the clinical behaviors, costs and outcomes of typical intensive care illustrate. Our national consciousness is steeped in optimism, hostile to all processes and manifestations of aging and enraptured by a limitless faith in technology; as a people we have come to revile death as much a personal defeat as a personal loss.”

In other words, given America's medical culture, physicians, patients, and lawyers are likely to keep on doing what they're doing.

2. The Culture of Large Health Organizations.

Remaking Health Care in America: Building Organized Delivery Systems is an excellent book on the culture of large health systems. The authors – Stephen M. Shortell and four other consultants – describe the cultures of 10 large multi-hospital systems, which had 1994 total revenues of $500 million to $1.5 billion. These hospital systems have worked hard, with mixed success, to create physician group cultures stressing teamwork, cooperation, sharing of information, pride in the organization, and attentiveness to physicians.

Salaried physician stakeholders drive certain tightly integrated organizations – nonprofit HMOs such Kaiser and clinics such as Mayo. These successful models, led by physicians selected for their dedication to the organization's mission, have not been replicated on a broad scale.

Academic medical centers have special cultural problems. These centers, burdened with educational expenses, are fragmented, overspecialized, notoriously difficult to organize, and not very enthusiastic or good at training primary care doctors in outpatient settings. Too often the culture of academic health centers consists of sharply departmentalized and overspecialized independent fiefdoms, connected only by a common plumbing systems and grievances over parking.

3. The Culture of Physicians
Health industry leaders have repeatedly told doctors they must consolidate into larger groups or integrate with hospitals to survive; achieve greater size, critical mass, and scale; cultivate managerial care expertise; work in multidisciplinary teams; seek capital offered by large companies; follow evidence-based or standardized guidelines to practice good medicine; practice preventive medicine; develop systems approaches to managing chronic disease; enter into primary care specialties to assure a less costly health system; install information technologies in their offices; establish practice web sites; offload business functions to the Internet; communicate with patients through the Internet and by e-mail; convert to paperless offices, prescribe electronically; standardize codes and transactions for diagnostic procedures and develop leadership skills.

These admonitions from health leaders have left many clinicians unmoved. Physicians have not bought into the argument that bigger is better or that managed care and corporate models for achieving quality are in their best interests or their patients’.

To understand why physicians have resisted, you have get inside their minds and skins. The way many physicians think can be illustrated in the following list of ideas:

1. You became a physician to serve patients, not hospitals or business corporations.
2. Your customers are “patients,” sick individuals who need your help, even when that help is expensive and experimental.
3. You're "the patient’s advocate," a protector and a guide through a world fraught with obstacles to care.
4. You see patients one at a time, and you don't feel responsible for "population health."
5. You don't really care about the financial health of investor-owned HMOs who profit from minimizing care.
6. You realize patients spent 99 percent of their time outside your office, and you know ill health often stems from flawed life styles and rarely rests on your advice, which you are not paid for offering.
7. You distrust group activities. Your success has always been by dint of your individual effort, whether that effort has been getting good grades in college, doing well in medical school to qualify for the residency of your choice, or caring for sick patients in academic medical centers or inner-city hospitals.
8. Your rewards have come through working hard, mastering your specialty and impressing colleagues, not through participating in hospital, HMO, or corporate bureaucracies.
9. You dislike organizational politics. You detest meetings. You turn a wary eye toward any activity that takes you out of the operating room, off the wards and away from your office, for those locations are where the patients, your joy in doing well and your income are.
10. What has any managed care organization, hospital or business corporation done for you? HMOs, in your mind, manage cost not care. Has any HMO medical director or health executive ever helped you care for a patient better? Has any HMO policy improved quality of care for your patients? Has adherence to clinical guidelines really helped you find the right answers to your patient’s problems? Has any managed care organization placed at your fingertips in the waiting room, at the “point-of-service,” an easy-to-use information system that saves you time by telling you what drug to use, what diagnosis to consider and or whether the patient can pay?
11. Everything that relates to the new competitive environment has discounted your fees, driven down your revenues, compelled you to hire more personnel to deal with HMO clerks or “Doctor Denial” HMO medical directors and forced you into organizations where autonomy is less, rules are stricter, income is lower, work is harder, and a production-line mentality is at work.
12. You’re a professional, not a "provider" to be ordered about. What do these health care executives and those on the other end of an 800 line know about practicing medicine anyway?

Given these states of mind, it's no surprise physicians resent being subjugated to HMOs, hospitals or PPMCs. It's no surprise physicians undermine organizations that try to manage them. It's no surprise that business executives are having such a hard time “herding cats,” as executives so quaintly and demeaningly put it.

It's no surprise that loose "integrated" systems, cobbled together to win managed care contracts, fail. It's no surprise physicians resist “retaining earnings” to pump into business organizations they innately distrust. It's no surprise that lawyers, accountants and executives are having such a hard time imposing business principles or systems thinking on physicians.

These cultural characteristics may reflect a self-centered, narrow-minded, and shortsighted worldview. But these traits dominate many physicians' minds and can’t be dismissed.

In Part II, we will look at strategies for redirecting this cultural mindset to better the health system