Healthcare Leadership (pt. 2)
In the second episode of his podcast, Dr. Andrew Agwunobi outlines potential ways to address problems facing healthcare organizations. He dives into how hospitals and other organizations can approach doctor satisfaction, systems management and cost improvements. To wrap up, Andy gives his outlook on the future of the industry.
TRANSCRIPT
S1 00:01 Hi, ThinkSet listeners, Eddie Newland here. As you might know, Phil Rowley, BRG's executive director and chief revenue officer, is getting into the podcast game. Check out his conversation with Jaime Diaz at the Golf Channel and other experts on leadership. Phil's podcast is called Intelligence That Works, and it's available in this feed and wherever you get your podcasts.
Welcome to BRG's ThinkSet podcast. I'm your host Eddie Newland.
BRG is a global consulting firm that helps leading organizations advance in three key areas: disputes and investigations, corporate finance, and strategy and operations. Headquartered in California with offices around the world, we are an integrated group of experts, industry leaders, academics, data scientists, and professionals working beyond borders and disciplines. We harness our collective expertise to deliver the inspired insights and practical strategies our clients need to stay ahead of what's next. For more information, please visit thinkbrg.com.
On this episode of the ThinkSet podcast, we'll be speaking with BRG special advisor Dr. Andrew Agwunobi. Andy is a board-certified pediatrician and a former co-chair of the Healthcare Performance Improvement practice here at BRG. Andy is now the chief executive officer and executive vice-president for health affairs at UConn Health. With more than twenty-five years of experience as a practitioner, consultant, and executive in healthcare, Andy brings a unique and informed perspective on the challenges faced by hospitals and other healthcare organizations. This, the second of two episodes with Andy, will focus on guidance for those in healthcare, some common misconceptions, and predictions from Andy about the years ahead. And with, that let's get started.
So if a fellow healthcare executive called you right now and asked what they should do to address these issues, what would you tell them? Is there advice that can be generally applied that this is step one, step two, step three?
S2 02:13 It does start, definitely in my mind, and you won't see a lot of this elsewhere in the lay press. But it does start with just stepping back and saying, "Okay. We're going to share this challenge of healthcare," which is very challenging, and the complexity, we're going to share it with physicians. We're going to give them a seat at the table, and we're going to listen to them and incorporate their ideas in our decision-making. I believe that will take care of a lot of problems in terms of physicians feeling they're helpless and they have no autonomy and nothing will change.
But as organizations—first of all, we need to commit to physician wellness in the workplace. It's not enough to say, "Yeah. I know about physician burnout. I'm going to hire a chief wellness officer, and then I'm going to go on to the next issue." The whole organization has to incorporate physician wellness and workplace satisfaction in the organization's documented strategic plan and direction.
And then we have to sort of focus on the executives, their leadership. We have to make sure that there is at least one person who is dedicated to overseeing the wellness and satisfaction of physicians. That could be a chief wellness officer, that could be the vice president of HR, who has that as part of their role, or it could be someone else, the chief medical officer. But there should be someone that is dedicated and thinking about that all the time.
One of the ironies is that, hospitals and health systems, if one could only choose. And I'm going to be careful about how I say this, because it's a team sport. Nurses are just as important, medical assistants are just as important. Everyone in the hospital health system is important, but one of the most important groups is the physicians. They are the ones that give the patient the care, bill for the patient's treatment. Of course, the care itself is delivered by a whole team, but they're extremely important, and failing to give them a seat at the table I think takes away from our ability as health systems to be successful or—put another way—the challenges that we as executives face in running our health systems and making them successful would be greatly diminished if we had the physicians at the table. So it's not just to help the physicians and their burnout and their dissatisfaction, it is to help us, the hospitals. And I think that we need to have that as a big part of what we put in place.
And then I think the last thing, without going into every single detail, is to remove barriers to efficient and convenient physician work. So what's most important is that we help physicians to work at the top of their license, to do the activities that they were trained to do and that we expect them to do for their patients, but not adding those activities that others could be doing for them or activities that they're doing just because the work environment is inefficient.
We should also be focusing on satisfying their patients’ needs. It's important to know that the patients and the physicians sort of act as, in my mind, as one unit; and that is, the patients want the organization or the hospital to satisfy the physician's needs for a good work environment, getting their lab tests on time, getting the scheduling done properly, et cetera, so that the physician can do their work. And the physicians expect that the patient's needs will be met, and sometimes that's everything from parking to wait times to getting in to see the physician, to discharge summaries afterward, whatever it might be. They expect that the patient's needs will be met, and if they're not, then the overall episode of care is not going to be as good as it could be, and it's not going to be as satisfying for the physician or for the patient.
And one example of an intervention—and there are many types of initiatives that can be put into place—but one example is scribes. So in some clinics and hospitals, when you have extremely busy practices and—one example might be dermatology, where they're seeing a lot of patients within a given hour. They may see a patient every five to seven minutes. In those kinds of situations, the physicians are working extremely hard, they're seeing a lot of patients. The clinic around them or operation around them needs to be like a well-oiled machine. Interrupting that flow with a lot of documentation into the electronic medical record is not a great thing to do and very dissatisfying for the physicians.
So in those types of situations—in some organizations, they have employed scribes, people who actually follow the physician around—and there's also virtual versions of this. But they follow the physician around, and they actually document in the medical record for the physician.
Now I will say at this point that it's not for every organization; obviously there's a cost associated with having scribes, and you have to kind of look at the cost value equation on that. But in some organizations, what they've done is there is a qualification for having scribes. So you have to be at a certain level of busyness or you might have to be in a certain specialty. But anyway, each organization has to evaluate that for themselves and decide if that makes sense. But it's just an example of one initiative.
But it's not the only way that you can address electronic health record inefficiencies. There are other ways. For example, actually looking at workflows within the electronic medical record, how many screens that a physician has to click on.
I'll give you a specific example. In one case, all of the procedures that were done by the physician were actually listed under a different tab than the tab where the documentation was listed. And so that's an extra click. You have to click out of one screen and click into another screen.
So those are the types of things that electronic medical record experts, IT experts can come in, sit with the physicians, understand what the issues are, and be able to streamline the workflow within the electronic medical record.
There are other operational inefficiencies that we have to address for the physicians. One of the basic ones is staffing. So we always expect our physicians to grow their practices. We want to see more patients, but we have to understand that that requires more support staff. So medical assistants, registered nurses, front- and back-office staff, and also a streamlining of the scheduling, and that includes surgical schedules. One of the big areas of dissatisfaction is if you have a surgeon and that person is not able to get time in the OR, in the operating room to do their cases. That's a big dissatisfier. So that's important as well.
And sometimes in a very busy organization you have to create a central mechanism for us to support the physicians. And one example might be a referral management function or office where, when a physician wants to refer a patient to another specialist within the same system, they just call one number, and a nurse or another type of professional does that for them so they don't have to be on the phone for ten or fifteen minutes waiting for another physician to pick up the phone and find out whether or not they can get a referral into a subspecialist.
These are just examples of ways that we can really show the physicians. both in a real sense and also from a perception sense. that we really care about them, and we want to support them, and that we know they are very hard and busy workers.
The last thing, or a couple of the last things, I'll mention that are really important are—is that—it's important that we give the physicians credit for the work that they do. Something that frustrates physicians is, if a physician knows that they've done twenty operations last month, surgical operations, and yet they're told that, "Well, your department is losing money." And when they go back and look at it, they find that you've only billed for ten of those cases or fifteen of those cases, and the other five nobody knows exactly where they are in the system.
So it's really important that—even your revenue cycle—making sure that that is streamlined and that the physicians understand the revenue cycle and how their department affects that. And it helps them to not just be recognized for the work that they're doing or understand that the work they're doing benefits the whole system, but it also is a motivating factor for them to do the things that are necessary to help the organization to be successful. So those are the kinds of things that from an operational perspective we need to do for the physicians.
And I think the last thing I would say is, we do have to also focus on the work-life balance of physicians. They are extremely hard-working individuals, extremely. Some of them round in the morning on patients, go to the office during the day, round in the evening, take work home, go to the OR and do surgeries. They're extremely busy. So we have to help them to be healthy. That can include things like, making sure, number one, that they're doing the kind of work they want to do. If they want to do some research, give them a little bit of time for research. If they want to do some teaching, give them a little bit of time for teaching. So it's not just clinics. Make sure that if they need time—flexible schedules. Let them have flexible schedules if they need to go on sabbatical. There are some organizations that are even saying, "If you worked here for a couple of years, you get to go on a sabbatical for six months or for three months or a year, whatever it might be." So we work with them to keep them healthy, make sure they have access to counselling, make sure they have access to employee assistance services, to mental health services, to exercise gyms, et cetera. But we should follow what they need; we shouldn't prescribe it for them. We should ask them what do they need to be healthy.
S1 12:02 So when you talk to those in the field, what are some of the things that you think they get the most wrong?
S2 12:07 There is a lot of myths. And by the way, I have huge respect for executives. I'm one of them. Some of the most talented, compassionate people that I've worked with are not physicians, some of them are executives. So it's not a blame game, but there is a culture that is—a stereotypical culture, I would say, among health systems of looking at physicians in certain ways. So for example, one is saying, "Well, you know, the reason I don't involve doctors in my decisions is because doctors don't know business. They know about treating patients."
And that is a myth that's very, very harmful because—first of all, doctors, to get through medical school and residency and fellowship, you're pretty intelligent, you're pretty smart, you could have gone to business school, you could have gone and run a business. Many of them do. Many of them start multimillion-dollar businesses. So they can learn business, but they need to be taught it.
And I think, instead of saying, "I don't share decisions with them because of this," we should be sitting with them and saying, "Okay, here are the financial reports. Here is what drives the business of the health system. Here's what drives the business of your clinic. Here's why we talk about the coding being correct or the billing being correct or are you putting this information into the computer. Let's sit down and let's do it together and understand it together."
And some health systems, what they've done is, they've created what they call "dyads," which is: they partner a physician with an administrator, and the two of them are held responsible for the business of the health system. Now, we have to be serious about that. It's one thing to say, "Oh, I've created a dyad." It's another thing—as they do in some of the better systems, they'll say, "Yes. We've created a dyad." And by the way, the same incentives that the executive is given for success is the incentives we're going to give the physician for success. So if the executive gets a bonus, the physician gets a bonus. Now, it has to be done carefully and in the right way, because there are regulations around that, but making sure that they're truly sharing in decision making.
Another myth that is problematic is that physicians are in it for the money, and that the reason there's this sort of—in some systems, a schism between the physicians and the executives—is that, the executives look at the physicians are saying, "You're just after more money. The reason that you're dissatisfied, you're asking for more compensation. It's really just all about the money."
But the truth is that the vast majority of physicians got into medicine to treat patients. And I often used to say when I was younger and I was a pediatrician, if you take the full amount of time that I spend in the hospital rounding on patients, in the clinic seeing patients, doing procedures in the emergency department, or at home with a pager—in those days it was pagers. At home with a pager where I can't go further than thirty minutes from the hospital, I can't drink socially with friends, dinner, or something like that. If you took all of that time, and you divided it by my salary, I was earning less than minimum wage. And the truth is that even though physicians do get paid well for what they're doing—and they should be paid well for what they're doing—there's so much extra that is not noted, and there's so much that they do that they never talk about. I know physicians that get up at 2:00 a.m. and drive from their homes in to see a patient, and go back and go to bed, and wake up for a 7:00 a.m. meeting.
So physicians are not in it for the money. They should be paid reasonably well, and they are paid reasonably well, but they go above and beyond. So I think that myth is something that causes issues. And by the way, it's on both sides. Physicians also look at executives and say, "They're just in it for the money. They're not doing the actual work of seeing the patients." So I think myths on both sides need to be dispelled. And that's an important one.
And then the last thing that I would say in terms of myths is the myth of what I call "incompetent doctors." So you've heard a lot probably in the lay press about the fact that there is so much variation in healthcare. And the way it sometimes comes across is you'll hear people saying, "Well, one doctor does it like this, and another doctor does it like that, and they can't get their act together." There is a prescribed way of doing certain things, and they should be following that method. And the fact that they're not following that method implicitly suggests that they don't know what they're doing. And that's damaging, because what happens is physicians perceive that. When an executive goes into a room and says, "Your variation in the way you practice is too high based on our data," what you're saying to the physician is, "You don't know what you're doing," and that the organization knows better. That's extremely demoralizing. It's also incorrect.
I mean, the truth is that physicians train in multiple medical schools, and when they come out of these medical schools they are practicing to the gold standard that they were taught in medical school or in fellowship or in residency. There may be differences in how those processes play out for physicians, but the outcome that they are seeking is usually the same.
So, yes. There is an opportunity to standardize processes so that everyone is using the same process to get to the outcomes. But that doesn't equate to the physicians not knowing what they're doing. And I think inadvertently, we sometimes communicate that to physicians and that demoralizes them, because it says to them, "People who are not even physicians are telling me that I don't know what I'm doing," and that plays into the devaluation and the demoralization of physicians.
S1 18:07 The final question we like to ask on things at podcast is a forward-looking one. And generally, we think about it in a cheery way or something that's optimistic. But I think in light of the conversation we've had, we can sort of flip it today and think pessimistically. What happens if healthcare executives in the entire sector don’t address the problems that you write about and that we've spoken about today? In that scenario, where are we headed? And I guess then to think forward on a happy note is, beyond all the things that we just talked about today, how do we make sure that we don't end up in this scenario of excessive burnout and doctor dissatisfaction?
S2 18:42 I hope this doesn't occur, because again I think this has gotten the attention of a lot of healthcare executives and physician organizations. But if we don't do enough about this, I think we'll have the problem that we had with nurses several years ago, where we had a national crisis in terms of the number of nurses who were entering the field of nursing. And I think what we will see is, we'll see a lot of physicians retiring, leaving organizations, going to part-time, going to different professions, going to different organizations, and there will likely be a crisis in the physician workforce. We already see shortages in some areas. So I think that's sort of the most benign version of it.
But I think that we also could see a whole change in the model of affiliation between health systems and physicians. Right now, the pendulum is swinging toward employing of physicians. Physicians have been becoming employed in much greater numbers than ever before in part because they thought or they think that there will be a better work-life balance if you're a salaried employee as opposed to running your own clinic, where you have to worry every year about paying the staff, and reimbursement is declining, et cetera. But I think that what we'll find is that, over time, if we do nothing about this problem we have, physicians will realize that it is not better to be employed. That being employed leads to dissatisfaction and burnout, and therefore they will speak to each other, get together, get together with investors, and they will figure out another model of care, another model of practice which separates them from the hospitals and health systems.
And by the way, before we employed physicians, we competed with physicians in many regards. And I think we could go back to that type of situation. And then of course, one that I hate to even think about is that I think we will see more physicians burning out and ending up unwell, or God forbid even having problems like suicidal ideation or suicide. So that's not a path we want to go down. I think it's something that can be changed, and there are a lot of companies working on ways to do that.
S1 21:00 Great. Well, Andy, thank you so much for joining us on the ThinkSet podcast today. We'll look forward to catching up with you again in the future.
S2 21:06 Thank you, Eddie. It was my pleasure.
S1 21:09 [music] This ThinkSet podcast is brought to you by BRG. You can subscribe to the podcast and access other content from ThinkSet magazine by going to thinksetmag.com. Don't forget to rate and review on iTunes as well. I'm Eddie Newland, and thanks for listening.
The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the opinions, position or policy of Berkeley Research Group or its other employees and affiliates.