Letter From the Front Lines                  March
21, 2013

Leonard Zwelling

must question the employer-employee relationship of the medical staff and the
hospital administration. What will happen to the already fragile balance
between quality patient care, the fair treatment of the medical staff and
hospital profit? Will your average hospital administrator or health-care
executive have the ability, moral character, leadership skills and knowledge of
medicine to effectively steward a staff of hundreds of physician employees in different
medical and surgical specialties?

prediction is a demoralized physician workforce. It is already happening.
Decreased doctor productivity will result from this kind of workplace
environment, but that may be the least of our problems”.

Brian D. Kent, M.D.

I have posted above is a letter from Dr. Kent to the Wall Street Journal that
was published today, March 21. It was in response to an article about the
effects of ObamaCare on physician behavior, moves to salaried status by doctors
and their lack of availability written by Dr. Scott Gottlieb (WSJ-3/15/13; http://online.wsj.com/article/SB10001424127887323628804578346614033833092.htm),
a physician and fellow at the American Enterprise Institute, a former official
at the FDA and CMS, and a friend of MD Anderson. Dr. Gottlieb spoke in my
Seminar Series that was sponsored by Cancer Prevention.

found this uniquely germane because it is absolutely not the case at MD
Anderson where the care providers of all stripes have been on salary since the
place opened. Yet, the recent Faculty Senate morale survey suggests that we too
have a “demoralized physician workforce”. Since the salaried physician model
has been in place here for years and the low morale is very recent, perhaps the
two are not causally linked at MD Anderson. If they are not, what is causing
the low morale?

am going to posit that the morale problem on the clinical side comes from two
very different views of what patient care at MD Anderson is to be—one held by
the administration and one held by the faculty. This also refers back to the
above letter in which the suggestion is that hospital administrators and
executives may not really understand what it is they are charged with running.

my discussions with the leadership of MD Anderson, I have learned that they believe that the recurring budget shortfalls of which we are informed on a monthly basis are
attributable to a decrease in patient (especially new patient) volumes. So
naturally, their view of the solution is to increase the number of new
patients. Thus, the clinical faculty is being pushed to see ever-greater
numbers of patients regardless of whether we can help the patients or they can
assist us in our other mission areas like research. The leadership views the
problem as quantitative. The reason stated by the President for this drive to
increase revenue is his perception that the faculty are calling for expansion
and modernization of facilities and a desire for a research mission analogous
to a government program like NASA.

conversations with clinical faculty are far different. Most faculty who care
for patients want to do just that but feel the press to see more and more
patients is interfering with the QUALITY of the care they wish to give. This
quality includes a period to think about the right course of action, the time
to clearly explain to the patient and his or her family why that course of action
was advised and the time to do this with the most up-to-date and complete
diagnostic data. All these things take time and are not consistent with high
volume patient care. Furthermore, many of the clinical faculty members also
want to do clinical research which is the toughest kind of research to do
correctly because the investigator is also the care-giver and the human
research subject is NOT a cloned, genetically manipulated animal who will develop
cancer, but a frightened human being who already has cancer.

we have two views on what our clinical enterprise is to be, what its role is in
paying the bills and just how much of which activities we will chose to do.

of this is a problem until you realize that only the administration gets to control
the model. The faculty members do not control what occurs at the front door.
They cannot sort through the patients trying to enter Anderson for those who
they could uniquely help or who would qualify for a clinical trial. They have
no control over what is charged for their services and even less over what is
actually reimbursed. Thus the whole competitive strategy of MD Anderson is in the
hands of the very people who probably don’t have the “ability, moral
character, leadership skills and knowledge of medicine to effectively steward a
staff of hundreds of physician employees in different medical and surgical
specialties” as Dr. Kent stated above. They also don’t know what the faculty
members want because they don’t ask.

we really want to solve the problem of the recurrent budget shortfall and the
ever-dropping morale of the faculty, the two groups of greatest significance,
the leadership and the care-givers, had better agree on the problems as well as
the strategy and the tactics to fix the problems. This has yet to occur and the
onus is clearly on the leadership to decide if it wants the problems fixed and,
if so, do they want to continue to go it alone using a host of
non-physician, highly paid administrators or might they want to partner with
the people who actually understand the task at hand and are probably filled
with great ideas if someone would only ask them—and give them the time to
answer thoughtfully?

far—not so good!

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