FAILURE

Failure

(This
is a longer one than usual. Sorry. Too much to say for brevity)

By

Leonard
Zwelling

      Success is more fun than failure, but it
is also more transient.

When I accomplish a goal that I established for myself, I
am certainly pleased, but only for a minute. I am on to the next challenge and
tend not to bask in my accomplishments. I guess this is why I play golf, a game
where what you just did is virtually meaningless if you louse up the next shot.

Doing well is great, but it does not leave a lasting
impression, at least for me. This may derive from the Groucho Marx line about
not wanting to belong to any club that would have me as a member. I do have a
funny view of my own worth, I guess. If I can do it, how hard could it be? The
pursuit of the Gold Star is everything. The Star itself, nothing.

Happy? So what!–now let’s move on. What have I done for
you lately?

      Failure is different. I wallow in my
failures, usually for days and weeks. And in this arena I have had much
practice. I once worked for someone who claimed never to have failed at
anything. No one who ever worked for me could make such a claim about his or
her boss.

I thought I had progressed beyond this in my professional
career because I thought I had gained control and diffused both my passion and
my intensity when it came to work. Silly me! (I suspect that no one I worked
with ever thought I had gotten control of my passion).

Thus, my latest failure at Legacy is particularly painful.
I failed at the job and failed at diminishing the importance of success. What a
head case!

This is a learning moment however as failure always is.

First, what did I fail at doing?

I did not come to Legacy to be the Chief Medical Officer,
but rather to work for the man who had that position for five years and who was
going to ease me into task-specific projects that needed doing and which might
be amenable to skills I had acquired in academia. These included bolstering the
clinical care quality effort and gaining federal designation as a
patient-centered medical home (PCMH). Ten weeks into the work, and only 8 weeks
after the CMO’s return from an Asian vacation, he departed unexpectedly. At
least his departure was a surprise to me.

The Executive Director asked if I would step in until they
found a new CMO.  I was not interested in
pursuing this as a permanent position in which 140 providers reported to me. I
preferred a job where I would oversee a few staff in quality and PCMH. After
all, how hard could it be for three to six months to be the acting CMO?

Hard.

The medical directors of the six clinical areas—adult
medicine, pediatrics, OB, behavioral health, dentistry and ophthalmology—were
lovely, competent, and bright, but in shock. Why? Not only had they just lost
their leader who had hired most of them, they had been clawing their way
through a newly installed system of care that included a new electronic medical
record with servers in Chicago, two newly acquired distant sites of care in
Baytown and Beaumont and the recent acquisition of a Chief Operating Officer
who controlled all the resources that supported the docs and other health care
providers. These functions used to be owned by the CMO. In other words, all of
the support for clinical care, scheduling, call center communications, staffing
and nursing were lifted from the CMO’s portfolio and placed into that of the
COO. For help in resolving all operations problems, the docs and the CMO would
have to have their hats in hands begging for the COO’s assistance. He had been
given our Handy Andy or Mr. Fix-It Tool Box.

Not surprisingly, the COO, a nurse, had very definite ideas
about how to organize and support a clinic and these ideas did not agree with
those of the original CMO, me, or the docs. The COO just wanted the docs to
stay behind the examining room doors and see patients with little or no input
into patient flow or types of appointments scheduled in succession. A 15-minute
time block was a 15-minute time block. Period. New patient. Return patient,
consult, pediatric adolescent or Medicare. A patient is a patient after all.         

The COO’s support staff would run
these clinics their way. And they did.

And the war ensued and I walked in as it was escalating to
a particularly intense level due to the expanded number of care sites and a
very rapid expansion in patient numbers without the necessary increase in financial
or personnel support (sound familiar you Andersonians?). Given that none of the
three individuals who actually run Legacy is a physician, I was out of luck
when a dispute arose for no one on top was willing to adjudicate and decide,
yet the COO had all the resources upon which the doctors and other providers
depended.

Of course, I tried to fix things as I always do, but it was
very difficult taking orders from a nurse and the COO’s staff as to how a
clinic should run and as hard as it was for me, it was even harder for the
medical directors who reported to me. After all, until the COO came they were
in charge of the clinics.

Apparently, the Executive Director and the Chief Financial
Officer were unhappy with the fiscal performance of the clinics when they were
run by the last CMO so hired the COO to find a way to turn the crank more
rapidly. The operating quote from the CFO was, “the last CMO was unwilling to
take responsibility for the profit and loss statement of clinical activity.”

The docs, motivated by a need to control their own
schedules as well as the desire to continue a tradition of quality patient care,
were feeling rushed and unhappy. Let the sniping begin.

At first, I couldn’t figure out what all the screaming and
yelling was about. Shortly thereafter, when the COO went back on a specific
agreement we had made, I joined the screaming and yelling. And that’s when I
started to fail for only the executive leadership was allowed to show anger and
especially anger aimed at “those lazy doctors.” Oops! What had I gotten myself
into?

Then the CFO fired one of the docs without telling me. The
Chief Marketing Officer was informed of two needle stick incidents in the
clinics when I was not, and in general I was left out of most decisions. I
found myself overseeing the activity that was generating 85% of the revenue for
the “non-profit” enterprise, clinical care, and having no power to do anything
to improve the quality or volume of that care. Hmmmm……

It was only a matter of time before I, too, had a few
blow-ups and as I said above, I was not allowed to have a temper although
others in the organization were allowed to scream and curse at will. There were
two favorite examples of the lack of doctor input into the running of a
clinical care provider. There was the day the leadership decided to cancel the
President’s Day holiday and open the clinics that scheduled holiday because
there had been two days of closure due to ice and revenue would be adversely
affected. As the discussion ensued I suggested that they might consider consulting
with the physicians and other providers before opening up the Presidents’ Day schedules
to make sure they would be there. This seemed to be an after thought for
everyone around the executive table but me. A subsequent discussion about
applying for a clinical care grant completely omitted my input and that of the
COO. Yet it would be our teams who would have to implement whatever plans the
rest of the executives decided to pursue with this grant application, feasible
or not. These were pretty standard descriptions of the way decisions were made.
Clinical care was not very high on the strategic agenda despite being the major
generator of revenue.

I found myself in the middle of a microcosm of American
medicine. Non-physician leadership desired to compete with other health care
providers in the geographic area on the basis of quality. In fact they were paying
this strategy lip service, while actually pushing their providers to see ever
more patients faster and faster.

How bad did it get?

I made myself a patient to find out. Human subjects
research 101. I filled out about 20 pages of forms before my scheduled visit
only to watch as none of the data was entered into my medical record for my
doctor to use. The physician I saw asked all the questions that were on the
forms again recording the information on her laptop as she spoke with me. I am
quite certain she looked at the screen more than she looked at me. This process
left her almost no time to examine me within the 15-minute window she was
allotted before her next patient so I was never even undressed.

Welcome to primary care medicine 2014. Round ‘em up; move
‘em out! The electronic medical record was well cared for while I, the patient,
remained largely untouched.

This was further echoed by a story told to me by one of the
primary care doctors who was evaluating a new patient. She was a 74-year old
woman with an enlarged abdomen. In discussing the patient with the director of
adult medicine and the doctor I asked about her pelvic exam.

“I didn’t do one,” the doctor said.

“Why not?” I asked innocently enough.

“I didn’t have enough time in the 15 minutes I was given to
see her.”

Foolishly I commented, “you only had 15 minutes to see a
new 74-year old woman? How about I see her with you when she returns?” The
director and I both thought that she either had a serious liver problem or
intra-abdominal cancer.

Needless to say, I never saw the patient, probably because
she never returned. Why would she? Patient-centered care? I don’t think so.

As I have written many times, my primary identity and ego
strength derive from my being a physician. It may be naïve and old-fashioned,
but it is true. There is no club that I have ever joined of which I am prouder
to be a member than that of the fellowship of physicians. (Groucho or no). So
when an entire organization, whether it is MD Anderson or Legacy, makes a high
throughput conveyor belt out of the delivery of clinical care by trying to
create a faster assembly line rather than a better product, I am deeply
troubled.

So I failed at being a modern corporate physician manager.
Now, 14 days after the end, I look back and wonder could I have done this all a
better way? Yes, I could—in theory. In truth, probably not. If I had stayed out
of trouble another week, the new CMO would have come and I would have been out
anyway. My brief, ad interim tenure was successful in having mentored a few
folks and improved their self-esteem and decreased their PTSD, but I was
obviously a failure in that I am out on my ear.

There are several possible lessons:

1.        
Keep your mouth shut, your head down and your ego in check.

2.        
Work quietly and settle for incremental improvement.

3.        
Work slowly and don’t expect instant change.

4.        
You catch more flies with honey than with vinegar.

These are all true and good advice, though essentially
rationalizations for passivity.

But I would rather fight and go down in a hail of bullets
like Bonnie and Clyde when patient care or any human welfare is at stake. Thus,
I do and did fight. The only neurotic part is feeling bad about it. Neurotic?
Moi?

I certainly failed in my transition from Legacy board
member to Legacy employee. I failed at being a clinical corporate doctor
executive willing to play the “Game of Suits” by kowtowing to the money men and
forcing the docs to run faster on the treadmill. I failed as a leader for I was
not permanent so had no need for a long-term vision and my will was so poorly
aligned with that of the group for whom I worked that I was bound to fail in
their eyes.

In the end, the Executive Director fired me because I
displayed too much anger and was too disruptive. She was well within her right
to do so, especially with a new, less experienced CMO coming who the leadership
will undoubtedly find far more accommodating and malleable than I ever was.

I failed the way I usually do. I do fine with those on my
level or below on the org chart, but just can’t seem to buy into the company
line put out by those above me. Like Lewis Black, I guess I have “trouble with
authority.”

Or, this can be expressed as my father-in-law said to me so
many times. It is what I would say to the lay leaders (my father-in-law would
call non-physicians ‘civilians’) of all health care delivery entities when it
comes to clinical care:

“What do you know?”

The next time you get sick, call an accountant.

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