Patients often ask, “Do you know of a good doctor?”
Managers ask something similar: How do we identify good doctors and manage them?
Patients ask because they want good care. Managers ask because they want to make doctors good. Or because they want to learn what it means to be good, if one is a doctor.
This post adds a new discovery to our previous discussions:
Impossible to Manage Doctors? (July 2016)
Manage Doctors for Patient Benefit (Dec 2016)
Should Doctors be More Accountable? (Sep 2018)
How to Change Doctors Behaviour (Dec 2018)
How to Manage Doctors
Patients find good doctors by asking around.
Managers cannot ask around. Even if they could, they would not. Managers measure. They benchmark, spot check, and create colourful reports with pie charts. They want to manage, not just find.
If we were managers, we would do the same. The Ministry of Health (MOH) spends $13 billion of taxpayers’ dollars to pay for everything that doctors do in Ontario. The public expects oversight of spending, which means oversight of doctors.
James Q Wilson tackled this in his classic, Bureaucracy—What government agencies do and why they do it.
Wilson wrote that managers of public agencies face different problems depending on what they have been asked to manage. This seems obvious, but his insight is not.
Public agencies fall into four organizational types. In each organization, managers try to manage ‘operators’: the people who do the work. Wilson wrote about outputs and outcomes. I find these words too similar and thus confusing. So I use activity instead of output.
Four Organizations:
Production
Example: the Post Office. We can see the work done (activities, sorting mail) and measure the outcome (letters delivered).
Activities and outcomes are obvious.
Procedural
Example: the Military in peace time. We can see marches and training exercises, but we cannot know about performance until a war starts.
We see activities but not outcomes.
Craft
Example: professional negotiators. Negotiators negotiate in secret, but their deals are public.
Activities are unseen, outcomes obvious.
Coping
Example: police. Officers keep the peace, but how can we know how much peace has been kept or lost? Furthermore, how does one keep the peace, a metaphysical concept?
We cannot see activity or outcome.
Manage the Invisible
But what is an unseen activity? After all, police officers are not invisible.
Again Wilson:
“Of course some work can be observed some of the time and some examples of results achieved do occasionally come into view…A police sergeant periodically sees a patrol officer working the street…”
But keeping the peace is intangible. Parades, parties, and picnics each have crowds but present different tasks for officers. Peaceful behaviour at Caribana might be mayhem at lawn bowling.
Schools are coping organizations too.
“A school administrator cannot watch a teacher teach (except through classroom visits that momentarily may change the teacher’s behaviour) and cannot tell how much students have learned (except by standardized tests that do not clearly differentiate between what the teacher has imparted and what the student has acquired otherwise).”
Is Medicine A Coping Organization?
Medicine aims to “To cure sometimes, to relieve often, and to comfort always.”
Doctors can sometimes diagnose, treat, and cure. Managers can measure how many diagnoses led to treatments and then to cures. Cause and effect holds for some diseases. But it is more rare than patients realize or doctors admit.
Doctors work in private. Outcomes appear decades later, if at all. For example, we tell patients to stop smoking.
But smoking does not always cause death. Counselling does not always cause quitting. And we cannot know for sure whether counselling, individual effort, or something else played the biggest role.
Or again, a surgeon assesses a sore hip. It is too soon for surgery.
But how did he decide? What, exactly, did the surgeon do?
How can we manage an assessment that advises no action? Different surgeons might arrive at different assessments.
Can Data Save Us?
Statistics offer a pseudo-solution. For example, managers identify more hip replacements in Ottawa than Peterborough. Why does this happen?
Do surgeons in Ottawa provide unnecessary care?
Are Ottawans obese, causing bad hips?
Is access to surgery poor in Peterborough?
We might never know. But horse-sense and managers tell us that rates should be the same everywhere. Outliers indicate greed or sloth.
Modern sense tell us that medicine is nothing but scientific technique applied to crisp diagnoses. Problem, procedure, outcome.
But Sir William Osler said that medicine is a science of uncertainty and an art of probability. Much of what doctors do is invisible, with loose association to outcomes.
Medicine is most often a coping organization. Sometimes it is craft. Rarely it is production and never procedure.
Solutions
If the best argument supports medicine being a coping organization, then it is the worst case for managers. Managers of coping organizations face an impossible task.
“They can try to recruit the best people (without having much knowledge about what the ‘best person’ looks like), they can try to create an atmosphere that is conducive to good work (without being certain what ‘good work’ is) and they can step in when complaints are heard or crises erupt (without knowing whether a complaint is justified or a crisis symptomatic or atypical).”
When this fails, managers try to turn coping organizations into procedural ones.
Even if we cannot know exactly what happens in a counselling session, or whether counselling works at all, we can at least measure how many minutes of counselling took place.
“In procedural organizations the general bureaucratic tendency to manage on the basis of process rather than outcome is much magnified because processes can be observed and outcomes cannot.
Since the work of operators must be watched, it is watched all the time. Managers use many forms of continuous surveillance to ensure conformity to correct procedures, ranging form direct observation to periodic statistical reports.”
Dire Summary
“In coping organizations, effective management is almost impossible.
Of course some work can be observed some of the time and some examples of results achieved do occasionally come into view…A police sergeant periodically sees a patrol officer working the street…
Commending those employees whose good conduct happens to come to light also sends a message, but since citizens have more incentive to complain of the abuses they have suffered than to praise the virtues they have seen there tends to be more punishment than commendations issued by coping managers…
Consequently, operators in coping organizations often feel they are treated unfairly by managers who don’t ‘back them up’ or who are ‘always getting on their case.’”
Morale Suffers
When managers make medicine into a procedural organization, it crushes doctors’ morale.
“The great risks in procedural organizations are that morale will suffer (operators may resent the surveillance, believing they know — even if they cannot show — how to do the job right) and that the surveillance will bias the work of the agency (by inducing operators to to conform to rules that detract from the attainment of goals).”
Sound familiar? Morale suffers. Surveillance increases. Regulation creates a bias to follow the rules instead of serving patients.
Attempts to turn medicine into something it is not makes doctors focus on meaningless things for unimportant outcomes.
We need to stop blaming doctors and start looking at medicine for what it is—a coping, or craft organization—and not what managers want it to be.
Photo credit: Berzin at Pixabay
Excellent article.
“ A government bureaucracy is a giant mechanism operated by hubristic pigmies suffering from an exaggerated sense of self importance” (paraphrasing Balzac).
Medical doctors respond better to leadership than management…one suspects that the powers that be will select, for entry to medical school, more agreeable and docile individuals who would find it difficult to work alone and function better in teams.
As an aside, Korean War MASH 4007 ( medical black comedy) type doctors such as the refreshing Hawkeye did exist in the 1950’s and ‘60’s, today they would be cast aside with the Burns’s promoted….the older generation of doctors would relate to that excellent TV series, the snowflakey PC moderns would likely be horrified by their behaviour, which did occur .
Always excellent quotes and comments, Andris. Thank you!
Cheers
PS I corrected the edit you mentioned…
I am a Gen X era doc (15.5 years in practice, 44 years old). I grew up watching reruns of MASH with my dad. I watch my DVD collection of it with my ten year old daughter. As bizarre as it sounds, Hawkeye is one of my primary role models as a physician. At a simple level I dress like him. I wear Aloha scrubs all the time to work. To me it symbolizes a desire to break down the barriers with my patients. To connect as a person with them and not solely rely on my position to convince them to trust me with their care. Of course it also symbolizes a certain counter cultural attitude towards my “overseers” be they more senior physicians in leadership roles (although for a time I was a physician leader as a department chief, I am now simply a worker bee and loving it).
Of course I don’t have a still in the doctors lounge (how could I when I have worked in nine ERs in the last six months in my new role as a Homeless ER Mercenary ;-)). But I do break rules when it is in the best interest of my patient. Sometimes it’s little things like giving repeats on a script for HTN meds to an orphan patient I see in the ER so they don’t have to wait in the ER every three months for a refill (are the BP readings we get in the ER relevant to surveillance of this persons HTN, likely not after waiting in an uncomfortable waiting room for four hours then being ushered into a scary treatment room in a busy ER where I have been running a code in the next room while they are waiting, if their BP is lower than mine they are likely doing well). Other times it means telling management that we will need to get extra staff to hold a patient in a small hospital without an ICU for a few days while arrangements can be made in the city for definitive care. Or siding with the nurses in the need for formal code debriefs after complex, sad outcome high acuity situations. Other time’s it means writing a five page review of the evidence against CPOE with references, only to have it file in the recycling without being read.
The irreverence keeps me sane (ish). It lets me look at the whole screwed up system from the outside and laugh when you really want to cry. It lets me say things with my patients that others might not. To admit we are human. To admit our system is broken but we are doing the absolute best we can with the tools we have. To say “I don’t know” or “I can’t fix it but I can bear witness to you suffering and that matters!”
Has the irreverence gone missing in the newest generation of physicians? I don’t really know. I can’t think of anyone I know that pushes the boundaries in quite the same way as the characters from the past but my gut says they are there. But I do worry that the “system” has gotten so large and powerful that they can’t really make a difference anymore. Could someone with the radical ideas that Osler had about the role of medicine and physicians make it to the vaunted level that he did? Could his ideas survive the pressure of the academy or college to conform? History will decide I suppose.
I just watched a TED about conformity. It says that ninety seven percent of people stay inside the comfortable boundaries of their “box” and only three percent can break out of those boundaries and see the world truly differently. Our current organizational structure in medicine certainly doesn’t encourage people to jump past the boundaries very often.
Here is the link to the TED talk. I found it inspiring.
https://youtu.be/VNGFep6rncY
Wow. What a fabulous post, Dan. Really appreciated this.
I like your call to irreverence. It is certainly counter cultural to be a traditional, Hawkeye-esque doc.
Looking forward to watching the TED talk. Thanks so much for reading and posting such a thoughtful comment!
Cheers
Love it.
“ Curiosity and irreverence go together. Curiosity cannot exist without the other.
Curiosity asks , “ Is this true?” “ Just because this has always been the way, it is the best or right way of life, the best or right religion, political or economic value, morality?”
To the questioner, nothing is sacred. He ( or she) detests dogma, defies any finite definition of morality, rebels against any repression of a free, open search of ideas no matter where they may lead.
He ( she) is challenging , insulting, agitating, discrediting, stirring unrest.”
A Saul Alinski quotation who also stated “ Control healthcare and you control the people”.
Crushing the “Hawkeyes” is essential for the “ success” of the centrally planned collectivized health care system soon to be imposed….where they exist they will have to be rooted out, which is where the Colleges come in.
( I’m ambivalent about Alinski, an old style SJW…but his quotes nail it)
Odd, I always felt uncomfortable when everyone agreed with me…I thought to myself , where did I go wrong?
🙂
Don’t get too comfortable, Andris! We can start arguing about something anytime you want. 😀
I agree with Andris. We were fortunate to have greater freedom to practice what we saw as correct and needed. Not all physicians were altruistic then, but most were. We were very fortunate!
I hear the same appreciation from many doctors who remember practicing before Canadian-style managed care.
Thank-you! In the past physicians did not need to explain who they are (identity) or what they do (purpose) as this was understood to be obvious. The doctor- patient relationship was at the centre of both of these questions. However these are different times and being explicit about our identity and purpose is required for competence, effectiveness, ethics, strength, pride and morale in our profession. The erosion of the doctor-patient relationship has resulted in an erosion of both our identity and purpose. Your work explicating these abstract concepts that are urgently and practically important is appreciated.
Great comment, Anita. And thank you for your encouragement!
I like how you re-oriented it all back to the doctor-patient relationship. I agree, this is the moral high ground.
Sure appreciate you reading and posting a comment!
Cheers
Shawn,
This series, my friend, is destined to become a classic. In coping and craft organizations the role of “informed intuition” in good choices is given too little credit. Einstein said something like “not all things important can be measured and not all things that are measured are important”. Your clearly conveyed insights elegantly explain why!
Hey Glenn!
Great to hear from you. Excellent nugget there: informed intuition. I really like that. It reminds me of Kathryn Montgomery’s How Doctors Think (not to be confused with Groopman’s book by the same name). Montgomery focusses on phronesis, or what she calls practical reasoning: “…which Aristotle described as the flexible, interpretive capacity that enables moral reasoners…to determine the best action to take when knowledge depends on circumstance.”
Thanks so much for offering some encouragement, for reading, and for posting a comment!
Be well,
Doctors don’t need to be managed. Period.
The system may require management re. resource allocation, logistics, supply chain, purchasing, etc.
Doctors sometimes want support and occasional leadership but largely need to be left alone to ply their trade.
Intervention (support, consultation, coaching, leadership) is different than interference (management).
Doctors and patients can manage their own relationship.
Why have we spent so much time screening, selecting, and training physicians for preferred traits and skills only to assume that they require a phalanx of autocrats with clipboards to monitor, measure, and manage their performance?
Autonomy or bust!
Wow — so well said, MD!
I especially like this part: “Why have we spent so much time screening, selecting, and training physicians for preferred traits and skills only to assume that they require a phalanx of autocrats with clipboards to monitor, measure, and manage their performance?” I couldn’t agree more.
The system controllers need to decide whether they want knowledge workers or factory technicians. Knowledge workers get paid to think. By definition, it requires a very different approach to managing them than workers who do concrete things to specific problems.
Thanks again for posting and excellent comment!
Cheers