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Building a Better System with More Physician Accountability and Autonomy


Policymakers, payers, and administrators must all play a role in the evolution of healthcare in the US. But they cannot fix the system alone.

Chris Trimble

“My job is to serve the patient in front of me. Fixing the system? That’s someone else’s problem.” My guess is you’ve heard a comment like that more than once. You may have even heard it during your residency, from a mentor whom you respected deeply.

Let me be clear. Only physicians can fix the system.

Policymakers, payers, and administrators can help create the right incentives and right conditions, but they cannot finish the job. Their core tools are too blunt. Consider payers. Their most potent levers are choosing whom they will work with, what they will pay for, and how much they will pay. These choices may help contain costs, but they almost inevitably do so by trading costs for something else of value — for patients, it’s quality, access, or out-of-pocket expenses; for physicians, it’s income or work conditions.

Having given up on payers, some people are now wondering if employers can fix the system. They are paying the bill, the thinking goes, therefore they have the greatest incentive to get the job done. To me, the rising energy behind this line of attack shows just how far we have strayed. Do you really think that a corporation that is best in the world at, say, building jet engines is likely to also be adept at managing a network of primary care clinics?

Enough. The action is on the front lines. We need leadership on the front lines.

I want you to step up to the plate and lead innovation in healthcare delivery. If you do so, you accept a challenge. You make a bet that you can build a better system — not for the entire country, of course, but within your own geography, your own clinic or hospital, and your own medical domain.

Here, specifically, is the challenge for you:

1. Choose a patient population.

2. Be certain that you understand these patients’ wants and needs.

3. Design from scratch a team that can meet those needs.

4. Define the roles and responsibilities of each team member.

5. Hire and train each team member.

6. Invent the schedules and operating routines for your team.

7. Accept responsibility for both outcomes and costs for the population.

Note that designing, building, and leading a team is the crux of innovation in healthcare delivery. There has been a lot of chatter of late about the importance of team-based medicine. Less talked about is the reality that these teams by and large do not yet exist. I’m asking you to build them. My bet is that many of you — tens of thousands of you out of the nearly 1 million physicians in the country — are eager to call this challenge your own.

Note there is nothing technically or scientifically complicated on that list. I give my MBA students a deep dive into similar material in a course with just nine 90-minute sessions. The course has no prerequisites. Though I ask my students to work hard, it is well understood that any student who does the work will do well.

You’ve demonstrated the academic horsepower and discipline to emerge through many years of medical school and residency. My instinct: If you have at least a year or two of clinical experience, then you likely have what it takes to lead innovation in healthcare delivery.

Not long ago, I attended a conference for primary care physicians. I went to sit quietly, listen, and learn. Many of the presentations that day were excellent. There was, however, one true stinker — the one that was more about management than medicine. At first, I wondered if I was less interested only because I already knew plenty about management. As I looked around the room, however, it became painfully clear that I was not the only one who was bored.

I was reminded, in fact, of my days in engineering school, where I was exposed to a small dose of coursework that was managerial in nature. My passion at the time was applied mathematics. On any given day, I was as likely to pick up a calculus textbook as I was to pick up the new issue of Sports Illustrated — and I was then, and remain today, an avid sports fan.

Compared to the glitter of mathematics, the stuff on management seemed dull in the extreme. My attitude was that if it didn’t involve partial derivatives and double integrals, it couldn’t possibly be all that interesting or even relevant. Furthermore, the management concepts felt an awful lot like common sense, only dressed up with contrived terminology. Today I know that there was a lot of truth in that youthful assessment. There is way too much incentive in management scholarship to be needlessly inventive with language and to make straightforward ideas overly complex.

The major challenge that you’ll face in leading innovation in healthcare delivery will be one of leadership. In particular, you will need to be able to communicate what you are doing and why, so that everyone involved in your initiative moves in the same direction as a cohesive unit. This won’t be as easy as it sounds because innovation and conflict go hand in hand. Many of the people on your team will experience opposing pressures, subtle and otherwise. You’ll need to help everyone anticipate these conflicts and pressures, mitigate them and guide the path forward.

If you say yes to the challenge of leading innovation in healthcare delivery, two aspects of your work life change — accountability and autonomy. You get more of each. You accept that you are responsible for the patient in front of you and for system performance (as it pertains to a specific and local patient population). In return, you get more freedom. You hire the team. You design the care. You set the schedule. You refuse to be infantilized by rules that specify what you can and cannot do and what you will and will not be paid for. You refuse to run endlessly on a hamster wheel designed by others. Instead, you create the apparatus — hamster wheel or otherwise.

When you are successful, you will feel much better. You will feel more empowered, you’ll have a broader span of control, and, given the incentives built into new contracts, your income will improve or you’ll be able to justify a higher salary. In short, you’ll diminish most of the pressures that are driving your profession’s morale into an abyss.

Of course, it’s not all about you. There is a larger mission here. By answering the call to lead innovation in healthcare delivery, you are taking on a new kind of patient — a very ill one — the US healthcare system. And, you are taking on the challenge of building new teams that can deliver better value for the individual patients you see every day.

Not every physician will answer this call to action. A few docs will continue to brazenly work the system. You, however, are not one of them.

You want to innovate. Value-based contracts are opening doors. The opportunities are nearer at hand than ever.

Reprinted with permission from the American Association for Physician Leadership.

Chris Trimble is an adjunct professor at the Tuck School of Business at Dartmouth College. He is the author of How Physicians Can Fix Health Care: One Innovation at a Time (American Association for Physician Leadership).

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