How Physicians Feel About the Top-Down Nature of Medicine

The following is an excerpt from an email regarding an initiative handed down to the authors department. It reflects the sentiment of many physicians regarding the nature of top down leadership that is common in healthcare. Those outside of healthcare may think that physicians are at the top of the “top down” structure, but they are actually at the bottom. Healthcare is run by non-clinicians. Both physicians and nurses are forced to practice medicine as directed by those who have never done so themselves.

“As I recall, it was made to sound like this [initiative] was well vetted and working smoothly other places…not that our comfort level with the new tool was ever even a factor to begin with, since to the best of my knowledge it was already a done deal by the time it was presented with any formality to our group. Consequently, I am really frustrated that we as a group are now proposing to take on yet another job/responsibility (ie addressing the inadequacies of this tool) that we will not be getting compensated for. Just the time we as a group have put in so far dealing with an incompetent tool during our actual real time work day (giving initial feedback, reading about it and opening up and reviewing attachments) probably equates conservatively to somewhere around 450 minutes (~30 people at 15 minutes each) – this is close to $1000 of time we will not get paid for.

I suspect on a daily basis, again conservatively, if we each spend 5 minutes per day fielding unnecessary calls/putting in 5 to 10 more unnecessary EPIC clicks and then collecting data on all of the unnecessary work that we are doing (realistically the time I would think could easily for some escalate to 10 or 15 or more minutes depending on individual patient load and acuity), we are giving the organization free labor of – again very conservatively- around $100 to $150 per day or $700 to $1050 per week. Say this takes a month before it is fixed and running smoothly – conservatively this is around $6000 of our time to fix a problem that we did not create. And it isn’t just our time – it’s nursing time as well. The longer it goes “unfixed”, the more time/money we are all losing, and the less time we all have to actually provide the care to our high acuity patients that the organization expects to provide and, more importantly, we expect ourselves to provide. Common sense seems elusive.

While $6000 in a month (conservatively) is not a critical amount of money in the larger scheme, I think that there is a principle at stake here. Where is the line between being a good citizen and being taken advantage of? If this rollout were an outlier, and if I otherwise felt well respected and valued by the organization as a whole, I would be much more inclined to take this in stride and behave as a traditional “good citizen”. But it seems like the norm has evolved to this place where the organization is free to cut corners and forego due diligence, develop crap, and then use us to road test their crap with total lack of regard for even acknowledging the problem (leaving us to wonder if they even recognize it, let alone whether they will actually implement the appropriate administrative time and resources to address the problem AND take efforts not to repeat the problem in another form).

While I am extremely grateful to S. and G. [a physician partner and clinic manager] for taking efforts to correct this crappy tool, I cannot extend this gratitude to the organization. In fact, I now feel that if I continue to take things like this in stride, I will be anything but a good citizen. I am beginning to feel an increasing responsibility not only to myself and my colleagues, but also to the organization at large, to speak out when I see injustice. George Orwell said, “The most important thing is to see what’s obvious and tell us about it”: I am seeing crap, and I am telling you about it.”

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