When I was young, I heard older folks use the colloquialism “that dog won’t hunt”. The term is a reference to a dog that has not been trained or has lost the inspiration to hunt – a futile effort. I am reminded of this expression when there is a relationship incident wherein either a community hospital (CH) or a doctor expects the other party to do something that seems intuitive.
Sometimes we do get crossways for trivial and minor reasons. This calls for a simple “I’m sorry.” Both parties understand, forgive, and move on. But the causes of most incidents are not simple. The roots of these incidents are deeper.
Cause
These “unmet expectations” are seldom resolved amicably. One of two things usually happens. The parties grudgingly coexist, or the doctor walks away. Seldom does either party win. Coexistence may be the worst of the two outcomes.
Trust is broken. The future work relationship may be tense, awkward, and may discourage staff and/or the doctor. But it rarely gets better. The CH continues to have a doctor and the doctor provides patient care, but the CH never gets the best of the doctor’s and CH staff’s capability. This dysfunction may continue to deteriorate and tarnish the CH’s reputation and the doctor’s credibility. These incidents become irritations to both CH and the doctor who each store them in their respective memories. Each brings these memories out every time an incident occurs in the future. And the level of emotion grows with each successive incident.
And the absence of overt turmoil is not harmony and teamwork.
If the doctor walks but is otherwise competent, this irresolution may result in the loss of a valuable resource and a gap in continuity. Replacement is costly and can be disruptive. Both outcomes erode the quality (customer satisfaction and quality of medical decisions) and efficiency (revenue and/or cost) of patient care. The financial impact may be subtle and difficult if not impossible to measure and know.
Choices
Who is at fault? Both. One initiates the conflict. The other fails to reconcile and resolve the matter.
From another perspective, it doesn’t matter. The outcome is the same.
Who should take the first step? Both. Does this happen? No.
It takes two parties to disagree; each with a different point of view, often an emotional point of view. So why do these incidents occur?
CH Expectation
From the CH’s point of view, doctors are intelligent, highly trained in the field of medicine, and paid well. It is easy to expect them to know and do things that seem intuitive and much less complex than medicine. Residency is about medicine, not customer service and satisfaction, and the economics or financial management of medicine. This is a people-to-people relationship matter, and the root cause is usually intrinsic to one’s personality. Our expectations should have nothing to do with intelligence, training, and pay.
Doctor Expectation
From the doctor’s point of view, he is trained to provide patient care. His role is medicine. He is not trained in customer service and financial and economic implications of the practice of medicine. His perspective is that if service and economics were fundamentally important, he would be trained in these along with medicine. These responsibilities belong to the CH.
But I would argue that hospital staff and the doctor should both be more engaged in active communications that improve patient safety and facilitate improved medical decisions and treatment more timely.
Is there any CH structure that aligns the doctor and CH staff? Performance initiatives in CHs promote competition between doctors and nurses. Satisfaction surveys report separate scores for doctors and nurses. And participants of any sport compete against each other if it keeps score by the individual. Patient care is a team sport. We should provide team medicine and patient care.
Conclusions: Unexplained and unmet expectations “won’t hunt.”
Impact
This article is not a criticism of CHs. Nor is it a criticism of doctors. It is a criticism of “unmet expectations;” historic relationships in which the doctor and CH compete, and often distrust. The current system of patient care and interpersonal relationships is broken. But they must not be adversarial. Most organizations spend little or no time coaching doctors AND staff about customer satisfaction and economic outcomes. They just expect each other to know what to do. I too was confronted with my ignorance several years ago when I read a book titled Telling Ain’t Training, Association for Talent Development, copyright 2011.
The CH will never be any more successful than the collective efforts of its doctors and clinical staff. Remember, doctors control 90% of your revenue. CHs need doctors, doctors don’t need CHs. If surgeons figured out how to do surgery in their offices, doctors will figure out how to provide more acute services in their offices. One can disagree with me. But only doctors can write an order.
