Doctors and hospitals must play together or risk extinction

As recently as five or 10 years ago, if a hospital made a doctor unhappy, the doctor could just pick up his marbles and move to another hospital. But the rules and cultural norms are changing, Dr. Bob Wachter told FierceHealthcare. Among his many titles, he is chief of the Division of Hospital Medicine and chief of the Medical service at UCSF Medical Center. He is also a national evangelist for patient safety and healthcare quality.

Now, the hospital across town may be just as intolerant of doctors who act like three-year-olds or who fail to comply with house hand hygiene or time-out rules, he says.

We are going through a transition, Wachter says. The phase we're leaving is one in which the doctor was king and professional autonomy was the dominant value for physicians and hospitals were places they worked. Hospital administrators were there partly to keep the doctors who bring in the patients happy.

We're moving to a world where hospitals, more than doctors, are being held accountable for safety and quality. "You have a clashing of tectonic plates here where the hospital is under the gun to try to improve quality and safety," Wachter says.

With the Joint Commission or Medicare and other stakeholders holding them accountable, the hospitals have to figure out how to get everyone to play together or risk getting dinged on a Leapfrog report card or fail to pass a Joint Commission survey.

Getting doctors to play is hard because in many cases, the doctors are independent entrepreneurs who don't work for the hospital and in some ways compete with the hospital. Wachter predicts the tensions between hospitals and doctors will disappear over time. Here's why.

In a market where hospitals and doctors increasingly compete on safety and quality, the hospitals and doctors that figure out how to play in the sandbox well will complete more successfully, Wachter says. Those that don't manage to work together may suffer. Hospitals could be harmed and the doctors themselves could find their livelihoods compromised.

"And I think that's good," Wachter says. "Healthcare systems where the doctors and hospitals have learned to work together to provide the highest quality safest care should be the ones that do the best, get the most patients, get paid the best, and look best on reports."

Certain kinds of behavior that were tolerated over the years are now no longer culturally acceptable, he says. For example, racist or sexist comments that were laughed off or simply raised eyebrows in the OR 25 years ago no longer fly. And a doctor who comes into a hospital and smokes, which was the norm 30 years ago, would be considered crazy now.

Those doctors who rant about or simply fail to follow what others might see as perfectly reasonable patient safety rules may be headed for extinction.

Their cranky behavior, which has bubbled up in comments to this website, is what Wachter calls "the last screams of a dying breed of doctors who are used to a set of ground rules that were very different." People liked being on pedestals and liked being able to behave any way they wanted. "But we have begun to realize that does not lead to the outcome we want," he says, "which is the highest quality and safest care, so we can’t tolerate it." - Sandra

Editor's note: This is part  one of a two-part series.