The hospital-physician relationship is a delicate dance. If one steps on the other's toes, it can make or break success — particularly in an era of reform that calls for ever-closer collaboration. To learn more about what helps or hurts alignment, we asked 13 physicians for their unfiltered opinions about their hospitals and CEOs.
Editor's Note: Physician and organization names have been kept anonymous. Responses have been edited lightly for length and style.
1. Anesthesiologist at a 795-bed health system in the Southeast
Question: What do you like most about your organization?
"We are a physician-led, evidence-based, data-driven organization, with a board and senior executive team that values engagement around quality and safety. It has alignment around ideals that most of us have aspired to from our earliest days in school and training. The system has a great core strategy that resonates with doctors and patients."
Q: What do you dislike the most?
"The vast proportion of physician compensation is built around productivity metrics. While satisfying compliance and good business practices, these emphasize delivery of services more than transformation of care. I would like to see the emphasis in compensation shift to value rather than volume."
Q: What do you wish the CEO did differently?
"Our CEO maintains great balance among the many stakeholders and navigates the cross-currents when opinions don't completely mesh. Some regard this approach as indecisiveness, and physicians in particular can see the pace as too slow compared to medical decision-making they are accustomed to in the field. Allowing time for resolution can be very effective."
2. Cardiologist at a 300-bed hospital in the Midwest
Q: What do you like most about your organization?
"I like that it's on the smaller side. The hospital has the ability to be more personable than the big universities. They [administrators] are supportive of new and upcoming technology for the doctors to use."
Q: What do you dislike the most?
"Sometimes the administration gets lost in what's involved in day-to-day patient care. They don't understand what people on the frontlines are doing — they don't see the small things we do on a daily basis. Leadership also needs to find a way to be more involved in making sure there is enough staff and making sure they are doing enough to keep the staff happy."
Q: What do you wish the CEO did differently?
"I would like [him/her] to have a more clear understanding of what's involved in taking care of patients every day. The CEO could do more rounds, but the problem is when the CEO walks around, everyone is sure to act ship-shape. But sometimes we have just one nurse for 12 patients — there's not enough staff. There isn't enough help for the acuity of care."
Additional comment
"Healthcare has become much more complicated in terms of delivering quality care while containing costs and supporting the future and technology that's out there. The government is making it harder for doctors and hospitals to function with all of the ever-changing rules, and ultimately this can be detrimental to the patient."
3. Surgeon at a 260-bed hospital in the Southwest
Q: What do you like most about your organization?
"I like the history of the institution."
Q: What do you dislike the most?
"Unfortunately, despite its inspiring history, things at the organization have really deteriorated in the last few years. Once upon a time, it was an integrated system. It included a hospital, health plan, physician group, labs, pharmacy — everything. It was a one-stop shop for patients. Now, there is no more health plan. The laboratories are owned by some other company, the pharmacies are owned by another company. Across the country many of the big hospitals are trying to become more and more integrated, while this hospital is beginning to spin off all of its components. Before, patient care was stellar. Now it is quite fractured, and this makes it more challenging for the patient.
The second part is it is a for-profit system, so unfortunately the focus on profit diverges from the more central focus that I or another clinician would have — on the patient. Every hospital says they are all about patient care, but hospitals practice and subscribe to this pledge to varying degrees."
Q: What do you wish the CEO did differently?
"I wish they would renew the focus on integrating patient care and make it easier for patients to get the care they need. While they are in the business of making a profit, I wish there were a more sincere and genuine drive — not just a theoretical focus — on patients other than for advertising purposes."
Additional comment
"You hear from patients that healthcare is becoming more expensive. It's also becoming harder to access, and I'm afraid it's losing its human touch for compassionate care. Once upon a time, healthcare was a mission. Now it is beginning to truly look like a business enterprise."
4. Anesthesiologist at a 200-bed hospital in the Southeast
Q: What do you like most about your organization?
"I work at a close-knit community organization where everybody knows everybody. Patients receive very personalized care in a friendly environment. Working here is a lot like primary care, even though I'm a specialist. Since our hospital is so small, I'm oftentimes the first line in dealing with a patient's health."
Q: What do you dislike the most?
"I dislike that there are treatment limitations due to the hospital's small size. The biggest question I face every day is whether ancillary care patients who need more radical surgeries should be sent to a bigger hospital than ours. If you turn a surgical case away, the hospital and physician don't earn money, so sometimes hospital leadership sees me as an obstacle or product of financial inefficiency. That dilemma has weighed on me philosophically."
Q: What do you wish the CEO did differently?
"The CEO is turning the hospital around and trying to meet the needs of the patient population within financial constraints. Our 12-bed intensive care unit is managed by primary care physicians and surgeons. If a physician is in the OR, then they're not available to care for patients. Our CEO recently hired an intensivist to cover night call from 7 p.m. to 6 a.m. when practitioners in the community are not readily available."
Additional comment
"It's hard to see a patient, go through their whole medical history, become invested in their case and then send them away to a larger hospital. The hardest case you ever do is the one you never do."
5. Plastic surgeon at an 848-bed hospital in the Midwest
Q: What do you like most about your organization?
"It's hard to say because there are so many things I don't like about it. Perhaps one of the things I like the most is the physicians' lounge. It provides good food and a nice atmosphere, but I would trade that in a minute for so many other things I don't like."
Q: What do you dislike the most?
"I don't like the authoritarian way the hospital operates. The rules and regulations interfere with patient care and take away physicians' independence. Leadership takes advantage of physicians and makes them do inappropriate things that are adverse to patient care. The hospital hires outside physicians and will terminate contracts if they don't act subservient to leadership."
Q: What do you wish the CEO did differently?
"I wish they wouldn't buy physician practices. I also wish they would honor and respect physician autonomy."
Additional comment
"Leadership expects physicians to refer patients to other clinicians only within the health system when in some cases it may be in the patients' best interest to be referred elsewhere."
6. Geriatrician at a 500-bed hospital in the Midwest
Q: What do you like most about your organization?
"One of the nicest things about working with a large organization is increased access to specialty care. Having that access for patients to see any specialty physician is so much more seamless. We have the ability to consult other specialty physicians without patients leaving our office. If I have a question for a neurologist, I can ask for his or her recommendations, and it saves the patients a lot of time. I also like the research opportunities, which can translate to practice changes. Lastly, I like that none of the patients are turned away if they can't pay."
Q: What do you dislike most?
"The biggest challenge would be — just because my organization is so big — when I want to make changes at the personal level, I can't just do it. It has to go through a big committee. And everything has to be standardized, even putting up a poster to inform patients about a new medication. It becomes harder for physicians to make those changes.
Since my organization is large, it is compared to other large organizations, and there is a lot of pressure to meet quality metrics and improvements. That means physicians are asking patients about colonoscopies and other preventive care measures when someone comes in for back pain. It takes away from patient care, so in some ways it can be negative. However, sometimes it's making sure every one gets preventive care no matter what they come to the hospital for, which is good."
Q: What do you wish the CEO did differently?
"We [physicians] hardly interact with the CEO. My CEO is fairly new and a physician, so we're hoping the individual will have a better understanding of what it is like to practice and make more practical changes. I think most CEOs are very receptive to opinions. However, since we don't interact on a daily basis, I would not consider going to my CEO with recommendations, as they would redirect me to someone else closer to me."
Additional comment
"I really enjoy working at my organization. Even if I need to relocate, I would always look for a large organization. I like that security. I don't have to worry about medical records, and we have lots of resources. Physicians can focus on patient care."
7. Emergency department physician at an 80-bed hospital in the Northeast
Q: What do you like most about your organization?
"I like the overall character of the organization. We have a mission to take care of the poor, uninsured and homeless — we take care of everyone. I also like the people who work here. We treat patients better than we know some of our competitors do."
Q: What do you dislike most?
"Sometimes the organization can be a bit small-minded and bureaucratic. There are some difficult people. Even in a good organization, there are difficult people you have to deal with. Nobody is 100 percent."
Q: What do you wish the CEO did differently?
"On the whole, I like the CEO. I wish I had a more direct line to the CEO; now there are layers in between us. I wish the CEO was more accessible to physician leaders and physicians in general. There is someone in between us now, and that person is difficult to deal with. Everything is filtered through that person before it gets to the CEO."
Additional comment
"The hospitals that do well engage their physicians in operations and planning and don't dictate things. My hospital has done a good job of that. Sometimes physicians don't realize hospitals want their input."
8. Orthopedic surgeon at a 700-bed hospital in the Midwest
Q: What do you like most about your organization?
"I think the hospital I work for is a phenomenal institution. As a whole, it's incredibly progressive and both the faculty and upper level management understand the changes in the healthcare industry and are adaptive to those changes."
Q: What do you dislike most?
"The institution is large, so some of the minute details of the day-to-day work get lost in the bigger picture. It's also a very specialized center — it isn't necessarily primary care-based, and that may not be what's best for the future. It's still an incredible institution in terms of its attention to private practice and academic needs."
Q: What do you wish the CEO did differently?
"Our CEO is a physician himself, so he really understands what other physicians need. My only complaint is as he's getting older, there isn't as much of an emphasis on face-to-face interaction with other physicians. It doesn't detract from the work that he's doing, but it's something I wish would change a little bit."
9. Orthopedic surgeon at a 900-bed hospital in the Midwest
Q: What do you like most about your organization?
"Our institution has a really good reputation in the medical field, which means there's a number of opportunities to pursue research — specifically surgical research. The facility is constantly introducing new technology and innovations. But its reputation is key; patients recognize the name and are much more willing to participate in studies. It also provides a sense of security for them, knowing their information won't be shared."
Q: What do you dislike most?
"The institution is separated into two entities. There's the medical school and there's the hospital system. There's this internal struggle between the research/education aspect and the profit, corporate side, and physicians are stuck in the middle. We're employed through the hospital, not the university, so whenever the executive management communicates with us, the metrics are entirely corporate-driven — such as the number of patients we see daily, etc. As a result, the research/education falls behind. There needs to be more of a balance between the education and profit sectors. It feels almost like we're replaceable cogs in the machine. You can't expect physicians to be engaged, it just doesn't work like that."
Q: What do you wish the CEO did differently?
"Our CEO is completely removed from our daily operations and any sort of interaction with the physicians that practice here. If you put our CEO in a room full of doctors, I can bet you that they won't know who he is and he won't know which doctors are actually employed by the hospital. There is this huge disassociation between C-suite management and physicians. That division doesn't necessarily exist in smaller hospitals, but it's much more common in bigger ones."
Additional comment
"I believe employment does not equal engagement. Surgeons are different from other specialties, like general medicine or emergency room physicians. You can't expect automatic engagement. All these deals between doctors and upper management crumble because physicians don't care. You have to figure out a way to make them engaged with in the hospital's mission. If your goal is to make profit, profit, profit, figure out a way to make the physicians more invested in making a profit — pay them more. If your goal is to be a leading research facility, figure out a way for your doctors to want to do research."
10. Orthopedic surgeon at an independent specialty group in partnership with Midwestern hospitals
Q: What do you like most about your organization?
"I like that our organization is able to provide a complete spectrum of care. Everyone employed here has the same goals, and we have the resources to provide patients with that type of care."
Q: What do you dislike most?
"My biggest issue is the amount of paperwork we have to do; it doesn't improve the quality of care we're able to offer our patients. It's burdensome. Also, insurance companies don't want to reimburse us, it's almost a game they're playing. [Tests and] procedures get bundled together so the insurers pay us less. As physicians, we're increasingly paid less for the same work while the cost of doing business keeps going up. All of it really hinders our ability to provide patients with the care they deserve."
Q: What do you wish the CEO did differently?
"A lot of CEOs have a bias based on past interactions with physicians. They're not willing to alter their business plan or model. For example, we work with a health system that will only work with physicians employed by their facility — they won't work with independent physicians. I strongly believe that one model doesn't always work; you need to modify it to fit the situation and you need to be open to modification."
Additional comment
"The way the industry is going, [if] physicians aren't independent, they become a commodity. They're bought and sold in the market. If you lose that independence as a physician, you can't make decisions. Large health systems may not have patients' interests at heart. Instead of quality, profit and loss is what drives most systems, and because they're so preoccupied with cost, they may not hire the best physicians because the best are not the cheapest."
11. Employed physician at an 800-bed hospital in the Midwest
Q: What do you like most about your organization?
"What I like most about the organization is the ability to interact and work with folks who share the same mission and vision of the future. That helps a lot. It helps that everybody is striving toward the same goal, rather than people wanting to go in their own direction."
Q: What do you dislike most?
"Like every big organization, there is bureaucracy. It is partially inevitable, and I guess what attracts people to smaller organizations and private practice is the fact that they don't have to deal with bureaucracy. Sometimes you understand why decisions are made a certain way and sometimes you don't."
Q: What do you wish the CEO did differently?
"Balance the needs of the system with the local needs of different sites. In my humble opinion, there are some decisions and some initiatives that benefit a lot from standardization across sites and there is no reason to have variation. But, there are some local idiosyncrasies that are unique to certain sites. The strength of a CEO is to know how to balance both."
Additional comment
"My wish is that more hospitals are encouraged to be at the forefront of healthcare. Often our hospitals tend to react to changes, whether in the legal or commercial environment, rather than lead and make that change happen.
The other thing is hospitals need more of a focus. Hospitals have traditionally been the place to go to when someone is sick, but I think it would be great if physicians could really focus on population health and keep patients out of the hospital."
12. Pediatrician at a 400-bed pediatric hospital on the East Coast
Q: What do you like most about your organization?
"Everything we do is team-based. We always have at least two sets of eyes on the child when taking care of them. When we have a difficult situation, which is common, we have someone there to help — either someone with more experience or we have the opportunity to teach someone with less experience. I've been at three to four hospitals over the last 10 to 15 years, and that's something I really appreciate here."
Q: What do you dislike most?
"As a physician, we have a lot of oversight from the administration, as well as from the more senior physicians. There is a lot of standardization. They try to make us abide by a very certain way of delivering care. Sometimes there's not a lot of flexibility in the way we have to practice a certain technique, or in my case, deliver anesthetics. The second big issue — it's kind of a two-edged sword, because it's also a strength — is that we focus a lot of time and resources on each patient. Every child gets a full amount of care, to fulfill a certain criteria, before they go on to the next place in the hospital or get discharged. The most cost-effective measures are not necessarily employed to deliver care."
Q: What do you wish the CEO did differently?
"In terms of patient care, there's not much more that can be done. In my experience both in and out of the operating room and interacting with consultants around the hospital, patients get the best care possible in terms of the attention, treatment and degree of detail. That said, in terms of timeliness, sometimes there are a lot of delays in care because it's a very busy hospital. We are dependent on specialty-specific care, but often a patient has a health issue that affects multiple organ systems, which requires three or four specialists and several different teams. Our team-based approach could be improved over time. Our chair could foster it such that we have more oversight of perioperative care, for example. As an anesthesiologist, I could be more responsible for patients after care and be there to answer questions that may otherwise take three or four people to answer.
In terms of physician workload — I'm interested in academics. I value time for educational activities, and I am able to spend 60 percent of my time on clinical activities and 40 percent on research. I really like that research time the chair gives us. From a clinical standpoint, we need more leeway in terms of calling for a quality improvement or an initiative from a workflow perspective. Although it is important to be stringent on how care is delivered, we don't have the leeway to practice how we would like."
13. Employed physician at a 1,500-bed academic medical center in the Midwest
Q: What do you like most about your organization?
"The acuity of patients, the quality of care, having all of the resources under one roof, the inquisitive nature of the colleagues and the desire to tackle tough problems. There's not just one thing."
Q: What do you dislike most?
"I would say bureaucracy and impersonal relationships. I don't know one, two or three cardiologists, or gastroenterologists or podiatrists. It's impersonal and siloed. Colleagues don't need to intermingle because of the size."
Q: What do you wish the CEO did differently?
"To be forward-thinking rather than reactionary. For instance, we respond to changes legally or with payments, or changes to the way that care is delivered after the fact. As one of the U.S. News' top hospitals, we can really be the people who start change, do things differently and look at problems differently. We are in that position. Perhaps that's one missed opportunity."