On Being Physician-centric
If you find yourself examining patient flow in an emergency department, you are likely to come across a new vocabulary of terms used to describe behaviors. “Physician-centric” is a description I have been hearing more and more, but not in the manner it was originally intended.
The term “physician-centric care” was originally coined to describe the healthcare business model in the US. This type of system places the physician in the driver seat of a patient’s healthcare, making the physician the center point of decision making AND by default, responsible for the flow of healthcare dollars. The idea being that an alternative model, like patient-centric care, provides better results at lower costs with improved outcomes. Today, the term is used in a variety of settings to describe any process where the needs of the physician are placed in the center, or at the highest priority. Depending on the process, this may be a good thing, but the connotation has been negative.
I was recently in a conversation discussing the ailments of an emergency department when someone mentioned, quite negatively, that the culture in place was very physician-centric. When I probed with a few questions, I discovered the term was being used to describe a set of behaviors that were perceived to be impeding patient flow. Specifically, this person was concerned that patient placement in the department was being dictated by physician workload. They believed if physicians were simply taken out of the equation, patient flow would improve. Is there a problem with that view point? In short, yes. I’ll explain.
Improving physician workflow gives a physician more time to spend with a patient, more time to mentally process a patient’s presentation and diagnostic results, and a more comfortable atmosphere for decision making. All of these lead to safer and better delivery of healthcare, AND improved job satisfaction for the physician, not to mention improved patient satisfaction. The critical decision is when to insert workflow into the conversation. In the scenario above, the department had open beds with available staff but patient placement was being dictated by what the physician was doing in a given treatment area. Labeling this behavior as “physician-centric” and dismissing it was the wrong approach. A deeper examination of the workload, acuity, and physician staffing was necessary. But this exercise isn’t unique to physicians.
Healthcare delivery is personal. There is a human being in need at the core of the system, and that system is supposed to provide care in a personal and healing manner. However, it is a system which means it is susceptible to all of the problems that can impede its goal. These can be mechanized, like dependence on diagnostic machinery or electronic health records to preform at peak capacity at all times; or they can be human, like asking staff to report problems, ask for help when overwhelmed, or just follow guidelines. Operational efficiency is important and can lead to significant gains and there is a whole market built around efficiency in healthcare (lean processes). Achieving efficient workflow for all those in the system results in significant gains, and in healthcare that means safer, better care for patients. In achieving that goal, it is easy to take a term like “physician-centric care” and misunderstand it’s meaning, believing that attention to physician workflow is unnecessary or worse, bad for patient care. In fact, the opposite is the case.
Improving workflows for all staff members (physicians included) results in improved patient flow, reduced errors, fewer distractions, and safer, more efficient care. It is very important to consider how any change impacts your staff as much as it impacts the patient. If a change results in a perceived improvement for a patient but negatively impacts your physician, nursing, or ancillary staff, it is doomed for failure. Careful implementation and consideration, weighing effects on both the patient and the physician (insert “nurse”, “tech”, or any staff member) is important. So how do we achieve the balance?
At the start of the process, make sure all parties are aware that impact on staff is important; ALL staff. Set a standard that decisions that impact workflow should be examined by those staff members prior to implementation. That allows them to speak to the process and present concerns or clarify the impact on them. In addition, do not discount the effects on one type of staff member. “The physicians are going to complain about this… they are focused only on themselves” … if you hear or speak those words, you have a problem well beyond simple patient flow. Pull a physician into the discussion. Better yet, invite one you like at the start of the process. Make them a part of the “team” and if you can not find a physician champion to walk the process with you, ask questions: Why is there no physician involvement? Are you missing something historical? It is not normal for physicians not to care about their work. Get them talking; ask about frustrations. It doesn’t take long but the gains are large.
When you have clarity about the impact, begin discussing losses and gains. It is very likely that someone will have to give a little for any new process but if the gain is significant, it may still the right thing to do. Make sure the gains are well articulated and everyone’s voice has been heard. Do not alienate any part of your staff, especially since we know the best systems utilize a cohesive team. So, give up the use of the phrase “physician-centric” and start asking more questions.