Doctor, if you have recently visited with upper hospital management in the plush executive suite, it was most surely you who stood out conspicuously. Being greeted by one of the administrative secretaries, you were asked to be seated and wait along with others, consultants, lower level management, salesmen, business associates, insurance executives and maybe even golf buddies. You were notable as the only one not appearing in sartorial splendor, groomed to the hilt, well rested and adorned in a three-piece suit. You were the person bleary-eyed from the night shift or up all night with an emergency, dressed in a white coat with pockets full of papers and baggy greens or blues. Curious though, it is you, the physician, who is responsible for all of their incomes.

Granted, as healthcare has become a complex, shifting regulatory nightmare with falling reimbursement rates and myriad payment mechanisms, hospital management has become more complicated. Looking for the easy way out of revenue erosion, managements’ expensive consultants have likely suggested reducing costs; and the most important driver of costs in virtually all hospitals is the medical staff. While physician compensation accounts for only 8 percent of healthcare spending, physician decisions account for up to 80 percent of the nation’s healthcare budget. Therefore, to cut costs hospitals must either gain control of their physicians or collaborate with them to create value. With the ongoing obsession to employ physicians, the approach preferred by the occupants of the posh offices of hospital executives is the former, control being the goal.

Regardless of nuance, hospital management and its growing bureaucracy increasingly influence the decisions of their physician employees. How is it possible to transform an independent clinician with years of commitment to developing their craft, caring for patients and working autonomously into a supplicant “worker bee?” Certainly linking compensation to the egregious, impersonal wage equivalent of an hourly worker via some formulaic RVU (relative value unit) is a good start but not enough. However, the lynchpin is to create circumstances that convince doctors that they are not as important as they think they are, just another member of the team. Relegate that precious doctor-patient relationship to peripheral importance or even of no importance at all.

Create physician dependency by introducing complex systems outside of their expertise and make them dependent on such. EMR, other IT, coding and billing puzzles meet this goal. Remember to change these systems frequently, be sure they are costly, idiotically complex, quite unreliable and of course user un-friendly.

Absolutely necessary is designing a variety of schemes to put physicians’ compensation at increasing risk. Population-based decision making according to “evidence based” hospital guidelines must replace professional judgment, intuition, experience and compassion. Promotions, imperiled compensation and any additional physician rewards must rely on these hospital mandates. Ah, yes, just like unrealistically designed productivity standards for assembly line workers, physician productivity standards must be set just out of reach. This may be the ultimate conundrum for physicians.

Here is the one I really love. Administrators are going to give physicians the responsibilities they have asked for; in fact they demand physicians assume these. Then, administrators allocate no authority or provide any tools. For example, physicians, responsible for patient satisfaction scores, have no authority to control staffing, staffing attitudes, the workability or selection of IT, cleanliness, operating room efficiency or even parking.

There must be a hurried goal of driving a wedge between physician and patient. Create a design whereby the patients come to identify the hospital, not a particular physician, as their source of care. Centralized scheduling is one of the magic tickets here amongst others. Phrases such as refer to ortho; refer to derm; refer to peds; demonstrate meeting the desired outcome.

If any of this sounds familiar, do not be surprised. Those who seek to control healthcare, know virtually nothing about medicine and are sopping up ever more healthcare dollars know such tactics well.

If you enjoy economics this might be of interest. Max Weber (1864-1920), a political economist, was a champion of hierarchy. “Precision, speed, unambiguity, knowledge of files, continuity, discretion, unity, strict subordination, reduction of friction and of material and personal – these are raised to the optimum point in the strictly bureaucratic administration.” Then there is the view of the more contemporary Gary Hamel who firmly believes that in order for organizations to prosper bureaucracy must die and that it actually bears key blame for discord. He states, “By their very nature, bureaucracies are inertial, incremental and uninspiring. That’s a problem because today operational efficiency is just the price of entry, a necessary, but far from sufficient, condition for competitive success.” I choose Hamel, but surely, in many hospital executive offices, Weber is still their guy.