June 1998

MDs Learn to Become Team Players

Maureen Glabman Specialty Consult

When the leaders of the only two hospitals in Great Falls, Mont., merged last year, physician staffs saddled with long-simmering feuds and caught in turf wars brought their hostilities to the newly formed company. After lots of hand-wringing among directors eager to secure the financial future of the newly formed Benefis Heathcare Inc., they called in organizational psychologist Jack Singer, PhD, of Las Vegas. Singer, whose expertise is in health care, was able to help the physicians let go of their anger and learn to trust each other.

"Dr. Singer brought to the surface the fact that a merger causes stress and stress can be harmful," says Cascade County Medical Society president M. L. Margaris, MD., "You have to recognize and deal with stress, rather than let it boil under the surface."

U.S. manufacturers discovered organizational psychologists (OPs) in the 1940's. Known at the time as efficiency experts, OPs visited manufacturing plants to observe, listen, assess problems objectively, and make suggestions to improve productivity. Their suggestions worked, and their popularity grew. Today, OPs are commonplace in corporations, and as medicine becomes more businesslike, health care providers are also recognizing the value of these specialists. Leaders of physician groups and other health care provider organizations are coming to understand that when staff members fail to cooperate, productivity suffers. Kaiser Permanente, GroupHealth Inc., PacifiCare, hospitals that are part of Columbia/HCA, and many other such organizations have used OPs with success.

By dropping the veils of secrecy to reveal deep-rooted problems of resistance, denial, and reluctance to accept health care change, many provider organizations have created streamlined, competitive organizations that compete more efficiently.

"We're finding enormous support for our kind of help," says Samuel Davis, senior director of health care for Delta Consulting Group, a company in New York that employs OPs. Singer says that his business has "picked up exponentially. In 1994 I worked with five medical groups. Last year I worked with 35."

One measure of OP popularity is in membership figures for the Society of Industrial and Organizational Psychologists, a trade organization in Bowling Green, Ohio. From 1990 to 1997, SIOP's roster rose nearly 40%. And, in an organizational psychology PhD program at the California School of Professional Psychology, in Alhambra, most graduates receive job offers before they have even completed their dissertations, according to professor Michael Jospe, PhD, a consultant to health care groups.

OPs believe the single greatest threat to any group is internal variables. Groups that function well weather changes in external variables, such as government intervention, financial difficulties, and market turmoil caused by increased enrollment in managed care. But when people within an organization cannot work together toward common goals, the group can't succeed and may eventually fail.

"Where the individual's sense of larger purpose coincides with the organization's, there are higher morale and success," says Mary Lynn Pulley, PhD, author of Losing Your Job, Reclaiming Your Soul (Jossey-Bass: 1997). Pulley is also an OP who has consulted with Vanderbilt University Medical Center in Nashville, Tenn.

Singer says sick organizations unable to foster cooperation produce sick employees who experience increased stress levels, low morale, high turnover, burnout, absenteeism, violent behavior, substance abuse, and hypertension. The price tag is increased health insurance costs for stress-related illnesses.

Most often, OP's are hired before or after mergers and acquisitions. The goal is to help disparate physicians used to working solo learn to work as part of a team, to calm fears, and boost morale.

"Getting along is something doctors were never taught," Jospe says. "They're thrown together in a group practice and tensions crop up."

BLENDING CULTURES

Tension causes morale problems, says Cynthia Scott, PhD, of Changeworks, Inc., San Francisco, who consults with medical groups and has written 13 books on OP. "And when groups have problems, they make more mistakes," she says.

When a merger or acquisition is pending, Scott advises managers to plan to address issues of identity, loss, and fear. "Hospitals that merge don't realize that signing the papers is not all they have to do. They also have to blend cultures with different histories and rationales," she says. She suggests that managers involve physicians in decisions and conduct meetings to let them vent their feelings. "If you involve people in the process of change that requires them to alter their behavior, they are less resistant to change," she adds.

OPs are most effective when administrators who call them in have clear goals. "Instead of saying, 'I want people to feel better about working here,' they say, 'I want communication between physicians and nurses to improve,'" says Dorothy Largay, PhD, an OP in Los Gatos, Calif.

OPs and physicians share a similar modus operandi. They both take a patient through interviews or surveys, determine a diagnosis, and prepare a treatment plan. OPs aim to: foster two-way communication, teach how to set priorities, train for new responsibilities, give feedback, eliminate double standards, hold brainstorming sessions that lead to productive solutions, determine strengths and weaknesses, and enhance customer service so that patient satisfaction surveys improve enough to win contracts.

OPs rarely introduce themselves to physicians as psychologists, preferring the word "consultant" so as not to alienate. Surprisingly, reticence is rare. "If the situation within the organization is unpleasant enough, doctors become willing to talk," says John Fennig, PhD, of DRI Consulting, Minneapolis, who works with health care groups. "Where we're not welcomed by physicians, we probably can't help. that's when people disband."

OP fees can run a hefty $350 hourly and $3,500 daily, and success is not guaranteed. "In 20% of cases, the organization is not willing or able to make changes," Fennig says, "because the changes are unpleasant, scary, or too onerous."

Fennig offers the example of a case in which a partner was gender insensitive, and changing that behavior "wasn't in his tool box." Fennig's services were cut short. "I lament those situations because the did exploratory surgery, and had to sew the patient up before correcting his problem," he says.

PREVENTATIVE MEDICINE

Then there are the organizations that seek a quick fix to their problems. One or two visits with an OP may not work if the treatment plan requires a longer duration. The symptoms may be ameliorated, but the underlying systemic problems may remain unfixed.

Forward-thinking corporations call in consultants before problems arise. Such was the case with ProHealt, now a 150-physician primary care group in Farmington, Conn. In 1994, 38 doctors were considering forming a management services operation. They held a retreat and asked William Roberts, a Connecticut organization consultant, to guide them. Roberts, formerly a theologian, was not an OP but had extensive experience in mergers and acquisitions, having worked with Prudential Residential Services when it purchased Merrill Lynch realty in 1989.

"It was the most satisfying part of what we did," reflects ProHealth chief medical officer and founder James Cox-Chapman, MD. Roberts administered the Myers Briggs, a standard personality test. "We found we were all different types, but we had no risk takers," explains Cox-Chapman. "So we had to compensate. We learned that people had different strengths and skills. Roberts made us think about ourselves as a group rather than soloists, and he made it clear we needed to confront change head on."

But OPs can't resolve all problems. Fennig worked with a 200-physician multispecialty group in the Midwest that had among its members a respected and gifted primary care physician. "He was saving a lot of lives, but the testing he was ordering was costing the practice a fortune," Fennig says of the PCP. "I was referred by one of the group's pschychiatrists who wanted someone outside the organization to solve the problem." Fennig assessed personalities, administered psychological tests, and conducted interviews. "Eventually, the physician's spending was curbed, which pulled him outside his comfort zone because he was having to use more clinical judgement and less lab-driven testing. Again, his spending increased, and he could not meet goals. Eventually he negotiated a severance," Fennig says.

Unfortunately, some organizations don't realize their problems are serious enough to ask for help. "What is the cost of frustration?" asks Largay. Adds author Scott, "What is the cost of workers' comp claims, a strike, or angry people making mistakes?"

To avoid the maelstrom of problems that plague medical groups, physicians must learn to cooperate and collaborate, both of which are relatively new concepts to physicians. Under fee-for-service medicine, many physicians worked in solo or small-group practices. Under managed care, physicians are finding they have to work in larger groups. In other words, they need to work closely and collaboratively with many other physicians. Unfortunately, collaboration is not a simple concept to teach.

"The difficulty is that physicians self-elect because they have high needs for autonomy," says Deborah Crown, PhD, an OP who teaches in the business school at University of Alabama at Tuscaloosa. "the profession requires a high degree of autonomy--those who can make choices on their own. But now there are other variables. It's very hard for physicians to decide where they can give up control and where they can maintain control. That's a difficult balance."

Ostensibly, physicians complain about money, space, hours, scheduling, and reimbursement. Behind those concerns are issues related to turf, ego, status, reputation, and deference to seniority, according to Leonard J. Marcus and others at the Harvard School of Public Health and authors of renegotiating Health Care: Resolving Conflict to Build Collaboration, (Jossey-Bass, 1995). The trick is to get doctors to focus on the bigger picture.

"I ask doctors what are the individual strengths of each team member," says Jospe. "this is a simple concept, but it alters their perception about being empowered. I make sure everyone's skills are used to best advantage. If doctors think they're better or more qualified than their colleagues, its hard to get teamwork."

FORTIFIED FOR COMPETITION

Some health care organizations find it's more cost-effective to hire a staff OP than to call one continually for consultation. Three years ago, Lisa Collings, PhD, was brought in to serve Harris Methodist Health System, a six-hospital group in Fort Worth, and with St. Paul Medical Center, a Catholic hospital nearby.

Harris had a managed health care plan coveted by Presbyterian. Presbyterian offered access to a larger physician network to attract larger employers, such as American Airlines, Lockheed Martin, and Bell Helicopter. Harris, and other nonprofit hospitals, were being threatened by for-profit competitors, and at least one hospital was having financial problems.

Collings was invited on staff retreats or initiated talks with groups to understand problems. Her mission: delineate business gaps, and offer tools, such as training, to close the gaps. "Some staffs were very progressive," Collings says, "and were willing to discuss trust and distrust issues. But there were a significant number of holdouts who thought they could continue their careers as soloists."

One clinic she worked with has three physicians and 80% turnover. Each physician preferred to schedule patients differently. One wanted emergency patients scheduled through lunch, another didn't. Each time the staff changed, preferences had to be explained again.

Collings and her staff called a meeting of the physicians to air complaints. "it sounds so simple, but it was the first time these doctors had scheduled time to talk together," she says, "Even when issues can't be resolved immediately, merely acknowledging their presence can be significant."

Although she was frequently frustrated, Collings says, "I look back to a year ago and realize we've come pretty far. I suspect it's an evolution. Now physicians are asking for my services."

OPs agree that not every physician group needs help. "What happens if organizations don't hire us? Sometimes they're lucky. They have natural managers of change. Increasingly, though, consolidations fail because the strategy or the implementation is wrong," Davis says.