The implications of practice guidelines for physician medical malpractice liability

Medical practice guidelines are increasingly coming into use, and as more and more physicians are presented with guidelines to follow in the delivery of health care, the question arises of whether these guidelines will become instruments for imposing greater medical malpractice liability on physicians. This column will briefly describe what guidelines are, how they are developed, and how they have been and may be used in litigation against physicians, hospitals, and other health care institutions. As hospitals and managed care organizations continue to implement guidelines, the role these guidelines play in malpractice cases can be expected to increase. It appears, however, that, although guidelines will contribute to the establishment of the standard of care by which a physician's actions will be measured, they are not likely to become the standard that all physician treatment decisions must meet.     

Physicians and economics: a commentary

This article discusses the physician in the United States in relationship to economics. Because economics forms the basis of most of the debate concerning health care in this country, it is important to look at the physician's background, position, and future as they relate to this important area. Eight economic encounters met by the physician are considered: the physician's relationships with knowledge, patients, peers, hospitals, medical technology, malpractice, managed care, and the future. The purpose is to encourage discussion and introspection and to suggest possible future avenues of education and training to address more completely the economic necessities that now are so closely entwined with the profession.     

Helping physicians manage challenging patient encounters--Part I

In today's rapidly changing and challenging health care environment, where physicians have limited time with patients who have become more knowledgeable and demanding, the relationship between physician and patient has extra stresses placed on it. Medical malpractice litigation has increased as the physician-patient relationship has become more complex because of those stresses. In this article, some of the problems and effects of poor physician-patient interaction are explored, and a program designed to develop existing physician skills for successfully interacting with challenging patient encounters is described. In the January-February 1991 issue of Physician Executive, the author will describe the method of implementing the program in an organization.     

After the revolution: the physician executive of the future

There is a revolution in health care occurring in our midst. The roots of this revolution are explored. The physician executive of the future will need a new set of skills because the health care system will change. This new, evolving set of skills includes being: Savvy about business; simultaneously employer- and customer-focused; and technologically driven. This manager must be a team builder rather than a lone ranger. These skills are learnable, just like piloting a plane or doing a surgery. None of us was born with the skill to practice medicine any more than we were born with business skills. While many physicians are depressed by the present health care climate, feeling a loss of power and a loss in spirit, the vision of the physician manager must carry them and the organizations they build forward through uncharted waters to a future which is every bit as exciting as our past.     

Clinical reengineering. Integrating medical and operational management

In the continuing push for cost containment in health care, many organizations have turned to cost reduction methods that fundamentally change the way care is delivered. As health care organizations continue to make financially-driven staffing changes that impact patient care, medical leadership must take on greater responsibility for operational management. Physician executives are uniquely qualified to take on leadership roles in work redesign, and must do so to ensure excellent and fiscally-responsible patient care. This article presents a proven methodology for work redesign that helps physician executives apply their clinical skills to operational management in designing new health care delivery models.     

The Bonus Scheme,Motivation Crowding-out and Quality of the Doctor-Patient Encounters in Chinese Public Hospitals

Methods of paying health providers have been extensively studied in health economics. Bonus as a powerful incentive has been widely used to boost staff morale and improve productivity in hospitals. This may, however, also create unintended consequences. This study analyzes primary data collected from a physician survey in China and demonstrates that the extensive use of quantity-based bonuses has not only led to the provision of unnecessary care but also crowded out physician’s intrinsic motivations, resulting in a decline in the quality of services. More appropriate physician remuneration mechanisms must be introduced in China’s ongoing health reform.     

Physician leadership. The time is now

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.     

Physician and nonphysician managers as decision makers: are the differences justified or just an illusion?

If the cost of health care is to be curtailed, it is necessary to understand physician behavior and decision making. Not only is physician decision making critical from a clinical perspective, but, as the number of physician executives increases, they must be able to integrate their clinical expertise and management skills into the business context. This article explores differences in decision making methods between physician and nonphysician managers.     

Making a match: inexperienced physician executives and the job market

Hospitals and other health care organizations are adding physician executives at such a rate that demand is outstripping supply-there are more opportunities for seasoned physician executives than there are physicians with track records as medical managers. It is possible that hiring management will have to consider the employment of a physician who wants to be in management but has no track record as a physician executive. In some cases, it may even be preferable to employ a neophyte physician executive, especially when the physician is a respected clinician already on the organization's medical staff. In selecting such a physician, however, an evaluation must be made of the probability that the physician will be successful in the new role. The author points to 10 criteria that the hiring organization should observe in hiring inexperienced managers.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

The remote practice network: new concept in health care delivery.

It is widely acknowledged that a trend toward greater competition is creating dramatic changes in the way that health care is provided in the United States. Physicians and hospitals, in particular, face a difficult period of adjustment as the nation's health care system increasingly turns toward the competitive model. Physicians, particularly those in leadership positions, must meet the challenge of competition by developing and implementing effective coping strategies. Medical directors and other physicians in key leadership and decision-making positions have a responsibility to their institutions, their patients, and indeed their own careers to recognize and understand the implications of current trends in health care delivery. This article discusses an innovative approach to competition in today's challenging health care marketplace.     

Reducing litigation costs through better patient communication

The most common cause of malpractice suits is failed communication with the patients and their families. Explore ways that better communication could lead to fewer malpractice claims and allow health care organizations to reduce litigation costs.     

Physician payment in Canada, Germany, and the United States

As the debate about reforming the U.S. health care system intensifies, interest has focused on three alternative delivery systems: the predominantly private-sector model in the United States, the provincial-government health insurance model of Canada, and the social insurance model of Germany. The organization of physician payment is an important part of all these health care systems. To maintain an affordable system that delivers high-quality care, payment to physicians must be sufficient to attract and maintain an able group of doctors, while not exceeding an amount that the country can afford. In this article, these three systems will be examined, and an attempt will be made to apply the lessons learned from Germany and Canada to the direction of physician payment reform in the United States.     

Will physicians replace MHAs?: reflections from Australia

Tom Weil, in the preceding article, sees the physician executive playing an increasingly significant role in negotiations between payers and service providers, in offering the public acceptable explanations for the inevitable changes in the provision of care, and in developing more cost-effective methods of delivering high-quality health care at affordable prices. Effective involvement of physician executives will be facilitated by their having received professional training somewhat different from that of the traditional MHA. How do these prognostications relate to the health care scene in Australia? Factors that must be taken into account in considering their applicability to Australia include differences in the structure and management of the Australian health care system, the current state of that system, the background of the leadership that makes the key managerial decisions in the Australian system, and emerging trends within the system.     

Mirror, mirror on the wall: reflections from failure to establish a truly uniform national health care policy

When the author gazed into the proverbial mirror and asked if the U.S. health care system was the fairest of them all, it shattered. In this article, Thompson tells why the system is broken and what failure to fix it means to physician executives. He suggests that we, as Americans, must reinvent ourselves by realigning our value systems and and stifling our obsession with profit before trying to reinvent health care.     

Behavioral quality assurance: a transforming experience

The captains of the health care industry are leading a transformation in health care. Increasing numbers of physician executives are acquiring the knowledge, skills, and attitudes essential to both the science and the art of management. If they wish to practice the art of management at a high professional level, however, physician executives must be willing to experiment with their behavior in interactions. Change and growth in this aspect of human nature will also bring them face-to-face with their self-images. More important, attention throughout an organization to behavior toward one another will have a significant bearing on the quality of the organization's services to clients.     

The future of medical practice

Managed care of some kind will dominate the future of health care, but the unresolved crucial question concerns ownership of the managed care plans. An investor-owned managed care industry now holds sway, but I do not expect it to last very long. In the long run, physicians must be in charge of medical care, but they must live within budgets and be accountable to payers and to their patients. The only solution that makes sense to me is one based on multiple local physician networks, organized on a not-for-profit basis. I predict that staff and group-model HMOs will be the mainstay of the medical care delivery system within a few decades.     

Physician leadership. Learning to be a leader

As the business role of health care delivery expands and complex reform is imposed, physicians must assume leadership roles and imprint medical expertise on business dynamics. Before the end of this century, health care and its delivery will likely become unrecognizable to those who ended their practices only a decade ago. Traditional management will wither away to be replaced by self-managed, self-trained, and self-motivated workers, no longer employed in jobs but working through processes, projects, and assignments in integrative health care delivery systems. Becoming a leader is an active and arduous process that can no longer be approached haphazardly. To be effective, the physician must plot a course with clear and calculated intent and effort, which requires acquiring organizational tools and administrative skills to innovatively alter medical care for the good of all.     

The 7 habits of highly effective medical directors

Like the well-known 7 Habits of Highly Successful People, the seven steps for successful medical management outlined in this article offer an inspirational guide for physician leadership in today's chaotic health care arena. Setting a vision, communicating the vision, and leading employees to realize the vision may sound like the simple characteristics of any leader. True leaders, however, must be prepared to delve deeply into their health care organizations. They must understand the inner workings of their committees and develop positive relationships with the staff. They must provide the technical tools necessary for the staff to work toward the vision, and understand the measured steps that managers must take along the path to achieving success for the entire organization.     

Economic feasibility of a primary care practice

To make informed career decisions, the new physician must acquire basic skills in medical management and health care economics and learn how to evaluate the potential survival and growth of a primary care practice. The authors have developed a model designed to aid physicians in determining the economic feasibility of establishing a practice in a specific community or joining an established practice.