Commentary:  In the End, We’ll All Stand a Little Taller

With great promotions come great challenges. In this satirical parable, a new physician leader discovers a fresh spin on the common business concept of being “overextended.”

Dr. Jones walked into the chief medical officer’s office. “I was asked to see you, sir?”

The CMO rounded his desk, extended a warm handshake and smiled. “Dr. Jones! We’ve noticed you’ve led several impressive quality improvement projects lately. As you may know, there are a lot of positions in physician leadership open across the country. And we have a position here we think is perfect for you.”

Brent Beasley

Dr. Jones was flattered. “Please, tell me about the position.”

“Well, first of all, lie back on this table. It may be easiest if I demonstrate exactly what the position will require,” the CMO said, walking him over to a solid oak slab, unfinished and rough.

Interesting, Dr. Jones thought to himself as he looked at the table. “Those aren’t blood stains, are they?” he asked, lying back.

“Oh, don’t mind them,” the CMO said, laughing. “The position we would like you to take is the executive leader for our physician practices. As you know, we have employed several hundred doctors in the health system over the last 20 years. We have a new strategy to integrate their offices into a high-functioning, multispecialty physician group.

“To begin with, we’ll take your right foot and place it in the right stirrup,” which he did. Dr. Jones’ foot had never been placed into a stirrup before, but it was not too uncomfortable — until the straps were tightened.

The CMO continued, “This foot represents one of the primary jobs you must accomplish. You have to control costs.

“The physician practices are operating at a loss to the health system. We think we are losing too much on them. We know that physician practices, particularly primary care, don’t make much money. But we need these practices so that our physicians are tightly …” he pulled the strap on the stirrup tighter, which made Dr. Jones groan a bit, “… aligned with the health system.”

Dr. Jones thought about the issue of losing money on the practices. “Were they losing money when you purchased them from the doctors?”

“Let’s move on,” said the CMO, waving off the question. He grabbed Dr. Jones' left foot and began strapping it into the other stirrup. “On the other foot, you have to keep the doctors satisfied. There is a lot of unrest and dissatisfaction within the practices. The doctors don’t trust the health system very much. Our competitor across town is trying to pick off some of the best and brightest. The doctors don’t think we value them.”

“Do you?” Dr. Jones asked, naively.

“Of course, we do!” the CMO exclaimed. “Without the doctors, there are no procedures performed. And without procedures, there is no income to the health system. Just like in a Toyota auto production facility, there are line workers who are critical to the functioning of the business. The doctors make the cars. If they don’t function at peak performance and efficiency, the health system can’t survive.”

Dr. Jones wasn’t sure the doctors would like being thought of as factory workers. “And the cars are … ?” he asked.

“The cars are the patients, of course!” the CMO said with a smile.

“Of course. That should have been obvious to me,” Dr. Jones said with a nod.

“Let’s take the left hand next,” said the CMO, grabbing him by the wrist. He pulled the hand over Dr. Jones' head and slapped a handcuff on it. “Is that too loose?”

Dr. Jones looked up at his wrist with wide eyes. “Uh, no. I’d say it's plenty tight. Uncomfortable, too.”

The CMO chuckled and patted Dr. Jones on the chest. “That’s what I thought the first time I put on the cuffs. The left hand reminds us that the ever-present eyes of CMS are watching to ensure we are not inuring doctors.”

Dr. Jones bit his lower lip and shook his head. “I’m not familiar with that term, unless it’s like enuresis — surely not urinating on doctors?”

“Ho! Dr. Jones, you have a dry wit. No, it means ‘desensitizing to something unpleasant through constant exposure.’ It also means ‘taking advantage of someone.’ CMS is concerned that health systems would pay physicians an extravagant amount of money to send patients to their hospitals. So, we are very careful to make sure our contracts for employed doctors don’t smack of that!”

Dr. Jones responded with a wrinkled brow, “That seems backward from the definition. If a doctor gets paid a lot of money by the hospital, aren’t they taking advantage of the hospital?”

The CMO shook his head. “Don’t get off track, Jones. Stay with me. Currently, we have doctors on staff who are working at the national 20th percentile of work RVUs but getting paid at the 80th percentile of physician salaries. If we get audited tomorrow by CMS, people around here could go to jail.”

“Hence the handcuffs?” asked Dr. Jones.

“Where was I? Oh, yes, the right hand,” the CMO said as he grabbed Dr. Jones’ right hand, pulling it tight over his head and strapping it to the head of the table. “The board of directors is very concerned that our doctors and hospitals are listed in the yearly top 20 of the U.S. Newsies and Worldly Reporters. They know such designations are critical to their market share in our community.”

Dr. Jones was feeling rather uncomfortable at this point. “Top 20?” he asked. “Does it really make that much of a difference? How am I supposed to impact that?”

The CMO frowned. “I know what you mean. That’s the way I feel, too. But it really is used by our marketing group to lure patients from the guys across town. And, when the market share increases, we use those results to demand more payment from the insurers to care for their patients.

“You can impact that by making sure we recruit the best doctors to work for us, which leads to a great reputation nationally. That means they need to be highly satisfied with their employment.”

At that point, the CMO turned a large crank wheel on the wall, tightening the straps holding Dr. Jones’ limbs.

“Ooomph!” Dr. Jones groaned. “You know, I’m not sure this amount of tension is good for me.”

“Oh, come on, Jones,” the CMO said. “See me? I’m 6-foot-2. When I started in physician leadership at your age, I was only 5-11. One of the benefits, if you ask me.”

Brent W. Beasley, MD, MBA, is medical director for the internal medicine practice and a professor in the School of Community Medicine at the University of Oklahoma-Tulsa.