Shut Up and Sell – the Corporate Physician’s New Motto?

Evidence has been seeping into public view about the extent physicians who sign up to take care of patients as corporate employees give up their professionalism.

Shut Up…

In April, 2013, Medscape published an article whose striking title was “Can You Speak Out Without Getting Fired or Being Labeled a Troublemaker?”  The answer was basically “no.”

Physicians often see problems at their workplaces relating to patient
quality of care, financial practices, mistreatment of staff, and other
issues. But as more doctors take jobs as employees of hospitals, medical
groups, and other large organizations, they increasingly face the same
dilemmas as millions of other working stiffs. When they come across
actions or policies that they don’t think are right, they have to decide
whether it’s worth it to speak out and get labeled as a troublemaker —
or perhaps even get fired.

 Across the country, a growing number of physicians are indeed losing
their jobs — and often their hospital staff privileges — after
protesting employment conditions. Such complaints may involve patient
quality-of-care problems, short staffing, misallocation of funds,
improper financial incentives, fraud and abuse, discrimination, overuse
or withholding of medical services, or other misconduct, say organized
medical groups, employment attorneys, and physician recruiters.

Of course, physicians swear oaths to put the needs of their individual patients first, and doing so within a large organization might well involve protesting conditions and practices that may affect the quality of care or even endanger patients.  But woe unto physicians who try to fulfill their professional responsibility when doing so goes up against the top executives to whom the physicians must now report.

‘We were naive when we went into this,’ says Maria Rivero, MD, who with
her professional colleague and significant other Derek Kerr, MD, filed
administrative complaints against their long-time hospital employer in
2010. ‘We thought if we just brought it to people’s attention, they
would fix the problem and leave us alone. But if you blow the whistle on
high-level executives, you need to prepare to be harassed and lose your

Even working within the system to fix problems can lead to big trouble,

Still, the formal professional approach doesn’t always work either.
Cloyd Gatrell, MD, an emergency physician who was employed by EmCare,
says that he and his wife Kathryn, a nurse, voiced concerns and
presented data to executives at Carlisle Regional Medical Center in
Pennsylvania in 2008 and 2009 on what they saw as inadequate nurse
staffing levels that endangered patients.

After getting no results, Dr. Gatrell
contacted the state health department, prompting a state inspection that
found insufficient staffing. In 2010, he was fired by EmCare at the
request of the hospital,
according to his 2011 lawsuit against the
hospital and EmCare claiming violation of whistleblower protection laws.
His wife was fired earlier, and she sued separately. The hospital
issued a statement declining comment on the litigation.

‘We’re supposed to be advocates for patients,
but being employed puts us in a precarious position in taking a
position on patient interests that’s against what the hospital
administration favors,
‘ says Dr. Gatrell, whose suit is in the discovery
stage. ‘I think a physician still has that responsibility.’

Physicians who sign contracts with corporate employers, perhaps thinking that they will have less bureaucracy with which to contend and a more certain salary than they did in private practice, seem blissfully, or willfully unaware that those contracts may take away their ability to control their practices and stand up for their patients.

Still, federal and state whistleblower laws only provide protection
from retaliation for physicians in certain situations, such as those
employed by public entities or those who complain about civil rights
violations or Medicare and Medicaid fraud and abuse. Otherwise doctors
may have to rely on contract provisions or on state employment law,
which may not offer much protection.

[An anesthesiologist on the AMA Board of Trustees and his hospital system’s board,] Dr. Annis says that the AMA’s new statement
of principles for physician employment — which asserts that physicians
should not be retaliated against by their employers for speaking out on
patient care issues — provides support for doctors when they raise
legitimate professional concerns with their employers.
He says it’s best
for physicians to work through their medical staff organization.

But Dr. Gatrell points out that the AMA statement explicitly accepts
that physician employment contracts may allow hospitals to strip doctors
of their medical staff membership and clinical privileges at the same
time they are terminated,
known as a ‘clean sweep’ clause. ‘If that’s
accepted by the AMA, the rest of the principles protecting physicians
are meaningless,” he argues. “If physicians can be fired without cause
and then automatically lose their medical staff membership and its due
process protection, how many will dare be a patient advocate?

Some experts advise physicians not to sign
employment agreements with such onerous provisions
. But others say that
physicians often have little leverage to remove them. ‘It’s not an equal
negotiating table,’ says Dr. Gatrell, who’s now working for a small
urgent care practice.

A May, 2013 article again in Medscape about the “4 Top Complaints of Employed Doctors,” explained why physicians often see a lot they could or should protest to assure the quality of their patients’ care,

 Some doctors report that hospital administrators treat them with a lack
of respect. One female doctor said, also on condition of anonymity, that
her biggest challenge on her job was ‘how to handle nonphysician high
school grads bossing you around when they function as your ‘superiors’
in your employer’s organization. They manage their insecurities by
bullying physicians and through passive aggressiveness, but always seem
to gain the upper hand with those at the top

These are the sorts of brilliant administrators often hired by brilliant top executives, maybe at a cheap price to keep the bottom line and executive compensation healthy..  Furthermore, given that as we have discussed, “financialization” of hospital management often puts a bigger priority on short-term revenue than on quality care, as per one senior physician,

 ‘physicians are being increasingly targeted when they get in the way’ of hospitals’ agendas

To make more money faster, many hospital systems now seem to want physicians to only make referrals for lucrative tests and treatments within the system, even if some patients might be better served elsewhere,

The AMA recently issued guidelines for physician employment stating
that ‘a physician’s paramount responsibility is to his or her patients.’

Employers should not retaliate against physicians for asserting their
patients’ interests, according to these guidelines. ‘In any situation
where the economic or other interests of the employer are in conflict
with patient welfare, patient welfare must take priority,’
the AMA says.

The guidelines also call for employers and
employed physicians to disclose to patients any agreements or
understandings they have that restrict, discourage, or encourage
particular treatment or referral options.

Nevertheless, employed physicians are often
expected to refer patients within their own groups and send tests to a
hospital laboratory or imaging center
. Hospitals may tell employed
surgeons which kinds of joint implants to use, and according to a New York Times article even whether to implant defibrillators in Medicaid patients. It’s unclear how often any of this is disclosed to patients.

‘What we doctors say is that we’re ethically
bound to our patients because we took an oath, and that’s what our
license is based on,’ says Linda Brodsky. ‘But many hospitals say, ‘No,
you’re employed here, and what we say goes.

Note that so far there seems to be little evidence that the AMA guidelines about physician employment are being honored other than in the breach.  It is also disappointing that the leadership of the medical society that represents internists seems so unworried,

 David L. Bronson, MD, President of the American College of Physicians,
disputes Brodsky’s assertion that hospitals tend to squelch doctors who
criticize leadership for policies that they believe harm patient care.
In fact, he says, healthcare organizations may identify outspoken
physicians as potential leaders,
‘as long as they’re collaborative and
trying to solve problems, and not just be a thorn in the side of
everyone they know. Organizations are looking for physician leaders, and
physicians who can collaborate and not just be adversarial can go far
inside organizations.’

I would guess, having seen so many examples of generic management, mission-hostile management, management that seems more focused on the money than patient care, and management that seems to be able to make itself rich without evidence that it has done anything noteworthy to uphold hospitals’ clinical missions, that hospital systems that promote physicians who are willing to speak out against hired executives are vanishingly rare.

And Sell

In June, 2013, Beckers Hospital Review published an article suggesting that now hospitals are going beyond just pressuring employed physicians to refer potentially profitable patients within the system, and now are pressuring physicians to act as salespeople to their colleagues,

 A few hospitals are beginning to train their employed physicians to
“sell” the hospital, which involves asking referring doctors in the
community to send patients their way….  the pressure to bring doctors into sales is mounting.

The author, the former publisher of Modern Healthcare, made a remarkable argument based on a definition that seems wildly optimistic,

 Customer service lies at the core of salesmanship. The Business
Dictionary defines salesmanship as satisfying customer needs through a
sincere and mutually beneficial process aimed at a long-term

Of course, skeptical physicians used to exposure to the sales tactics pharmaceutical and device companies use (look here, here, and here,  for example) might wonder why the author did not discuss such marketing tactics as the employment of half-truths and biased information, and the use of emotional appeals to trump reason and logic.

That the author was serious was shown by his list of seven pointers for hospitals seeking to transform its employed physicians into marketers.

Of course, physicians who are already “key opinion leaders” employed by drug and device companies, whose marketing executives may think. that “key opinion leaders were sales people for us,” (see this post), might not be fazed by now being asked to market their own hospital.  Never mind about Principle II of the AMA Code of Ethics

II. A physician shall uphold the standards of professionalism, be honest in
all professional interactions, and strive to report physicians deficient
in character or competence, or engaging in fraud or deception, to
appropriate entities.

The Moral of the Story

We have previously discussed various aspects of the travails of the brave new world of the corporate physician.  Physicians and other health professionals who sign on as full-time employees of large corporate entities have to realize that they are now beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation.  Physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.

It is disappointing that even medical societies that ostensibly support physicians’ professional values have been afraid to warn against such employment, or do much to help physicians trapped within it.

Physicians who go to work for big corporations have to realize that they may be forced to put corporate executives’ vested interests ahead of their patients.  Patients whose physicians work for big corporations must realize that their health care will now be corporate, with all that entails.

  As I have said before, we need to
challenge the notion that direct health care should ever be provided, or
that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to
have good quality, accessible health care at an affordable price until
we restore physicians as independent, ethical health care professionals,
and until we restore small, independent, community responsible,
non-profit hospitals as the locus for inpatient care.