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Editorials

Last 50 Editorials

(Click on title to be directed to posting, most recent listed first)

A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS
Equitable Peer Review and the National Practitioner Data Bank 
Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership 
Disclosures for All 
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy 
Breaking the Guidelines for Better Care 
Worst Places to Practice Medicine 
Pain Scales and the Opioid Crisis 
In Defense of Eminence-Based Medicine 
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now 
Mitigating the “Life-Sucking” Power of the Electronic Health Record 
Has the VA Become a White Elephant? 
The Most Influential People in Healthcare 
Remembering the 100,000 Lives Campaign 
The Evil That Men Do-An Open Letter to President Obama 
Using the EMR for Better Patient Care 
State of the VA
Kaiser Plans to Open "New" Medical School 
CMS Penalizes 758 Hospitals For Safety Incidents 
Honoring Our Nation's Veterans 
Capture Market Share, Raise Prices 
Guns and Sleep 
Is It Time for a National Tort Reform? 
Time for the VA to Clean Up Its Act 
Eliminating Mistakes In Managing Coccidioidomycosis 
A Tale of Two News Reports 
The Hands of a Healer 
The Fabulous Fours! Annual Report from the Editor 
A Veterans Day Editorial: Change at the VA? 
A Failure of Oversight at the VA 
IOM Releases Report on Graduate Medical Education 
Mild Obstructive Sleep Apnea: Beyond the AHI 
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
   Reflections 
VA Administrators Breathe a Sigh of Relief 
VA Scandal Widens
Don’t Fire Sharon Helman-At Least Not Yet 

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine.

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Tuesday
Feb062018

Brenda Fitzgerald, Conflict of Interest and Physician Leadership 

Barely noticed in the news last week was Brenda Fitzgerald’s resignation as director of the Centers for Disease Control (CDC) after only 6 months on the job (1). Her resignation came one day after Politico reported that she bought shares in a tobacco company one month after assuming the CDC directorship (2). The stock was one of about a dozen new investments that also included Merck and Bayer (3). Fitzgerald had come under criticism by Senator Patty Murray for slow walking divestment from older holdings that government officials said posed potential conflicts of interest (1). While serving as director of the Georgia Department of Health, Fitzgerald owned stock in five other tobacco companies: Reynolds American, British American Tobacco, Imperial Brands, Philip Morris International, and Altria Group (4).

“It gives you a window, I think, into her value system,” said Kathleen Clark, a professor of law focusing on government ethics at Washington University in St. Louis (2). “It doesn’t make her a criminal, but it does raise the question of what are her commitments? What are her values, and are they consistent with this government agency that is dedicated to the public health? Frankly, she loses some credibility.” Purchasing tobacco stocks by any physician is disturbing, even more so when done by the director of the agency that spearheads the US government’s efforts to reduce smoking.

The influence of money on healthcare legislation has become increasingly concerning. Merck, whose stock Fitzgerald purchased on August 9, has been working on developing an Ebola vaccine and also makes HIV medications (2,3). Bayer, whose stock she purchased on August 10, has in the past partnered with the CDC Foundation to prevent the spread of the Zika virus (2,3). Fitzgerald’s purchases of tobacco stocks represent just one more instance of a potentially inappropriate relationship between politicians and business. Previous research published in the Southwest Journal of Pulmonary and Critical Care (SWJPCC) demonstrated a correlation between tobacco company political action committee contributions and support of pro-tobacco legislation (5).

Fitzgerald’s ethics issues are apart from a broader assessment of her leadership at the CDC. She had no research experience while leading an organization where research is one of its primary functions. She had previously promoted anti-aging medications to her patients despite no evidence of their efficacy (6).  She made few public statements during her time at the CDC and waited 133 days before holding her first staff meeting. She was scheduled several times to testify before Congress but sent deputies instead.

Fitzgerald seems to represent a high-profile version of the obsequious physician executive (OPIE), i.e., a physician obedient or attentive to an excessive or servile degree (7). Like the OPIE at the local hospital, Fitzgerald may have been appointed not for skill as a leader but her compliance as a subordinate to her supervisors. It raises the question of who would want to be director of the CDC when the current administration has been openly hostile, targeting the agency for deep budget cuts.

Hopefully, the next director of the CDC will be less conflicted. Previously, the SWJPCC has published tobacco company PAC contributions to candidates for political office (5). At the request of the Arizona Thoracic Society we intend to do the same prior to the November 2018 elections (8). In the interim, you can check tobacco company PAC contributions to federal candidates on the Campaign for Tobacco Free Kids website or for contributions at the state level at followthemoney.org (9,10).

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Sun LJ. CDC director resigns because of conflicts over financial interests. Washington Post. January 31, 2018. Available at: https://www.washingtonpost.com/news/to-your-health/wp/2018/01/31/cdc-director-resigns-because-of-conflicts-over-financial-interests/?utm_term=.05ee75769108 (accessed 2/3/18).
  2. Karlin-Smith S, Ehley B. Trump's top health official traded tobacco stock while leading anti-smoking efforts. Politico. January 30, 2018. Available at: https://www.politico.com/story/2018/01/30/cdc-director-tobacco-stocks-after-appointment-316245 (accessed 2/3/18).
  3. Fitzgerald B. Periodic Transaction Report | U.S. Office of Government Ethics; 5 C.F.R. part 2634 Executive Branch Personnel Public Financial Disclosure Report: Periodic Transaction Report (OGE Form 278-T). Revised 12/21/17. Available at: https://www.politico.com/f/?id=00000161-4804-d9fe-a9fd-5af5834d0000 (accessed 2/3/18).
  4. Fitzgerald B. Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e). Revised 10/12/17. Available at:  https://www.politico.com/f/?id=00000161-4867-da2c-a963-cf770b6b0000 (accessed 2/3/18).
  5. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
  6. Levitz E. Trump’s CDC pick peddled ‘anti-aging’ medicine to her gynecologic patients. New York Magazine. July 10, 2017. Available at: http://nymag.com/daily/intelligencer/2017/07/trumps-cdc-pick-peddled-anti-aging-medicine-to-patients.html (accessed 2/3/18).
  7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]
  8. Robbins RA. September 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;15(3):122-4. [CrossRef]
  9. Campaign for Tobacco Free Kids. Tobacco PAC contributions to federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions (accessed 2/3/18).
  10. The National Institute on Money in State Politics. Money in state politics. Available at: https://www.followthemoney.org/tools/election-overview/?s=AZ&y=2016 (accessed 2/3/18).

Cite as: Robbins RA. Brenda Fitzgerald, conflict of interest and physician leadership. Southwest J Pulm Crit Care. 2018;16(2):83-5. doi: https://doi.org/10.13175/swjpcc029-18 PDF 

Monday
Dec182017

Seven Words You Can Never Say at HHS

The recent announcement of the seven words you can never say at Health & Human Services (HHS) reminded me of the late George Carlin’s routine, “Seven Words You Can Never Say on Television” (1). Policy analysts at the Centers for Disease Control (CDC) in Atlanta were told of the list of forbidden words at a meeting last Thursday, December 14, with senior CDC officials who oversee the budget, according to an analyst who took part in the 90-minute briefing (2). The forbidden words are "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said. In other cases, no replacement words were immediately offered.

This is the latest attempt by government departments to distort fact. As an example, The New York Department of Education tried a similar tactic in 2012 (3). Among the words were dinosaur, birthday, and Halloween. Some of the reasons given were that dinosaurs suggest evolution which creationists might not like; Halloween was targeted because it suggests paganism; and birthday because it isn’t celebrated by Jehovah’s Witnesses; The Bush administration waged a similar war on climate change (4). That war has been extended by the Trump Administration as part of their war on any science that the Trump administration does not like (5). Science that does not fit Trump’s agenda or ideology is insulted or called “fake news”. Climate change is fact and not a hoax dreamed up the Chinese as Trump has claimed (6).

Mr. Carlin is not alive to make fun of the latest war on free speech but perhaps others will take up Carlin’s calling. Seven words they might suggest be banned include stupid, moron, fool, clown, weird, dumb and incompetent-all frequently used by President Trump on Twitter (7). The CDC is a scientific organization. Appointing unqualified politicians to head scientific organizations to carry out a political agenda is like mixing oil and water. No matter how times you say it, the water will not float on top of the oil. Science relies on a precise vocabulary and is not Republican or Democrat, conservative or liberal, or right or left. In my view, those that banned these words made an indirect attack on fact and should be “ashamed” (7).

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Carlin G. 7 words you can never say on television. Available at: https://www.youtube.com/watch?v=kyBH5oNQOS0 (accessed 12/18/17).
  2. Sun LH, Eilperin J. Words banned at multiple HHS agencies include ‘diversity’ and ‘vulnerable’. Washington Post. December 16, 2017. Available at: https://www.washingtonpost.com/national/health-science/words-banned-at-multiple-hhs-agencies-include-diversity-and-vulnerable/2017/12/16/9fa09250-e29d-11e7-8679-a9728984779c_story.html?utm_term=.c983e2f2af81 (accessed 12/18/17).
  3. CBS News New York. War on words: NYC dept. of education wants 50 ‘forbidden’ words banned from standardized tests. March 26, 2012. Available at: http://newyork.cbslocal.com/2012/03/26/war-on-words-nyc-dept-of-education-wants-50-forbidden-words-removed-from-standardized-tests/ (accessed 12/18/17).
  4. Union of Concerned Scientists. Scientific integrity in policy making. September, 2005. Available at: https://www.ucsusa.org/our-work/center-science-and-democracy/promoting-scientific-integrity/reports-scientific-integrity.html#.Wjf0TFWnGUk (accessed 12/18/17).
  5. Editorial Board. President Trump’s war on science. New York Times. September 9, 2017. Available at: https://www.nytimes.com/2017/09/09/opinion/sunday/trump-epa-pruitt-science.html (12/18/17).
  6. Marcin T. What has Trump said about global warming? Eight quotes on climate change as he announces Paris agreement decision. Newsweek. June 1, 2017. Available at: http://www.newsweek.com/what-has-trump-said-about-global-warming-quotes-climate-change-paris-agreement-618898 (accessed 12/18/17).
  7. Lee JC, Quealy K. The 394 people, places and things Donald Trump has insulted on twitter: a complete list. New York Times. November 17, 2017. Available at: https://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html (accessed 12/18/17).

Cite as: Robbins RA. Seven words you can never say at HHS. Southwest J Pulm Crit Care. 2017;15(6):294-5. doi: https://doi.org/10.13175/swjpcc154-17 PDF 

Friday
Dec082017

Equitable Peer Review and the National Practitioner Data Bank 

The General Accounting Office (GAO) recently reported that Department of Veterans Affairs (VA) did not report most physicians whose clinical care was found to be, or suspected of being, substandard to the National Practitioner Data Bank (NPDB) or to state licensing boards (1). The GAO examined 5 VAMCs and found required reviews of 148 providers’ clinical care after concerns were raised from October 2013 through March 2017. Of the 148, 5 were subjected to adverse privileging actions and 4 resigned or retired while under review but before adverse actions were taken. Only 1 of these 9 was reported to the NPDB and none was reported to his or her state medical board.

In response to GAO's report and in testimony to the Subcommittee on Oversight and Investigations, VA officials said the agency was taking three steps to improve reporting of providers who don't meet required standards:

  1. Reporting more clinical occupations to the NPDB;
  2. Improving the timeliness of reporting;
  3. Enhancing oversight to ensure that no settlement agreements waive the VA's ability to report to NPDB and state licensing boards (2).

What is lacking in the report is determination if substandard actually occurred and how it was determined. The VA has 3 ways of identifying substandard care (1).

  1. Tort claims (the VA equivalent of a medical malpractice lawsuit);
  2. Complaints or incident reports;
  3. Peer review.

Each has major problems of accuracy and fairness at the VA.

The majority of US physicians have been sued (3). The minority of suits are associated with malpractice and malpractice has no apparent association with the outcome of the litigation (4). Over 90% of medical malpractice cases are settled out of court (5). A common misconception is that settling a case before trial means a large financial settlement. However, 90% of the 90% or 82% of all claims, close with no payment (5). However, the VA uses US District Attorney to defend malpractice claims (6). In many instances, the US District Attorney’s office settles the case without determining if there is malpractice. The VA then submits the offending physician(s) name to the NPDB or state boards whether malpractice has been shown or not.

Complaints or incident reports are common in many hospitals, and many, if not most, have little merit (7). However, the weight given to a complaint should be viewed differently depending on the source. When colleagues raise concern about a physician’s care this is more credible than a patient complaining about not receiving their narcotics to a patient advocate. In the GAO report it is unclear if this was a source the of possible substandard care.

Lastly, there is peer review. There are several problems with this process in the VA. The VA selects the “peers”. In many instances the reviewers are un- or under-qualified to review the case (6). Furthermore, the selected reviewers may be conflicted clouding a balanced and fair determination if the physician’s care met the standard of care. There are multiple instances of this at the VA, of which a couple have been cited in the SWJPCC (6).

No surprisingly, a bureaucracy in the federal government has suggested a bureaucratic solution to a nonexistent problem. The goal should not be for more bureaucratic reporting, but a system for determining if a physician’s care has met the standard of care. The VA has shown it is incapable of making this determination fairly and accurately. What is needed is an outside review separated from VA influence and politics. If malpractice is still questioned after an initial VA review, the medical schools or private practioners could provide a source of physician peer review. The case could be presented to a panel of non-VA physician peers chosen in an equitable ratio by the VA and the accused practitioner. In the absence of a more equitable review process, the VA will only succeed in driving away the quality practitioners the veterans need.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. General Accounting Office. VA health care: improved policies and oversight needed for reviewing and reporting providers for quality and safety concerns. Report to the chairman, committee on veterans’ affairs, House of Representatives. GAO-18-63 (Washington, D.C.: November, 2017). Available at: http://www.gao.gov/assets/690/688378.pdf (accessed 12/6/17).
  2. Terry K. VA medical centers fail to report substandard doctors, GAO says. Medscape. December 5, 2017. Available at: https://www.medscape.com/viewarticle/889600?nlid=119420_4502&src=wnl_dne_171206_mscpedit&uac=9273DT&impID=1501593&faf=1 (accessed 12/6/17).
  3. Matray M. Medscape malpractice report 2017 finds the majority of physicians sued. Medical Liability Monitor. November 15, 2017. Available at: http://medicalliabilitymonitor.com/news/2017/11/medscape-malpractice-report-2017-finds-the-majority-of-physicians-sued/ (accessed 12/6/17).
  4. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec 26;335(26):1963-7. [CrossRef] [PubMed]
  5. Chesanow N. Malpractice: when to settle a suit and when to fight. Medscape. September 25, 2013. Available at: https://www.medscape.com/viewarticle/811323_3 (accessed 12/6/17).
  6. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013 Dec 1;2(3):e27. [CrossRef] [PubMed]
  7. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight bureaucracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.

Cite as: Robbins RA. Equitable peer review and the national practitioner data bank. Southwest J Pulm Crit Care. 2017;15(6):271-3. doi: https://doi.org/10.13175/swjpcc152-17 PDF

Friday
Oct272017

Fake News in Healthcare 

An article in the National Review by Pascal-Emmanuel Gobry points out that there is considerable waste in healthcare spending (1). He blames much of this on two entitlements-Medicare and employer-sponsored health insurance. He also lays much of the blame on doctors. “Doctors are the biggest villains in American health care. ... As with public-school teachers, we should be able to recognize that a profession as a whole can be pathological even as many individual members are perfectly good actors, and even if many of them are heroes. And just like public-school teachers, the medical profession as a whole puts its own interests ahead of those of the citizens it claims to be dedicated to serve.”

Who is Pascal-Emmanuel Gobry and how could he say something so nasty about teachers and my profession? A quick internet search revealed that Mr. Gobry is a fellow at the Ethics & Public Policy Center, a conservative Washington, D.C.-based think tank and advocacy group (2). According to his biography, Gobry writes about religion, culture, politics, economics, business, and technology, but not health care. He is a columnist at The Week, a contributor at Forbes, a blogger at the Patheos Catholic and his writing has appeared in the Wall Street Journal, The Atlantic, and The Daily Beast amongst others. He holds a Master of Science in management from HEC Paris (Hautes études commerciales de Paris, a quite prestigious business school) and lives in Paris.

To make his point on waste, Mr. Gobry comments on Atul Gawande’s 2007 New Yorker “exposé on the Herculean efforts by a handful of scientists to get intensive-care physicians to implement a basic hygiene measures checklist so as to stop hospital-borne diseases” (3). He goes on to quote the Centers for Disease Control that hospital-borne diseases kill about 100,000 people per year, that the checklist was of no cost to the doctors, and its scientific rationale was unquestionable. “Doctors still resisted it with all their might because they found it mildly inconvenient; perhaps they found it even less acceptable that anybody might tell them how to do their jobs”. I showed this article to one of my former pulmonary/critical care fellows who has been in practice about 10 years. He commented, “Another guy who doesn’t practice medicine or know what he’s talking about.”

Gobry is referring to the Institute of Healthcare Improvement (IHI) central line associated blood stream infection (CLABSI) guidelines. These include hand washing, sterile gloves, sterile gown, wearing of a cap, full body drape, chlorhexidine, and not using femoral sites for insertion. In our intensive care units only chlorhexidine usage was associated with a decline in CLABSI (4). Every ICU I have practiced in has emphasized handwashing and demanded use of sterile gloves, gowns and drapes. The remaining guidelines are not supported by good evidence.

Gobry also claims that a computer is better at diagnosis than most physicians. He claims that the evidence is “pretty robust at this point, and the profession resists it tooth and nail. In a few years, we’ll be able to know how many unnecessary deaths this led to, but the number will have lots of zeroes”. However, in the only direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms (84.3% vs. 51.2%) (5).

Journalists like Gobry are writing melodramatic articles about medicine and often getting it wrong. In this case he sensationalized Gawande’s article and misquoted the evidence for both the IHI guidelines and computer diagnosis.

There’s a TV commercial about an actor playing a doctor. Gobry is a business journalist attempting to play a doctor at the National Review. My former fellow is right. Gobry is a guy who does not know what he is talking about. Unfortunately, his writings can affect public policy and influence politicians who know even less. As President Trump said, “Nobody knew that health care could be so complicated” (6).

I am a doctor playing a journalist at the Southwest Journal of Pulmonary and Critical Care. Our articles may not be as sensational as Gobry’s, but we stick to what we know-pulmonary, critical care and sleep medicine. I think we usually get it right. President Trump has railed against “fake news”, most recently on Lou Dobbs Tonight (7). Journalists like Gobry contribute to fake news by being deliberately obtuse, appealing to emotions, name-calling, and omitting or distorting facts. As physicians, we have been denigrated by journalists like Gobry and others who make outrageous claims for their own purposes. It is the responsibility of physicians to challenge those like Gobry who get it wrong.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Gobry P-E. The most wasteful health spending is also the most popular. National Review. October 25, 2017. Available at: http://www.nationalreview.com/article/453088/health-care-spending-wasteful-popular (accessed 10/25/17).
  2. Ethics & Public Policy Center. Pascal-Emmanuel Gobry. https://eppc.org/author/pascal-emmanuel-gobry/ (accessed 10/25/17).
  3. Gawande A. The Checklist. The New Yorker. December 10, 2007. Available at: https://www.newyorker.com/magazine/2007/12/10/the-checklist (accessed 10/25/17).
  4. Hurley J, Garciaorr R, Luedy H, et al. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73. Available at: http://www.swjpcc.com/critical-care/2012/5/10/correlation-of-compliance-with-central-line-associated-blood.html
  5. Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016 Dec 1;176(12):1860-1861. [CrossRef] [PubMed]
  6. Howell T Jr. Trump: 'Nobody Knew That Health Care Could Be So Complicated'. Fox News. February 27, 2017. Available at: http://nation.foxnews.com/2017/02/27/trump-nobody-knew-health-care-could-be-so-complicated (accessed 10/25/17).
  7. Trump DJ. Lou Dobbs Tonight. October 25, 2017. Available at: http://video.foxbusiness.com/v/5624925494001/?#sp=show-clips (accessed 10/26/17).

Cite as: Robbins RA. Fake news in healthcare. Southwest J Pulm Crit Care. 2017;15(4):171-3. doi: https://doi.org/10.13175/swjpcc132-17 PDF 

Friday
Oct062017

Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad Leadership 

Obsequious is defined as “obedient or attentive to an excessive or servile degree”. Obsequious comes from the Latin root sequi, meaning "to follow”. An Obsequious PhysIcian Executive (OPIE) is more likely to be servile to the hospital administration than a leader of the medical staff. This is not surprising since they are chosen for a “leadership” position not by the physicians they purportedly lead, but by the hospital administration they serve. OPIEs become the administration’s representative to the physicians and not the physicians’ or patients’ representative to the administration. Their job often becomes keeping the medical staff “in-line” rather that putting the success of the medical center first.

My own views have developed over 40 years of observing OPIE behavior in a multitude of medical centers. Although there are many exceptions, OPIEs often share certain characteristics:

  1. Academic failure. OPIEs are usually academic failures. They are the antithesis of the triple threat who excels as a physician, teacher and researcher. In contrast, they excel at nothing and often are obstructionistic of others’ attempts to accomplishment anything meaningful.
  2. Advanced degrees not pertaining to medicine. Frustrated by their lack of success, they seek advancement by alternative routes such as nontraditional career paths or obtaining degrees outside of medicine, e.g., a master’s degree in business administration (MBA). Though they will argue that they are just serving a need or advancing their education, more likely they are seeking the easiest path for advancement, especially if their past accomplishments are best described as “modest”. Beware the unaccomplished physician with a MBA.
  3. Blame others for failure. Not all ideas, even from good people, are successful. Some are bad ideas destined to failure. When an OPIE’s idea fails, they blame others. Worse yet, they lie about a staff in order to place themselves in a good light. This appears to be one of the root causes of the waiting time scandal at the VA. In contrast, a leader accepts responsibility for failure and proposes a new and hopefully better plan.
  4. Bullying. OPIEs often fail to see two sides to any argument and are usually impatient and short-tempered with any who disagree. Rather that attempting to build a consensus, they attempt to bully those who show any resistance.
  5. Retaliation. If bullying fails, OPIEs seek retaliation. This can be through various means-often denial of resources. For example, one chief of staff sat for over a year on a request for a Glidescope (a fiberoptic instrument used for intubation) in the intensive care unit and then was faultfinding when a critical care fellow did not use a Glidescope during an unsuccessful intubation intubation. OPIEs might limit clinic space or personnel but then disparage the physicians when patients are not seen quickly enough to meet an administrative guideline. Lastly, if all else fails they may retaliate by invoking quality assurance. Quality is often ill-defined and it is all too easy in this day of “patient protection” to slander a good physician.

One of the latest buzzwords in healthcare is dyad leadership, a term that refers to physician/administrator teams that jointly lead healthcare organizations (1). A recent editorial touted the success of the partnership between Will Mayo MD and Harry Harwick at the Mayo Clinic in Rochester (2). My own positive example comes from Mike Sorrell MD, Charlie Andrews MD, and Bob Baker at the University of Nebraska Medical Center in Omaha. However, simply putting a physician and administrator together in leadership positions does not guarantee organizational success. In fact, if not done correctly, it leads to confusion, resentment, lack of consistent direction and divided organizational factions.

Based on their Mayo Clinic experience, Smoldt and Cortese list five key success factors they believe bring success to a dyad leadership (2):

  1. Common core values. Perhaps the most important factor in a successful dyad is that members of the physician/administrator team have the same core values and goals. Furthermore, these need to be consistent with the staffs' values and goals. Smoldt and Cortese (2) point out that at Mayo Clinic the core value of “the needs of the patient come first” is deeply imbedded. The staff of an organization will primarily deduce leadership core values from their daily actions. Administrative bonuses or increased reimbursement are not necessarily common core values, and if emphasized over patient care, the dyad is doomed to failure.
  2. Willingness to work together toward a common mission and vision. In a medical center, if the administrative leadership and staff can work together toward a vision, it is more likely to be achieved. If leadership becomes too territorial or engages in OPIE behavior, the ideal of leveraging each other’s strengths will be lost. If the staff perceives that the dyad is emphasizing their personal goals and finances over institutional success, the staff will be unwilling to work with or support the dyad.
  3. Clear and transparent communication with each other and the organization. To gain the most from dyad leadership, each member of the team should leverage and build on the strengths of the other. The more time the individuals spend together as a leadership team and with staff at a medical center, the more frequent and open the communication will be. If over time, communication declines, it is probably a sign that the dyad is not working and is often followed by the OPIE behaviors of bullying, lying and retaliation.
  4. Mutual respect. A team works best if its members operate in an atmosphere of mutual respect. If the dyad team does not share or show mutual respect for each other, mutual respect will likely also be lost among the healthcare delivery team. It is especially important for the dyad to remember that respect must be earned, and a big part of earning respect is to show respect for the views and positions of the staff.
  5. Complementary competencies. No one organizational leader is good at everything that needs to be done in a medical center. Employing a dyad leadership approach can expand the level of competence in the top leadership. For example, in a physician/administer leadership team, it is not unusual for the administrator to have better financial skills than the physician. It goes without saying that physicians and nurses have better medical skills in their own scope of practice than an administrative/physician dyad.

Integrated delivery of care is an absolute for a successful medical center. OPIE behavior dooms the medical center. Establishing a physician/administrator dyad leadership team with the right administrator and physician can be a good step towards success.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Zismer DK, Brueggemann J. Examining the "dyad" as a management model in integrated health systems. Physician Exec. 2010 Jan-Feb;36(1):14-9. [PubMed]
  2. Smoldt RK, Cortese DA. 5 success factors for physician-administrator partnerships. MGMA Connection Plus. September 24, 2015. Available at: http://www.mgma.com/practice-resources/mgma-connection-plus/online-only/2015/september/5-success-factors-for-physician-administrator-partnerships (accessed 10/4/17).

Cite as: Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. doi: https://doi.org/10.13175/swjpcc121-17 PDF