In the Arena: Can You Smell It?

ACEP News 
June 2009

baehrenBy David F.Baehren, M.D.


The ability to alienate the medical staff seems to be a prerequisite for promotion in many hospital systems.


It's natural, as we get older, to yearn for times past--times that we remember to be better than the present.


Quality of service comes to mind right away. I told my kids that you could once talk to a human being who lives in this hemisphere when calling for customer service. They looked at me, wide eyed, like I told them we had an outhouse when I was their age.


Many things in our lives, of course, are much better now; but we forget these things in moments of frustration. It's hard to remember when there were no ATMs, cell phones, or computers. It wasn't all that long ago that childhood leukemia usually resulted in death, people of color were segregated in public, and the Cuyahoga River caught on fire. All in all, I'd say that things are much better now than they were when I graduated from high school thirty-some years ago.


What is written hereafter requires a caveat. These words are in no way a commentary on my particular hospital or employer but a commentary on hospitals in general. (I do still have to put food on the table, don't you know.)


The management and culture of our nation's hospitals has changed dramatically over the past 20 years, and I find myself longing for the days when there was no health care "industry."


It used to be easy to tell the difference between the for-profit and the not-for-profit hospitals. You could almost smell it when you walked in. There was a sense of togetherness and dedication in the not-for-profits that you didn't find anywhere else. Now you need to look at a tax return to tell the difference.


There was a time when the CEO of a hospital lived and died by his or her relationship with the medical staff. CEOs who consistently antagonized the medical staff found themselves working in the men's department at Sears. Just the thought of some of these weasels pushing cheap suits makes me smile. Now, the ability to alienate the medical staff seems to be a prerequisite for promotion in many hospital systems.


If the CEO can please the insurance companies, he can practically flip off the medical staff on the way to collecting a six-figure bonus. When is the last time your CEO spent any time in your department cultivating a relationship with you? A lot of these guys can't find their way to the ED without help, anyway ("So, this is that place they keep complaining about...").


Why make nice with the doctors? That takes time and energy. It's much more efficient to intimidate them as a bunch and be done with it. At many hospitals, the culture of fear is so pervasive that no one in his right mind will stand up and say that the behavior of the CEO is unacceptable. Unless you want to be blackballed or labeled as a "disruptive physician," it's much safer to keep playing the piano in the proverbial whorehouse than it is to do what is right for the institution and the patients.


It seems that in the fight for market share and shareholder value, patients have been forgotten. Gargantuan amounts of money are spent on construction projects for the "revenue-generating" departments--while patients are crammed into emergency departments so tightly that the docs have to go outside just to take a deep breath. Impressive advertising budgets are spent on billboards and television ads, but there is no money to add another shift to the ED coverage.


It seems that the CEOs of many institutions would rather talk about being the best instead of actually being the best. In their minds, saying it is as good as being it.


I've known two fantastic CEOs early in my career: Erie Chapman and Steve Caywood. These men were a joy to be around. Patient care was the top priority with them. Keeping physicians and hospital employees happy and engaged was a close second. When the priorities were kept straight, the profits seemed to naturally follow. Now, in many places, the patients almost are an afterthought and the employees are thought of as liabilities, not assets.


Toxic CEOs don't work in a vacuum, so there's plenty of blame to spread around. They work for a board of trustees. These boards were once populated by civic-minded people who saw the hospital as a community asset that required close stewardship. Now, many hospital boards are filled with cronies and insiders who are yes-men to the CEO. Contrarian views are frowned upon, and notions of what is right for the overall community are dismissed out of hand.


Worse yet, some of these board members have financial dealings with the hospital. The significance of these kinds of inappropriate alliances seems to go right over the heads of these cretins.


There are some bright spots out there, with enlightened CEOs and hospitals that understand that a toxic hospital culture is bad for everyone--especially the patients. The good hospitals have recaptured, or possibly never lost, the essence of their existence and the core of their mission. Consider yourself blessed if you work in such a place.


Unfortunately, many physicians still long for days past. They endure the culture of intimidation and duplicity, hoping that the hands of the cultural clock will reverse.


I don't want to go all the way back to the days of the outhouse, but it couldn't smell any worse than it does now.


DR. BAEHREN lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo Medical Center. Your feedback is welcomed at .
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