Guest post by Dr. Kenneth H. Cohn

With demonstration grants in Colorado, Oklahoma, New Mexico and Texas, The Center for Medicare and Medicaid Services (CMS) has stimulated our thinking about global payment and how physicians and hospital administrators can share one check. I cringe each time I hear, "We need to align our doctors...," because, as a fellow surgeon confided to me, "The hammer remains unchanged, but the nail gets pounded!"

We need to step back a moment, reflect on the desired end state, where we collaborate to improve clinical and financial outcomes and consider what we need to do to arrive there. Cultural change embodies personal change, wherein lies the rub.

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To paraphrase the "dance of the blind reflex":

• People at the top of an organization feel burdened by unmanageable complexity.

• Those at the bottom of an organization feel oppressed by insensitive higher-ups.

• People in the middle feel torn and become weak, confused and fractionated.

• Physicians, patients and families feel righteously done-to by an unresponsive system, which irritates hospital leaders who feel that their efforts are under appreciated.

• Nobody sees his or her part in creating and sustaining any of the above conditions.

Getting to alignment involves a non-linear three-step journey of transparency, engagement, and co-mentoring.

Step One: Transparency

Taking the first step requires admitting that we do not know or understand each other very well. As Dr. Joseph Bujak wrote in Inside the Physician Mind, we have different cultures, training, and perspectives. Physicians tend to see themselves as members of a competitive, individually focused, outcome-driven expert culture, where the word "team" conveys an image of a golf team. Winning a match accrues points for the team, and at the end of the day, the team with the most points wins the competition.

On the other hand, hospital administrators tend to see themselves as members of an affiliate culture that is mission-driven and pays careful attention to process issues to establish and maintain consensus. Teamwork within a healthcare organization is like volleyball (dig, set, spike), where team members function more interdependently than a golf team. We can come to know each other better by completing projects that improve the practice environment in a timely fashion, where we celebrate milestones and collaboration. We need to respect Tuckman’s stages of group development (forming, storming, norming, and performing), so that members of both groups understand that overcoming conflict (storming) is an essential prerequisite to obtaining lasting results (performing). (Tuckman BW. Developmental sequence in small groups. Psychological Bulletin, 1965; 63:384-399.)

Physician champions--outstanding clinicians who are willing to leverage their social capital to improve care for the community at large--may help with transparency by:

• Presenting and discussing clinical data with fellow physicians.

• Creating a safe environment for learning.

• Minimizing physician-hospital battles.

Step Two: Engagement

Engagement has two meanings: Interfacing, in which two parties occupy each other’s attention in a positive fashion, even to the point of pledging their word, and entangling, as in, "We engaged the enemy." Engagement implies that conflict is inevitable in times of rapid, disruptive change, and that managing it can produce superior solutions to ignoring it.

I am often asked, "What do you do if a physician does not want to be engaged?" to which physicians have replied:

"To me, it is all about building trust and identifying areas of passion for them, and areas where you can improve their lives [processes] or their incomes...you have to come up with something of interest to them...what you can do for them, not what they can do for you.

"If they do not want to have anything to do with you, ask them 'why not?'...that is a definable set of reasons and (mis)perceptions you might have to dig out of them, realizing that you might not like and may not want to hear what they say, but once understood gives you something to work with."

Step Three: Co-mentoring

Co-mentoring implies that each of us brings valuable knowledge, skills, and experience to the table. I recognized this principle when I learned laparoscopic surgical skills from residents whom I was supposed to be supervising, because nobody did laparoscopic cholecystectomies when I was a resident in surgery. None of us has the skills, time, or knowledge to care for patients by himself or herself. We need to learn to work more interdependently.

So, what do you think?

• Are we living in such a state of siege that we have lost the ability to work interdependently

• What stories come to mind when you read about physician champions?

• What has helped you work more interdependently in your organization?

I welcome your input.

Ken is a practicing general surgeon who divides his time between providing general surgical coverage and speaking, writing, teaching and consulting on physician-hospital relations. Learn more about what he does by visiting http://healthcarecollaboration.com.