by Dr. Kenneth H. Cohn

"We have some issues here," a CEO of a mid-sized community hospital told me.

"We have a pluralistic medical staff of employed, contracted, and independent doctors who are in revolt. After our residency was put on probation several years ago, we set up a hospitalist teaching service, where a third of unassigned patients went, which angered the private doctors.

"Also, we have adopted a more hands-on policy with our case managers, to meet state and federal core-measure guidelines, which physicians feel interferes with their autonomy to care for patients. And we just divested a service line that lost over $2 million in the past five years, which meant that some physicians who've been with us for more than 30 years lost their jobs.

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"Nobody is happy. The private docs split admissions, so our volumes and revenues have tanked as they voted with their feet, which has decreased the volumes that our employed specialists see. Everybody is contemplating next steps.

"I can't afford to lose the private or the employed docs. I would like to engage them in a different way...if they want to be engaged. Do you think that a physician advisory group is a solution?"

At the end of the call, I told the CEO that even though I had worked with physicians in 40 states over the past decade, I've learned that when you work with one medical staff, you've worked with one medical staff. Each group of doctors has its own culture based on beliefs, attitudes, habits, and stories that one ignores at one's own peril.

To avoid "skeet-shooting," in which people make suggestions that physicians eventually shoot down, one has to admit cluelessness and encourage the physicians to come up with their own ideas so they'll have buy-in and eventual ownership. Resolving a medical staff crisis requires a facilitator--"a guide from the side, rather than a sage on the stage," a VP of medical affairs once told me.

Working with the president of the medical staff, we devised a questionnaire that could provide insight into what was going on rather than assume that we knew the answers. Questions included:

* How would you rate your experience here?
* What is going well for you?
* How likely are you to recommend this hospital to a friend, colleague, or a family member?
* On what do you base your rating?
* What is the future of this hospital?
* What role do you see yourself playing?
* Which obstacles need to be addressed now for the hospital to thrive?
* Whom else should we interview?

Most found the discussions that resulted therapeutic, and an indication that someone valued their input and validation of why they were angry and apprehensive.

Momentum began to build. Physicians who were initially too busy to participate began asking why they weren't interviewed, so I returned about a week later until we had more than 25 physicians' comments in our database.

We then set up an evening meeting chaired by the medical staff president, with opening remarks by the CEO. About 40 physicians attended. We seated them at tables of eight and asked them to discuss the things that resonated with them, the successes that we could build upon, and their recommendations for how we could improve the practice environment and their care for the community. These small-group sessions were critical for promoting physician-physician dialogue rather than physician-administrator harangues.

Result: Affirmations, such as "This is our hospital," and "We can turn this situation around," outweighed negative comments that insufficient time was allotted for discussion of past injustices.

Although I was surprised that the physicians' recommendations were not more specific than, "We need to involve physicians in proactive strategic planning rather than informing them of decisions that were made," we now have a few areas to pursue where we can draw up focused action plans for physicians to review.

And while volume, revenues, and trust may require months or even years to return, heightened transparency can facilitate an improved working environment, provided that action to improve outcomes occurs promptly. As I have previously written, chunking large tasks into two-week increments in which each step represents an outcome measure to be checked off, can bring a sense of momentum and progress to otherwise skeptical physicians. Although a kitchen cabinet of physicians may help prevent future crises, that step will have to wait till the physicians see proof that people are listening and that physicians are making their time count.

What do you think?

* Do you see reason for optimism in the face of crisis, an opportunity that creates urgency for change?
* Does reading about crises like this one make you more proactive about acting on physicians' complaints in a timely fashion, to prevent crisis where you work?
* What successes can we build on where physicians and hospital leaders work together to improve care for their communities?

I welcome your input.

Kenneth Cohn is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations.