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When it comes to physician-hospital relations, which entity is the cobra and which is the mongoose? While such adversarial scenarios unfortunately play out in hospital settings across the country, a New England surgeon contends that healthy doses of improved communication and mutual respect are capable of curing the ills that plague the interactions between hospitals and medical staffs.

“I’m convinced that in times of rapid change that conflict is inevitable, and it can be good or bad. It depends on how we manage it. If it’s managed well, I think it can lead to richer solutions,” said Dr. Kenneth H. Cohn, a board-certified general surgeon who remains clinically active in New Hampshire and Vermont. A former associate professor of surgery at Dartmouth-Hitchcock Medical Center, Cohn earned a master’s in business administration from Dartmouth’s Tuck School of Business in 1998. Since then, he has increasingly devoted his time to helping physicians, nurses, hospital leaders and board members work more interdependently. He’s the author of about 40 peer-reviewed articles and two books: “Better Communication for Better Care: Mastering Physician-Administration Collaboration,” and its sequel, “Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses and Hospital Executives.” He is the chief executive officer of HealthcareCollaboration.com.

Cohn said the goal of his second career direction was “to try to equalize the playing field between physicians and hospital administrators. … I thought I would be spending most of my time teaching physicians about spreadsheets, and profit and loss, and the basics of finance. Yet I’m spending 80 percent of my time dealing with what we might call the soft skills – how to communicate effectively, how to listen actively, how to negotiate in a win-win fashion. Most doctors talk about lose-lose negotiation. In other words, if they have to give something up, the hospital has to give something up. I try to teach them the importance of developing a more Copernican perspective that puts the patient and the family at the center, because that’s a way doctors and hospital administrators and nurses and board members can all find common ground.”

In much of his writing, Cohn promotes “structured dialogue” (see diagram), which he defines as “a process that helps a group of practicing physicians articulate their collective, patient-centered self-interest.” Cohn has implemented this process in at least 30 hospitals, with positive results, he said.

The process is led by a medical advisory panel (MAP) of clinicians who review and recommend hospital priorities after hearing presentations from all the clinical departments. While this method might sound more than a little frightening to a hospital administrator, Cohn acknowledged, the result is physicians who “learn to think beyond their silos, and through the process of discovery, they begin to act as owners rather than renters, so to speak.” The hospital administrator chooses two co-chairs for the MAP, and then turns the committee over to them. They pick a panel of five to 14 similarly talented physicians from different clinical areas. Cohn added that the hospital’s administration must commit to implementation of the MAP’s recommendations, which generally constitute performance improvements and minor expenditures.

Cohn shared a list of eight tips for hospital leaders to help ensure a positive and rewarding relationship with doctors.

1. Doctors enjoy listening to and learning from other doctors who are still taking care of patients. Cohn encouraged administrators to “cultivate physician champions” who are comfortable in a leadership position and capable of presenting data to other doctors.

2. Make communication with physicians a high “proactive” priority, rather than waiting for a crisis.

3. “It’s very important to use face-to-face communication to build trust. How do you solve the complexity in healthcare? You have to solve it one face-to-face conversation at a time. I don’t know any other way to do that,” Cohn said.

4. Neither hospital leaders nor physicians should assume they know what the other one wants.

5. Find common perspectives inside and outside the hospital. Cohn told a story of a hospital administrator who boned up on the Civil War because his top orthopedic referral was a Civil War buff. In a conversation, the administrator said to the orthopedist, “This sounds a little bit like Antietam.” The doctor’s response was, “This is the first time that I realized you knew something.”

6. Administrators need to show that they value physicians’ time. “The only time I hear money come up is when physicians feel disrespected,” Cohn said.
Physicians will agree to be involved in hospital processes if they see results from their efforts. Thus, Cohn recommended what he called “chunking.” If an initiative will take the hospital two years to accomplish, then break it down into chunks of time with “a box to check off” when each chunk of the project is completed, he said. And make each accomplishment mean something, not just an agreement to form a committee, for example. “Most doctors, because we’re not schooled in process-type skills, think of that as a smoke screen,” he said.

7. Celebrate victories as a team — and remember that gatherings promote conversation.

8. Create a safe environment for learning. Hospital leaders and physicians “pretty much agree on the who — we take care of the same patients, we live in the same communities, we have a lot of intersecting social networks. We also agree on the why, in that we’re both attracted to healthcare to make a difference in patients’ lives. … It’s the how that forms this life-long learning journey,” Cohn said.

Finally, Cohn encouraged both administrators and physicians to embrace the concept of “winning ugly.” Cohn said, “I think you have to accept every so often that there are going to be processes that … are like sausage being made. At the same time, they can produce spectacular outcomes.”



June 2008

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