Horizontal Leadership in the Evolving Physician Profession

In the Spring and Summer of 2017, the Doerr Institute for New Leaders at Rice University awarded the HRC a leadership development grant to advance the center's medical humanities programming and promotion of undergraduate research, specifically in the area of "Medical Leadership." With supplemental support from the HRC, the HURC 306 course on "Medical Leadership" was complemented by a speaker series on the subject, bringing in experts on the topic from Houston and beyond. Read more on the speaker series here. In the Summer, the HRC awarded three research fellowships to non-graduating undergraduates, to pursue their own research projects on the topic. Working with medical faculty at Baylor College of Medicine, Augusto De las Casas worked with Dr. Ricardo Nuila to study leadership in the context of medical translators' work, Sarah Lasater worked with Dean Jennifer Christner's office to study leadership in the context of physician professional education, and Shaian Mohammadian worked with Robert Trieu's office to study leadership in the context of hospital administration.

Sarah and Augusto's work has continued in the Fall 2017 semester; they are currently going through Baylor's IRB process to continue their research.


Introduction

The medical profession has retained a unique cultural and economic authority in the United States since the Progressive Era. No profession has yet been able to match the "noble" profession as an equal in “sovereignty”, which sociologist Paul Starr describes as encompassing authority and autonomy.[fn]Paul Starr, The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry (New York: Basic Books, 1982) 1-29.[/fn] And yet, as the concept and structure of health care expands to encompass fields outside of a traditional physician's clinical specialty, physicians have come under pressure to take on new roles and new knowledge in order to better serve their patients and retain their sovereignty within new systems.[fn]Starr, Social Transformation, 420-449.[/fn] As the influence of public health, policy, and administration in health care grows, doctors must adapt to function either as leaders of or advocates for these spheres of influence. Furthermore, doctors are expected to treat patients within these new frameworks while growing in cultural and communicative competency to address issues within the current healthcare system.[fn]M.L. Clayman and G. Makoul, “An Integrative Model of Shared Decision Making in Medical Encounters,” Patient Education and Counseling April 2006: 301-312.[/fn] While the issues that arise in the clinical consultation setting are attributed to the doctor, in truth they often stem from problems and fields outside of the clinician's office. Thus, one cannot reasonably expect doctors to bear the sole responsibility of addressing the widespread and diverse health issues that originate from the multiple, growing facets of what we now consider "health care." If physicians expect to maintain their sovereignty, they must have a direct hand in addressing the threats to their patients' wellbeing and the wellbeing of their practice. As the current epicenter of healthcare, doctors must be careful to not fall to extremes: either in becoming the removed leader of a field or becoming a mere machine in an assembly line. To maintain a well-balanced, effective practice that retains physician authority, treats patients humanely, and contributes positively to health care as a whole, doctors should be properly educated on the multiple origins of health care issues, how to communicate about those issues, and how to knowledgeably shift responsibility to allies in the healthcare setting who, with the same objectives as the doctor, seek to assist the patient in a system that seems to be constantly changing. In other words, physicians must make use of horizontal forms of leadership as their professional identity evolves.

According to John W. Gardner, a national leader in organizational cooperation and health, “leaders unwilling to seek mutually workable arrangements with systems external to their own are not serving the long term interests of their constituents.”[fn]John W. Gardner, On Leadership. (New York: Free Press, 1993) 99.[/fn] If the central tenet of the physician profession is to “do no harm,” this must mean that it is the physician’s job to treat the patient to the best of the physician’s abilities. In order to achieve this service objective central to their professional status, physicians must make use of horizontal forms of leadership. The physicians, as professionals and leaders, to “serve the long term interests” of their subsystem’s members and to treat a patient most effectively within an increasingly complex societal and health care organization, must consider the patient in a holistic manner; this, in turn, helps maximize the potentials of health care’s other patient-focused subsystems. In other words, for the physician’s professional role (inclusive of autonomy and authority) and objectives (the treatment of the patient) to flourish, the other segments of the whole system must flourish. This can only be achieved by physicians stepping back from their traditional perception of their profession as sovereignty and stepping forward in their allying with and understanding of the adjacent groups that affect a patient's care.[fn]Ibid.[/fn] My research project with Baylor College of Medicine seeks to capitalize precisely on this theory of “stepping out of the box” and considering other perspectives. This may redefine the medical profession by reassessing the scope of the profession’s responsibilities (the societal expectations and the social function) and competencies (the technical expertise and code of ethics required) to include horizontal leadership.

Background

Characteristics of Professionalism and Why Physicians Fit the Bill

According to American sociologist Paul Starr, “sovereign” physician professionalism calls for the interdependence of autonomy and authority. The professionals built their autonomy and authority on two bases: legitimacy and dependence.[fn]Starr, 1-29.[/fn] Physicians did not always have the legitimacy required for professional status. Originally, the profession was unorganized, divided and weak, with insecure incomes and status. The antimonopoly sentiment of the Jacksonian era of the 1830s divided the practice of medicine up further and eliminated licensing laws. However, the cultural success of the Progressive era (1900-1920)--with its emphasis on science as a means of moral and political reform and professions as a basis of order--spurred the rise of a stronger medical organization, higher status, and larger income. Science and technological improvements gave physicians a superior and legitimate way of controlling reality and thereby provided legitimacy to the profession, as did the urbanization movement, where people in large cities became more dependent on strangers with special skills, and so were more willing to rely on the supposed expertise of physicians. Doctors began forming networks and the profession became more cohesive and organized. With this organization came the two pillar characteristics of professional legitimacy: training and accreditation.

Professionalism involves an establishment of a standardized education, with strict standards to bolster claims of exclusive jurisdiction. American sociologist Harold Wilensky argues that professionals must champion a specialized technique supported by a body of theory.[fn]H. Wilensky, "The Professionalization of Everyone?" American Journal of Sociology [Chicago] Sep. 1964: 137-158.[/fn] The technical competence must include rigorous standards of training and often requires many years of dedication to successfully link knowledge to practice. The medical profession fits this mold perhaps better than any other: it requires years of collegiate training, professional medical school training, and years of residency under the supervision of superiors. The self selection of the persons who apply themselves to this training and the clients who agree to use the doctors as sources of judgement further support the claims to a specialized, technical profession and provide legitimacy to the body of theory it rests on.[fn]Wilensky, Professionalization, 137-158.[/fn] In addition to the training system, the trainees themselves, and the patient’s “buy in” and support of this technical basis, professional careers including medicine are also reliant on peer groups.

Colleague groups provide the accreditation necessary for an individual’s acquisition of professional status. While many professions rely on the approval of clients, and while even now certain careers have become hybridized with client and peer approval, indisputably established professions rely on the approval of their colleagues as affirmation of their “good work.” Professionals claim authority as members of a community that objectively validate their competence, which is determined in part by their training success, but also in their adherence to an established code of ethics and a service ideal.[fn]Ibid.[/fn] Colleague groups can then restrict entry into the practice, separating the competent from the incompetent. The colleague groups have greater authority and more advanced judgement than the clients in that they have the permission and specialized knowledge to evaluate the quality of a performed procedure or the ethicality of a physician’s behavior based on years of experience. Thus, professionals adhere to a service ideal in that they operate under a code of ethics, professional norms, and a patient-orientation. The peer groups further provide opportunities for promotions and allow for the demand of continuous income.[fn]Ibid.[/fn] In short, physicians receive their legitimacy from training on culturally-accepted, technical bases and from approval not by clients but by colleague groups, who judge their qualifications and determine the future of their careers.

Professionalism involves authority based not only on legitimacy, but on dependence. The medical profession stands as a prime example. Medicine serves as an interesting market in that while medicine has become increasingly commodified, the market does not follow normal “free choice” capitalism because consumers are dependent upon the physician's expertise. There are real consequences if one does not obey the physician's order, and so the patients are physically, emotionally, and even psychologically dependent on the expertise, advice, and care of the professional.[fn]Starr, Social Transformation, 1-29.[/fn] Similar parallels can be drawn with a client’s dependence on lawyers or a spiritual person’s dependence on religious leaders. Medical professionals embody the establishment of authority based on dependency in three main ways: through their control of the economy, the establishment of the increasingly complex healthcare system, and the “gatekeeper” role acquisition.

Once the medical profession became more cohesive and organized after the Progressive era, physicians understood that they needed to control the political and economic elements of healthcare to maintain their autonomy and legitimacy. Coupled with the anomalous characteristics encompassed by the medical “service-as-commodity” market, the professional organizations successfully augmented demand and controlled supply to influence economic policy.[fn]Ibid.[/fn] Next, they used their establishment of codes of practice to receive licensing and legal protection, further solidifying the physician monopoly over medical care and driving out competition and control. On a more local level, as hospital and bureaucratic organizations grew, physicians not only saw the need to insert themselves into the management hierarchy, but also held firm to their roles as the direct and most intimate providers of care to leverage their position as crucial elements the hospitals depended on for success. Next, with the establishment of financial agreements between hospitals and physicians, the inter- and intra-hospital physician referral network assured that not only are clients dependent on their current doctors to refer them to specialists for care, but hospitals with profit motives are dependent on their doctors to keep patients within their hospital jurisdiction.[fn]Ibid., 420-49.[/fn] With their influence in national policy, hospital policy, and the medical market, professionalism served as the basis of solidarity on which physicians maintain some semblance of authority and autonomy.

Dependence on physicians is not limited to the political or economic realm, nor has dependence increased in the recent decades because of rising social authority and respect for physicians. Rather, it has increased because physicians have come to serve as the stereotype of “experts” and so have become “gatekeepers” to all other elements of life.[fn]Ibid., 1-29[/fn] Children must be immunized to go to school, the laborer must receive a form from the doctor assuring his back is healed enough that he can return to work, etc. Patients, then, are not reliant on doctors solely as sources of judgement and advice, but rather are reliant on them as stepping stones, as a check in the box that will allow one to pass a milestone. Thus, the unique nature of dependency cultivated by professionalism, coupled with legitimacy, enhances the authority and autonomy of professionals, especially within the physician profession.

It is well established, then, that the medical profession fits the characteristics and development pattern of professionalism. Its “sovereignty” is an expert blend of autonomy and authority, which rely on legitimacy--in the form of training and accreditation--and dependency--found in economics, politics, hospitals, and the “gatekeeper” role. Yet, as governments seek greater control over insurance and health care, physician autonomy diminishes; as hospitals become more stratified and bureaucratized, physicians lose their service orientation and are encouraged instead to care for patients with profit-motives in mind. Sociologist Paul Starr gives a detailed description of the pressures that are mounting on physicians and healthcare, as well as their origins and their potential impacts.

Starr explains that the type of autonomy that physicians sought to preserve as the bedrock of their sovereignty may actually be a great bane to the profession. Starr reasons that “the great irony is that the opposition of the doctors and hospitals to public control of public programs set in motion entrepreneurial forces that may end up depriving both private doctors and local voluntary hospitals of their traditional autonomy.”[fn]Ibid., 445.[/fn] Pressures that threaten the physician autonomy and sovereignty came into focus with the 1970s move to produce more doctors in the United States that resulted in a doctor glut. This has led to the formation of more group practices and doctors taking on administrative roles. And while doctors moved into institutional services, hospitals moved into ambulatory care. The rise of Medicare and Medicaid in the late 1960s became the open door for public financing of health care (instead of public control), making the business profitable for outsiders, and so for-profit corporations moved into medical services, changing the behavior of nonprofit and voluntary hospitals along the way.

The emergence of corporations in health care is part of wider trends of corporations taking over self-employed arenas and the transfer of public services to private corporations. Polycorporate and multihospital systems have grown by buying up individually owned proprietary facilities, pushing managerial capitalism into medicine, where integration, contracting, greater standardization, and centralization followed. The breakdown of traditional bounds of voluntarism has followed the penetration of the corporations and profit-making businesses. For-profit attitudes combined with hospital and insurance agreements are pushing doctors to see more patients everyday within shorter time frames, changing treatment quality and the doctor-patient relationship.

The growing presence of corporations and the glut of doctors renewed conflict, competition, and fragmentation within the profession--the exact opposite of the consolidation that made the profession initially powerful in the Progressive era. The market idealists of the 1970s did not predict the industrialization of medicine; they were so wary of governmental regulation as the threat to their autonomy, where really their demands on private health insurance and public programs caused private insurers and employers, rather than government, to want to control medical expenditures themselves. This all has left the profession fragmented, subject to great for-profit motives, standards, and direction, and with weakened ties between doctors and patients due to growing medical specialization.

Horizontal leadership can help change that. Paul Starr explained that the “rise of the profession required internal cohesiveness and collective organization, yet rising pressures now threaten to drive a wedge between different segments of the medical profession.”[fn]Ibid., 445.[/fn] This will not only weaken professional sovereignty, but will bring greater disunity and conflict throughout the entire health care system. This disunity and the industrialization of medicine has resulted in the transfer of ownership and the locus of health out of the community and into large, multihospital, polycorporate hands. If physician authority originally came from consolidation and patient dependence on physicians and trust of their judgement, then physicians can act on those points, oppose the articulated threats, and retain their autonomy and authority by taking up again that central position of care and the service ideal. Intimate understanding of such key elements as community needs and communication have fallen through the cracks as a result of this for-profit industrialization of medicine. Horizontal leadership can bring these perspectives back to the table within this new and evolving health care system, especially through formats like those used in the project I am involved in at Baylor College of Medicine, where we are learning where curriculum can be changed to benefit the doctor-patient relationship, the patient experience, and the treatment process.

What Medical Professionals Need to Learn about Leadership

Outside pressures multiply, communication and cooperation decreases, and physicians are stretched thin. For physicians to maintain their autonomy and their authority as service-focused, caring, patient-oriented professionals, doctors must step in and engage as leaders. To assure optimal care of their patients and success of their practices, doctors must become more involved in these evolving systems and bureaucracy by assuming leadership positions and becoming better team players. Leadership pioneers and commentators James Reinertsen and John W. Gardner articulate key features of leadership that may help physicians achieve these objectives. At the time, Reinertsen and Gardner are responding to the rising pressures on physicians, specifically the financialization of american culture and medicine and the pull for physicians to become better administrators.

Reinertsen proposes that leaders are initiates of change: they recognize the need for improvement and create new systems that rely on data-defined reality, tested changes, courage, and persuasion, among other things. Reinertsen also advocates for the “balcony concept,” where effective leaders first step back and assess their system’s current provisions, priorities, and goals from an overhead viewpoint, and then descend from the balcony to get to know the people on the ground.[fn]J. Reinertsen “Physicians as Leaders in the Improvement of Health Care Systems” Annals of Internal Medicine 15 May 1998 vol 128 (10): 833-838.[/fn] Becoming acquainted with team members is essential for leaders, who “must do much of their work outside of their immediate area of responsibility.”[fn]Ibid., 834.[/fn] They must think outside the box and consider the perspectives of all players: from the customers, leaders must understand how they view the provided service and then bring that viewpoint to the team, whose viewpoint also must be understood so they can be guided toward a shared purpose and encouraged to support adjoining or involved systems to that end (the latter is a key element to officer training in the military, for example, and is woven into “active-learning” curriculum). This descent from the balcony provides valuable information to strategize and become process-literate; it helps the leader to form a more cohesive practice by showing personal credibility, driving out fear, proving that he or she cares about the team members, addressing processes before blaming people, and creating a culture of trust.

Within a similar vein of thought as Reinertsen, Gardner insists leaders are also those who work outside of their own groups to establish cultures of adaptability, creativity, and renewal. He advocates for Reinertsen’s “descent from the balcony” strategy, arguing that true leaders approach the “frontline people [who] wrestle with action problems every day and know a lot more than anyone ever asks.”[fn]Gardner, On Leadership, 86.[/fn] Leaders establish cultures of upward and two-way communication with these people, assuring them their voice will be heard and they will know what is going on. Gardner proposes leaders foster lateral communication by tearing down internal walls, establishing working groups that cross boundaries, and cultivating informal information exchanges to combat turf syndrome. The connections weaving between subsystems and the redesigning of malfunctioning processes foster motivation and initiative, where people feel they “share ownership in the problem and are part of the solution.”[fn]Ibid., 81-120.[/fn] Garder understands no system segment can flourish if its adjoining segments do not flourish, and nor can the system as a whole. Leaders, then, must be coalition-builders and foster internal and external unity by assuring they and their teams are well acquainted with the constituencies of the other moving parts of the larger system. In other words, the leaders and their teams must be familiar with those segments of the community’s needs and wants, which may provide a better understanding of their language and improving inter-group communication. From these coalitions built through communication and shared goals arise networks of responsibility and collaboration, which cultivate trust, teamwork, efficacy and efficiency, and better morale for all workers within the system. Therefore, to achieve these results, leaders must become acquainted with subsystems and systems other than their own, and they must work with and build networks of communication between said groups and their own, reconciling differences and lifting up the groups within framework of shared purposes.

Project Association

Medical professionals can no longer afford to remain isolated in the name of independence. Rather, they must become engaged and formidable as leaders. Their cultural and economic authority--bolstered by legitimacy and dependence--requires that they form new networks and emphasize common goals so that they may adhere to their code of ethics to treat patients most effectively and may successfully lead their teams, associated groups, and patients.

In other words, physician must enact a horizontal form of leadership, where they step outside their traditional box of presumed methods and roles to learn about and ally with other parts of the healthcare system. Horizontal leadership chips away at problems of communication and misunderstandings. It promotes efficiency and more effective, holistic patient care. It presents a unified front with the patient and helps them navigate the system, allowing them to feel less overwhelmed, have a better experience, and better understand their situation. Assuming a horizontal form of leadership involves taking into consideration the opinions and goals of others, so that to ensure the physician group flourishes other groups must flourish as well. This will involve building bridges of communication and cooperation instead of competition and distrust, where the leader helps the groups find commonalities, outline goals, and address conflicts. Furthermore, in stepping outside of their “box” or “zone” and using horizontal leadership, physicians are in fact responding to the many demands placed upon them by reassessing their profession: What skills should they learn? Who do they need to ally with? How will this allyship make the pressures placed on physicians more manageable? Who can they learn from to improve their patient’s experiences? What resources can patients be directed to? By reassessing the role of their profession and what it requires and entitles through horizontal leadership, physicians are giving up a small portion of their autonomy: they recognize that they are not the sole decision makers of their patient’s experience and allocate aspects of patient care--the core of their profession--to entities that are not directly under their control. And yet, in giving up this component of autonomy, physicians are in fact reinforcing their sovereignty: they are assuming the leadership role of organizing and bridge-building. This new leadership form does not require that doctors even assume an administrative role or overburden themselves. Rather, as the connecting point for their patients and their teams--and as the person who still is known for technical expertise and is depended upon as the center of care--physicians are left with the freedom and authority to coordinate, direct, and allocate. Some forms of autonomy must be sacrificed in order to maintain a greater sovereignty and to adhere to the requirements and ideals of medical professionalism.

Overall, professional authority in medicine must be redefined to a) encompass horizontal leadership, where physicians may sacrifice some of their autonomy in opinion and judgement in order to cooperate with groups separate from their own to achieve the professed ends of the profession, and b) to consider and act upon evaluation separate from the typical circle of peers, which requires humility, in order to, again, better themselves and the experiences of their patients within an evolving system. Improving the quality of patient care and assuming a directive, involved, cooperative form of leadership will allow physicians to maintain authority and autonomy as the center of patient care. Horizontal leadership will define professional authority in medicine as one of connection and exploration instead of isolation, of autonomy through initiated collaboration instead of passive acknowledgement, and of an approach to medicine that has a broader, more holistic scope instead of a narrow, strictly scientific one. If physicians wish to remain at the forefront of medicine, to retain their sovereignty, they must become aware of adjoining systems and learn how to cooperative with them to achieve their tenet goals of patient care.

My project with Baylor College of Medicine aligns with these leadership perspectives within a professionalism framework. We are exploring how doctors communicate with each other, collaborate with other parties, and treat patients. We seek to understand perspectives outside of the traditional physician sphere and learn what is missing from physician knowledge and training to make Baylor’s doctors the best leaders for their teams and patients as possible. We are descending from the balcony to engage with those on the ground to understand where there are gaps in medical training and practice. What is missing? What are doctors not learning that they need to learn? What perspectives do they need to take into account? As an overall goal, we want to improve the way physicians treat patients, who “are often at a disadvantage when presented with a health decision because of the novelty, complexity, and stressfulness of the medical challenges they face” and live everyday, unlike the doctors, within a “one shot lived experience” reality.[fn]J.G. Hamilton, et al, “What is a good medical decision? A research agenda guided by perspectives from multiple stakeholders.” Journal of Behavioral Medicine 26 August 2016, 40:52-68.[/fn] The end-goal improvements in physician preparation and in the way physicians treat patients should allow doctors to maintain sovereign professionalism within a constantly changing system. To do this, we need a deep understanding of the physician-patient relationship and the relationships patients have to others within the healthcare systems that have a stake in their healthcare experience. We want to establish lateral and upward communication between groups by encouraging doctors to explore and consider perspectives outside their immediate area of responsibility. We seek to bring the physicians, healthcare associates, and patients together under the common goal of improving the patient experience. The end result is to discover what to add to the curriculum and teach in the future, thus bolstering the technical expertise element of professionalism, and winning the approval of peer groups as physicians adhere to their service ideal and improve the experience of others.

Potential tensions and pitfalls can be expected from this study’s theories. Physicians may push back against the initial loss of autonomy--where others’ opinions and judgements matter and must be taken into account with the patient decision--and a required acquisition of humility--where the doctor must admit they do not have all the answers. Furthermore, in redefining the profession, payment may be allocated differently to the adjoining groups that take part in patient care alongside the physician. The profit incentive for physicians would incite pushback against this measure as well. Lastly, tension may develop between the groups because medical professionals would now be forced to accept criticism from associated groups as legitimate, instead of only criticism from a peer group. The two groups may not believe one truly understands the other.

Beyond the individual physician experience, some may perceive a risk for the nature of the profession to change. In truth, it is already changing in the push for more patients in shorter periods of time, and overprescription of tests based on profit-motivated financing and preventative medicine. Perhaps these theories also pose risks for the profession as whole. For example, in teaching doctors how to ally with other health care groups, their mindsets may shift so that they think more like those groups to the point that the medical profession ends up more to do with, for example, business than public health. But, in my opinion, this is an extreme and unlikely.

There are hurdles in the connection of the theory to the practicality of the study and the study’s expectations for the future, as well. Doctors have not yet been trained to manage or direct this kind of collaboration. Training may require new courses of health systems, which may be hard to implement within an already packed medical curriculum. Push back by medical schools can be expected. Second, there exists a worry of overburdening the physician and over complicating their jobs. Physicians are certainly overstretched and short on time. However, this is precisely why I think education on this allyship is necessary: so the doctor does not become overwhelmed, and is instead aware of the roots of situations and what they necessitate. The doctor will knows who to direct the patient to as well as where the patient is coming from, and so can better tailor treatment for that patient. This can result in fewer unnecessary appointments and more time with the patients still in the waiting room. I believe teaching doctors how to manage these conflicts and become familiar with healthcare groups and systems early will lead to more effective management of physician teams, adjoining teams, and patient care later on.

Our study navigates these tensions and pitfalls through several methods. The first is to listen. Our study focuses on listening to perspectives and values of adjoining groups and patients to fight depersonalization. In the words of John Gardner: “People live in different worlds and are out of touch with one another in essential matters.”[fn]Gardner, On Leadership, 86.[/fn] People wish to be heard and so their participation must be welcomed in order for a common language and goals to be found. Second, we are committed to understanding their perspectives from the roots and understanding the criticisms as legitimate evaluations of the medical profession--suggestions for what doctors should know about what those people need and want, and how they can act to address those needs to reflect the core tenet of the profession. This introduces humility early in physician training, which should prevent it from presenting as a large issue later on. Third, our study’s final goal is to act upon these new understandings, values, and perspectives. Hopefully, BCM will introduce health systems courses and patient navigation initiatives shaped by our interview responses to inform future doctors of the complex world and system they and their patients will live in. Because the initiatives will start at a root educational level, the doctors will be more prepared and familiar from the beginning; this will gradually minimize pushback against a perceived “loss of autonomy.” Instead, the understanding and action upon these new perspectives will touch on empathy and humility and will make the doctors better organizers and communicators. They will better understand their patients’ experiences, what to ask their patients, and who to direct them to and collaborate with in order to improve their care. Hopefully, this redefinition of the profession that starts at education will put doctors in a newfound position where their autonomy is recognized not through isolated decision making, but rather through knowledgeable collaboration and cooperation, facilitated and directed by horizontal leadership principles. In fact, as the physicians refer to their technical expertise in new educational and professional circles, their perceived legitimacy and the dependency of others on their knowledge may grow, bolstering respect for physician authority and thereby autonomy. These methods should guide physicians into positions to maintain their authority, autonomy, and professional status.

Project Description

Writer, physician, and researcher Maree O’Keefe presents a convincing argument in favor of and a model for lay involvement in medical curriculum building.[fn]See O’Keefe’s “Promoting lay participation in medical school curriculum development: Lay and faculty perspectives” (Medical Education, 2007; 41(2):130-137) and “Lay participation in medical school curriculum development: whose problem is it?” (Medical Education, 2005; 39(7):651-652).[/fn] Related studies have mainly referenced patients as general evaluators, but we feel that other groups that doctors currently work with or are expected to work with should have some input to facilitate smoother collaboration. Our project hopes to host focus groups of three kinds: Medical Legal partnerships, social worker/patient navigator, and patients.

When Boston Medical Center instituted the first Medical Legal Partnership in 2001, immediately other institutions saw its potential and sought to replicate it, resulting in an additional 75 partnerships formed in just five years. Today, over 300 Medical Legal Partnerships have been established in 41 states, and the numbers and impact are still growing.[fn]M. Regenstein, et al. “The State of the Medical Legal Partnership Field” (2016 Report) 3 August 2017.[/fn] The National Center for Medical Legal Partnerships states that the mission of MLPs is to “improve the health and well-being of people and communities by leading health, public health and legal sectors in an integrated, upstream approach to combating health-harming social conditions.”[fn]See the The Center for Medical Legal Partnership’s website: http://medical-legalpartnership.org/[/fn] The results of Medical Legal Partnerships over the past decade have been positive and influential, and trends show that they will continue to have a role in the health care field. Our research team has elected to interview a focus group of Medical Legal partners because we believe they can provide a valuable third party perspective. Medical Legal Partners are deeply familiar with the patient’s situation and treatment regimen, and provide valuable direction for and collaborate with the doctors and patients to assure the best and most effective care possible. We believe Medical Legal partners, as the third party observer and member of the doctor, lawyer, patient trio, can provide insight into the doctor-patient dynamic. Perhaps they can articulate what the doctor might not realize the patient needs or is struggling with. We hope the partners can share how they help the doctor and patient improve the situation and care regimen and share that knowledge with future doctors through curriculum. We hope the partners can help identify what needs to be enhanced in medical education, as well as what is missing and what skills the doctors should become familiar with in order to assist in the improvement of a patient’s situation and treatment efficacy. Ideally, as a result of the sharing of these ideas and a resulting implemented program, doctors will be able to collaborate more easily with Medical Legal Partners, so that when a patient has an issues, say, with mold in housing and wishes to address it legally or is worried about legal guardianship for their child and the forming of a will, doctors will know who to collaborate with, what actions they can reasonably take, and who to direct the patients to.

A second focus group we’d like to interview for a focus group is one consisting of patient navigators and social workers. Patient Navigation really drew attention when it was implemented into the Penn State Curriculum after receiving a one million dollar grant from the American Medical Association in 2013.[fn]See Penn State’s article on their website: http://news.psu.edu/story/279329/2013/06/14/impact/penn-state-college-me... Both social workers and patient navigators guide the patient through and over hurdles that they encounter while receiving treatment. They assist the patient in understanding their treatment, the health care system, insurance, and community resources. (A distinction worth mentioning is that social workers have a greater depth of knowledge and connection to the legal and community resources side of treatment, whereas patient navigators--a group that tends to include former nurses--seem to be more intimately familiar with the healthcare system hierarchy and the science behind illnesses and treatments). Like MLPs, social workers and patient navigators serve as guiding forces for patients, but with a greater focus on the healthcare system and the treatment process. However, where MLPs advocate for patients more in a legal and financial context, social workers and patient navigators seem more focused on directing the patient through the healthcare system clearly and cleanly, helping them address some legal and situational issues, and directing patients to community resources. Still, like MLPs, social workers and patient navigators serve as a third party in the doctor-patient interaction, and can provide valuable insight into the patient experience that the patient might not articulate to the doctor and be able to provide advice for the doctor on who he or she could connect with to improve patient’s situation and treatment. A third, outside perspective should be helpful in learning more about the patient’s experience and needs in the healthcare system and outside of it, and how to best address those needs with available resources.

The foundation of these partnerships is cooperation--a central element to horizontal leadership. And yet, there are tensions that may arise within perspective exchange and collaboration between these groups. With respect to the Medical Legal Partnerships, doctors have had a contentious relationship with lawyers, one which is mostly defined by mistrust and wariness, mostly due to malpractice law. It may be difficult to organize a more widespread attitude of cooperation between the professions. Furthermore, doctors may be wary of losing money via redirected reimbursement and insurance plans and of losing some of their autonomy by having to listen to other groups when forming judgement. Lastly, doctors may see patient navigators and social workers as below them and so may not take what they have to say seriously. And yet, I still believe the benefits of collaboration between doctors and patient navigators, social workers, and medical legal partners outweigh the costs because the collaboration serves the holistic treatment of the patient.

Fittingly, then, patients comprise the majority of our intended focus groups. Several medical schools have performed studies with community members to evaluate their performance, including their level of engagement with the community and how well the doctors may be addressing a certain common illness.[fn]See D. Nestel and associate’s “Community perceptions of a rural medical school: a pilot qualitative study” (Advanced Medical Education Practice 2014 Nov 7;5:407-13) and SM Greenfield and associate’s “Community voices: views on the training of future doctors in Birmingham, UK.” (Patient Education Couns. 2001 Oct;45(1):43-50).[/fn] However, we found the literature on gathering curriculum input from community members (who are, in fact, patients) lacking. Patients are, clearly, the ones receiving the care directly are the most vulnerable. Not only are they less knowledgeable and less familiar with the malady than the doctor, but they are emotional and afraid. Their life is the one at stake and they have no second chance (whereas the doctor can always, in a crude sense, try to treat the illness again). Thus, we wish to know how doctors can have better clinical interactions and gather more holistic knowledge of a patient’s situation. Perhaps the patients we talk to with remark on specific medical or insurance policies their doctors consistently fails to understand or address, or perhaps they will remark on the fact that their doctors don’t appreciate the difficulty in transportation or the values of their communities when prescribing a treatment regimen. Perhaps they will mention other members of the health care field who they feel doctors can learn from, or they will mention an aspect of health they wish their doctor would more willingly address with them. Perhaps there are areas of communication and consideration that can be improved as a result of these shared perspectives, and we can draw on the themes we find to propose curriculum changes for BCM.

Next Steps, In Theory

Looking to the future, there are several pieces of information that should be gathered and considered before wider implementation of horizontal leadership and collaboration. On one hand, the economic costs and benefits of a growth in cross-group collaboration need to be evaluated. In some cases, the components of this collaboration are already in place and are only in need of better connection, but in other cases these groups have yet to be established. Establishment and upkeep will cost money. Ideally, however, better informed care will lead to better treatment decision and less wasteful diagnostic testing and direction, which could balance out the costs of facilitating group collaboration.

Furthermore, data should be collected on how Medical Legal Partnerships, patient navigator programs, and social workers are currently compensated; if insurance plays a role in the compensation, then it should be explored what kind of shift in coverage and financing will occur with a greater use of cross-group collaboration. One might consider effects on payer premiums, potential integration of other funding sources, and response of group constituents. Economic costs and benefits need to be quantified to further support physician use of horizontal leadership in practice.

A second practical element to explore before wider implementation is the influence of tort laws, where doctors don’t necessarily want to be liable for everything the patient tells them. Doctors are wary of malpractice lawyers, who can place blame on doctors for any little bit of information told to the doctors that they did not pick up on, risking the future of the doctor’s careers. This fear may make doctors less willing to listen to what the patient says about environmental elements that could be affecting their health, as that would be one more thing for the doctor to worry about that they, in fact, don’t have expertise on but could still be held liable for. Thus, policies regarding liability must be reevaluated so that doctors can feel more comfortable and thus be more willing to listen to their patient and ask questions about broader health influencers. Then, doctors can give their best possible suggestions and directions to allies. This would help the patient optimize the things that are generally in their control, given the constraints of the broader environment, by providing them with resources and better tailored care. Overall, while these costs must be considered and quantified before wider integration is implemented, and while the theory may have its limits, I believe that horizontal leadership and cooperation will make physicians and patients lives easier, not harder, with a more holistic approach to care.

These changes may be more practical for some physician specialties than others. Family doctors and doctors who see patients with chronic illnesses may particularly benefit from horizontal leadership. And yet, I believe that treatment of any patient should be holistic in considering not only the patient's physical and mental needs, but also elements of environment or public health that could be affect them and provide valuable information for treatment. Patient behavior is often a result of their circumstance, and so understanding the circumstance is imperative, regardless of what kind of doctor one is.

The first steps towards these kinds of collaboration are, in fact, already underway. The National Center for Medical Legal Partnerships has held conferences all around the country and has published their data on significant improvements in patient treatment as well as financial improvements for patients, doctors, and hospitals. More institutions through their medical schools and residency programs are implementing patient navigating experience into curriculum or training, and several institutions are establishing permanent patient navigator departments, including one at Houston Methodist at the Texas Medical Center. Furthermore, nearly every hospital in the medical center has a social worker department. These programs exist and are growing and valuable. They serve a need for the community that the doctor is either not engaging with or can’t satisfy completely. Thus, it is important for doctors to be trained in how to collaborate, both for the sake of the status of their profession and to the benefit of the patient.

There are several practical examples of how to implement horizontal leadership principles into curriculum, and future models should include or emphasize thoroughly both the patient perspective and how to address patient needs in a multigroup setting. As mentioned, Penn State has implemented a highly successful patient navigator program in their curriculum. Several schools have implemented community-based learning and engagement tracks, including Baylor. However, something that seems to be lacking in curricula are case-based, group-collaborative courses that bring together the different parties that engage with a patient’s care: the nurse, the social worker, the patient navigator, the physician, the PA, etc. In a 2011 article in American Scientist, health-science policy analyst Nancy L. Jones describes how, at Wake Forest University School of Medicine, PhD students are presented with cases that “cultivate moral sensitivity by presenting the perspectives of multiple stakeholders and promoting awareness for legal, institutional and societal concerns,”and require them to “identify ways that the various stakeholders...could manage their competing interests”.[fn]Nancy L. Jones, “Raising Scientific Experts,” American Scientist Nov-Dec 2011, vol 99: 458-461.[/fn] This collaborative model could apply to the health system, and I think it would be a very informative experience for medical students if they were presented with situations they may encounter in the future, and taught what resources are available for them to collaborate and consult with on behalf of their patient.

Conclusion

Howard Wilensky explained that in the area of colleague relations, two norms seem to be well developed in established professions: the first is for the professional to do what he or she can “to maintain professional standards of work,” and the second is “to be aware of the limited competencies of [his or her] own specialty within the profession, honor the claims of other specialities, and be ready to refer clients to a more competent colleague.”[fn]Wilensky, "Professionalization," 137-58.[/fn] Members of our first trial focus group at the end of July shared this sentiment; one person, who had worked in hospitals as a medical professional for decades, declared that he would never trust a doctor who said they knew everything, and that if a doctor does not have an answer for the patient, he or she should be able to either go find the answer or direct the patient to someone who does know. In any case, both established norms described by Wilensky are essential to the maintenance of “the technical service ideal”--in the physician case, “to do no harm,” or to treat the patient to the best of the physician’s abilities. The best way to achieve these objectives, to be able to “honor the claims of other specialties” and maintain professional standards, is for physicians to operate with a horizontal leadership mindset. In a health care system that has stretched doctors thin, the view of their profession has narrowed so much that, as a budding element in an assembly line, while they feel the outside pressures of other healthcare forces, they do not understand them nor know how to navigate them most effectively for themselves, much less for their patients. Medical professionals, then, must descend from their balcony, step outside their profession’s box, and consider other perspectives and other reasons for problems when making decisions. John Gardner elaborates that “depersonalization of the society may be a greater enemy than autocracy.”[fn]Gardner, On Leadership, 104.[/fn] In other words, to navigate a growing bureaucracy and hospital autocracy, depersonalization must be avidly avoided: convergence issues must be highlighted for common goals to emerge, for the flourishing of all related segments within a system, and thus the related constituents of a system must be listened to. Gardner further argues that constituents--physicians included--must be adequately informed to make sound judgements, but that there is so much information to know that it becomes hard to remember and navigate the information. That is why allyship is necessary, and why physicians must humbly accept that they cannot know or solve everything alone, and so should adopt a new form of autonomy and leadership that advocates for cross-boundary collaboration and better-informed judgement. In other words, the response to diverse and growing pressures on doctors, which are leading doctors to potentially become mere pieces in an assembly line, requires a reevaluation of the profession.

My project with Baylor College of Medicine seeks to explore the redefinition of the profession through the consideration of adjoining perspectives, with the final goal of understanding how to best prepare doctors, including how to ally with system constituents, to best address patient needs starting in medical school. Our project puts into practice the horizontal leadership theory that hopefully will trickle down to future doctors--where in order to fulfill the technical service ideal of their profession and maintain authority and autonomy as the connecting point in this changing and challenging health care system, physicians must enact horizontal leadership methods, eliminating insularity between groups by fostering communication; understanding perspectives, values, and providable services; and working for collaboration between groups to improve patient care and make the health care system more manageable for everyone.