This article was originally published on 1/17/2012

“I’m as mad as hell, and I am not going to take this anymore!”*

I think I know why physicians seem so ticked off right now. You may say physician discontent is an old story, but right now it feels different.

I know this from almost a year of traveling around the state talking to physicians. They’re almost universally discontented and worried right now, and many feel backed into a corner and silenced by what I’ll call the “conflict triangle.” (I’ve avoided allusions to the Bermuda Triangle, but please feel free to draw your own conclusions.)

Standing at the vertices are management physicians, employed physicians, and independent physicians. They’re eyeing each other, but often they’re not really communicating.

The conflict triangle is a product of the laser focus that hospitals and health systems on retaining and growing market share while improving quality. To do these things simultaneously, and quickly, they’re busy hiring physicians, appointing quality oversight, and encouraging (either indirectly or directly) internal referrals and trying to make many changes in a short time.

What most of them are not doing—and quite honestly may not know how to do—is to consider how these rapid changes are affecting physicians across the board. And physicians aren’t talking to each other about it because they feel trapped in their respective corners.

In one corner, management physicians are torn between the white coats and the suits. They’re attracted to employed salaries, passionate about the focus on state-of-the-art quality improvement, but at the same time frustrated by lack of interest in quality improvement (QI) among rank-and-file and independent physicians. And they may hate the pressures from above to meet financial and institutional goals.

In another corner, independent physicians wearily head home many a late night worried about daily reimbursement challenges, escalating loss of referrals and disenfranchisement from local hospitals. They lament the number of colleagues who are now employed, and apparently free of the struggles of running a practice, and now refer to fellow employed physicians. They swallow their rancor about the mounting daily struggles of running a practice while pressured globally to improve quality and implement EMR.

In the final corner stand the employed physicians, many younger and iPad in hand. Their complaints vary; some are satisfied with the compensation and work environment; others gripe that they are unheard, overworked, and compensated solely on “production.” Still others resigned from trying to run their own practices and “sold out” to a hospital purchase. Practicing medicine as an employee is not what they thought it would be. They face no easy way out of their restrictive covenants and referral mandates. They worry about being fired on a whim. Clinging to commitments to family and community, they also worry that they’re trapped and voiceless, for fear of being labeled a troublemaker.

So how can we start open and honest dialogue? How can we use the Pennsylvania Medical Society’s resources to help bend the triangle into a circle of health care quality and value? Do governance changes come first? What about incentive alignment? How do we prevent the conflict triangle from becoming a Bermuda Triangle in which all focus and goals are lost and the triangle envelops the state?

*http://en.wikipedia.org/wiki/Network_(film) accessed 1/17/12