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A Medical Director’s Perspective

Understanding the Physician Perspective
By Christopher Snyder, DO

“The first duty of a wise advocate is to convince his opponents that he understands their arguments, and sympathizes with their just feelings”
Samuel Taylor Coleridge, 18th Century English Philosopher

Effective interventional case management depends on trust and demonstrating progress in the patient’s chart. Documentation showing
relationships, but can at times seem closer to refereeing between good progress creates pressure for discharge to a less acute level of care.
opponents. The medical director of case management is an advocate If a physician does not understand the nuances of the criteria for level of
for case managers, the medical staff and, ultimately, the patient. While care decisions, he/she may not recognize the impact of the
often times the opponent is a third-party payer, care must be taken to documentation. Consequently, when documentation “pushes” a
prevent relationships with attending physicians from becoming discharge or transfer too quickly, a patient may be readmitted soon after,
adversarial during the case management process. One major cause reflecting poorly on the physician’s quality of care, creating additional
of this potential adversarial perception is that many physicians (perhaps unreimbursed) costs for the hospital and potentially placing
increasingly feel that they are on the defensive most all the time. the patient at unnecessary risk.
Understanding what contributes to this sense of “being under attack”
allows medical directors (and case managers) to better communicate
with and influence attending physicians. There exists a sound and
sympathetic common foundation of knowledge and experience upon
which to build lasting, positive relationships. This article examines In order to be effective and credible,
some major concerns shared by many practicing physicians, and
presents strategies to address and incorporate these concerns in a medical director supporting case
medical director-physician interactions. Doing so will increase the
medical director’s ability to succeed in accomplishing both his role in management will need to incorporate
supporting case management requirements and providing advocacy
with third party payers on behalf of physicians and their patients. these concerns into interactions with
DOCUMENTATION practicing physicians.
Medical documentation continues to grow in its importance to
healthcare transactions of all types, and expectations are both very
high and very specific. Several different parties review a patient’s medical
record during and after a care episode – case managers review charts Hospitals are similarly focused on caring for patients, and must
concurrently to the care being provided, payers review charts to determine also ensure they have the resources to provide care in the future.
if and how much a hospital and physician will be compensated for This requires effective documentation, as it directly affects hospital
providing the care, and quality initiatives necessitate review and reimbursement. Tensions and suspicions can develop because of these
abstraction of data. When the medical record replaces actual conversation different needs; hospitals may be perceived as solely focused on
as the only communication of the physician’s medical judgment, its reimbursement while physicians may be thought to not care about
importance is elevated further. It is critical that the documentation documentation quality. Physicians, as well as hospitals, can be
effectively communicate the physician’s active plan of care. aware of and caught in this tension. Ultimately, the most effective
Documentation is, in some ways, a dialogue between the physician documentation accurately and completely reflects the acuity,
and the hospital – the means by which a physician conveys a patient’s clinical state and needs of the patient, and through this accuracy
symptoms, diagnoses, treatment, and progress – and the tool used by provides optimal benefit to physicians, hospitals and patients.
case managers to assure the patient receives the appropriate level of
care. Ultimately, it is also the tool by which the hospital is reimbursed for THREATS TO AUTONOMY OF PRACTICE AND AUTHORITY
the cost of providing care. A certain tension can develop in this dialogue, In any medical case, attending physicians are the authorities over
and the physician’s and the hospital’s needs regarding documentation patient care and expected to lead the care team. They most often
can potentially be viewed as competing with each other. possess the highest level of training, knowledge and skill. With their
Physicians are committed to healing or curing their patients and level of medical training, they are not only often the most educated
are naturally inclined to document improvements to this end, clinician on the case but also the one most accountable for the patient’s

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outcome. Generally, physicians understand and are comfortable in this Many have heard this condescendingly called “cookbook medicine.”
role. Although most also understand the important need for guidelines Strict guidelines, protocols and care pathways can feel like a “recipe” to
and accountability, guidelines that appear to be driven by anything a physician with a patient who simply does not fit the parameters of
other than actual patient condition and prognosis raise serious the “prototype patient.” Payers, however, see the consistency of these
concern. Any restrictions on physicians’ judgment and ability to put protocols as a means to assuring a level of quality of care and
the patients’ interests first are viewed as ominous and threaten a predictability of costs.
physician’s autonomy of practice. These restraints can and do come Moreover, over-reliance on this approach seems to threaten the
from various sources: very reason many physicians chose to pursue medicine, and what they
love most about practicing medicine – the use of critical thinking skills,
Hospital the process of diagnosing and developing treatment plans, and helping
When case managers’ review and “management” of a patient’s to heal challenging patients.
course of treatment is perceived as a restraint on a physician’s This tension also appears to launch a direct attack on several
autonomy of practice, this can especially impact trust and things that are held sacred to physicians – that they will treat their
communication between the medical staff and the medical director patients without respect to the type of insurance they hold.
of case management. Case management is a function of the hospital Physicians are likely to resent any interference by third-party clerical
administration. Administration is involved in the negotiations with or financial staff members who have neither the medical
payers or clinical service lines regarding many of the guidelines and qualifications nor the first-hand knowledge of the patient, or who
perceived restraints on the practice of medicine, and can potentially be appear to advocate for patient care decisions on the basis of financial
viewed as an opponent for this reason. It is important to recognize this rather than clinical implications. This resentment can impede taking
filter through which case managers and the department may be appropriate documentation steps that could defuse a future
“heard” – that the case management department and its employees challenge or denial by a payer.
may well be viewed as having more administrative power than a Compounding these tensions is the constant threat of litigation
physician. The feeling of powerlessness is uncomfortable for most regarding liability, negligence and malpractice threats. This ever-
people, and is especially so for physicians who have the ultimate present threat makes some physicians feel that practicing medicine
accountability for patients

Patients
An engaged patient, proactive in his/her own treatment and
recovery, is always a delight for a physician. However, the advent of the The goal of the medical director
internet, pharmaceutical “direct-to-consumer” marketing, and endless
opportunities to view health “experts” and experiences on various should be the perception that
media sources, have created a significant challenge for physicians.
Armed with just enough information and understanding to be he or she is working to assure
dangerous, some patients are placing themselves in the position of
“overseeing” their doctor’s decisions rather than engaging in a that the medical staff has the
meaningful discussion about treatment – ready to ask questions and
learn. Physicians’ years of training and experience build effective maximum autonomy possible
medical judgment, and when patients do not recognize or respect this
level of knowledge, it creates significant frustration for physicians.
while providing accountability for
Payers
hospital quality assurance.
Medicare and other payers continue to increase their reliance on
Evidence Based Medicine (EBM). The scientist inside a physician
understands the value of this approach to the science of medicine.
However, the experienced practitioner inside the physician sees too requires more calculated risk than the fulfillment of a passionate desire
heavy a reliance on EBM guidelines as the removal of intuition, to help people. Underlying these resentments, however, is the reality
listening, past experience and unique co-morbidities that truly that by following EBM guidelines, physicians will actually protect
distinguish an excellent physician – able to practice the art of medicine. themselves from future litigation

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Understanding the Physician Perspective (continued from page 15)

PATIENT AND SOCIETAL EXPECTATIONS STRATEGIES FOR MEDICAL DIRECTOR EFFECTIVENESS

With more and more medical advances, expectations continue In order to be effective and credible, a medical director
to increase that a visit to the doctor will bring a full return of health. supporting case management will need to incorporate these
The amazing capabilities of our healthcare system can be a concerns into interactions with practicing physicians. This can take
double-edge sword when it creates false hope and unrealistic several potential forms, from more formal “internal marketing”
expectations for complete “cures.” This atmosphere puts enormous regarding the how case managers can provide valuable partners in
pressure on physicians and families alike, and may lead to pressure such concerns as documentation and difficult social situations, to
for unrealistic or medically inappropriate treatment. informal incorporation into daily medical director-physician
Additionally, while the last few decades have produced great interactions. The following are three specific strategies to
leaps in our understanding of treating and preventing disease, there incorporate these practicing physician concerns for medical
has not been a corresponding increase in the level of responsibility director effectiveness.
taken by many patients regarding compliance with treatments
plans, or healthful or preventive behaviors. For example, a patient Act as Physician and Medical Staff Advocate
with newly diagnosed diabetes who is morbidly obese, alcoholic, to Hospital Administration
and smoking two packs of cigarettes per day may not ever have Physicians value an ally when dealing with problematic family
easily managed glucose levels – despite the care team’s best efforts members, payers and administrative policies. Case managers can
at education and access to the best pharmaceuticals. effectively provide advocacy, and a medical director needs to be
Emotional situations can also be intimidating, time consuming perceived as a strong and credible medical staff ally. For example, a
and frustrating for physicians. Raw emotions, which are present in medical director can help physicians understand the continual
most serious or end-of-life medical situations, often decrease the changes in the healthcare environment and how those changes
patient and family’s ability to make difficult and timely decisions, impact interactions with the many constituencies to whom a
and can increase the pressure placed on the physician to create a physician is accountable. The goal of the medical director should be
cure. Also in many such cases, conflicts arise between patients and the perception that he or she is working to assure that the medical
family members as these individuals struggle with decisions. staff has the maximum autonomy possible while providing
accountability for hospital quality assurance.
QUALITY REQUIREMENTS AND REPORT CARDS
The traditional view of what constituted a “good doctor” was Provide the Voice for Medical Staff Concerns in Administrative
based strongly on patient experience – a physician who sees and and Payer Discussions/Negotiations
treats his patients as unique individuals, listening to and addressing By working with all of the healthcare team, a medical director
their unique concerns and particular ailments. The definition of an can ensure that all parties are being represented fairly and
effective physician, however, has radically changed through the communicating effectively. More important, a medical director has
efforts of both payers and healthcare quality oversight access to payer and administrative negotiations, and can provide
organizations. Today, physician report cards and quality data on voice and champion for medical staff concerns – especially where
both physicians and hospitals are readily available. those concerns align with case management priorities.
Are the current measures adequately measuring the quality
of a physician’s professional performance? Do these measures Develop Improved Data Metrics to More Accurately
truly represent physician quality? Many physicians strongly Reflect Physician Practice
question the validity of the currently accepted measures. The Medical directors working with case management are
current measures have primarily been developed by payers and are uniquely positioned, through access to reporting tools and
strongly based on charge captures, which are highly subject to interface with both physicians and administration, to develop
inaccuracies and the effectiveness of a physician’s documentation. improved data measurement that more accurately reflects
Physicians have little input or control over which statistics are used physician quality practices. Improving metrics will be the outcome
to paint the picture of their quality of care. While such statistics as of open communication between hospitals and physicians, and
mortality are important, these do not account for long-term medical directors provide the necessary link to create such a
outcomes and quality of life for patients, particularly with chronic positive partnership.
diseases such as CHF (Congestive Heart Failure) or diabetes.
Christopher S. Snyder, DO, is Chief Medical Information Officer,
Additionally, most physicians are responsible for patients
Utilization Medical Director, and Hospitalist at Peninsula Regional
across many different levels of care. Acute care is perhaps the most Medical Center in Salisbury, MD. Dr. Snyder has been in his current
resource-intensive settings, but is by no means the level of care in position for seven years. He was previously in Family Practice for five
which the physician can most influence the long-term quality of years. Dr. Snyder earned his DO at Kirksville Osteopathic in Kirksville,
life for his/her patients. MO, and is board certified in family practice.

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