1. How do the unique goals, values, structures and interpersonal orientations of doctors and managers lead to tensions between the two groups? How might the relationships between doctors and managers be improved?

Tension between doctors and managers arise from the different perspectives and values the two groups hold even though both are working towards the same aim of improving the health of patients (these values are a generalisation and do not reflect the views of every doctor and manager). These views, especially those of doctors, arise from the socialisation into a particular set of beliefs associated with the profession, which is then exacerbated by the isolation of doctors from other professionals during training and then in the workplace (Edwards, 2003).

Doctors focus on each individual patient with the primary goal of providing the best possible care, taking personal responsibility for the outcome (Edwards, 2003), while managers are more focussed on the running of the ‘business’, with the main goal of managing costs so that the most people benefit from the limited resources available (Glouberman & Mintzberg, 2001). There is generally a misunderstanding between doctors and managers regarding their prime motivations. In a survey conducted in the United Kingdom, seventy six percent of clinical directors believed that management were more driven by financial reasons than clinical (Rundall, Davies, Hodges, & Diamond, 2004). These differences in priorities cause conflict with allocation of resources, as managers, who understand the need for compromise and value accountability over autonomy, may not allow expensive tests and treatments without sufficient evidence of the benefit, and doctors may be offended at having to justify their clinical decisions (Edwards, 2003), especially to someone who lacks medical knowledge (Glouberman & Mintzberg, 2001). Doctors, generally, do not allow financial costs to influence their medical decisions and feel that restricting practises due to costs are harmful to the patient and prevent doctors from doing their job properly (Edwards, 2003).

One of the largest issues causing conflict between doctors and managers is the shift of control from doctors to managers, with doctors feeling that their autonomy is disappearing (Blank & Burau, 2007). Doctors value autonomy, the ability to dictate their own workload and priorities (Davies & Harrison, 2003). As managers must also align with outside bodies such as the board and the Government, and implement rules and procedures in response to pressure from external factors, especially those concerning costs (Edwards, 2003), they may make decisions that doctors do not agree with, such as increasing workload and cost cutting, leading to tension between the two groups (Rundall et al., 2004). Doctors seem to have an inherent mistrust of managers and their ability to perform their job competently (Rundall et al., 2004) and feel that the decisions and rules imposed on them limits their ability to best diagnose and treat their patients (Stoeckle, 1988). This inevitably leads to a power struggle between the two groups as they try to work against each other instead of together.

The differing views on working relationships also contribute to the tension between doctors and managers, as doctors prefer to work individually, while managers prefer a system that is more hierarchical, teamwork based, with sharing of responsibility (Edwards, 2003). Many doctors believe teamwork undermines their authority and autonomy, and conflict occurs when managers try to implement teamwork procedures in an effort to increase efficiency and quality of care (Edwards, 2003).  This is illustrated by the difference in opinion regarding the relationship between the two groups. In the survey mentioned previously, seventy six percent of chief executives were positive about the relationship between doctors and managers while only thirty seven percent of clinical directors were positive (Rundall et al., 2004).

There are a number of strategies that can improve the relationship between managers and doctors. These include strategies to improve communication between doctors and managers, provide greater transparency in making decisions and more involvement from doctors in decision making (Rundall et al., 2004). These approaches are interrelated and each affects the success of the others. Improving communication involves employing all forms of communication to bring together the different perspectives using initiatives such as regular newsletters and group meetings, to provide a platform for different groups to express their opinion and share news, in order to gain a better understanding of each others’ roles, responsibilities and motivations (Rundall et al., 2004). Increasing understanding helps to build a mutual trust and this, in turn, helps develop a strong relationship and also assists in the second strategy of transparent decision making.

Greater transparency in decision making is achieved through communication, allowing doctors to understand the reasons for the decisions that managers make, and the necessity of those decisions (Rundall et al., 2004). By understanding those choices, doctors are more likely to accept them and the limitations that result. Another way to improve the clarity of the motivations behind decisions is to increase the involvement of doctors in decision making, especially those concerning resources and ethics (Edwards, 2003). Increasing the input of doctors may also involve more doctors becoming managers (Rundall et al., 2004). As these managers would have clinical knowledge, doctors may be able to trust and relate to them more, relieving some of the tension between the groups. Involving doctors in important decisions allows discussion and consideration of both parties’ perspectives (adding the clinical perspective to management decisions), and compromise between the two extremes of opinion by developing a common approach to decisions (Edwards, 2003). Collaborative decisions are more likely to satisfy both parties and benefit the most people, especially patients, by removing the opposition to management decisions from doctors who do not agree.

2. Consider how the focus of healthcare work has changed over time from treating and curing infectious diseases to managing chronic conditions. Discuss the impact of this change on the traditional roles, responsibilities and autonomy of physicians.

For many years, the focus of health care was centred on diagnosing and curing communicable diseases, but in recent years this has moved to focus more on managing chronic conditions due to a rapid increase in the prevalence of chronic illnesses (Pruitt & Epping-Jordan, 2005) Although the rates of chronic illnesses have risen in all countries, this shift in focus is more significant in developed countries, as developing countries still have a huge problem with infectious diseases, channelling most of their focus there (Yach, Hawkes, Gould, & Hoffman, 2004). This change has come about due to medical advances and a change in lifestyle which has caused chronic illnesses to be the largest cause of death in the world (Yach et al., 2004).

New medical knowledge and technology has dramatically increased life expectancy and has contributed to an ageing population (Wagner et al., 2001). The frequency and severity of chronic conditions increases with age and this has caused a significant increase in the prevalence of chronic illnesses, especially in comparison with acute diseases (Rothman & Wagner, 2003). This medical knowledge has also allowed people with chronic illnesses to live longer, increasing the demand for health services for managing and treating chronic conditions such as diabetes and cardiovascular disease (Wagner et al., 2001). Lifestyle changes (usually associated with globalisation and urbanisation) including smoking habits, diets containing high levels of saturated fats and increased sedentary behaviour are all risk factors for many chronic conditions (Yach et al., 2004). For example, by controlling obesity, the risk of diabetes can be reduced by fifty to seventy percent (Health Funding Authority, 2000). Although recent public health schemes have been targeting these issues and risk factors, chronic conditions result from an accumulation of risk factors over a long period of time and the present prevalence of chronic conditions is a result of  exposure to these risk factors in the past (Yach et al., 2004).

This change in focus towards management of chronic conditions has and will affect the way physicians treat their patients, because chronic illnesses require different services than patients with infectious diseases. Often, chronic conditions require management over a lifetime, and the strategies used to manage these illnesses do not just involve diagnosing and prescribing treatment (Yach et al., 2004).

One of these new roles is individual based prevention. This involves identifying risk factors in individuals and their risk of developing the disease, and then working with the patient to lower their risk by making lifestyle changes such as cessation of smoking (Health Funding Authority, 2000). This is a change from the role doctors play with infectious diseases, as the prevention strategy is specifically targeted to the individual instead of the entire population, like vaccinations are, and treatment of the patient can begin before symptoms appear (Yach et al., 2004). Preventing the illness instead of just treating or curing it will reduce the prevalence of the disease in the population. Early detection of the disease is also a new role, and this involves screening high risk individuals for the disease before, as well as after, symptoms appear (Health Funding Authority, 2000).

The way in which chronic conditions are treated has also changed. Traditionally, with infectious diseases, doctors would diagnose and then treat the patient, often with a generic treatment or drug, but with chronic conditions, once the diagnosis has been made, the physician works with the patient to devise a treatment and self-management plan which is unique to each individual, taking into account their needs, expectations and the roles of their family and community (Health Funding Authority, 2000). Patients set their own goals and decide what works best for them, removing some of the decision making from the doctor, who takes the role of advisor and educator (Health Funding Authority, 2000). The treatment plan must actively involve the patient, their family and community as the treatment of many chronic conditions includes a change in lifestyle, requiring family support (Yach et al., 2004).

Regular follow ups are also required for patients suffering from a chronic condition, as their treatment may need to be adjusted or complications may occur, and actively seeking out patients for follow ups is also a new responsibility (Health Funding Authority, 2000). However, increasingly with chronic conditions, many of the services required after the initial diagnosis and treatment can be provided by other health professionals (Bayless & Martin, 1998). Chronic care provided by a team of different health professionals can be more effective than care from just a physician, and this reduces the doctor’s autonomy as they must also rely on and answer to the opinions of other professionals (Pruitt & Epping-Jordan, 2005). For example, a patient with diabetes needing regular checkups can be seen by a diabetes nurse who can review the patient’s everyday treatment plan and make changes (Bayless & Martin, 1998). This reduces the role of doctors with the ongoing management of chronic conditions, as the nurse may only refer the patient to the doctor when required, whereas traditionally, with infectious diseases, the treatment of the patient is almost fully managed by the physician (Health Funding Authority, 2000). The doctor’s role regarding a diabetes patient, for example, may just be the diagnosis and treatment of the initial condition and any resulting complications such as diabetic retinopathy (Health Funding Authority, 2000). Even though the physician may not regularly meet with the patient, the doctor usually takes on a leadership role in the team of professionals caring for the patient (Bayless & Martin, 1998).

3. Explore what these changes mean for the future of the healthcare workforce. Describe the type and mix of professionals that will be needed. Explain how they will need to work together and where they will need to work.

Chronic conditions require a different approach to treatment than infectious diseases and this means that the way the healthcare work force operates must change (Wagner, 2000). Treatment of these conditions must involve a team of professionals with a range of services, for effective treatment and management of the disease (Bayless & Martin, 1998). The health professionals that comprise these teams vary depending on the disease but all incorporate some common professions. These include doctors, nurses, pharmacists, allied health and community health workers (Wagner, 2000).

Doctors traditionally took responsibility for the full treatment of patients, but this is now moving towards doctors working as part of a team that is designed to increase efficiency (especially in coordination of services) and cater for all the needs of the patient. Doctors will continue to diagnose and treat the patient’s condition, while practice and specialist nurses coordinate the everyday management and care of the patient (Bayless & Martin, 1998). Pharmacists may also be part of these teams providing the necessary drugs and developing a schedule that has fewer or less severe side effects and increased effectiveness (Wagner, 2000).

Other professionals and allied health workers are also required. These professionals can include dieticians (for patients with conditions such as diabetes and cardiovascular disease), who educate patients and help create healthy eating plans and goals that are specific to the patient’s lifestyle and situation (Bayless & Martin, 1998), and podiatrists (for diabetics), who work with patients to care for and prevent diabetic foot complications (Health Funding Authority, 2000). The other type of health professional that makes up this team is community health workers, who provide support for the patient that the other members of the team may not be able to (Wagner, 2000). The rates of chronic conditions such as diabetes is much higher in minority groups like Maori and Pacific Islanders in New Zealand, than other ethnic groups, and because the health system may not be designed to best care for these patients, community health workers help to overcome the cultural and language barriers that these patients may face (Wagner, 2000).

This team of professionals will need to work together to provide coordinated care for the patient. Regular meetings and communication can facilitate this, allowing each member of the team to discuss their professional opinion on the progress of the patient and any changes that need to be made to the patient’s treatment plan (Bayless & Martin, 1998). Good teamwork and integration is required to make the patient’s treatment effective as disjointed contributions from a large range of providers could be detrimental and confusing for patient (Pruitt & Epping-Jordan, 2005). The care team should mostly be based in the community, making access to these services much easier, and patients should only have to visit specialists and hospitals rarely as these can be very difficult to get to, especially if the patient lives in a rural area (Pruitt & Epping-Jordan, 2005). Treatment and management of a chronic disease must take place in a community setting as it requires a change in lifestyle and support from and for the patient’s family and community for it to be most effective (Rothman & Wagner, 2003).

References

Bayless, M., & Martin, C. (1998). The Team Approach to Intensive Diabetes Management. Diabetes Spectrum , 11 (1), 33-37.

Blank, R. H., & Burau, V. (2007). The Medical Profession. In Comparative Health Policy (pp. 131-158). Basingstoke: Palgrave Macmillan.

Davies, H. T., & Harrison, S. (2003). Trends in Doctor-Manager Relationships. British Medical Journal , 326, 646-649.

Edwards, N. (2003). Doctors and Managers: Poor Relationships May Be Damaging Patients - What Can Be Done?. Quality and Safety in Health Care , 12 (1), 21-24.

Glouberman, S., & Mintzberg, H. (2001). Managing the Care of Health and the Cure of Disease - Part 1: Differentiation. Health Care Management Review , 26 (1), 56-69.

Health Funding Authority. (2000). Diabetes 2000. Wellington: Ministry of Health.

Pruitt, S. D., & Epping-Jordan, J. E. (2005). Learning in Practice: Preparing the 21st Century Global Healthcare Workforce. British Medical Journal , 330, 637-639.

Rothman, A. A., & Wagner, E. H. (2003). Chronic Illness Management: What Is the Role of Primary Care? Annals of Internal Medicine , 138 (3), 256-261.

Rundall, T. G., Davies, H. T., Hodges, C., & Diamond, M. (2004). Doctor-Manager Relationships in the United States and the United Kingdom. Journal of Healthcare Management , 49 (4), 251-270.

Stoeckle, J. D. (1988). Reflections on Modern Doctoring. The Milbank Quarterly , 66, 76-91.

Wagner, E. H. (2000). The Role of Patient Care Teams in Chronic Disease Management. British Medical Journal , 320, 569-572.

Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving Chronic Illness Care: Translating Evidence Into Action. Health Affairs , 20 (6), 64-78.

Yach, D., Hawkes, C., Gould, C. L., & Hoffman, K. J. (2004). The Global Burden of Chronic Diseases: Overcoming Impediments to prevention and Control. The Journal of the American Medical Association, 291 (21), 2616-2622.