Agent for change: Doctors must buy into shifts in practice

One of the more popular Super Bowl commercials in recent years depicts a group of cowboys on the range, driving the herd to its destination.

Rather than cattle, though, the cowboys are tending to cats.

The ad, which promoted a technology services company, probably elicited chuckles from a few physician leaders. They might have seen parallels to their practices, where proposing change among a group of doctors can be a challenging task.

"It's kind of like herding cats, because physicians are all such independent people," said William G. Gamel, MD, CEO of TMF Health Quality Institute, a Texas quality improvement organization for Texas. "Time is money, so you have to show how they're going to benefit from the change."

Persuading physicians, and to a lesser extent staff, to embrace a new idea can be like trying to convince the Tasmanian Devil to stop spinning and walk. Doctors are always in a flurry of activity, and chances are, a change is just going to slow them down.

But by appealing to physicians' intelligence, offering proof of the benefits and involving doctors in the decision-making process, group leaders have been able to spearhead change in their practices. The same principles apply to a group of any size, although it's obviously easier to get a small group together for a meeting, doctors said. But having a smaller group does not guarantee you'll reach an agreement, they said.

Whether you're trying to adopt an office policy or purchase a six-figure electronic medical record system, you need physician buy-in to phase in the initiative smoothly. The problem is that because of their skill, talent and knowledge, physicians generally are even more resistant to change than the general population, said Craig Samitt, MD, an internist and chief operating officer of Fallon Clinic, a 260-physician multispecialty group based in Worcester, Mass.

"Simply being a charismatic leader might not work," Dr. Samitt said.

Several years ago, Fallon Clinic underwent a transformation that focused the group more on service and applied benchmarks commonly used in other industries to measure performance.

The vision necessitated ground-level changes among physicians and staff. The magnitude of the change usually helped determine the strategy clinic leaders used to persuade physicians. About four years ago, for example, the clinic simply required physicians to start using the voice mail system, but it took more inclusive approaches when it came time to address global issues, Dr. Samitt said.

"Doctors appreciate constant communication, and inherently, they want to do the right thing," Dr. Samitt said. "If you essentially just said to me that you want to improve on X but didn't offer any evidence for why, I would challenge you."

That's what makes data so important, consultants said. If you're trying to show your partners why the practice needs a new ultrasound machine, you should put together a profit-and-loss projection for the equipment and collect information that proves it will be a clinical benefit for patients, they said.

Not only does the presentation have to be well-prepared, but it also has to be well-timed, said Kathy Bowman Atkins, president of the Lattitude Group, a business consulting and coaching firm based in Greensboro, N.C.

Introducing the idea well before your target implementation date gives doctors "more touch points" as well as time to digest the information, she said. A business-style SWOT analysis, which analyzes the project's strengths, weaknesses, opportunities and threats, can make the idea easier to embrace, she said.

"Most doctors are analytical people," Bowman Atkins said. "So if you can work through that and show a return, both quantitative and qualitative, they might be more apt to accept it."

Staff likely will follow the physician's lead, said Elaine Berke, founder and president of EBI Consulting in Westport, Mass. Conversely, while staff members don't wield the same power in the group as a physician, they certainly can influence the doctors, so it's important to keep them informed of pending changes, she said.

Front office staff might spend the most time working on a new practice management system, for example, so their comfort level is key to the project's success.

"[Staff members] will keep their grumblings to themselves, but they'll ask things like, 'Do we really have time for this?' " Berke said. "You have to be prepared for those questions."

Seeking involvement

Of course, doctors will be more likely to embrace an idea if they have been involved in its formation, experts said. Larger groups generally will form committees to address certain topics, while smaller groups simply might have all partners meet regularly, with different physicians taking the lead on varying projects.

When Lexington Clinic, a multispecialty group with 160 physicians in Lexington, Ky., began looking into buying an EMR a few years ago, it started by using a steering committee to investigate the project's feasibility.

As the idea grew legs and moved into an implementation stage, the group phased it in by first installing the system at pilot sites, where enthusiastic supporters could work through the kinks, said Michael McKinney, MD, an internist and pediatrician with the group.

"A lot of times, the groups we set up are made up of people interested in the project," Dr. McKinney said. "The good side to that is they are very enthusiastic, but the bad part is you could lose the views of the people who aren't enthusiastic."

The way to avoid further alienating resisters is by educating them about the project and engaging them to help pick out the flaws, physicians said. Not only will doctors be more tolerant when issues arise, but their input also will help solve problems more quickly, they said.

"A lot of doctors feel when a decision is made, it will be forced down their throats," said David Delaney, MD, a critical care physician at Beth Israel Deaconess Medical Center in Boston and vice president and chief medical officer of MedAptus, a health technology company. "But if you feel like you're part of the team, when you have any hiccup along the way, you're engaged and you want to help fix it."

When resistance persists

Despite your best planning and involvement efforts, you might not be able to win over everyone to your idea immediately. If you laid the right foundation, though, the politics of the situation might work itself out over time.

Within every group, you will have early adopters, resisters and doubters, consultants said. Rather than taking on the adamant opposition, you should try to sway those on the fence and let peer pressure run its course, they said.

Letting the group police itself is one of several strategies Fallon Clinic uses when it's trying to spearhead change, Dr. Samitt said.

Adopters, enthusiasts and anyone who was intimately involved with the project committee naturally will spread their support through the group, which will filter down to the doubters and eventually the resisters.

It's a word-of-mouth, one-on-one method of persuasion that can have a more powerful effect on a group than a top-down announcement, he said.

Dr. Samitt said the group pulls several other "levers" as it sees fit. A short-term option of persuasion is data comparing physicians who have adopted a proposed strategy to those who have not to prove financial benefits. A longer-term strategy involves actually recruiting new physicians to the group who will "embrace change, so the resistance gets diluted," Dr. Samitt said.

Once you have successfully persuaded partners to embrace a new idea, of course, your credibility is at stake.

If you don't deliver on your promise or if the project doesn't meet physician expectations in a reasonable amount of time, you could hinder your chances of spearheading further change, said Bart Asner, MD, CEO of Monarch HealthCare, an Irvine, Calif.-based IPA representing 1,800 physicians.

Monarch had to sell its contracted physicians on the Integrated Healthcare Assn.'s Pay for-Performance plan, which involves six of the largest health plans in California. Through gradual education and soliciting input, the IPA convinced doctors to be a part of the program, "and now they've gotten their bonus checks, so they feel good about it," Dr. Asner said.

"You can't make idle promises, and you can't overpromise," he said. "Physicians have been so beaten down in so many areas that they're naturally skeptical."

And yet physician leaders understand that above all, doctors would just like respect and open lines of communication.

"Physicians want a seat at the table," Dr. Delaney said. "Communication is everything."