Dr. Robert Bowman explains how a community solved the problems of physician recruitment and retention by seeing that the two problems are really one: how to build quality relationships.
When people focus on quality, the rest falls in place. That was the credo of William Edwards Deming, the 20th Century’s guru of organizations. A statistician and expert in product design, Deming found that insistence on quality often incurs higher costs at first, but in the longer run costs are lower and the entire system improves.
A core concept, and my favorite among Deming’s ideas, considers quality in “the matrix of relationships.” This principle is key to health care.
many ways our country seems to be instructing the world to de-emphasize
the most important human bonds: the earliest parent-child
relationships, student-teacher relationships, the sense of belonging.
These connections affirm people in life and ground
them in community, family and health. In medical education where a priority should be on relationships, this focus is displaced by attention to academics, sciences, and technology. Instead of assuring that a future physician can establish and maintain the most important relationships, admissions and training place too much emphasis on standardized testing.
What people may not realize is that rising health care costs are often due to inappropriate medical responses to patients’ needs — a direct result of weak or non-existent relationships. When physicians have not followed patients for a period of time, when there’s no continuity of care, doctors are more likely to miss significant health changes and symptoms.
What Does Quality Look Like?
A standard way of looking at health care systems is via the cost-quality curve: the more investment that that goes in, the better the health care outcome. The concept of managed care was based in large part on the idea of a flattening cost-quality curve: after enough resources are applied, the reasoning went, the quality improvement per unit of resources injected begins to decline. Managed care emphasized compromise, presuming we can get nearly the same quality for less cost. The focus was more on economics than on true quality and relationships.
A few years back a doctor from the Guthrie system in Pennsylvania presented data on physician recruitment and retention efforts. Guthrie had tried a new approach, one that saw recruitment and retention were the same. Administrators began retention interventions at the beginning of the relationship with a new physician and continued to focus on relationships throughout the first months and years.
Meetings were set up — initially every few weeks, then monthly — to exchange awareness regarding the new physician’s adjustment and relationships. Guthrie expected improvements in retention, but did not expect quality measures to go up, as well as productivity and patient satisfaction. They all did. Accountants count the cost of “giving in” to physician or to patient requests. But from the perspective of quality, what counts is quite different: a mutually beneficial relationship for all involved.
As a person responsible for state recruitment and retention of rural family physicians, I learned to work with an entire state and local team with a focus on trainees, the future rural workforce of a state. I learned to involve the spouses of the residents. Some of our best recruitment functions involved bringing great rural people in need of health care to the same place and time with physician-residents and their spouses – and getting out of the way. Let the courtship begin as each tries for a best fit.
I also learned to instruct the family practice residents to examine the recruitment process that they had just experienced. If it had been a process that would help them, in turn, to recruit colleagues and replacements, they should sign the final contract. If not, they should go somewhere else. What I did not realize all along is that the true focus was relationships.
The best recruitment that I heard about from a family practice resident faced the problem of retention at the start. The health center administrator met the resident and his spouse, spent about 45 minutes with them discussing their various interests, and then had a colleague give them a tour. The real purpose was not a tour. The purpose was to give the administrator time to call about six or seven people in town whom he assessed as likely to be able to relate to this potential new doctor and his wife. Over the next two days the couple just “happened” to meet these people, and a few more, as the key priorities of the couple were discovered.
While this may seem sneaky and self-serving, it also established the beginnings of retention for the physician couple. By the way, the weekend closed with the resident and his spouse taking an active role, singing at the local firehouse. This is not a usually scheduled recruitment activity, but it did help create an important result — a young professional, along with his wife and family, came to serve in the town and belong.
As a family physician, my most common challenges have been loneliness and brokenness. These problems have been expressed in physical, emotional, and spiritual terms. Perhaps you were thinking that I was talking about my patients only. Actually the loneliness and brokenness applies just as much to me. But when I have developed relationships with patients, I share their brokenness and their loneliness, and not uncommonly we both experience some healing.
In health care, we tend to see too narrowly, in single dimensions or abstractions – like economics. But the quality of health care improves only when it impacts patients and the physicians, technicians, and nurses who serve them. If we work to strengthen the central relationships of both patients and health-care workers, we stand to gain more than simple improvement. We can achieve quality and health.