RO Helps Understanding the Nature of Work in Healthcare Systems

Speaker A And what was interesting to me at the time was I knew that not all physicians were working at the direct output. Levels varied dramatically. You may have a young physician working at level two, you certainly would have somebody working at level three, and your more higher level care physicians would be working at level four and trying to put together a total package. And so you had people that were that differentiation from running a department, which was a level four department, from also being a department head with level four colleagues that were independent practitioners that were providing cardiology services or cardiothoracic types of services. And so what was unique is that probably in the medical profession more than others, you had direct output at virtually level two through level five. In terms of the specialists.

Speaker B Well, it was a very interesting way that being introduced to this theory was being understood over time by all the various specialists. And it was really one of the first models that I had ever seen that helped figure out how we were going to get, quote, primary care doctors who might be doing more complex work because they're department heads or major, in fact, hospital commanders or CEOs and have them relate to thoracic surgeons or neurosurgeons that were doing very complex work that had output generally. The idea within medicine is there's always been a pecking order, and it shows up in terms of training as well as income from the highest level neurosurgeons and other surgical subspecialties that make multiple six figures in their income. And the kinds of cases that they have to handle to the primary care doctors that don't necessarily get paid as well for their work. And it's been a matter of how people have been not really been able to fully understand what is the difference and why are the challenges of a different kind of intensity and why do people get paid differently? And now when you came in with a theory, it became to be understandable to these folks what was going on, and they could realize that also. So that was very important so that a department head could say, here's what I'm doing, I'm operating this particular complex department, and this is why it's very difficult. And these are the complexities, because these are the outputs and this is the timelines I've got to think about when I'm operating this department, but these are the timelines I have to think about when I'm seeing this kind of patient and the concerns that I have. And it really opened people's minds to a very different way of thinking about.

Speaker A The complexity of a department really was dramatically different because not only were they their own practicing physician, but they were now managing colleagues, if you will, or subordinates that were learning that particular process. So the complexity of running a department was far greater than we had originally envisioned it to be.

Speaker B Much far greater and much, much greater than people had recognized that they were managing. Because we now said to the department heads, as you looked at the financial environment that the military medicine was working in, one of the trends here was that the private sector was much more economic and efficient and therefore there was a huge push to contract out services. We said to the department heads, your responsibility goes far beyond just that contact with the patient so that you are responsible for the delivery of all that kind of care to a defined population. And in fact, as department head, you will be balancing what is delivered directly and what is purchased in contract or might be also offered by insurance. And you're going to have to start analyzing that very complex system of patients and what their respective points of care are and also make some guesses and approximations of what the course of their illness is going to be over time so that you can project what resources are going to be required over time.

Speaker A And because we did that at the department, we were in fact establishing a developmental program. It was growing the next generation of hospital commanders. Now in the military, the doctors do command the hospitals and we don't have a non physician by and large doing that. And so that became a very useful way of growing the next generation of hospital CEOs. That's probably not the same kind of phenomena you see in society in terms of that.

Speaker B Well, I mean, there's been a trend. I mean, now that I'm working a lot in the private sector, first of all, after that there was a change and not all commanders now are physicians, right? So that changed. We said the role of commander is really because we want people qualified and who've had either have the experiences and show that they've got the capability to handle the kind of problems that they're going to face at that level of work. And often it is a physician. Often now it's not a physician because we've got people coming in that have got those talents and skills.

Speaker A And it's interesting, 15 years later, we see the fruits of that because we've got the best person that we put in, not necessarily the only person available, but it's the best athlete.

Speaker B There's a big change.

Speaker A That was pretty traumatic.

Speaker B Pretty traumatic.