As a relatively young physician, I always enjoy my conversations with the older members of our profession, who’ve seen so much change over the last few decades. I’m fascinated with their stories about how different the medical world was when they were residents, how treatments were so novel, and how they used solid clinical skills to get to the diagnosis. Those were the days when the family doctor would know their patients inside out, visit them at home, and follow them in the hospital. Those were the days when physicians didn’t have to spend huge chunks of their day navigating inefficient computer systems or dealing with mountains of bureaucracy. Another theme that emerges is how physicians have ceded so much of their power and control to third parties and health care administrators — who have proliferated vastly in number. I’ve heard stories of how not so long ago, it was the doctors who were the bosses at all levels in health care. I remember talking to a general surgeon in Florida who recalled to me an incident 25 years ago when he saw a major patient care issue, how he burst into the CEO’s office, slammed the patient’s chart on the table and voiced his disgust with what had happened. The CEO calmed him down and then apologized profoundly for the problem, assuring him that it would be addressed. The surgeon felt like he was the boss, and that hospital administration existed to serve the best interests of doctors and their patients. Needless to say, that wouldn’t happen today. While I can’t speak for the different environment that doctors used to work in before my time, I can say that after the best part of a decade in clinical practice, it’s obvious that the number of health care administrators has, and continues to, increase exponentially. And while most of the ones that I’ve worked with have been perfectly pleasant on a personal level, the fact that so much of what a physician does nowadays is also processed by an army of administrators — whether it’s related to productivity, efficiency (including length of stay), or admission status — is pause for thought. Who is actually running the show here and is the tail wagging the dog? I remember a time in a previous job when a new administrator, relatively young and fresh out of education, had been hired by the hospital to help process metrics and perform administrative tasks within the group. He had been given some title such as “administrative director,” and had gone up to the medical floors to introduce himself to the nurses. When I later went up to the same floor, I was told by some of the nurses that they had just met “my boss.” Excuse me? It was very telling that this could have happened, and that he had given the impression that he was somehow in charge of a group of 20-plus experienced doctors. Many physicians believe that only physicians should ever be their boss (whether or not they are also officially administrators). Not random non-clinical folk who don’t understand the rigors of frontline medicine. For me personally, I have only ever worked in situations where physicians have officially been my “boss,” and thankfully most of these have been entirely supportive. I also ultimately consider the patients to be my boss. But as health care consolidation and the ranks of employed physicians expands, it’s a question all of us need to think about: Who’s your boss, doctor? Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha Source
