The Culture Chasm Between Non-Clinician and Clinicians (2024)

August 01, 2024

When Sister Irene Kraus, a Catholic nun who became the first woman Chair of the American Hospital Association, coined the phrase “no margin, no mission” in the 1980s, she unwittingly provided a tagline for the “non-clinician MBAs (suits)” in healthcare to use and undermine the fundamental purpose and mission of physicians (whitecoats). Over time, this dynamic has led healthcare leadership to focus more on “the margin” than “the mission.” This transition has displaced from center stage the quality of and access to healthcare services for patients — a costly mistake.

With nearly twenty cents of every dollar of the U.S. gross domestic product (GDP) spent on medical care, the migration of MBAs into the healthcare arena has predictably occurred. Mergers, acquisitions, consolidations and the involvement of other financial entities in medicine have all grown exponentially. Vertical alignment and integration of private insurance companies with pharmacies (and their benefits managers), skilled nursing facilities and health systems have led to huge entities with scalability, market dominance and valuation of more than $500 billion (e.g., UnitedHealthcare), making it very difficult for smaller hospitals and independently practicing physician groups to compete and survive.

Many of these entities have incorporated free-market-type strategies into their business models to gain market share — resulting in financial distress for many smaller, critical-access hospitals and physician practices that must ultimately sell or declare bankruptcy. Many of these displaced physicians then have little choice but to either reluctantly become employees of the larger entities or move their families and give up ties and commitments to their communities.

Companies like Optum Health, a subsidiary of UnitedHealthcare, employs nearly 90,000 physicians, which is almost 10% of the U.S. physician workforce. Once employed, physicians are often positioned to work as if they are assembly-line workers, which can diminish their sense of purpose and autonomy, inflict moral injury and lead to burnout. In these scenarios, patients also experience fewer choices and less healthcare access. This dynamic can exacerbate the disparities and financial strain for patients in affected communities. Indeed, nearly 75% of Americans with health insurance between the ages of 20 and 65 cannot afford to pay their medical bills, and medical debt now exceeds all other personal debt in the U.S.

This transition has displaced from center stage the quality of and access to healthcare services for patients — a costly mistake.

Meanwhile, from 1975–2010, the number of administrators (suits) in the U.S. healthcare system increased by 3,200%, as compared to the 150% physician and population growth. In addition, many hospital CEOs and other C-suite members are making more than $5–10 million per year. It is not unheard of for some administrators to extract dollars for their own benefit rather than investing some of those dollars into patient-centered care. One glaring example involved the CEO of a large system being paid more than $4 million even though the health system was in the process of declaring bankruptcy.

Why does this dynamic matter to you, your patients and our healthcare system? As the costs for medical care continue to strain the U.S. economy, administrative activities in medicine now account for about 25% of all healthcare costs (e.g., almost 5% of the entire U.S. GDP). This expense is about 500% more per capita than 10 other wealthy countries and more than the costs of physicians and clinics. Yet, the Medicare Physician Fee Schedule has actually decreased by 29% over the past 23 years when adjusted for inflation. During the same period, hospital outpatient and inpatient reimbursement from Medicare has increased by more than 75%, and the Medicare Economic Index (a measure of practice cost inflation) also increased more than 50%.

As illustrated above, using free-market productivity models for physicians and health systems has resulted in the healthcare system “ignoring universal access, siphoning health-care resources into the pockets of investors and executives, and stripping away patient-physician autonomy as it subverts the ethical value of caring for the individual,” as written by Steven D. Pearson, James Sabin and Ezekiel J. Emanuel in “No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence.” Further, though the U.S. spends 500% more on administrative functions and over 200% more for healthcare compared to 10 other wealthy countries, the U.S healthcare system does not perform nearly as well as these countries when it comes to healthcare metrics such as infant and maternal mortality rates per live births, avoidable deaths, mortality rates from assault and overall life expectancy.

Healthcare is not driven by a supply-and-demand business model where patients, as buyers, can freely choose where they want to take their business. Unlike a traditional free-market model, patients often do not know what they need, have difficulty in assessing their options and are controlled by third-party payers and governmental and legislative rules on where they can seek care. In addition, physicians, pharmacies and health systems are often not paid directly by patients. Medicare and private payers control market prices, determine allocation of resources and add to the many inefficiencies in accessing and paying for healthcare services (e.g., prior authorization, the No Surprises Act). Navigating healthcare and payment for medical services is so complex and opaque, buyers/patients cannot make educated decisions about their choices. For that matter, most physicians do not fully understand the processes or options.

All physicians, including those with MBAs, must come together and embrace the clinical and mission-driven roots from which we grew and do the right thing. We must leverage our moral values, understand the implications of our choices and become more engaged in healthcare leadership. As we begin to have more seats at the table, we must inculcate our mission-based servant leadership values and have the courage to hold administrators and each other accountable to supporting patient-centered, quality medical care — ever emphasizing that compensation plans for physicians based on RVU production only feed into the margin-over-mission conundrum. If physicians are expected to produce above the 50th percentile of benchmarks to be paid at the 50th percentile of benchmarks, by statistical definition year-over-year, physicians will need to increase their productivity annually. At a time when physician burnout and suicide rates are remarkably high and healthcare workforce shortages continue to increase, we must push back against the suits for our own well-being and for the benefit of our patients. Until the healthcare payment system is radically changed, the free-market productivity models do not work for providers.

Most physicians choose the medical profession for the “why.”

It is the “why” that drives them — they want to make a difference. To make that difference, we must make sure the margin does NOT subvert our mission and work to influence the systems to recalibrate how they set priorities. Ultimately, we need to embrace the reality that having a lot of money does not equal happiness. As Malcolm Gladwell writes in “Outliers: The Story of Success,” “Three things — autonomy, complexity, and a connection between effort and reward — are, most people agree, the three qualities that work has to have if it is to be satisfying. It is not how much money we make that ultimately makes us happy. It’s whether our work fulfills us; that's worth more to most of us than money.”

The Culture Chasm Between Non-Clinician and Clinicians (2024)

FAQs

What is a cultural difference that can cause conflict between healthcare providers and patients? ›

Incongruent beliefs about the causes and treatment of an illness, language difficulties, strong religious beliefs and ethno-cultural norms and values (e.g. gender values) are often described as root causes of tensions.

Why should clinicians be aware of a patient's cultural and ethnic background? ›

(1) A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities.

What are the two benefits of having culturally sensitive communication and culturally competent professionals in healthcare situations? ›

Benefits of Culturally Competent Care

Social benefits include fostering mutual respect, understanding, and trust; promoting inclusion and patient and family responsibilities for their health; and increasing community participation and involvement in health issues.

What kind of assumptions do providers sometimes make about people from other cultures? ›

Providers often make assumptions about people from other cultures. One of the most common assumptions is that all people from a certain culture share the same values and beliefs. Another assumption is that all individuals from a certain cultural background think and behave the same way.

What is an example of a cultural misunderstanding in healthcare? ›

One of the most widely cited examples of cultural misunderstanding in medical practice involves the Asian practice of “coining.” In this procedure, a coin, which may or may not be heated or oiled, is vigorously rubbed on a patient's back.

What are two common causes of conflict between a healthcare professional and a patient? ›

Disagreements, misunderstandings, impaired trust and different expectations may all challenge the patient–clinician relationship. In a context in which children and adolescents form at least half the clientele, the potential for conflict is intensified because of the involvement of parents.

What are some examples of cultural barriers in healthcare? ›

Other cultural barriers to care include health beliefs that differ from the biomedical disease model and religious customs or practices that conflict with standard medical practice.

Why is it so important for a healthcare professional to understand different cultural backgrounds? ›

Personalized Care: Every culture has beliefs and practices related to health, illness, and healing. By understanding these differences, healthcare providers can tailor their care to better suit each patient's individual needs.

How do cultural differences affect healthcare? ›

Cultural differences can be a source of frustration for both patients and healthcare professionals, and may result in poor health outcomes. By practicing cultural competence, you create situations that can improve health outcomes, increase patient satisfaction and reduce overall frustration.

What are 2 barriers to providing culturally sensitive care? ›

Current Barriers to Culturally Competent Care
  • Lack of diversity in healthcare leadership and care teams.
  • Poorly-designed or poorly-functioning systems unable to meet the needs of diverse patient populations.
  • Cultural insensitivity or misconceptions.
  • Poor communication with patients of different cultural backgrounds.
Mar 28, 2023

How to respect cultural diversity in healthcare? ›

Provide modest clinical garments and ask patients what additional measures would make them comfortable. Provide linguistically appropriate care. Address health literacy by ensuring that all patient-facing materials are written in plain language. (See the CDC's Plain Language Materials and Resources page.)

What is an example of cultural sensitivity in healthcare? ›

Examples of culturally sensitive practices include: Providing information in a patient's native language. Offering culturally appropriate food choices in hospitals, accounting for special dietary restrictions or beliefs. Engaging family members in decision-making whenever possible.

How can healthcare professionals be trained to become culturally aware and sensitive? ›

Attend cultural competence training at your organization or through a continuing education program. Be aware of your own culture and how that may affect how you communicate with your patients. Reach out to cultural brokers to help you learn more about the differences and similarities between cultures.

What are the concepts of cultural awareness important for healthcare professionals? ›

It includes people's beliefs, values, behaviors, and ways of understanding their world. In medicine, managing cultural differences—including customs—is essential to providing high-quality health care.

Why is it important to avoid making assumptions about patients from other cultures? ›

While cultural competency focuses on understanding and respecting patients' diverse backgrounds, addressing implicit bias in nursing is equally important. Implicit biases can skew our perceptions and lead to assumptions that negatively impact patient care.

What is an example of a cultural difference that causes conflict? ›

An example of cultural conflict is the debate over abortion. Ethnic cleansing is another extreme example of cultural conflict. Wars can also be a result of a cultural conflict; for example the differing views on slavery were one of the reasons for the American Civil War.

How can cultural differences affect patient care? ›

Culture influences patients' responses to illness and treatment. In our multicultural society, different customs can lead to confusion and misunderstanding, which erode trust and patient adherence.

What are examples of cultural challenges in healthcare? ›

Dietary customs: Disease-related dietary advice will be difficult to follow if it does not conform to the foods or cooking methods used by the patient. Interpersonal customs: Eye contact or physical touch will be expected in some cultures and inappropriate or offensive in others.

Which cultural factors affect a patient's interaction with health care providers? ›

In order to improve the care of patients in general, health care providers should be aware of the following cultural influences.
  • Family and Community. ...
  • Religion. ...
  • Perspectives on Death. ...
  • Gender Roles. ...
  • Health Beliefs. ...
  • Beliefs about Medication. ...
  • Responses to Medications.
Feb 16, 2015

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