Letter from the Editor

Differences in Perceptions and Cultures Between Doctors and Hospital Administrators Undermine Physician Engagement

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

There has been tension between physicians and hospital administrators for years. This tension has been mostly related to limited resources and nonaligned goals. This problem is well documented in hospital surveys of physicians, and seems to only be growing as hospitals have acquired physician practices over the past several years. With increased emphasis on physician burnout, attention has been refocused on this lack of physician engagement in hospital decision-making. However, despite this growing problem, there has been very little objective research into the issue.

An interesting research study was recently conducted at a large academic medical center to investigate the cultural differences between physicians and hospital administrators as a way to identify the underpinnings of the lack of physician engagement at hospitals.1 A single researcher, Dr. Erik Keller, interviewed 20 physicians and 20 hospital administrators using a novel, qualitative, mixed methods analytical approach branded as HuNamic Analysis (HuNamics, LLC) to investigate this issue. He then validated his findings and determined which results were most meaningful by interviewing an additional 400 local doctors and administrators. This apparently unbiased and rigorous investigation found a significant professional cultural disconnect that was undermining efforts to improve physician engagement.

Perceptions were very different. Compared to physicians, administrators had a much more positive perception of hospital systems and initiatives, such as the physician compensation plan, the centralized call center for patient scheduling, recent surveys of physician engagement, and even the new physicians’ lounge. Representative comments that were reinforced by the validation process included the following by an administrator: “Now there’s a centralized scheduling system. It’s one number, one pool of people. If the call center gets 60,000 calls and you had two mistakes this week, if you think about an error percentage. They’re human; that’s not the worst of errors.”1 Compare this to a comment made by a physician: “Do they know us? Of course not, how could they know hundreds of physicians? They don’t know whether we specialize in this or that, and sometimes people are scheduled completely wrong. . .. If someone cancels, anybody with a random condition will take that spot even though it could be something completely idiotic for me to see.”1

Cultural differences were also very different between administrators and physicians. Administrators had more diverse backgrounds compared to physicians, who tended to all have a similar intense socialization process during medical training. Administrators felt loyalty and connection to the organization, whereas physicians felt loyalty to their specialty and profession. One of the most striking differences in cultures was that administrators tend to distill information into multiple options over a time period of months to years in contrast to physicians, who are accustomed to quickly distilling information into a single best course of action within minutes to days. This inherently leads to deferred decision-making by administrators, resulting in frustration and a lack of engagement amongst physicians.

What is interesting, and not discussed much in this study, is that half of the administrators who were initially interviewed were either doctors or nurses themselves. This would suggest that health care professionals who are either brought in or who are attracted to hospital leadership positions share the same cultural phenotype as their administrative partners rather than those of their physician or nursing peers. Promoting physicians who have similar perceptions and cultures as the administrators to hospital leadership roles is not improving physician engagement — it is only perpetuating the problem.

Many hospitals claim that increasing physician engagement is a goal. This may or may not be true. However, what is clear is that the differences in perceptions and cultures between doctors and hospital administrators are huge, and represent major obstacles to improving physician engagement. If greater physician engagement is truly a goal of a hospital leadership team, then these vast differences in perceptions and cultures between physicians and hospital administrators must be addressed. A reasonable next step is to position doctors and nurses in hospital leadership roles who share the same perceptions and cultures as their peer healthcare providers, rather than those currently shared by the hospital administration.

Disclosure: Dr. Knight reports that he is a consultant, speaker, investigator, and offers fellowship support for Abbott, Baylis Medical, Biosense Webster, Inc., BIOTRONIK, Boston Scientific, Medtronic, and SentreHEART.

  1. Keller EJ, Giafaglione B, Chrisman HB, Collins JD, Vogelzang RL. The growing pains of physician-administration relationships in an academic medical center and the effects on physician engagement. PLoS One. 2019;14(2):e0212014. doi: 10.1371/journal.pone.0212014.