Workforce

Understanding the Physician-Hospital Relationship

What boards should know about building relationships between valued clinicians and the organization

By Todd Linden and Adam Barkin, M.D.

Growing up, my father, Charles, was the administrator of Boone County Hospital, a rural facility in Iowa. We lived just half a block away, and I began my health care career at his hospital when I was 14 years old. My first tasks included mowing the lawn and scrubbing down the operating room (OR) and obstetrics (OB) walls every night. Over the next few years, I held various roles — housekeeper, gardener, facilities engineer and orderly. I even became an EMT, driving ambulances. I did anything they allowed me to do, and along the way, I fell in love with the place.

I learned invaluable lessons from my father during those early years and throughout my career. One of the most important was the significance of his relationships with the women and men on his medical staff. Back then, nearly all physicians spent part of their day at the hospital. My dad would begin his mornings in the physician’s lounge with coffee and conversations, discussing the day ahead. At the end of the day, many of those same physicians would stop by his office, where my dad would open his liquor cabinet, and they’d unwind over scotch and cigars. I will never forget the respect and admiration my father had for his medical staff and the profound impact they had on the hospital.

It is important that both physicians and administrators have an “open door” policy to discuss and work through issues. While scheduled meetings are important, impromptu conversations are also essential to facilitate relationship building and problem solving. 
Adam Barkin, M.D.

In this article, I’ll explore what I’ve learned over my 30 years as a hospital CEO and the last seven years consulting hospital boards about what physicians seek in their relationships with hospitals. I’ve also included some thoughts from Adam Barkin, M.D., chair, emergency medicine, Sky Ridge Medical Center, to emphasize key points from a physician point of view. For hospital governing bodies, understanding these relationships is key to sustaining strong partnerships. I often compare hospitals to a three-legged stool: the board, administration, and medical staff represent each leg, while the seat represents the hospital’s key stakeholders—patients, families and employees. If any leg is unstable, the entire mission of the hospital is at risk.

Understanding the Difference Between Physicians and Administrators

For boards, the first step is understanding the inherent differences between physicians and administrators. Grasping these differences helps to understand why conflicts arise and how best to respond.

One of my greatest mentors in this area was Tom Atchison, president and founder of Atchison Consulting. He taught me the most critical aspect of working with physicians is understanding their “fierce protection of the individual prerogative.” Physicians are trained to focus on the patient in front of them, diagnose the issue and create a treatment plan. They take their oath to provide the best possible care seriously. Although they may consult with colleagues, the ultimate responsibility for the patient’s care rests solely on them. This sense of autonomy is the lens through which most physicians view their work and their relationships with the hospital in all matters.

Physicians are scientists. They work within a hierarchical structure, view time as “now,” and feel a deep loyalty to their profession and colleagues. When they write a patient order, it’s not a suggestion — it’s an instruction, and they expect it to be followed promptly. They are fiercely independent, driven by their responsibility to the patient. This is where the common analogy of “herding cats” comes from: physicians, often stubborn and finicky, are above all, independent.

On the other hand, administrators tend to be interdependent, collaborative and team-focused, with a longer-term view of time. While the perception may be shifting, a long-standing stereotype suggests that administrators — or “suits” — prioritize finances, while physicians — or “white coats” — focus solely on patient care. In reality, both groups care about quality and cost; after all, these are the same things patients care about. However, given their differing roles, responsibilities, and perspectives, it’s easy to see how conflicts arise between the two groups. Recognizing and appreciating these differences helps boards better manage these tensions when they arise.

As with any relationship, honesty is crucial. An administrator who is willing to tell a physician, “I understand your request, but this is something that I am not going to be able to provide at this moment,” is far preferable to false promises or stringing a conversation along. The latter approach will inherently create friction and distrust.
Adam Barkin, M.D.

Communication and Engagement: Building Trust with Physicians

Trust is the foundation of any strong relationship, and with physicians, it begins with good communication. I’ve learned over the years that most physicians value honesty, transparency and direct communication, especially when it involves listening first. Providing physicians with a strategic seat at the table, following through on commitments, and removing obstacles that hinder their ability to provide safe, efficient care are critical to building lasting relationships. Whenever I found myself at odds with a physician, I’d return the conversation (in person) to focus on the patient. This approach usually helped us find common ground and work towards a solution together.

Establishing alignment in mission allows teams to function at a high level. If hospital execs, boards and the medical staff are all focused on the highest quality and efficient care, some of the superfluous issues become far less important. 
Adam Barkin, M.D.

Addressing Physician Burnout

According to the Medscape Physician Burnout and Depression Report 2023, 53% of physicians reported burnout — a significant increase from 42% in 2018. Factors such as lingering effects of the pandemic, shifts in medical practice, and specialty shortages have all contributed to increased stress levels. Hospital boards can show their support by acknowledging the pressures physicians face and expressing appreciation for their contributions to the hospital’s success.

In a 2018 Journal of Health care Management article, Stanford University researchers identified seven principles for boards to consider in addressing physician burnout:

• Burnout is prevalent in health care professionals.
• Health care professionals’ well-being impacts quality of care.
• Distress among health care professionals costs organizations significant money.
• Greater personal resilience is not the sole solution.
• Different professions have unique needs.
• Evidence and strategies exist to address burnout.
• Interventions are effective.

Boards can adopt these principles to better support their medical staff. Stanford’s three-pronged approach focuses on fostering a culture of wellness, improving practice efficiency, and building personal resilience. More information can be found at wellmd.stanford.edu.

Boards should also be mindful of the stigma surrounding mental health treatment among physicians — 8 in 10 believe there is stigma, and 4 in 10 refrain from seeking help for fear it could negatively impact their credentials. Credentialing practices should not inadvertently discourage providers from seeking care when needed.

Keep it simple! I had an executive start at my hospital and repeatedly said, “If you take care of the people who take care of the patients, everything else takes care of itself.” This type of statement allows teams to narrow focus and establish priorities. 
Adam Barkin, M.D.

Suggestions for Boards to Engage the Medical Staff

Attend Medical Staff Meetings

Boards can foster stronger relationships by having the board chair occasionally attend medical staff meetings. Inviting the medical staff leadership to extend the invitation ensures the visit is collaborative rather than perceived as an inspection.

Create Task Forces

Establishing task forces with board, medical staff, and administrative leaders to address specific issues, such as physician recruitment or using AI in reducing administrative burdens, can foster collaboration and build trust.

Support Physician Recruitment and Retention

Board members can be instrumental in physician recruitment and retention. As community representatives, board members can be powerful ambassadors for the community. Selling the attributes of the community best comes from board members. Spouses speaking to spouses and providing community tours and/or connecting their children can create connections that I have seen turn into lifelong friendships. Participating in recruiting activities, hosting social events, and connecting new physicians with the community can make a lasting impact.

Include Physicians in Strategic Planning

Physicians value having a strategic seat at the table, especially on clinical matters. Inviting them to strategic planning retreats allows for collaborative decision-making and mutual respect.

Social Gatherings

Breaking bread together—whether through holiday parties or informal potlucks — can strengthen relationships. I recall a gathering of board, physicians and administrators where we hired a chef to help us make pasta together. There was flour everywhere and wine flowing. When we sat down together to eat the meal we prepared, strong bonds were forming and there was a deep respect for one another. Without a doubt, it was one of the best team-building experiences I can remember. These gatherings build bonds that help manage conflicts when they arise.

In this day and age, it is important to keep in mind generational shifts. We are working and living in an era where Baby Boomers, Gen X and Millennials all play important parts in the workforce. We need to keep in mind the different motivations, sensitivities, and needs of these groups. 
Adam Barkin, M.D.

Board Members and Individual Physician Concerns

When approached directly by a physician with concerns, board members must avoid undermining the hospital’s administrative authority. Taking on these operational issues can hobble the C-suite and create a notion that anytime a physician has an issue, all they need to do is find a sympathetic board member to champion their concerns. The appropriate response is to listen, direct the physician to the C-suite for operational issues and inform the CEO of the conversation.

Conclusion

While much has changed since I was working at my dad’s hospital in the late 1970s — such as scotch and cigars in the CEO’s office — one thing remains constant: physicians appreciate respect. Building strong relationships between the board, medical staff and administration is crucial to delivering high-quality, affordable care. To this day, my 92-year-old father is still friends with the doctors who are still alive and his admiration for them is as bright as ever. It still brings a smile to my face when I hear Judith and Chuck (aka Mom and Dad) discuss their visits with Dr. Jack and Judy Murphy — a relationship that has thrived for over 50 years.

Todd Linden (tlinden@lconsult.org) is president, Linden Consulting and CEO emeritus, Grinnell (Iowa) Regional Medical Center, based in Colo. Adam Barkin, M.D., (abarkin@carepointhc.com) is chairman, Emergency Medicine and president, Medical Staff, HCA HealthONE Sky Ridge Medical Center, based in Lone Tree, Colo.

Please note that the views of authors do not always reflect the views of AHA.