The Covert Rationing Blog

Medical Informatics Leadership - Why Doctors Need Not Apply

August 10th, 2007 by DrRich

In the Health Care Renewal blog (highly recommended by DrRich), contributor MedInformaticsMD wrote earlier this year that executives of large healthcare companies are strangely reluctant to consider physicians for leadership positions in healthcare IT. Instead, they are specifically seeking non-physicians (but non-physicians with clinical experience) to fill this role. This week, he added a second post to the same effect.

MedInformaticsMD found himself puzzled by a job description he saw “on the website for the national organization for informatics in the U.S., seeking a Director of Informatics at a large multistate, multihospital organization.” The job description virtually specified a nurse. Could they really be avoiding physicians, even physicians who are formally trained and experienced in IT? He made further inquiries.

“when I inquired about this role with the large national firm’s recruiter retained by the healthcare system to conduct the search, I received an initial positive response on my voice mail the very next morning. Then, I found I could not contact the recruiter for several days, only getting voicemail, and the recruiter was not returning my calls.

I finally reached the recruiter yesterday, and the the response I received was unexpected and disappointing: “the organization was looking for a nurse and they would not even talk to a physician.”

MedInformaticsMD then asked for opinions from his readers as to why doctors have been placed on the “need not apply” list for these important positions in healthcare. DrRich replied thusly:

“Admittedly I, an MD who is not an IT professional, could be off base here. But please consider the following possible explanation for why physicians are not being welcomed with open arms to directorships of medical informatics.

In an era of covert healthcare rationing, controlling physician behavior is job one. (This is because most covert rationing must occur at the bedside.) There are many ways to control physician behavior, most of which require seizing control of the doctor’s professional viability. In any case, a very promising method for getting doctors to behave in advantageous ways is to collect large volumes of clinical data, massage it via computers, and announce conclusions that, logically applied, will require physicians to alter their clinical behaviors. A prominent form of this behavior modification is Pay for Performance.

If covert rationing were not the prime directive, such methodologies would no doubt be incredibly useful (and physicians could be trusted to direct medical informatics programs). This is because the data could simply be followed to wherever it might lead, to the ultimate benefit of patients’ outcomes. However, since covert rationing is the prime directive, and since sometimes the best clinical outcomes are achieved by more expensive instead of less expensive therapy (implantable defibrillators being just one obvious example), to get the results you’re looking for sometimes you’re going to need medical informatics people who are, well, malleable.

My guess is that the executives who are hiring these medical informatics directors believe nurses to be a good compromise. That is, nurses have clinical experience, but by training and tradition are used to taking orders, even when those orders are obviously blockheaded. Doctors, on the other hand, are often seen by these executives as entirely unreasonable and intractable.

I do not mean to disparage nurses here. In my personal experience they very often have ethical standards that are far superior to most doctors. Indeed, I think the executives may be mistaken in their assessment of the tractability of doctors vs. nurses.

I’m just trying to find a logical explanation for your observation that physicians need not apply for these postitions. I do NOT believe that avoiding physicians is an oversight, or inexplicable, or illogical. I think it is very deliberate, well-thought-out, and entirely compatible with the real goals of these executives.

Keep up the good work.”

To reiterate, medical informatics is incredibly important today, because those who control the outcome of the analyses performed therein will (ultimately) control the practice of medicine. Docs are already being trained to accept, as received knowledge, “quality” measures from on-high. Pay for Performance is a major step in that direction. So this is a critical time for those running medical informatics efforts. Precedents are being set (in terms of establishing physician responses to centralized directives) that will probably hold for at least a few generations. If the “real” purpose of Pay for Performance and other physician behavior-mod efforts (efforts that fundamentally rely on medical informatics for their legitimacy) is to control costs rather than to improve quality, you just can’t let doctors run the show. It’s too risky.

Posted in General Rationing Issues

2 Responses to “Medical Informatics Leadership - Why Doctors Need Not Apply”

1. Dr Malchik wrote on 08/11/07 at 2:24 am :

   Interesting analysis, I have encountered this quite a few times in my stint so far in Healthcare IT. If this is the trend to be followed, how abt clinicians like me who have taken full time jobs in Healthcare IT to make a difference. Will we ever be paving the direction where Healthcare IT should go?

   How else should we contribute and be perceived by the different stake holders?

2. DrRich wrote on 08/15/07 at 8:23 am :

   I’m not an IT professional so I can only do platitudes here. Stick to your guns; work your way into leadership positions; insist on following the data to where it takes you; fight against leading the data to where the authorities want it to go.

   - DrRich

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