Wednesday, January 13, 2010

The Disease Management Care Blog's 1/3-1/3-1/3 Rule of Physician Engagement

The Disease Management Care Blog has a television cable function called "video on demand." Its push-of-a-button weekly offerings have been more than an occasional source of friction between the DMCB and the spouse. A recent addition has been the latest Star Trek movie. It's excellent plot features the usual combination of Kirk's plucky derring-do, Spock's ironic logic and McCoy's emotional martyrdom, this time pitted against the nefarious and vengeful Romulan Captain Nero. Thankfully, unlike the 'Zombieland' movie option, the DMCB spouse has not exercised her viewing veto power.

Speaking of Star Trek, the DMCB is reminded about physicians. Whether you're a Medical Director for a health insurer, a VP for Medical Affairs at a hospital, the operating room Charge Nurse or the Chief Resident responsible for setting up the physician call schedule, the Kirk-Spock-McCoy triad is a useful lens when it comes to thinking about physician behavior:

Spock-Doctor: Ever the eminent scientist, this evidence-driven logician will accept the merits of a transparently contrived and evidence-based intervention that is reasonable and serves patient needs. When approached by disease management (DM) nurses, asked to change how discharge summaries are dictated, confronted by a change in surgical trays or asked to take call next Saturday, they'll pause, ponder and then say 'OK.'

Kirk-Doctor: Armed with a uncanny degree of intelligence, these physician leaders can reconcile multiple options and find the best if unexpected choice for their patients and their clinical practice. They're unlikely to take the DM nurses' word for it and expect proof that their approach actually works. The discharge summaries will not only be done, they'll probably be shorter, they didn't use all the items on the surgical tray anyway and taking call on Saturday means they won't have to host the mother-in-law for dinner.

McCoy-Doctor: Dammit Jim, they're continuously reminding everyone they're doctors and are not above exercising maximum passive aggressiveness to get their way. Highly unlikely to be convinced that any departure from the norm has any merit, they're not going to cooperate with DM nurses, getting discharge summaries done sooner, changing surgical trays or taking call next Saturday. Unless, of course, they want to.

What does this mean for population-based care management? Spock-Doctors, with little fanfare, will generally accept the merits of patient coaching, cooperate with the nurses, and respond to clinical prompts. Kirk-Doctors need to be convinced and may or may not respond, at least in the usual way or the same way on each patient. McCoy-Doctors will drive the DM nurses crazy even if a general lack of cooperation means they're only involved in a small percentage of the patients.

The DMCB thinks 1/3 of any population of docs are Spock, 1/3 are Kirk and 1/3 are McCoy. Launch a DM program, and 1/3 of the physicians will readily cooperate and be a significant source of patients. The McCoy physicians will generally not buy in without significant effort. It is the Kirk doctors that will be the difference between high and low patient enrollment numbers. They are the key to success or failure. They are the path to a competitive advantage

Succesful care management programs and their nurse-coaches gratefully accept the Spocks, move past the McCoys and focus on the Kirks. The latter are the real key to increased recruitment and achieving high outcomes.

Last but not least, the DMCB predicts that when the patient centered medical home gains traction, the dynamic in the Accountable Care Organizations or the insurance networks will be exactly the same.

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