Why Are Doctors’ Offices So Badly Run?

Seven years of medical school doesn’t prepare you to run a business.

Patient in a doctor’s office
“They didn’t teach me how to handle dimwits like you in med school.” KatarzynaBialasiewicz/Thinkstock

This piece was originally published in Slate on Jan. 27, 2016.

A few years ago, Katherine White was feeling burned out. The Massachusetts dermatologist runs a private practice at which she oversees a nurse, two medical assistants, two receptionists, and an esthetician. Dr. White’s practice sees about 40 patients per day, which means that she’s on a tight schedule that often has her rushing from one patient to the next. But her staff used to bother her constantly with questions—about billing, about lab reports, about pharmacy refills—and White always felt compelled to stop and fix the problem. “I was sort of micromanaging everything,” she says. “I was so busy that I couldn’t really fulfill all those roles and had kind of buttoned into a role—which is very programmed from medical training—of basically doing everything yourself.”

White’s micromanaging wasn’t only driving her (and probably her staff) crazy—it also prevented her from detecting big-picture problems with her practice. One problem became glaringly obvious when a long-standing patient came in to talk about a troubling mole. “Within two seconds of walking into the room, I could see that she had a skin cancer on her arm,” says White. The patient had had to wait two months for an appointment. “It was not OK that she had waited that long,” says White now. “I was appalled that she couldn’t get in on a timely basis.” White realized then that she needed to change the way she supervised her receptionists—and her entire staff—to make sure patients could always see her when they needed to.

As patients, many of us have picked up on the kind of tension that plagues doctors’ offices and hospitals—the tension among doctors, nurses, and administrative staff. There are horror stories about bully doctors who punish any questioning of their authority with verbal abuse, a dynamic that can result in deadly medical mistakes. But even conscientious doctors, like White, can be bad managers, and miscommunications and dissatisfaction in a medical context are bad for doctors, nurses, and patients. A recent Mayo Clinic study found that poor supervision in a medical setting is associated with burnout—which is associated with medical errors and a lack of empathy with patients. Burnout also, unsurprisingly, leads to turnover, which exacerbates the national shortage of doctors and nurses.

Doctors “do very, very well independently, but we don’t know how to engage the people around us,” said Keith Gray, the chief of surgical oncology and the co-creator of a medical leadership training program at the University of Tennessee Medical Center, when I asked him about the average doctor’s management skills. “We don’t know how to delegate, we don’t know how to empower, we don’t know how to add value to others.”

This is a problem whether a doctor runs an independent practice or is employed by a hospital system. Thanks to the increasing complexity of insurance billing and medical record keeping, doctors who work in small or independent practices, like White, are essentially business owners, responsible for hiring, retaining, and managing a team of receptionists, nurses, and medical assistants. And running a practice has a particular challenge: In most businesses, bosses can delegate important tasks to underlings to make the organization run smoothly, but in doctors’ offices, only the doctor can perform the central activity of seeing and diagnosing patients—which makes the hierarchy of a medical practice less like a pyramid and more like a wheel, with the doctor at the center.

American doctors are increasingly choosing to take salaried positions at hospitals or large health centers, in part to avoid the administrative headaches associated with running their own businesses—but working at a hospital doesn’t get physicians off the hook when it comes to directing staff. In fact, the organizational structures of hospitals can make management even more complicated and frustrating than it is in private practice, since doctors, nurses, and administrators fall under different branches of the hospital hierarchy. “It’s just a series of silos that are not communicating well with each other,” says Gray of his hospital. In practice, this means that doctors are giving orders to nurses and assistants who officially answer to other people. “In fact, my medical assistant doesn’t work for me,” says M., a physician who works for a large urban health center—rather, the assistant works for the head nurse. “I am effectively managing her impotently. I can’t say, ‘If you come in late again, X or Y.’ There is no ability to discuss consequences.”

If almost every doctor needs to effectively manage a team, why don’t medical schools and residency programs teach students the skills they’ll need to oversee medical staff? For one thing, it’s hard to see where formal management training could fit in, since the four years of medical school and three years of residency are jam-packed with clinical education. But, according to Dike Drummond, a former primary care physician who now coaches doctors and blogs at the Happy MD, the problem goes deeper than that. “Why don’t they teach this in medical school?” he says. “It’s a blind spot.” Even worse, medical school and residencies can inadvertently teach doctors how to be bad managers.

Drummond, who describes the average doctor personality as “workaholic superhero Lone Ranger perfectionist,” says that doctors are trained, throughout medical school and their residencies, never to show signs of weakness. In most residency programs, says, M., “I don’t think people try to be humble, they try to be right. And that certainly doesn’t teach you how to motivate your staff.” Medical school and residency programs typically model an authoritarian, top-down model of management. “You just watch, go watch on rounds in a residency, watch an attending [physician] be a dictator over the care team that’s learning with them that day,” says Drummond. By the time doctors enter their own practice, they’ve had this militaristic form of leadership drilled into them and start treating their own staff the way they’ve been treated for the past seven years. “They train their people to never do anything without the doctor’s permission,” says Drummond.

There are few resources for doctors who need help figuring out how to manage their staff. Physician executive MBA programs and “physician leadership” training programs, such as the one Keith Gray developed in Tennessee, are intended for doctors who either are or want to be high-ranking executives in a hospital system. They’re not much use to doctors working in the trenches.

So what’s an average doctor—one who’s not angling for a “leadership” role in a hospital or practice group—to do? Drummond teaches his clients to recognize the difference between clinical contexts and administrative contexts. In clinical settings, doctors have the expertise to answer questions—that’s what they went to medical school for—and it (usually) makes sense for them to expect their nurses and medical assistants to follow instructions. But in administrative contexts—billing insurers, maintaining electronic medical records, documenting visits, keeping medical supplies in stock, handling appointments—doctors have no special expertise. Drummond advises doctors to “take off the doctor hat” when they’re asked an administrative question. “Because it’s exhausting for the doctor to always think they have to have the answer always, and give orders and have everybody obey them. It’s just exhausting.”

White, who called in Drummond to help her improve her practice, had a hard time letting go of her habit of micromanaging her staff. But one day, when her nurse asked her the proper dosage for the flu vaccine (which White had purchased for her staff, not her patients), White realized she didn’t have to do everything on her own. “Everything about my personality and my training would be, ‘Oh I don’t know; let me look it up,’ ” she says. But White resisted her programming and told the nurse to look at the package insert. “For me, that was a really important moment. … Instead of my employees feeling passive about things and waiting for me to tell them what to do, it’s trying to make a shift toward them thinking about problem solving.” Since then, White has worked with her staff to find solutions to problems instead of giving them orders, and as a result her staff spends less time bugging her in between patients. She’s also instituted twice-daily staff huddles, monthly staff meetings, and “quick-look visits” so that patients with urgent concerns won’t have to wait two months to see her. (The patient with the malignant melanoma, by the way, turned out fine.)

Most physicians have to figure out how to manage their staff on their own—which is what M., the physician at the urban health center, did. “I remember my first medical assistant, who did absolutely nothing for me,” says M. “She wasn’t very interested in being helpful, and there was almost nothing I could do about it. And I didn’t know how to deal with it. I remember photocopying my own stuff and writing all my referrals and watching her—it was before phones—read the newspaper.”

Eventually, M. figured out that she needed to give  her staff “as much authority as possible, so they feel empowered and feel good about what they do.” Now, when she teaches residents, “I say, ‘No one has ever told you how to manage staff. And that is something I am going to do for you.’ ” Most medical students and residents still aren’t so lucky.