Physician Culture - “Good and Bad Apples”
Dear Colleagues:
Here is another great short video from Dr. Eric Bricker. I highly recommend you watch this. The link is provided below, followed by my reply to Dr. Bricker. I wonder what you all think.
Kind Regards,
Jon “JP” Warner MD
Founder, CSS
Dear Dr. Bricker:
Thank you for yet another informative and provocative look at the world in which we physicians work.
I love that you’re considering physician culture and that you make the point that there is a continuum from good to bad culture; but it is really hospital institutional culture that is important here, as this defines what physician can and can’t do. Culture has been studied extensively outside of healthcare as it is the basis for the most successful for-profit companies, and you’ve mentioned companies like Southwest Airlines and many more. It may also be the same case in healthcare, however, in most cases culture in our large medical centers is not directly considered. Certainly, it is the framework for physician behavior. Compensation plans can be complex and must incentivize behavior that is “patient-first” as a priority. You suggest that FFS only incentivizes more care that is less effective. I don’t think that in the surgery world this is entirely true. As you mention in the case of Southwest Airlines, the culture is “hire for attitude and train for skill.” Unfortunately, this doesn’t often work in the world of surgery, as many surgeons are hired for their skill and not their attitude. This is improving now, but it has taken a long time.
Your analogy of “Bad Apple doctors” and “weeds” gives the impression that there are places where there are a lot of these physicians. I think these are a minority of physicians, and there is no direct correlation to the compensation model (FFS vs salary) when it comes to the quality of care offered by good doctors. In fact, there are many studies that demonstrate that in Orthopedic Surgery the volume of a given type of surgery a surgeon performs is directly correlated to value achieved for each individual patient. In a recent study we looked at 151,000 shoulder replacement surgeries and found that high volume surgeons have a dramatically lower reoperation and complication rate than low volume surgeons and it is not clear that the compensation model in which they work makes a difference in the patient’s outcome (1,2).
I do agree with your analogy of “raisons and rabbit turds” as sadly, in even the most prestigious institutions, there are “rabbit turds in the bowl of raisons.” The culture in some such organizations is to keep these rabbits (also “bad apples” as you describe them) on staff because they make the hospital money. One of my colleagues used the analogy “dead wood still floats.” That is a hospital culture problem not a physician culture problem.
I do like the concept of money, power, reputation and publications as “weeds” if they are put first over patients, but your message resonates more with this argument than saying physician culture can result in “weeds” and that FFS is the fertilizer for such weed growth.
Finally, you also mention the HBR article on What is Culture? One thing in your discussion which is missing here, is that a culture of measurement and transparency, for both outcomes and cost, is the antidote to bad behavior. Again, hospital systems and physicians in these hospitals do a poor job of measuring the impact and cost of services provided. So, I would argue the hospitals in which physicians work create the culture and the behavior of their doctors. You also say this but seem to emphasize the doctors more than the hospitals in which they work. So, measurement and transparency achieve the culture you highlight as our priority which is “patient first.”
Thank you again for this short video and your many videos which stimulate critical introspection of our healthcare delivery system.
Kind Regards,
Jon “JP” Warner MD
Some useful references:
1. Warner JJP and Higgins LD: Editorial Commentary: Volume and Outcome: 100 years of perspective on value from E.A. Codman to M.E. Porter. Arthroscopy J. Vol 33 (No. 7) July 2017. Pp 1282-1285,
2. Best MJ, Fedorka CJ et al, Avant-Garde Health and Codman Shoulder Society Value-Based Care Group: Higher Surgeon Volume is associated with lower rate of subsequent revision procedures after total shoulder arthroplasty: A National Analysis. Clin Orthop Relat Res. 2023 Aug 1:481(8):1572-1580
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