The working relationship between the hospital and the surgeon.
Surgeons work in a variety of clinical settings in performing the tasks and roles that make up their professional lives.
Globally, surgeons generally work either as a full time employee of a private hospital group or public hospital system, or they work in their own practice and provide their services to hospitals and emergency rooms.
If a surgeon has their own practice or is part of a private group practice, they work in a role best described as an independent contractor – although they probably don’t think of it in those terms.
This is an oddity of history, as surgeons’ relationships with hospitals have evolved through the tradition of the “visiting medical officer”. It was never designed as an employee or contractor role.
The way this works is that hospitals need specialists and specialists need hospitals.
Over the past century, a system simply evolved as a clinical appointment process where the hospital provides “clinical privileges” or “admitting rights” to the specialist who may apply to work there after reviewing their credentials through a hospital “medical advisory committee” of senior clinicians.
There is little administrative paperwork, and usually no real contract. The specialist signs an agreement to remain up to date with their CPD, and to conform to the hospital by laws. The hospital all now have a re accreditation process where periodically the specialist must re verify their credentials and currency of registration.
Importantly and at the heart of this mutually interdependent relationship (and which is the most common working relationship between surgeons and hospitals in the developed world) – there is no payment or financial relationship between the hospital and the specialist.
Both entities (the surgeon and the hospital) bill the patient or the patient’s insurer fees for providing the necessary care. Neither the surgeon or the hospital bill each other.
The problem of changing work processes
As the hospital does not employ or pay the visiting specialist, there is no employee / employer relationship. The hospital has little power to “make” the specialist do something on their own time and the specialist has little power to change hospital work processes where they appear to be suboptimal.
In the real world, change in hospitals happens via clinical committees and through mutual acceptance of all affected parties. It’s in the interests of both parties to see improved work processes, equipment, patient care and patient safety at the hospital, but the actual way this happens is a dance, not an order, and not an orderly process.
The hospitals do not pay the specialists for their time in training or adopting a new process. And they can’t in general make them adopt it.
So, where a specialist has no interest in or personal benefit from a new process, they are likely to resist to use it or simply refuse. Why would they be expected to devote their own time and cost to a change they see no benefit in, or which might even add to their administrative burden?
A real world example
I work at a hospital which is about 15 years old. On its establishment, it introduced an electronic drug chart. This was perfectly functional, but required specialists and anaesthetists to use a keyboard and screen for entry of all drug orders for their patients. The remainder of the patient record was and still is paper based.
The hospital had no means of properly training specialists in its use. Virtually 100% of clinicians refused to use it. Anaesthetists (all of whom were visiting specialists) were up in arms. There was anger. The hospital quickly reverted to a paper medication chart. Which 15 years later is still in use. It will probably still be in use in a decade. Digitising the medication chart has never been re-discussed.
Change resistance 101
There is no funding mechanism, employed relationship or clinician’s volunteered time available to enable visiting specialists in Australia (and most of the world) to put the time and effort into changing their work processes at a hospital in which they work.
If they see the proposed change as making their life easier, and it is simple to learn – they’ll do it.
If they see the change as being difficult, and potentially adding to their administrative burden or taking up their (unpaid) time, they will not do it.
And in the real world, this is why over 90% of private hospitals in Australia still have paper based clinical note systems. It’s where we are, and it’s a massive block to progress.
At Praccelerate, we believe that the paper clinical note has no place in the 21st century and we have started the journey to make that a reality. It should be quick and easy for a surgeon to create digital operative notes.
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