Shouldn’t Doctors Control Hospital Care?
Who ultimately should be in charge of care at our nation’s hospitals — physicians or businesspeople? In January 2016, the board of directors at Tulare Regional Medical Center, a small community hospital in central California, voted to terminate the elected leaders of its medical staff office. 

Doctors were once expected to scrutinize and, when necessary, challenge administrative actions on behalf of patients. No more.

The dispute at Tulare must be viewed in the context of this larger struggle. As hospital managers make decisions based on business, not clinical, imperatives, both patients and their care providers are getting squeezed. For example, doctors are being pressed to discharge patients quickly — sometimes too quickly — to maintain “throughput.” There is a focus on increasing the rates of profitable procedures, such as orthopedic and heart surgeries, at the expense of relatively poorly remunerated general medical care. Administrators are even exerting control over traditionally medical domains, such as the credentialing of new physicians with hospital privileges. If a hospital board can dismiss elected medical officers with impunity, as at Tulare, it will indicate to many doctors the increasingly tenuous nature of the position they currently hold.

The very best hospitals in America are still run by physician chief executives — Toby Cosgrove at the Cleveland Clinic, for example, and John Noseworthy at the Mayo Clinic. The Mayo Clinic says that it is physician-led because “this helps ensure a continued focus on our primary value” — namely, that “the needs of the patient come first.” Indeed, a study in 2011 found “a strong positive association between the ranked quality of a hospital and whether the C.E.O. is a physician.” Overall hospital quality scores were about 25 percent higher when physicians, not business managers, were in charge.

Of course, correlation does not prove causation; it is certainly possible that better hospitals choose physicians as their leaders. But when day-to-day decision making is done by people with clinical training, it appears that patients do benefit.

There are many factions to blame for the corporate takeover at America’s hospitals. Doctors need to accept some of the responsibility, too. If we had taken better care of our institutions, perhaps there would not have been a need for others to manage them for us.

How the court rules in the Tulare case, once it resumes, will have profound consequences for whether medical staffs can do their work independently of nonclinical administrators. And it will also provide an answer to the more important question of who should be in charge of hospital care.