As I write, it has been a very thought provoking recent past for me. The Enron fiasco is back on the front page and Andersen Accounting has been indicted. The ED Benchmarks 2002 Conference concluded and a discussion of the ethics of direct to consumer marketing of prescription pharmaceuticals is raging on the emed-l emergency medicine mailing list (subscribe using the ED Subscriber at The National Center for Emergency Medicine Informatics). In our ED this past week, we implemented the computerized telephone system directory with answering and calling that the hospital telephone operators use, while we continue to struggle with too many patients in too little room with not enough nurses. At peer review on Wednesday one of my colleagues concerned about a problem angrily demanded, “Who do I see about that?” I don’t have an easy answer, so there’s lots to think about and lots to write about.
The thread that pulled all these diverse occurrences together for me was Bob Lewis’ March 2002 column in Infoworld, a weekly trade publication for the information technology business. Over the past two years, Bob’s column has become the prime reason I still read Infoworld, since while I have the interest in technology, I don’t really have the time. Through story telling, Bob’s column often identifies human foibles that impair information technology effectiveness in a particular business scenario.
In this week’s column, “The Moral Compass” Bob Lewis concludes:
“You are a moral entity, and confine your actions to what your moral code allows. But you’re employed by a corporation, which isn’t a moral entity, and you’re supposed to act in that corporation’s best interests. I’ve even been told that this is a moral obligation.
Nonsense. ‘Maximizing shareholder value’ is a financial proposition, not a moral one.
Which is why, if you want your company to behave morally, you’ll have to bring the morality there yourself.”
The connection to morality and ethics is I suspect pretty apparent to most of you in regards to the situations of Enron and Andersen. Many of you, regardless of your feelings about “big pharma” do at least acknowledge that there can be different views regarding direct to consumer marketing, including those informed by the physician’s ethical imperative, “Primum non nocere.” But, what’s the connection to my other activities of recent weeks and why should it matter to you?
Since I’ll presume that you seek to “lead beyond the bottom line” as do I (see my EMN columns of October and November 2000 on “Leading Beyond the Bottom Line” in emergency medicine at my website and go to the American College of Physician Executive’s website for the original columns at http://www.acpe.org/lbblarticles.pdf) then you know the value of your employees, staff and co-workers. At the ED Benchmarks 2002 conference (The syllabus will be posted at the Florida Emergency Medicine Foundation site about the time you read this.) Thom Mayer spoke about compensation models and briefly raised the issue of what constitutes “open financial books.” While not much explored directly in his presentation, Thom clearly was thinking about and talking about ethical and supportive models of working with colleagues and employees in group practice. He readily acknowledged the struggle implicit in fair compensation and reinvestment in the group and the hospital—the many competing “goods” that could be weighed. He identified compensation or “pay” as more than mere dollars but included the recognition and supportive working conditions that we strive to create. He didn’t prescribe a specific answer, but through the complexity of the individual issues and the potential overwhelming number of considerations in front a single group practice provoked the thought that no one approach necessarily suits everyone.
Just last week I again learned the same message from our ED communication clerks. Practically all of our clerk-registrars rotate among the various clerk roles in our ED. While some prefer registration and others the telephones or flex-clerk duties, all do everything at one time or another. This past week we implemented the Xtend MediCallä system in our ED, the same product used by our hospital telephone operators and I’m told at over 500 hospitals around the country. (Disclosure: I have no relationship to Xtend beyond that of a satisfied customer.) We worked with Xtend personnel to customize screen prompts for our use in the ED, a novel application for the vendor. We committed to hours of training and two weeks of continuous on-site support. We told our docs and nurses that they would have to be patient with the clerks while telephone message handling went slower and that lots of mistakes would be made during the early days and weeks since this was a new way of working for the communication clerks. Still, some of the clerks were fearful. Why?
These men and women feared that they could not live up to their own expectations for their performance as communication clerks. They did not fear reproof from the physician or nursing staff. No. They feared that their ineptitude with the new computer based telephone system would slow down the works for all of their co-workers and delay patient care. That was their concern. Just as the physician staff expressed their distress at one of our patient outcomes during peer-review this past week, our clerks feared failing our patients and their own high expectations for themselves. Wow! I’m proud of all of them.
The world of healthcare, indeed all of the “knowledge economy” of which we are a part has never been more dependent on the intangible assets of employees, patients (customers) and community acting in ethical interdependence as moral human beings. Andersen Accounting, its competitors and today’s giants of our economy don’t and won’t measure those intangible assets in their own businesses, let alone ours. Yet, I truly believe our leadership in our EDs, hospitals and communities is conditioned on bringing our morality as people—which as Bob Lewis points out preceded both government and corporations—with us everyday to our work while manifesting it through our work as physicians and leaders.