Medical Professionalism In An Organizational Age: Challenges And Opportunities

Over the past two decades the structure of medical practice in the United States has undergone an extraordinary transformation, affecting hospitals, health care delivery systems, physicians, other health professionals, and patients.¹ These novel developments pose significant challenges and opportunities for maintaining and advancing the principles and responsibilities of medical professionalism. First, organizations, not independent solo practitioners, now dominate health care delivery: Physicians are increasingly becoming salaried employees of hospitals and health care organizations.^2–5 Second, the collection and dissemination of clinical data are being altered by new technologies that both encourage and facilitate transparency in health care settings^6,7 and allow patients to use the internet and tracking devices to better manage their own health care.⁸ Although these changes have been the focus of substantial research, their implications for medical professionalism have not been fully addressed.

The literature explicating professionalism is rich and substantial. We used the definitions put forward by the American Board of Internal Medicine because they capture the essential elements of the concept and duties. As a national survey of physicians documented, there was widespread agreement with the board’s standards for professional behavior.⁹ According to this formulation, professionalism required physicians’ commitment to altruism, thereby putting patients’ interests first and foremost.¹⁰ It also obliged physicians to pursue lifelong learning and take responsibility for monitoring colleagues’ performance. Finally, physicians were to advocate for the welfare of all patients, seeking to reduce inequities in health care resource distribution and social determinants of health. In return, as part of a social contract, society granted the medical profession the right to set its own educational standards, define best practices, and exercise oversight over its members.

How will the fulfillment of these responsibilities fare in the new practice environment? Will physicians be able to live up to these obligations? Will employers permit salaried physicians to consistently prioritize patients’ well-being? Will novel methods for collecting and disseminating clinical information promote or undercut physicians’ oversight of their own and their colleagues’ competence? Will expanded consumer access to medical information build or subvert trust in the physician-employer and doctor-patient relationships? To be sure, earlier systems of medical care, in which most physicians operated small businesses, posed their own challenges to professionalism. Fee-for-service payment allowed and even incentivized some physicians to benefit financially by overtreating and overcharging patients.^11,12 In addition, one- or two-person practices made monitoring the quality of care exceptionally difficult. At the same time, however, individual physicians committed to professionalism had ample discretion to translate its precepts into practice. The difference now is that vertical integration and data transparency have narrowed this discretionary space, making professionalism at least as dependent on organizational policy as on personal commitments. In effect, organizations and physicians need to join together to uphold professionalism and ensure that all health care providers can live up to its responsibilities.

Health Care Delivery In The Twenty-First Century

The expanded role of hospitals and health care systems as employers of physicians is mirrored in the marked decline of solo practice. In 1994, 29.3 percent of physicians were in one- or two-person practices that relied on fee-for-service payment; by 2014, the figure had dropped to 17.1 percent.² Between 2008 and 2013, as Marah Short and coauthors have reported, “the share of hospitals with physicians on salary rose from 44 [percent] to 55 percent of all facilities.”^13[p2] The employed practitioners were not only hospitalists but also specialists and primary care providers.¹⁴ Furthermore, between 2007 and 2017, about one-third of cardiology and oncology practices underwent vertical integration.¹⁵ Surgeons followed the same pattern: The percentage of self-employed surgeons dropped from 48 percent in 2001 to 33 percent in 2009.¹⁶ To be sure, one-third of physicians are still in practices of ten or fewer physicians.¹⁷ However, the trend toward large groups is unmistakable and likely to accelerate given legislative, regulatory, and marketplace changes. Recruitment firms report that almost no physicians completing residency seek to purchase or join solo practices.¹⁷

In most hospitals and health systems, management, not individual physicians, sets the conditions for the delivery of care.

In most hospitals and health systems, management, not individual physicians, sets the conditions for the delivery of care. Management—often with but sometimes without negotiations or consultations with physicians—determines salaries, work schedules, the number of patients to be seen, and the average time for each visit, and it may use financial incentives and penalties to reinforce its choices. What have been the consequences of vertical integration on clinical outcomes and health care costs? After an extensive literature review, Mathematica investigators reported a “large number of mixed findings, both within and between studies,”^4(p170) some improvements in patient care, but no reduction in spending and prices.⁴

The effects of organizational transparency policies are also difficult to assess. Clinical decisions by physicians in private practice were usually inaccessible because findings and recommendations were recorded on paper charts and stored in private office file cabinets. Now, electronic health records make the information readily accessible. Analysts using information technologies to collect data on diagnosis, treatment, referral, and outcomes are positioned to evaluate individual physician performance and group performance. These data, shared among clinicians, could improve clinical knowledge and outcomes and promote physician and group competence.^6,7,18,19 But management could also use the findings to design and implement payment and reimbursement formulas that are more responsive to bottom-line considerations than to patients’ well-being. Nor is it apparent precisely who will have access to the data and in what forms. Will unblinded data that link individual physicians to practice outcomes be available only to management? Will fellow physicians, insurance companies, and regulators be able to examine them? Will patients and the media?²⁰ Again, uncertainties about outcomes and implications are widespread.

Finally, patients are becoming more knowledgeable and active consumers. One traditional underpinning of physicians’ professional status was a near monopoly on specialized technical knowledge.²¹ Today the public has extraordinary access to general medical information through websites ranging from those of the National Institutes of Health and Mayo Clinic to WebMD. Although patients are not consulting the data assiduously, the Pew Internet and American Life Project reported that “eighty percent of American internet users…have searched for information on at least one of seventeen health topics.”²² The public is also gaining access to personal and specific health data. Technology companies are rapidly developing consumer medical devices that track not only HbA1c levels but also cardiac rhythms.^23–25 Patients may begin their office visit not by telling the provider where it hurts (as Michel Foucault would have it), but what their newest devices reveal about their glucose levels or arrhythmias. Advice to doctors on managing patient relationships has only begun to incorporate the newly “quantified self.”^26–28

The shift in the informational balance of power is intensified by the fact that more than ever, doctors and patients are strangers to each other.²⁹ Once, only intensive care unit physicians preempted the place of primary care providers. Now, the roster extends to a broad array of specialists, from hospitalists to laborists—the latest term for obstetricians. As Jeannie Haggerty and colleagues observe, effective continuity of care demands that not only the treating physician but other care providers and management teams share the individual patient’s medical and social information. However, the task becomes more essential and more difficult when the caregiver and the patient do not know each other.³⁰

Strategies To Help Promote Professionalism

Given these fundamental changes, the goal of this essay is to explore potentially effective strategies for ensuring the relevance of professionalism. Because developments are just under way, data on the impact of possible initiatives are relatively few. Hence, our intention is to start a dialogue: What strategies might organizations implement to make it more likely that clinicians can live up to the core responsibilities of professionalism?

Institutional Culture

One useful beginning point is with institutional culture, “that which is shared between people within organizations…the shared way of thinking…the values, beliefs and assumptions.”³¹ When physicians were practicing in one- or two-person offices, culture was less of a concern. Practice styles varied considerably, reflecting individual personalities more than fixed policies. At the same time, physicians shared many assumptions about professional values. Now, given organizational ascendency, culture takes on a new importance. As Edgar Schein has observed, a culture committed to professionalism and its norms, philosophy, rules, and climate may provide a unifying vision for an organization, shaping policy and daily practices and defining behaviors to be encouraged or discouraged.³² If the organizational culture does not support the responsibilities of professionalism, then people are able to fulfill them only through acts of personal heroism.

Although the power of a culture to shape behavior is well appreciated, methods for creating and sustaining such a culture are ill defined. In some instances, the culture reflects the vision and authority of founders—in health care, for example, those of Charles and William Mayo. But how can a culture be introduced or altered? What specific areas and policies might best align organizational cultures with professionalism?

Physician Leadership

Much of the current literature emphasizes the fact that “the primary mechanisms for culture embedding and reinforcement” start with leadership—more specifically, with “what leaders pay attention to, measure, and control.”^32(p224) In addition, leaders’ reactions to critical incidents, what behaviors they reward, and how they recruit and promote personnel are highly relevant. This has led a number of commentators to advocate placing more physicians in leadership positions to ensure that organizational decisions better reflect professional values.³³ Earlier, when the bulk of medical practice took place outside an organizational frame, considerations of leadership selection and training were less pressing. Now, however, hospital leaders are typically drawn from the business world: In 2009 only 235 of the 6,500 US hospitals were physician led (and only a handful have been nurse led).^34,35

With this in mind, the American Hospital Association and American Medical Association recently issued a joint report that emphasized the benefits to a professional culture from the appointment of “a group of practicing physicians capable of leadership selection, broad management capabilities, mutual accountability and collective performance measurement and improvement.”^36(p282) As Short and coauthors have concluded, particularly at this moment of transition when self-employed physicians are becoming employees, “it is crucial for hospitals to create an effective governance structure that includes strong physician leadership and experienced practice administrators.”^13(p8) In this way, formerly independent practitioners may be better able to integrate themselves into an organizational infrastructure.

There are some examples of the integration of physicians into leadership teams. Kaiser Permanente partners physicians in its group practice (Permanente) with hospital and health system administrators (Kaiser Foundation Health Plan and Hospitals) to set policy.³⁶ Others, such as Mayo and Ascension Health, rely upon a dyad model within a single organization: They pair individual physicians with administrators at the CEO or chief financial officer level through the departmental or division levels to better integrate clinicians’ values with administrative practices.^37,38 The policy and management literature that analyzes the outcomes of physician leadership on hospital performance is cautiously favorable. Some studies indicate that there has been little change, but more point to better outcomes. One recent study that compared physician to nonphysician leaders at the 100 top hospitals reported that quality scores were at least 25 percent higher when CEOs were physicians.³⁴ A meta-analysis of leadership research found that having physicians in high administrative positions positively affected the management of financial and operational resources and improved both the quality of care and doctor-patient relationships. It also helped foster trustworthiness among hospital staff and improved staff recruitment.^39,40 Thus, on a variety of metrics, physician leadership often, but not always, correlates with better hospital performance.^34,39–46

Physician Compensation:

On the basis of these findings, what organizational policies would best promote professional practices, and how might leadership realignment contribute to their success? One obvious and crucial issue is setting the formulas for physician compensation. Some organizations continue to rely on relative value units, essentially a fee-for-service policy.^17,47,48 Others have introduced fixed salaries, adjusted for physicians’ clinical outcomes and behaviors.⁴⁷ Kaiser Permanente and Geisinger, for example, use metrics of clinical quality and patient satisfaction to adjust salaries by from 5–10 percent (Kaiser Permanente) to 20 percent (Geisinger).⁴⁷ Still others use an assortment of methods, including mixing financial and nonfinancial incentives.⁴¹

Physicians’ participation could improve the match between compensation incentives and desired results.

Although the formulas vary considerably and data on promoting physician satisfaction and better clinical outcomes are incomplete, physicians’ participation could improve the match between compensation incentives and desired results. As a recent and extensive RAND study concluded: “Co-designing A[lternative] P[ayment] M[ethods] with practicing physicians and other leaders…might help improve physician engagement and…produce real improvements in patient care.”^41(p66) The operating premise is that physicians are well positioned to recognize when financial rewards encourage more referrals, tests, and procedures, tipping the balance to overtreatment; and they can identify when a system implements “ill-conceived incentives” that force physicians to “sacrifice their livelihoods to stay true to professional responsibilities.”^49(p16)

To be sure, expanding physicians’ roles in leadership does not guarantee that professionalism and compensation will be neatly joined. Not every physician, as we know from fee-for-service experience, will put patients’ best interests above personal financial gain. Nor will having physician leadership resolve questions of whether incentives should be positive (augmenting salary) or negative (deducting from income); whether extrinsic motivation (incentives and payment) is better than intrinsic motivation (personal commitments);^50,51 or whether nonfinancial incentives such as organizational, peer, and public recognition might be more powerful than salary to promote professional behavior. But in light of organizational context, physicians’ participation in leadership could encourage the use of compensation formulas that best promote professional practices.

Transparency:

Transparency is another controversial area where physician leadership might buttress professional responsibilities. Organizational policies vary considerably on how clinical data should be collected, identified, and shared. Should outcome data be blinded by physician or clinical division? Who should be privy to the results? One survey of leaders at ten high-performing US hospitals found general agreement that quality improvement and patient safety required internal transparency. However, little consensus emerged on how or whether to make data externally available. Only half of the responding hospital leaders supported such a step, and one-quarter strongly opposed it. In practice, five of the ten institutions shared some information with the public, but none reported data by physician name.⁵²

There are also differences of opinion among physicians on transparency policies. Some worry that plaintiffs’ attorneys will use the data in malpractice suits,⁵³ and others complain about the media’s tendency to expose low performers instead of celebrating high performers. Some skeptics of transparency policies believe, too, that transparency may encourage physicians to turn away high-risk patients.⁵⁴ However, still others contend that there is no better way to enhance physician and group clinical practice than through transparency. Sharing unblinded data on diagnostic, referral, and treatment decisions, as well as outcomes, would reveal adverse variations as well as best practices.

Given the differences among both organizations and physicians, it would seem useful to include physicians in the group of decision makers who set transparency policy. Physicians are more likely to be receptive to sharing and using the data when they participate with management in determining how the data are selected, aggregated, risk-adjusted, and released.^7,49 Working together, practicing physicians and leadership might be able to use the data to promote better clinical outcomes.⁵⁵

The Empowered Patient

Although patients have never been as passive and ignorant as some observers have claimed, the present level of engagement is unprecedented. Not only are patients more frequently exploring the medical literature and reviewing their personal health records,⁵⁶ but as noted above, they are also checking their latest medical tracking devices. Technological innovations are encouraging a “quantified self” movement, described in a JAMA article as a commitment to the “recording and reporting [of] information about behaviors such as physical activity or sleep patterns” to “educate and motivate individuals toward better habits and better health.”⁵⁷

The medical self-tracking industry occupies a significant space in the “Internet of Things” device world, linking consumers to their data to facilitate self-measurement, self-tracking, and data exchange. The technologies go well beyond home blood pressure cuffs and blood sugar monitors to include such “connected” devices as fitness trackers (Fitbit), heart rate and heart rhythm monitors (Apple Watch), disease outbreak aggregators (Propeller Health), gait monitors (Smart Insole), and pill tracking devices (PillDrill). The open question is whether this wave of new and ever more intelligent devices will alter the traditional doctor-patient relationship and balance of authority in a way that adversely affects trust and destabilizes physicians’ commitment to putting patient interests first. Specifically, will users act upon misinterpreted or false data from a poorly designed monitoring tool, thereby harming themselves, burdening health care personnel, and wasting health care dollars? Will placing health monitoring devices in patients’ hands lead to “erroneous characterization of true activity due to infrequent or sporadic use and compromised accuracy”?⁵⁸ Will it produce a “blitzkrieg of data”⁵⁹ that would make it even more difficult for health care providers to understand, interpret, and apply the information?

Under these circumstances, clinicians and health care organizations should join together to incorporate health-tracking technologies into care delivery. Specialized clinical knowledge and evaluation of device-derived data could help them determine which devices to recommend to patients, which data to incorporate into patient charts, and what tracking devices to privilege in organizational record gathering. Physician-organization cooperation in this domain could serve as a model for addressing future challenges in patient technology.

Conclusion

Although it is simpler to identify the challenges and opportunities now confronting medical professionalism than to propose effective responses to them, the approaches set forth here—with their focus on organizational culture, leadership, compensation, transparency, and doctor-patient relationships—are intended to stimulate further discussion. The changes in the structure of medical care are so profound that their implications for medical professionalism must be vigorously pursued.

ACKNOWLEDGMENTS

Funding was provided by the Institute on Medicine as a Profession (IMAP). Additional funding was provided to IMAP by the Josiah Macy Jr. Foundation, Kaiser Foundation Health Plan, Kaiser Permanente National Community Benefit Fund, and Permanente Medical Group. The origins of this article rest with a task force appointed by IMAP that met in the period 2016–17. All task force members helped identify and clarify the many issues raised by the changing structure of medical practice. (The members are listed in the online appendix. To access the appendix, click on the Details link of the article online.) The initial findings of the task force were not published, in part because journals were reluctant to publish committee reports. This article builds on the insights of the task force and adds new materials to the analysis. It was discussed with and reviewed by Jay Crosson and Sharon Levine, two of the four task force cochairs. They made very important contributions but did not sign on as authors to this article. Kristy Blackwood, then a research associate at Columbia University and now a medical student at Brown University Warren Alpert Medical School, helped organize task force meetings, conducted research, and helped draft the task force report. Her successor as research associate, Elizabeth Pudel, conducted research on the closing section of this article and contributed to its drafting. The authors were fortunate to have such skilled assistance.

NOTES

• 1 McKinlay JB, Marceau LD. The end of the golden age of doctoring. Int J Health Serv. 2002;32(2):379–416. Crossref, Medline, Google Scholar
• 2 Kane CK, Emmons DW. New data on physician practice arrangements: private practice remains strong despite shifts toward hospital employment [Internet]. Chicago (IL): American Medical Association; c 2013 [cited 2019 Sep 30]. (Policy Research Perspective). Available from: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/premium/health-policy/prp-physician-practice-arrangements_0.pdf Google Scholar
• 3 West J, Johnson G, Jha AK. Trends in acquisitions of physician practices and subsequent clinical integration: a mixed methods study. J Eval Clin Pract. 2017;23(6):1444–50. Crossref, Medline, Google Scholar
• 4 Machta RM, Maurer KA, Jones DJ, Furukawa MF, Rich EC. A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes. Health Care Manage Rev. 2019;44(2):159–73. Crossref, Medline, Google Scholar
• 5 McKinlay JB, Arches J. Towards the proletarianization of physicians. Int J Health Serv. 1985;15(2):161–95. Crossref, Medline, Google Scholar
• 6 Crosson FJ. Physician professionalism in employed practice. JAMA. 2015;313(18):1817–8. Crossref, Medline, Google Scholar
• 7 National Patient Safety Foundation, Lucian Leape Institute. Shining a light: safer health care through transparency [Internet]. Boston (MA): Institute for Healthcare Improvement; c 2015 [cited 2019 Nov 13]. Available (registration required) from: http://www.ihi.org/resources/Pages/Publications/Shining-a-Light-Safer-Health-Care-Through-Transparency.aspx Google Scholar
• 8 Reh G, Korenda L, Cruse CB. Will patients and caregivers embrace technology-enabled health care? Findings from the Deloitte 2016 Survey of US Health Care Consumers [Internet]. New York (NY): Deloitte University Press; 2016 [cited 2019 Sep 27]. Available from: https://www2.deloitte.com/content/dam/insights/us/articles/3164_Technology-enabled-health-care/Technology-enabled-health-care.pdf Google Scholar
• 9 Campbell EG, Regan S, Gruen RL, Ferris TG, Rao SR, Cleary PDet al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795–802. Crossref, Medline, Google Scholar
• 10 Brennan MD, Monson V. Professionalism: good for patients and health care organizations. Mayo Clin Proc. 2014;89(5):644–52. Crossref, Medline, Google Scholar
• 11 Ovens H. Model of payment should not be the key concern when it comes to emergency department physicians’ remuneration. CJEM. 2018;20(2):158–9. Crossref, Medline, Google Scholar
• 12 Innes GD, Scheuermeyer FX, Marsden J, Sing CK, Kalla D, Stenstrom Ret al. Impact of physician payment mechanism on emergency department operational performance. CJEM. 2018;20(2):183–90. Crossref, Medline, Google Scholar
• 13 Short M, Ho V, McCracken A. The integration and de-integration of physicians and hospitals over time [Internet]. Houston (TX): Center for Health + Biosciences, James A. Baker III Institute for Public Policy of Rice University; 2017 Jan [cited 2019 Sep 30]. Available from: https://scholarship.rice.edu/bitstream/handle/1911/93929/CHB-pub-PHITrends-012417.pdf Google Scholar
• 14 Muhlestein DB, Smith NJ. Physician consolidation: rapid movement from small to large group practices, 2013–15. Health Aff (Millwood). 2016;35(9):1638–42. Go to the article, Google Scholar
• 15 Nikpay SS, Richards MR, Penson D. Hospital-physician consolidation accelerated in the past decade in cardiology, oncology. Health Aff (Millwood). 2018;37(7):1123–7. Go to the article, Google Scholar
• 16 Charles AG, Ortiz-Pujols S, Ricketts T, Fraher E, Neuwahl S, Cairns Bet al. The employed surgeon: a changing professional paradigm. JAMA Surg. 2013;148(4):323–8. Crossref, Medline, Google Scholar
• 17 Physicians Foundation. 2016 Survey of America’s Physicians: practice patterns and perspectives [Internet]. Boston (MA): Physicians Foundation; c 2016 Sep [cited 2019 Sep 30]. Available from: https://physiciansfoundation.org/wp-content/uploads/2018/01/Biennial_Physician_Survey_2016.pdf Google Scholar
• 18 Fleming DA, McDonald WJ. Professionalism charter provides guidance to health care organizations in these troubled times. Ann Intern Med. 2017;166(9):665–6. Crossref, Medline, Google Scholar
• 19 Egener B, McDonald W, Rosof B, Gullen D. Perspective: organizational professionalism: relevant competencies and behaviors. Acad Med. 2012;87(5):668–74. Crossref, Medline, Google Scholar
• 20 Ferris TG, Torchiana DF. Public release of clinical outcomes data—online CABG report cards. N Engl J Med. 2010;363(17):1593–5. Crossref, Medline, Google Scholar
• 21 Haug MR. The deprofessionalization of everyone? Sociol Focus U S. 1975;8(3):197–213. Crossref, Google Scholar
• 22 Fox S. Online health search 2006: most internet users start at a search engine when looking for health information online. Very few check the source and date of the information they find [Internet]. Washington (DC): Pew Internet and American Life Project; 2006 Oct 29 [cited 2019 Sep 30]. Available from: https://www.pewinternet.org/wp-content/uploads/sites/9/media/Files/Reports/2006/PIP_Online_Health_2006.pdf.pdf Google Scholar
• 23 Tsukayama H. What cardiologists think about the Apple Watch’s heart-tracking feature. Washington Post [serial on the Internet]. 2018 Sep 14 [cited 2019 Nov 13]. Available from: https://www.washingtonpost.com/technology/2018/09/14/what-cardiologists-think-about-apple-watchs-heart-tracking-feature/ Google Scholar
• 24 Dans E. Responses to innovation: Apple Watch vs. the specialists. Forbes [serial on the Internet]. 2018 Sep 16 [cited 2019 Sep 30]. Available from: https://www.forbes.com/sites/enriquedans/2018/09/16/responses-to-innovation-apple-watch-vs-the-specialists/ Google Scholar
• 25 Carroll AE. That new Apple Watch EKG feature? There are more downs than ups. New York Times [serial on the Internet]. 2018 Oct 8 [cited 2019 Nov 13]. Available from: https://www.nytimes.com/2018/10/08/upshot/apple-watch-heart-monitor-ekg.html Google Scholar
• 26 Shull PB, Jirattigalachote W, Hunt MA, Cutkosky MR, Delp SL. Quantified self and human movement: a review on the clinical impact of wearable sensing and feedback for gait analysis and intervention. Gait Posture. 2014;40(1):11–9. Crossref, Medline, Google Scholar
• 27 Barrett MA, Humblet O, Hiatt RA, Adler NE. Big data and disease prevention: from quantified self to quantified communities. Big Data. 2013;1(3):168–75. Crossref, Medline, Google Scholar
• 28 Swan M. The quantified self: fundamental disruption in big data science and biological discovery. Big Data. 2013;1(2):85–99. Crossref, Medline, Google Scholar
• 29 Smits SJ, Bowden DE, Wells JO. The role of the physician in transforming the culture of healthcare. Leadersh Health Serv (Bradf Engl). 2016;29(3):300–12. Crossref, Medline, Google Scholar
• 30 Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;327(7425):1219–21. Crossref, Medline, Google Scholar
• 31 Mannion R, Konteh FH, Davies HTO. Assessing organisational culture for quality and safety improvement: a national survey of tools and tool use. Qual Saf Health Care. 2009;18(2):153. Crossref, Medline, Google Scholar
• 32 Schein EH. Organizational culture and leadership. San Francisco (CA): Jossey-Bass; 1985. Google Scholar
• 33 Egener BE, Mason DJ, McDonald WJ, Okun S, Gaines ME, Fleming DAet al. The Charter on Professionalism for Health Care Organizations. Acad Med. 2017;92(8):1091–9. Crossref, Medline, Google Scholar
• 34 Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med. 2011;73(4):535–9. Crossref, Medline, Google Scholar
• 35 Gunderman R, Kanter SL. Perspective: educating physicians to lead hospitals. Acad Med. 2009;84(10):1348–51. Crossref, Medline, Google Scholar
• 36 American Hospital Association, American Medical Association. Integrated leadership for hospitals and health systems: principles for success. J Okla State Med Assoc. 2015;108(5–6):281–8. Google Scholar
• 37 Baldwin KS, Dimunation N, Alexander J. Health care leadership and the dyad model. Physician Exec. 2011;37(4):66–70. Medline, Google Scholar
• 38 Springer K. Commentary: Ascension combines clinicians, administrators in “dyad” leadership teams. Modern Healthcare [serial on the Internet]. 2016 Nov 5 [cited 2019 Sep 30]. Available from: https://www.modernhealthcare.com/article/20161105/MAGAZINE/311059981 Google Scholar
• 39 Sarto F, Veronesi G. Clinical leadership and hospital performance: assessing the evidence base. BMC Health Serv Res. 2016;16(Suppl 2):169. Crossref, Medline, Google Scholar
• 40 Swensen S, Kabcenell A, Shanafelt T. Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience. J Healthc Manag. 2016;61(2):105–27. Crossref, Medline, Google Scholar
• 41 Friedberg MW, Chen PG, Simmons M, Sherry T, Mendel P, Raaen Let al. Effects of health care payment models on physician practice in the United States: follow-up study [Internet]. Santa Monica (CA): RAND Corporation; 2018 [cited 2019 Oct 24]. Available from: https://www.rand.org/pubs/research_reports/RR2667.html Google Scholar
• 42 Jiang HJ, Lockee C, Bass K, Fraser I. Board oversight of quality: any differences in process of care and mortality? J Healthc Manag. 2009;54(1):15–29, discussion 29–30. Crossref, Medline, Google Scholar
• 43 Colla CH, Lewis VA, Shortell SM, Fisher ES. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff (Millwood). 2014;33(6):964–71. Go to the article, Google Scholar
• 44 Prybil LD. Size, composition, and culture of high-performing hospital boards. Am J Med Qual. 2006;21(4):224–9. Crossref, Medline, Google Scholar
• 45 Bai G, Krishnan R. Do hospitals without physicians on the board deliver lower quality of care? Am J Med Qual. 2015;30(1):58–65. Crossref, Medline, Google Scholar
• 46 Veronesi G, Kirkpatrick I, Vallascas F. Clinicians on the board: what difference does it make? Soc Sci Med. 2013;77:147–55. Crossref, Medline, Google Scholar
• 47 Khullar D, Kocher R, Conway P, Rajkumar R. How 10 leading health systems pay their doctors. Healthc (Amst). 2015;3(2):60–2. Crossref, Medline, Google Scholar
• 48 Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff (Millwood). 2016;35(3):411–4. Go to the article, Google Scholar
• 49 Hendrickson MA. Pay for performance and medical professionalism. Qual Manag Health Care. 2008;17(1):9–18. Crossref, Medline, Google Scholar
• 50 Dewhurst M, Guthridge M, Mohr E. Motivating people: getting beyond money [Internet]. New York (NY): McKinsey and Company; 2009 Nov [cited 2019 Sep 30]. Available from: https://www.mckinsey.com/business-functions/organization/our-insights/motivating-people-getting-beyond-money Google Scholar
• 51 Wynia MK. The risks of rewards in health care: how pay-for-performance could threaten, or bolster, medical professionalism. J Gen Intern Med. 2009;24(7):884–7. Crossref, Medline, Google Scholar
• 52 Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21(9):722–8. Crossref, Medline, Google Scholar
• 53 Kesselheim AS, Ferris TG, Studdert DM. Will physician-level measures of clinical performance be used in medical malpractice litigation? JAMA. 2006;295(15):1831–4. Crossref, Medline, Google Scholar
• 54 Goddard M, Davies HT, Dawson D, Mannion R, McInnes F. Clinical performance measurement: part 2—avoiding the pitfalls. J R Soc Med. 2002;95(11):550. Google Scholar
• 55 Wynia MK. The role of professionalism and self-regulation in detecting impaired or incompetent physicians. JAMA. 2010;304(2):210–2. Crossref, Medline, Google Scholar
• 56 Ford EW, Hesse BW, Huerta TR. Personal health record use in the United States: forecasting future adoption levels. J Med Internet Res. 2016;18(3):e73. Crossref, Medline, Google Scholar
• 57 Patel MS, Asch DA, Volpp KG. Wearable devices as facilitators, not drivers, of health behavior change. JAMA. 2015;313(5):459. Crossref, Medline, Google Scholar
• 58 Chiauzzi E, Rodarte C, DasMahapatra P. Patient-centered activity monitoring in the self-management of chronic health conditions. BMC Med. 2015;13(77):2. Medline, Google Scholar
• 59 Sarasohn-Kahn J. Making sense of sensors: how new technologies can change patient care [Internet]. Oakland (CA): California Health Care Foundation; 2013 Feb 27 [cited 2019 Sep 30]. Available from: https://www.chcf.org/wp-content/uploads/2017/12/PDF-MakingSenseSensors.pdf Google Scholar