Both Werner and Webster say there are still occasional flare-ups between nurses and physicians, but the relationships between the two groups is significantly better due, in part, to the clinic model.
Employed physicians are more keenly aware of the principles of the organization and are held to a higher level of accountability than when they were an independent agent, as well, says Green. "You have direct reporting responsibility within the administration of the hospital, and your bonuses are based on your ability to play well in sandbox."
A traditional medical staff model is a more cumbersome and legalistic process to work through to address disruptive behaviors, he explains. "Physicians who are employed recognize there is a more direct accountability for their actions and behaviors, so it changes that dynamic in a positive way."
Concord Hospital, which has about 340 physicians on its active medical staff—more than 100 of whom are employed—has a very collegial relationship with both employed and independent physicians, says Green. The hospital has collaborative relationships like joint ventures with the independent physicians, so that there is alignment with the organization. "Employment, in general, has its advantages, but the real critical thing is the alignment with medical staff," says Green.
"You can't just rely on the good intentions of people," Werner says. "That is how we have done healthcare for the past 100 years."
A physician-employment model may foster a more collaborative spirit, but it has a few challenges of its own. Namely, that as physicians and nurses work more closely together, communication and trust becomes even more imperative.
"We've had to more directly address the importance of trust," says Mark J. Werner, MD, executive vice president and chief medical officer at Carilion Health System in Roanoke, VA. "When we come together as an interprofessional group, I have to trust that the other people care about my needs and demonstrate my trust in caring about their needs."
One lesson that Carilion learned was the importance of language. For example, when the system first rolled out the clinic model, they used the phrase "physician-led." Unfortunately, that was misunderstood to mean doctors were king. "We found many people getting passive and deferential to physicians in a way that was not our intention," Werner says.
Senior leaders immediately began using the phrase less often and changed their language to include words like collaborative, shared, and teamwork. Carilion also provides all staff members—including physicians—training in service, communication skills, and leadership.
"Words can mean different things to different people," Werner says. "We've had to be more careful that we are communicating accurately, saying what we mean, and people are hearing what we intended to say."