JACR: The upside of bureaucracy

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As solo physicians become increasingly corralled up by multispecialty practices and larger organizations, medicine faces a growing bureaucratic trend, for patients and physicians. Though the thought of bureaucracy may conjure negative sentiments, radiology can learn and benefit from some important models of bureaucracy, according to the author of an article published in the July issue of the Journal of the American College of Radiology.

Revenue has been an important catalyst to the growing size of medical practices. With this, the structure of providers has become increasingly bureaucratic, which at times can stand in the way of the delivery of quality and efficient care due partly to poor incentives and a lack of buy-in for participants.

On the other hand, “Despite the pejorative connotation of the word bureaucratic, bureaucracies have much to offer,” wrote Richard P. Gunderman, MD, PhD, from the department of radiology at Indiana University School of Medicine in Indianapolis.

Gunderman posited a list of advantages to bureaucracies, including rational organizational structure, clear hierarchies of authority, well-defined rules, meticulous documentation, strong training and meritocratic promotion systems.

The common, though not definitive, dividing line between effective and inefficient bureaucracies is typically private versus public sector services, Gunderman claimed.

Comparing the Bureau of Motor Vehicles (BMV) with McDonald’s, Gunderman contended that the franchise’s employee profit-sharing programs, delegation of authority to managers and sense of common purpose marked the distinction between a profitable restaurant-giant and the less popular BMV.

“This should not be taken as a blanket endorsement of the corporatization or privatization of the public sector,” Gunderman continued. Rather, he opined that radiology learn some important lessons from the discrepancies visible between many public- and private-sector bureaucracies.

First, radiology leaders should incentivize quality and efficiency. Though bonuses can be an effective force, “money is not the only answer and often not the best one,” Gunderman warned. Even more powerful, he offered, can be setting up face-to-face time between radiologists and patients as well as referring physicians, to help radiologists apprehend the impact they wield on patients’ lives.

A second theme for larger practices should be the inclusion of radiologists in discussion and decision-making, a form of collaboration by which radiologists can buy into the organization’s larger purpose. Soliciting the feedback of radiologists, as well as other physicians and patients, is likely to make for a more efficient and higher-quality organization with stronger ties to the healthcare community, Gunderman added.

“One of the greatest opportunities for physicians in this area is to attempt to weed out the perverse incentives in medicine that lead to unnecessary, inefficient and low-quality care. We can improve medicine by attempting to ensure that physicians are recognized and rewarded for the appropriateness and quality of care we deliver, not simply how many procedures we perform,” Gunderman wrote.

“The status quo has proved to be financially attractive to many physicians and healthcare organizations, but as the baby boomers retire and begin consuming substantially more healthcare resources, simply doing more of what we have been doing will prove untenable.”