THE BUSINESS OF PERIOPERATIVE MEDICINE

Often thought of as medical doctor, in financial circles MD stands for money dumb. Sad to say, at least in academic circles, it seems less of a joke than a stereotype with overwhelming anecdotal support. As one academic medical center after another crumbles, distraught leaders throw their hands in the air, pray for government intervention, and end up in the arms of a cost-cutting corporation that transforms once proud institutions into shadows of their former selves. Concepts such as cash flow cycles, returns on investment, load management, queuing theory, and other mainstream business concepts wait in the wings. These concepts are like a poor understudy, hoping to get a chance to come on stage, knowing they can save an ailing, overtired show. Physicians can no longer hope that administrators have the authority to make the type of sweeping changes that are necessary to preserve the system of medical care, because authority alone will not result in people or systems changing. The need for leadership and management arise from the pace and complexity of today's organizations and because, in most organizations, implementing a change is at least as difficult as making a decision to change. Formal authority cannot compel professionals to change as an officer can command a soldier in the military. Medical organizations are complex, notorious for resisting change and for being rife with politics. Management is the process of dealing with complexity in organizations, such as medical institutions. Leadership is needed to guide change in organizations that may have difficulty in making a decision to change and implementing such a decision. The challenge for medicine is twofold: (1) reinvigorate morale and enthusiasm for the practice of medicine so that the profession continues to attract the best and brightest; develop and implement systems that reward academic physicians for clinical and teaching excellence and research accomplishments; continue to develop new information essential to progress in patient health and wellness; and ensure the continued strength of community practices; and (2) overhaul the continuum of care, medical practice, and education and research so that it is financially sound and efficient. The profession cannot achieve its full potential and be of maximal benefit to patients and society without having its financial house in order. Perioperative medicine has the opportunity to be part of a medical system that advances humankind's ability to cure more diseases each decade than has been done in the previous thousand years. Savvy leadership, however, will be needed before bankruptcy derails the locomotive of medical advances. Sophisticated leadership and management will be needed to change the cultural and organizational aspects of medicine. Regardless of the success of efforts to change and achieve financial stability, medicine itself will survive, although it will not achieve its greatest potential without making changes. Against this turbulent background, however, the prospects for a successful transformation of anesthesiology into perioperative medicine are dim—unless the specialty begins to use the leadership and management skills, techniques, and knowledge well known in the business world, which have, in the last 10 years, reinvigorated countless firms (evidenced by today's robust economy). Physicians must lead or be guilty of inaction. It is no longer sufficient to provide solace and cures to patients. Physicians must provide value and direct how that value is produced. The tools to do so are used every day in the business community, and are slowly becoming part of medical establishments, although the pace at which the medical profession is adopting them is slow. The people to do so must be found in the medical profession. The right tools and people will be needed to guide the development of perioperative medicine. The complexities of modern medicine and medical organizations, significant financial constraints, and governmental regulations have resulted in many physicians seeking additional management and leadership training. Frequently, the education that is sought is that of a business degree. Although physicians traditionally have tried to maintain that medicine is and should be separate from business, the reality is that medicine can learn many lessons from the business world. The importance of customer satisfaction and surveys of customers, project analysis, determination of service levels, advanced mathematic techniques to optimize routing, formalized quality improvement, process reengineering, the importance of politics, and the use of negotiation are examples of knowledge, tools, and techniques that are used every day in the business world and that can and should be used in medicine. This article describes some of the subjects taught in a business school curriculum, and highlights their relevance to perioperative medicine.