Turf Battles – Navigating the Landscape

When I agreed to write this article, it seemed to me that I would be painting a large bull’s eye on my back. No matter how I approached this subject, it would be controversial. I accepted the task only because there are plenty of places to hide when you live in Oregon. The topic did appeal to me, as I was asked not to write about why there were turf battles between physicians so much as how best to deal with the ever-changing landscape for everyone who works in the cardiovascular arena. I usually have my cardiovascular blinders on, so I can’t think of another area in health care that is experiencing such a dynamic change in the type of work being performed and the range of specialists who want to do the work. This is especially true in the area of diagnostic and interventional vascular procedures, traditionally the stronghold of interventional radiologists. But in a growing number of departments, it is not unusual to have these procedures performed by cardiologists, vascular surgeons, neurosurgeons, cardiac surgeons and even anesthesiologists. With this kaleidoscope of specialties coming together, is there any wonder we see turf battles? Turf battles have existed for many years in the cardiovascular arena. My first encounter with physician turf battles occurred many years ago (notice how I am avoiding an actual number) when a group of neurosurgeons began performing pre-surgery cerebral angiograms on their patients. This territory was new to the surgeons, as it had always been a procedure performed exclusively by the interventional radiologists. Turf battles have recently taken on greater prominence, especially in the cardiovascular arena. Very often, those who originally possessed an exclusive skill no longer hold sole rights to this area. This group often reacts by trying to protect their turf and trying to find ways to exclude the new group of physicians. These efforts can include exclusive contracts, narrowly defined medical staff privileges and an increased effort to secure patients from referring physicians. Unfortunately, these turf battles can also result in some very intense interactions. These confrontations are often a topic of discussion at cardiovascular management meetings. It is interesting to me that many managers complain of a high level of frustration over these turf battles, often feeling as though physicians should be above these types of behaviors. Yet, within minutes, these same managers may be commenting on a very common problem in cardiovascular departments: a “silo effect” between their individual, staff professions. In the silo effect, there are sharp boundaries between specialties, and individual specialists become isolated within the boundaries of their own specialties, unaware of what others in related fields are doing. Individuals protecting their turf often create this silo effect. When you step back and study the two circumstances, they have many similarities. Cardiovascular team members are very proud of their profession, have invested years in their individual training, and as a result, often feel their individual specialty should be the only ones to provide a specific type of patient care. Now, consider the physicians who also have pride in their profession; as a specialist, have committed most of their adult life to obtain the training to perform their service; and, as a result of this training, feel they should be the one to perform a particular set of procedures. In addition, the inability to perform these procedures may affect their financial livelihood. It is no wonder that any shift of one specialty into another is often met with acts of protectionism. So, how do department staff and leadership navigate these turf battles? Very often, the first and most important strategy is to make every attempt to avoid participation. I will pause for the laughing and snide remarks to die down, because this is easier said than done. However, with the exception of times where there are direct patient care issues, the cardiovascular team members should make every effort to avoid being drawn into the battle. These disagreements can sometimes result in physicians involving the staff by including them in discussions about the subject. This is especially true if the established physician is popular with the staff. This type of behavior can only result in polarization of the staff and physicians, and can even result in a polarization of the staff themselves. The manager needs to remind the staff to focus on the patient and reassure them that the issue is being dealt with in a fair and professional manner. For the manager, avoiding participation in the battle may be much more difficult. They must be the first line of defense in protecting the staff from involvement. At the same time, managers must be the ones to facilitate a solution to any department issues that may arise as a result of these battles. These are almost always complex issues and for each situation, there are often different, critical elements to consider. No matter where your department is located along the continuum of physician specialty metamorphosis, the following are possible tools to use to prevent or resolve these turf battles, or at least minimize the overall effect on the patients, department, and staff: 1. Work closely with your medical director. Make sure you keep your medical director constantly apprised of the issues and partner with them on any resolution. Your physician leader best addresses many of the patient care issues. Your medical director’s leadership will be invaluable when interacting with the medical staff department. 2. Establish specific credentialing requirements Many facilities have been very successful in minimizing turf wars by establishing credentialing requirements for specific procedural areas. These can be structured in such a manner that they are built on core privileges, such as diagnostic catheterization and angiography, with specialty privileges, such as percutaneous transluminal coronary angioplasty (PTCA) and cerebral interventions added as sub-privileges, requiring additional training and experience. There are several excellent resources available through national organizations containing recommendations on the qualifications necessary to obtain these privileges. Where appropriate, these national guidelines can be blended with the local, community standards. I highly recommend you work closely with your medical staff department in this process. Having them facilitate this effort will allow the process to originate from outside the cardiovascular department in a more neutral forum. The medical staff department may refer the task of creating privileges to a specific committee. If so, it may be valuable to have the committee chair be from a specialty outside the cardiovascular world. This will allow the chair to approach the process without bias and provide some insulation from the politics that “sometimes” occur in these discussions. As the credentialing requirements are being established, it is also important to consider a pathway to credentialing for those physicians currently on staff who choose to start performing procedures new to them. Consider a vascular surgeon, who for various reasons, wishes to start performing endovascular work. Again, there are well-established programs for this process that can be accessed outside of your individual facility, but you will still need to consider the requirement for physician proctoring once a candidate has returned from the outside training. Do you require every physician who has privileges in a specific area to participate in the proctoring of a physician new to this area, or do you place this responsibility on the medical director? Make sure there is also a requirement to participate in the department quality assurance process. 3. Oversight Oversight is one element that can provide some security to those physicians who are already practicing in a specialty area and perceive their turf as being challenged by the entry of another specialty. One such tool is mortality and morbidity (M&M) review. Often a task assigned to the medical director, a set of criteria can be developed that when met, will trigger an automatic M&M review. Physicians who use a department’s services often have little direct exposure to another physician’s work and outcomes. Much of their information comes in an indirect manner, and unfortunately, is sometimes delivered through the cardiovascular grapevine. We all know how accurate this source of information can be. Having a set of trigger criteria helps control this process of review by rumor. An M&M committee or a sub-committee can also be charged with review and pre-authorization of new and highly visible procedures such as carotid stenting or thoracic stenting. You may also consider creating a method by which the staff can submit cases for consideration by the M&M process. You can construct a simple process by which any staff member can provide the information they believe supports the need for review. This can be submitted, even anonymously, to the manager. The manager can then review it with the medical director to decide if the case is appropriate for inclusion. This is also a process helpful in controlling the rumor mill and involves the staff in quality improvement. Our medical director also incorporates cases in the M&M process which qualify under the criteria of being unusual or interesting. This allows the M&M meeting to be supportive and educational rather than punitive. 4. Create a process to “on-board” new physicians The earlier you know about a new physician planning to use your department’s services the better. Isn’t it wonderful finding out about a new physician the day before they are scheduled to do a case? Advanced warning is also very important for those physicians who are currently on staff and are planning on expanding their privileges into new territories. Work with your medical staff department and create an early warning system to notify you as soon as there is any application for a new privilege in your department. This will allow you to anticipate problems and reduce some of the potential for turf issues. You might also work with your team and develop a process to orient the new physician, or a physician new to a procedure, so they can enter the department as seamlessly as possible. Often, especially with physicians fresh from their fellowships, success and quality of work is directly affected by how your team members support them. 5. Establish standards of behavior We all have an abundance of human resources rules and regulations, which establish expectations for professional employee behavior. But, do you have a shared expectation between physicians in this same area? Most likely, this is covered in the language of the medical staff bylaws, but in situations where there exists outward and inappropriate behavior between physicians, there may be a need to develop a more department-specific set of expectations. Obviously, support from your medical director is critical in this process. 6. Patient Care is #1 This seems so simple, but is often overlooked. In the heat of discussion, where pride, finances, history, contracts and many other items are being discussed, the goal of quality patient care is one thing that everyone should be able to agree upon. The health system in which I have the privilege to work has a very specific mission statement. Any decision can be justified if it supports the goal of quality patient care. Yes, I understand many problems don’t lend themselves to such a simple solution, but using quality patient care as the acid test will often quickly eliminate many of the arguments that are being used to support individual turf battles. Hopefully, I have shared some food for thought on how to navigate through the turf battles that currently exist and those that will inevitability surface in the future. I encourage all of you to share your ideas with each other on this subject. In doing so, you will not only help other healthcare team members, but most importantly, you will improve the quality of care for the patient. Dan Scharbach can be contacted at Daniel.Scharbach@providence.org

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