Amrita Rajesh could tell that the Doctor sitting across from her felt uncomfortable. Exit interviews were usually handled by junior managers on the HR team, but Amrita felt that given the high rate of attrition among doctors at Krisna over the past year, it was her responsibility as head of HR to talk to Dr. Vishnu Patel, a respected cardiologist who’d just given his notice.

“Everyone is always very polite in these interviews, but I need your honesty,” Amrita told him.

Editor's Note

Dr. Patel shifted in his chair. “There are a host of reasons for my departure, many of which you can’t do anything about. My family obligations, for example, and the demands in my own practice.”

Most of the physicians at Krisna saw patients in their private practices, but they also partnered with and referred patients to the hospital for procedures that weren’t possible in an office setting. As the largest multispecialty hospital in Noida, in the National Capital Region of India, Krisna provided secondary and tertiary services in cardiology, orthopedics, neuroscience, oncology, renal care, and gastroenterology.

“Is there anything that would’ve made you stay? Any particular incidents that made you decide to leave now?” Amrita prodded.

Dr. Patel paused, and she gave him an encouraging smile.

“There was that argument I had with the PCE,” he finally said, referring to a relatively new position in the hospital: the patient care executive. Three years ago, in response to patient complaints about not fully understanding doctors’ explanations about their diagnoses and treatments, Krisna had introduced this liaison role. It was meant to be a win-win: Patients and their families would get a better, more personalized hospital experience, and doctors could spend less time managing patients and more time practicing medicine. The program fit well into the hospital’s brand as an expensive but high-quality care center with the best talent, technologies, and service. Unfortunately, Amrita had heard grumbling from physicians from the moment she’d hired the first PCE.

Dr. Patel explained how the PCE assigned to one of his more complicated cases—a patient who had bypass surgery and needed a pacemaker—had caused the patient’s family to lose trust in him. “I don’t know what he said to them during the operation, but from then on, they wanted to talk only with him, and they acted like I was an enemy. It was definitely the PCE and the family against me.”

“To make matters worse,” he continued, “he gave them misinformation about the pacemaker, and when I tried to explain to them that he’d been wrong, they didn’t believe me. It took several meetings to convince them that he didn’t know what he was talking about.”

It was true that the PCEs they’d hired didn’t have medical training. Most had MBAs but just a few years of experience in customer care. And Dr. Patel wasn’t the first to complain about PCE interference in the doctor-patient relationship. But given the improvement in the hospital’s customer satisfaction scores, the hospital’s leaders were generally happy with the PCEs.

“Is this the reason you’re leaving us?” Amrita asked.

Dr. Patel reluctantly admitted that it was. “To be honest, it just makes the job that much harder. I already have to answer to the patient, the patient’s family, and the administration. Now I also have to answer to the PCE. It’s just too many people to please. Why wouldn’t I prefer to work in a hospital that doesn’t interfere in the same way?”

Amrita didn’t have a good response, and she was pretty sure Dr. Patel wasn’t expecting one. “Could we convince you to come back?” she asked instead.

“Fire that PCE. Actually, fire them all. And let us doctors do our jobs. Then maybe I’ll return.”

Leaving in Droves

Later that day, Amrita sat down at a table in a corner of the hospital’s cafeteria with Vinod Kumar, Krisna’s chief medical officer. The two executives had worked together for nearly two decades, first at a large hospital system in New Delhi and at Krisna for the past eight years. Despite their hectic schedules, they tried to have lunch at least a few times each month even if it was just a quick cafeteria meal.

Amrita was still thinking about her earlier conversation with Dr. Patel and broached the subject of PCEs with her friend.

“I wish I could tell you that he is an anomaly,” Vinod said, “but you know as well as I do, he’s not. Many of our doctors are unhappy about the PCEs.”

“Why didn’t you tell me this earlier?” Amrita asked.

“Every time I try, you say ‘Give it time.’”

Amrita smiled sheepishly.

Vinod continued, “I know I’m biased because of my position, but I agree with my physicians that the PCEs are unnecessary and, in a lot of cases, do more harm than good. From the stories I hear, they seem inexperienced and intrusive. Sure, they understand the lingo, but they don’t really understand medicines and treatments.”

“That’s not fair,” Amrita replied. “It’s not like they’re making medical decisions for patients. The doctors are still in complete control. The PCEs are just helping patients better comprehend their options.”

“That’s not what I’m hearing,” Vinod countered.  “The attending doctor in gastroenterology told me that one of the PCEs talked a patient out of an important diagnostic test because she was having panic attacks in advance of the procedure. The gastroenterologist tried to explain that they could treat the panic attacks and that the test was critical, but the PCE wouldn’t budge, thinking he knew best.”

Amrita took a breath, about to speak.

“I know what you’ll say,” Vinod said. “‘That’s one bad apple.’ But I hear more stories like that every day, and in my opinion, this is why our doctors are leaving in droves.”

The hospital’s attrition rate had been between 20% and 25% for the past 18 months. It was true that because of the current doctor shortage throughout India, many hospitals were fighting talent wars, but Amrita knew from talking to her counterparts at other health care providers that Krisna scored among the worst on this metric. It was also the only medical center to have the patient care executive role.

The new program had been positioned as cutting edge by Jai Srinivasan, the head of patient services, which had appealed to the hospital’s board. Now, sitting across from her friend, Amrita wondered if they were ahead of the pack or venturing in the wrong direction.

Good or Bad Attrition?

A week after Dr. Patel’s departure, Ghiridhar Iyer, Krisna’s CEO, called Amrita and Jai to his office to discuss the doctor turnover issue. He explained that the hospital’s board members had asked about it at their last meeting.

“Have we identified any patterns or root causes?” he asked.

Amrita glanced at Jai, then answered, “There are the usual reasons, of course, but I’m starting to wonder about the PCE position.”

She could see Jai immediately tense up next to her. The PCE program had been his baby—and Amrita knew that he didn’t take criticism well. She’d thought that bringing the issue up in front of the CEO might encourage Jai to listen. But his body language now made her think she had miscalculated. Still, she pressed on, quickly summarizing her conversations with Dr. Patel and Vinod.

“We wouldn’t need PCEs if the doctors had better bedside manner,” Jai interrupted. “I’m sick of trying to keep them happy at all costs. We are a ‘patient-centered care center,’” he said, citing Krisna’s mission statement.

“Yes,” said Ghiridhar, “but we can’t deliver patient care if we don’t have doctors.” Krisna’s compound annual growth rate was 82%, and it had been struggling to keep all sorts of positions filled—including nurses and administrative staff—not just physicians.

Amrita felt like she needed to get Jai back on her side. “There is no doubt that the PCE program has been great for the hospital. Revenue is up, as are patient retention and referrals—”

“That’s right,” Jai said. “When we treat patients with dignity and care, they come back to our hospital for all their health concerns and tell their friends and families to come here as well. And the customer satisfaction scores say it all: They love the PCEs.”

“We aren’t debating that,” Ghiridhar said. “Who wouldn’t love a person whose primary interest is to hold your hand though a difficult time? The question is: What are we losing as a result?”

Jai jumped back in. “I don’t believe that the PCEs are driving the doctors out. It’s an easy thing to complain about, but they’re not the real reason for the attrition. I think the doctor’s are tired of splitting their revenue with us. And they’re not happy that the patients prefer coming to see the PCE at the hospital rather than going to the doctor’s private practice. They’re also jealous that the PCEs get paid and recognized no matter who comes through the door.” At Krisna, and most Indian hospitals, physician salaries reflected the number of patients they have treated.

“One possibility is to do more training,” Amrita suggested. She had brought the idea up with Vinod who’d shot it down, but she hoped Jai and Ghiridhar might be open to it. “We did sessions when the role was introduced, but maybe we should bring the doctors and PCEs together again and teach them how to more effectively work together, share best practices.”

“They don’t need more training. We had enough trouble getting the doctors to show up the first time. What we need to do is find the right doctors — ones who believe in the hospital’s mission and want to collaborate instead of prioritizing their own interest,” Jai said.

“According to Vinod, those are exactly the kind of doctors we’re losing. We all know that there is good attrition and bad attrition, and Vinod assures me that we’re now dealing with the latter.” She caught Jai rolling his eyes, but Ghiridhar didn’t seem to notice.

“Well, this is a top priority for me,” the CEO said.  “I know where you stand, Jai. And I agree with you that we need to be careful not to alienate patients. But let’s not let this escalate into a crisis. Amrita, I’d like you to think carefully about the potential remedies.” 

An Emotional Decision

On the elevator ride down from the hospital’s administrative offices, Amrita replayed the meeting in her mind. She took issue with Jai’s characterization of the doctors as money-hungry and disinterested in empathetic care. She knew that most of them could live very comfortably on the revenue from the patients they see and procedures they do in their private offices, but they choose to take on more-difficult cases and bring them into the hospital system, splitting the revenues, because they want to help people. If the PCEs were making doctors’ jobs more difficult, surely she as head of HR should do something about it.

Her thoughts were interrupted when the elevator stopped on the intensive care floor and the doors opened. A woman in her 40s stepped into the elevator, crying into her cell phone, oblivious to Amrita’s presence. “It’s like they don’t care if he lives. They want to do test after test, but no one will decide what to do. There’s only one person I trust: Karthik.”

Amrita recognized the name. Karthik was a recently hired PCE, and sure enough, when the doors opened again on the first floor, the man she remembered was waiting there. He caught Amrita’s eye for a moment, but then quickly focused his attention on the woman, who fell into his arms sobbing. Amrita moved out of the elevator slowly, hoping to see the PCE in action.

Karthik and the woman spoke quietly for a few minutes, then hugged again. As she watched this intimate moment, she couldn’t help but think that the PCEs were indeed filling a critical, and much-needed, role at the hospital. She doubted any of their competitors in Noida, or the rest of India, were providing this level of service.

Amrita now felt weepy herself.  This was business, yes, but one in which emotions invariably played a huge role.  She needed both doctors and patients to trust that Krisna was doing right by them.

Question: Should Amrita recommend eliminating the PCE role?

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