The report, delivered in an unmarked envelope and left on Neil Farber’s desk, confirmed the doctor’s long-held concerns: Things were bad within UC San Diego’s hospital system.
Bottom of the barrel bad.
Farber said he spent years talking about the doctor-morale problem as the acting medical director of UCSD’s internal medicine group in La Jolla. And he knew there had been a survey about how he and his colleagues felt toward their managers and workplace, but he couldn’t get hold of the results. Now, an anonymous source had left them in his hands.
“This is dynamite,” Farber remembered thinking.
The survey was one of UCSD’s first insights into the morale of the doctors in its clinics and hospitals. More than 100 physicians participated — first in 2016 and again in 2018 — and rated their “engagement” (job satisfaction) and “alignment” (trust in leadership).
Farber said he wasn’t surprised the numbers were low. But he was surprised, he said, at “how low they were.”
Trust in leadership among doctors at UCSD’s La Jolla and Hillcrest medical centers and the university’s outpatient clinics ranked in the bottom 1% when compared to more than 3,400 other U.S. health care organizations, including hospitals, private practices and long-term care facilities. Job satisfaction at UCSD ranked in the bottom 3%.
One in five doctors said they would not recommend working at UCSD and would not stay at the institution if offered a similar job elsewhere. Almost half said they didn’t have adequate input into decisions that affected their practices. The same amount said administrators were not responsive to feedback.
“That’s a pretty strong indication that something’s going wrong with the culture,” said Kristin Baird, a Wisconsin-based registered nurse and businesswoman who has helped hundreds of health care organizations with patient and faculty experience.
She described UCSD’s low scores as a “huge red flag.”
University higher-ups told inewsource they were surprised by the results, and since the scores came out they’ve taken many steps to address poor morale.
The survey was administered by Press Ganey Associates, an Indiana company known for developing and distributing patient satisfaction surveys — which are easy to come by.
However, Press Ganey surveys of doctor morale aren’t generally public. inewsource obtained them from a source inside the university, then interviewed physicians, faculty and leadership to better understand the problems highlighted.
Employees said the results reflect long-standing problems within the hospital system.
Doctors at the medical centers, UCSD employees said, are treated as second-class citizens caught between hospital administrators, who see doctors as money-generating machines, and academic leaders, who expect them to conduct research and teach students without providing the necessary resources.
Two UCSD health leaders spoke with inewsource at the Jacobs Medical Center in July. Doctors Christopher Kane and Thomas Savides, UCSD’s dean of clinical affairs and chief experience officer, respectively, said the scores were a wakeup call.
“The survey was shocking and disappointing, and it didn’t really reflect who we thought we were organizationally,” Kane said. “There were many lost nights of sleep worrying about that survey and how we should respond.”
Since 2018, they said, UCSD leaders have tried to address the morale problem in a myriad of ways: They’ve changed the hospital’s leadership structure, created physician lounges, put more doctors in management roles, set up social events outside the hospital and conducted listening dinners.
Plus, within a week of receiving a 2019 letter from UCSD faculty about low morale at the hospitals, university Chancellor Pradeep Khosla called a meeting with leadership and began addressing employees’ requests, including paying travel costs for conferences.
“There’s huge attention being placed on this,” Savides said.
“This is a cultural change,” he added. “This is a journey.”
Under the surface
UCSD hospitals are run separately from the university but share some money and staff. Hospital doctors can also work as faculty at the university’s School of Medicine, where they pursue research and teach medical students, residents, fellows and other trainees.
While hundreds of faculty in UCSD Health Sciences — many who spend little or no time with patients — rated their morale as excellent or very good, according to a separate survey conducted last year, the Press Ganey survey was specific to the doctors who work at UCSD’s hospitals and clinics.
The 2018 Press Ganey survey revealed that morale was low across most medical disciplines. The departments of Psychiatry, Pathology, Neurosciences, Medicine and Family Medicine performed in the bottom 1% out of thousands of health care organizations.
The highest-performing department was Radiation Oncology, which ranked in the 53rd percentile on job satisfaction and 65th on trust in leadership.
Farber, who is now retired, didn’t know who put the envelope with the scores on his desk or why, he said, but he passed them on to some of his colleagues, who started to spread the word.
“That’s how the physicians got wind of it,” he said. “Otherwise I don’t think they ever would’ve found out.”
Two other faculty members who spoke with inewsource said they believe the Press Ganey results were kept from employees to protect the university’s reputation.
University spokesperson Jackie Carr denied the scores were hidden.
“The survey results were shared and discussed with all levels of the organization, from the Chancellor's office to the Academic Senate to all School of Medicine departments and divisions, plus multiple governing bodies and other committees through personal meetings and presentations,” Carr said. “We opted for meaningful personal interactions versus a single website posting. We were proactive versus passive.”
Dr. Gerry Boss, who worked in the Department of Medicine for 41 years before retiring in July, said the Press Ganey scores reflect concerns that have been “simmering under the surface” for 15 to 20 years and have yet to be completely addressed.
“The problem with some of the hospital administrators is they don't understand academia,” Boss said.
The doctor said that hospital leadership doesn’t give physicians enough time to teach and perform research, instead, encouraging them to see as many patients as possible.
“They don't understand research, they don't understand teaching and how terribly important that is to a medical school. The lack of that appreciation is sometimes reflected in how they operate, and they mostly operate from a bottom line,” Boss said. “What they're concerned about is keeping the hospital afloat.”
Desperate to change
UCSD was in flux in the years leading up to the Press Ganey surveys.
The university opened the Jacobs Medical Center in La Jolla in 2016 and hired hundreds of new employees. Around that time, UCSD leadership tried to improve morale by raising physician salaries to be on par with national averages, Kane and Savides said.
To do that, they switched the hospitals and clinics to a “work-productivity model” of compensation, meaning staff were paid based on how much and how well they performed their duties.
As a result, many felt pressured to spend their work hours caring for patients, leaving less time for teaching, research and the necessary paperwork that comes with their jobs, employees told inewsource.
“I don’t think most of the clinicians are unhappy about their salaries,” Boss said. “I don’t think that’s why they give poor scores. It’s much more the lack of respect they feel from the administration.”
When the Press Ganey survey was administered in 2018, it showed doctor morale was even lower than it had been when the first survey was conducted two years earlier.
“We recognized that this was a major concern,” Kane said. “And that if we didn't address things in a thoughtful and consistent way, that we would risk having faculty leave the organization, we'd risk potentially adverse outcomes, because a disengaged group of faculty and staff isn't good for patient care.”
In the past two years, UCSD has placed several doctors in new leadership roles, including three positions for associate chief medical officers who oversee hospital operations, quality and faculty. Plus, a physician-in-chief now oversees the Moores Cancer Center, and doctors co-run each of the hospitals’ 65 clinics with another manager.
Kane and Savides said hospital leaders tried to improve operations by expanding the customer service call center, adding more support staff in clinics and revamping the medical recordkeeping system. They also added 400 peer facilitators to the university's burnout prevention program.
In addition, the university conducted listening dinners with physicians, held department meetings with leadership, hosted speakers on topics such as burnout and women in medicine, and ran social events at Petco Park and Birch Aquarium.
An internal March survey measuring the success of the recent changes showed almost half of UCSD doctors most valued the addition of exclusive amenities, including physician-only parking lots and lounges. About a quarter most valued the steps taken to give doctors more leadership roles.
“A comprehensive approach is a complementary way of saying how we did it,” Kane said.
“A shotgun approach is a less complementary way because we were desperate to make the needle move and we weren’t quite sure which domain would make a difference.”
Rankings from U.S. News & World Reports show the public reputation of UCSD’s hospitals has improved in the past year. The Jacobs Medical Center in La Jolla tied for the No. 1 hospital in San Diego and No. 6 in California in the newly released 2020 report, higher than it scored in 2019.
Last year, four of UCSD’s medical specialties made the report’s “Honor Roll” for ranking as one of the best in the U.S. The new report from July shows 10 of its specialties are now among the nation’s best, including oncology, cardiology and geriatrics.
But UCSD employees said some causes of low morale continue, including productivity-driven compensation, unnecessarily high administrator salaries and a system that discourages complaints about possible bullying.
“Are they listening?” Boss asked about UCSD leadership. “They pretend they are, but I don’t think genuinely they do. I don’t see it.”
Kane said the university has a “very robust” reporting system for intimidation, bullying, sexual harassment and gender bias.
“The implication that we don’t address those issues is incorrect,” Kane said. “If I had to take actual offense to a comment, I take offense to that one.”
A letter to the chancellor
Robert Horwitz, a professor in UCSD’s Communication Department, said he thought the 2018 Press Ganey results were “atrocious” and believed he was in a position to effect change.
As the chair of the Academic Senate, he helped oversee the university’s curriculum, set student admission requirements and advise administrators on budgets and faculty issues.
Horwitz interviewed doctors who taught in the School of Medicine about their concerns but did so confidentially because the employees were worried their managers could “come down on them” for speaking out, he said.
Those conversations led to an April 2019 letter from the Academic Senate to Khosla, the UCSD chancellor. The letter said the Press Ganey scores reveal “serious morale problems” at the university hospitals and included nine recommendations to address doctors’ concerns, including more flexible work hours and avenues for faculty input.
“I was sort of placed perfectly to be the one to write this memo because, not being from Health Sciences, I had no dog in the fight,” Horwitz said. “I wasn’t attacking anybody or defending any turf or seeking advantage.”
Within a week of receiving the letter, the professor said, Khosla called a meeting with leaders in the Health Sciences and gave them 90 days to report back on possible changes.
The chancellor also quickly addressed the request to give physicians money for traveling to academic and research conferences.
“I saw that as an extremely good sign that he thought this was now something that had risen to the level of importance that it required immediate attention,” Horwitz said of Khosla.
When Horwitz tried to publish the Academic Senate letter online, he said he faced pushback: Savides, the experience officer, told him posting it would discourage future employees and medical students from joining the university.
Horwitz said he agreed not to publish it if Savides took the letter’s recommendations seriously, and Savides followed through on his end of the deal.
“I don’t want to mess up their ability to recruit,” Horwitz said. “It was sort of like it was a quid pro quo.”
Carr, the UCSD spokesperson, said there was no “quid pro quo.”
“Outreach on the Press Ganey surveys and the initiatives to improve physician satisfaction were in place well before the Academic Senate letter was sent,” Carr said.
“A decision was made that posting the letter on a website without equal education on the survey’s methodology and the university's comprehensive efforts to improve morale would be a disservice to our doctors and the public.”
inewsource reached out to Khosla for comment about the surveys and Academic Senate letter.
Dr. David Brenner, the vice chancellor for Health Sciences, responded in an email on behalf of the chancellor and said every effort is being made to address doctors’ concerns and give them more opportunities to share their feedback.
“When the time is right, hopefully beyond this current pandemic, we will survey our physicians again,” Brenner said. “Between now and then, we will continue to invest in organizational changes, leadership education, improved operations, expanded communications and well-being programs that enhance the quality of their experiences here.”
“Our physicians do a magnificent job of caring for our patients; and we must care for our physicians, too,” he added.
Although the Press Ganey survey hasn’t been conducted since UCSD leaders made their many changes, Kane and Savides said they believe physician morale has improved.
“I’m a hundred percent sure the environment of care is better for the majority of our faculty,” Kane said. “We still have a long way to go.”
Then again, he and Savides thought morale was higher than it was when the 2018 Press Ganey survey was conducted.
“I've seen our gaps and I've seen our weaknesses,” Kane said. “I’ve tried to work on each of those in the organizations that I was working with. But I would have predicted that we would have done better than we did.”
