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President’s Letter
The Middle
By Elizabeth B. Moran, MD
E veryone reading this likely has seen some version Most physicians have met many demands in their studies and have
of the Venn diagram (on the right), perhaps in the continually risen to myriad challenges academically and professionally.
classic Triangle schema. This concept has been
In short, we are a group of people used to providing superior effort
referred to in various terms including the in all aspects of our lives. It is almost counter to our nature to
Triple Constraint, Iron Triangle and Project Triangle GOOD realize we cannot be all things to all people all of the time.
and is used to model the constraints of project Some research from the AMA suggests physicians
management in the business world. Summarized, it with lower burnout rates have certain characteristics
means the ultimate quality of work is constrained of their practice settings. Four areas have been
by the project’s budget, deadlines and scope. identified. First, physicians with lower burnout have
A project manager can trade between EXPENSIVE SLOW + more autonomy associated with their work
constraints, but the changes in one + GOOD GOOD environment and decision making. Second,
constraint necessitates changes in others they have the ability to control the number
to compensate, or quality will suffer. NOT of hours worked. Third, they are in a
POSSIBLE position to develop and maintain deeper
For example, a project can be
completed faster by increasing budget FAST LOW CHEAP relationships with their patients. Finally,
or cutting scope. Similarly, increasing QUALITY
scope may require equivalent increases they have increased “adaptive reserve
in budget and schedule. Cutting budget score2.” This fourth characteristic means
the physician has the ability to rearrange
without adjusting schedule or scope leads the practice setting to promote better
to lower quality. organizational change.
In practice, however, trading between In addition to giving physicians better
constraints is not always possible. Throwing money personal tools for avoiding burnout, as a Medical
(and people) at a fully staffed project can slow it down. Moreover, Society we should also nurture environments in which discussion,
poorly designed projects might be impossible to improve regardless of communication and thoughts on these topics can bring us together.
what the manager does. We are hopeful the program we have planned for October 24 at Noble
Health care delivery is obviously unique from other industries, Smoke, facilitated by Dael Waxman, MD, and Joanna Furr, RN, BSN,
but similar schemas have been used to define the unique challenges. entitled “Love it or Leave it: Enhance Your Wellbeing by Regaining
Perhaps the best known is the “Iron Triangle of Health Care,” a concept Control at Work” will be helpful to our members as an avenue to begin
developed by William Kissick, the father of Medicare, in his 1994 book, exploring some of these ideas in a concrete and collaborative way. For
“Medicine’s Dilemmas: Infinite Needs Versus Finite Resources.1” He those who have an interest in reading more on this topic and exploring
describes three healthcare issues that are the primary concerns of all alternative ideas to the Iron Triangle, one resource you might find
healthcare systems and that operate in a dynamic and complex Cost interesting is Institute for Health Improvement, founded by Don
relationship: cost, quality and access. The Triangle is “iron” Berwick and his “Triple Aim” concept.3
because it generally is difficult to have a low-cost, high- quality, Reference:
wide-access healthcare system. It is assumed that if quality
increases, then costs must increase, as well. 1 https://medium.com/more-health/what-is-the-iron-
I personally think a lot of physician burnout stems from triangle-of-health-care-9ce6f5276077.
the fact that we find ourselves stuck in the middle of the 2 https://www.ama-assn.org/practice-management/
triangle, trying desperately to meet the demands of physician-health/small-practice-less-doctor-burnout-4-
many competing pressures. I also think that only reasons-may-be.
focusing on the Triangle as a model of healthcare 3 http://www.ihi.org/Engage/Initiatives/
success is clearly deficient because it omits crucial TripleAim/Pages/default.aspx.
dimensions, including education and learning, Kissick’s Image credits:
research and development, and let’s not Triangle https://businessesgrow.com/
forget the satisfaction of those who work
in the middle of the triangle (health care 2012/09/26/content-marketing-
workers) and those who are trying to Access strategy-are-you-good-fast-
access it (patients). Quality or-cheap/.
6 | October 2019 • Mecklenburg Medicine
