Suits vs Scrubs: The Evolving Healthcare Workplace

— The patient pays the ultimate price

by Harry Severance, MD April 19, 2023

Healthcare administrator numbers increased by 3,200% from 1975 to 2010. From a practical perspective, this means a growing proportion of workers in hospitals and clinics are now spending far too much time transiting from meeting to meeting to meeting. With a worsening crisis in hospital finance and closures, these administrators and managers are increasingly besieged by corporate “top-down” instructions: to find better ways to “generate more revenue,” “cut more expenses,” and “get the ‘troops’ in line!” This evolving climate of hospital management systems encourages oppositional attitudes — a specter of “us versus them” — and serves to pit management against their clinical healthcare worker counterparts.

It has become a culture of “suits” versus “scrubs.” As healthcare systems become increasingly incorporated and large-scale, these effects are increasingly seen in all types of hospitals and healthcare facilities.

This evolving management system can often contribute to negative outcomes for the workplace:

1. It increasingly isolates first-level managers from their clinical “hands-on” workforce
2. It allows and encourages a manager group “clique” and can cultivate peer group oppositional attitudes of “suits versus scrubs”
3. In a heavily saturated manager marketplace, there is intense pressure to perform, and thus “showing up” for all meetings (even if they’re unnecessary) is seen as critical for advancement and/or job security
4. The system encourages an indoctrination of the management clique by a senior leadership who is increasingly corporate and remote, with little to no understanding of what goes on at the “boots on the ground” level of their own workplaces
5. At the top, senior leadership is increasingly isolated from the realities of the clinical care workplace

New research suggests that senior management leadership (such as executive boards and governing bodies) is becoming increasingly dominated by those from the business and finance sectors, with minimal leadership representation of those with any clinical experience. Across the 15 hospitals studied, physicians made up just 13.3% and nurses 0.9% of these seated positions; the study doesn’t indicate how many of these doctors and nurses are still clinically practicing.

Thus, with little clinical workplace representation and likely less input from their own clinical seated members or from lower management, senior management decisions may increasingly focus on issues of financial success — at the exclusion of other factors and “at the expense of clinicians, patients and communities.”

In this era in which increasing numbers of hospitals and healthcare facilities face worsening financial strife, promoting financial success is understandable. But such a climate can also further promote oppositional attitudes between management and clinical workers — this time from the top down. I have personally heard a “corporate” healthcare leader share her opinion that doctors and nurses were one of the bigger obstructions to a “profitable” healthcare workplace. Huh?!

Such top-down postures and directives contribute to oppositional attitudes from managers about the company’s own clinical, hands-on workforce. The resulting workplace oppositional divide (suits versus scrubs) leaves doctors, nurses, and other hands-on healthcare workers with an accelerating sense of loss of any input into and lack of any control over what occurs in their healthcare workplaces — and decreasing autonomy over the provision of quality care for patients. The mood of the workplace environment thus devolves into one of divisiveness and mistrust: a toxic workplace.

These evolving workplace attitudes and conditions are a chief driver of the discord, discontent, and burnout among clinical healthcare workers. They’re also a chief contributor to the growing exit rate of these workers from healthcare to other professions.

As a result, we’re falling further into clinical workforce shortages, which in turn worsen healthcare facility financial crises.

Notably, the real impact falls upon the patient. Patients now enter a more divisive and increasingly short-staffed workplace, with steadily decreasing availability of timely access to quality healthcare. This is all being promulgated by a system that was supposed to be there to serve them in their times of need.

This past fall, I published and op-ed about at least one healthcare facility that is reportedly bucking this trend, and may outcompete other hospitals for the increasingly rare commodity of doctors and nurses. How are they doing this? They’re creating a more attractive, employee-friendly healthcare workplace that starts with managers being instructed by the C-suite to treat their healthcare workers as “internal customers.” By better serving their clinical team, they can attract and keep good doctors and nurses. More hospitals and health facilities should follow this trend if we want to keep the healthcare system afloat.

Harry Severance, MD, is an adjunct assistant professor in the department of medicine at Duke University School of Medicine in Durham, North Carolina.