Physicians as Administrative Leaders

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October 2001

By Jack A. Carroll, PhD, MHA

In ever increasing numbers, physicians are entering into either existing traditional leadership positions or newly created ones. Arguably, there are many factors that serve as the catalyst for these career shifts. Most likely heading the list is physicians' disillusionment with a practice career that they believed would allow adequate time with patients, autonomy, control, and respect. For others, they may want to move on to new challenges. Some believe that administration provides an opportunity to make a difference in health care, are bored with the day-to-day routine of clinical care, or believe they can achieve greater financial rewards and that elusive power at the top.

What are the more obvious skill sets that are pivotal to successful leadership in general and to physician leadership specifically? What mind-set does the physician bring to a leadership position? Do physician leaders have challenges that are greater than those of their nonphysician counterparts? Most important, does a physician in a leadership position make the overall team stronger?

The Skill Set
There are two critical factors in leadership success: problem-solving and communication. Obviously, successful physicians in clinical practice solve problems on a daily basis. However, when a patient's life is at risk, you cannot practice medicine by committee. Clear, authoritative communication is required. Physicians automatically accept the inherent risks always associated with clinical decision-making. Many physicians believe that by virtue of their training, experience, and intuitive skills they possess exemplary leadership abilities. Curiously though, when officially placed within administrative positions, like their nonphysician counterparts, some physicians are immediately effective, some become effective with training and experience, and others just fail.

Administrative management is a profession with its own body of literature, formal curriculum, professional associations, and, hopefully, codes of conduct. During their regular course of study, few physicians receive formal training in management. There are independent programs offered at universities that specialize in health care business education for midcareer professionals. These credentials are increasingly important and demonstrate physicians' desire to fill in the gaps that may preclude their success.

Few of us can appreciate the sacrifice, responsibility, perfectionism, and total cost of being a physician. When the salary of a professional wrestler far eclipses those of numerous physician specialties, you begin to understand the frustration that some physicians might harbor. Larry Vickman, MD, has categorized some of the thought constructs that underlie physician behavior both in and out of official leadership positions.1 He elucidates the inherent sense of personal, as opposed to team, responsibility that is often felt by physicians. Thus, it is no surprise that, justly or unjustly, physicians are perceived as fitting a profile of frequently making independent decisions in isolation; being pragmatically adverse to risk; being uncomfortable with change without clinical evidence; questioning the appropriateness of "excessive" accountability; possessing a deep, but narrow education; having traditionally enjoyed high job security; possessing higher than average intelligence; usually demonstrating a strong work ethic; and being stereotyped as horrible business people.

The Expectations
Administrative expectations may be driving physician leaders to failure. We want physicians engaged in the highest level of productivity and patient satisfaction and, at the same time, we want physician leaders who can fully participate in the management and leadership processes that we deem important. Physicians who want to practice hands-on medicine while always leading the group discussions on clinical service delivery often are trying to be in two places at once. Furthermore, there are the logistics of physicians, who are paid on a production formula and do not want to administrate during prime practice hours. Even those physicians who are receiving management stipends or partial base compensation for administrative services prefer that clinical time not be interrupted.

The schedules of the nonphysicians on the leadership team can be as demanding as those of physicians. I suggest that if the physician leader is bringing value, structure the time and money to pay for the value received. The challenge is in open, honest dealing with any non-value-added team members, whether or not they are physicians.

Physicians who begin working "the other side of the street" are often surprised by the difficulty of the work, the inherent uncertainty within the decisions made, the fact that risk can be managed but not eliminated, the need to take extremely long views of situations, the fact that perseverance is the rule not the exception, the high level of accountability, their acceptance of a position as servant leader, others' requirements for praise and recognition, their own colleagues labeling them as the token physician, and the fact that the reward system is not always perfectly correlated with effort and production.

Successful physician executives assist other members of their team to achieve optimal clinical outcomes; change physician behavior when warranted; reduce practice variation; improve the organization's profitability; and foster innovation and continuous process improvement. They will accomplish this by acknowledging their personal strengths and weaknesses and by surrounding themselves with others who can supplement missing competencies. They will demonstrate behavior that earns them the respect and trust of their physician and nonphysician colleagues, and they will understand that you gain power by giving it away to associates. They will understand that their attention to leadership will necessarily take away from being totally devoted to medical issues and that patient care is not just a convenient place to hide when stuff is hitting the administrative fan. Finally, they will understand partnership. Not everyone is capable of working in a true team environment. Occasionally, a despot leader will not only survive, but thrive. It is just a question of whether the people surrounding that leader are there for the mission, for the money, or for the time being.

Bendel2 has studied and reported on clearly identifiable characteristics that are notable within effective physician leaders. They are there for the right reason-to make positive practice and/or system changes; can remain focused on a common vision often for a protracted period; can build credibility and trust with physicians; understand that the need for political skills often supersedes technical skills; can build consensus, welcome diversity of thought, and have an ego that allows them to be a servant leader; can freely give others recognition; and perform continuous self-assessment that builds on strengths and addresses weaknesses.

True leaders, physicians or others, have to work diligently to remain effective leaders. As the environment changes, so must the situational leadership skills of the incumbents. Input from physician leadership is crucial to helping us create effective health care delivery systems. However, remaining a value-added team member is hard work no matter what initials follow your name.

References
1. Vickman L. Understanding the many faces of physicians: insights for improvement within your organization. Presented at: Spring Conference Virginia Hospital and Research & Education Foundation; April 16, 1998. 2. Bendel A. Effective physician leaders exhibit key characteristics. Medical Group Management Update. 1999;38(18):2.

Jack A. Carroll, PhD, MHA, is president/CEO of Sheltering Arms Physical Rehabilitation Hospital, a postacute hospital system in Richmond, Va.

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October 2001