A Data-Driven Argument for Physician Leadership
 
            I realize it is confirmation bias in action, but I was glad to see an article titled “Why the Best Hospitals Are Managed by Doctors” on the Harvard Business Review website recently.[1] The lead author is a physician leader at The Cleveland Clinic, but they cite a study from 2011 looking at the “top-100 best hospitals” as judged by US News and World Report and found that hospital quality scores ran about 25% higher in those run by physicians compared to those run by professional managers. They also found that hospitals where the separation of clinical and managerial knowledge insides hospitals was associated with worse outcome.
            The authors postulate this outcome is explained by “domain expertise,” a concept from the management literature, where expert leaders in a given organization are associated with better outcomes. They also consider several “soft” possibilities, such as the ability of the clinician leader to create a more productive work environment for other clinicians or having a deeper understanding of the motivations and incentives of other clinicians.
            This latter idea strikes me as particularly true. Over the years I have worked in several different environments, including a hospital which has maintained a wall of separation worthy of that between church and state for many years. As I have listened to managers talk (and complain) about the clinicians, it has become clear to me that they have not grasped any motivation other than money. Yet, when I talk to other physicians about this, we all agree it is not money that gets us out of bed in the middle of the night or keeps us in the hospital after our “shift” has ended making sure things are done. And while it would be naïve to assume money does not matter, it is also naïve to assume physicians don’t really care about the quality of their care. I suspect one of the great contributors to the current epidemic of “burnout” is the recognition on the part of more and more physicians that the quality of their work is determined more by the system they work with than they had ever realized before. And when that system is making it harder, not easier, to achieve the goal of good patient care, they get discouraged. 
            The authors note from their own studies that a manager who know through experience what is needed to complete a job to the highest standard is more likely to “create the right work environment, set appropriate goals and accurately evaluate others’ contributions.” Finally, we might expect a highly talented physician to know what “good” looks like when hiring other physicians. This has been true in my multi-specialty group which is physician owned and physician led (with professional management of the business.) When we are hiring, we are looking for people who share our values and priorities. And, if we misjudge someone during the hiring process, we are prepared to separate from them. This does not mean they are bad physicians, but it does mean they are a bad fit with our value system. One of our professional managers once described us as “a for-profit organization that acts like a non-profit.” It turns out we will take care of the patient first, even when we know we aren’t going to get paid.
            The article concludes by noting that successful physician-led organizations have a systematic approach to identifying and training the next generation of physician leaders. In some sense medical training has to begin with the notion that it is “I” who is important. I have to gain the knowledge and the skills to do the tasks involved in being a physician. It is only after I have gained the knowledge and the skills can I begin to deal with the fact that it is really “Thou” who is important. And getting to that point takes a long time, probably at least a decade from matriculation in medical school for most physicians. Clearly, not all physicians develop past the earlier stages of development, but most do, and more would if appropriate methods for coaching and mentoring were available.
            Unfortunately, I do not think we can develop enough physician-leaders and cannot develop them fast enough to guide medicine through these turbulent years of conflicting forces for change. What is needed, then, is a collaborative model that seeks to exploit the expertise of the clinical staff and uses the expertise of the professional managers to make sure the expertise becomes “the way we do things around here.”
            This is why I favor the notion of the clinical microsystem. Here the dominant issues are usually not “business,” but medical. Yes, staffing and costs are relevant concerns, but are framed in the context of trying to deliver the best care for the patient every time. Physicians and nurses are the natural leaders in the clinical microsystem—it is up to the managers to make sure the microsystems are supported, sustained, and allowed to progress as far as they can. It is up to the physicians to get over their cynicism and reluctance to get over the notion that anything other than direct patient care makes one a “suit.” I only hope it is not too late.
 
3 January 2017


[1] Stoller JK, Goodall A, Baker A. Why the Best Hospitals Are Managed by Doctors. https://hbr.org/2016/12/why-the-best-hospitals-are-managed-by-doctors.html.

Further Reading

Clinical Leadership for Practicing Physicians

Clinical Microsystems
Clinical microsystems are composed of front-line clinicians engaged in direct patient care.  Despite a lack of formal authority, they are the key to successful healthcare reform.

How To Make Physician Leadership Real
So you recognize the need to get physicians involved in the leadership of your organization. Now what?

Leadership in Medical Organizations

New Leadership Skills for Physicians
David Brooks has identified highly valued skills in the modern world.  The good news is that physicians already use three of them.

Paradoxes for Physician Leadership
I started this website to share some notions about physician leadership. I have also reviewed many other people’s ideas about these subjects, some of which I have shared in other articles. What strikes me about much of the “literature” on physician leadership, though, is how they fail to grapple with the inherent paradoxes of the role of physician leader. Here are some that I think matter, with some links to other articles on this site, which develop the ideas in more detail.