How to Make Physician Leadership Real
 
            One of my principal objectives in creating this website was to help people, physicians in particular, see the crucial need for physician leadership in medical organizations. There are now several reputable sites that deal with aspects of this topic. Most, though, tend to focus on formal leadership, which is to say, people with job titles, whereas I have tended to focus on informal, clinical leadership. Several years ago I made a presentation to our local hospital trustees, and pointed out our traditional vision of an organizational chart as a sort of pyramid would work better if we thought of it as an inverted pyramid—all the important work was being done by the people who interacted directly with our patients, and who are typically at the “bottom” of the pyramid. I still think that is a useful way to think about the tasks.
            Lately, though, I have been asked to think about the question of how to make physician leadership real in an organization where there is no tradition. Like most people, I started with my own experiences. I have two basic conclusions.
First, where I have operated in functional systems, physician leaders were paired with administrators to accomplish organizational tasks. This “dyad” arrangement allows the complementary skills of physicians and administrators to be yoked to accomplish the dual aims of health care organizations—delivering medical care and running the business. However, this is not just a matter of putting squares on an organizational chart, but is a necessary step.
            Second, to get physicians involved, the leadership tasks need to start with issues involving direct patient care. This is where clinicians spend their time and have their emotional investment.
            As I survey our local environment, several challenges are immediately apparent. First, very few physicians and administrators have actual experience working “yoked” together. In fact, the tendency has been for each side to blame the other for whatever organizational tasks are not being accomplished successfully. Second, it is not at all clear we can activate our medical staff to participate. There has been a lot of discussion of burnout among physicians, and we suffer from all the stressors described by others.
            The challenge begins with the fact that physicians and administrators conceive of leadership differently. Physicians typically view the leader as “first among equals” and his/her success depends heavily on whether or not he/she is able to persuade the majority of colleagues to cooperate in attaining organizational goals. Thus it was with interest that I read a recent paper by Mary Jane Kornacki entitled “Three Starting Points for Physician Leadership.”[1] Recognizing this reality, Ms. Kornacki notes:
 
“Deep and fundamental change within organizations is required to morph from having doctor leaders in name only to them gaining respect and functioning effectively. Here are three issues that need to be addressed: authority commensurate with responsibility; balance of roles with administrative leaders so that doctor leaders can be empowered; acceptance by the rank-and-file physicians of the need for leadership.”
 
            She makes several cautionary statements about these three issues, all of which ring true with what I have seen. First, administrators will be appropriately leery of giving real authority to physician leaders where the history has been to advocate for narrow rather than broad goals.  Said another way, do the physician leaders worry about doctor issues or do they worry about patient issues first?
            Second, creating effective dyads is challenging and requires a cooperative spirit. But that spirit can be undermined if administrators retain the power and the physicians are seen primarily as protectors of the status quo. Likewise, using the physician leader as Superman, who swoops into fix a problem with another doctor does not work either. I have certainly seen by attitudes at play and agree they don’t work.
            Lastly, and perhaps most importantly, practicing physicians have to decide that leadership is a necessary evil, but one that if done well works to the benefit of all concerned. Ms. Kornacki suggests it is necessary to create a new, explicit “compact” for physician leadership in order to be successful.
            During my time as medical director for The Jackson Clinic, I became aware of the issue of the implicit contract—the expectations that a physician brought to the job when they joined the group. The actual contract was quite short and dealt exclusively with legal and financial issues. The “implicit” contract, which was part of the recruiting process, indicated that as long as the clinical care was acceptable, few restraints would be placed on the physician’s time and effort. When I brought up the notion of the implicit contract—that we had never explored what each of us brought to sign our contracts—one physician immediately assumed I was going to try and force a new, written contract that would threaten his practice. The concept was so threatening he was not even willing to think about it—an attitude I failed to anticipate.
            A few years later, the Board chairman decided that our Bylaws were out of date and needed revision. He and the corporate counsel reviewed them, drafted a new set and presented them to the Board. Based on my previous experience, I suggested that the Chair needed to make the case for a revision BEFORE presenting the draft, otherwise the move would be seen as a threat. He did not accept my advice and went ahead with the presentation to the associates. As predicted, many saw the change as a threat and attacked it, either in principle, or by trying to dictate the language. The fact that the changes were minor and reflected current reality and would not have a significant effect on anyone did not matter—it was the threat. At least I had learned my lesson from the first episode.
            Given that many of the medical staff at our hospital are in various stages of burnout, and that most of the changes they have experienced in their practice environment in the last ten years are negative, I predict instinctive resistance to attempts to negotiate a new compact for physician leadership. Although I agree it is important, getting there will require a prolonged campaign of information sharing and pointed attempts to bring the disaffected into meaningful conversation about how things are done.
            So what might help? First, serious efforts must be made to reduce the “hassle factors.” Government regulation won’t go away, but the organization can recognize that freeing the physician from as much of the burden as possible will free him/her to see and take care of patients. Enough has been written about the EMR as a hassle factor that I need not dwell on it, but it is instructive to consider why it is an issue.  Administrators saw the need for documentation to assist with billing as a key issue, but physicians saw that their time was being spent as a typist.  At least at my hospital, the administrative view won. Our electronic record is available, but is used less for communication among the care no more than it was in the days of the illegible handwritten note.
            Second, clinicians need to be able to be able to solve problems that interfere with direct patient care. Are your surgeons spending too much down time in the lounge while the system struggles to get the next patient through all the steps necessary to get into the OR?  If so, own the problem and realize that making the surgeon efficient is good for everyone, but particularly for the patient.  Administrators are quick to complain when a surgeon is not ready when their start time arrives, but slow to recognize when the system fails. Surgeons, on the other hand, respond like the airlines—they overbook to compensate for the downtime. Hence the vicious circle. Getting the surgeons involved in helping to resolve the issues rather than blaming each other is the crucial first step.
            Third, give physicians who show an interest a chance to pair with nursing leadership to improve the clinical microsystem of the specific ward or care area in the hospital. Task them with helping to define the boundaries of clinical failure, to help the nursing staff with the boundaries of staff failure, and work together to reduce staff turnover so care processes can be improved and old problems resolved.
            Perhaps if these things can be done, physicians will be willing to negotiate a new contract and give their physician leader colleagues authority to make commitments about what the medical staff will do to help attain organizational goals and then work with them to make it a reality.
 
27 September 2016


[1] Kornacki MJ. Three Starting Points for Physician Leadership. http://catalyst.nejm.org/three-starting-points-physician-leadership. 1 September 2016. Accessed online 7 September 2016. Ms. Kornacki is a principal in the consulting firm Amicus, which I helped bring to town some years ago for an initial assessment of our environment. They concluded we were not ready to move toward joint governance, which was a correct assessment.

Further Reading

Changing Physician Behavior
Gail Wilensky, an expert on Medicare policy as observed that "changing physician behavior is harder than we thought."

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.

Engaging Burned Out Physicians
Healthcare organizations are told to engage their physicians, many of whom are "burned out." is this squaring the circle?

Leadership Skills

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.