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Leadership For Physicians—Some Paradoxes
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. Physicians won’t listen to the leader’s ideas if they don’t believe in the leader, but they won’t buy into the leader unless the ideas resonate with their own beliefs.[1] Physicians are “thinking types” who prefer to see themselves as rational human beings who keep their emotions at bay. (Given that many of the emotions stirred up practicing medicine can be destructive if not contained, this is probably a useful coping strategy.) When taking a leadership role, then, a physician will tend to assume what is needed is a clear, logical presentation of the facts and the conclusions, and all will be well.[2] As any experienced medical leader will tell you, this almost never works. One of the uncomfortable facts is that physicians will reject an idea, now matter how sound, if they don’t trust the speaker. This is uncomfortable because it is an emotional reaction, not a rational reaction, which conflicts with the physician’s preferred self image as a calm rationalist. In response to this paradox, the standard response is to question the trustworthiness of the speaker. So how does the speaker gain trust? By showing that he/she is “one of us.” A speaker who understands the realities of clinical practice because they are or have been there, has some face credibility. A speaker who can be written off as a “suit” will have major problems, no matter how rational their argument. But, the physician who is enmeshed in the burdens of clinical practice may not have the time or the inclination to engage in “leadership.” Physicians are involved in both formal and informal leadership in all medical organizations, but are often in conflict, despite a common commitment to patient care.[3] Formal leaders imagine their authority flows from their position in the organization’s hierarchy, with its various levels of formal reporting and supervising functions. Physician leaders who are not careful will assume that “employed physicians” will do what the organization requires simply because they are lower down the organizational food chain. Again, experienced leaders will tell you this seldom works, because physicians don’t generally respect or value formal leadership.[4] The Chief Medical Officer almost always has a genuine personal commitment to improving healthcare, but the practicing physician will always be concerned that the CMO may/will subordinate that desire to organizational imperatives imposed by administrators who do not understand their “reality.”[5] Physicians do respect informal leaders, but this respect is grounded in admiration for their professional clinical skills. The informal leader is the one “everybody” would recommend to friends and family. If the informal leader decides to leverage his/her position to improve “the system,” they will do so by relying on the network of relationships they have built over the years inside the organization. They “know” who is trustworthy, and who is effective.[6] But building stable relationships requires organizational stability,[7] and as the managers of medical organizations have come under increasing financial pressure, there is increased pressure on staffing levels and human resource management.[8] This financial pressure invariably increases organizational instability, but managers usually don’t see the downside until things are “falling apart,” because measuring organizational resilience is not well defined.[9] The commercialization of medical care has improved both survival and outcomes for most patients, but threatens the ability to provide compassionate care. The ability to prolong life for patients with kidney failure has been made possible by the commercialization of dialysis machines, supplies, and providers. Yet as a commercial process, all of the players have a vital interest in maintaining their economic position, which means “growth.” Recognizing this may cause problems, CMS has developed a number of metrics designed to ensure “high quality care” to the “beneficiary.” Providers face financial penalties if they do not meet pre-determined threshold performance on these indicators, so they develop treatment protocols and invest resources to make it happen.[10] As noted by Finkelstein in a recent article, though, the question remains: what is the goal?[11] He argues that the ultimate goal is trying to tailor treatments to “maximize each patient’s health-related quality of life.” An obvious example would be skipping construction of an arteriovenous fistula because of the patient’s frailty. However, if this is done too often, the facility will be penalized for failing to meet the threshold for numbers of patients dialyzing with a fistula. Similar issues are now pervasive in medicine, yet many physicians seem reluctant to grapple with the implications. Most don’t know, and don’t want to know, how much each of their decisions cost the patient, and don’t want to know how often their recommendations are influenced by the pressures of the “medical-industrial complex” that undergird much of the clinical enterprise today. I think much of the emphasis on “efficiency” is based on the notion that industrial production standards are appropriate to apply to medical care.[12] The assumption is that efficiency would finesse the financial problem. Those who would question this goal are usually rebutted with the argument—“who would be for waste?” The issue is not waste versus efficiency, it is uncertainty versus certainty. Many business managers assume much medical care is routine and can be packaged in pre-determined bundles of service. Those remaining areas of uncertainty can be resolved if we just bring the resources of “big data,” or “big pharma” or “big government” to bear.[13] I don’t think medical progress is associated with reduced uncertainty. As a young graduate, my patients died of intractable congestive heart failure treated with oxygen, morphine, digoxin, and furosemide. Today they die of intractable congestive heart failure, treated with oxygen, furosemide, ACE inhibitors, spironolactone, beta blockers, implantable defibrillators, and extracorporeal fluid removal. We have spent enormous time, effort, and money finding things to do, but we have not spent time, effort, and money finding out when we should stop doing things.[14] But the pressure to maintain the status quo is enormous, as all of the commercial organizations, from hospitals, to insurance companies, to the pharmaceutical industry, have a vested interest in keeping the money flowing. The unique role of the physician leader is to hold the tension between the particular and the general and to stay open to the possibility that one viewpoint may be superior in one situation, and the other in a different situation. All of these paradoxes are grounded in the difference in a focus on a particular individual, be it nurse, doctor, family member, or staff member, versus a focus on the general, the organization, the budget, the mission. This is not to say an administrator can’t see the particular, but the physician will have personal experience with the stress in caring for the sick, hurt and dying that causes him or her to see the issue more vividly—it is not just an illustrative anecdote, but a real person who is suffering. When we take on a leadership role we do not forsake the desire to relieve suffering, it just comes as different tasks which require different skills. [1] Leadership in Medical Organizations—Why is it so rare and so hard? [2] Medical Evidence, Physician Leadership, and the Value Proposition in Health Care. [3] Organizing for Success—Lessons From Keystone. [4] Clinical Microsystems. [5] Physician Engagement. [6] Culture Matters. [7] A Physician View of Human Capital in Health Care. [8] What Hospitals Are Doing. [9] Measuring Teamwork. Nursing Staff Turnover. [10] Medical Director: Everything You Wanted to Know. [11] Finkelstein FO. Performance Measures in Dialysis Facilities: What is the Goal? Clin J Am Soc Nephrol 2015;10:156-158. doi: 10.2215/CJN.04780514. [12] Productivity and Efficiency in Healthcare, Part 1. Productivity and Efficiency in Healthcare, Part 2. [13] Thoughts on Clinical Realities. [14] On Dying in America. |
Further Reading
Assumptions Doctors and hospitals operate with different cultures and unexamined assumptions may cause conflict. Leadership Lessons From the Military Lessons from leading the military in Afghanistan have implications for which medical organizations will thrive in the current turmoil. 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. The Case for Physician Leadership Why the successful healthcare organization of the future must find a way to create physician leadership if it is to achieve the IHI Triple Aim. |