Perspectives on Physician Leadership
My belief in the importance of physician leadership in medical organizations is experiential, but I am always looking for other perspectives. Van Biesen and Weisbrod, writing in that well-known medical journal, Harvard Business Review, reported on surveys done by Bain & Company. There opening line states:
“U. S. hospitals and health care groups have experimented over the past decade with new management structures and alternative payment models to provide quality health care at lower cost. But physicians have been slow to embrace these for a host of reasons. Chief among them, our research shows, is that they feel excluded from the process.”
They go on to note:
“It may sound odd to suggest that the industry overlooked physicians as it set about reshaping the health care system. But that’s how physicians see it. With our colleagues at Bain & Company, we recently surveyed 980 U. S. physicians in eight specialties, 100 health system finance officers, as well as 100 health system procurement officers—people in charge of buying supplies for hospitals. What we found was starting: Physicians clearly understand the challenge posed by rising costs for clinical care and prescription drugs, but many don’t feel they are in a position to help rein in costs. They do not feel sufficiently engaged in making important decisions about cost control, performance improvement, and adoption of new reimbursement models. Indeed, many feel overruled, with mandate after mandate from hospitals and management-led health organizations being done to them, not with them.”
In a recent article, two physicians summarized a survey of physician and non-physician leaders in healthcare organizations about the skill sets needed to be successful. Interpersonal skills were ranked as key by 90% for leading physicians, followed by 69% who marked clinical training. Interpersonal skills were ranked as key by 82% for leading organizations with administrative skills, clinical training, negotiating skills, and financial acumen all receiving between 38 and 49%.
72% of respondents were working in a “dyad” relationship that paired a physician and an administrator, and 85% felt their dyads were at least effective if not extremely so. The authors conclude their analysis by noting:
“However, when it comes to defining vision and managing people and teams effectively, the largest share of respondents say there is no difference between clinical leaders and non-clinical leaders. This speaks to the importance of core leadership skills independent of formal degree…More than half (53%) of respondents—many of whom are physicians—think physicians make better leaders of health care organizations. Only 10% think physicians are worse leaders, with 37% saying there is no difference.”
These articles indicate recognition of the need for physician leadership, but as noted, it continues to be more talked about than done. So how did this become the norm? I suggest it is a combination of factors, one of which includes physicians actively withdrawing from leadership roles. Why do they do this? Perhaps it is best summarized by a colleague currently serving in a leadership role, who observed, “It sure isn’t going to help your standing with your friends, and the pay is trivial.” Dr. James Stoller, of the Cleveland Clinic, was interviewed about his notions about the physician leadership. He said:
“We, of course, have the universal challenge of providing quality care, providing access to care, and doing so at an affordable cost, the Triple Aim of the IHI. We add to that what some would call the Quadruple Aim, the need to make sure caregivers are engaged, have minimal stress, and avoid burnout. When one puts those four features together of the Quadruple Aim, the challenge requires significant and effective leadership competencies at the helm of the health care organization. So, I think that’s the perfect storm, if you will, that creates the need for leadership…
When one puts those four features together of the Quadruple Aim, the challenge requires significant and effective leadership competencies at the helm of the health care organization…The acronym VUCA among leadership circles is a driving force. It’s recognition that we need to be prepared for uncertainty and embrace it, rather than resist it, because it is an ineluctable force and it basically defines the pace of change that we’ve been discussing…Physician leaders straddle two worlds. The first world, of course, of clinical medicine with deep passion and commitment to patient care. We spend most of our early lives, actually not so early, learning the practice of clinical medicine, and [spend] the rest of our lives refining it. And yet, I and many others would argue that leadership competencies are a specific discipline and differ profoundly from the clinical competencies that we spend so much of our lives trying to master. So we have this funny paradox, that it takes so much time and energy to master our clinical and scientific and academic — for those of us who are academic — lives. There are specific skills and competencies that are cultivated and developed in our traditional medical training and yet, that attention leaves little bandwidth for learning leadership competencies.”
Dr. Stoller goes on to define four attributes of medical training that cause physicians to be “collaboratively challenged.” First is the training, which favors individual performance. Second, the training is long and hierarchical. Third is extrapolated authority—the tendency to extrapolate expertise in our medical specialty to other endeavors where we have no special expertise. Fourth, physicians are “deficit-based thinkers.” In other words, we are always looking for problems to solve, which may not be the best approach for leading an organization.
“the antidote to deficit-based thinking is what some would call appreciative inquiry…(which)…frames a question through a much more, if you will, appreciative lens. What are we when we are at our best? It seeks positivity rather than deficit, and if the notion is that words create worlds, [then] when we frame questions from an organizational point of view through an appreciative lens, we get a very different set of answers than we do through a deficit-based lens.”
He notes that the challenge, then is to be emotional intelligent and mindful of the conflicts.
“I love the quote — of course I’ll botch it — but it comes from F. Scott Fitzgerald who said essentially, “The sign of an intelligent mind is the ability to hold two conflicting realities and still function.” And I think that is the challenge of physician leadership. On the one hand, there are many dimensions of how we are trained that are time honored and highly effective, so the notion of differential diagnosis and being deficit based in the clinical work, and there is no reason to suspect that we should fundamentally alter some of those things. At the same time, the recognition that we need to be nimble and mindful and be able to pivot between our clinical context and our organizational context is also important. Again, that’s where mindfulness becomes such an important leadership competency.”
Given these challenges, what should physicians and their healthcare organizations be doing? First, I suggest we all need to appreciate we are in this together. Our times are saturated with “us and them” rhetoric, but to succeed we must get past this. Second, I think we need to re-think what we mean by physician leadership. Too often, we are thinking about upper level position, but most physicians are only going to be interested in their immediate environment. A surgeon, for instance, will care deeply about how things work in the operating room, but won’t be particularly interested in the laboratory or food service issues. To me, the notion of the clinical microsystem is the best way to “organize” our thinking about our care organizations—and we do need many physicians to be engaged and providing leadership at that level. Of course, some won’t be interested, or won’t have the skill sets, but many do.
Lastly, we need to do deep thinking about what physician habits are useful in an organizational setting, rather than trying re-tool the educational process. I maintain that almost all physicians are masters at two skills: agenda setting and living with their decisions. All physicians prefer to be busy, probably too busy if truth be told, but they all are good at prioritizing their activities. From an organizational perspective they may not be prioritizing the way management would desire, but they do prioritize. So perhaps a starting spot is to get the physicians to identify the major problem/irritant/challenge they face in caring for their patients.
Physicians know it is a “VUCA” world—we learn early to make our assessments and initiate our treatments, but always to monitor the “progress” (or lack thereof) by the patient and adjust our plans accordingly. Given time pressures, decisions are made often and quickly. From the organizational perspective physicians may be too quick to pick a course of action and to close out exploration of other means to achieve desired ends, but they can overcome “paralysis by analysis.”
I agree, of course, with the notion that emotional intelligence is the key to leadership success regardless of a person’s background. All organizations need to invest in training and education designed to cultivate this skill set in both managers and clinicians. Sure, it costs money, but how much does it cost if you don’t?
12 October 2017
 Van Biesen T, Weisbrod J. Doctors Feel Excluded from Health Care Value Efforts. 6 October 2017. Accessed 9 October 2017 at https://hbr.org/2017/10/doctors-feel-excluded-from-health-care-value-efforts.html.
 Swenson S, Mohta MS. Leadership Survey: Ability to Lead Does Not Come from a Degree. 17 August 2017. Accessed 24 August 2017 at http://catalyst.nejm.org/ability-lead-degree-dyad-leadership-interpersonal-skills.html.
 Stoller J, Mohta NS. Leading in a VUCA World: Volatile, Uncertain, Ambiguous. 16 August 2017. Accessed 24 August 2017 at http://catalyst.nejm.org/leading-vuca-world-james-stoller/.
 Volatile, Uncertain, Confusing, and Ambiguous.
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Dr. J. K. Stoller of the Cleveland Clinic and associates have written an article entitled "Why The Best Hospitals are Managed by Physicians."
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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.
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