Physician Leadership That Leads to Success
One of my key beliefs is that medical organizations must incorporate physicians into leadership roles to survive. I am always encouraged to find others who make the same point. Recently, C. S. Rihal of the Mayo Clinic posted an article looking at this issue.
“…health care organizations are increasingly recognizing the importance of engaging physicians in their leadership teams, and this engagement will become even more important as the health care environment becomes more challenging…In this context, what does leadership mean, what are its attributes, and what tools do physician leaders have at their disposal? A simple definition of leadership is the ability and willingness to take ownership of the organization…combined with an intrinsic drive to what is best for the organization. However, for leadership to be effective, it must be built on a solid foundation consisting of a clear mission, a vision for the future, a specific strategy, and a culture conductive for success.”
Dr. Rihal goes on to consider these issues in more detail and notes three key traits a leader must possess: communication skills, empathy and emotional intelligence, and team-building skills. He notes these skills improve with time, practice, and study.
What he does not address is how to be effective in organizations where the mission, vision, strategy and culture do not include recognizing the need for physician leadership and therefore don’t have an approach to cultivating and developing physician leaders. The Mayo Clinic was started by physicians and has a long history of being physician led; it is part of the organizational DNA. Certainly, there are other organizations, many explicitly built on the Mayo model, that have a similar culture and tradition. But there are many more that do not have any tradition of physician leadership, and there are others where that tradition is fading as “consolidation” takes place. In these organizations, the emphasis may be on “physician engagement.”
Dr. Rihal used the term physician engagement, but a lot of what I read in the medical press about physician engagement does not mean getting the doctors to lead. It is usually a code phrase for “how do we get the doctors to do what we need them to do to help us meet our (financial) goals?” Perhaps this is too cynical, but it is certainly what I hear when the staff person makes a presentation at my hospital medical staff meeting to report on the activities of the physician engagement committee, (which has no physicians on it.) So far, most of what has been discussed is “irritant reduction,” which I am all in favor of, but it really delays addressing the key question: “How do we change our culture, so physicians expect to become active leaders in the organization?
My first effort at culture change was in the 1990’s, driven by what was forecast to be the “managed care revolution.” It quickly became apparent that one of the major challenges was a clash of cultures. (I once heard a non-physician executive describe this as “the rough Jacksonian democracy of the medical group colliding with the genteel high society manners of the hospital.”) Attempts to start a conversation about culture, cultural expectations, and becoming aware that accommodations from both sides would be necessary, was painful. The conversation quickly turned to what the business arrangement would look like, and the conversation died as culture trumped strategy.
Brent James, a long-time leader at Intermountain Health, said his organization uses a different approach.
“If culture eats strategy for breakfast, then infrastructure eats culture for lunch…Clinicians are the only ones who have fundamental knowledge about workflows that define their care. But they don’t control the systems that set the context within which they work. The key question for the leader is, how do we make it easy for them to do right?”
Dr. James articulated the process they use. First, they identify a high-priority clinical process. Then they build an evidence-based guideline around the process, even though the guideline may not apply to the majority of patients. Third, they blend the guideline into routine clinical workflow, so memory is not required. Fourth, they build a data system capable of tracking variation from the “guideline,” but also able to know what happened to the patient.
Fifth, and in my view, the most important—place a thinking mind at the interface. “It is not that we allow or even encourage—we demand that our clinicians vary from protocol based on individual patient need. That trained expert mind can then focus on a narrow band of questions that can make a real difference.” Lastly, the data on variations and patient outcomes are fed back to the teams so “adaptive learning” can occur.
A contrarian viewpoint was expressed by Pagel and Zwart, who wrote “Wanted: Talented, Energetic, Creative People to Work on Difficult, Boring Problems. No Perks.” As they say, one unacknowledged truth is:
“solving some of health care’s problems in practice is JUST PLAIN BORING…the lack of status attached to tackling or even solving boring problems compounds the fact that they are not interesting to solve, making it easier and easier to just give up. For doctors, nurses, and academics, there will always be competing and more interesting and rewarding priorities for their time. Eventually, one may rise high enough in one’s career that the impact of these intractable problems on daily life fades and can be forgotten, to be despaired at anew by the next generation.”
While they suggest some ways to overcome the challenge, they have wonderfully articulated the challenge. It is exciting to think about a grand new scheme but resolving the intractable issues that characterize daily reality—not so much. I fear a lot of the buzz around “value based purchasing” and “population health” are just this decade’s version of “the managed care revolution.” Which is too bad, because there are some notions that would, if implemented, make patient care better.
24 January 2018
 Rihal CS. Physicians Leading/Leading Physicians: The Importance of Leadership to Organizational Success. 14 December 2017. Located at https://catalyst.nejm.org/importance-leadership-skills-organizational-success.html, 20 December 2017.
 James B. Infrastructure Eats Culture for Lunch. 12 July 2017. Accessed online at https://catalyst.nejm.org/videos/infrastructure-eats-culture-lunch/.
 Pagels C, Zwart D. Wanted: Talented, Energetic, Creative People to Work on Difficult, Boring Problems. No Perks. 17 November 2017. Accessed online at https://catalyst.nejm.org/difficult-boring-health-care-problems/.
A Data-Driven Argument for Physician Leadership
Dr. J. K. Stoller of the Cleveland Clinic and associates have written an article entitled "Why The Best Hospitals are Managed by Physicians."
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.
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.