Why Physicians Don’t Lead
In several recent articles I have quoted others who have discussed the essential role physicians should play in healthcare organizations and have considered a variety of perspectives. In this article I want to take the perspective of the non-physician organizational leader who wants to get his/her medical staff involved in the workings of the hospital, but encounters apathy, if not outright resistance, when an effort is made to start. Why is it so difficult to get physicians to lead?
I’m not sure there is a definitive answer, but I have some observations. First, the education and training of a physician focuses on what the physician knows and does. Consider the surgical resident in the operating room. All his attention is focused on knowing the anatomy, knowing the surgical considerations, and learning the mechanical skills needed to execute the procedure. The operating room team is barely visible, and there is no time or mental energy to consider what they do to get the patient ready for the procedure, help execute it, and get the patient safely to the recovery room. And that is as it should be. But there is no course at the end of residency that challenges to surgeon to expand his horizons and teach him that the infrastructure supporting that OR determines his effectiveness and his success.
When the surgeon enters practice, he may find that he gets the same OR team and develops rapport. He may even come to believe this rapport contributes to success, so will want that team every time he operates. Management, on the other hand, knows the surgeon only operates two days per week and rarely uses the entire day in the OR. Mindful of the need to efficiently use expensive resources, including skilled OR teams, the manager will resist “blocking” the team for one surgeon. Sometimes, the manager will even suspect inappropriate boundary violations if the surgeon advocates for “his” team too strongly. Thus, instead of cooperation, we end up with confrontation.
A surgeon may decide he wants a leadership position in the organization, so he can “fix” the operating room problem, but soon find it isn’t possible. (And using one’s position for personal advantage will undercut the leader almost immediately with everybody.) Alternatively, the surgeon may be told by the physician with responsibility for operations in the OR that his request is denied. Being a leader, then, seems to consist mainly in telling people no. If they have had experience with their own children going through the terrible two’s, they may decide they can do just fine without a job that consists of saying “no, no, no.” Finally, I have long maintained the prolonged adolescence of medical education is something that some physicians never grow out of. Persistence of teenaged behaviors underlines many of the war stories administrative folk tell about doctors when they want to vent.
Perhaps related to this intense personal focus, physicians have a strong preference for informal leaders and tend to adopt the Roman consul and proconsul concept when faced with a crisis. (Of course, they don’t recognize that is what they are doing. For those who don’t recall, the consul was effectively the head of state and given the power of the veto, but his term was limited to one year. And, as time went by, his powers were limited in that other consuls could veto each other. In times of crisis, consuls could be named proconsuls for extended terms, but their authority was always exercised OUTSIDE of Rome itself. And the person with the greatest influence is often NOT the consul of the moment.) This ad hoc approach to leadership is mystifying to those coming from a business or bureaucratic background.
I started my leadership career in military medicine. In the military, formal hierarchy is established by emblems worn visibly on one’s uniform, but so, too, are the emblems signifying one is a physician. But there were some telling details. For instance, doctors with a rank less than colonel (or captain in the Navy) usually called themselves doctor to almost everyone. Second, the medical “chain of command” was established by rank, but the daily clinical operations were determined more by influence—who was the best clinician to deal with the patient’s problem. This was recognized and valued by the commanders in my time, some of whom were influencers and some were not.
Lastly, even when physicians perceive the need for leadership in their organizations, they don’t value it. In all the years of serving in various leadership roles, I can recall fewer than five times when someone came up and said thanks for making things better. I can recall a lot more instances when I was called various unflattering things because I did not agree with the physician’s desired course of action and told him/her so. And in physician organizations, no one wants overhead to go up to actually pay money to another physician to do the job—they presumably should do it for the privilege of doing it.
All these forces practically assure most organizations will find physician leaders only among their senior staff, who are financially and professionally secure, and who have become convinced they need to put their shoulder to the wheel and try to make things better for everyone, not just themselves. So what advice would I give to that non-physician executive looking to get started?
First, figure out who the influencers are on your medical staff. If you have someone from your staff already involved, they may be able to give you the short list, but one way to find out is to ask, “Who would you recommend to a patient with ____ problem?” Not all the best clinicians use their influence, but they are the ones with the potential.
Second, get to know your influencers. Find out what they think and feel about your organization and their role in it. Find out what they are passionate about. If it is a clinical topic, good. If it is about their own efficiency, skip them for now, but keep them alive—you will need them later. (If you can operationalize their efficiency along with everyone else, you will reduce operational expenses.) Look for the common issues that keep coming up in the conversation—that is your agenda.
Third, organize an ad hoc group of the passionate influencers, including yourself and at least one doctor-friendly manager, to address one of those common issues and feed them lunch. Give them the power to make changes—not just recommend something you will consider. Yes, it may look like carte blanche, but commit to make happen whatever is decided upon. Then tell everyone what happened—it will get others to think about joining the next effort. Then repeat ad infinitum.
Does this sound too simple, too elementary? Does it sound boring and time-consuming? Maybe. But if you can make it work, and you get your medical staff on your team you will move your organization. Yes, you can delegate the task to someone else, but then that person must have the same authority you do to move the organization and commit resources.
Physicians almost never want to manage the operation; but they do want to practice medicine in an environment that responds to their needs and their thoughts about what makes for better patient care. In most organizations, it is up to the non-physician executive to create the conditions that foster participation, then bolster it with training and further opportunities to address problem areas. But remember, physicians did not go to medical school to be managers—keep the assignments focused, short term, and decisive. Remember the Roman consul. Those who want to pursue medical management careers instead of practice should be considered proconsuls—they can work in the colonies, but not in Rome.
20 February 2018
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?
On Leadership and the Pygmalion Effect
Perspectives on Physician Leadership
Physician leadership is receiving more attention. Three recent articles illuminate the need for and the challenges to physicians leading.
Is physician engagement a strategy to promote physician leadership, or a code word meaning how do we get the doctors to do what we want?
Physician Leadership That Leads to Success
Some organizations deem physician leadership essential, others don't. Why?