'Caducean ceiling' blocks docs from CEO posts. (Climbing to The Top).

YOU MIGHT CALL IT THE caducean ceiling.

Like the famous glass ceiling that constrains ambitious women executives, the caducean ceiling is the unseen organizational barrier that repels physicians when they aspire to be chief executive officers. Despite the wings on their profession's symbolic caduceus, they can't fly through this final obstacle. Invisible it may be, but the caducean ceiling is up there. Look at the evidence.

In 1972, according to the American Hospital Association, there were 7,061 hospitals in the United States with 813-11.5 percent--headed by physicians.

Thirty years later in 2002, mergers and closures in a turbulent health care marketplace winnowed the total number of hospitals nationwide to 6,044. But doctors who are chief executives run only 200-3.3 percent of the total. That's more than a 70 percent decline in the proportion of physician CEOs.

Indeed, among its 23,065 current members, the American College of Healthcare Executives can count only 28 who are doctors and hospital CEOs. When the field is widened to include organizations of all types, not only hospitals, the ACHE's physician CEO corps rises to just 54.

To be sure, the American College of Physician Executives boasts among its 11,030 members many more doctors in top positions--711, according to the database. But by far the majority are CEOs of medical groups rather than more multifaceted health care organizations.

They constitute a tiny clique huddled in a lonely corner as the laughter rings out and the glasses clink at the big chief executives' ball.

What's going on here?

Oxymoron?

Larry Mathis, former CEO of the Methodist Healthcare System in Houston, took early retirement at the age of 54 in 1997 and wrote a book about what he'd learned in his 14 years at the helm of a major medical enterprise. (During that span, he also wedged in presidencies of the AHA and the ACHE.)

He titled it The Mathis Maxims: Lessons in Leadership (Houston: Leadership Press, 2001). One of his maxims: Physician executive: an oxymoron.

"There's nothing in a physician's education and training that qualifies him to become a leader," maintains Mathis. "And that's what executives Are--leaders... persuaders...team builders...communicators...organizers.

"The physician is challenged throughout his education and training to be an outstanding individual performer. But leadership is not an individual action.

"It's a participatory process.

"I respect and admire physicians," Mathis hastens to add. "They are consummate professionals, the best and brightest of the best and brightest. But when they leave the confines of medicine, they can be a danger to themselves and others."

Clearly, then, among some who have been in a position to look down upon them through the caducean ceiling, there's a prejudice against-or perhaps more accurately, a profound skepticism about--doctors as candidates for senior executive roles.

Not surprisingly, many who have worked under physician executives share those dim views.

"They just don't get it!" moans a woman executive who fled a professional organization headed by a physician. "They brag they don't have management skills. My boss just wanted to be the doctor's doctor. But that was not what was needed."

Other statistics are telling, as well. Consider a June 2002 study published in the American Journal of Nursing that found 93 percent of nurses, physicians and administrators at 84 VHA hospitals had witnessed or personally experienced "disruptive behavior" by a doctor.

The behavior was defined as inappropriate confrontation or conflict ranging from verbal abuse to physical and sexual harassment. Nearly a third of respondents said bad organizational karma--resignations of valued nurses, for example--followed.

So maybe it's understandable that many successful physician chief executives themselves join the chorus of negativity.

"Emotionally we're often like seven-year-olds, a little bit retarded," confesses Donald Hofreuter, MD, CPE, FACPE, chief executive officer of the Wheeling Hospital in Wheeling, W.Va. "Beyond that, our focus is one-on-one--one patient at a time. We want to be healers, loved and honored and respected. We've envisioned ourselves almost as God-like."

Ironically, though, he says, "we don't want to make the hard call. And that's what's necessary on the business side of medicine. Physicians, by nature, want to transfer the blame to other people because they need to be God-like. There are very few times that you'll hear a physician say, 'Boy, I blew that baby!"'

Hofreuter isn't convinced that physicians really want to take on the top post.

"Many say they want the CEO job, but I don't think they do. It's lonely at the top. They're fine as vice presidents of medical affairs and clinical administrators, keeping the medical staff in check and that kind of thing," he says. "But that's not running an organization. The CEO spot is where the buck stops. It's totally your call. And physicians are reluctant to be out there that way. Deep down, they'd rather be where they are, where they don't have to make the really hard calls."

Training and experience

The first thing physicians who challenge the caducean ceiling have going against them is the stereotypical baggage so many of their colleagues have saddled them with.

"I spent my entire career interacting with physicians and I am still baffled that they have so much trouble with the basics of organizations," Mathis says. "They don't get delegation; they don't understand process; and they don't believe in being represented by others."

Kevin O'Connor, a speaker and management consultant based in Long Grove, Ill., says one health care CEO he knows says he likes his physicians very much, but "they don't know the business." The CEO says physicians don't understand influence, collaborative power and the business of health care from a non-prejudicial physician viewpoint.

"It would be as dangerous to turn a health care organization over to most doctors as it would be to turn United Airlines over to the pilots," O'Connor says. "They'd be seeing it as 'How can I do more for my fellow physicians?' 'How can I do more for my fellow pilots?'

O'Connor says many doctors who have MBAs or have gone through a physician executive program continue to visualize themselves as doctors first and foremost.

Asked to determine the prevalence of CEOs who've risen from other health care disciplines like nursing, ACHE vice president for research & development Peter Weil suggests that the data would be untrustworthy.

"As soon as most nursing executives get broader responsibilities," Weil explains, "they drop the RN. They don't want to be perceived as being narrow, only able to manage nurses. Can you imagine a physician executive dropping the MD? Not in this lifetime."

Which is probably just as well, actually. Because on the flip side, says O'Connor, "When you run into a doctor who does understand the business, it's extremely obvious and they stand head and shoulders above anybody else."

Even Mathis concedes "being a physician is actually an excellent background for a person who aspires to be an executive leader, but only if they've had specific leadership training."

There is unanimity among observers that for a physician to enjoy any realistic chance of penetrating the caducean ceiling, advanced management education is required. At the very least, participation in courses offered by the ACPE and the ACHE will help, but even better is a master's degree in business administration, health administration, medical management or even another professional degree, in law or accounting, for example.

But classroom training is not enough--not by a long shot.

"An MBA is a 'nice-to-have,"' says executive recruiter Carol Westfall, president of Cejka and Company, in St. Louis. "The 'musthave' is experience."

And that's precisely where most would-be doc-CEOs fall short.

When physicians are vying for top jobs, they keep being weighed against people who have strong business skills and have been doing management for 20 years," says Thomas Dolan, ACHE president. "It's only in the last 10 years that there has developed a substantial cadre of physicians interested in management.

Pulling down salaries with a mean above $150,000 a year in primary care and upwards of $200,000 annually for almost all specialties, few physicians can be enticed into the trenches of modestly compensated second- and third-tier hospital management-overseeing food service, building maintenance, transportation, nursing or the laboratory.

But those are the humdrum settings where their civilian competitors have honed their abilities and punched their tickets en route to the CEO desk, explains Mitchell Rabkin, MD, FACE, former CEO of Beth Israel-Deaconess Medical Center in Boston and its corporate parent, CareGroup.

For that matter, how much enthusiasm can most physicians muster for the daily grind of a chief operating officer?

"Sixty, 70, 80 hours a week of building buildings, scheduling nurses, leveraging financing...," as O'Connor describes the job. "Most physicians hate that stuff!"

Yet the COO's office is almost always where the trapdoor through the caducean ceiling is located.

Fire in the belly

Traits of personality, incompatible career objectives, insufficient opportunities for early line management responsibility are some of the reasons so few doctors wind up in the CEO's seat.

But maybe the biggest reason, as Hofreuter suggests, is that so few physicians can muster the burning desire it takes to get there.

And why should they? The list of sacrifices is daunting:

* "The career track of a physician-CEO is typically assistant vice president of medical affairs, then VPMA, then COO of a hospital, then CEO," says Dolan. "For most doctors, the thought of spending 15 years working toward a goal which is often where the first payoff in remuneration will come--if they make it to that goal--is not particularly appealing."

* The actual practice of medicine, certainly on anything but the most nominal basis, is next to impossible as soon as one assumes a full-time management role. And that, says Hofreuter, is an essential leap--the earlier the better, too--if you want ultimate credibility as a CEO candidate. "Are you willing to walk away from the clinical expertise you've gained and start again at the bottom?" asks Hofreuter. If so, "you need to say, 'I'm now in business. I'm ready to take on all its vagaries. I have to be prepared to lose my job. I have to be prepared to move my family.'"

* The best opportunities for physicians with CEO aspirations are in small communities, says health care consultant Leland Kaiser. But doctors typically prefer to live in large, culturally rich metropolitan areas. Big-city CEO slots are admittedly more prestigious and higher paying--but accordingly, competition is 30 or 40 times fiercer.

Finally, says Kaiser, "my guess is that most physicians, if they got to the CEO position, might not like it too much. Nothing can prepare you for the lifestyle. Being CEO is all-consuming. You have very little personal or family life. You spend your time in conflict resolution, building hospitals, raising money... areas foreign to most doctors. I'll be interested in seeing if the ones who get MBAs actually do go on to be CEOs. Because it takes a lot of dedication."

Still, for those with the urge and the stomach for the long haul. "becoming CEO of a health-related organization is a logical and to-be-pursued objective for a physician," says Frank Riddick, MD, FACPE, CEO emeritus of the Alton Ochsner Medical Foundation in New Orleans.

Hofreuter, despite his caveats, agrees. "The physician, in general, has a conscience for the house of medicine that people not trained in medicine don't have. So if you can find the right person, the qualified physician, they'll make an excellent CEO."

Absolutely, echoes recruiter Westfall. "A physician executive who masters business skills and leadership skills," she promises, "becomes a very powerful CEO candidate."

References

(1.) Mathis, L. The Mathis Maxims: Lessons in Leadership. Houston, Texas. Leadership Press, 2001.

David O. Weber is a frequent contributor to this journal and 2002 winner of the eighth annual award for trade journalism presented by the National Institute for Health Care Management Research and Education. He can be reached in Mendocino, Calif., at [e-mail].