8 keys to the chief executive suite. (Climbing to the Top).

HERE'S THE PROBLEM: there ought to be a lot of physician chief executive officers by now. But there aren't.

Despite many predictions over the years that hiring physician leaders to head the best health care facilities is "an idea whose time has come," I regret to report that it's just not happening. Health care CEOs who are also physicians continue to be a very small, select group.

That's been something of a letdown for me and others who are looking for a surge in the physician-CEO population. Of course, no one can account for all the reasons why the surge hasn't happened, but here are some.

One key issue preventing more MDs from moving into the CEO ranks is the unrealistic aura (a blend of naivete and ego) that still surrounds the transformation from physician to physician executive.

Both young physicians and their senior colleagues still routinely ask if it's necessary to have a management degree to be considered for the CEO and executive vice president roles.

Yes, it's necessary. No, it's not optional.

Abandon the notion that you can be qualified for the CEO position without solid academic credentials in business management. While there are a few physician CEOs without formal management training, it's very rare to find a recently appointed physician CEO without a graduate management degree of one kind or another--MBA, MMM, MPH or MPA. The market has become much more competitive for aspiring physician CEOs, so those with serious aspirations get a management degree.

Here are 8 more important traits--mostly tangible, although some are not--that boards of directors say any successful candidate for the CEO position must possess. Those who can't demonstrate excellence in these areas can't expect to rise to the top of the organization.

1. Show proven community understanding.

Health care CEOs must understand and be skilled in a broad range of community matters, including politics, philanthropy, government agencies, as well as important local and regional issues. To get a taste of community involvement, become a member of your own organization's board, run for the school board or serve on local committees that deal with hot local topics. Boards see this as a transferable skill. If you've had success in affecting one community, it's likely you'll be able to do the same elsewhere.

2. Enhance your relationship with physicians.

To be effective, every health care CEO needs to have good rapport and clear lines of communication with the organization's physicians. As a physician yourself, you have an advantage, but only if you work hard at honing your skills and raising your profile in this area. Seek elected representation on internal committees, volunteer for ad hoc assignments and look for appointed roles in which you can strengthen your bonds with physicians.

3. Develop an operations focus.

This requires experience--perhaps beginning as a medical director with P&L and hiring/firing responsibility for operating rooms or as a member of a quality team that works with patient units or hospital-wide initiatives. Another way to develop operations experience is by leading a patient satisfaction task force that combines your clinical and management skills. You'll have to roll up your sleeves and learn management on the ground, as a daily exercise, if you want to rise in the ranks.

4. Understand finance and debt management.

A successful CEO leads confidently by ensuring the organization's financial stability and long-term growth. It's simply essential. Some physicians begin to develop their financial understanding by learning to negotiate on behalf of the facility with insurance providers, while others hone their skills in working on capital campaigns or facility planning teams. Board members often assume that physicians know little or nothing about finance, so it is important to demonstrate real experience in this area.

5. Know your board.

As CEO, the board is your boss. A board can make the right policy decisions only when it is confident of the skills and knowledge of its CEO, who must be attuned to the nuances of community, business and industry. The best way to understand a board is to serve on one. Consider serving on hospital, for-profit organization, community service and professional society boards to achieve breadth. Let it be known that you want this experience and you'll get offers. (It may be wise to tell your own boss if you sense any possibility of conflict of interest or political intrusion.) But get your feet wet in this exotic new water. You may find you enjoy board work.

6. Possess leadership 'presence.'

Is there a polite way to say it? Some physicians look like the senior executives they aspire to become and others simply don't fit the part. Boards want to hire an individual as CEO who will represent them in all arenas. They demand poise, high energy, focus, self-confidence, strong communications skills and charisma. There is room for all styles here; not every CEO is larger than life. Some work quietly but effectively--without flash, but leaving no doubt as to who is top dog in their organization. Saggy jackets and 20-year-old shoes don't inspire confidence or get the nod in competitions for CEO positions. Sorry about that, but it's the way the world works.

7. Be a team builder.

Unlike many physicians, CEOs are not solo performers. A strong team of talented people who understand and support the mission--and the CEO--is needed to lead a successful organization. Learn team-building skills. Build or be part of building effective teams that deal with issues like human resource shortages in nursing or pharmacy. You'll learn a lot about how to identify and nurture talent. Boards expect CEOs to possess expertise in recruiting and retaining top talent.

8. Develop strategic

The successful CEO uses data to achieve the organization's mission and vision. The physician executive must become an entrepreneur within the organization, to discern ways to maximize quality while containing costs or maintaining programs. Analyze data and apply it to find new directions for services that will add value or improve financial and clinical outcomes. Boards often look for past evidence of focus and tenacity in achieving a strategic direction.

Will trickle become a flood?

Along with many of my colleagues in the executive search profession, I maintain a hope that the current trickle of physicians into the CEO position will become a flood, because I am sure that well-prepared physician executives can best resolve the difficult problems that confront our health care delivery systems today.

But there is no free lunch. If it comes, it will only be because of hard work and sincere effort on the part of many aspirants throughout the country. As I see it, the CEO role is yours for the taking.

Scott Ransom, DO, MBA, MPH, CPE, FACPE is vice president at Witt/Kieffer in Oak Brook, ill. In addition, he serves as an associate professor in health management and policy at the University of Michigan and associate professor in obstetrics and gynecology at Wayne State University School of Medicine. He can be reached by phone at 630/575-6130 or by e-mail at [e-mail]