Adopting the CEO model--why physician executives should not be required to practice medicine.

Several times in my career I have been passed over for physician executive positions simply because I no longer see patients.

One of the reasons I have worked in industry for the past decade is that, compared with working in hospitals and health care systems, managed care organizations and pharmaceutical companies have less of an expectation for physicians to continue practicing medicine.

It is certainly acceptable if a physician executive chooses to see patients and has the time, but it is entirely different if a physician executive chooses not to practice because of the competing demands of practicing and managing. The growing complexity and diversity of the delivery system have created the need for more physicians to become involved full-time in directing the medical-industrial complex.

So why are physicians sometimes penalized for refusing to see patients when most jobs in the executive suite call for a full-time employee?

Generating revenue

One reason is money. Historically, physicians have demonstrated their value to organizations by generating revenue, and revenue is derived mainly from seeing patients. For many organizations, there is also the issue of paying a high-priced salary to a physician executive when a lower cost lay administrator would appear to be equally acceptable.

However, administrators often have management goals other than medical standards. Witness the downsizing and closing of psychiatric state hospitals over the past several decades. While the effort might be commendable from a public health perspective, success appears to be measured by how few patients are treated in the hospital rather than how well patients are treated.

Health care administrators truly seem to value the contributions of physician executives. It is disconcerting, therefore, that some organizations may require physician executives to see patients when it would be counter/productive.

I believe this stems from an erroneous belief that physician executives must see patients in order to maintain credibility and serve as role models for the medical staff. Unfortunately, administrators who subscribe to this philosophy fail to consider alternative ways physician executives may demonstrate medical leadership, for example, by providing consultation to other physicians, mentoring younger physicians, discussing cases on "walking rounds," and lecturing and writing on topics in their clinical specialty.

Apparently only powerful physicians who pull their weight through research grants are immune to seeing patients. Most clinical investigators, however, are forced to see patients while conducting research, even though the demands of research can be as great or greater than the demands of medical practice.

Young physicians with research aspirations are especially affected by the pressure to see patients. They are considered an "endangered species" because navigating between clinical care and clinical research is time consuming and simply not feasible in many cases.

"You're no longer a doctor"

Another reason physician executives have difficulty extricating themselves from patient care is because many people hold negative views toward physicians who don't see patients. "You're no longer a doctor" is typical of the criticism physician executives can expect if they enter medical management.

Physician executives have been accused of forsaking healing for business. Medical students with a legitimate interest in learning management theory have been called "traitors" by their teachers who believe that a medical student cannot possibly have both business and patient interests in mind at the same time.

Sadly, practicing physicians tend to view physician executives as turncoats, and non-physician executives tend to view them as outsiders. Many physician executives live in a twilight zone between the worlds of practicing and managing, but they are not 100 percent in either world.

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Of course, there are exceptions where physician executives are successful at both practicing and managing and claim to be more satisfied than their non-practicing counterparts. But considering that private practice physicians often find the dual role challenging, wearing two hats as a physician executive can be more daunting.

More than a doctor

I work in the pharmaceutical industry. When people ask about my background, I usually state, "I am a psychiatrist by training," instead of answering, "I am a psychiatrist." I have consciously tried to change my identity because I consider myself more than just a doctor.

My job requires a variety of skills. Knowledge of clinical medicine provides the foundation, but competencies obtained on the job and in business school are also important. I have stopped practicing voluntarily. I don't have the time or interest to see patients although my employer would permit me to practice a small percentage of time.

Table 1

To Practice or Not?

PRO                                     CON
Maintain credibility   Avoid the chaos and upredictability of
with peers             clinical care.

Remain tuned into the  Maintain a focus on management
realities of           responsibilities.
Practice

Experience greater     Reduce scheduling and travel conflicts
job satisfaction

Stay abreast of the    Free up valuable time.
latest research and
technology

Signal a commitment    Minimize identity confusion.
to the medical
profession

Switching identities from physician to executive is not easy. Because I have a medical degree, the doctor persona will probably follow me the rest of my life, just as other physician executives are symbolically wearing white coats along with their business suits.

Perhaps the greatest compliment I ever received was from a physician who labeled me a "double agent." At the time, I was working for a managed care firm. The physician seemed incredulous that I could genuinely have his patient's best interest in mind.

As we discussed the case, he had a change of heart and told me I was a change agent, trying to improve care from the "inside." I would submit that this type of compliment is the raison d'etre for physician executives.

Internecine war

Still, the myth that physician executives must continue to see patients is perpetuated throughout one's career. Not uncommonly, practicing physicians have called physician executives to task in what has become an internecine war among physicians.

A prominent cardiologist, bemoaning the trend among many disgruntled physicians to leave clinical practice for careers in management remarked, "Nobody ever went to medical school because they couldn't get into business school." His comment earned loud applause during a meeting of the American Medical Association.

Ten years ago, physicians with MBA degrees were denounced in a commentary written by a distinguished physician and published in American Medical News. The author of the commentary wrote, "When push comes to shove, and when the stethoscope hits the chest, I don't want these double degreed physicians providing hands-on medical care for my family or me."

A backlash occurred among physician executives and even practicing physicians. Letters flooded the AMA (more letters were received on this topic than any other in the history of American Medical News). Most of the letters supported physicians in their quest for business degrees and urged practicing physicians not to impugn the values and ethics of physicians with MBA degrees.

But that was a tall order, as studies have shown that business school students cheat more than all other graduate students. Nevertheless, it was recognized that "He who controls the lexicon controls the battle" and physicians who learn the health care business lexicon may be better equipped to serve their patients and populations of patients.

The CEO model

Medicine is not the only field where highly trained and skilled professionals shed their skin as they move into management. Lawyers and engineers have also described experiences similar to physician executives as they assumed management roles and responsibilities and became marginalized in the process.

A joke that once made the rounds in the cloistered halls of the most august law firms was that the CEO was the person who missed the partners meeting the day they chose a new leader. This is equivalent to the practice of selecting physician executives based on personality traits rather than management experience and competencies.

As lawyers ascend to CEO, they forsake the practice of law and billable hours. At the biggest law firms, the job of the lawyer who is also the CEO has evolved into something approaching a corporate CEO. The top-down strategy set by the CEO model empowers lawyers with authority and responsibility.

Law-firm CEOs now manage multi-billion dollar budgets, devise strategic plans, and oversee large workforces. They renew (or terminate) leases, deal with partners with mental health and substance abuse problems, and try to figure out how to market their firms and undercut competitors. Changes in the management of law firms began slowly about a decade ago and recently accelerated, driven largely by economic factors.

The management of law firms contrasts sharply with the management of hospitals and health systems, where physicians and administrators have been mired in tension and conflict for decades. Physicians comprise only about three percent of hospital CEOs, and unless they can be relieved of patient care responsibilities and become fully engaged in management activities, their future as health care leaders may be in jeopardy.

Acceptance by the medical establishment of the full-time CEO model is necessary to cement the role of physician executives as leaders in the healthcare industry. I believe giving up the practice of medicine is a critical component of the model.

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Arthur Lazarus MD, MBA, CPE, FACPE 

Arthur Lazarus, MD, MBA, CPE, FACPE, is senior director of clinical research for AstraZeneca Pharmaceuticals in Wilmington, Delaware. He is a frequent contributor to Physician Executive and author of MD/MBA: Physicians on the New Frontier of Medical Management (American College of Physician Executives, 1998). He can be reached by phone at 302-885-4542 or by e-mail at [e-mail]. His opinions are not necessarily those of AstraZeneca, its management, agents, or employees.