Ask the coach: physician executive experts answer your medical leadership and management questions.

Underpaid, Unappreciated Medical Director Seeks Career Advice

( ) I'm the part-time medical director for a mid-sized (400M) system. In my four years on the job, I've been successful at returning our owned practices to profitability and leading a number of quality and strategic initiatives. My CEO says I'm a "wonderful asset" and regularly seeks my advice on a wide range of issues. Unfortunately, he doesn't seem willing to create any better opportunities for me or to deal with our dysfunctional physician leadership team (headed by a totally ineffective but long-term VPMA). I've completed a variety of management courses and feel like I'm doing virtually all the senior medical management work around here, but not getting the title, the compensation or the growth opportunities I deserve. Should I start job hunting elsewhere?

On the Verge 

(*) Dear Verge,

Yes probably, but quietly. Before you tell anybody that you're job hunting, consider meeting with your CEO a few times and giving him a clear chance to solve the problem. Make the following points:

* You enjoy management and intend to stay in it for the foreseeable future

* You've run out of "growth" room in your current job

* You'd like to stay but, aware that he doesn't want to deal with what you see as an ineffective physician leadership team, feel like you're being forced to look elsewhere

* Does he see any way to create reasonable career opportunities (with commensurate titles and compensation) for you in the years ahead?

* If not, would he be willing to help you search for alternatives elsewhere?

Chances are that your CEO is quite aware that his VPMA is weak but just doesn't want to upset the applecart (i.e.medical staff relations). Besides, he's got you filling in for the guy. Your CEO needs a reason to consider a change, maybe even somebody to help plan it. If your dissatisfaction and potential loss to the organization are insufficient reasons to consider that change, you might as well start job hunting.

( ) Our hospital is being acquired by a for-profit company along with another larger hospital in our community. I just learned that over the next year we'll probably be merging the two medical staffs as well as some of the hospital-owned practices. I'm the VPMA of the smaller hospital and head of our 20-physician, hospital-owned practice. What does this merger mean for me?

Merging in Michigan

(*) Dear M in M,

It means freshen up your CV and stay on your toes. Hugh Greeley, veteran consultant and a frequent national speaker on this topic, says a merger can either be a major opportunity or a career-limiting event.

He recommends taking a proactive approach and believes your personal consequences are to a large degree determined by what you do early in the process. Hugh's book, Merging Medical Staffs, published by Opus Communications is an excellent reference on this subject.

Hospital mergers are fraught with tough decisions, internecine warfare and good career opportunities usually masquerading as problems. Their history is checkered at best and their exact future is never really known at this stage.

Even some mergers that have been totally completed on paper, never actually happen, e.g. the infamous UCSF/Stanford fiasco. Start by doing your homework, right now. Investigate some key questions.

* Does the acquiring entity intend to bill under a single Medicare provider number and what are the likely implications?

* What are the strengths of the clinical programs at each hospital and which are most likely to thrive in a merged environment?

* What's the socio-political climate between the two medical staffs?

* What's the status of hospital-owned practices at the other hospital and what's the acquiring company's track record for dealing with such practices?

* What are the relative strengths and weaknesses of administrative and senior medical leaders at each facility?

* Who are the likely survivors?

Do your homework and make some early decisions about where your interests and skills might best fit in a future organization. Merger scenarios always abound with task forces and committees. Volunteer to work actively on those groups that will deal with your areas of greatest interest. Watch out for your own excessive turf protection.

No one can predict at this point what exact shape the new entity will take. Your best bet is to work with others to achieve the best overall result, both for the merging organizations and ultimately for yourself.

* I'm the CMO of a three-hospital system and I'm having a public relations problem. I recruit and negotiate salaries for all our new hospital-based physicians, but our chief administrative officer (CAO) has final authority over the salaries. He thinks I'm way too generous and has begun saying so to everybody on the senior management team including my boss. He recently reversed me on two important positions, causing the loss of excellent docs, and he doesn't want to meet regularly to work out our differences. I'm concerned that over time this will begin to erode my credibility with both the management team and the docs. What can I do?

Getting Bad Press

* Dear Press,

You have one of those classic responsibility-without-authority dilemmas. The key is to get the two better aligned.

Since your GAO doesn't want to work on resolving the generic problem with you, one possibility is to simply cede salary negotiations directly to him. That way, rather than you playing used car salesman making repeated trips back and forth to your dealer, you could let the dealer negotiate for himself.

Another option is to sit down with your GAO before opening each new position and ask him to lay out what he sees as the appropriate salary benchmarks before you even begin to discuss numbers with your candidates. That way at least you'll have your debates in advance and reduce the risk of being tripped up half way through a candidate negotiation.

One final possibility is to describe the problems and its consequences to your CEO, asking him/her resolve the structural problem between the two of you. Personally I wouldn't do that unless I already knew what the outcome would be and wanted that particular outcome, (i.e. Mayor Daley's strategy, "Don't hold an election until after you've counted the votes").

Pick one of these three approaches. All of them are better than your current situation.

Howard Kirz, MD, MBA, FACPE, is a retired physician executive and past president of ACPE who provides executive coaching to health care boards and to a number of successful senior physician and health care executives. Questions for his future columns are encouraged and should be sent directly to [e-mail]

(*) Ask the Coach offers practical advice to answer your questions about medical leadership issues and physician executive concerns. ACPE faculty member Howard Kirz writes the column with help from experts both inside and outside the College. Questions for future columns are strongly encouraged and should be sent directly to Kirz at [e-mail]. All questions will be considered strictly confidential.