Breaking the glass ceiling.

THE GLASS CEILING IS DEFINED AS "THOSE ARTIFICIAL barriers based on attitudinal or organizational bias that prevent qualified individuals from advancing upward in their organization into management level positions." (1) Despite the large number of physicians in the United States (approximately 700,000), only about 2 percent identify administration as their primary professional activity. Physicians are not represented in medical management in proportion to their numbers among practicing physicians and in proportion to the number of non-physician administrators. Yet, a greater percentage of physicians are showing an interest in health care administration, and the demand for physician executives is rising dramatically. (2)

Several authors have written about the impact of the glass ceiling on physicians and how it has prevented them from achieving positions of governance and leadership. In fact, health care management resembles other industries in its severe lack of women and minorities in senior management positions. The issue of pressing importance, however, is not whether female and minority physicians are victimized by the glass ceiling (they clearly are), or whether physicians as a class are unfairly denied access to senior management positions in health care organizations. Rather, what factors contribute to this situation and how can physicians break the glass ceiling?

What is the professional profile of physicians in management, and are there specific developmental factors that affect the transition of physicians into management? Many of these factors are related to cultural differences between physicians and managers.

Professional profile

The profile of a physician executive is a white male in his 50s, trained and board certified in a primary care specialty--internal medicine, family practice, and pediatrics. Increasingly, however, specialists outside primary care are swelling the ranks of medical management. But according to Lyons and Cejka, (3) organizations tend to discriminate against surgeons and psychiatrists.

Surgeons are viewed as impulsive, behaving as if they were commander-in-chief. Psychiatrists are viewed as fuzzy thinkers, unscientific at best, and not considered "real doctors." Psychiatrists and the psychiatric profession have been stigmatized throughout time. That bias is unfortunate because psychiatric training can provide a strong base in organizational theory and dynamics.

As further evidence of discrimination against psychiatrists, a recent survey (4) by the National Association of Psychiatric Health Systems (NAPHS) showed that chief executive psychiatrists were greatly outnumbered by their non-physician counterparts. Only eight member organizations of NAPHS reported having a CEO-medical director, compared with 100 reporting a CEO-administrator (survey findings were based on responses from 60 percent of NAPHS member facilities). On the average, however, CEO-medical directors earned far higher salaries ($232,625 versus $102,483). Thus, although psychiatrist executives are well paid, non-physicians fill most of the top slots.

Lyons and Cejka (3) also found that female obstetrician/gynecologists were not inclined to pursue careers in management because these physicians, more than others, practice autonomously and are still able to dictate their own terms of employment.

Pathologists, although severely underrepresented among the ranks of management, appear to make excellent physician executives. Korpman stated, "As the socioeconomic structure of health care changes, the need for health care executives with an understanding of administration, medicine, finance, quality assurance, and medical information management increases. Of all medical specialists, the pathologist is typically the most likely to have had some exposure to all of these areas." (5) Korpman further observed that "as has been so clearly demonstrated over the last few decades, those first to embrace a new practice area are most often those who eventually wield maximum influence in that area." (5)

Unfortunately, breaking the glass ceiling does not appear to be a high priority for health care organizations. Many people have been concerned about the lack of physicians in key managerial roles. (6) A shortage of physician executives may have precluded the Clinton administration from enacting definitive legislation on health care reform (the number of physician executives involved in high-level negotiations paled in comparison with other types of industry leaders). Given the growing number of physicians who aspire to the upper echelons of management, and declarations that the era of the physician executive has "arrived," (7) it is important to identify glass ceiling factors that thwart the advancement of physician executives.

Developmental issues

Silver and Marcos (8) studied the professional development of psychiatrist executives. Their results can be generalized to non-psychiatric physicians as well. They found that becoming a physician executive is a complex process that involves the interplay of at least five distinct factors: a mentor relationship, formal training in administration, personality traits, clinical training, and administrative experience. In addition, because gender and race interact with these factors, they also have an impact on career development. All of these factors should be considered as physicians strive for executive status in their organization.

Mentoring

Having a supportive mentor is important in the development of physician executives, just as it is in business executives. Mentoring is the process by which a senior manager helps a middle manager realize his or her potential and achieve growth within an organization. Generally, mentors are older, experienced professionals who encourage, sponsor, and support younger members in their career advancement. Through mentoring, upcoming managers develop sound judgment and wisdom as they seek to work to their full capacity. Mentoring is similar to, but quite distinct from, other developmental tools such as coaching, training, teaching and counseling.

Young management-minded physicians often lack a mentor. There are relatively few business-trained physicians in executive positions to begin with, making it difficult to find appropriate role models for young physicians interested in management. Some organizations do not value the role of the mentor and do not set aside adequate time for it.

They do not realize that mentoring is the cornerstone of any human resource development plan. To compound the problem, once physicians enter the corporate world, it is assumed they are not in need of mentoring because they were mentored in medical school and residency. That assumption is incorrect, and even if it were true, the mentoring process during clinical training would not likely include exposure to the business world. Also, trainees rarely stay in one place long enough to enter into a meaningful long-term mentor-protege relationship.

Training and Education

Business training for physicians often occurs haphazardly. "First-generation" physician executives usually learned on-the-job, through experience and trial-and-error. Now, however, classroom learning and less formal business training (e.g., through seminars, workshops, meetings, etc.) is necessary to understand the complexities of management.

For some physician executives, advanced business training is considered a prerequisite to a management career. Medical schools rarely have time to teach students concepts in business and practice management. Likewise, residency training programs emphasize clinical skills rather than business skills. For many physicians, the first true management position is Chief Resident, several years after medical school.

Increasing numbers of physicians are opting for training in business school. Some medical schools now offer combined MD/MBA degrees that can be completed in five years. Smallwood and Wilson (9) recommended formal training early in the administrative careers of physician executives. Physicians dedicated to a career in management are the ones most likely to benefit from an MBA. Nearly 10 percent of physician executives have MBA degrees and another 38 percent are working on an MBA or intend to pursue one, according to a 1994 survey. (7)

Practicing or Administering?

Formal training in business ensures that physician executives play on a level field with health care executives, at least in terms of credentials. But physician executives also retain the persona of "healer" and continue to be viewed as practitioners. In fact, physician executives are often expected to see patients to "set an example" for front-line clinicians. Many physicians, however, become bored after practicing about 15 years. (10) Practicing and managing compete for time and attention. As a result, neither may be performed adequately by physicians who try to combine both functions.

Also, as the role of the physician executive becomes more specialized, and as health care becomes more complex, it may make sense to sharpen the clinical skills of practicing physicians, while developing the business skills of physicians committed to a career in administration.

A study of the career paths of physician executives (11) showed that physicians sharply reduce their time in clinical activities as time spent in administration increases. The authors of the study concluded that physician executives move away from clinically-related duties as they advance in their careers. Senior physician-executives spend less than 10 percent of their time in direct patient care and about 80 percent of their time in management.

Physician executives must, therefore, be allowed to relinquish their clinical reigns (assuming they choose to do so), and organizations must help them make the transition into management. That entails, at minimum, releasing physician executives from direct patient care responsibilities and not pressuring them into seeing patients to generate part of their salary. Physician executives should not be made to feel guilty if they choose to give up practicing.

Cultural differences

There are significant cultural differences between physicians and non-medical health care executives that can be attributed to differences in educational and social processes. Shortell (12) has identified seven characteristics that distinguish physician executives from their non-clinical counterparts.

1. A physician's knowledge is derived primarily from the biomedical sciences. Non-physician health care executives are trained primarily in graduate schools of business administration. Presumably, that gap will close as more physicians seek business training.

2. Physicians are exposed to many types of caregivers in their training, but their exposure to the business and economic aspects of health care is limited. In fact, physician executives themselves tend to underrate the value of economic objectives in their organizations. They also fail to appreciate that managers who lack clinical training sincerely value their skills and that these managers expect physician executives to broaden their roles. It is naive of physician executives to think that capital budgeting, resource management, and similar functions can simply be left to others.

3. Physicians tend to focus on the needs of individual patients. Managers focus on patient populations. Physicians need to think globally, in terms of the larger community of "insured lives." Those physicians who develop this perspective will become effective managers. However, balancing these two different and conflicting perspectives may create thorny ethical issues for physician executives.

4. Physicians expect to complete tasks in a short amount of time, whereas executives plan more strategically over the long run. Physician executives must learn to be patient and determine how to position their organization for the future.

5. Physicians are indecisive because they wait to make decisions based on rules of evidence derived from well-established, tightly-linked causal relationships. Health care managers, on the other hand, are accustomed to uncertainty and ambiguity and understand the need to act on "soft" qualitative information.

6. Physicians view resources as unlimited, whereas other types of managers view resources as finite. Making decisions related to resource allocation is perhaps the single greatest challenge facing physician executives.

7. Physicians have a cohesive and highly developed professional identity compared with non-medical managers. The "Good Old Boy" network is much more pervasive in medicine than the corporate world. Physician executives frequently find themselves in "no man's land"--stripped of their white coat yet not entirely in pinstripes--when they make the transition from medicine to management. They are not readily accepted in their new role, especially when health care executives are competing for the same jobs.

Personality

O'Connor and Shewchuk (13) have noted significant personality differences between physicians and health care executives. The Myers-Briggs Type Indicator (MBTI), a widely used personality assessment, demonstrates that the quintessential business type tends to be extroverted, sensing, thinking, and judging.

Physicians, and students most likely to be attracted to medical school, are introverted, intuitive, feeling, and perceiving. Essentially, physicians and managers are polar opposites. The MBTI reflects not only personality traits, but also management style, values, attitude, and energy level. Therefore, it is important to understand differences between physicians and business people as revealed by the MBTI. These differences have implications for the way conflict is resolved and communication is channeled.

For example, since managers are more extroverted than physicians, they must avoid becoming too "personal" and defer to physicians' greater need for privacy. Physicians need to be very clear in their conversations. Are they announcing firm decisions or simply deliberating ideas and possibilities? Because physicians tend to think abstractly and react intuitively, they prefer communication that includes illustration, narrative, figures, and personal examples.

Managers are less "feeling" than physicians; therefore, physicians must indicate how a decision alternative is both quality-driven and cost-effective. Prior to raising contentious issues, both physicians and managers should recognize areas where consensus already exists.

Leadership and vision are important attributes of executives. Regrettably, these attributes are often lumped with "personality." Contrary to conventional wisdom, the ability to lead is independent of personality type, although temperamental individuals usually make poor leaders. Visionary leaders need not be charismatic. Some of the most outstanding chief executives in the history of visionary companies did not fit the archetypal model of the high-profile, charismatic leader. Indeed, such types can be detrimental to an organization's long-term prospects. (14)

Physician executives have the ability to use their clinical experience for organizational leadership and managerial expertise. However, clinical training may also be a liability. Medical training teaches physicians to expect quick results, "go-it-alone," and operate in a crisis mode--undesirable traits from a managerial perspective.

Discussion

The number of physicians in management has expanded rapidly. Between 1978 and 1994, the number of administrative physicians in the U.S. increased from 11,858 to 15,684. (15) In 1973, only 4 percent of hospitals reported compensating any physicians for administrative services. By the mid-1980s, about 41 percent of hospitals provided full- or part-time compensation to at least one physician for administrative duties. (16) Membership in the American College of Physician Executives is increasing by nearly 200 new members per month, and total membership now exceeds 12,000. It is expected that this growth will continue for the rest of the decade. In order to sustain that growth, however, the glass ceiling must be broken.

Clear and convincing evidence of the glass ceiling in medicine can be found in the observation that female physicians in academic medical centers are likely to be promoted at a slower rate and receive less compensation than male physicians with equivalent tenure. (17) These differences hold even when factors such as productivity and differential attrition from academic medicine are taken into account. In fact, the glass ceiling is probably more shatterproof in academic health centers, compared with other types of health care organizations. Nevertheless, glass ceilings are found in all health care organizations and not just in academic medical centers.

Glass ceiling factors may be blatant and obvious, as in sexual harassment and gender and racial discrimination. Alternatively, glass ceiling factors may be subtle and unintentional, related to developmental roadblocks and unattained milestones. This article focuses on the latter factors, specifically those that have been shown to influence the professional development of physician executives: a mentor relationship, individual personality traits, clinical training and education, formal training in administration, and managerial experience. Inadequate preparation in any of these areas could spell disaster for physician executives by creating invisible yet impassable barriers between them and senior-level positions. As opposed to harassment and discrimination, developmental deficiencies are harder to identify, yet perhaps easier to rectify.

To effectively bridge the clinical/managerial divide, physician executives must acquire skills that will bring them in line with their non-medical counterparts. The physician executive equivalent of a health care executive is a board certified physician with business training and credentials who is both a mentor and has been mentored, understands personality and cultural differences between physicians and managers, and recognizes the importance of economic as well as clinical objectives in his or her organization.

In reality, physicians are not trained for this in medical school and rarely in residency. Thus, the glass ceiling concept implies that physicians will be retrained to move into executive management positions.

Critical changes must be made by top management and boards of health care organizations to help physician executives crack the glass ceiling. Turf issues between physician executives and managers must be clarified, and conflict must be mediated and kept to a minimum. Limits should be imposed on managers handicapped by an inadequate understanding of clinical medicine.

Health care executives are likely to oppose the further development of physician executives, but in the future, health care organizations are just as likely to be managed by physicians with graduate degrees in business and health administration as they are by non-physicians with the same degrees. Until the responsibilities of physician executives are better defined, skepticism about their role is likely to prevail. Only with the trust and cooperation of practicing physicians and health care administrators can physician executives grasp positions that are within reach.

Acknowledgment 

I am grateful to Michael A. Silver, MD, whose research provided a paradigm for writing this article.

References

(1.) "U.S. Department of Labor: A Report on the Glass Ceiling Initiative." U.S. Department of Labor, Washington, DC, 1991.

(2.) Grebenschikoff, J. R. Rising Stars. Health Systems Review, September/October, 1996: 38-40

(3.) Lyons, M.F., and Cejka, S. Getting a Firm Grip on the Realities for Physician Executives. Physician Executive, vol. 20, no. 6 (1994): 8-12.

(4.) 1995 NAPHS Salary Survey. Washington, DC, National Association of Psychiatric Health Systems, 1995.

(5.) Korpman, R.A. The Pathologist as Physician Executive: Administrative Medicine Comes of Age. Archives of Pathology and Laboratory Medicine 112, no. 6 (1988): 579.

(6.) Relman, A. R. Medical Practice Under the Clinton Reforms: Avoiding Domination by Business. New England Journal of Medicine, vol. 329 (1993): 1574-1576

(7.) Lloyd, J.S., and Lyons, M.F. The Physician Executive "Arrives"--A New Generation Prepares for the Future. Physician Executive 21, no. 1 (1995): 22-26.

(8.) Silver, M.A., and Marcos, L.R. The Making of the Psychiatrist-Executive. American Journal of Psychiatry 146, no. 1 (1989):29-34.

(9.) Smallwood, K.G., and Wilson, C.N. Physician-Executives Past, Present, and Future. Southern Medical Journal 85, no. 2 (1992): 840-844.

(10.) Gumbiner, R. Perspectives of an HMO Leader. Inquiry 31, no. 4 (1994): 330-333.

(11.) Kindig, D.A., et al. Career Paths of Physician Executives. Health Care Management Review 16, no. 4 (1991): 11-20.

(12.) Shortell, S.M. Effective Hospital-Physician Relationships. Ann Arbor, Michigan: Health Administration Press, 1991.

(13.) O'Connor, S.J., and Shewchuk, R.M. Enhancing Administrator-Clinician Relationships: The Role of Psychological Type. Health Care Management Review 18, no. 2 (1993): 57-65.

(14.) Collins, J. C., and Porras, J. I. Built To Last: Successful Habits of Visionary Companies. New York, NY: Harper Collins, 1994.

(15.) Roback, G., et al. Physician Characteristics and Distribution in the U.S. Chicago: American Medical Association, 1995.

(16.) Shortell, S.M., and Kaluzny, A. Health Care Management. New York, NY: John Wiley and Sons, 1988.

(17.) Tesch, B.J., et al. Promotion of Women Physicians in Academic Medicine: Glass Ceiling or Sticky Floor? JAMA 273, no. 13 (1995): 1022-1025.

Arthur Lazarus,MD, MBA, is the Medical Director of Eastern Pennsylvania Psychiatric Institute in Philadelphia, Pennsylvania and Clinical Associate Professor of Psychiatry at Temple University School of Medicine in Philadelphia, Pennsylvania. He can be reached at 215/842-4155.