Crossing the culture chasm: making the jump from medicine to management.

IN THIS ARTICLE ...

Recognizing the differences between the culture of business and the culture of clinical medicine is a key to success for business leaders. Learn how to identify and adapt to a new management culture.

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As a physician, when you make the transition from the medical ward to the executive suite, there are a variety of challenges that you encounter.

You know you need to understand what the performance expectations will be, the impact on your job security and personal finances, and how your new leadership role will alter your relationships with family, friends and colleagues.

But many new physician executives--and more than a few seasoned ones--neglect to give serious thought to the cultural changes imbedded in the transition.

Culture, both professional and organizational, can be the pivotal factor in whether you will succeed and be happy in your new roles. So what is this phenomenon we call culture and why is it important?

Culture is the unspoken framework for how people interact, implicitly defining values and expectations. It's easy to overlook until you get pulled up short after crossing some invisible line in the sand. Every culture has built-in strengths and weaknesses that can improve or destroy relationships.

Unidentified cultural differences are a major contributor to leadership failures. Successful leaders know the power of culture and look for ways it can help them or hurt them.

No training needed?

Last year, our organization hired a physician as a utilization review consultant. This gentleman was everything we were looking for: board certified, academic background, peer-reviewed publications. Exactly the kind of credible clinical expert we wanted to make critical decisions about the medical necessity of services.

His second day on the job, he asked to be excused from the remainder of his utilization review training--he was, he said, an experienced and expert clinician and didn't want to waste his time on matters of such little importance. He felt he was ready to get down to the "real work."

When the nurse manager responsible for his orientation patiently tried to explain the importance of completing his training, he responded that a nurse wouldn't understand and requested a meeting with me. I repeated the explanation about why training on our policies and procedures was important, observed that administrative work is very different from clinical work and requires different skills, and asked him to give the training protocol a chance.

Two weeks later he failed the required examination at the end of his training and I was forced to let him go.

How could such an apparently capable clinician fall so flat when he tried to take on a relatively simple administrative position? He didn't see the cultural chasm. He made several very common mistakes that ultimately cost him his job.

For starters, he assumed his clinical expertise and skills were immediately transferable to an administrative role. These were the skills people had always valued in the past and he couldn't see that they were necessary but not sufficient for his new role. He didn't listen when we tried to explain our perspective. We knew this job would be new and different for him--that's why we had the training protocols in the first place.

He did not accept the new social structure; it particularly rankled him to be reporting to a nurse and it was of no importance to him that the nurse in question is a seasoned and effective manager with years of experience in cleaning up the messes that occur when utilization review is badly done.

Ultimately, he expected that we would change our policies, our procedures and our culture to accommodate him and his preferences. It was a recipe for disaster.

Crossing the chasm

The first step to harnessing the power of culture is to recognize that everyone is immersed in at least one. Like Neo waking up and seeing the Matrix clearly for the first time, you need to understand your own cultural framework in order to successfully function in different ones.

Most of us were acculturated into a pretty traditional model of medicine. The traditional physician is intellectually analytical, works autonomously and is highly self-motivated. Physicians are trained to maintain emotional detachment and to think and act at a fast pace. Medicine values and rewards calm, rational practitioners capable of deftly handling life-threatening situations as they occur.

Contrast this with the traditional culture of management. The world of business and finance faces different challenges so it's not surprising that it has evolved a different model. Prototypical business leaders are intellectually empirical and team-oriented. They are emotionally engaged in the work and get a great deal of their motivation from accomplishing the mission of the organization. They move forward at a measured pace, considering options and making thoughtful deliberate decisions.

Management values and rewards committed visionaries capable of using a relational approach that strategically leads people to improve performance and accommodate change.

Neither model is "right" or "wrong," and neither is the "better" way. There is no single best approach. Each of these cultures evolved in response to demands of a particular micro-environment. Each exists in the context of the macro-culture we call 21st century America and co-exists with countless other professional, social and ethnic cultures.

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If you think about it, your experience will tell you that there are regional and local variations, micro-cultures nested in subcultures, and different individuals will express themselves uniquely within the prevailing cultures of organization, profession and place. The trick is to recognize differences and deal with them creatively, constructively and compassionately so that the work can get done and no one inadvertently comes away feeling unvalued or disrespected.

Once you've taken a hard look and identified the cultural chasm looming between where you are now and where you want to be, how do you get across?

First, you need to remember that culture is usually silent, at least until someone breaks some unwritten rule. People imbedded in one culture may not recognize the differences between their worldview and that of people operating in a different cultural framework.

Nearly every medical director can recall a frustrated phone call from an angry physician that hit the cultural brick wall when the doctor said. "What do you mean you need to have a meeting? Just fix it!"

Any manager knows that that's like asking a surgeon to get by without scalpels and suture, but how do you explain it to someone who is spitting bullets? Particularly in roles like medical directors where the job includes frequently being the bridge between two cultures, making sure that everyone understands from the start that different agendas, needs and goals will enable you to negotiate collaborative win-win solutions without doing violence to the organization (or yourself).

Next, know yourself and, as Polonius said to Laertes in William Shakespeare's Hamlet, "To thine own self be true." Some people's personalities are not well suited to some cultures. Some of us knew in medical school that we wanted to be psychiatrists and others of us only did the psych rotation because it was mandatory.

Before you change roles or organizations, do some homework and make sure it will be a good fit. If you are a pianist, don't take a job in the brass section of the orchestra unless you are a really quick study and up for a challenge. Do a self-assessment.

Are you interested in learning about new perspectives or are you comfortable with how you've become accustomed to doing things? It may be better for you to sit tight in your comfort zone if physically or mentally you are not interested in tearing down some walls and moving the furniture around.

Because you can be sure of at least one thing: Cultures rarely change to accommodate the needs or desires of individuals. If you take on a new role you will almost certainly have to be very flexible if you want to succeed.

Transition time

Once you make a transition, it will take some time to reacculturate. Big transitions obviously take longer than smaller ones. In the meantime, stay vigilant for potential cultural mistakes. It is much better to anticipate sensitivities than to try to make amends after a misstep--some genies just will not go back into the bottle.

In particular, try to avoid reinforcing any stereotypes the new culture may have about you and your cultural baggage. For example, if one of your new co-workers is a former social worker who thinks physicians are generally domineering loudmouths who don't care what anyone else thinks, then it might not be a good idea to interrupt her mid-sentence at the first meeting you attend together.

Don't laugh, I've seen it done and the new guy never got rid of his 'problem doctor' label in that manager's eyes. It's a good habit to try to know what you don't know and to assume. "There be dragons" as the old maps used to say. By knowing what you don't know, you can identify your cultural blind spots and plan ways to avoid getting into trouble while you learn the new culture.

It's important to solicit feedback and watch for early warning signs. People still tend to defer to physicians. You command a high salary and a higher profile.

My own experience was that even after nearly a decade in my last job, there were still a few of my peers in senior management who could not bring themselves to challenge me when they disagreed, even when what we were discussing had nothing to do with medicine. Sometimes their body language or facial expressions provided clues, but that wasn't always reliable. Because they were key players, I had to develop a system of informants in order to know what some of these folks were thinking, which was too bad, particularly when they were right and I was wrong.

The bottom line is that because of the lofty social status afforded to physicians, you may not get critical negative feedback until it's too late to repair the damage if you are not looking for it.

One thing many physicians overlook when they become business leaders is the importance of personal relationships. In medicine, the patient is in the exam room and you know the drill--chief complaint, HPI, ROS, PE, labs, assessment and six minutes later the encounter is over. Not much time in there for relationship building.

In management, a great deal hinges on personal relationships and taking the time to build and nurture them can make a huge difference in whether or not you succeed.

Every administrative office I have ever worked in has a list of everyone's birthday hanging somewhere. It's not there for decoration; it's there because it matters to remember birthdays. In management, your co-workers are some of your most important customers.

Becoming a successful physician executive involves learning a whole new set of social skills, because management relies much more heavily on teamwork than traditional medicine does. The typical manager's most valuable tool is a Rolodex (or the electronic equivalent).

Finally, when dealing with cultural differences, keeping an open mind is always a good idea. Cultures evolve in ways that work for the people in them. Some cultures are dangerous or destructive--terrorist groups, extreme religious cults, corrupt corporations.

But most cultures are merely different from the ones you already know. And just because something is different or unfamiliar doesn't mean you should assume it's bad or wrong.

Medicine and management have very different cultures, but astute practitioners learn to comfortably inhabit both worlds and to use their cultural insights to help themselves and their organizations succeed.

RELATED ARTICLE: Quiz

MEDICINE OR MANAGEMENT?

Think about the answers you would give to these questions. They may help you decide if management is right for you.

1. Do you introduce yourself using your first name or "Doctor?"

2. When you go to lunch or dinner with people from work, do physicians predominate?

3. Name your top three professional role models. How many are physicians?

4. What was the topic of the last national meeting you attended?

5. What is the job title of the perfect capstone to your career?

By Christopher Gorton, MD, MHSA 

Christopher Gorton, MD, MHSA, is faculty practitioner in negotiation at Johns Hopkins University School of Professional Studies in Business and Education, Baltimore, Md. Previously, be was chief medical officer of the Pennsylvania Department of Public Welfare. He also is a health policy and management consultant in private practice in Hershey, Pa. He can be reached at 717-533-8910 or [e-mail].

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