I can't believe they think I'd. (Physician Executive Leadership).

MUCH HAS BEEN MADE OF THE METAMORPHOSIS IN one's professional identity that accompanies the shift from physician to physician executive. In this context, there are a wide variety of educational opportunities available to assist physician executives in the process of building essential skills. The accrual of these skills--in leadership, communication, problem-solving, business strategy, finance, and information systems--inevitably gives rise to increasing confidence and competence. This allows organizations that make thoughtful use of physician executives to garner a convincing competitive advantage.

However, very little has been written about the personal jolt which many physician executives experience as they move to work in a very different relationship with their colleagues. As one medical director told me, "The job is going well, and I like it very much. The only problem is that I've just lost all my friends." What happens? How can we understand this phenomenon? What can we do to minimize the personal toll so often exacted by the transition to leadership?

Shifting gears

The transition to leadership inevitably requires the development of skills which, although latent, were probably not actively cultivated in clinical practice. Depending upon the particulars of the leadership position, necessary skills may range from those in the domain of business (project management, basic accounting, contracting negotiations), to political skills (influence, understanding of motivation, alliance building), to communication and conflict resolution (the art of leading a meeting, public speaking, mediation). Physicians may feel that they know more than enough about these issues, only to be rudely surprised by unanticipated gaps in knowledge. They may expect to need one kind of training, only to find out that, in fact, they need to develop a different set of skills. They may need to attend courses, accept supervision, be exposed to criticism and feedback--all in ways that are new and unfamiliar.

The inevitable discomfort encountered during this learning curve, which can last from two months to two years, often comes as a surprise. Many physicians who have been elevated to leadership positions because of their success and interpersonal acceptance, have not had to struggle with this sense of being "a fish out of water" since very early in their professional careers. Unless there is someone in place to reassure and mentor, the resulting confusion--which I am defining as a developmental inevitability rather than an idiosyncratic reaction--can be quite unnerving, resulting in reflex defensiveness. We sometimes see this defensiveness manifest as passivity, or an unwillingness to make a decision; just as often it results in impulsiveness, or irritable brusqueness.

As skills solidify and comfort returns, these minor deflections from "personal baseline" fade to insignificance. Often, in fact, physicians who grow into their new leadership position experience interpersonal comfort and confidence beyond what they have known in the past.

"Self-concept" versus" role identity"

Despite the inevitable turbulence involved in moving from full-time clinical practice to full or part-time work as a physician executive, mature adults are quite unlikely to experience the kind of dramatic epiphany of early adult life--"suddenly I realize who I really am..." Most of us, by the time we have achieved leadership positions, have developed a sense of self which can be modified by experience, but which is not likely to be reinvented. Thus, new physician leaders describe increased perspective, a broader repertoire of skills and strategies, and some incremental expansion of what psychologists would call "self concept." The emphasis here is on the linear, quantitative nature of the change involved.

By contrast, the move from a clinical to an administrative role is indeed a quantum step. The change is not one of degree, but of an order of magnitude. This, precisely, is at the heart of the tension which comes with the transition to leadership. Those who had been peers, comrades in arms, equals in the complex challenges of clinical work become, at some level or other, subordinates. No matter how egalitarian the leadership structure, a leader becomes, at some level, "the boss."

Although one's close friends may be able to look past this dramatic shift in role, more peripheral acquaintances are often not able to do so. From their perspective, the new leader has not undergone a change of degree, a change which, in fact, may be causing some personal discomfort and confusion. Quite to the contrary, the new leader is likely to be seen as having made a giant step into a different strata. This strata involves certain privileges, potentially gives access to restricted information, and potentially gives power and authority which can be a threat.

Transference 

Psychologists and psychoanalysts have known for some time that all of us, regardless of how psychologically healthy we are, are vulnerable to viewing the world around us through lenses which subtly distort. The tendency to see contemporary situations in ways colored by past experience or unconscious assumptions is called transference.

Transference to leadership figures is ubiquitous. Sometimes it takes the form of worshipful trust, other times of suspicious distrust. To the extent we experience our leaders as having power over us, we are likely to lean towards distrust. To the extent that one is heavily invested in autonomy, as most physicians are, this tendency towards caution and suspicion with leadership figures is heightened. Finally, to whatever extent colleagues feel jealous, competitive, or excluded from the leadership selection process, these currents of suspicion or distrust are likely to be amplified.

Transference, by definition, is unconscious. Therefore, new leaders may find that those who were their colleagues, friends, and partners, begin to act toward them out of a complex set of feelings-some of which are conscious and easily articulated, some of which are unconscious and, hence, enormously hard to talk about. This can lead to further confusion and feelings of uncomfortable isolation.

Issues of context

In organizations with a long history of physician leadership, where the transition to leadership roles can be gradual--accompanied by adequate educational opportunities, peer support, and readily available mentoring--these transitions are much smoother. Where these buffering influences are absent, the transition is inevitably more difficult.

To the extent that leaders are called upon to drive an unpopular process, the burden is much greater, and the interpersonal cost often much higher. When physician leaders are seen as "pawns" of administrators, or "dupes" of insurance agencies, or when they are seen as having personal responsibility for macroeconomic conditions, the transition can be quite personally painful. In these circumstances, there is often a vicious and unrecognized spiral of alienation.

It happens like this: The physician leader struggles, as we have described, with confusion and a steep learning curve. He or she begins to encounter unexpected coolness, aloofness, or even hostility from medical peers. Very much wanting to make a contribution, and to assist colleagues in being proactive, the new leader pushes forcefully to "help" his or her colleagues embrace change. This is seen as an attack or a demand. Resistance and hostility heightens. The new leader, disillusioned in feeling unfairly attacked, pulls back with a kind of reciprocal aloofness. The chasm which results is both personally painful and organizationally wasteful.

What can be done?

The issues described herein take on a particular texture in health care, in no small part because of the unique characteristics of physicians and health care organizations. However, they are well known in all organizations, and can be seen whenever managers are promoted "up from the ranks." The American College of Physician Executives and other organizations have developed comprehensive educational programs for physicians in order to speed the process of skill acquisition and increase the comfort of physicians who are embracing a new role identity.

Unfortunately, these programs are often of only limited success, because they take place "in vitro"--removed from the crucible of change and conflict. These leadership programs must be paired with three other crucial elements in order for the transition to leadership to be most effective. First, the leadership selection process must be open, above-board, and based upon objective parameters of talent, interest, and commitment. Such a process minimizes jealousy, and legitimizes the authority conferred upon new leaders.

Second, mentoring is essential. It involves regular access to a physician who has already negotiated the transition to leadership, and can supply validation, support, perspective, as well as an ongoing process of coaching which fades away as the need evaporates. This can be provided by a senior physician in the same organization or an affiliated organization, or it can be supplied by a consultant. A warm, comfortable, and mutually respectful relationship between the mentor and the developing leader is essential.

Finally, there is a real need for peer support. Peer support involves a network where questions can be asked and answered, while ventilation is allowed and encouraged. There need to be easy, informal opportunities for expressing frustration, and sharing information and insights. These networks are an essential antidote to what is often described as "the loneliness of command."

Conclusion

Selecting and developing talented young leaders has long been a high priority for the United States Armed Forces, and most of the successful large corporations in this country. The American College of Physician Executives and related organizations bring much that has been learned elsewhere to health care. However, it is ultimately up to each and every health care organization, regardless of size or scope, to assure that the path to leadership is well traveled, and traveled well. Without competent, strong, and resourceful leaders, we will be unlikely to deliver the combination of quality and efficiency increasingly demanded by our patients, our payers, and the marketplace.

RELATED ARTICLE: A CHILLY RECEPTION: FROM THE OPERATING ROOM TO THE BOARD ROOM

As physicians of many clinical backgrounds make the transition to management, they will find the reception awaiting them from other non-physician administrators very different from the welcome they received when they finished their specialty training and entered clinical practice. A number of tips are offered to make new physician executives aware of this phenomenon and to ease their transition to the board room.

Many speakers at physician educational meetings, such as at the American College of Physician Executive's (ACPE) Physician in Management seminars, (1) as well as authors in medical management literature, (2) detail the differences between a medical practice involving purely clinical intervention and one requiring administrative attention. In particular, they stress the longer scope of thinking, the less immediate gratification, the need to work in teams or groups, and the requirement to focus on population needs instead of individual patients.

As more and more physicians become interested in management, organizations from ACPE to prestigious academic institutions have worked to fill the perceived knowledge void with timely and worthwhile information. Many physicians have pursued advanced degrees, either through ACPE's Certificate Program, the new Certified Physician Executive program, or formal, advanced degrees like the Masters in Medical Management. One of the strengths of these educational endeavors has been the near-pure physician audience, like the medical school and residency training that went before, as well as the high quality of the faculty.

Many physicians are unprepared, however, for the chilly reception they receive when they leave the operating room and enter the administrative ranks. There are many reasons for this phenomenon and as physicians make this career transition, they need to be aware of what awaits them. Most physicians arrive out of training as newly minted, freshly trained, eager neophytes that appreciate, enjoy, and bask in the welcome that they receive in their new practice. The response will likely be somewhere between, "Glad you're here and, by the way, you're on call tonight" to "My golly we've been waiting what seems like a lifetime for you, you brand, spanking new, academically trained marvel of medical science and revenue-generating capacity."

This ego boost is nothing akin to the experience physicians will have when, newly trained in management. they arrive in the administrative wing with their MD sheepskin under one arm and a freshly framed diploma under the other. Making their way to the board room, the physician executives' presence may not be universally welcomed by many health care administrators--their MD degree makes these new physician executives "one of them," one of those irksome physicians that administrators and board members may be uncomfortable with, The initials behind their names that give them such credibility with physicians may actually be a deterrent to their acceptance by nonphysician administrators.

Unlike their clinical training, which clearly qualifies them for specific privileges, procedures, and practices, physicians' new management training and degree will mean very little. What matters, the real issue, is what skills they can bring to the administrative team. And unlike the hospital, where doctors only have to work at proving themselves (via reappointment) every two years, in the administrative arena, physician executives must constantly and continuously prove themselves. Having an advanced management degree is just not the same as specialty training or Board certification.

Tips for making the transition

An MBA, MMM, or MPH may prove of value to the physician in the long run, but on a day-to-day basis, the doctor must demonstrate his or her trustworthiness, interest, patience, and intellect to new colleagues and the administrative team, a group that may have had less than stellar experiences with other physicians. If the reception accorded fledgling physician managers is less than a welcome with open arms, there are some suggestions that may help them along the way. The following tips are offered as observations from a clinician who is making the transition from the operating room to the board room.

1. Check your ego at the door

Physicians may well find that their egos are a constant problem. The intense, impatient, petulant behavior that might have gotten results in the ICU or operating room won't gain a thing in the administrative wing. Tip number one is to check your ego at the door. You should not totally abandon your ego, because you surely will need it at some point, but in your day-to-day activities, a kinder and gentler demeanor will gain you much more acceptance. As a new physician executive, you need to appreciate that your degrees--the old MD degree and the new management training and degree--may be useful in the clinic or emergency room, but in the board room they may only get in the way It's who you are and what you can do that's important. Put your ego in your back pocket and don't expect to be the captain of the ship. Be prepared to be a coworker on a team and, as hard as it is, plan on not being the leader of the first few teams you work on.

2 Look respectable

If, as a physician executive, you are going to be an interface player, working with both physicians and administrators, you need to be recognizable to both, but don't forget the need to look respectable. Dirty lab coats, scrub suits, and used shoe covers may be very acceptable in the surgeon's lounge, but to the board of trustees, such attire may look like something quite different. You will need to dress up enough to look like an administrator, but not so dressed up that the doctors don't recognize you. If your administrative compatriots dress more like downtown and your physician colleagues always look like they are ready for a weekend in the country, you should be prepared to forego the cotton twill pants and dress sneakers for starched shirts and suits. Others have debated garb and facial hair for the interview process, but it's just as important in the ongoing work situation. (3)

3. Recognize that your clinical knowledge will be nearly worthless

Keep in mind that the specific clinical knowledge that you possess will be nearly worthless for your new role in the board room. The new management information that you have gained will prove itself of value in countless small ways but do not equate it with new specialty knowledge. Use your clinical background as a general reference and appreciate that many others sitting around the administrative table not only have as much management education as you, but probably most have a lot more practical management experience.

4. Have patience

You will need patience and lots of it. You will have myriad suggestions for the management problems that you hear discussed. You will regard such problems as a diagnostic test and apply your sharply honed acumen to coming up with a 'differential' and then rapidly move to a final 'diagnosis.' Your prescription for a 'cure' will come quickly, but it won't necessarily be well received. You will need the patience that was required to deal with your most intransigent or recalcitrant patients--the ones that wouldn't lose weight, stop smoking, or stay on their medicines-to finally gain respect from your administrative colleagues and begin to win grudging admiration.

5. Find a mentor

You are not likely to have many peers. To your old medical colleagues and your new administrative colleagues, you are a strange hybrid, full of conflicting ideas and knowledge. You must seek out management peers through local ACPE, managed care, or hospital association meetings. The work of management is on a different and slower time frame. Discussing medical management issues is not the same as talking about a new class of antibiotics or a new H-2 antagonist. The issues are more complex and the solutions not as easy or clear. Peer support is important in clinical medicine, however, the value of a fellow physician manager as peer and/or mentor is essential. Work to find one.

6. Remember that you represent the competition

Bringing physicians into management, like the work that Shortell describes in the pursuit of clinical integration, (4) is a difficult and life-long effort, but it's worth it. When administration became so complex in the '50s and '60s, physicians and boards of trustees turned the job of running hospitals over to professional administrators. Now comes an era when many physicians believe that a majority of the ills of the current health care delivery system can best be cured by reintroducing physicians into prominent positions in management.

Physicians must not forget, however, that there are legions of professional administrators who have built or are building careers in health care and for them, this new crop of physician executives represents nothing other than pure competition for lucrative jobs in a fast-changing, but still relatively high-paying sector of the economy; one that may not offer the opportunities for advancement that existed in the "cost-plus" era of the '70s and early '80s.

Conclusion

One of the great strengths of educational programs, like those from ACPE, is that in knowing the audience well, authors and speakers can appeal to the quick intellect of physicians. A shortcoming of this physician-only education may be, however, that physicians are insulated from the real world that they will face, just as they were in residency training. They are taught to be solo acts, completely responsible for their own actions and for patient outcomes that may attend their interventions and ministrations.

As managers, physician executives need to work almost always as a member of a team. And for the next few years, until their roles are more common, established, and accepted, they must appreciate that their journey from the operating room to the board room may be strewn with boulders, booby traps, and land mines. The effort will be worth it for them personally and for the health care delivery system. But neophyte physician executives need to understand that the reception awaiting them in their new management careers may be far different from that which they received when they arrived at their chosen institutions as fresh-faced, eager doctors.

James D. Butterick, MD, MMM, is Chief Medical Officer at Southcoast Hospitals Group in Fall River, Massachusetts. A physician executive who spent nearly two decades in cilnical practice before making the transition to medical management, he has taken a number of management courses. He can be reached by calling 508/679-3131 or via fax at 508/679-7669.

References

(1.) Schenke, R.S. Physician in Management II seminar, April 1992, San Antonio, Texas.

(2.) Lazarus, A.L. Breaking the Glass Ceiling. The Physician Executive, vol. 23, no. 3 (1997): 8-13.

(3.) Lyons, M.F. Career Rx: Counsel on a "Hairy" Subject. The Physician Executive, vol. 22. no, 2 (1996): 33-34.

(4.) Shortell, S., et. al. Remaking Health Care in America: Building Organized Delivery Systems. San Francisco, CA: Jossey-Bass, 1996.

Eric D. Lister, MD, is Managing Partner at Ki Associates, an organizational consulting firm in Portsmith, New Hampshire. He can be reached by calling 603/433-2305, via fax at 603/433-6341. or via email at [e-mail].