My Pulse Is not What It Used to Be: The Leadership Challenges in Health Care.

My Pulse is presented as a case study--gripping and all too true. The "patient" is a revered 70-year-old multispecialty clinic--the Nalle Clinic in Charlotte, N.C. As the clinic grew in number and stature, it regressed as an organization. My Pulse is about personal and organizational growth and development, and how they parallel one another. In retrospect, it is apparent that "in many ways the Nalle Clinic did not want to be led."

The patient's primary care physician is Ray Fernandez, MD. Dr. Fernandez progressed rapidly at the clinic from clinician, to part-time medical director, to full-time medical director, to medical director and CEO. But the clinic's mission was unclear and his authority and responsibilities were poorly defined. The latter weren't provided by the clinic...and he didn't ask. The patient's condition deteriorated despite the doctor's best efforts. A new attending (PhyCor) was brought in to manage the patient, and Dr. Fernandez returned to his previous role as medical director.

Dr. Fernandez, with stunning personal candor, chronicles his leadership roles in the clinic. His honestly allows the reader to see what he saw and feel what he felt. He speaks painfully of the plight of the physician manager--caught between two worlds. Accountable to both, but often accepted by neither.

Dr. Rubin provides insight into the unfolding drama, as if commenting from off stage. He compares the clinic's growth with all organizations' stages of development. Stage I is the Fraternity Model, where goodies go "to those with the largest arms and quickest hands." Stage II is the basic business organization--not unlike a football team, where plays are called and each player, ideally, carries out his assignment. Stage III is the most advanced, an organization in search of excellence. Here, beliefs and values no longer need to be explicit. They are now implicit. Stage III organizations can be compared to a basketball team, whose players innately know each other's moves.

Rubin maintains that, before a health care organization can heal others, it must first heal itself. Not insignificantly, the first letters of The Leadership Challenge are TLC! He challenges physicians to focus more on the art of medicine, to broaden themselves by improving their interactive skills and behavior. Physician executives must work to facilitate this process.

Above all, My Pulse is about leadership. The Nalle Clinic case study provides a striking backdrop for the reader's learning experience. Rubin confirms that "knowledge without wisdom is useless, and wisdom is impossible without the courage to learn from experience." This book describes "the stage which is set for the most familiar confrontation of modern life--between people who demand change and organizations that resist it. In the resulting conflict, we find our institutions in a savage crossfire between uncritical lovers and unloving critics...where human institutions are concerned, love without criticism brings stagnation and criticism without love brings destruction."

My Pulse is must reading for every physician executive and an eye opener for physicians and all those entrusted with providing health care. In a larger sense, this book is not just about Nalle Clinic. It speaks to all individuals and organizations that aspire to grow and develop. How fascinating it is that those in organizations who demand change ascribe resistance to change to their organizations, as if their organization were something other themselves. My Pulse probes the depths of this human drama.--Mark A. Doyne, MD, FACPE, Medical Director, Texas Back Institute, Dallas, Tex.