Physician career development: toward building a model.

The survey reported in this article attempted to discern the role of career development at numerous managed care organizations and to develop a broad, conceptual model of what a successful career development program might look like. The organizations represented in the survey include regional group- and staff-model HMO, a large mixed-model HMO, a national insurance company-based HMO, a large regional IPA-model HMO, and numerous consultants. We conducted more than a dozen indepth interviews over a two-month period.

At the same time that we clearly identified what is missing from most managed care organizations' career development programs, we were able to discern the overall components of a successful program. More important, most of our survey respondents felt that, by focusing the intellectual and experiential capital of the physicians involved, a comprehensive career development program can play a crucial role in fulfilling the mission of a managed care organization, as well as help physicians respond to the rapid changes in managed health care.

Present State of Affairs

Generally speaking, the HMOs we surveyed considered the following six areas as the core of the their "corporate mission": clinical excellence, managerial expertise, research, teaching, community service, and building shareholder equity. Within these six areas, however, we noticed a marked difference in emphasis concerning career development. Most of the organizations we studied stressed only two programs:

* Clinical improvement programs, including aspects such as total quality management, epidemiology, clinical policy, formal decision methods, and specific clinical procedures.

* Management development programs, including basic managed care skills courses, communication skills, finance, personnel management, and time management.

Virtually none of the organizations we questioned maintained any sort of research program activity as a formal component of career development, and, when present at all, research was usually linked to an internal research journal. In addition, we found that almost every program ignored teaching, although sometimes it was linked to residency training programs, and nearly every managed care organization ignored public service as a valid arena for career development.

Method of Delivery

Most of the career development programs we surveyed reached their audiences through a combination of internal staff teaching courses and external consultants who provide workshops for physicians. We discovered that most of the physicians who wanted career development programs preferred the university model of instruction--i.e., taking selected topics in a classroom or group-oriented forum with a college professor or an outside consultant. In fact, some managed care organizations work in conjunction with professional organizations, such as the American College of Physician Executives, or make strategic alliances with local universities to offer "mini-MBA programs."

Impetus 

We found that the senior medical officer or the medical director was the individual most often responsible for the creation of a career development program; we also found that physicians themselves frequently proved instrumental in the creation of a viable career development program. This means that, when given an opportunity, physicians perceive a real need for these types of programs.

Most HMOs do not have a formal career development mechanism for individuals. The lack of programs means that physicians do not have the opportunity to participate in an assessment followed by the articulation of a career development plan. Career development becomes a passive activity, dependent on the individual physician's initiative and not on any institutionalized process. This institutional passivity encourages physicians to follow their own interests rather than engaging in activities that would enhance the organization's ability to meet corporate goals. We found that, rather than creating tangible incentives for physicians to take a dynamic interest in their own futures, most career development programs simply depend on the units that direct education and training to disseminate literature about their offerings to physicians. Only individuals who are interested sign up for the courses that they wish to take.

Many of the doctors and administrators we interviewed feel that this passivity creates a situation where it becomes markedly easier for the HMO doctor to coast, burn our, or lose his or her sense of engagement. Clearly this is not the proactive approach necessary to foster the learning environment so necessary for the rapid and systemic changes most managed care organizations are presently experiencing. It also reflects another problem with most of the career development programs we examined: they exhibit a vague sense of just how their programs fit into the larger goals of the managed care organization. .

We did find some exceptions to this general passivity, and the manner in which a few managed care organizations handled the issue of how career development is delivered sheds light on how a well-run program might look. The Geisinger Clinic/Health Plan and the Henry Ford Health Plan, for instance, avoided the problem of passivity in a variety of ways. Geisinger's management program asks that its center chiefs and associate medical directors identify and evaluate individuals who could benefit from development of their management skills. The directors suggest strongly to targeted physicians that they take appropriate management courses. The Henry Ford Health Plan goes even further. It requires that all new hires participate in the clinical improvement program (although, again, there is limited emphasis on teaching, research, or public service). Unlike virtually all other managed care organizations, Henry Ford has created a highly structured program that grew out of its Center for Clinical Effectiveness, which stresses outcomes and utilization management, both essential aspects of a successfull managed care organization.

Nonlinkage to Corporate Goals

Most of the administrators we interviewed believed that career development would improve the quality of their institutions, as well as create "a learning culture." But beyond these vague goals, very few of them thought very much about how career development could be directly linked to the corporate goal of his or her HMO. Simply put, few administrators considered career development an integral part of their "corporate missions," whether the mission was clinical effectiveness for a group- or staff-model HMO or quality care for an IPA-model HMO. None of them thought that they might be able to accomplish their corporate goals more efficiently with an effective career development program. This attitude creates two impediments to the creation of fully articulated career development programs. First, most organizations do not allocate either the time or the resources to do the actual development work. Second, career development is often the first thing to go when budgets get tight.

We did find some exceptions to the general lack of "corporate linkage." Prudential's South Eastern, Group Operations, for instance, directly linked its career development programs to its strategic alliances or partnerships with medical groups. Prudential recognized that, in order to be mutually successful, they had to enhance the medical management skills of the groups. And, of course, the incentive of career development is the most cost effective way to promote those management skills. In addition, we found that the most mature" career development programs built on some existing strength of the managed care organization. At Henry Ford, this appears to be the Center for Clinical Effectiveness; at the Lovelace Foundation, it seems to be the many linkages they have with other organizations around the country; and, at FHP, the strong educational focus traditionally associated with the organization greatly aided its development efforts.

Lack of Accountabitity

Generally speaking, none of the organizations surveyed assessed outcomes, nor did they develop any formal system of accountability for career development programs. None of them articulated "base-line data" that would enable them to evaluate both the overall effectiveness of their career development programs and the effectiveness of individual physicians. We discovered that most organizations do not collect hard data because they feel it is not "cost effective." Failure to collect evaluative data further retards the growth of a successful career development program, because the organizations lack the ability to judge how effective their efforts are. We found the same problem with respect to performance evaluation. For example, few, if any, managed care providers linked career development activities with performance. Two health plans proved the exceptions. One is considering linking career development for clinical effectiveness to an assessment of physician practice patterns in the near future. The other will probably go a step further and develop a point system that relates to pay scale.

Creating Successful Career Development Programs

One of our primary goals in carrying out these interviews was to discover the strategies employed to develop career development programs. None of the managed care organizations we surveyed employed a formalized needs assessment to identity subject matter that might be included in a program. It was often just the "gut feeling" of the medical director that drove a commitment to move forward. Furthermore, individuals charged with developing programs had few guidelines to draw upon when deciding how to structure the programs, what the content should be, or how to get buy-in of both potential participants and senior executives of the plan. From the interviews we conducted, we drew conclusions that suggest tangible methods that can be used to foster program development.

Leadership

The senior leadership of the managed care company must believe in the concept of career development. It must intuitively understand that such a program can only add to the "corporate mission" of the organization. Additionally, the center chief or senior chief must directly involve him- or herself in the planning and early phases of the program development and must allocate the necessary resources to get the program off the ground. This will make it immediately clear to the organization as a whole that the activity has a high priority. IPA and group organizations might also stress that such programs can provide financial payoffs to the various constituencies of the organization.

Linkage to Corporate Goals

As any managed care executive can attest, rapid changes in the marketplace have buffeted virtually all HMOs. Career development represents an organic way for organizations to prepare for these changes. Specifically, a successful physician career development program should be structured around issues that will improve the quality of an HMO's primary services. Career development must resonate with the corporate goal of the HMO, whether that goal is related to clinical excellence, managerial expertise, or research and teaching. In many cases, this means that management will have to rethink policy and procedures. Because we found that the stronger career development programs grew out of existing strengths at particular HMOs, it seems that a successful program could be "jump-started" from within the managed care organization, based on what that organization does best.

Integration

In order to be most effective, career development programs must become proactive rather than passive. Managed care organizations must integrate development into their overall governance structures so that the needs of physicians dovetail with those of the HMO. Indeed, if career development becomes part of physician recruitment and retention, if, in fact the senior management says to physicians, "You must participate," it will prove that much easier to merge career development into the overall "mission" of the organization.

In addition, the content of any career development program needs not only to reflect the organization's goals (which differ from HMO to HMO), but also to support the interests of individual physicians.

Communication

Building a successful program depends on effective communication. Through the use of retreats, project bulletins, videotapes, and presentations, management can educate the organization about career development. In addition, the senior leadership of an HMO should initiate activities that will help physicians understand the function of career development, how it will influence the work site, and how it will enhance physicians' success.

Accountability

Accountability remains a difficult subject in health care because it cannot be easily ascertained. Nevertheless, the general movement toward "quality" and the growing impetus for outcomes measurement have made the managed care industry aware of the importance of accountability, of the need to quantify it, and of the value of descriptive evaluation measures. This same attitude must be applied to career development.

As with college professors and other highly trained professionals, career development of physicians is often viewed as an obvious good. Nevertheless, in order for organizations to make a serious commitment to development over an extended period, the program must be held accountable to meeting the larger goals of the organization. HMOs will need to decide what to evaluate and how to measure it before they create career development programs.

Areas of accountability should also include subjects both directly and indirectly related to career development programs. Did physicians make more clinically effective decisions relative to, say, Cesarean sections after data and protocols were presented? Was participation in physician career development programs related to the retention of physicians in an HMO? In order to answer questions such as these, managed care groups will need to articulate base-line data so that they can measure progress. Based on our interviews, it seems crucial that organizations create an archive for materials related to career development and periodically publish (and widely distribute) project evaluations.

Conclusion

Managed care organizations have underutilized career development as a tool to focus their corporate missions, as well as a way to improve the excellence of physicians. While some organizations have taken a few hesitant steps forward, most HMOs have not made the commitment to develop programs. It is clear from our survey, however, that physicians have begun to see the financial benefits and that administrators are beginning to recognize that career development is a way to help an organization keep pace with the changing market.

Finally, our respondents felt that career development programs may prove vital for ensuring that physicians stay energized and committed throughout their "corporate" fife at any given managed care organization. A proactive, formal career development program will keep doctors enervated and engaged.

In short, planning, initiating, and carrying through a successful career development program can transform a managed care organization make it more vital, as well as more responsive to its constituency.

John P. Pufahl, EdD, is President, Avalon Health Group, New York, N.Y., and Lee Raiola, is Director of Human Resource Development, Harvard Community Health Plan, Boston, Mass. This research was originally commissioned by the Physicians Career Development Charter Group of the Harvard Community Health Plan and was conducted under the auspices of Avalon Health Group. The authors may be reached through Dr. Pufahl at 245 E. 54th St., Suite 3T, New Yor, N.Y. 10022, 212/758-5243, FAX [phone]