Physician executive offers advice from the front lines. (Career Management).

Rod Hochman, MD, is on the front lines of physician leadership as CMO for Sentara Health and CEO for Norfolk General Hospital, the anchoring tertiary-care hospital in the Norfolk/Hampton Roads area of Virginia.

Recently, I questioned Hochman about a number of issues that aspiring physician executives face as they move through their professional development. I think you'll find his comments interesting and thought-provoking.

Sentara is nationally recognized as the No. 1 or No. 2 health care system for overall performance and innovation.

Why should a physician strive to reach an executive role?

Hochman says it's a leadership issue--and more. He notes that physicians were recognized as leaders way back when they were accepted into medical school--but that alone, he adds, is not enough to make the difference in the complex world of health care management.

"Physician executives who are going to succeed in the executive suite have to do more than want to be CEO. They must have an agenda they can put in place more effectively from the executive side.

"They need to articulate a clear vision while being able to combine clinical acumen with the business realities to improve health care delivery. It gets them out of the office and offers the opportunity to make bold, exciting decisions about what to support, what to finance. Bringing others to the same vision takes considerable time--it's the broad leadership challenge faced by all high-level executives."

What are some major differences between general and medical management?

Hochman acknowledges that with the role of general manager come many responsibilities that have nothing to do with anything he learned in medical school.

"I have responsibilities and decision making in plant and facility maintenance. I have a highly capable VP who is the lead person in that area, but nevertheless, I need to understand enough to make good decisions. The implications are considerable. Think about the upside of knocking off $3.5 million in supply chain management!

"Since I don't have expertise in this area, it highlights the importance of having the right materials management executive. Additionally, I spend a lot of my time on labor relations, looking at wage scales and shifts and how decisions might affect the unions. The work force has changed, as has the way we deal with them. About 20 or 25 percent of my time is spent on labor force issues."

What are the greatest challenges in medical management?

Hochman emphasizes the challenges of limited resources, limited capacity and growing demand for services.

"As a clinician, I understand which patients can go home and when. That's a major advantage when we're trying to care for a patient population with an increasing demand for services. Sometimes, issues have substantial impact on resource availability--for example, a physician who goes to multiple hospitals and has a sicker patient panel privileges will likely have a large inpatient population. That physician may not see patients first thing, and his or her discharges will take place later in the day, limiting bed availability.

"Every principal plays a role in the bureaucracy of moving patients through the system--physicians, nurses, transport, etc. For example, the discharges from my facility are usually around 50 per day. Now, one day we had a pseudo-snow day and operated as though we were heading into the kind of blizzard that would have paralyzed the region for several days. The physicians acted differently; the hospital functioned differently, and patients' expectations were different, too. They didn't want to be in the hospital any longer than necessary; they wanted to go home. Housekeeping and transport mobilized. That day, we discharged 90 patients. What changed? Why can't we do that every day? This was the equivalent of adding between 50 and 100 beds in capacity!

"This has become my 'stump speech.' In talking with physicians, it is now more straightforward to highlight the negative impact on the hospital of late discharges and the favorable impact of frequent rounds. Clearly, it makes sense to involve hospitalists for early discharge planning.

"When we talk with them, the surgeons see the advantages of medicine patients moving through the system and not spilling over into surgery beds, which limits the admissions of their surgical patients. The medical staff is now behind this kind of thinking and in full support of a higher level of clinical operations.

"I know the fact that I am myself a clinician has made a difference in being able to convince them of these imperatives."

What other challenges do you face?

"Another key issue is patient safety. We are one of the inaugural systems using VISICU, an electronic ICU. Much has been written about it and its potential. A large part of our patient safety efforts have been more common sense and mundane. We have begun to subcompartmentalize much of our high-volume/high-risk care areas, like the cardiac units, vascular surgery and neurosurgery.

For example, the LVADs were taking up beds that could not then be used for straight open heart cases. Figuring out how to put those in a different category and on a different trajectory has allowed us to reallocate resources in ways that allow for better care, safer patient management, better outcomes--and no bottlenecks.

"When we first started to address patient safety, we went outside health care by choosing the nuclear power industry to help us analyze our systems. They pointed out that our thick books of policy and procedure contain hundreds of points--and that all were deemed important for best function. The nuclear power industry has a different system, in which rules are stratified in importance. At the highest level there are only a few 'red rules,' or critically important absolutes.

"We looked at this in light of our cultural approach to patient safety and are now spending more time determining how to use their prioritizing methodology where we are at highest risk. We'll be using this approach to medication errors and other high-risk activities as well as areas of diagnosis and treatment."

What about operations and finance? How and where did you learn what you needed to know? Do you think business school training is a necessity?

Hochman acknowledges it's important to identify key business knowledge and skills.

"Your university is your own health care organization. I have always made it a point to get to know the CFO in each situation, Sitting down and asking questions, showing respect for that role. CFOs can be fountains of information. The currency of exchange is that I know the clinical operations side, so we trade our expertise for the ultimate benefit of the organization. He or she will raise an issue and I'll respond with the clinical implications, and together we identify approaches for resolutions. This is high-yield bartering; most members of the senior management team are hungry for this type of understanding and knowledge.

"You learn that you can have a busy month, and expect to look at wonderful numbers, only to find that you went $2 million into reserves. It teaches you new respect for all the complexities and permutations that contribute to a high-performing health care delivery system. This includes capital planning. My threshold for involving physicians in these important resource allocation decisions is low, and they have responded with a warmer and more cooperative ethic, showing the value of this type of education."

Does clinical practice matter?

"Right now, I do have my license, though I have not had a clinical role in direct patient care since I came to Sentara. It's critical to have a track record of practice; physicians want to know that you have had success in the clinical sphere. Of course, when I was coming here, they got on the phone to colleagues in Cincinnati just to be sure I measured up. I guess I passed muster."

What other advice do you have for aspiring physician executives?

"Figuring out the nuances and the culture of a health care delivery system is critical to your ultimate success in each place. It's just as important to get the nuances right for the greater community and to understand how things happen locally and regionally.

"Be alert to opportunity. When the position at Sentara came to my attention, I wasn't looking for a new position. I did know that Sentara is nationally recognized for excellence, so on that basis I decided to take a look. It's important to note that this was a lateral move, at least on paper. Do a 'gut check' when something comes to your attention, and don't lose too much sleep over considerations of 'right time/right level.' You can second-guess your career planning too much.

"Find someone close to you in management who is not a physician and ask for their help as a mentor, It's one thing to be a member of a senior management team and get along. It's another to be part of a high-performance team that is achieving synergies based on your relative spheres of knowledge.

"I convened a group of physician executives within this system to meet in the evenings every so often for mentoring sessions. We talk about the importance of being willing to move to advance. Retrofitting a career rarely works well, although many physicians try to do this to accommodate family needs.

"Shoehorning professional advancement by putting the desire not to move first is not the way to promote best career advancement."

RELATED ARTICLE: 6 Tips for Aspiring Physician Executives

From Dr. Rod Hochman

1. Be strategically opportunistic. Listen up when a good position comes along.

2. Be strategic. A lateral move can represent genuine career growth. It's easy to add responsibilities once you show how talented you are in medical management.

3. Join a great organization with the expectation that you can grow there professionally. "Perceived" lateral moves can be beneficial if they want someone with specific experience, and that someone is you.

4. Make your clinical background provide greater value. Be creative, use analysis, look outside of health care for approaches and don't stop searching for new solutions.

5. Always continue learning, whether formally or with mentors and colleagues. Similarly, always develop and mentor others. When you need to move on, you'll be able to make your exit knowing that you're leaving a legacy and talented professionals behind.

6. Move when you need to. Enough said.

Hochman, an internist, began his career at the Guthrie Clinic, a multi-specialty group practice in Sayre, Pa. From there, he moved to Cincinnati to take an educational past before moving up into a broader management role. He joined Sentara Health as its CMO and was promoted to the EVP level within the system. Sentara is a regional health care delivery system with seven facilities.

Mary Frances Lyons, MD, is a senior consultant at Witt/Kieffer in St. Louis. She can be reached by phone at [phone], or by e-mail at [e-mail].