Physician executives' characteristics and attitudes.
The number of physicians involved in management has accelerated in the past decade, and physician managers can be found in a wide range of health care and related settings. Evidence of physician interest in management as a career, or as an adjunct to a clinical career, is found in the rapid growth of the American College of Physician Executives and the continuing interest in certification for physician managers. As this new sphere of activity has emerged as a principal interest of increasing numbers of physicians, a variety of articles have appeared in the literature that comment on trends in the field, the scope of activities of such managers, their compensation, their preparation, and their attitudes and behaviour. Relatively little has appeared dealing with the reasons physicians opt for expanded management responsibilities and with how they are prepared to assume these responsibilities. Anecdotal reports and conventional wisdom suggest reasons such as desire to escape the rising costs of practice and an increasingly bureaucratic practice environment, or a desire to work more regular hours and have greater control over one's time.
Participants in the study reported in this article were respondents from a random sample of 300 members of the American College of Physician Executives, supplemented by a special random sample of 60 from among female members of the organization. The basic sample represented 10 percent of the membership at the time of the survey. The separate sample of women was drawn because of the small number of women in the total membership. There were no duplicates drawn, and the total mailing sample was 360 individuals. There were 176 questionnaires returned, for a response rate of 48.8 percent. Eighty-one percent of those responding were male and 19 percent female. Thirty-two percent graduated from medical school before 1960, while only four percent graduated after 1980. Thirty-four percent graduated in the 1960s, and twenty-nine percent in the 1970s. Ninety-three percent graduated from American medical schools, while seven percent graduated from foreign medical schools.
The questionnaire consisted of 44 elements. Respondents were asked to indicate their responses on a five-point scale, with one representing the most negative end of the scale (e.g., "not at all important" or "strongly disagree") and five the most positive end (e.g., "very important" or strongly agree") Two types of questions were posed. The first series consisted of statements describing factors often cited as bearing on physician decisions to enter management careers, and respondents were asked whether they agreed or disagreed with those statements as they described the respondent's own experience. The second series consisted of factors bearing on development of physician managers, and respondents were asked to scale the importance of each factor on the basis of a stated condition or conditions.
Why MDs Become Managers
Do physicians enter management to escape the increasingly regulated practice environment? Forty-three percent of respondents indicated that this was an important factor in their moves toward management careers, while 32 percent minimized the importance of this factor. Overall, this motivation does not appear to be a significant one for the physician managers in the sample, nor are there differences among respondents based on year of graduation or sex.
Increased regulation and complexity of medical practice influenced me to become more involved in management and less involved in clinical practice.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 17% 15% 25% 25% 18% 3.1
Two other factors that conventional wisdom suggests might be important in physician decisions to move away from clinical activities to administration were not significant to the respondents. Only a third of those responding to the survey gave weight to a desire to gain better control over time (e.g., regular hours) as a factor in their expansion of management responsibilities. The number influenced significantly by the rising costs of medical practice was even smaller, with 17.1 percent reporting this factor as important. At the same time, nearly half (44.5 percent) of respondents did cite "quality of life" considerations (family time, stress levels) as important in their decisions to increase the percentage of their time devoted to management.
A desire to make my hours more regular and to gain better control over demands on my time influenced me to become more actively involved in management.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 22% 23% 19% 25% 11% 2.8
The rising costs of operating a medical practice influenced my desision to become more active in management and less active in clinical practice.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 34% 29% 20% 12% 5% 2.2
Financial considerations, such as salary and fringe benefits, were important influences on less than a third of those responding to this survey.
Economic considerations (e.g., income, fringe benefits, retirement plans) were: Not at all Important Very Important
1 2 3 4 5 Mean 24% 19% 25% 22% 10% 2.8
The single most important factor influencing these physician executives in choosing a management career was the perceived opportunity for leadership to a medical organization, highly valued by 87.6 percent of those responding to the survey.
Opportunity to exercise leadership in organization was: Not at all Important Very Important
1 2 3 4 5 Mean 2% 3% 8% 37% 50% 4.3
The majority of the respondents (63.5 percent) indicated that they had enjoyed the management aspects of clinical practice, such as serving on medical staff committees or financial management, and that this led them to seek a larger management component in their activities.
I enjoyed the management aspects of my clinical practice (e.g., serving on medical staff committees, managing the financial aspects of my practice, and so forth) and wanted to spend more time on management activities.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 7% 8% 22% 38% 25% 3.6
An even larger proportion of those responding to the survey (69.8 percent) identified a need for more physician-centered direction in the management of medical organizations as a factor in their decisions to expand their management activities.
My move into a management role came with my recognition of a need for more physician-centered direction in my organization.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 5% 7% 19% 38% 31% 3.9
Similarly, 78.9 percent of respondents cited a desire to have an impact on organizational policies governing medical care as a factor in their career decision to participate in management.
My decision to move into a more active role in management resulted from a desire to have an impact on the organizational policies governing medical care.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 5% 3% 13% 39% 40% 4.0
Participants were asked whether they were sought out by organizational management to become involved as physician executives. Nearly half of the respondents reported that they entered management in this way. It is interesting to note that a significantly higher proportion of physician managers who graduated from medical school prior to 1960 were approached by their organization to assume management responsibilities.
My move into a management role came when executives in my organization recognized the need for more physician-centered management in the organization and approached me to fill that role.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean
14% 13% 26% 19% 29% 3.3
Graduated before 1960
9% 6% 23% 13% 49% 3.9
Graduated after 1960
15% 16% 27% 21% 19% 3.1
Satisfaction with Management Career
Physician executives responding to this survey are highly satisfied with their choice to enter management. This is true on both absolute and relative scales. More than 85 percent of respondents reported a high level of satisfaction with their roles as a physician executives, and only 17 percent consider their management responsibilities relatively less satisfying than clinical practice. Nearly three-fourths of the physician executives agreed that their management activities provided them with a strong sense of accomplishment.
I have found my role as a physician executive very satisfying to me as a professional.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 2% 3% 10% 44% 42% 4.2
I have found the management portion of my career to be relatively less satisfying than the clinical portion of my career.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 24% 33% 26% 12% 5% 2.4
My role as a physician executive gives me a strong sense of accomplishment.
Strongly Disagree Strongly Agree 1 2 3 4 5 Mean 1% 2% 14% 45% 32% 3.9
Although there were no significant differences among respondents on the latter two factors, physicians who graduated prior to 1960 reported significantly less satisfaction with their roles as physician executives (the first of these three items) than those who graduated after 1960.
Factors in Development of MD Managers
A second area examined in the survey was the importance that physician executives attach to various experience and educational factors in preparing them for management responsibilities. This was examined in two contexts--the factors the respondents felt had been important to their development as physician executives and those seen as important to development of such executives in the future.
The responses show that service on medical staff committees or in medical staff governance and participation in practice management were much more highly valued than were experiences in medical society activities, non-medical community organizations, or the military. Respondents also rated service in medical staff committee work and governance highly for development of future physician managers. In all other experience areas, there were statistically significant differences between the factors rated important to their personal development and those that they see as important for future generations of physician executives. In each case, the respondents felt that the factors were more important to future managers than they had been to their generation of managers.
Education Factor Considered Self Others
Formal management training leading to a management degree
Formal management training leading to a certificate or other nondegree recognition 2.7 3.8
Continuing education programs in management (e.g., short courses correspondence courses) 3.8 4.3
For this group of executives, formal training in management through continuing education was a much more important factor than formal graduate education leading to a management degree or a certificate. However, their view of the relative importance of formal education for future physician executives was quite different.
Physician executives' view of the importance of education varied with year of graduation from medical school. Those who graduated prior to 1960 placed less value on formal education leading to a degree or certificate, either as important to themselves or to development of physician executives in the future. The differences between the two groups of respondents were significant.
Importance of formal management training leading to a management degree (e.g., MBA, MHA, MPG, etc.) to my development Not at all Important Very Important 1 2 3 4 5 Mean
42% 16% 19% 14% 9% 2.2
Graduated before 1960
33% 28% 24% 12% 4% 2.2
Graduated after 1960
46% 10% 17% 15% 11% 2.3
Importance of formal management training leading to a management degree (e.g., MBA, MHA, MPH, etc.) to others' development Not at all Important Very Important 1 2 3 4 5 Mean
2% 9% 27% 46% 16% 3.6
Graduated before 1960
2% 17% 36% 34% 11% 3.8
Graduated after 1960
2% 6% 23% 52% 18% 3.4
Future Development of Field
The survey asked participants to weight the importance of several factors to the future development of management as a medical specialty. Of eight factors assessed, the respondents rated the existence of opportunities for promotion and wider responsibilities highest as a factor in the future development of the field. Also highly rated were the increasing importance of managers who are technically competent individuals in health management positions; the need for physician involvement in management in a system increasingly concerned with quality; increased availability of graduate programs in management tailored to needs and interests of physicians; and appropriate levels of compensation for physician managers. Recognition of medical management as a medical specialty was highly regarded as a factor in future growth of the field by 69 percent of respondents.
A reduction in clinical opportunities as a result of increased competition was considered important to the future development of the field by only 19.4 percent of respondents. Again, despite anecdotal evidence that physicians are "fed up" with regulation and the business aspects of practice, only 22.8 percent of respondents rated that factor as important in determining the future development of the medical management field.
Despite a wide range of differences among the respondents in age, sex, background, and current employment, there were relatively few significant differences in responses based on any subgroup characteristics. The exception was year of graduation from medical school. Respondents who graduated before 1960 did show statistically significant differences in their responses on several survey questions. These differences showed no pattern that suggests any real difference that might guide future development of the field.
Physician executives responding to this survey are remarkably consistent in their responses concerning the reasons they have moved into management roles. They assumed larger roles in management because of a desire to have greater influence on organizational policies and because they perceived a need for more physician direction in the organization. Factors often suggested as bearing on physicians' move into management--rising costs and bureaucratization of practice or a desire to control time better--were not significant influences among this sample of respondents, nor were economic considerations.
Physician executives find their role as managers satisfying and experience a strong sense of accomplishment from their executive responsibilities and indicate that more satisfaction is derived from these activities when compared to clinical activities.
The participants in this survey see the development of wider opportunities for promotion and assumption of a wider range of responsibilities as a major factor in the future development of the physician executive career path. Similarly, they expect that technological developments in medicine requiring increasingly technically sophisticated managers will positively influence demand for medically trained managers. Conversely, they do not expect that physician disillusionment with the practice environment or constriction of clinical opportunities will have strong effects on the future of the field.
The most interesting results of this survey fall in the area of physician preparation for careers in management. Reflecting the relatively short time since the resurgence of interest in management among physicians, relatively few of the respondents valued formal degree or certificate education highly in their personal development as managers, while continuing education was a significant factor. When the respondents turn to the matter of future managers, however, they rate the need for formal education in management much higher, while maintaining a priority for continuing education. One can speculate that the difference as regards formal management education reflects a perception that future physician executives will carry broader responsibilities in a more complex environment, requiring broader educational preparation in management. The priority accorded continuing education as a factor in development of physician executives reflects respondents' experience in medical education, where formal education is limited to a discrete period, with extensive dependence on continuing medical education for maintaining currency.
Given the growing trend toward full- and part-time management careers among physicians, the results of this survey provide several interesting conclusions. Clearly, this sample of physician executives sees management as a desirable and fulfilling career choice. Their motivations are drawn from a perception of need for more physician leadership in an increasingly technologically complex health system rather than from disaffection with medicine and the practice environment. The route to expanded involvement in management most frequently is through participation in medical staff governance and practice management activities, and continuing education has been the most frequent source of specialized management knowledge for today's active physician executives. When these managers look ahead, however, they see a much more important role for formal management education for physician executives.
Looking to the future development of the field, a clear majority of these physician executives see development of expanded opportunities for leadership as a key factor in growth of the field. The increasing emphasis on quality in health services will require more physician participation in management of health care enterprises in the future. They conclude that availability of graduate education programs "tailored to physician executives' needs and interests" is an important factor in the future development, as is recognition of medical management as a medical specialty.
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(4.) Irwin, B., and Harvey, N. "The New Physician Executive: The Next Decade." Healthcare Executive 1(2):21-3, Jan.-Feb. 1986.
(5.) Wallace, C. "Physicians Leaving Their Practices for Hospital Jobs." Modern Healthcare 17(10):40-1,44,48,55-6, May 8, 1987.