Physician executives--the Lone Rangers of administration?

Craig Slater did not venture into the surgeons' lounge during his first six months as vice president medical affairs at the 445-bed Memorial Hospital in Gulfport, Miss. "I could sense I was not welcome," he says.

"One day I was an orthopedic surgeon and chief of staff, the next day, I was essentially the VPMA," says Slater, 55. "My colleagues thought I had gone over to the dark side. Doctors are funny. It's kind of like being in a club and violating the rules."

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Some administrators were inhospitable to the new MD in the executive suite too. "Even though the CEO had faith in me and acted as a mentor, the management team did not fully accept me," Slater recalls. "I didn't have the good business credentials they had. Things I would say at meetings were taken with more skepticism than what they had to say."

Slater was hired to bridge a gap between the hospital and its doctors--a sort of Lone Ranger position. Turf wars were raging, such as one between cardiologists and radiologists over peripheral vascular intervention. He needed to create a disruptive physician policy. Despite his efforts, initially he remained mistrusted and unaccepted by both physicians and executives, stymied in trying to accomplish goals.

Isolation is a familiar concept in management according to professors who teach at some of the nation's top business schools, Wharton, Harvard and Sloan. They say it is common, not only in physician to executive shifts, but in other radical transitions, such as when engineers become managers, reporters move up to editors and when professors are promoted to deans.

Lawton Burns, PhD, a Wharton department of health care systems instructor who has studied and trained doctors calls the elevated, "marginal men," a term used by early 20th century sociologists to describe those who travel between different cultures. "They are people who have a foot in two different worlds, not 100 percent in either world," he says.

Marginal men--or women--break out of involuntary confinement by maintaining skills in both camps, by being credible to both sides and by developing the ability to communicate with both groups as interpreters, teachers, reformers, conciliators, Burns says. That is easier said than done.

Doctors often suggest loudly that physicians should have more say in how health care is run. Ironically, practitioners have a hard time reconciling how a once trusted colleague could give up medicine to join an administration, says Hugh Greeley of the Greeley Company, a Marblehead, Mass., health care leadership advisory firm.

Stolen prescription pads

Slater practiced for 14 years, some of that time in the same community in which he assumed an executive role. A month into what became a decade-long administrative tenure, Memorial's director of pharmacy asked him to resolve the issue of stolen hospital prescription pads.

In one of his first executive committee meetings, Slater notified physicians he was keeping the pads under lock and issuing keys to the medical staff.

A cardiologist at the meeting castigated him, telling him, "It was none of my damn business since I was not using prescriptions any more," Slater recalls. A shouting match ensued, something he thinks would not have transpired under the same circumstances today, now that he has 11 years administrative experience and completed an MBA. Slater became senior vice president, medical staff affairs at Owensboro Medical Health System in Owensboro, Ky. last year.

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Non-hospital MD executives experience similar discordance with colleagues. "It's very difficult for physicians to understand. They ask me all the time, 'What are you doing, and why?'" says Scott Young, MD, 46, a former Salt Lake City family doctor who is the U. S. Health and Human Services director of health information technology for the Agency for Healthcare Research and Quality, Rockville, Md.

Colleagues typecast physicians who sign on as administrators as just another suit. Lack of confidence springs from the conviction that in managed care settings, doctor/administrators are insensitive executive roadblocks to obtaining patient care. In hospitals, administrators are perceived as unable to get the right things done in a timely manner, such as putting more RNs on units or purchasing essential equipment.

"Doctors just don't believe management is effective for their purposes," Greeley says.

Community physicians complain their former friends have turned against them and are now advocating positions that are occasionally at odds with private practice, Greeley says.

One angry Southeastern cardiologist, a solo practitioner who did not want his name published, said, "Whoever pays the piper calls the tune. These physician executives push the agenda of what the hospital wants. They forget they were once in hands-on medicine."

Indeed, physicians are sometimes ambivalent about their own ascendance. "I ask myself in a constant monologue: 'Is this the best use of my time? Where is the best place for me to contribute?'" says Young. "I struggle with the fact that there are not enough doctors. I could help fill the void. But in the longer run, I can bring a unique perspective to the federal dialogue and help distribute physicians better.

"Sometimes I can buy it and sometimes I can't. Some days I think I'd like to go back and see patients. It's something I remember fondly. Then my wife reminds me the grass was not necessarily greener."

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Adds Mark Hauser, 58, VPMA Baptist Hospital of Miami, Fla., who left 25 years of pulmonology practice only two years ago, "When someone starts a clinical conversation, resting pathways spring to action. It's like having a Ferrari in your garage you can't drive."

Responding to children is toughest, Young adds. "My 13 year-old daughter says, 'You were a doctor once, what do you do now?' Her eyes glaze over when I explain it." To keep his hand in medicine, Young volunteers at a Maryland homeless clinic.

Clinical competency helps doctors retain legitimacy, says Ingo Angermeier, president and CEO, Spartanburg Region Healthcare System, Spartanburg, S.C. However, he thinks it is nearly an impossibility to wear two hats.

While about half of all physician executives hang up their stethoscopes for good, cold turkey, or after a gradual winding down, the other half maintain a foothold in clinical practice, according to an analysis of ACPE member data.

Wharton's Burns finds that troublesome, adding the only easy transition is an abrupt one--leaving medicine for an executive post, or leaving practice to complete an MBA.

"Most conflicted of all are doctors that try to do 50-50 practice and administrative role, because they can't do justice to either," Burns says. "They feel bad because they can't be doctors 100 percent of the time. They don't feel like they can stay current on medicine and try to learn a whole range of new skills."

Paradoxically, as soon as doctors stop practicing, clinicians view them with increasing suspicion, Burns says.

To add to their woes, physician executives are often hired without clear job descriptions or thought concerning how the doctor will fit into the overall management team, executive trainer Greeley says. Their jobs are nebulously designed, not well documented, and expectations are unclear.

It sometimes comes down to a COO who is tired of banging her head against the wall saying, "Let's get a VPMA who will solve our medical staff problems," Greeley adds. As a consequence, they fumble around not realizing that some of their efforts result in stepping on another administrator's toes.

Administrative adjustment

Changing focus from patients to an organization requires a psychological adjustment. At the end of a day, physicians get patient feedback that they did or did not do a good job.

For executives, the results of what they do may not be felt for an extended period so they often don't know how they're doing. They don't produce anything and they have few concrete results to point to and say, "I did that."

Barbara Brannen, a management consultant who was formerly vice president of Human Resources for Denver's Rose Medical Center, recalls an incident involving a VPMA who had been in the "C" suite (chief-titled leadership jobs) for a year.

Rose had an employee appreciation program called, "You're the Apple of Our Eye." If one employee thought another was helpful, he or she could call HR to have an embroidered apple delivered and attached to a lapel.

"I remember taking one apple to an MD in the "C" suite. I read him the letter from the employee who thanked him for his work on a committee. He had tears in his eyes as he said, "'I was beginning to think no one noticed.'"

Once entrenched, doctors often pursue new careers with the same vigor they applied to medical school and residencies. They take business courses and hire coaches, soon learning the road to acceptance and trust is paved with communication skills.

"Ideally, the chief medical officer is a tool by which both administrators and the medical staff communicate with each other," CEO Angermeier says. "Those who can communicate with both can make life so much easier."

Memorial's Slater had to change the way he interacted with people. He moved from the independence he had as a doctor to a role of interdependence on others to get things done. Slater left the comfort of a long-standing career where he called the shots and moved into the muddy world where issues are not resolved in 15 minute, Dx-to-Rx appointments.

Changing mindset is critical for administrative success. "I see managers disrespecting physicians because they expect immediacy," Angermeier says "Physicians initially don't understand the time it takes between when management wants to do something and when the action hits."

Says obstetrician Carol Solie, MD, 49, VPMA at the 250-bed Marion General Hospital in Marion, Ohio: "I had to understand that I was no longer in charge. You've been used to being the expert. But most doctors have never run a multimillion-dollar business. There's a lot of subjects you're not an expert at any more."

Moreover, in clinical practice, "there's a time pressure, so you finish people's sentences. As an administrator, I can't do that," Solie says.

Eventually Slater became less isolated by looking past the snubs from other doctors and the perception of administrative interloper with trained MBA and MHAs. He poised himself at the midpoint of a seesaw, balancing the interests of both camps, learning to be bilingual in both cultures. He explained the administration position to doctors and the physician point of view to administrators, earning the acceptance of both.

Slater felt an MBA was essential to put him on equal footing with other executives. But CEO Kester Freeman, of Palmetto Health System, Columbia, S.C., says doctors do not need advanced business degrees to relate to other administrators. Instead the jobs they do require interpersonal and mitigation skills, most of which are innate.

"They need to have the ability to take people who don't agree with each other, who are in conflict, to go into a room where there is warfare and come out not making it worse," he says, chuckling. "Clinical skills will help a little but not as much as a natural ability to negotiate a conflict."

Doctors don't always make the transition from clinician to executive easily and isolation persists, say management experts. Sometimes they fail as leaders because they are unable to relate to the people they oversee, they are unable to engage and motivate others, they are more focused on the technical aspects rather than leadership and they don't see the strategic picture, says Margo Stewart, of the Boulder-based Center for Executive Leadership.

Janice Klein, PhD, of MIT's Sloan School of Management estimates half of all "marginal men" and women are not successful at bridging the gap between their two worlds. "They remain in these administrative jobs and isolation continues," she says.

They're not only Lone Rangers, but very lonely rangers.

Jackson, Wyoming, psychologist and executive coach, Kevin Fleming, PhD, once advised a physician who fell into management of a group practice. He unconsciously sabotaged his administrative role in order to go back to practice. How? By being late to meetings, by not getting reports done and by having poor conflict resolution skills.

Maureen Glabman is a Miami-based health care reporter and recipient of the 2000 Reuters Fellowship in Medical Journalism at Columbia University's Graduate School of Journalism.

RELATED ARTICLE: Unmasking the Lone Ranger

Mistrust, and the isolation that springs from it, is one of the most endemic issues in business today, says Massachusetts executive coach, Steve Lishansky. Despite all that is written and talked about, the quality of people's communication and relationships with each other define success more than virtually any other factor.

Trust and respect are the fundamental foundations of any relationship that has growth potential. Here's how to obtain them.

Be a bridge between two cultures by being a teacher, says Janice Klein, PhD, of MIT's Sloan School of Management. There is a lack of understanding on both sides. Help the other side gain an appreciation of the other's viewpoint. "This ability will make or break you," she says. Don't push an agenda. Help others see the need for change. No one likes to have ideas pushed on him or her.

Demonstrate what you can bring to the party, says Klein. Build credibility by showing you have competence, that you understand business issues and can make sound business decisions.

Get out of your office. Physician administrators who stay in their offices and do not affiliate with doctors will be considered administrators, says Hugh Greeley, of the Marblehead, Mass., medical management training group, The Greeley Company. "Get out and interact with other clinicians in any setting possible--medical staff lounges, general staff meetings and so on. Baptist Hospital of Miami VPMA Mark Hauser eats as many lunches as possible in the hospital's physician dining room. "You don't have to turn into a hand pumping politician. You can do it without looking phony," says consultant Margo Stewart of the Center for Executive Leadership. "It fosters the perception that you're available."

Boost staff leaders. Make volunteer staff leaders look good by helping them to do their jobs and letting them take the credit. Greeley offers this example: If the chief of staff complains about an overcrowded ER, design a strategy where a free clinic staffed by volunteers relieves the situation and give credit to the chief.

Champion patient causes. Boost activities that clearly benefit doctors and patients, such as improvements in technology, care, staffing. However, "if doctors only champion for patient care and not for structural performance, management will perceive them as being in doctors' camp," Greeley says. "A firm foothold in both camps is essential."

Dive into administrative matters. Become more intricately involved in management. Constantly seek opportunities to demonstrate your expertise. "Never miss an opportunity to interact with the executive team. Ask to attend every meeting, suggests Greeley. "Say to the CEO: 'I could learn from it.' Sometimes, VPMAs stay away because they don't feel comfortable talking about strategic planning so they stick with medical staff stuff." Ingo Angermeier, president and CEO, Spartanburg Region Healthcare System, Spartanburg, S.C., says doctors should absolutely attend financial meetings to represent the interests of the medical staff, especially, for instance, when there is a discussion of capital expenditures.

Assume more tasks. Especially when a manager is departing, ask to take on some of the jobs assigned to that manager. "Physician executives go wrong by failing to demonstrate they are willing to take on additional administrative responsibilities. They allow themselves to be pigeonholed into working solely on medical staff issues," Greeley says.

Get the training. You have to learn new skills and it's unlikely your employer will teach them to you. "If doctors don't educate themselves via MBA programs, ACPE courses and more, they will forever be perceived as the interface between management and physicians, not a full member of the team," Greeley says. "If a job in the C suite becomes available, the VPMA sometimes won't apply for it because they don't believe they have the skills. They won't learn the skills if they don't constantly interact in a collaborative mode with the administrative team and avail themselves of educational opportunities."

Determine the issues. Physician executives must understand the issues management is interested in, Greeley says. Go to management retreats, he suggests. By the same token, doctors stuck in an office need to keep abreast of clinician issues. Carol Solie, VPMA at the 250-bed Marion General Hospital in Marion, Ohio, started a physician help line that rings directly into her office. She also began a physician newsletter to keep doctors in touch with what's going on at the hospital.

Enhance your value. If another vice president is working on a project that involves patient care, make yourself available. If a non-physician is put in charge of building a clinical tower, an MD can be a valuable member of the design team, Greeley says.

Don't ignore physical gestures. "Symbolism means a lot," Greeley says. If a physician administrator allows doctors to perceive them as doctors, they will be better accepted. "Don't walk into a meeting of doctors wearing a sports coat," he says. "By the same token, don't walk into a meeting of administrators wearing a lab coat." Eliminate the secretarial habit of announcing doctors who are waiting to see you. Keep your door open and tell doctors to just come in.

Engage key players. Sit down with the head of surgery, chief of medicine and committee chairpeople and ask what they want from you in your role, suggests Stewart. "Tell them you are still a doctor and ask how you can be of service, how you can continue having an excellent relationship. Tell them this is an opportunity. While you cannot fix every problem they have, having an MD on the inside can only improve conditions for the medical staff in the long run."

Build relationships. Ask the chief of surgery: "Here's what we propose to do about thus and such. What do you think?" It helps unearth unproductive assumptions before resentment occurs and build trust, especially if you are new to the organization," says Stewart. However, beware of doctors who will try to capitalize on your role to advance their own agendas.

Win people over. A journey of a thousand miles begins with a single step, said Confucius. In a like manner, you may have to win over people on a one-to-one basis. And if you can't win over a key person, find someone close to the person you want to reach, win over that person, and let that individual work on the skeptic, Klein suggests.

Develop social networks. There is a school of thought that says you should go drinking with the boys. It can be viewed as artificial and isolation can spring from artificiality," Klein says. Better to manage by walking around. Go have coffee with someone. Tap into what's important to that person. Adds Amy Edmondson, PhD, professor, Harvard Business School, who is trained in organizational behavior and psychology, "Don't invite the boss to dinner unless you like to cook. Anything that is disingenuous is probably not worth doing just for show." Doctors who try to maintain friendships they've had with other physicians do not usually work. "I think they try to pretend to keep up friendships but the question is: do your friends still think of you as like them?" says Lawton Burns, PhD, a Wharton department of health care systems instructor.

Learn differences between the sexes. Slater says he was used to dealing with the men in orthopedic surgery but had no idea how to relate to women COOs or committee members. "The best management book I read was Men are From Mars, Women are from Venus by John Gray, (HarperCollins 1993). Men and women don't view the world the same way and you have to adapt your behavior accordingly," he says.

By Maureen Glabman