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Physician leaders see eye-to-eye.

In the hospital environment, the relationship between the chief medical officer of the organization and the chief of the medical staff can be critical to the success of the institution. It is no secret that it is also critical to the success of the physician executive. Both anecdotal evidence and a smattering of articles have suggested that this relationship may be more stormy than is satisfactory for either party.

To test the validity of this anecdotal information, the College undertook a survey of its hospital-based members in July 1990. Two survey instruments were sent to a random sample or 707 hospital physician executives. The were asked to complete the document labeled "Physician Executive Survey Questionnaire" and to pass the document labeled "Chief of Staff (President) Survey Questionnaire" along to the appropriate colleague. By the end of September 1990, valid responses were received from 353 physician executives (50 percent) and 227 chiefs of staff (32.1 percent). The basic survey questionnaire is shown in figure 1, page 27. The comparative results are shown in figure 2 and 3, page 28.

The most surprising finding on how physician executives and chiefs of staff rank issues of concern to hospitals (figure 2) is the unanimity in the responses. The average rankings for the two groups on the various issues are either identical or separated only slightly. In no case did either group of respondents rank an issue higher on average than 4 or lower than 2.4. For the issues selected in the survey, therefore, the respondents did not seem to have a high emotional involvement. The key concern for chiefs of staff was credentials/clinical privileges/reappointment, followed by medical staff/administration disputes and internal peer review, with identical scores. Staff bylaws and physician/nurse relations tied for fourth on the list. Credentials/clinical privileging/reappointment and internal peer review were tied for the top among physician executives, followed by medical staff/administration disputes and then physician/nurse relations. Staff bylaws were next on this list, tied with medical staff turf wars.

Overall, comparison of the two datasets shows very close concordance offocus for chiefs of staff and physician executives. The two groups generally agree on what's important in hospitals. Also, all of the issues identified by the two groups as important tend to be areas in which conflict is usually present or for which the potential for conflict is high. The high degree of agreement between the two groups makes the possibility of successful resolution of the conflict promising.

The largest difference of opinion on an issue occurred for physician recruitment. Physician executives ranked this issue much higher than did chiefs of staff, indicating a higher level of concern. Even so, it is surprising that physician executives did not rank the item even higher, given the competitive stance that hospitals have taken regarding physician recruitment. According to a recent report, 52 percent of U.S. hospitals are actively seeking family practice physicians. [1] The other most sought-after-specialties, in order, are internal medicine and Ob/Gyn.

It is surprising that there is so little difference between physician executives and chiefs of staff over the issue of managed care contracting. Neither group recognizes the issue as being of major concern, in spite of the fact that reports show that net patient margins are shringkin [2] at the same time that the number of enrolles in managed care plans is increasing. [3] The pressures on hospitals are already large and are growing. At the very least, it would have been expected that physician executives would have identified this as a significant problem.

On the question that asked each of the physician leaders to rate the overall performance of the other, physician executives gave chiefs of staff a 3.9 average rating, and chiefs of staff gave their physician executives colleagues an average of 4.1. These assessments are extremely positive, even though the difference is slight. Although there is plenty of anecdotal evidence that these two positions are sometimes at logger heads, this survey would suggest that there is a backdrop of respect between them that will be useful to hospital as external factors cause greater and greater need for cooperation among physicians and between physician leaders and others on the hospital management team. If anything, it is surprising that chief of staff give their physician executive brethren the slightly higher rating.

The results are even more startling in the ratings for specific characteristics (figure 3). On every characteristic, chiefs of staff ranked physician executives as high of higher than vice versa. Only three of the rankings are below 4. The chiefs of staff believe that physician executives are "less good" as creative problem solvers (3.8) and in putting aside personal biases (3.8). The lowest average ranking (2.8) was given to physician executives for dealings with the medical staff. It is expected that physician executives will acquire more capability in problem solving and will be perceived as creative in their approaches as they gain experience in management. The survey did not provide demographic breakdowns, so it is not possible to determine if more experienced executives received higher scores on this point, but intuition leads one to believe that might be the case.

The issues of personal bias and dealings with the medical staff may be related, although this logic cannot be pushed. The low score for dealings with the medical staff indicates that chiefs of staff still believe that physician executives are more concerned about the hospital than about the medical staff. This attitude may account for the fact that physician executives receive a slightly lower score on the issue of personal bias. The attitude is not surrising, considering that physician executives are paid in most cases by hospitals. One of the most difficult challenges for the physician executive is to strike the appropriate balance between obligations to the organization

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and obligations to physician colleaques and their patients. It is possible that this ranking will never rise much higher, but a comparative survey will tell the story.

One surprising finding is the score of 4.1 from chiefs of staff on the issue of the physician executive's experience for the job. Considering the conflicts that arise between physician executives and staff physicians and the frequently high level of contention between the two groups, this is quite a vote of confidence. Once again, it is finding that can be built on as hospitals and their physicians grope with changes in the health care delivery system and in the competitive posture of hospitals.

As stated earlier, physicians executives generally rated chiefs of staff somewhat lower than vice versa. The lowest score once again went for dealings with the medical staff. In his case, the data suggest that physician executives may believe that chiefs of staff more blindly follow the dictates of the medical staff. The highest ranking is given to trustworthiness (4 4), which was one of the highest rankings for physician executives from chiefs of staff. It seems most plausible to attribute the generally lower scores for chiefs of staff to the fact that these individuals are usually not professional managers. They do not have management skills for the most part and are not interested at the moment in acquiring them. Still, it is impressive that the scores are so high for a group that is less separated from clinical practice.

Almost total agreement occurred between the two groups on the issue of whether medical staff officers of the future will be elected or salaried. For each group, the average response was 3.1. It can be surmised that physician executives and chiefs of staff are agreed that there is a slightly better than even chance that, by the year 2000, medical staff officers will be replaced by salaried physicians. It is the unanimity of the responses of the two groups that is most interesting. One is encouraged to conclude that such positions as department chairs are more likely to be paid in the future, whether they are elected or appointed.

In the final question on the survey, the two groups were asked for their views on the organizational status of physicians in the year 2000 (figure 4, above). Both groups believe that the

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system will remain pluralistic, but both see major shifts in the offing. Chiefs of staff foresee 78 percent of physicians being either employees or under some form of contract, with 22 percent remaining independent. Physician executives, on the other hand, foresee 94 percent being employees or under contract, with only 6 percent remaining independent. Both groups believe that most medical groups will be hospital-affiliated rather than freestanding. The results support a conclusion that it will be more and more difficult for physicians to operate in independent fee-for-service practices or even find an association with a freestanding medical group in the future. The picture that develops is of more and more physicians affiliating with larger and larger groups, which in turn will be affiliated with larger networks of providers. For physician executives, this forecast is good news indeed. All of these organizations will have increasing demands for the services of physicians trained and experienced in management.

References

[1] Delmar, D. "Demand for Family Practitioners High, but Supply Seen Lagging." Physician's Financial News 9(8):3-4, April 30, 1991.

[2] "Hospitals End 1990 with Negative Net Patient Margin in Aggregate." Hospitals 65(9):34,36,38, May 5, 1991.

[3] Kenkel, P. "HMOs Show New Signs of Consolidation." Modern Healthcare 21(23):50-1, June 10, 1991.

Kenneth C. Cummings, MD. FACPE, is Vice President for Medical Affairs, St. Joseph Health Center, Kansas City, Mo., and Chairman of the Editorial Advisory Board of Physician Executive Wesley Curry is Editorial Director of the journal.
COPYRIGHT 1991 American College of Physician Executives
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Copyright 1991, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:relations between physician executives and chiefs of staff
Author:Curry, Wesley
Publication:Physician Executive
Date:Sep 1, 1991
Words:1630
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