Physicians in transition.

The first and most obvious question to ask in assessing the movement of physicians from clinical practice to management in managed care is, "Who are they? The demographic profile indicates that 90 percent of the group were men and their average age was 49, but I was more interested in the age at which they made their transition from full-time clinical practice, something that has not been previously detailed.

Figure 1, page 17, shows, by 5-year cohorts, the age at which doctors first left full-time clinical practice. I interpret this chart as an indication that the transition to an alternative career is a first cousin of mid-life crisis and is not a mid-career change. Figure 2, page 17, shows the number of years that the respondents were in full-time practice before they made a transition, and confirms that the change occurs fairly early in their practice careers. That doesn't seem so strange or unexpected to me. The practice of medicine, especially a procedure-oriented specialty, is not inherently intended to be creative.

In some measure, physicians, like athletes, acquire expertise and confidence by doing the same things repeatedly. That's not to say that doctors are not supposed to, or don't, learn anything new. But for me, one of the primary motivations to do something else was looking down the road 30 years and realizing that most of my time was going to be spent doing pretty much the same old thing. At the same time, the world I saw evolving was one in which doctors were going to largely be in one of two camps. There would be those who would be observers of the changes in health care, sitting in the stands, watching the game as it unfolded and cheering either for the home team or the opposition. And there would be the players. They would be down on the field, getting dirty, sometimes getting injured, but being in the game. Ultimately, the question for me resolved itself into deciding where I wanted to spend my time. I suspect that I wasn't the only one wondering.

There are three paths by which physician executives entered managed care. As seen in Figure 3, page 17, the most common pathway was an evolution from full-time practice, to a combination of administration and clinical work, and finally to a full-time administrative position. The average time spent in the transition was 4.3 years, with a range of less than one to more than 20 years. Only 16 percent of physicians made the transition directly from full-time practice to full-time administration; 29 percent of the survey group remained in part-time practice. Some of the perceptions of these subgroups will be examined later in this paper.

More than half of the physicians were trained in a medical specialty, with few surgeons, OBGs or psychiatrists (figure 4, below); 93 percent were board certified. Those coming from solo practice, single-specialty groups, and multispecialty groups were about equally represented (figure 5, page 19). It doesn't seem that any particular practice setting exerts a greater or lesser hold on physicians.

Advanced degrees were held by 26 percent of the respondents (figure 6, page 19), most of them MBAs along with a number of MPHs. This is a remarkable statistic, considering that when Kindig and Lastiri surveyed 878 physician administrators in 1985, only one percent of that group had earned an MBA, compared with 10 percent in this survey.[2]

Two-thirds of those who responded spent 95 percent or more of their time in administration (figure 7, page 19), and even those in part-time administration spent the majority of their time in administration rather than in clinical work (figure 8, page 20).

After looking at the question of who is making the transition to management, I wanted to look at why doctors get involved in managed care. What motivates people who spent from 7-15 years preparing for a career in clinical practice to change course?

The reasons have been viewed as either push factors or pull factors.[3,4,5] Push factors are those that friends and colleagues often believe are the real reasons that doctors leave practice. Because it is so difficult for people to understand why a physician would leave clinical medicine, they not uncommonly believe that a doctor who does so must be running from rather than running to. If you look at the state of medical practice today, it's not hard to understand why people might think that. But accounts of physician executives do not bear this out. For example, one physician wrote. "The reason for my involvement in medical management is not, as some disparagingly suggest, either incapacity to remember medication doses, an inability to build and maintain a practice, or the results of ostracism from the ranks of real doctors .... The reason is the maddeningly seductive belief that I would be able to `straighten things out' if only I were at the administrative helm."[6]

In the study by Kindig and Lastiri, respondents were asked to specify their primary reason for choosing administrative careers. The most common reason given was a desire to have a broad impact on health care delivery and to ensure high-quality patient care. Most of the other reasons given were positive attractions to management, with only 4 percent reporting dissatisfaction with patient care. This was in sharp contrast with the results of a study in 1962, which indicated that most physicians found administrative activities unrewarding.[2]

What did physicians who responded to the present survey have to say about why they took the road less traveled? Table 1, page 18, shows the transition factors that were asked about in the questionnaire. For the purpose of analysis, responses of 1 or 2 were assigned a score of minus 1 and a response of 3 or 4 was awarded a value of plus 1. The scores for each factor were then summed, producing an overall negative score or positive score. The more negative a score, the more unimportant it was considered to be and the more positive a score, the more important it was. If the respondents were split 50-50 on the issue's importance, the overall score would be zero.

Table 1. Transition Factors
a. Third-party "interference
b. Medicolegal climate
c. Falling practice income
d. Desire for more personal time
e. Loss of autonomy
f. Desire to reduce job stress
g. Transition to retirement
h. Personal medical problems/disability
i. Oversupply of MDs in my specialty
j. Desire to relocate
k. Lucractive job offer
l. Interest in administration
m. Bored with practice
n. Desire to change "the system"

Figure 9, page 20, shows the overall results for all respondents. There were only two factors that were considered important in the decision to leave full-time practice--an interest in administration and a desire to change the system. All other factors received overall negative scores and were therefore considered not to have been critical in the decision. Not all of these factors were equally unimportant, however. Desire for more personal time, desire to reduce job stress, and some dissatisfaction with practice were considerations for many of the physician executives, even if the majority didn't consider them factors that drove their decisions. This response pattern held true across 10-year age cohorts with two predictable exceptions. Those who made a transition when they were less than 30 years old considered reduction in job stress much less important than did those in any other age group, and for those who were more than 60 years old, transition to retirement was a motivating factor.

The responses of one other subgroup--the group of physician executives who had made a transition directly from full-time practice to full-time administration--were analyzed to see if they held a different view of the world of practice than did the group as a whole. Figure 10, page 20, shows that their responses mirror the responses of the larger group.

The results of the survey confirm that the decision to enter administration involves primarily pull factors. The things that many doctors complain about often and loudly don't seem to be the factors that lead them to change the direction of their careers. Clearly, administration is not a sheltered workshop for angry or disappointed physicians. Still, there is at least the suggestion that some very personal push factors set the stage for a transition. The long hours, the nights and weekends away from family, and the stress that comes with full-time clinical practice are a part of the decision. So is a desire to grow beyond the confines of practice and get to play in a larger arena.

Once the decision has been made to make a transition, there are a number of issues that arise. One of the first is the need for education.[5,7] Guthrie acknowledges this first-hand: "I realized then, and in retrospect I am even more convinced, that I was unbelievably naive about this transition. Looking back, I had no understanding whatsoever of what this move might entail. The job description was one page long .... It had nothing to do with the practicalities of the authority and responsibility of the position, and I didn't have the skills required to perform adequately."[8]

That statement contains the central issues of education and training for the transition to a management position. The majority of physicians who responded to the survey agreed that they had little or no formal preparation for a management role. And although there was clear agreement that further education was highly encouraged, only a quarter of the respondents felt they were likely to pursue an advanced degree in the future, in spite of the fact that slightly more than half felt that an advanced degree would be important to career advancement. Physician executives who do not intend to enroll in graduate school or executive MBA programs will depend on the support of their organizations to pursue seminars, certificate courses, and conferences. They will also need mentoring within the organization, but 42 percent said that they lacked a role model or mentor within their new organizations.

All too often, I suspect that a new medical director finds everyone in the organization too stressed or too busy attending meetings to act as a teacher, no in-house education program, a job description that offers more confusion than clarity, and so much emphasis placed on getting the new person operational that little or no time or attention is devoted to helping him or her succeed. If this "sink or swim" method of orientation sounds familiar, it's time for your organization to take a careful look at whether it is part of the solution or part of the problem. It's only a matter of common sense to recognize that planting a seed in rocky soil and giving it little water or sun is not going to encourage its growth.

There are potentially significant professional and personal issues that may arise for those who enter management. Doctors don't think like executives, they don't talk like executives, they don't even dress like executives. Doctors don't like to plan for potential future events. They are generally trained to be reactive. Someone is bleeding: stop it. Congestive failure: treat it. This makes it difficulty to engage them in a planning process.

Doctors are fiercely independent. They learn to make decisions unilaterally and to be held accountable for the results. They typically are not comfortable with or skilled in the processes of consensus building and delegation. This may lead them to be impatient with the politics and bureaucracy of most organizations.

Physicians who make the transition to management should also be prepared to deal with issues of self-image. In many cases, the physician in transition may have not "reported" to anyone since residency and may find the "chain of command" uncomfortable or even worse, especially if his or her boss is not a physician. Doctors are used to being at the top of the hierarchy and may find that starting over again in new careers may mean a view that isn't the one the lead dog has. They may find, being new or inexperienced, that their opinions are not sought out or are not highly valued, or that they may be left out of "important" meetings. This lack of visibility will be a new and highly disconcerting experience for someone who has been "the expert" for many years.

The most difficult aspect of the transition may be the change in feedback. Virtually all doctors in practice get positive feedback about themselves every day, many times every day. Patients keep telling doctors in many ways, both spoken and unspoken, that they are valued people, pillars of the community, compassionate healers. And we all believe it. Enter the corporate culture. If you do something good, the chances are high it won't be noticed. But if you do something wrong, there is not likely to be any lack of people willing to point out your mistake.

Hirsch says, "To me, when doctors want to leave medicine, it's one of the more painful kinds of changes, just because of the investment involved. Some doctors chose medicine from day one, or they had very early ideas about practicing medicine. So ... their identity is tied up in being a doctor."[3] If that's the case, "doing" something other than practicing medicine may be the equivalent of "being" someone else, an idea that may get inadvertently reinforced by family, peers, or friends who now see and treat you differently than they did before. It's not hard to see how that career fork in the road could pretty easily become a right-hand turn onto an emotional roller coaster.

I was surprised that the survey results didn't reflect problems in these areas. As you can see in table 2, page 18, the survey asked about adapting to a nonpractice culture, organizational status, isolation, and job satisfaction. Looking at figure I 1, page 23, it is apparent that the great majority of the group did not experience problems in these areas.

Table 2. Transition, Professional Issues
The transition from full-time practice was
accompanied by:
 6. Difficulty adapting to the "nonpractice"
    culture.
 7. Initial boredom with the management
    position.
 9. Difficulty starting "all over again" as
    low person on the totem pole.
10. Isolation--not belonging in the either the
    clinical or the nonclinical world.
11. Decreased job satisfaction compared to
    patient care.

In terms of personal issues, self-image, support from peers and family, and social and professional status were examined (table 3, below). The results, shown in figure 12, page 23, indicate that there was no perception of enthusiastic support or respect from colleagues among those who responded. There was, however, an interesting age cohort difference. Physicians younger than 40 disagreed that they had strong support for their decision from their peers and yet reported an enhanced self-image. On the other hand, physicians who were 50 and older reported that they had an impaired self-image, in spite of the fact that they also felt that they had more support from their peers for their decisions. Once again, the results seem to point at managed care physicians as a self-directed maverick group. They don't require approval from their peers to change their career path, and they don't seem to have as much difficulty with transition as might be expected. They seem to be primed to start over, to start something new and in general gain in self-esteem and job satisfaction from the change.

Table 3. Transition, Personal Issues
The transition from full-time practice was
accompanied by:
 2. Increased status with my physician
    peers.
 3. Loss of social status.
 4. Lack of spouse support for the decision.
 8. Enhanced self-image.
14. Strong support for my decision from
    peers.

After the transition to part-time or full-time management duties is made and there has been some time to gain perspective, what do physician executives feel about their new role, particularly about the role stress they may experience in their new positions. Burke and his coauthors developed seven questions that physician executives were asked to respond to on a seven-point agree-disagree scale.[9] The surveys were sent to a random sample of members of ACPE and analysis was based on the responses of 121 physicians. My interest in the results of that study led me to mimic the format they used. Some of the questions were worded in a slightly different way (but with the same intent) and a five-point scale was used. Also, the physicians surveyed in the present study are a subgroup of ACPE members--those involved in managed care. The results here are therefore not directly comparable to those in the earlier role stress study, but comparison of the two shows close agreement.

Table 4, page 21, shows the questions that were asked, which were ranked along a five-point scale from strongly agree to strongly disagree. For analysis, responses of 1 or 2 (strongly disagree) were assigned a score of -1 while responses of 4 or 5 (strongly agree) were assigned a score of 1. Responses of 3 were scored as zero.

Table 4. Present Perception, Role Stress
PP1. Management conflicts with my duties
     as a physician.
PP2. Practicing physicians respect me as
     an executive.
PP3. Practicing physicians respect me as a
     physician.
PP4. Nonphysician managers respect me as
     a health care executive.
PP5. I have considered giving up management
     to return to practice on a full-time
     basis.
PP6. I have considered reducing my management
     duties to return to part-time
     clinical practice.
PP7. I am able to have positive influence
     on the quality of medical care in my
     organization
PP8. I have enough time for family.

The results (figure 14, page 24) indicate that managed care physician executives do not perceive a conflict between their management and clinical roles and that they overwhelmingly agree that they have the respect of both their physician and their managerial peers. The highest level of agreement was seen for the statement, "I will able to have a positive influence on the quality of medical care in my organization." On the other hand, the issue over which the group was most divided was the question of sufficient time for family, with a large number of respondents feeling that they did not have enough time for their families. When the survey responses were looked at in 10-year age cohorts, no significant differences were found. These results mirror almost exactly the findings of the survey by Burke and suggest that managed care physicians do not experience significant role conflict related to their jobs. This is reinforced by the finding in both surveys that few physician managers seem inclined to give up management and return to practice.

The study by Burke did not collect data on the differences between physicians who dropped clinical practice altogether and those that stayed in both worlds. In order to compare the two groups, which were unequal in size, I converted the summary score for each statement into a percentage of maximum possible positive or negative score. It appears from figure 14 that there are some significant differences between the two groups. While neither group felt that management and clinical responsibilities were in conflict, it isn't surprising that part-time physicians were a little more uncomfortable with the balance. Both groups were in general agreement that they were respected as executives by physicians and nonphysicians, but full-time executives were less confident that they had the respect of their peers as physicians. Part-time physician executives did not lean toward going back to full-time practice, and the full-time people were even less inclined to do so. Again, there was almost unanimous agreement in both groups about the ability to influence the quality of medical care. The most striking difference between the two groups was over the question of family time. Those who were in management full time tended to agree that they had enough time for their families, but those who were part time did not.

Whether it is better to be a full-time or a part-time physician executive is unresolved and difficult to answer.[10,11] If credibility as a manager rests on respect as a clinician, how will physicians who have been out of practice for years be regarded by their practicing peers? While full-time doctors in this study didn't seem to perceive a loss of respect by clinicians, it would be interesting to get the perspective of the other side. A larger question, however, is what will happen over time to the relevance of a medical degree and clinical training. If physicians who are now in full-time management continue that career path, at some point they will have been out of practice a decade or more. Will they reach a point at which they no longer think of themselves as doctors? Will they reach a point at which no one else thinks of them as doctors? As more and more physicians get MBAs, will they start signing their memos MBA, MD, instead of MD, MBA?

Many of us who entered the land of managed care came to a place that was largely unexplored and labeled on maps with only the words, "Here there be Tygers." Being a physician executive has been compared to being in constant white-water (no Democrat slur intended) or to driving a track loaded with nitroglycerine over a bumpy road. I think that our survey has shown that it's more like climbing a mountain. It's good to bring some training and skills to the challenge, and some practice on smaller peaks can be useful before the big assault. Determination and discipline are important, but so is a helmet. Most people who climb do it because they have an inner need to, usually against the advice of others, and they learn that the real challenge is not the mountain, but the voices inside their heads.

[Figure 1-14 ILLUSTRATION OMITTED]

References

[1.] Lloyd, J., and Schalowitz, N. "A Profile of Today's Medical Director." Hospital Medical Staff 9(2):17-23, Feb. 1980. [2.] Kindig, D., and Lastiri, S. "Administrative Medicine: A New Medical Specialty?" Health Affairs 5(4):146-56, Winter 1986. [3.] Balagot, M. Leaving the Bedside. Chicago, Ill.: American Medical Association, 1992, pp. 5-13. [4.] Crane, M. "Thinking About Leaving Practice? Read This First." Medical Economics 65(16):132-6, Aug. 15, 1988. [5.] Hillman, A., and others. "Managing the Medical-Industrial Complex." New England Journal of Medicine 316(7):417, Feb. 12, 1987. [6.] Sams, B. "Managed Care: The Need to `Straighten Things Out.'" In Roads to Medical Management: Physician Executives' Career Decisions, Curry, W., Ed. Tampa, Fla.: American College of Physician Executives, 1988, pp. 54-62. [7.] Kralewski, J., and Wingert, T. "The Emerging Role of the Physician in Administration." Physician Executive 20(3):3-7, March 1994. [8.] Guthrie, M. "Hospital Management Career Happened; It Wasn't Planned." In Roads to Medical Management: Physician Executives' Career Decisions, Curry, W., Ed. Tampa, Fla.: American College of Physician Executives, 1988, pp. 6-11 [9.] Burke, G., and others. "Role Stress among Physician Executives." Physician Executive 19(5):9-14, Sept.-Oct. 1993. [10.] Vavala, D. "Physician Executives: Managers First, Clinicians Second." Physician Executive 20(2):31-5, Feb. 1994. [11.] Weiner, L. "Part-time Medical Director: Way Station or End of the Line?" Physician Executive 20(3):12-5, March 1994

Paul Bluestein, MD, is Senior Vice President and Medical Director, ConnectiCare, Farmington, Conn.