Reclaiming physician power: your role as a physician executive.

Dr. Schmidt, the newly hired vice president of medical affairs at a large Midwestern hospital, was charged with halting the decline in physician morale. He soon learned that things were worse than he expected. The medical staff seemed to have little in common beyond their opposition to administrative actions.

In addition, it appeared that he was now seen as part of the "them," someone who had joined forces with the dark side in order to wrest more power and control from the physicians. He was viewed as part of the problem.

Sitting in his lonely office, he pondered what role he could play in bringing physicians together to enhance health care in their community.

The challenge

Schmidt's situation seems pretty grim. And according to a National Survey on Physicians conducted by the Kaiser Family Foundation in 2002, the level of discontent of the medical staff at his hospital is not unusual.

When asked about the state of their morale, the majority of physicians reported that both their colleagues' and their own morale has been waning in recent years. Almost half are thinking about leaving medicine, and would not recommend it to a young person today. (1,2)

While physician satisfaction and medical school applications increased slightly in recent years, both are still far below levels reported during the good old days a decade or more ago.

The number one reason for dissatisfaction that physicians cite is administrative hassles. (1) As one physician's wife stated, "my spouse's judgment is constantly questioned by nameless and faceless corporate minions armed with the rule books." (2)

Physicians are feeling a loss of control and a loss of status. And information that used to be restricted is now available to everyone (RN's, patients, insurance companies), thus empowering others, seemingly at the expense of physicians. (2)

If that isn't enough, many physicians are facing increased workloads in response to higher overhead costs, decreased reimbursements, sky-rocketing malpractice claims, and more competition. (3)

Third parties and limited budgets seem to be controlling the direction of medical care, and this shift of power has left many physicians feeling a loss of both control and authority. (4)

In addition to these losses, physicians' collective voice seems to be weakening over time. Evidence of this can be seen in American Medical Association's declining membership, that dropped by almost 43,700 members--a decline of 15 percent--between 2000 and 2004. (5)

Moreover, a 2002 VHA study found that physicians lack responsibility for clinical care as a collective whole, there is a lack of respect for physician leadership, and health care organizations tend to avoid partnerships with their medical staff, even if they could potentially enhance quality and safety. (6)

Increased outcome measurement and a shift in control from providers to customers further threaten the physician's traditional identity as captain of the ship. The lack of a new, common, generally accepted group identity has contributed to making any efforts to unite physicians a risky endeavor.

Pressures to reform our health care system have led to even further constraints on physicians, requiring them to accept reductions in reimbursements and to alter practice styles. Many physicians find themselves in what has been described as a zero-sum health care system comprised of enemies, cost-shifting, declining trust, lack of standardization, quality challenges, skyrocketing costs and plummeting value. (7)

It is hardly surprising that a study by Archives of Internal Medicine showed that over 80 percent of physicians responding believed that their commitment to undivided patient loyalty had diminished. (8)

Bringing physicians' social contract back on track will require that the profession of medicine come together to reclaim its power. Bringing physicians together, however, has typically been a difficult hill to climb.

Opposing forces include the lack of explicit, shared mission, vision or values along with the fact that one of the few things that typically unites physicians is their mutual commitment to the preservation of their individual prerogatives. (4)

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Fighting for control

As physicians witnessed the rise to power of administrators and hospitals as institutions in their own right, they naturally fought to protect their control over medicine. But rather than fighting for a place at the table in the hospital of the future, battles frequently seem to be about bringing back what are considered to be the "good old days" of individualism, autonomy and escape from the influence of the bottom line.

Autonomy has been the rallying cry. (9) However, conflicts between clinical demands and limited budgets appear to be here to stay.

Physicians have tried to regain their autonomy and control in a number of ways. For example, many physicians learned the methods of the "enemy" by enrolling in MBA and MMM programs. The output of such programs is the physician executive with enough financial management know-how to be able theoretically to fulfill the role of translator between the clinical and financial domains of health care, (4) using the tools to protect physician rights in the boardrooms of management.

How have these attempts fared? Have physicians begun to regain the power from the past that was perceived to be lost? Unfortunately, the answer seems to be a resounding no. Indications are that many current physician executives--armed with management skills--are not experiencing the hoped-for results.

Rather than being viewed by their fellow physicians as respected protectors of their rights, many bilingual physician executives are neither listened to nor respected by either physicians or administrators. Administrators frequently doubt the physician executives' business acumen and they are often viewed by physicians as traitors or administrators with honorary MD degrees. (10)

Suffice it to say, relations between hospital administrators and their physicians appear to be as bad as they've ever been, (11) and physicians are no closer to reclaiming their power.

Power over whom?

Power is about gaining influence and control--but over whom? Attempts to regain physician power so far appear to be directed at gaining authority and control over those others--administrators, third parties, and even patients--who are seen as responsible for the current negative state of things.

In spite of these efforts, constraints on physician power and restrictions on their work seem only to have increased. To date, economic pressures, autonomy desires and a resulting unwillingness to make time to engage in dialogue have constrained physicians to operating as a reactive versus creative force in shaping their role in the future of health care.

True power may only come by focusing on gaining control over one's own turf and one's own activities, rather than focusing on gaining power over others. It is time for physicians to shift the focus from battling "them" to strengthening "us." And you, as a physician executive, are in a unique position to help all physicians do this. But to do so, you must consider carefully what it means to be a physician executive.

Defining your role

The term physician executive is simply a signpost--an indication that a physician is occupying an executive role. The actual definition of duties associated with the title varies greatly across organizations and positions.

Some physician executives are viewed as educated defenders of physician rights while others are seen as senior leaders responsible for delivering the physician constituency to the support of organizational goals.

Given the limited success in uniting physicians and administrators around resolving today's health care challenges, we suggest that there is an additional, important, often overlooked role critical to both physician morale and health care outcomes.

The physician executive profession is young and further maturing is likely over time. In addition, the relationship between physicians and administrators is still in transition as environmental pressures place strains on health care organizations that demand new answers.

Clearly hospitals and health care systems are dependent upon the physicians who deliver care. Similarly, those physicians who care for the seriously ill are dependent on hospitals and health systems to provide the resources required for clinical success. While interdependence may be ultimately desirable, moving there directly from a dependent relationship is unlikely. (12)

Independence is an intermediate step between expecting others to come through for us blaming them when they don't and maturely working together. Some physicians and administrators, reacting to the unpleasant realities of being dependent on each other, view independence as a large leap forward. However, the complexity of our current health care system requires moving to a place of self-reliantly choosing to work together for the common good of all involved.

Unfortunately, one cannot easily achieve the cooperation, teamwork and communication required for interdependence. (12) Each group must first establish a self-reliant, inner-directed, independent identity before participating in the interdependent collaboration required for success.

Strength and power come, not from succumbing to or resisting someone else's story, but rather from authoring your own. While it is true that a boundary-spanning role between clinical and administrative worlds may be valuable to health systems, it is most likely to be effective if the "story" of each separate world is first strong and clear in its own right. (11)

A strong and clear physician story is about who you are as a group and what you are passionate about. That story has been slipping away as physicians increasingly feel burned out, badgered and powerless. The idea that the medical staff of most hospitals is organized and structured with a story of its own is appealing but untrue.

While physicians tend to be a fragmented lot, typically coming together only in the face of threats, they were attracted to a career in medicine because of their desire to care for others. Today many physicians hunger to rediscover a meaning and purpose in their work beyond the pursuit of money. (4)

As a lead author of your physician group's story, physician executives are uniquely positioned to be the impetus for regaining true physician power. Rather than focusing on succumbing to or resisting administrative initiatives, you have the opportunity to help physicians define their passion and their own unique perspective.

In a recent article in The Physician Executive on hospital-physician relations, we described five steps for strengthening the bond among physicians and engaging them in co-authoring their story:

1. Establish frequent meaningful contact among physicians

2. Develop a medical staff vision based on values the physicians hold in common

3. Make membership in the physician group highly visible

4. Enhance the attractiveness of belonging to the group of physicians

5. Develop a clear measurement system for documenting the value created by the physician group (11)

By giving physicians control over their clinical story, they will regain the power they have felt was lost. Moreover, evidence suggests that control over their own story will lead to better relations with administrators and break down the battle lines that have crippled healthcare institutions. (11)

And if physicians are confident in their own identity as a group after co-authoring their story with you, they will be less likely to view you, their physician executive, as a traitor to their cause.

Advocating an independent physician identity may be troublesome to many health care leaders. After all, haven't administrators and physicians been far too separated in their thinking during recent years? Isn't it important to get administrators committed to clinical care and physicians responsibly balancing health care quality along with the financial and regulatory realities of today's environment? Don't we have to move past compartmentalization and get everybody together in the same room working with a good facilitator to understand our interdependencies?

The answers are clearly yes--we should work together. Physicians and administrators, along with others, need to make major decisions together to heal our health care system.

The current challenge, however, is to find sufficiently secure non-threatened leaders in both camps, clear about their independent distinctive identities and contributions, who can then work together to create the interdependent health care system of the future.

Redefining physician executives

Dr. Schmidt, from our opening vignette, faces a dilemma that is unfortunately all too common. Many of you have faced it yourselves. The place to begin is not to succumb or resist the will of administration. The place to begin is to show physicians how to author their own powerful story.

The challenge, of course, is that you--like Schmidt--may be starting from a place of physician distrust and lack of respect for you as a physician executive. The suggestions for building a unified group of physicians will do you little good if no one is listening and no one cares what you have to say. It is not likely, for example, that Schmidt will turn things around by simply getting the physicians together and providing them with his vision of their collective future.

To build credibility as a lead author of your physicians' powerful story, you may begin with three simple steps.

First, emphasize the similarities that unite those physicians who initially come forward to participate by asking: What are we, as physicians, passionate about? Communicate your passion and listen avidly to theirs.

Second, spread the passion by creating a vivid picture of a clinical future in which physicians are front and center. Give your physicians a focus that extends beyond their specialties and let them know that they are the heroes of a collective story.

Finally, very publicly recognize even small contributions toward that future. The recognition will begin to encourage additional physicians to come forward and bond with your initial group. Maybe more importantly in these early steps, the fact that the recognition comes from you will further enhance their growing respect for you.

In the end, physicians need to reclaim their power for reasons that go well beyond their own well-being. Physician behaviors and attitudes significantly affect the cost, quality and appropriateness of health services. Mounting evidence of avoidable medical errors and wide variance in the use of evidence-based clinical practices suggest that we must question the value of the health services we are currently providing in the U.S. (13)

Many clinical quality improvement initiatives launched by accreditation bodies, government agencies, medical societies and quality improvement organizations are designed to address the clearly identified quality problems. These efforts often produce more angst, confusion and skepticism among already overworked. (14)

There is tremendous opportunity for your physicians to create a united front as they lead the way to clinical quality improvements. But they need to find their story--and tell it well.

Edward J. O'Connor, PhD, is principal with the Implementation Institute, a professor of management and health administration at the University of Colorado at Denver and Health Sciences Center and a member of the faculty of the American College of Physician Executives. He can be reached by calling 303-573-1273 or by e-mail at [e-mail].

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C. Marlene Fiol, PhD, is a professor of strategy and health administration at the University of Colorado at Denver and Health Sciences Center. She can be reached by phone at 303-556-5812 or by e-mail at [e-mail].

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References

1. National Survey on Physicians Part III: Doctors Opinions About Their Profession. The Kaiser Family Foundation, March 2002, www.kff.org.

2. Bottles K. "Why are physicians so angry?" The Physician Executive. 26(5), September/October 2000.

3. Howard C. "Restructuring hospital-physician relationships for future success." Frontiers of Health Services Management 20(2), 2003.

4. Bujak J. "How to improve hospital-physician relationships." Frontiers of Health Services Management. 20(2), 2003.

5. Romano M. "Back to basics: AMA simplifies philosophy on membership." Modern Healthcare January 5, 2004.

6. Dickey N. "Hospital-physician relations--A response." Frontiers of Health Services Management. 20(2), 2003.

7. Porter ME & Teisberg EO. "Redefining competition in health care." Harvard Business Review. June 2004.

8. Mayer T. "Renewing our social contract: Collective accountability as the key to improving our professional image." MGMA Connexion. July 2003.

9. Stevens RA. In Sickness and in Wealth, American Hospitals in the Twentieth Century. New York: Basic Books, 1989.

10. Hoff TJ. "The paradox of legitimacy: Physician executives and the practice of medicine." Health Care Management Review. Fall 1999.

11. Fiol CM, O'Connor EJ & Guthrie M. "Separately together--Build unity by strengthening physician groups." The Physician Executive, 32(4). July/August 2006.

12. Covey SR. The Seven Habits of Effective People. New York: Fireside, 1989.

13. Shortell SM. "Increasing value: A research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States. Medical Care Research and Review. 6(3), 2004.

14. Kizer K. "Conducting a dissonant symphony: NQF is working to bring more healthcare players into harmony on quality." Modern Healthcare. April 5, 2004.

By Edward J. O'Connor, MBA, PhD and C. Marlena Fiol, MBA, PhD