Secrets of a chief medical officer: what they didn't teach you in medical school but you wish they had.

IN THIS ARTICLE ...

An experienced chief medical officer shares pearls of wisdom on ways to maintain the delicate balance between the medical staff and the administration.

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"No margin, no mission," "physician satisfaction," "patient satisfaction," "high quality at low costs" are frequent topics of discussion occurring in the administrative "C suites" of today's for-profit and not-for-profit hospitals.

As the challenges facing health care grow in scope and complexity, the role of the physician executive has evolved beyond the traditional duties of a medical director. Today's vice presidents of medical affairs and chief medical officers are often positioned as major decision makers for hospital budgeting, operations and strategic planning.

Like a double-edged sword, the expanded responsibilities are coupled to higher expectations of performance as negotiator, facilitator, change agent and disciplinarian. Expecting Camelot, many new physician executives find ruling the hospital medical kingdom a daunting task for even the most politically astute.

Tom Dolan, president of the American College of Healthcare Executives, once described the physician executive "as a minister of state without portfolio." Your physician colleagues believe you have gone to the dark side and your administrative associates consider you an enigma.

As a previous hospital chief of staff and current CMO of a two-hospital system composed of nearly 600 medical staff, I am often faced with decisions that must be made in times of crisis. I consult the works of Aristotle, Sun Tzu, and Machiavelli and then debate which one offers the appropriate advice.

The job life expectancy of a CMO is five years or less: therefore the physician executive today is often hired with expectations of immediate results with a short--if any--honeymoon period.

I find the adage "experience comes from doing many things and wisdom comes from doing many things badly" applicable to the physician executive. Here are some pearls of wisdom--or secrets--offered not from the perspective of a perfect CMO, but from one who has learned his lessons in harm's way.

Tell no lies

Your personality may get the door open, but only your integrity can keep it open. Each day the busy physician executive has 10 to 20 conversations with members of the medical staff, very few of which are discussions of the weather. A staff member is often inquiring about the hospital's strategic plans, the status of a future partner's privileges or the purchase of the latest medicated, coated cardiac stent.

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Telling the truth is always the best practice, even if the message is not the most pleasant. The CMO is frequently the messenger of bad news in the form of new policies concerning medical records or surgical equipment that will not be purchased. Physicians are bright people and will see through your lies. Remember the old cliche "say what you mean and do what you say." It will serve you well.

Relativity matters

When most of us think of the subject of relativity, we think of Albert Einstein's famous theory about time. You probably do not realize that relativity is also important to your success as CMO.

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The time references used by hospital administrators differ from the time references of physicians. A physician will make numerous decisions each day regarding treatments and patient care, many of which really are a matter of life and death. The medical staff member cannot begin to fathom why it takes six weeks and four committees to approve a new foley catheter.

Occasionally, the physician executive may reduce the endless red tape of hospital policy; he/she must always acknowledge the physician's frustration with the system. Return all physician phone calls on the day received and make it a habit to follow up on the progress of a project with your medical staff member either in writing, by phone or in person Remember, time is relative.

Be principled, but not inflexible

If this is your first physician executive position, you may believe many issues are black and white; after all, managing a hospital is not brain surgery. Unfortunately, after a short period of time, the wise CMO will discover multiple shades of gray. Compromise and negotiation are part of the job. Knowing which hills to charge and die on and those to carefully climb will distinguish the average physician executive from the exceptional one. Remember, do not let perfect stand in the way of possible.

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Go to the problem

Japanese business executives do not tolerate their young associates who try to describe problems they have not seen firsthand. If the surgeon tells you the OR is a disorganized mess, put some scrubs on and make your own assessment. It will more often than not be an enlightening experience. Remember, a picture is worth a thousand words.

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Never forget why you are there

Even if you are one of the 18 percent of physician executives with management degrees, the letters behind your name that got you the job were MD or DO. You were not hired because of your business skills: the woods are full of hotshot MBAs.

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You were employed to be the conduit between the medical staff and hospital administration because the most expensive piece of equipment in the hospital is the physician's fountain pen. A few strokes of the physician's pen can be the difference between black and red ink at the bottom of an income statement. Often you are the only one on the senior hospital administrative team that has gotten out of a warm bed at 2 a.m on a cold winter's night to treat a scared, frightened patient in the emergency room.

Despite the fact that some of your medical staff feels like you are sleeping with the enemy, never forget you earned your place in the "club" and that position does not go away just because you go through the doors of administration.

Leadership delivers ROI 

You will never be able to accomplish your goals and objectives without developing your own leadership skills, as well as the leadership skills of those around you. Provide your key medical staff leaders the opportunity to attend off-site leadership development meetings and also provide on-site speakers and books. Leadership can be your "true North" when faced with the difficult decisions encountered frequently in the role of CMO. Leadership isn't everything; it's the only thing.

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Be a life-long learner

When you were sitting before the medical admissions committee, you undoubtedly were asked. "Why do you want to be a doctor?" I suspect you did not respond "because I want to be a chief medical officer."

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The skills that made you a great clinician are not enough to make you a successful physician executive. In fact, some may even impede your development.

As a clinician, you make rapid autocratic decisions each day about the care of your patients. The physician executive also makes autocratic decisions, but more frequently the process is collaborative, requiring leadership to reach consensus. Ask your CEO and board to provide the gift of an external coach/mentor to provide frank and sometimes painful advice regarding your weaknesses and blind spots.

Advanced management degrees like MBA, MMM, MHA, and MPH are required by many large hospitals because of the expanded operational roles physician executives play. Even if not required, I strongly recommend them because the degree differentiates you from others who may be experimenting with the role of physician executive because they are unhappy with clinical medicine.

Remember, you can only go as far as your current level of knowledge.

Always ask for help

Most physicians went into medicine to fulfill a need to help others. You will be surprised how often your medical staff will help if you will only ask. It does not mean they will necessarily like the idea, but it may buy you some time to win them over.

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When a physician does help, a follow-up handwritten note of thanks goes a long way to increasing future positive behavior. Remember, the four most powerful words of the CMO: "I need your help."

Don't go to a gun fight with a knife

Sun Tzu in The Art of War teaches us to avoid a battle and bloodshed through diplomacy whenever possible. Unfortunately, conflict is inevitable in certain circumstances and the physician executive must be prepared for and committed to war.

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Do not come to a meeting regarding disruptive physician behavior with anecdotal stories. Come armed with dates, times and detailed accounts of past and present unacceptable behavior displayed by your medical staff member. Have a plan of action that is agreed upon by the department chairman and bring him/her to the meeting; even if the chairman remains neutral, it will be interpreted as a triad of two against one.

I prefer the philosophy of the "iron fist in the velvet glove," but when that fails and the gloves come off, you must not waffle in your commitment or will to see the conflict through. Louis Pasteur said "luck favors the prepared mind." Remember, in the absence of data, any opinion will do.

The role of today's physician executive is one of the most challenging and rewarding jobs in medicine. The good news is that most physicians are not fighting to take your job; the bad news is there's a reason.

Your satisfaction will not come from the thankful patient following a successful operation but from the quiet knowledge that your leadership has made the hospital a safer, more efficient place for many and that your leadership has played a small part to align the incentives of the medical staff with those of the hospital.

In today's health care crisis, physicians and hospital administrators must work together to solve the myriad of economic and quality problems. The words of Ben Franklin have never been more relevant. "We must hang together or we shall surely all hang separately."

Robert W. Chappell Jr., MD, MBA

Robert W. Chappell, Jr., MD, MBA, is vice president and chief medical officer at Huntsville Hospital in Huntsville, Ala. He can be reached at 256-265-6990 or [e-mail].

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