Seven deadly assumptions for new physician managers.

The Medical Director asked you to chair the Department of Internal Medicine when the previous Chair suggested you for the position. You took on the challenge, despite a growing practice, because you felt you could make a difference. Your approach to this new assignment in the first few weeks can make the difference between success and failure. Many physicians who should (and could (be good managers fail because of the assumptions they bring to the assignment. Here are the most common assumptions and the accompanying disastrous results we've observed.

* Assume that, because all human beings make rational decisions, the way to resolve conflicts is by giving people more data.

Remember the last time you were on a hotel elevator and noticed that there was nothing between the twelfth and fourteenth floors? The "thirteenth floor phenomenon" is important for new managers from a scientific discipline. People are not always rational when they make decisions. (Physicians see the results of patients' irrational decisions every day.) Much as we may dislike it, there are rarely only two sides to a question. Finding the right answer may require more, or better data, and/or analyzing it differently. Demeaning the other person's opinion or jumping to a decision without getting enough input from those affected by the decision can create serious problems. Managing people is an art, not a science, and is more a matter of juggling competing interests than searching for perfect truth. In fact, the truth may be unnecessary, because the right answer is probably what works best for the organization.

Possible disasters: You may be seen as inflexible, always needing to be right, cold, aloof, distant, or too logical; this can lead to being "left out of the loop" and discounted. Hints for new managers:

* Appreciate that differences in opinion stem from different values, different perceptions, and different experiences, not just from different information.

* Work hard for consensus on your staff. Consensus built before a decision is made will save a lot of time when the decision is implemented.

* Conflict, when managed properly, is an opportunity for growth and improvement. Don't cover up conflict in the hope it will go away.

* People close to a problem have the best insights into it. They work around the problem daily.

* Managing people means asking for, and listening to, opinions. It's a strength, not a weakness.

* Assume that teams in the surgical suite or the emergency department are the same as management teams.

Teams are omnipresent in health care. Physicians are familiar with medical teams in operating rooms, in emergency departments, and in case management. However, these teams are different from management teams, because the physician always plays a leadership role. Often he or she is the leader. These teams are hierarchical, and roles are very clear. Nurses understand they must defer on certain issues. Management teams require a major readjustment in thinking and behavior, because the physician may not play the lead role. Management teams need constant monitoring and nurturing. It's damaging to effectiveness and career not to recognize the differences and respond appropriately.

Possible disaster: Losing touch with what is going on or, even worse, being eased off the real team (the team that gets the work done and makes the important decisions).

Hints for new managers:

* Clarify your role and play it consistently.

* Recognize the differences in teams.

* Observe how good team members play their roles and emulate them.

* Assume that, because a manager's job is to make decisions, your new title confers all the decision-making authority, trust, and power needed to do the job. Assume that ancillary and management staff have limited knowledge about what really goes on, or what they need to do. Assume that relationships with your colleagues will not change.

A first lesson, often painfully learned, is how little authority, trust, and freedom of action you have. Other physicians expect you to check with them before you make decisions. They interrogate you as if you were the enemy, and as if they had opposed you for the job from day one. Your loyalty is questioned, and your motives are challenged. Ejected from your professional fraternity, you have only partial membership in the manager's club.

Who needs this? It's your new role, not you, that other physicians are uncomfortable with. Your job looks political, not managerial. Correct this misperception by representing your constituency effectively. Represent their professional interests. Report to them often in balanced detail. Don't think of this as an "added burden"; it is the essence of the job. Whether you succeeded the best manager or the worst, you must prove yourself and earn your constituents' trust, which does not come with the title. Trust is hard to get, easy to lose, and very difficult to regain. Trust, in a managerial sense, is based on a belief or experience that you will deliver what you say you will, that you will understand and act to the limit of your authority, that you will make good decisions, and that you will communicate often, early, and nondefensively.

Possible disasters: Giving up because of the early negative response from colleagues or because the questioning of your role, decisions, and actions seems directed at you personally rather than at the position you hold.

Hints for new managers:

* Remember, your colleagues don't mistrust you. It's the authority they have given up that they worry about.

* Your authority and freedom of action will go up as trust goes up. Trust takes a long time to build, so don't expect overnight success.

* Represent your colleagues. That's why they put you in the position.

* Assume that communication techniques at the bedside are the same ones used in the board room.

Physicians spend considerable time communicating with patients, and many physicians become excellent at it. Communicating with colleagues is another area in which physicians develop good skills. Neither translates automatically to communicating with management peers or with employees. However, some of the skills that are effective in patient and collegial communication are less effective outside a medical context. What's needed with other managers and employees is active listening, restatement, insightful questioning, offering information before being asked, an overlay of collegiality, and the willingness to learn from anyone, regardless of rank or role.

Potential disaster: Not being taken seriously by managerial colleagues because you haven't switched roles.

Hints for new managers:

* Use clear, open communication techniques.

* Give direct feedback when needed.

* Respect the knowledge, experience, and dedication of others, regardless of rank.

* Look for opportunities to understand the opinions and viewpoints of others.

* Assume that a financial statement is pretty much the same as a checking account statement.

A new manager must gain a general understanding of financial reporting systems immediately but must resist the temptation to get into the minutia of financial reports. Most systems seem intended to intimidate or anesthetize the uninitiated, but most financial managers are delighted when a physician shows an interest in the numbers and are happy to instruct or explain. Ask detailed questions and insist on clear answers. Start with "What does this mean? What are the implications for us? Is this a trend or an anomaly? What is the potential impact on patient care?" Bring your medical perspective to the financial system. You are both patients' and providers' advocate. When you are involved in finances, let other managers be concerned about the organization's interests. (Don't go overboard and lose your credibility, but don't give in too easily either.)

One of your most important roles is to help educate nonmedical managers about the relationship between financial decisions and quality of care. Your approach to this responsibility will determine your success as a manager.

Potential disaster: Getting lost in the details, being coopted as a financial analyst, and missing the forest for the trees.

Hints for new managers:

* Take a short financial management or introductory managerial accounting course. Learn to understand the reports that come to your department.

* Stay out of the details, but ask probing questions.

* Learn to think like a department manager, but don't get sidetracked by special interests and pet projects.

* Assume that there are no politics in management or that you can ignore the politics.

New managers are always staggered by heavy workloads. It's tempting to let the politics swirl around you while you withdraw into your new role until you've mastered it. Don't do it. Stay plugged into the grapevine. You're now part of three distinct, but overlapping, political systems: physicians, other employees, and management. Your job is to move gracefully through all three. To do this, deal with problems informally, i.e., when you hear a complaint, confront the issue immediately. When someone comes to you and says, "Everybody is concerned about..." don't ask, "Who is this everybody?" Don't worry about anonymous sources. When people find out that you're responsive without putting someone on the spot, they'll tell you more of what's bothering them in person.

Potential Disasters: Getting blind-sided because you're not staying plugged into the grapevine.

Hints for new managers:

* Listen carefully, without prejudice, to every rumor.

* Act on rumors that could hurt the department or your effectiveness.

* Correct any misunderstanding by putting the facts back through the grapevine.

* Assume that, if you read every important management text, you will be a great manager. Assume that managing your way through medical school, internship, and residency and establishing and managing a practice gives you the tools necessary to be an effective manager.

The most important outcome measure for a manager is making a difference. If things aren't better, quality higher, and employees more satisfied because of your work, you aren't performing. Like any skills, management skills are acquired through discovery, practice, and drill. There are few absolutes, so success results from study, observation, trial, and listening: listening to mentors, experienced managers, employees, and physicians. Experiment. Try new things. Make your department innovative, interesting, and an exciting place to work. Don't worry about an occasional disaster. If you provide a role model for taking reasonable risks to get the result, the process of leading and responding to change is quicker and less painful.

Potential disaster: Failure through inaction.

Hints for new managers: Take courses, find a mentor, learn from physician and non-physician managers. Why repeat in health care the mistakes of other industries?

* Listen, reflect, discuss, generalize.

* Recognize that becoming a good manager requires time and experimentation.

* Have fun. If you aren't having fun in your role as a manager, you aren't doing it right.

Marilyn Moats Kennedy, MSJ is Managing Partner of Career Strategies, Inc., Wilmette, Ill., and a long-time member of the ACPE faculty. Ronald B. Pickett is an organization effectiveness consultant in San Diego, Calif.