Should the physician executive be the physician's advocate?

Medical staff commonly want to know if a prospective physician executive will serve as their advocate to management. A successful physician executive must like and respect physicians. But the question of advocacy must be answered thoughtfully, because the candidate must not imply that he or she will defend any action by any physician. A three-part conditional response is advisable.

Candidates of the position of vice president of medical affairs may be asked, by interviewing madical staff leaders, "Would you be the physician's advocate?" A thoughtful response to this question might include the following three parts.

* "Yes, by educating administration and the board to the feelings and attitudes of physicians."

For example, a vice president of medcial affairs might relay physicians' feelings about how executives and mangers try to motivate physicians. "Dick," one physician told me, "administration has four ways of getting us to do what they want us to do. They pull the Joint Commission on us, they pull our malpractice fears on us, they pull state regulation on us, and they tell us our practice habits are going to make the place go broke. When are we going to hear something about patient care and an appeal to physicians' professionalism?" The vice president of medical affairs might point out to administration that some CEOs gain medical staff support by declaring, "Our commitment to quality doesn't have to be forced on us; it comes from within."

The physician executive can coach the governing body on how to question clinical reports. For example, it is not always necessary for the board's first question to be, "Who is the doctor?" The board needs to know that matters are being dealt with effectively by medical staff mechanisms on which the board depends and that unacceptable partterns of practice are not emerging. A better question than, "Who is the doctor?" would be, "Would you orient us to the format of your reports, so we can doublecheck for trends in the practice of physician or a physician partnership?" Of course, the board must know the identity of the physicain if you insist. But please realize that (for staff leaders and executive/management staff, as well as for the board) the key to effective performance review is avoiding the four Ps: Personalities, Politics, (Unrelated) Past Events, and Pocketbook considerations. If your first question is, 'Who is the doctor?' staff members may suspect (usually unjustifiably) that your interest is in attacking individuals, rather than dealing objectively with information for the purpose of protecting patients. I'm sure none of us wishes to be part of creating a scenario of mutual distrust."

Another example of recognizable advocacy is ensuring that conclusions from patient care information are valid. The physician executive will help statisticians understand that attribution of a patient infection to a physician by the computer (because the physician's name is on the face sheet as the attending) does not justify attributing the infection to the physician's performance until after cause-and-effect analysis.

* Yes, but in ways you might not initially recognize as advocacy."

The physician executive must insist that patients' medical records be completed in a timely, legible, and accurate fashion. This insistence on physician discipline is physician advocacy because of the threat to physicians, as well as to the hospital, of incomplete patient records. But some physicians may have a different view. Complete records are required by the Joint Commission on Accreditation of Healthcare Organizations. Many physicians do not like the Joint Commission, and refusing to complete medical records is one way a physician can rebel against the Joint Commission. A good physician executive will help physicians understand the self-defeating nature of this "logic?'

The physician executive will also encourage thoughtful selection of staff leaders, such as clinical department chairs. The physician executive knows that selection of ineffective leaders is counter-productive to the interests of physicians and their patients, as well as to those of the organization. But some physicians may not recognize this urging to select good leaders as physician advocacy. Some physicians believe that staff leaders are selected to be loyal opposition to "administration and the board."A suggestion that selected leaders are really an important part of the organization, with day-to-day responsibilities, may be viewed by some physicians as "trying to get us to go over to the other side."

An effective physician executive will assist in establishing clinical information systems, including physician profiles.* The physician executive knows that sharing information confirming dependable performance is necessary to obtain or regain public and political support. (Continuous quality improvement attention to systems, and aggregate data, is not sufficient to satisfy public demands for information comparing practices of three physicians whose names are obtained from a physician referral service.) Many physicians, on the other hand, view accumulation of any physician-specific information as threatening, because they fear "police state" type uses of the information.

* "No, I cannot promise to be the physician's advocate in every circumstance."

The effective physician executive will never be a party to covering up, ignoring, or finding excuses for needless, careless mistakes in clinical practice or for lack of respect for other physicians; hospital personnel, including nurses; or patients and family members.

* Roth, L. "The Physician's Practice Profile: A Piece of the Quality Puzzle." Physician Executive 17(5):16-21, Sept./Oct. 1991