The future of Physician Executives?

THE PHYSICIAN EXECUTIVE: HOW WILL MEDICAL education change in the next five to 10 years?

LeTourneau: We're going to see a big change toward just-in-time or point-of-service medical education, if you will, where physicians or caregivers go to the Internet and get the information when they need it. I think we also will start to see more people not traveling for the bulk of their education, but doing it on their computers or by teleconferencing or video satellite links because its much more efficient. There still will be what I think of as vacation education, where you go to Mazatlan and you take a course and spend your afternoons on the beach. But the bulk of the education will come to the learner, rather than the learner going to it.

Pfifferling: One thing for sure will happen. Medical education at all levels will finally begin to incorporate what we've learned from educational psychology about how adults learn. At the postgraduate and residency level, and hopefully very soon at the medical education level, we'll be using the kinds of things that help adult learners learn best and most efficiently. At the medical school level, we're going to have much more team problem-solving like the McMaster model or the University of Waikato model in New Zealand that prepares students for the team problem-solving domain in the real world.

Todd: Clearly, medical education is going to change, and my concern is that its not going to change enough. Nobody is really looking at the content of what kids are being taught in medical school today. Half the things I learned in medical school I had no practical use for whatsoever and yet they're still being taught. Graduate medical education is still being taught in the hospitals where the bulk of health care is no longer being given. The problems are very different in the ambulatory setting and the residents need that experience.

Continuing medical education is a vast wasteland and I would agree that computerization is going to be the greatest boon to continuing medical education. But we really need to look very carefully at the content of medical education at all levels to be sure we're preparing doctors for the practicalities of what they're going to see and not necessarily the research bench.

Pfifferling: Let me add one more thing in agreeing with Dr. Todd. Not only the practicality but the accountability and the nature of validating evidence-based medicine is going to be much more necessary at the med student, resident, and certainly at the practice level. Sophisticated medical information systems are aggregating data and identifying what we know and what we don't know and what we've done and haven't done and the underlying logic. That's all going to hit now that we have the technology to do that. Medical informatics will demand much more honesty and I wonder if the system is ready for such honesty.

Todd: That's going to be very problematic for physicians all the way from students right into practicing physicians because accountability has been assumed up until now. But that's going to change. The public is going to demand objective accountability and that's going to make physicians nervous.

Reinhardt: Actually, this is now actively being explored in a number of academic health centers. Managed care poses two major challenges for the training of physicians. First, the bulk of graduate medical education has taken place in the hospital, often around tertiary care, in part because that is where the financing for graduate medical education went. Academic health centers now have to learn how to shift the focus of training more to the ambulatory setting, but that won't happen until the financing makes the shift first.

A second major challenge was just mentioned by both Drs. Todd and Pfifferling, and that is accountability. It is one thing to develop systems of accountability that do more good than harm. But another facet of accountability that we sometimes overlook is that physicians as human beings have to be taught to be comfortable practicing medicine in a statistical fishbowl, so to speak. Its like sleeping in a bedroom without curtains, to mix a metaphor.

Attempts will be made to quantify absolutely everything physicians do in their daily practice, the hours they work, the patients they see, the resources they conscript when treating patients, the patient satisfaction scores they achieve with their work, and so on. These data will be configured in physician profiles and then used in managerial decision-making that will directly affect the physician. Jim Todd is right. That could make you nervous as a professional. We do not know what all of that will do to the trust underlying the doctor-patient relationship. Whatever benefits objective accountability may bring, and there are apt to be a good many, one price might be an erosion of this trust.

I recall reading a lovely little book [Technology, Healers and Bureaucracy] by Roger Bulger, President of the Association of Academic Health Centers, wherein he points out that the British do not even insist on informed consent in the doctor-patient relationship. It is based strictly on trust, and yet the British generally show themselves to be more satisfied with their health system than do Americans. We shall see what happens here, as physicians more and more present themselves to us, in brochures and on the Internet, in terms of purely quantitative measures.

Todd: We have to keep in mind that not everything in medicine can be quantified. Its still an art to practice medicine. The danger in statistics is that certain people will be shortchanged, while other people will come out looking better than they ought.

Pfifferling: The assumption that its always going to be accountable from a quantifiable perspective forgets that it can be aggregated from a behavioral decision-making perspective also. What was your decisionmaking logic? What did you arrive at? What did you do in relation to that? That's also accountability. In the early 60s and late 70s, Larry Weed developed about four levels of sophistication in his knowledge coupler system. He asks not only what we know from the evidence, but what's your logic and will you share it with your colleagues? Of course, that makes physicians and other health care professionals very uncomfortable, but I think we're going to have to look at that in the future.

Todd: But the physician in the emergency department at three in the morning is never going to remember what his decision tree was all about.

LeTourneau: I think we're going down a path of looking at decision-making as having some kind of science behind it. My clinical specialty is emergency medicine and in many specialties we go on our gut feelings. We don't always have a huge amount of information. Often the lab, X-ray, and other data is confirmatory to our initial impression and not necessarily the primary tool in trying to sort things out. Although a decision tree is certainly a key learning tool, the subjective sense of what's going on with the patient is something that is also learned to a huge extent during our medical education.

Pfifferling: We're doing very little to look at what that all means. How do we increase the value of using gut feelings and intuitive senses? How do we transmit that from generation to generation or mentor to mentee? That's all going to be new stuff now that we have tools to begin to look at that. There will be a revolution in analyzing and using more science derived from studying subjectivity.

LeTourneau: There was an article in JAMA this week about malpractice cases and their lower frequency in physicians who communicated with patients, as opposed to those who did not. In other words, that communication style is a key factor in malpractice cases. When we start to train physicians, how can we ignore that type of research in how to deal with the patients?

The Physician Executive: What do you see happening with physician supply and demand in the next five to 10 years?

Reinhardt: There's a general presumption that we have too much of everything, that we might have a balance in primary care, but too many specialists all around. If you believe Jonathan Weiners paper from about two years ago in the Journal of the American Medical Association, he projected that if by the year 2000, 60 percent of Americans were in HMOs, we would have 32 percent too many physicians, mostly specialists. Of the 510,000 practicing physicians available, 165,000 would not be needed. But if you look at the economic data, they show almost the opposite. You have in San Francisco something like 300 doctors to 100,000 population. I think the national average is about 190. And yet, San Francisco docs are not driving taxis. They're okay.

We saw the AMA data last year which showed that physicians had a rather healthy increase in average income, about 7 percent. If you count bodies, it seems that we have a physician surplus. If you look at the price data, which is physician income data, they suggest that, if anything, we might still have a shortage. The models and the market contradict one another.

Cejka: Speaking as a recruiter, the media has predicted an oversupply of physicians since 1981 when I founded my company and we have seen no diminishing of the demand for physicians thus far. Both in primary care and in most specialties not all specialties, but most specialties think that I come down on the side of Uwe, that the statistical evidence is not borne out in real life. We do a survey with Modern Healthcare every year on the demand for recruitment, and for the last five years there has been no lessening in the demand for recruitment of physicians.

Todd: The difficulty in all of this modeling is that nobody's gotten it right yet and I'm not sure they ever will. But there's a big difference between need and demand. Americans are the most heavily overtreated people in the world when it comes to all the elective medical care that they can get, and if you're going to model the ideal work force, then you should be looking at what the need is for these various physicians, rather than what the demand is. But that's not going to satisfy the American public. They want their specialists. They want self-referral. They're not going to be happy with the gatekeepers that they're not entirely confident in. You can diddle with the work force figures all you want, you're still not going to come out right.

Pfifferling: There are also some interesting dollar interventions. If I recall, I just read something about New York state paying the medical schools and medical education training environments, including residencies, something like $400 million to reduce the number of slots that train residents.

Reinhardt: The New York Times really didn't put that right. I was part of the creation of that one at least on an Institute of Medicine panel. New York and New Jersey use medical graduates, particularly foreign medical graduates, as cheap labor. That's just a fact. Particularly in the inner cities, that's the only physician labor you've got to give care to the uninsured, and they exploit them mightily. There was the proposition that we should yank the federal dollars out of these teaching hospitals to reduce the number of resident slots they could offer, whereupon these hospitals reminded us that then they would have to retrench on the delivery of indigent care.

So the suggestion was, why don't we keep them whole as far as the money goes and they can find substitute personnel like nurse practitioners and others to do these jobs and still reduce the number of medical graduates, particularly IMGs [international medical graduates] they let in. So it wasn't that we're paying people not to produce doctors, we're simply saying we're going to give you about the money you had before so that the slave labor you used to have, you now have to hire them off the labor market of nurse practitioners. That would have made a totally different headline. When you actually read the proposal, its pretty reasonable.

The Physician Executive: What role will so-called alternative or complementary therapies play in the next five to 10 years?

Reinhardt: Well, Oxford Health Plan is paying for them, isn't it?

Cejka: Right, they are. I think its going to play a huge role for the chronically ill.

Reinhardt: Right. I think so, too.

Todd: And for the worried well. The American public in 1994 or 95 spent $13 billion on alternative therapies.

The Physician Executive: Out of pocket?

Todd: Right, out of pocket. Now some of the HMOs are beginning to cover it, and its going to become increasingly popular, but nobody knows whether it works and whether or not it is money well spent. It seems to work very well for the chronically ill and for the worried well who are concerned about their future, but I think its unlikely that it will ever assume a dominant place in American medicine.

LeTourneau: I would agree that its unlikely to assume a dominant role, but I think that there is a huge role for alternative or complementary therapies. We need to separate out what I think of as two different types. One type is a little bit more mainstream or accepted by traditional allopathic physicians, and that would be things like acupuncture and hypnosis, podiatry and chiropractic, to some extent, therapies that have been around a little longer. But when you get into things like rolfing or astrology, that's much more difficult for the general public to deal with and we're not likely to see those things becoming very commonplace in the near future.

Pfifferling: I want to share a comment about what I heard from somebody in England two weeks ago. A British physician I know uses the term gatekeeper for the training that allopathic physicians get about all kinds of alternative or complementary or integrated therapies so they're more knowledgeable. Because the patients are using many of these therapies anyway and if the physicians know about them, patients will be more likely to share a complete history so that the allopathic physician is not left out of the loop. So they use the term gatekeeper to designate an enhanced educational domain, at whatever level, in England for GPs.

I think that the same thing is going to occur in medical education here, probably in residency and certainly in continuing education, especially if these therapies are being paid for by third party payers, so that physicians can at least discuss alternative therapies with their patients and be truly knowledgeable about what's going on.

LeTourneau: I agree with that. Here in the Twin Cities, we're seeing a lot more practicing physicians becoming educated and reading some of the journal articles. There's a journal called The Journal of Alternative Therapies which publishes legitimate scientific research about these therapies. Many of our hospitals here in Minneapolis and St. Paul have somewhere between 10 and 15 types of alternative therapies that we offer, from massage therapy to guided imagery to doulas [labor coaches] for women in labor. They're getting pretty good results and no harmed patients, so I think that's where we'll go a little at a time.

The Physician Executive: Will we have any independent academic medical centers left in five to 10 years?

Reinhardt: When you say independent, what do you mean?

The Physician Executive: Non-merged.

Reinhardt: If you look at Duke, they are going to do their own thing. They may work on a joint venture with an insurance company or merge with other hospitals in the area, but they won't merge with another academic medical center. I doubt that Vanderbilt will merge. But in New York, they will have to because there are too many of them [academic medical centers] there. I bet you in Boston they will, too. And its happened before, whenever you have too many of them [academic medical centers].

Pfifferling: My understanding is that all five medical schools in Philadelphia have some kind of hospital merger relationship and that mergers are inexorably increasing. I see kind of a two-tier track developing, and again, we're talking about 10 years down the line where a few medical schools will be very research-oriented and training specialists and cutting edge. Another level like East Carolina Medical School and the University of North Carolina Medical School and many others will have a very primary care orientation. I hate to use the word trade school, but primary and practically oriented. So there's sort of an elite research track and a practical track. A lot of that will depend upon what kind of funding they get, where they get the funding, and who wants to support medical school education.

LeTourneau: That's right and we see it in Minnesota. I don't see Mayo merging, although they may have some affiliated relationships. An elite school may well remain independent because they don't have a hard time getting teaching material and generating revenues, whereas the University of Minnesota has had some difficulty providing enough patients to teach the residents without actually having a relationship with a larger system, so they've merged with the Fairview Systems. To me, that exemplifies what's going on around the country, which is these two tracks that Dr. Reinhardt and Dr. Pfifferling described.

Cejka: Then what happens to the University of Minnesota Duluth?

LeTourneau: Well, the University of Minnesota Duluth is separate.

Cejka: Does it just go away?

LeTourneau: No, it stays there, and its independent of the Fairview merger. The University of Minnesota Hospital in Minneapolis merged.

Cejka: I guess I'm asking a larger question. Is there a role for that kind of medical school in the future?

Pfifferling: In the future, where more dollars are paid at the preventive level, you get schools that are much more public health and health promotion-oriented, and you have tertiary care, secondary care, and primary care depending upon how managed care or whoever is paying the bill. I see a tremendous epidemic around the country of academic medical school faculty burnout. They have tremendous insecurity about their future. Their attitude is that the managed care companies are looking at the bottom line, and if it takes longer and costs more at the academic medical center, there's just going to be no funding at that level because the patients will be told, "You can't go there."

LeTourneau: I just have a clarification. I think we need to be careful. When you're talking about an academic medical center, are you talking about the hospital facility itself?

Pfifferling: No.

LeTourneau: Or are you talking about the hospital and the medical school? Because I'm talking about the hospital. The medical schools I see as potentially separate from the hospital, which can merge with someone else and have a medical school affiliated with it. The medical school can continue to be owned or run by the state or whatever private college has it. I see them as two separate entities and its not clear to me what you mean.

Pfifferling: I was talking about the epidemic of academic medical school faculty burnout in regard to the drying up of funding resources and therefore inordinate service obligations for faculty. I just see a tremendous burnout problem in faculties with almost nobody addressing that. The faculty will have a difficult time recruiting their replacements.

Todd: Part of the problem is that most of these academic health centers aren't really changing their fundamental thinking. They're trying to grow and preserve, in many respects, the status quo, maintaining their elitism and that's just not going to work in the future.

The Physician Executive: What about funding for medical education in the future?

Todd: It needs to change. The federal government shouldn't be saddled with most of the medical education, particularly when you have large for-profit organizations siphoning off huge amounts of money that might otherwise be used for medical education. The approach of a super fund for medical education supported by all of those in health care makes sense.

Reinhardt: I certainly would endorse such a superfund, financed by a broad-based surcharge or tax, if you will, on all insurance contracts, private or public. Furthermore, I am in favor of a proposal by the Administration to take out of the payments it now makes to HMOs that enroll elderly that part of the AAPCC [Adjusted Average Per Capita Cost] that covers the federal governments indirect support of for training residents. Right now, an HMO can pocket that allowance but then send its enrollees to community hospitals rather than to teaching hospitals. Money Congress had intended to support the training of physicians are now being diverted straight into the bottom line of the HMOs. That is not really tenable. The money should be taken out of the HMO payments and recycled to the teaching hospitals via this proposed superfund.

The Physician Executive: Will more physicians become employees?

Cejka: Id like to bundle the next two questions. Absolutely more physicians will become employees and absolutely more of them are going to join unions. Physicians are a very unhappy group of people right now and unhappy groups of people tend to band together to save themselves.

Pfifferling: As I travel around the country, I'm getting more physician organizations asking me, How can we work cohesively? How can we work together? They're asking the kinds of questions that are typically associated with labor movements. They detest the concept of unions and labor movements, but they feel so besieged that they see union-like organization as the only way they're going to get back the autonomy they've lost. This is a new trend that will continue in a very strong way. I agree with Sue.

Cejka: We have a couple of clients that are undergoing union attempts right now.

Reinhardt: Recently, I saw a statistic that half of American physicians are now employed by someone, but that someone typically is not a person with an MBA. Usually, its another physician.

Cejka: I would add that the wave of hospitals employing physicians has peaked and has probably ended.

Reinhardt: They're not going to buy them any more. Very few hospitals made money off that. But its not surprising. I mean, its just like buying capital on roller skates.

Pfifferling: The other factor is that traditionally, hospitals distrust the ability of the hospital management to manage its employees and presume that this will carry through to managing physicians. After x number of years, if the hospitals are not managing physicians well, then somebody else is out there in the marketplace saying, What are we going to do with all these physician employees? And, of course, there are lots of people out there who are interested in managing the hospital-employed physician population.

LeTourneau: But lets not forget that even though hospitals don't make money on the clinic operations when they buy a clinic, they certainly feel like its well worth the money invested, that they're able to bring patients to the hospital or maintain for the hospital, especially in a competitive environment. Even though in our area the hospital systems that own clinics are losing money on them, in the net they feel like they're making gains and that it would be bad to cut their losses and let the clinic go because they would eventually lose hospital patients. I personally don't want to be too negative on the losses. I agree that the trend has peaked, but I'm not sure that everybody's going to divest themselves of their clinics.

Pfifferling: I see a tremendous set of conflicts arising in the next five to 10 years with physician-hospital organizations competing with the non-hospital physician organizations that are pre-union, if you wish, and causing tremendous conflict between those two groups and the competing allegiances physicians owe.

LeTourneau: We had that happen at one of the hospitals I'm at. We had a PHO and we had groups whose practices were owned by the hospital. The PHO eventually went away because it was just too difficult to try to balance both sides and convince everybody that we didn't have a favorite child. It was too time-consuming. Others may have been more successful than we at doing that.

The Physician Executive: What is a physician executive?

Todd: It seems to me they come in two stripes. Those physicians who go on to get their MBAs and go directly into management to run the various organizations, and the physician who's been in practice for 15 to 20 years who's no longer at the frontiers and wants a change of career. I would say that the second type of physician executive is the more valuable one, because they've had the practical experience of knowing what is happening in the real world, rather than in the academic world. I think it's important to distinguish between these two groups.

Cejka: I'm going to second Jim's opinion. Speaking as a recruiter, nothing replaces experience. No number of degrees will replace hands-on experience.

LeTourneau: I think of a physician executive as a clinician who has a professional role in participating in administrative or managerial decision-making. That ranges from medical director of the small rural ER to the CEO of United Health Care.

Reinhardt: Eugene McGuire and Malik Hasan of HSI are physician executives.

Pfifferling: Don't forget there are many paths to being accepted by your colleagues. You may become an executive by education after you finish residency or med school, doing postgraduate work there, full-time or part-time taking classes with the American College of Physician Executives or MGMA, or any other postgraduate management education avenues that are open. People are coming to medical executive management for all kinds of different reasons. What I worry about is that physician executives have expectations of still being treated as a colleague by their peers, and lo and behold, they're neither fish nor fowl. They're expected by the person who's hiring them to be able to liaison well with physicians and often they don't have the respect and trust of the clinical staff. Often, they're very alone in the middle. We're going to have to look at what that loneliness in the middle means for physician executives. We will also have to train them in dispute settlement and mediation skills.

The Physician Executive: Are we going to need more physician executives?

Reinhardt: I would think so, if you're talking about the growing importance of PSNs, as we agreed in our last discussion. I always tend to think of one model of physician-run and -dominated practice as the analog of a university, and if you look at the university's management, with few exceptions, the top dog tends to be from the ranks of academia. To become a university president, at some point you had to have been a distinguished scholar, and that's true for the deans, too. The really important, powerful executives all tend to be PhDs and usually still do a little bit of teaching. It seems to me that if you want a physician service network in the sense that physicians are dreaming about, the top three layers have to be MDs. Therefore, I think we need more physician executives.

The Physician Executive: What market needs will physician executives fill?

LeTourneau: The key market need now is for physicians to participate in management decisions close to the patient care level. I'm not sure that we need more full-time MBA physician executives. I don't know that we need less, but I'm not sure that we need more. I think we definitely need more docs who are doing clinical care and are making time in their practice to participate with big business in decision-making. That's where the real gap is. Its the docs that have the hands-on care experience and are going to shape how that care is delivered.

Todd: That's a terribly important point. The people who are keeping the books and whatnot can be MBAs and the like, but the physician executive is the one that's going to be able to tell whether this course of medical treatment is the correct one or not. I think there's another role for physician executives, and that is to perhaps regain some of the credibility of the profession with the public. You've all seen the recent AHA [American Hospital Association] poll that shows that the public is down on the profession totally because they see it as a greed game instead of taking care of patients. Physician executives in clinical roles can return some degree of trust and credibility to the profession.

Cejka: I'm going to take this thought a little bit further. The demand for physician executives is higher than its ever been. There has been a tremendous prejudice against physicians in the very upper levels of management. They face a glass ceiling unlike any that I've ever seen. The next big thing that we're going to see is that they're finally going to break through the glass ceiling and we're going to see more CEOs who are physicians. If we look at physicians as a population, they're likely to rise to the top of most organizations. There is tremendous prejudice against specialists in medical management and among physician executives. In the next five years that will change. Many specialists have natural leadership personalities but they are almost excluded from leadership positions today.

LeTourneau: Uwe, I think you're right about the physician executives in the top leadership roles. A physician, even if he or she has left clinical practice totally or almost totally, still brings a clinical dimension to management.

Cejka: Absolutely.

LeTourneau: And when you have a person who has developed the management experience that a CEO needs and has the added dimension of understanding the clinical delivery of care, that person brings a special dimension. We need to continue to develop people at the full-time level but we need more people at the entry or part-time level to supplement them because there's different work to be done at the two levels.

Cejka: Agreed.

Todd: In general, I agree that specialists make good physician executives because they tend to be more focused. That's the way they've been throughout their medical career. They tend to be more active in their decision-making. The CEO at the Mayo Clinic is a specialist.

Cejka: You and I are in absolute agreement but there's a tremendous amount of prejudice against physician executives who are specialists. Most searches that we do have a limitation on them of primary care as a background.

Todd: Really?

Cejka: Yes.

The Physician Executive: Where is this prejudice against specialist physician executives coming from?

Cejka: Its coming from the notion that the physician executive has to have a broad-based background in terms of appeal. Internal medicine, followed by family practice, bring with them the broadest-based appeal to the largest number of other physicians. If we bring in an orthopedic surgeon, that person comes with a narrow constituency behind them that will alienate the primary care physicians. That's the root of the prejudice.

The Physician Executive: It's another version of primary care versus specialist?

Cejka: Of course.

LeTourneau: This is most interesting to me. I had presumed that the bias had to do with finances and that you had to pay someone from a specialty like orthopedic surgery or cardiovascular surgery much more money to make them switch than you would have to pay a primary care physician.

Cejka: Not really. For medical executives, we really and truly are paying on talent and expertise. We've pretty much left behind base specialty, so that's not really the issue. The issue really and truly is one of prejudice.

The Physician Executive: What skills will physician executives need?

Pfifferling: Let me share some things that I think relate to skills. I'm getting more requests for mediation interventions at the inter-physician level where there's a disruptive physician or outlier physicians. If management sees that the physician executive has people management, conflict resolution, arbitration, mediation and ombudsperson skills, and ideally some strategic vision so he or she can look at the larger picture, I think that's going to be a premium asset five to 10 years down the road.

Todd: Well, you know, that's something they don't teach.

Pfifferling: Its not being taught, obviously, in med school and residency. But, certainly, at the postgraduate level, the success of the conflict mediation, dispute settlement, arbitration, and mediation courses around the country by various entrepreneurs and by academic centers is a whole new ballpark, especially because there's more and more accountability for outlier phenomena, or whatever you want to call it, in physician skills and physician behavior. With the greater demands for patient satisfaction scores and what we do about it, you're going to get more demand for what do we do about the behavior of the physician? Who teaches that?

Can the physician executive, the medical leader at the local level, be the coach, the mentor, the support person to help change behavior so that there are different consequences that directly affect the bottom line. Accountability will demand less negative patient satisfaction responses and greater positive responses. A major training market will develop around dysfunctional communication prompting malpractice cases. Hopefully, residency and medical school will start dealing with these things. Will we prepare our residents to be more sophisticated at the management level, at the strategic planning level, at the mediation level, at the negotiation level, so they can take care of themselves and be more persuasive when they go out there in the marketplace?

Reinhardt: Well, fundamentally, you're talking about communication skills.

Pfifferling: Either management skills with communication as a component, or communication with management as a component. They're all related in behavioral education and interpersonal communication, which ought to be taught at every level of education, and especially in continuing education.

LeTourneau: Any executive, in order to be excellent, needs communication and interpersonal skills. But for physician executives, where they want to end up in the organization is going to drive some of the skills. For example, if they want to end up as a CEO, they're going to have to develop operations skills and some finance skills, whereas if they want to end up in a part-time position influencing how care is delivered at a local level, then the communication and interpersonal relationships are going to be more key than operations. I'm not sure that its an either/or. It might be more of an and.

Todd: Its going to be interesting to see how this develops in the future because if you look at the leading physician executives today, they probably have had no formal training whatsoever. They've just sort of risen to the top by their own natural talents. It'll be interesting to see if, in the future, we begin to train physician executives rather than allowing them to occur.

LeTourneau: The primary advantage to training is that it may give people sort of a head start or a jump start on it. Most of the stuff that you learn in MBA school you can learn on the job, but it takes longer. If you learn it in a more compressed manner, you can start to put it to use a little bit sooner. I don't think in the long run the people that have an MBA know any more than people who don't, its just that they learned it in a different way.

Cejka: Id like to expand on an earlier comment of Barbara's. Most physicians who wish to become a CEO will have to make a lateral move outside of medical affairs and into operations. That's almost an absolute on the path to CEO. They'll have to move into operations, finance, or planning.

Pfifferling: I want to add another unusual set of medical executive slots that I see building up. When individual physicians have specific kinds of skills or liaison relationships in multi-site clinical trial or care settings, they'll also have their own slot as medical executives. I see a bunch of specialty areas developing where physicians have their clinical background and then add another one which may not be in traditional management, but will give them the executive slot because of their special competency. I can envision physician liaison engineers who work in biomedical engineering companies.

The Physician Executive: Where will this training come from?

LeTourneau: Some of it, I think, will come from colleges and universities. We see that happening [at the University of Wisconsin] in Madison and at Tulane. But more and more big companies are providing their own training, so we'll see it coming from a number of different places and you'll see a different type of courses being offered. For example, the training in conflict resolution and communication skills is usually totally separate from what health care organizations or colleges and universities offer.

Pfifferling: I've been helping PhyCor with their very sophisticated medical leadership training, which is kind of a corporate college at about 70 sites and I'm convinced that other environments will emulate that approach. What are the needs we have out there in the field? Who are the medical executives? What kind of curriculum do we need? PhyCor brings people into their corporate college and assesses the value of what their medical leaders are getting at those corporate colleges. That's going to be a whole other model apart from the part-, quarter- or full-time advanced degree training. As we get larger and larger medical care organizations, they're going to develop their own in-house corporate college setting.

The Physician Executive: Is that what you were getting at, Dr. LeTourneau?

LeTourneau: Yes. PhyCor is a very good one. I think FHP, Kaiser Permanente, Intermountain all have in-house training. We may even start to see some consolidation as different systems or groups or corporations see similar needs and realize they can put people together for some of the training, but I haven't seen that yet. It will also be interesting to see what happens when medical management is accepted by the American Board of Medical Specialties, so that to be board-certified in medical management, you have to have formal management training. That will change the character of the training to some extent.

The Physician Executive: Your closing thoughts on these two topics, medical education and physician executives, in the next five to 10 years.

Cejka: I'm not going to comment on medical education because I don't really know anything about it. For physician executives, in the next 10 years its going to be a very, very explosively growing field. Were going to see physician executives rising higher in the organization than ever before and in a much broader spectrum of organizations. Until now we've seen almost no hospital presidents or health system presidents who are physicians. I think in the future we're going to see many, many physician executives rise to the top of traditional health care organizations.

LeTourneau: Postgraduate medical education is going to start to come to the physicians more than it does now. I think we'll see two tiers of physician executives, those who serve as a bridge to clinical care improvement at the delivery level and then physician executives who actually lead the corporation.

Pfifferling: Medical education is going to have to shift to where the dollars are going to be spent in terms of outcomes and a greater emphasis on health promotion and health psychology. There'll be a greater emphasis on understanding organizational and corporate health. When you understand health psychology and health promotion, you'll be able to bring that back to the management level for the viability of the organization, whether its medical school, residency, or anyplace in your organization.

Physician executives are going to have to be much more familiar with what Irv Rubin calls behavioral quality assurance techniques. What do we do to change actual behavior of people we're working with to get greater unity, cohesiveness, and efficiency if we're going to have fewer people, more cross-training, and more rationed resources. Physician executives of the future are going to have to apply behavioral quality assurance skills to ensure the viability of their organization.

Reinhardt: When it comes to medical education, I think physicians in the future, to be able to cope with the stress, probably have to understand a little bit better how medicine fits into the larger economy. They have to study some economics. They have to be more aware of public health issues than they have been if they want to remain the spokesmen for health care in general. As far as the clinical training is concerned, I really do believe we have to try to figure out how HMOs and other ambulatory care settings can actually get compensated for training physicians. At the moment, we massively bribe hospitals who make profits on training medical graduates but we don't really have a similar bribery system for the ambulatory care setting and we need to work on that.

I'm not an expert on what physician executives do but if you think of executives generally, they are not specifically trained. In fact, there was an article in Fortune magazine, True Confessions of a Management Consultant, who says basically if you look at the people who make it to the top of corporations, what they have is not a particular skill, like engineering or conflict resolution, but basically those people get to the top because they offended the least number of people. I've heard this many times, that they are more political people than anything else. So with physician executives, you have a really new breed. In terms of IQ, they are probably the smartest people that ever sat on top of big organizations. The question is whether they have that certain something, that political savvy, that makes for corporate executives and that's an interesting question. Corporate executives personally have almost no skill that they can't buy from some consultant. What they have is political skills at leadership, at getting along. I think that's an interesting thing because physicians by their very nature are not that kind of people.

Todd: If medical education is going to continue to be relevant, its going to have to be fundamentally restructured in the curriculum that it offers. Information technology will introduce a whole new way of teaching medical students. In terms of medical executives, I think Uwe's exactly right that a strong political sense is a strong suit to have. I think in the future they essentially will begin to dominate the role of health care intuitively. They know how health care can be delivered and how it can be done efficiently and effectively. Fortunately, doctors are more likely to listen to other doctors, so that if you have a well-respected physician with a political sense in a position of leadership, together they can accomplish all sorts of things.

Health Care Experts Who Participated in the Second Panel Discussion

In Part 2 of this discussion, conducted via telephone conference call on February 19, 1997, the following panelists talk about the future of medical education and physician executives:

Susan Cejka is President of Cejka and Company, a health care consulting firm in St. Louis, Missouri.

Barbara LeTourneau, MD, MBA, FACPE, is Vice President, Medical Affairs, North Region, of Allina Health System in Minneapolis, Minnesota.

John Henry Pfifferling, PhD, is Director of the Center for Professional Well-Being in Durham, North Carolina. The Center works with physicians to achieve balance between their personal and professional lives.

Uwe Reinhardt, PhD, is James Madison Professor of Political Economy and Professor of Economics at Princeton University.

James Todd, MD, is the immediate past Executive Vice President of the American Medical Association, a position he held from 1990 to 1996.

Robert P. Carlson, conceived and conducted this panel discussion. His articles appear in health care journals throughout the United States. He also works as a marketing communications consultant with physician groups and other health care entities. He lives in Indianapolis and can be reached at 317/769-4609.