The new health care civilization: integration of physician land and manageria.

The research study reported here began with a review of two national studies.[1,2] Both studies consisted of a national panel of respondents from the health care industry. Following review of the two national studies, we conducted a two-phase delphi survey of academic and private practice physicians who were performing leadership and management responsibilities in their practices or in state and national organizations.

Background Information: Driving Forces for the Future

According to the Arthur Anderson study of 2,600 health care professionals,[1] over the next five years, a universal health insurance program will not be in place, although support for one is accelerating. However, the Anderson study identified several important trends that will influence the health care delivery system into the next century. Managed care will become more prevalent. Payers will continue to restrain provider fee increases. Hospitals will face financial problems, causing smaller ones to close or to merge. Attention to quality and measurement of value received will increase. Providers will be required to release more information to payers and the public. The study suggested that controlling health care costs will be a major priority for payers and the most feasible methods will include:

* More home care.

* Shorter hospital stays.

* Use of physician extenders.

* Limits on advanced technology.

* Fewer hospital amenities.

* Travel by patients to centers of excellence.

* Less time with physicians.

* More emphasis on prevention.

Designing and implementing strategies for these cost containment initiatives will require collaboration among physicians and hospitals. Unfortunately, the Anderson study uncovered that physicians, one of the four groups of respondents, did not share the same perspectives and vision for the health care field as did hospital executives and hospital board chairs. The study concluded that physicians and hospital administrators must work together to arrive at a common vision for health care in their local areas. Both groups must participate as partners in developing mutually beneficial strategies.

The Healthcare Forum's study began with a literature search and interviews with health care management experts. A national survey of physician leaders, suppliers, consultants, and academics resulted in a response by 400 leaders. Respondents were asked to analyze three scenarios for U.S. health care in the year 2001 and to define leadership values and competencies that will be important for the future of health care. The major findings of the study were:

* Respondents acknowledged a significant leadership gap between present practices and those required for the 21st Century.

* Six transformational competencies will be needed by the 21st Century--mastering change, systems thinking, shared vision, continuous quality improvement, redefining health care, and serving public/community.

* These new transformational competencies are only minimally practiced today, if at all.

* Leaders want a greater emphasis on prevention and healing, as well as universal, cost-efficient, community-based managed care.

The Healthcare Forum's study predicts three driving forces for change into the next decade: globalization, empowerment, and orchestration of technology.

Globalization is a strategic leadership orientation requiring a shift from conventional practices, such as minimizing risks, repairing body parts, linear thinking, and protecting boundaries, toward transformational practices, such as redefining health care, serving the public, and creating and managing a diverse workforce.

Empowerment means allowing people to participate in the decisions that affect them. Continuous quality improvement will require team learning, a "we" approach, and cross-functional structures within each organization or group.

Orchestrating the enormous potential of technology will require integration of business planning and clinical decisions. Information and communication systems must be user-friendly to harness the biotechnology explosion. Invasive technology will be overshadowed by noninvasive therapies to predict, prevent, diagnose, and treat disease.

These two studies suggest that successful transition into the new civilization of health care (figure 1, below) will necessitate bridging the gap between physician land (the physician with absolute autonomy) and manageria (future-oriented, collaborative health care systems). Such an effort will require health care leaders to understand future trends and to take an active role in planning, organizing, and managing new systems of health care delivery and finance.

Study Method

Armed with information from these national studies, we wanted to learn how physicians who are currently in management and leadership roles perceive the complexity of medical economics and practice management. More important, we sought to understand how, if at all, these physicians are positioning themselves and their organizations for the rapidly approaching changes in health care.

A panel of 40 anesthesiologists and 30 family physicians participated in the first phase of the delphi survey. This group was selected because of its members' leadership roles and participation in administrative development programs. In the first phase of a delphi survey, respondents are asked open-ended questions to ascertain their general views of a subject. We asked our initial panel of physician leaders to list five major factors that will influence the economics of health care in the next 10 years and the most important problems that will keep the health care profession from meeting the goal of high-quality, cost-effective medical service. They were also asked what changes or innovations are needed to resolve the problems, what type of leadership is needed in their specialties during this dynamic period, what type of leadership role they would consider, what factors or circumstances would enable them to perform this leadership role, what factors or circumstances would prevent them from performing a leadership role, and what personal qualities and managerial competencies a physician needs to effectively perform in a leadership role. Finally, we included a time management analysis to determine how much time panel members spend in patient care, in management, and in other professional activities.

Following analysis of the first phase of the delphi survey, we designed a questionnaire containing five sections: factors that will influence the economics of health care, most important problems facing health care delivery system, changes or innovations needed to resolve problems, personal qualities of physicians as clinicians and as executives, and managerial competencies for physicians in executive roles. The questionnaire was sent to 230 physicians, who were asked to rate statements under each of the five headings using a seven-point Likert scale. The second delphi group included 40 anesthesiologists, 40 gyn oncologists, and 150 family phygicians. Members of the second panel were also selected on the basis of their roles in management or their leadership positions in their organizations or in national organizations. We received a 65 percent response to the second phase survey. Responses from the three physician groups were 79 percent om the anesthesiologists, 65 percent from the gyn oncologists, and 61 percent from the family physicians.

Results: Phase 1

Important findings uncovered in the first phase of the research were the time management profiles and the responses to the questions regarding leadership roles. The reports by the physician leaders in private practice indicated that they spend less than 25 percent of their time in management roles and other professional activities, with the remaining time in patient care. Academic physician leaders reported that they spend in excess of 50 percent of their time in management and other professional activities, with their time in patient care ranging from 25 to fifty percent. Most frequently mentioned management responsibilities of physician leaders in private practice included medical director of a group, head of a hospital department, and officer in a state or national organization. The majority of the academic physicians leaders were department chairs or program directors, and they served on several institutional committees and in state and national organizations. It was not uncommon that both groups were active in three or more management- or organization-related functions at the time of the survey.

When we asked our first panel of respondents what would keep them from assuming additional leadership roles, some salient factors were:

* Demands of busy clinical practice.

* Family responsibilities that prevent additional administrative roles.

* Lack of support from colleagues, including financial remuneration for managing or leading.

* Lack of management skills and unavailability of time for training.

* Enjoyment of clinical practice and unwillingness to give up this aspect of medicine.

* Lack of job security; what happens if administrative work is not successful or satisfying.

Other statements about the demands on physicians in management positions were as follows:

* I feel ill-equipped to tackle global issues; no education or courses are available to help me learn.

* Leadership within medicine will be difficult because of the huge differences in expectations and values among physicians.

* We have to decide if we want to be a factor for change, or just go along with the herd. Is it worth it?

* The personal satisfaction of working in a management role is nowhere near the satisfaction derived from the clinical role.

* Both patients and colleagues are quick to give positive feedback about clinical work. Comments from colleagues about administrative work are either nonexistent or negative.

The findings from the time management reports and the comments from our respondents indicate that the realities of medical practice focus almost exclusively on the clinical role, which demands a lot but is rewarding (secure and well paid). Unfortunately, the managerial role receives a smaller percentage of effort, particularly in private practice, and is considered much less rewarding personally, professionally, or economically.

Results: Phase 2

According to respondents in the second phase of the survey, the most important factors that will influence the economics of health care will be:

* Aging population.

* High cost of medical technology.

* Medicare/Medicaid.

* Universal access to medical care.

* Increase in ambulatory care.

* Cost containment initiatives by industry and government.

* Technological advances in medicine.

* Managed care.

* National health insurance.

The most important problems that will prevent the health care system from achieving its goal of being a high-quality, accessible, cost-efficient service industry include:

* Administrative bureaucracy by third-party payers.

* Uncompensated care resulting in cost-shifting.

* Lack of a national health policy.

* Financial incentives for providing high-tech medical care.

* Lack of incentives for reducing utilization and cost.

* Malpractice trends.

The family physicians' list of most important problems gave a higher priority to issues relating to family medicine, such as maldistribution of physicians in primary care and subspecialties, shortage of primary care physicians, lack of financial support for primary care, and excessive medical student debt.

Respondents in all groups were in general agreement about the most important changes or innovations needed to resolve the problems:

* Streamline insurance procedures.

* More resources for ambulatory care, prevention, and home care.

* Public education in prevention, rationing, and costs.

* Evaluation of high-cost technology before widespread use.

* Higher reimbursement for rural and underserved areas.

* Management education for physicians.

The list of most important factors, problems, and changes support many of the findings from the national studies previously discussed. The questions that remain are what role physicians will play in the economics of their field and what competencies they need to perform the executive role effectively.

Role Transition--Clinician to Executive

Social psychology states that roles serve to organize people's behavior so they can direct their talents and energies to appropriate expectations. If role expectations are congruent with an individual's needs and abilities, there is greater likelihood of a positive outcome for both the organization and the individual. Role expectations not only direct one's energies, but also create a predictable pattern of behavior for others to comprehend.

Traditionally, physicians, and those around them, have seen their roles almost exclusively as "clinical" specialists. Society socializes physicians into this role to such a great extent that there is little or no appreciation for other professional dimensions, specifically business and social sciences. Many of our respondents commented that their administrative work is viewed as add-on responsibilities, which receives minimal, if any, financial or psychological rewards.

Our survey indicates that physicians in small, single-specialty practices typically work in patient care on an equal basis with their clinical partners and then perform their executive roles in their "all other time." Many physician leaders reported that, even though their practices designate one physician as medical director, this person does not have adequate protected time or compensation to perform the myriad administrative tasks. As health care organizations become larger and as medical practices become multidisciplinary, a cadre of physicians will need to shift their professional identity from clinician to executive. According to Raymond Fernandez, MD, medical director of a large multispecialty practice, his initial time allocation of 50 percent clinical and 50 percent administrative was not adequate. He had to renegotiate to 15 percent clinical (no night call responsibilities) and 85 percent administrative to manage and lead the group.[3]

Realizing that the work of a physician as a clinician is different from the work of a physician as an executive, we asked the physicians in our survey to differentiate the qualities of these two professional roles. Figure 2, above, shows the distinction in these two roles. We also asked our respondents for the most important managerial competencies that physicians need for the executive role (figure 3, below).

Discussion

To physicians, one of the most threatening changes taking place in U.S. health care is organizational transformation. Rubin describes this process.[3] As a health care consultant, Rubin observed that many health care organizations, especially small group practices, are similar to a college fraternity. Individual freedom becomes the central driving force. Each member is committed to self-interest, with low tolerance for delayed gratification. The primary focus is personal security; the organization only exists to satisfy individual members' needs. The brothers and sisters merely rent space.

Rubin sees many similarities between health care organizations and college fraternity life. Just as one fraternity plots against other fraternities, the close-knit physician brotherhood often views administrators, other nonphysicians, and even colleagues in other specialties as enemies, causing a we-they, competitive dynamic. In-fighting is prevalent between primary care physicians and subspecialists and between academic physicians and community practitioners. The lack of constraints on physicians' behavior and the lack of a common purpose within the organizational setting results in a fraternity-like atmosphere that breeds such problems as income and work load inequities, inefficiency because of individual styles, and superficial planning and decision-making procedures. According to Rubin, physicians with managerial responsibilities in this stage receive token financial support and even less emotional support. It is not uncommon for physicians to quickly vacate their leadership role to return to the individual pursuits of clinical work. Short-term management assignments and flat organizational learning curves are the rule.

Rubin observes that some group practices, and larger health care organizations, outgrow the fraternity way of life. Physician managers and experienced administrators conduct long-range planning sessions and hold regular meetings to discuss quality improvement programs, affiliation agreements, and financial and personnel matters. Decision-making protocols minimize "oh, by the way" decisions. The organization becomes perceived as an entity that will outlive its individual members. Medical management becomes valued, and the role of medical director is not an annual rotation by senior physicians. Rubin describes this stage as the "basic business organization."

For successful movement from stage one to stage two, Rubin suggests:

* A mission statement that describes goals concisely.

* Designation and support for those with organizational authority and responsibility.

* A management system that plans, monitors, and reports on results.

Performance appraisal is at the heart of the stage two organization. People need clear expectations. Clinical and business behaviors need to be agreed upon, defined, measured, and fed back to members. For a successful transition to stage two, the managerial function must be seen as adding value as opposed to being an overhead expense.

Most health care organizations, particularly small to moderate sized group practices, struggle with the transition from the fraternity model to the basic business organization. Because of the trends and problems discussed earlier, it is unlikely that medical practices will be allowed the luxury of remaining in stage two. According to Rubin, the challenges facing health care organizations in the future will require a third stage of organizational development, which he entitles the organization in search of excellence.

The organization in search of excellence must successfully complete its evolution through stage two, which means a medical director and a practice administrator serve as partners in the executive function. The mission statement of the stage three organization includes long-range, difficult-to-measure goals and qualitative values. The organization provides opportunities for challenge, autonomy, and synergy. Individual members invest themselves in the organization as much as they do in their individual work. There is less emphasis on hierarchy and authoritative positions. Compensation and rewards are commensurate with effort and outcome, not with status, longevity, or just a clinical role.

Organizations that venture into stage three make a concerted effort to move to a higher plateau of organizational function. The corporate mentality of doing whatever needs to be done to serve clients is crucial to the search for excellence. The collective mindset is one of "organizational citizenship," with each member playing a key role to create something that really matters.

What will it take at a personal level for a physician to become a health care executive?

* Realize that there are no quick fixes. One management seminar or workshop will not make physicians competent executives. Keep expectations of self and colleagues realistic. People must change their attitudes before organizations can change their cultures and systems. Become a student of the new health care civilization. Take risks with innovation and changes and/or support those who step forward as change agents. As the fraternity model dissolves, be prepared for feelings of loss, anger, and grieving.

* Design a plan. Nothing happens without a road map. Build a curriculum of continual learning and skill development, much like your medical education and residency training. Incorporate didactic and experiential knowledge. Find a mentor, or at least a coach!

* Consider your personal learning style and the realities of your current personal and professional life. Look for learning opportunities, not merely instructional programs. Applied learning will keep you motivated, as well as provide enjoyment.

* Don't go it alone. Sharing your learning and skill development with colleagues will enhance the learning. Consider bringing the learning experiences into the organization. Leadership and management training often leads to organizational change.

We ask physicians to reaffirm their professional credo. In choosing a profession, physicians chose a call to service. This choice is more than an occupational pursuit. It is a covenant with society. Every profession consists of a unique body of knowledge and a code of behavior and ethics. Medicine's unique body of knowledge can no longer be limited to anatomy, physiology, pharmacology, and the behavioral sciences. The professional code of behavior and ethics is not confined to doctor-patient and doctor-doctor relationships. As professionals, physicians profess to serve the public's needs, regardless of patients' payment methods or socioeconomic status. Medicine provides a good livelihood for physicians. In return, physicians are expected to engage their character and heart, not merely their minds and hands, to create a new health care civilization for the country. Success in the new health care civilization demands integration of physician land and manageria. Physician executives must step forward to accept the challenge as bridge builders.

References

[1.] The Future of Healthcare: Physician and Hospital Relationships. Chicago, Ill.: American College of Healthcare Executives, 1990. [2.] Prezzano, W. "21st Century Healthcare: Bridging the Leadership." Health Forum 35(3):48-64, May-June 1992. [3.] Rubin, I., and Fernandez, C. My Pulse Is Not What It Used to Be: The Leadership Challenges in Health Care. Honolulu, Hawaii: Temenos Foundation, 1991.

John J. Aluise, PhD, is Clinical Associate Professor; Robert W. Vaughan, MD, is Professor and Chair; and M. Sue Vaughan, MSN PhD, is Consultant in Anesthesiology, Department of Anesthesiology, School of Medicine, University of North Carolina, Chapel Hill. Dr. Vaughan is a member of the College's Society for Academic Medical Centers.