The role of training in professional development.

Doctors act like doctors because they are trained (by doctors) to act like doctors. Managers act like managers, not like doctors, because they are trained differently. The training process-education, socialization, evaluation, and determination of rewards-differs remarkably between the disciplines of medicine and business. This article describes and compares characteristics of medical and business training as an explanation for the perceived differences between physicians and managers.

number of authors have commented on the differing characteristics of physicians and managers.* Physicians are relatively autonomous, work well independently, are primarily oriented to individual patients, have short-term objectives, and appreciate immediate rewards. This contrasts with managers, who typically value teamwork, work most effectively with groups, are primarily organization oriented, have long-term objectives, and enjoy the process of a project as much as its completion.

Medical education begins with intense study of an organism-the human body. One learns the language of medicine while dissecting layers of tissue, poring over the microscope, and memorizing the Krebs cycle. Business education, by contrast, begins by exploring the behavior of groups of organisms-organizations. Courses in accounting, marketing, and even statistics are focused on describing how groups of individuals, organized for economic gain, interact with each other.

Traditionally consisting of a large volume of factual material to be memorized, or otherwise mastered, medical course work is highly compatible with individual study and learning. The case study method employed by many schools of business requires group study and promotes collaborative learning. Students are often assigned separate, but complementary, roles in representing the various parties to a business situation, i.e., finance, marketing, human relations, etc., and are taught to resolve problems through discussion, negotiation, and development of consensus.

In both preclinical and clinical phases of medical education, learning is derived from reasonably short-term activities. Basic science courses are often divided into small but intense, more readily assimilated subunits. Patients are evaluated, treated, and discharged within minutes, hours, or almost a few days. Longer term hospitalizations are often interrupted from a learning perspective as students rotate from service to service. Outcome factors receive a great deal of emphasis. What was my grade on the last test? or, How did the patient do after surgery?

Business school projects are often long term, occupying the better portion of an academic quarter or semester. One course in particular, Business Simulation, typically organizes students in groups of three or four as competing "companies" for the entire course. Weekly strategy meetings, multiple decision points, and combined projects, such as "Annual Report," require a high level of cooperation and communication. The emphasis is clearly on the learning process rather than the business outcome, although students are competitively motivated to control costs and generate profits.

In medical school, patient evaluation is taught as a logical progression from data collection to definitive diagnosis to treatment. The history and physical examination, supplemented by laboratory, radiological, and other data, generally contribute to the determination of a given diagnosis from a longer"differential"list. While a number of acceptable therapeutic modalities may be entertained for a certain condition, it is not uncommon to designate a "standard treatment 'or "drug of choice." The analysis of a business situation is likewise initiated by data collection. The external business environment (industry, competition, economy) and internal business conditions finance, organization, marketing) are evaluated to form a conceptual understanding of the issues. Assessment of the organization's strengths, weaknesses, opportunities, and threats is followed by creative exploration of alternative approaches and selection of a strategic course. The process is characterized by tolerance for the inherent ambiguity of business decisions and an appreciation of the necessity for enlightened judgment. The "definitive diagnosis ... .. treatment of choice," "one right answer" approach of medical education is bolstered by the formal evaluation system. National Board exams and the testing practices of many schools rely largely on multiple choice and various types of true-false questions that evaluate recall of factual material. This testing method rewards memorization, cramming for tests, and skilled "testmanship."

It facilitates rapid computer grading and objective comparison of results. In business school, on the other hand, examinations are concept-based and require thinking, writing, and problem-solving rather than memorization. Responses are not generally evaluated as right or wrong, but as bad, good, better, and best. Creativity, judgment, and the ability to communicate effectively become the most valuable skills for success in this system. Grading is more cumbersome, requiring independent evaluation by the instructor, and the ultimate evaluation is relatively subjective compared to the medical school format.

What about rewards? The medical student "wins" upon achieving the highest scale score, astutely ascertaining the correct diagnosis in contradistinction to his or her peers, or demonstrating minute recall of clinical esoterica on rounds. The business student wins when the group term paper receives a favorable grade, the collaborative advertising project is a success, or the company's annual report to the board is a hit.

The inevitable process of socialization that accompanies professional education contributes to the effect of the formal training process. Medical students often share similar undergraduate educational backgrounds, with moderate to heavy emphasis in science and math. They spend most of their waking hours with people like themselves--other medical students, house staff, and attending physicians. Strong interdisciplinary bonds are formed, and there may be relatively limited opportunity for social activity external to the profession. The student body of a graduate business school is generally characterized by considerable diversity of undergraduate training. While a substantial proportion of students will have majored in economics, accounting, or business, many have obtained degrees in fields not directly related to business. The business curriculum offers further exposure to other professions, including law, banking, and engineering. Because there is no formal equivalent to medical residency training, the effects of socialization and role-modeling may not be as profound in determining professional behavior or style.

The traditional medical education experience promotes the development of independence, autonomy, self-reliance, decisiveness, highly focused behavior, and appreciation of immediate, specific rewards-We characteristics common to physicians. Business education favors group activity, communication, cooperation, negotiation, creativity, and appreciation for process and longer term, more subjective rewards-the behaviors and attitudes ascribed to managers.

Three inferences arise from these observations. * Health care managers should be neither

surprised nor threatened to have

physicians respond vigorously to controversial

issues, expressing strong,

personal opinions directed toward rapid

problem resolution. Physician input

will likely be logical and reasonably

well thought out, but may not have had

the benefit of wide discussion. Physicians

are likely to be impatient for

response and results and may fail to

consider sufficiently the impact of a

particular course on other interested

parties. * The viability of the physician-execu - tive concept is placed in question. Is it

reasonable to anticipate that physicians,

trained and enculturated in the medical

model, will be able to move successfully

from the clinical to the administrative

arena? Experience suggests that

it is possible, although not a course to

be lightly undertaken. Anecdotes

abound regarding physicians who ventured

into medical management only to

beat a fast retreat to the safer, more

familiar ground of clinical practice.

The converse is no less true-a growing

number of physicians have discovered

within themselves an aptitude and

appreciation for the unique combination

of attitudes and skills necessary to

successful pursuit of a career in health

care management. * Just as physicians have been educated

to become clinicians and practitioners

of medicine, they can be trained in the

science and art of management. The

requisite skills-financial analysis,

strategic planning, conflict resolution,

organization building-are no less real

and challenging than the use of scalpel

and suture. They can be learned, but

not by osmosis and not by chance. Several organizations, including the Medical Group Management Association, the American College of Healthcare Executives, and, most notably, the American College of Physician Executives, sponsor outstanding programs of education for physicians involved or interested in management. In addition, many local colleges and schools of business offer courses in management with a health care emphasis. And there is a rapidly growing bibliography of texts and journals with application to the physician executive role. The challenge of medical management demands the development of executives with credibility and capability in both clinical and administrative disciplines. And education and training are the key to development of these outstanding physician executives. 13