Today's physician has choices, but needs help.

Throughout most of this century, education for physicians has concentrated, with rare exception, entirely on the clinical practice of medicine. The sadomasochistic nature of postgraduate medical training further confines the exposure of physicians to entirely clinical matters. Outside the military, no other professional training provides the intensity of study, responsibility, decision making, and constant demand for accountability through interrogation. What leadership and/or management skills are acquired are done so accidentally. Much of the learning experience is in the manner of "see one, do one, teach one." The fortunate student, intern, or resident will be mentored by a senior physician, but, even under these circumstances, there is no assurance that the correct principles are being taught. A fortunate few are recognized for their leadership skills and interests and may be ordained to serve as chief residents or in comparable roles to exercise and further these skills.

The result of these deficiencies is significant in several respects. First, the physician is ill prepared for the business aspects of the practice of medicine and the delivery of health care. Second, there is reinforcement of the sense of autonomy and "sovereignty" that, until the recent incursions of government, accreditation organization, and payer regulations, has gone very much unchallenged.[1] Last, the physician in practice is ill prepared for any alternative career or profession. Like those in other professions and occupations, physicians must give serious consideration to the development of greater flexibility, diversity, and adaptability to change.

History and the Environment

With the rapid shift to managed care and capitation and the development of hospital-physician alliances and networks, a need for collaboration, cooperation, and communication between physicians and administration is now recognized. The complexity of managing the business of medicine has left the physician with less time devoted to patient care. Increasing regulation has turned the concept of autonomy to myth for many. Rising malpractice awards have generated a need in the minds of many to practice defensive rather than appropriate and effective medicine. Accelerating technology advances and demands by a society aware of them but lacking understanding of their appropriateness further encroach on the ability of the physician to make decisions. For some, it simply is no longer fun. Physicians are considering alternatives to the practice of clinical medicine.

It is increasingly recognized by physicians that, if we are to address administrative, operational, and managerial problems in the delivery of health care, physicians must actively participate and lead.[2] The passive or reactive approach is no longer acceptable or compatible with long-term survival and security. The latter has only been recognized within the past three years. Not only is the physician who expresses interest in or assumes administrative responsibilities less likely to be perceived as turncoat; he or she is encouraged by peers to make the move.

These real or perceived threats to autonomy, livelihood, dignity, and privacy have manifested themselves in the form of denial, anger, and depression. Environmental changes - disillusionment with the practice of medicine on the one hand and the need to influence the practice of medicine and the delivery of health care on the other - have led to a number of disparate and varied responses by physicians:

* Manipulation of control systems. * Job changes. * Specialty changes. * Career changes. * Collective action. * Increased stress and deviant behavior. * Conflict between hospitals and physicians.[3]

A few physicians have totally left health care to pursue unrelated interests, some having been heretofore only fed as avocations, e.g. writing, art, literature, liberal arts education, culinary endeavors (restaurants). More are planning for early retirement than ever before. A number seek satisfaction through participation in community affairs or other business interests. Some return to the practice of medicine only further depressed at having to recognize lack of ability to diversify for reasons explained above, or to embrace the passion for medicine regardless of costs.

Model

The Role of Counselor

Identification of the individual responsible for the provision of career counseling is critical. Physicians relate best to other physicians. Occasionally, however, an experienced recruiter for physician management positions may possess the interpersonal skills, knowledge, understanding, and credentials to accomplish the task.

Responsibility for the function can be incorporated into the position of senior-level medical director or vice president medical affairs. This would require that the individual be well versed in at least basic principles of career counseling; have access to human resources information and assistance; and be knowledgeable about external resources, professional societies, graduate education programs, and consultants. A basic requirement of a physician in such a leadership position is interpersonal skills to establish and maintain communication, credibility, and trust with the medical staff. Once this relationship is established, the physician naturally is sought for counsel.

When queried for advice and counsel regarding career choices, concerns, or development, the counselor provides the framework in which the individual seeking assistance can develop a solution. Four steps, based on principles utilized in continuous quality improvement methods, can then be employed to achieve resolution:

* Problem Identification. * Analysis and Data Gathering. * Development of Alternative Solutions. * Implementation.

Problem Identification

Clear identification and articulation of the problem is an absolute necessity lest the right solution be proposed but for the wrong problem. This may often require multiple interviews with the individual. Superficially, the problem may present as dissatisfaction or as a desire to leave clinical practice, but further examination may uncover dissatisfaction with the circumstances of practice of medicine, with associates, with location, etc.

Even more basically, the counselor may unmask long-standing unresolved issues of career and life stage and occupational choice related to content or personality.[4] Surveys of physicians who have left clinical practice for other pursuits identified patient demands, physical demands, time, emotional demands, and boredom as influencing factors.[5]

Once the problem has been articulated and the dissatisfiers identified, motivators, goals, and objectives need to be identified. This allows the individual to make a positive assessment of reasons for change in order to facilitate the appropriate change for the right reason. Influencing the decision, for example, to choose an executive position were attractions of management itself, peer encouragement, and family wishes. Goals address personal as well as professional needs and wishes. Within the former are included family, life-style, and geographic criteria.

Analysis and Data Gathering

The second phase consists of an analysis and data gathering process: an assessment of current circumstances and identification of factors. both positive and native, contributing to the problem. In the practice of medicine, this may include location, income, travel, associates, time, etc. It would also include abilities, interests, strengths, and weaknesses of the individual relative to alternative careers. Also included would be an assessment of conditions that must be met for change to be accomplished or that may result from the change: further education, training, loss of independence, relocation, financial risk, personal and professional risk.

Alternative Solutions

Following the assessment, alternative solutions are considered, including a brainstorming of possibilities. The use of brainstorming, with visual aids, flip charts, and graphics, helps to sort the possibilities in a concrete manner. Major categories that may be considered by the individual are:

* Current clinical practice.

* Change location.

* Recruit new associates.

* Obtain administrative support.

* Implement information system support.

* Join a group practice. * Become employed by a group, clinic, or system. * Explore an academic position. * Switch to another specialty/primary care. * Explore management positions. * Explore other areas of interest.

* Committee experience.

* Community education.

* Professional society activities. * Retire early. * Explore alternatives to health care.

There is a need to continual match alternative solutions with goals and objectives. A career change that would demand a major time commitment in education would not be compatible with the immediate need for more family or leisure time.

Implementation

In the exploration of alternatives, even before a final commitment is made to any one path, a preliminary review of steps necessary to accomplish the goal and the time frame for implementation needs to be accomplished. Not appreciated by the physician is the time required for recruitment, interviews, legal counsel when necessary, and negotiation. Other activities will involve referral for specific needs, such as relocation, education opportunities, contact with recruitment firms, exploration of positions available within current organization, and establishment of network contacts.

Conclusion

The foregoing provides a framework within which to provide guidance to physicians who, for the first time, are facing decisions and concerns regarding their careers and professional roles. Underlying the process must be provision of resources to facilitate decision making, provision of emotional support to the individual, and clear and consistent stipulation that the decision is made by the individual seeking help, not by the counselor. Under no circumstances is the counselor to make decisions for the individual. Last, and critical to sustain credibility in the process and with individuals, is the need for confidentiality.

References

[1.] Starr, P. The Social Transformation of American Medicine. New York, N.Y.: Basic Books, 1982. pp. 9-29. [2.] Shortell, S. "Physician Leadership: Key to Effective Hospital/Physician Relationships." The Quality Letter 2(7):6-9, Sept. 1990. [3.] Schneller, E., and others. "The Future of Medicine." In New Leadership in Health Care Management: The Physician Executive. Curry, W., Ed. Tampa, Fla.: American College of Physician Executives, 1988, pp. 37-8. [4.] Feldman, D. Managing Careers in Organizations. Glenview, Ill.: Scott, Foresman and Company, 1988, pp. 22-34. [5.] Guthrie, M. "Why Physicians Move into Management." In: New Leadership in Health Care Management: The Physician Executive. Curry, W., Ed. Tampa: American College of Physician Executives, 1988, p. 48.

Gerald M. Gawlik, MD, is Senior Vice President, Clinical Affairs and Network Development, Elmhurst Memorial Hospital, Elmhurst, Ill. He can be reached at 200 Berteau Ave., Elmhurst, Ill. 60126, 708/833-1400, Ext. 1050, FAX [phone].