Why physician managers fail - part one.

Why Physician Managers Fail--Part One (1)

It is no small step to leave behind years of medical education, training, apprenticeship, and practice to take on a new profession. Yet that is what increasing numbers of physicians are doing as they enter managerial jobs. And, as was the case with the senio-level physician manager described above, success in these new roles is far from automatic.

The doctor manager is the epitome of an oxymoron, for never in the history of language have two terms beens so utterly opposed. (2)

Sometimes physicians enter management with their eyes open, but often the implications of their decisions aren't apparent until long after commitments have been made. Whether anticipated or a belated surprise, the move from physician to manager turns out to be a major transition. And when physician fail in their new roles, the price tags are enormous. First is the phychological cost to the physician. While some physicians argue that there is no disgrace in failing at management (and returning to "honest work"), the psychological impact or resignation or of being demoted or fired is significant. (3)

While the personal pain of failure can be great, managerial failure can cause additional harm to the institution and to the people dependent upon the manager. Thus the second cost is in damage done to the organization and its mission and to the people affected by the manager's role.

Third is a far-reaching cost. The health care field desperately needs leadership, (4) and every talented physician who fails in management contributes to the perilous future of medical care in this country. Because of their knowledge of patient care and medical advances, physicians are a logical source for leadership in health care. Yet, as one physician we interviewed pointed out, "Lay management doesn't trust physicians as high-level managers." Every failure reinforces that stereotype and makes it that much harder for those who folow. Further, in the worst cases, not only does medicine lose badly needed leadership but also the physician is lost to clinical practice. Depending on how long and how far removed from clinical practice the physician has been, returning to it may not be an option.

While failure in management by physicians may be both dramatic and little-studied, it is by no means unique. Professionals of all kinds have difficulty making the transition from technical specialist to manager. (5) Developing managerial and leadership skills is not automatic for anyone, including those who achieve high levels in corporate hierarchies. Even people with demostrated managerial strengths can eventually stumble near the top of the executive mountain. (6)

Against this backdrop, we set out to explore the reasons that physicians who become managers sometimes fail. From other studies of executives, we knew that three kinds of information might shed light on the process:

* How physicians got to be managers in the first place.

* What flaws did them in.

*What situations surfaced those flaws.

To get this information, we used a variety of strategies. We interviewed 14 physician anagers in depth, (7) asking them about their own career experiences and transitions as well as about physician manager failures they had observed directly. (8) This information was supplemented by answers generated to similar questions asked in three workshops held for physician managers. (9)

The Leap into Management

In my experience in an academic setting, the greatest problem for physician managers is that whoever selects them in the first place uses the wrong criteria. They select a terrific independent investigator who can get government grants--or a good researcher or a good teacher. (10)

Unlike their corporate counterparts, physicians seldom view management as a natural career path--at least not early in their careers. As one doctor put it, only recently "have issues forced the words doctor and manager to be used in the same sentence with no pun intended." Why indeed would someone abandon a successful clinical practice, achieved at great expense and personal sacrifice, to take on managerial work?

There are at least six pathways from medicine to management: evolution, stardom, default, choice, takeover, and cultivation, roughly in that order of frequency. (11)

Management by evolution. Many doctors never really meant to become managers. Like slowly sinking in quicksand, they found themselves more and more committed the longer they stayed in it. Through a slow and often painful process, time brought them to grips with giving up clinical practice--which most of them loved--so they could devote the necessary time and energy to increasing managerial responsibilities. Eventually, clinical practice was all but gone and they were full-time managers. The gradual evolution usually started with very small-scale administrative duties (supervising interns or a small group, heading up a small department) and slowly grew (ofteh over many years). In essence, it was a progession through a series of slightly larger managerial jobs, or increases in the responsibility in the same position as the organization grew.

Management by stardom. The second most common path was being chosen for management on the basis of outstanding accomplishments or skills, almost always nonmanagerial. Depending on the organizational setting and the needs at the time, doctors might be chosen for managerial roles because of their national reputations, specialized medical credentials, entrepreneurial inclinations, networksof contacts, research or teaching track records, ability to attract grants, or other outstanding characteristics. Only rarely was the outstanding characteristics related to managerial or leadership qualities, and often, as we shall see, the admired characteristic was even antagonistic to effective management.

Management by default. Another route to management was by virtue of a shortage of physicians willing to take on a managerial role. As organizations or practices grew, the need for managers increased but available talent didn't. As a result, managerial roles were filed by coercion or seduction, and physicians found themselves managing as a way to get resources, status, "to help out," or even just to keep someone else from managing them.

Management by choice. There were a number of reasons that physicians actively chose managerial paths. For some, there was an early realization that they were good with poeple or enjoyed building things or had a knack for business. For others, clinical practice burned them out, or they tired of it, and medical management offered them new challenges. For still others came a realization that, while they were helping individual patients as physicians, they could make a larger contribution to more patients and even society through leadership roles. Less nobly, for a few it was the lure of anticipated status or power or office. Given the often open door to managerial positions, any of these reasons might cause a physician to step through it.

Management by Takeover. Everyone knows that the corporate world has been wildly turbulent for over a decade, continually turned upside down by mergers, acquisitions, bankruptices, divestitures, takeovers, and threats of takeover. Few realize the degree to which health care has joined the fray, with insurance companies snatching up and spitting out HMOs, group practices being taken over by larger organizations, hospitals and HMOs going into the red or belly up, and the other rastic convulsions of the past few years. These organizational changes have resulted in dramatic moves for physicians--especially owner/managers--who have found themselves propelled from one kind of managerial job in one kind of organization to very different levels of responsibility in different kinds of organizations. Legal and regulatory considerations have led some organizations to recruit physicians into certain roles solely because of their credentials--placing them almost overnight into high-level but ill-defined managerial roles. The result of all this turmoil has been substantial movement of physicians into managerial roles, and drastic shifts in responsibilities and organizational settings for physician managers.

Management by cultivation. Only rarely id we encounter physicians who were cultivated deliberately for management by a mentor or by their organizations. Unlike the corporate world, where management development is often a deliverate (if rarely well executed) strategy, health care organizations have not put a premium on preparing physicians for managerial responsibilities. While mentor relationships appear common, especially in academic medicine, and while many physicians who become managers are profoundly influenced by a mentor-like figure, deliberate management development is a rather isolated phenomenon. As one physician described it, "I had lots of support on the medical side, but no one tried to help me be a more effective manager. It's a very nonnurturing environment."

In these six pathways lies fertile soil for failure. overwhelmingly, physicians enter management for irrelevant or wrong reasons. As one physician manager put it, "They can't find a good candidate, so the person they choose may be incompetent to start with." Scant attention is paid to leadership and managerial qualities as conditions for entry to management or even for promotion to more significant responsibilities. The seeds for failure are plentiful in the physicians themselves. Physician managers are the first to admit that they are ill-prepared for the demands of management. Our first conclusion, then, is that many of the flaws that will eventually do them in walk in with them.

The high potential for derailment from the very beginning of a managerial career has been documented in corporate settings as well. McCall and Lombardo looked at why senior executives who later derailed had been successful in the first place. They report that almost all "derailed executives were identified as having 'it' and ran up a string of successes in engineering, operations, or project management assignments. . . . about half the time they were seen as technical geniuses...or brilliant problem solvers... They were less often well-liked or considered charming... Some executives who eventually derailed moved up during mergers or reorganizations.... Others were exceptionally hard-working and loyal, managed their careers well, or were excellent at motivating and supporting their subordinates." (6) Even corporations reward accomplishments in a specialty with managerial roles, confuse brilliance with ability to get things done, and make promotion decisions on the basis of incomplete or irrelevant criteria.

The Flaws of Physician Managers

Physician managers don't fail because of a lack of skills in their specialties. They run on instinct, gut, emotion--they are not detail oriented. They are naive financially. They love to diagnose and tell people what their problems are, but they're not so great at action.

If I could tell a new physician manager the foremost requirement, it would be to wrap up your ego and put it on a shelf. You've got to do what the institution needs or you'll not succeed. We have created the superman physician of today. They bring that to management

As this hospital chief executive observed, it's not their shortcomings as doctors that do physicians in as managers. The 10 kinds of flaws that described failed physician managers have surprisingly little to do with a lack of technical knowledge and everything to do with getting things done through others in a complex organization. Whatever the setting, managing is different than technical work. It requires its own unique set of skills, knowledge, attitudes, and values. (12) Seemingly unaware of this reality, some physicians think, for example, that their experience in dealing with patients has prepared them for dealing with all managerial relationships. (One physician manager quipped that pediatricians were especially well prepared for management because they had learned to deal with childish behavior on the part of both adults and children.) But even if a physician has a "good bedside manner," that is no guarantee that the same skills generalize to other kinds of relationships. The main reason physician managers fail is their inability to deal effectively with people--subordinates, bosses, peers, or themselves. As a senior physician executive put it, "It's almost always people management that does them in."

The 10 deadly flaws of physician managers are (in no particular order):

* Insensitivity and arrogance

* Inability to choose staff

* Overmanaging (inability to delegate)

* Inability to adapt to a boss

* Fighting the wrong battles

* Being seen as untrustworthy (having questionable motives)

* Failing to develop a strategic vision

* Being overwhelmed by the job

* Lacking specific skills or knowledge

* Lacking commitment to the job

Insensitivity and arrogance. Variously described as egocentric, insulting or abrasive to others, or unable to build and maintain constructive relationships, insensitive managers inevitably alienated others upon whom their ultimate success depended. "He was never any good at dealing with people," said one medical director of a failed physician manager, "and a managerial position creamed him." A physician department head noted that, "Some people walk in as cowboys. They love to intimidate people."

Among the many endearing charms of managers thus flawed were such practices as insulting people in front of others, showing impatience, failing to listen to others, and acting as if they could do anything. No one wanted to be around them or work with them, or, in the last analysis, help them out when push came to shove.

Insensitivity and arrogance can be a particularly thorny problem because individuals are often blind to such qualities in themselves. Take for example the experience of a head nurse describing a doctor-nurse relationship:

The doctors will come to me and say they're trying to get something accomplished and the nurse keeps butting in. Then the nurse will come to me almost in tears, and say, "This doctor is being a real horse's rear end. He won't answer his beeper. I can't get hold of him. Then he came to the desk and really worked me over in front of everybody."

Doctors take criticism very poorly from their peers, let alone from a nurse.... The nurse has already been put down so much that she won't confront the doctor. (13)

Not all physicians treat nurses this way, but many who do are unaware of their impact, or dismiss it as necessary for the good of the patient. The data suggest that bringing such behaviors into management, where "if you can't develop useful working relationships you can't get anything done," is a sure ticket to derailment. In spite of the widespread belief among nonmanagers that managers have great unilateral power, one of the first managerial lessons is that superiors, peers, and subordinates respond negatively to insensitive treatment and can be extraordinarily effective in blocking what a manager wants to do. (14)

Inability to choose staff. Many physicians make basic and costly mistakes in hiring or selecting people to work for them. Sometimes they view the position they are hiring for as insignificant, until a poorly chosen secretary or office manager turns their daily life into a nightmare. Others fail because they play favorites, surrounded themselves with cronies, paid little attention to screening, or otherwise staffed with less-than-effective people in key roles.

People witnessing these poor staffing practices attributed the errors either to the manager's insecurity around talented people, to playing politics, or to poor judgment. Whatever the attribution, two negatives resulted: the manager was viewed as ineffective, and the manager ended up with an ineffective staff.

Overmanaging (inability to delegate). He was one of the smartest people I've ever known. He could assess or organizational dynamics and lay out a plan. He was charismatic. But he derailed because he was too controlling. He attracted talented people, then strangled them. He needed to control otherS. They should have made him a policy maker and put him in a back room somewhere.

Thus did a medical director describe the derailment of a physician manager peer, graphically demonstrating the consequences of overmanaging. It is not surprising that physicians, who are used to being in charge ("You don't want your surgeon taking a vote at the operating table"), often have difficulty letting go. Used to hands-on and avan dictatorial control, managers with this flaw have trouble building consensus behind their decisions, getting people to take initiative, generating ideas from their people, and building an effective team. Not only do such managers alienate subordinates, they may eventually face a job bigger than they can handle all alone. Inability to effectively delegate insures failure as the scale of the managerial job increases.

Inability to adapt to a boss. For many physicians, the very idea of having a boss is bizarre. Even bosses who are physicians are suspect. "Physicians do not like being told how to treat patients by physician managers who have not seen their patients and may not have seen any patients for some time." But if physicians don't like having a boss, physician managers quickly learn that they have to live with one. This is often not an easy marriage. Even when the boss is also a physician, some managers ignore or fight expectations and otherwise bristle at the subordinate role. one physician manager put it well when describing his perception of the physicians reporting to him. "Physicians are very independent," he observed, "and they like a lot of rope. Just once, though, I'd like someone to accept a subordinate role!" He meant of course that behavior he admired (and maybe even engaged in) when he was a physician-subordinate was harder to tolerate in his subordinates now that he was the manager. Unwillingness of a subordinate to work on a team, to do things he or she doesn't want to do, or to cooperate for the larger good at some point outweighs the positives associated with rugged individualism. A superior can tolerate obstinateness (or outright defiance, as we saw in some cases) only to a certain point, especially from a subordinate manager. Neither physicians nor physician managers in subordinate roles are always sensitive to where that boundary lies.

The greater the chasm between boss and subordinate in style, values, and objectives, the harder it is for some physician managers to adapt to the boss. The ultimate test for many who failed, however came when their boss was a "lay" administrator. As one medical director put it, "Once you've played God, it's hard (or impossibe) not to feel good about yourself. Then a lay guy tries to tell you how to do your job." We heard stories of derailments caused by bright, aggressive physician managers running afoul of quiet, actuarial types of bosses; by medical directors who lost patience with or failed to understand the perspectives of home-office executives; and by blatant intolerance on the part of the physician manager for nonmedical executives above them.

There was some tension for any change in bosses, but the change to a lay boss for the first time was a particularly significant event. The bottom line, of course, was that when a clash became a war, the boss usually won. While these battles were often dignified by their connection to fundamental health care issues, the truth is that they most often centered on style and personality differences. McCall and Lombardo's study of derailed executives found that both successful and derailed managers ran into conflicts with their bosses. The successful managers "didn't get into wars over it, fought problems with facts, and rarely let the issues get personal. Derailed managers exhibited a host of unproductive responses--they got peevish, tried to shout the boss down, or just generally sulked around." (6)

Footnotes

(1) The authors gratefully acknowledge research support from the American College of Physician Executives and from the Center for Effective Organizations at the University of Southern California. Ron Pickett, formerly with ACPE, and Robert Spears, MD, FACPE, of the School of Medicine at USC were invaluable in helping design the study, identifying physicians to participate, and interpreting the results. David Molthrop, MD, provided us with extensive background on how medicine has been changing and on the resident's view of the physician manager. We are indebted to Esther Hutchison for her many useful suggestions on the early versions of the manuscript. We especially appreciate the enthusiastic support and unsurpassed editorial skills of Wes Curry, editor of Physician Executive. Last but not least, we thank the physician managers who shared with us their experiences, good and bad, and provided us with the insight that made this paper possible. We are especially appreciative to those among them who gave us constructive feedback on earlier versions of the manuscript.

(2) All unreferenced quotes came from physicians, usually from the interviews but occasionally from written comments. Some interview quotes had to be reconstructed from notes. Some specifics have been altered to protect confidentiality, but the essence of the comments has been preserved.

(3) Several streams of research have documented the potential psychological impact of failure at a job. For examples, see Mellow, C. "Out-Placement Passages." Across the Board, Nov. 1986, pp. 39-44; Finley, M., and Lee, T. "The Terminated Executive: It's Like Dying." The Personnel and Guidance Journal, Feb. 1981, pp. 381-4; and Sprague, R. "The High Cost of Personal Transitions." Training and Development Journal, Oct. 1984, pp. 61-3. Being fired or demoted is one of the most significant life stressors on the Homes & Rache (Homes, T., and Rahe, R. "The Social Re-adjustment Rating Scale." Journal of Psychosomatic Research, 1967, pp. 213-8, stress scale. Losing a job (even voluntarily) is a major "loss" and therefore can be a psychological event akin to divorce, death of a friend or loved one, or other significant losses.

(4) Many of the problems are documented in Herzlinger, R. "The Failed Revolution in Health Care--The Role of Management." Harvard Business Review, 67(2):95-103, March-April 1989. The sense of desperation is clear in the headlines of business and news publications: "Our Health Care is Sick," "The Prognosis on Health Care: Critical--and Getting Worse," "A Crisis in Care," etc.

(5) See McCall, M. "Leadership and the Professional" in Scientists, Engineers, and Organizations. Monterey, Calif.: Brooks/Cole, 1983, pp. 328-45; Lorsch, J., and Mathias, P. "When Professionals Have to Manage." Harvard Business Review, 65(4):78-83, July-Aug. 1987; and Von Glinow, M. The New Professionals: Managing Today's High-Tech Employees. Cambridge, Mass.: Ballinger Publishing Co., 1988.

(6) McCall, M., and Lombardo, M. "Off the Track: How and Why Successful Executives Get Derailed," Technical Report No. 21. Greensboro, N.C., Center for Creative Leadership, Jan. 1983.

(7) The 15 people interviewed consisted of 14 physicians and one non-MD hospital administor. Of the physicians, all but one held a managerial position at the time of the interview (the one had recently returned to clinical practice after holding a managerial jon). Titles represented included medical director (4), associate medical director (1), chief of staff (2), associate dean (2), department head (1), director (1), assistant to the associate medical derector (1), and chief executive officer (1). Organizations represented included four hospitals (private community, public, and university-affiliated), two national managed care organizations, three group practices, and a medical school. Most of the physicians had held multiple managerial positions in their careers.

(8) Unlike the executives interviewed in the earlier study, physician managers were reluctant to discuss failure among their colleagues. Some of the physicians were more open to discussing their own flaws and setbacks than they were to talking about someone else's. Sponsored by the American College of Physician Executives, the three workshops involved a total of almost 200 physician managers. The workshops generated a variety of information, including lists of reasons physicians became managers and of flaws that derailed them.

(10) Physician chief executive of a community hospital who had one career in clinical practice, a second career as a medical school dean, and was starting out on his third career as a CEO.

(11) Unfortunately, the nature of the data from workshops and qualitative interviews precludes an exact frequency count.

(12) See McCall, M., and others. The Lessons of Experience: How Successful Executives Develop on the job. Lexington, Mass.: Lexington Books, 1988, for a comprehensive discussion of 34 such characteristics.

(13) Wall, J. Bosses. Lexington, Mass.: Lexington Books, 1986, pp. 101-102.

(14) McCall, M., and others, Op. cit., pp. 18-29.

Morgan W. McCall Jr., PhD, is Senior Research Scientist and Visiting Professor, Center for Effective Organizations, Graduate School of Business Administration, University of Southern California, Los Angeles. Judith A. Clair is a PhD candidate in the Graduate School of Business at USC.