You have the job you wanted - now what?

All agreed there is a significant drop in morale right after taking the job. Many of the things you thought you could fix quickly take much longer than you anticipated. Everyone comes to you and complains. One said, "I was new. All the senior management people lined up in my office to tell me how horrible the CEO was. One after the other, after the other, and I was not smart enough to not allow that to occur. Ultimately, I got called into the CEO's office and was reprimanded."

The following accounts are not meant to be all-inclusive of difficulties new physician executives encounter in their jobs. But they do provide insights that may be useful to others taking or about to take the step into a new position.

Physician Executive 1

Initially, the most difficult part of the job was understanding organizational dynamics and politics. This is not something you are taught in medical school. I talked to a lot of people in the organization to figure out how things worked. I tried to not get my nose bloody twice when I made dumb decisions. So part of it was the school of hard knocks. I read. I used my network. But I didn't know how naive I was.

If you are dealing with the medical staff, they expect you to have a certain base of knowledge about by-laws, policies, procedures (when someone can quit taking call in the emergency department), health law, contractual law. That takes some homework.

I needed to know how to run a meeting. It's the bread and butter of what we do, but most of us weren't taught to do it well. Some of us do it naturally fairly well, but most physicians are not taught to do that. We are taught to be independent and autonomous souls, and then once a month we are thrown into a departmental meeting and asked to agree about things. The know-how is out there in books, in programs.

I also was called on to be a liaison a lot. The administrators would come into my office and ask me how to deal with the docs. The docs would come in may office and ask me how to deal with the administrators.

Physician Executive 2

I categorize the knowledge base into four areas: first is the basic hard administrative skills you need to deal with administrators--finance and economics so you can talk their language and deal with them on an equal level so they can't snow you.

Second is the knowledge base that is relatively unique to what we do--joint commission, by-laws, health law, running meetings. We have to know those things better than anyone else, because neither the administrators nor the medical staff usually know them, and we're the ones the job falls to.

The third group is the hardest, and that is the people stuff. Twenty years ago, when I was in my first department chairman job, I went to my first leadership course. Two weeks off in Washington. Boy was I excited. I thought I would come back and know how to make all these decisions and make the right ones. We studied all this stuff about management, and it didn't fix the problems. You have to learn by trial and error and hope you don't bleed too much while you are learning how to deal with difficult physicians and how to deal with conflict and negotiation.

In the fourth area, you rise to another level where you become knowledgeable about national health policy. Instead of reading medical journals, your body of literature becomes the hospital and the national and economic literature.

Physician Executive 3

I had to go up to a small town to talk to a large group of physicians in the hospital there. The hospital administrator sat down next to me at the beginning of this dinner, and a physician in the back stood up and said." John, you don't want to sit there. We intend to throw food." This was my introduction. By listening and not telling them what we were going to do and then responding to their concerns, they never threw any food. That was really enlightening to sit there and think--these are my fellow physicians. I had been in the job two weeks, and they were telling me they were going to throw food at me. They didn't even know me, and I was the enemy.

For me, the most important thing I needed was listening and collaboration skills. If you go in and say, "I'm the one who knows how to do this," and start telling everybody how to run the shop, even though you might be right, you are going to fail. You have to immediately sit back and let other people talk to you and tell you. You have to make the decision, but you have to draw those other people in and listen to them.

When I first came into the field, I replaced a physician who was staying on as my assistant. This was a retired physician who got the first award from the state medical association for all the work she had done around the state during her career. I was coming in at half her age to be her boss. That was a humbling experience. She was in this big corner office with all her things packed in a box. It was very clear that she didn't want to leave the office. After I had been there two or three days in another office down the hall, I asked her "Why is all your stuff in a box?" She said, "Aren't you going to take over the office?" I said, "No it's your office, you stay here." From that day forward, we had a great relationship. You have to look at the little things like that. It had nothing to do with my ability to be a medical director in the HMO or my ability to help the physicians practice high-quality, cost-effective care. It was a people skill--that's the top.

Physician Executive 4

One thing that is needed for new physician exectives, as well as experienced ones, is support. The position is usually so stressful that physician executives need to know that it is alright to call someone, to share what's going on, to ventilate. It really is okay to talk to a colleague about difficult issues.

New executives especially need to realize that they must explicitly block out some time, separate from what they think of as their official job duties, to do reading, thinking, learning, networking, and getting support. Most new executives are so busy attending meetings and acquiring new skills that they often fail to schedule any quiet time at all for simple reflection.

I get calls from new executives who are clearly looking for a quick fix. "Well, if you could just tell me what computer program to buy, or which spreadsheet to use, my troubles will be over." "If you will just tell me one person to call, who in ten minutes over the phone can tell me the answer to solve this problem...." "What one management course should I take that will teach me how to be a good physician executive...." Of course, there is no quick fix, but that is usually the hardest thing for executives to hear. To the new leader, there is an amazing amount of' disbelief on this point. "Well, obviously that guy didn't know anything, because he didn't give me a brief and easy solution. Who should I call next?"

When I was new to our group, we had a senior physician who was clinically very good, but no support staff member could be retained in his office for more than a few weeks because they felt ill-treated by this physician. I found that they were on their eleventh scretary of the year. With a little research, I discovered that it had been going on this way for 20 years. It seemed that the company was at risk for some very nasty employee lawsuits. So, as the new kid on the block, I said simply, "Why don't we just let him go?" The response from the other physician leaders was, "Oh yeah, that's a good idea." I ended up functioning as the chief prosecutor in the situation. I reread the bylaws at the time and made a complete formal presentation on this physician's behavior to the board of directors. They voted unanimously to fire him. Just a few weeks later, the board undid its action and voted unanimously to reinstate him. They said, "He's been here a long time, and he's always been that way." So, the lesson was that some battles are simply not worth fighting. In certain situations, you have to learn to say, "Bob is the way he is, he's going to be here many more years, and that's just the way it's going to be." There are other challenges to face that will be more important and more rewarding in the end. Once that lesson is learned, you will be able to accept some things that seem intolerable during a new executive's first few weeks.

By the way, that anecdote is several years old. That senior clinician is still on the staff, and we still have turnover of support staff members. The main action we took is to basically bottle him up. We put him in an isolated office in a hallway that is very difficult to find. He is all by himself, and he communicates to the support staff through a middle manager. There are only a few people that he can be on speaking terms with in the workplace. He still comes to work everyday. He's extremely obsessive-compulsive and very difficult to deal with, but excellent in his clinical role.

A final point is that physicians are fundamentally scientists, so we all come from a basic ethic and years of training that says that two and two are always four. We tend to think, "If it's so, why can't I just say it?" But, in the real world of large organizations and organizational politics, that doesn't always work. I'm a truth teller. I can't help it; it's in my genees. But an important lesson for new executives is to learn exactly how and when and where to say what is so.

Physician Executive 5

When I first took my senior management position four years ago, I felt my biggest areas of weakness were certain technical areas. In a managed care organization, I needed to know more about utilization management, contracting, capitation. In retrospect, my biggest areas of weakness were organizational politics, communication, running meetings, and delegation. I don't know how to get past that. Our organization is coming up with a set of materials and resources that will be good for new physician managers. And yet if we try to give them the information they really need, it could be that they won't be interested, because they have not made the mistakes that we've made.

Having some sort of support person really would be good. You could call this support person and say, "I'm just not having any luck getting these doctors to send their deliveries home the next day." Perhaps the resource person would point out that the medical problem was a communication problem. It wasn't a utilization problem at all.

Physician Executive 6

New physician executives need an IV solution of tincture of backbone. You can't go into a job with the expectation that you are going to be accepted as the leader. You have to earn that. I was never a hospital medical director, but some of my friends were, and I felt sorry for them. They had to grovel to get things done and really play the political game much more than I ever had to in managed care.

A technique that I liked and still use is, when I get resistance that makes me feel down, I go to some of the obvious leaders of the group and share what the problem is with them, always reminding them of the mission. As a physician executive, I am a leaders and know what the organization is aiming for in the long run--to give the best care we can to our patients, care that is as cost-effective as possible. We don't want to jeopardize their care. Say to an obvious leader, "We have four ob-gyns who keep patients in for three or four days, and my evaluation is that they don't need to be kept that long. How can we handle that, Joe? Help me with this." And then you sit and listen. You may have to do this with a couple or three people. But after a while you get a spirit of cooperation. An idea that he or she isn't here to tell us what to do. They really want to solve problems.

Physician Executive 7

The biggest asset you need to take to this job is a good sense of humor. So many ludicrous things happen the first few months. In the beginning, it is all fire fighting. I had to leave space to grow and plan for the job. At first, I tried to tackle everything. I thought I could fix things quickly and I found out I couldn't.

I had to get some small wins at first. One physician said her door opened the wrong way. The administrator said we can't afford to change the door. I said that we have to change the door. That's a very little thing, but it made all the difference in my relationship with that clinic.

Second thing I found was an incredible number of meetings. So I had to learn patience. I needed negotiating skills, facilitating skills.

General Comments

Another area mentioned by most of the group is what to do when employees come to you with complaints about physicians or other employees.

"People are unwilling to write down what they are willing to say, but they still want you to act on it. Then they think there is something wrong with you for not acting on it." I say to them, 'If you really want something done, you've got to help me. We've got to build a case. I need a piece of paper with documentation and quotes and times and dates. If I get enough of those pieces of paper, we can do something.' But they won't do that because they are afraid of retribution, and it keeps getting dumped on me. I haven't solved it yet."

Another member of the group said, "People will give you all their problems if you let them and you have to get over the guilt of saying no."

All the physician executives felt it would have helped them to know that other physician executives experienced the same surprising disappointments and frustrations when they took their first management positions. "The reality is that it takes a long time to learn this stuff, and the fact that there are no quick fixes is an awfully important lesson to learn".

RELATED ARTICLE: Skills Most Often Mentioned by Physician Executive Group

* Understanding organizational politics

* Listening skills

* How to run a meeting

* Collaboration

* Conflict resolution

* Dealing with difficult physicians

* Negotiation

* Communication

* Delegation

* Dealing with not being liked by physicians or administrators