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Crafting the new physician executive.

In retrospect, business historians have begun to view the Industrial Revolution not only as the launch pad for a century of economic progress but also as the fertile ground in which the seeds of future obstacles to sustained progress were sown. Industrialization gradually displaced the cottage enterprises and guilds that had previously characterized the economies of Western civilization. Once craftsman had created products whole. An entire plow, for example, would be made by a single person or family.

The Industrial Revolution broke work into tasks and assigned people to single tasks which, taken together, created a finished product. This allowed for significant expansion of the labor pool because now unskilled workers could be used to produce goods. It also allowed for the standardization of products and their components. What was once crafted became "manufactured." Of course, the work of unskilled labor had to be organized and directed. As a result the notion of managers was born.

Experts have suggested that the Industrial Revolution drew a line between "those who think" and "those who do." It also gave rise to the institutionalization of functions and departments as management divided itself into specialties such as finance, marketing, and operations. This specialization gave rise to focused knowledge and capabilities.

The same revolution that remolded the rest of Western society also reshaped hospitals and medicine. Today, hospitals, like factories, consist of scores of functions and departments. A typical 350-bed hospital has about as many job categories; of those, about 70 percent have one person in them. The house of medicine is segmented into specialties. And each of these specialties continues to fragment into even narrower fields of concern.

Gradually, another line was drawn in health care. This time between management and medicine. Doctors surrendered management to nonphysicians. A largely productive, but often uneasy, alliance was forged. Although lines that were drawn in health care delivered demonstrable benefits, they also created deep problems that now serve as major barriers to continued forward progress. Today, health care is so fragmented that its ability to serve the needs of patients is compromised. It has become so disjointed that all efforts to manage cost and quality are marginalized.

The separation of financing into a largely distinct insurance industry has only exacerbated the Balkanization. Organizational, functional, clinical, and scientific walls have piled up between health care professionals. As a result, health care is no longer delivered whole. Patients are shuttled between departments and specialists. Communication and collaboration between care givers have broken down. A profound myopia has set in.

In addition to having become disconnected, health care's center of gravity has shifted. Power and influence in healing was once centered in the clergy; it then shifted to physicians. It shifted from university-trained physicians to apprenticed physicians. Then it shifted back to the scientific model, to the universities, and to specialists. Slowly, it shifted to hospitals. And now it has begun to shift to health plans and to primary care physicians.

Entering a new world

It is into this world, disjointed and shifting, that the aspiring physician executive now steps, wondering where to focus talent and time. Some physician executives have already been left stranded in the hospital as influence has moved out of the traditional medical staff organization into emerging PHOs, MSOs, and group practice start ups.

Meanwhile, a new class of physician executive has been coming of age in the health plans. And a growing number of physician executives are gaining national prominence as leaders of evolving integrated delivery systems.

My answer to the question of where the future lies for physician executives is imbedded in the phenomenon of fragmentation and shifting change. Physician executives who focus on "removing the lines" will be best positioned for leadership roles in the future. The experience and skills necessary to make work whole again will be in strong demand in every industry worldwide, including health care. Indeed, we are at the beginning of another revolution. This one will not only redefine work but will also redefine the organizations in which the work gets done, along with the relationships among organizations.

What kind of new executive will be needed? The physician executive well positioned for leadership in the future will be:

A process connector. He or she will look at illness and see it whole. He or she will abandon tradition that David Ottensmeyer, M.D., the former president and CEO of the Lovelace Medical Center calls "fire engine medicine," an approach that focuses on a medical problem after it happens and then seeks to extinguish it.

Instead, the physician executive will look to causes that extend into the community and will be oriented to prevention. By definition, the new physician executive will be a generalist in perspective and approach. Every problem, be it clinical or management, will be addressed in a system context. He or she will be able to draw a flow chart that defines the nature of an organization's key processes. The physician executive will be dedicated to optimizing these processes.

An information builder. Cost and quality cannot be managed without information. Information abounds in health care. Unfortunately, it is trapped in receptacles that are unconnected. For the most part, health care information still lives predominantly on paper records organized in much the same fashion they were 100 years ago. No industry is as reliant on information yet underinvests so dramatically in it as health care. The new physician executive will liberate that information and set it loose throughout the organization, putting it into the hands of those who are closest to the patient in a form they can use.

A visualizer. It's not enough that the physician executive understand the dynamics of the care system he or she seeks to manage; the physician executive must paint a coherent picture of it and communicate it convincingly. DePree suggested that one of the great challenges of leadership in the '90s is to help workers see things whole and to see them in a way that they can connect with.(*)

A strategist. Strategy is the art of getting from point A to point B in the face of uncertainty and risk. Strategy formulation and its execution are the most valued of all skills in top executives. It is strategy that separates the consistent winners from the also rans. Strategy is both analytical and intuitive. German Field Marshall Rommel called it "Spitzenfigerefuhl" (feelings at the finger tips), and management gurus Tom Peters and Bob Waterman describe it as a "fine feel for the doable."

A project manager. One of the distinguishing characteristics of today's emerging organization is the disappearance of the traditional notion of a job - something you come to work and do with some consistency, day in and day out. Now the focus is on assignments and projects toward which multidisciplined teams are assembled and committed until the job is finished; then they are disassembled and reassembled elsewhere. This ability to assemble, manage, and disassemble will be a fundamental skill set every physician executive will want in his or her portfolio.

A team builder. Will Mayo once predicted that all progress in the 20th Century would be a function of organization and teamwork. The rugged individualism that has come to epitomize the American physician is also medicine's Achilles' heal. Physicians are disadvantaged because of their profound inability to work together and stand together. They also suffer because they have not developed the ability to muster, motivate, and orchestrate teams of nonphysicians.

A value creator. Like all executives, physicians must determine how best to optimize the relationship between cost and quality. This requires an understanding of the key drivers of cost as well as an intimacy with the fundamentals of continuous quality improvement. The challenge is to create an ever improving stream of benefits at an ever declining cost.

A generalist. The new environment of leadership requires jack-of-all-trades executives who can orchestrate the whole range of work because they know enough about its overall requirements. Imagine a basketball team where each player can shift into a new role - point guard now, then center, then power forward. A team that shifts, reshapes, and slides like quicksilver but always maintains its ability to conduct electricity - that's the kind of leadership corp the organization of the future will require.

A change master. Change has created a demand for fluidity. The environment changes faster, has greater swings, and is much more uncertain than it has been in the past. More than anything, this instability of change is tied to the rapid movement of information through societies and organizations. The new physician executive will keep the organization from settling into concrete. He or she will foster an amoeba organization that has the authority, competence, and resources to respond at its edges.

A market shaper. Success is built in the realities of the marketplace. The central realities of the marketplace are customers and competitors. Both are moving targets. And they both move faster than they used to. Effective executives stay close to their customers and keep a constant eye on competitors. That means watching and listening. You can't do either if you spend all of your time in meeting rooms. You have to do more than respond to customers. You have to lead them. No customer ever asked for a VCR, cable TV, a cellular TV, or an HMO. They had to be led to those products.

In some ways, practicing physicians are well suited to serve in the emerging role of the new physician executive. They are close to real value-added work of health care. They actually see, talk to, and often touch the ultimate customers every day. And they are in a position to relate closely with other caregivers who are extraordinarily close to the customer and constantly engaged in value-added work - nurses, physical therapists, and physician assistants. Physician are, by nature and by training, analytical. In other words, they are very good at converting data into information.

But physicians also come to the role of executive with some disadvantages. Because they are increasingly so specialized, they are compartmentalized. The kind of whole process orientation the new executive must embody is in short supply among most physicians. Physicians don't communicate particularly well with one another, with other health professionals, and often with their patients. They are more oriented to independence than to teamwork. To occupy roles of leadership in health care, physicians will need new behaviors. Donald Berwick, M.D., a pediatrician and a leader in the field of quality improvement, summed up well the transition that physicians will need to make:

"Soloist to orchestra leader Anecdote to fact Controller to participant Talker to listener Teacher always to learner often Decisionmaker to enabler Fear to trust."

Consulting Firm Targets Seven Areas

for Clinical Program Integration

Chi Systems, Inc., an Ann Arbor, Mich., consulting firm has identified cancer care, cardiac care, emergency/ trauma care, behavioral health sciences, neurosciences, post-acute services, and women's health as "prime candidates for systemwide integration." The firm says that the integrated health care delivery system can achieve significant reductions in unit costs in these areas through special attention to "patient volume and throughput, human resources/productivity, technology management, facilities/ capital, supply acquisition, ancillary support services, marketing, and data/quality systems."

J. Daniel Beckham is President of the Beckham Company in Whitefish Bay, Wis., a health care consulting firm specializing in integration and strategy.

(*) DePree, M. Leadership is an Art, New York, N.Y.: Doubleday, 1989.
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Title Annotation:Medical Management: A Profession in Transition
Author:Beckham, J. Daniel
Publication:Physician Executive
Date:May 1, 1995
Words:1902
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