In transit from physician to manager - part 1.
This was not an encouraging opening for a conversation. Alice replied, rather shyly, "I-I hardly know, Sir, just at present--at least I know who I was when I got up this morning, but I think I must have been changed several times since then." 
The 1980s saw convulsions in health care. Among the fundamental changes was the emergence of medicine as big business, complete with takeovers, acquisitions, and corporate ownership. While the days of the independent, house-calling physician were long gone, the era of the salaried physician embedded in a corporate bureaucracy marked a stunning change for both physicians and the corporations that hired them. Managers of these awkward behemoths faced more challenges than just the inevitable turbulence of a "new" industry. In the midst of a health care revolution driven by technological miracles on one hand and intolerable costs on the other, corporate managers (often developed in the insurance industry) found themselves out of their element and performed correspondingly. 
Caught between the pointing fingers of government and corporate clients who were concerned about costs; of physicians who were concerned about quality of care and preservation of the profession; and of patients who were concerned about quality, freedom of choice, and cost, health care organizations searched for options. Among them was to move physicians into significant managerial roles.  From an organizational point of view, the physician manager seems to be a good fit. Who better to oversee health care than someone intimately familiar with it? Who better to lead physicians than one of their own, who speaks their language and understands the issues? Who better to make strategic decisions regarding quality of patient care and responsible cost containment?
The corporate need for physician managers coincided with a greater willingness among physicians to accept managerial roles. With increasing numbers of physicians on salary and with increasingly regulated reimbursement for specified procedures, the disparity in remuneration between clinical practice and managing was narrowed or even reversed. Changes in practice, leading some physicians to see 8 to 10 patients per hour, led to burn out and disillusionment--and to increasing numbers electing a managerial alternative.
At first glance, it appears that physicians are especially suited for the managerial world. Many of the skills and abilities expected of an effective physician seem directly transferable to a managerial setting. Diagnosis requires analytical ability. Responsibility for patient care requires extreme self-confidence and comfort with command. Dealing with patients and families in distress requires interpersonal sensitivity. Yet, like other kinds of professionals, physicians are finding that the transition from one profession to another is sometimes rockier than expected.  There is a significant gap between a theoretically ideal fit and the realities of managerial life. Both the organizations that promoted them and the physicians who ended up as managers frequently have been disappointed.
Organizations sometimes find that clinicial dedication in a physician can become strategic myopia in a physician manager--especially in investment decisions that pit individual patient care against institutional objectives. Physicians sometimes find that a move into management is more than they bargained for. Some physicians enter management believing they can continue their clinical practice or medical research and manage at the same time. Sooner or later, they discover that being effective at both is impossible and that learning to manage effectively is more difficult than it first appears. When physician managers fail, it is rarely because they lack clinical skill.  Instead, they discover that the skills that served them well in clinical practice are only a small part of what they need to know to succeed in management. In fact, some of the clinical habits and skills can even get in the way.
Physicians discover that the move into management is no less than a change in careers. After many years of investment in becoming a physician and learning all the skills and values required to succeed as a doctor,  they now face learning the skills and values needed to succeed at something totally different. One way to understand the change from physician to manager is to view it as a series of transitions that reflect the fundamental differences between success at technical/professional jobs and success in managerial roles. Focusing on transitions puts attention on the differences between the two careers, on the new skills that must be learned, and on how one goes about learning the new. By transitions we mean the kinds of changes in an individual's skills, values, knowledge, or other attributes required to move from effectiveness in one profession (in this case, medicine) to effectiveness in another (management).
The Perspectives of Physician
It would be relatively easy to document the differences between medical practice and managerial jobs.  No doubt, the list would be both long and intimidating, and each difference could represent a transition that should be made. But a long list of objective differences begs several important questions, including which changes are most crucial and which are the most difficult. Of all the possible tribulations, which ones really precipitate the gnashing of teeth and pulling of hair?
To explore the role of the physician manager, we interviewed 14 physicians who had become managers (and one nonphysician who had become a hospital administrator)  about a variety of topics, including their careers, why they became managers, what and how they learned about managing, and the problems they dealt with in their managerial jobs.  Questions on each of these topics generated information relevant to the transition from physician to manager, but this article deals primarily with their answers to the specific questions, "What do you consider to be the major transitions you have been through in your career? What made them difficult? What helped you get through them?" We defined a transition as the movement "from" something "to" something else, emphasizing that what the "something" was was entirely up to them. It could be subjective or objective, a feeling or a fact, a skill or an attitude. We asked the physicians to be as specific as possible in describing changes they had gone through in making the shift from doctor to manager. A content analysis of the physicians' descriptions produce six themes that seemed to capture their experiences as they moved, or tried to move, into managerial jobs.  Three of the transitions seemed to involve substantial psychological or social adjustment, while the other three involved the development of new skills or abilities. The six transitions were:
* Psychological adjustments.
* From hard-earned independence as a clinician to dependence as a manager.
* From identity as a physician focused on individual patient care to identity as a manager focused on the institution.
* From naivete about organizational dynamics to acceptance of organizational realities as part of managerial life.
* New skills or abilities.
* From command and control in a clinical setting to persuasion and ambiguity in a managerial role.
* From comfortable relationships with professional colleagues to authority-based, boss-subordinate relationships with former colleagues.
* From competence in medicine to competence in business.
It was our sense that few if any of the physician managers we interviewed had successfully completed all of these transitions. Which of the transitions people were struggling with and how far along they were depended on their prior managerial experiences and the demands of their current managerial position. It appears, however, that, over time, all physician managers will have to face these issues. For some of them, certain transitions will not be difficult, but they can't be avoided altogether if a managerial career is pursued. In an increasingly difficult organizational environment such as health care, a manager's inability to resolve the issues in a transition eventually leads to a crisis. Sooner or later, either the physician seeks reassignment (for example, by returning to clinical practice, as at least one person in our sample did) or the organization takes action to remove the physician from management (as happened to another).
Three Psychological Adjustments
From Independence to Dependence. Physicians and other highly trained professionals make a substantial investment in their chosen careers. Physicians in particular spend a long period in student and apprentice roles, achieving professional independence only after an extended socialization process. When independence is finally won, the sweet feel of mastery and control is heady stuff. Further, it is noble stuff. More than just the Hippocratic oath, becoming an independent physician carries with it a strong set of values about the sanctity of the doctor-patient relationship, the primacy of quality care, and the physician's right (duty) to make decisions for the good of the individual patient.
Early in the process of becoming a manager, the very heart of this independence is threatened. The physician (who, as one physician manager said, "is very independent and likes a lot of rope"), finds himself once again dependent on superior authority for setting goals, evaluating performance, and determining rewards. Having metamorphosed once, resumed subordination is not inherently attractive, even if the "boss" is also a physician. Eventually, that boss in the organizational hierarchy will not be a physician, and the dependence becomes based completely on hierarchical rather than expert authority. It is seldom well received.
A typical reaction to the return of dependence was captured by a physician manager working for a nonphysician boss: "Once you've played God, it's hard (or impossible) not to feel good about yourself. Then a lay guy tries to tell you how to do your job." 
Like the fish in water, the average manager lives this dependency as a natural habitat. But for the professional, used to a certain level of autonomy and discretion by virtue of special expertise, the water is decidedly tainted. Former accomplishments and special status based on medical success count substantially less in the managerial sphere.
This transition, then, is more than a simple return to subordination. It is no less than accepting as legitimate a dependency relationship based on organizational hierarchy rather than on medical expertise, degrees, or technical knowledge. While this transition can begin early in an organizational career, its true impact is not apparent until the physician reports directly to a lay manager. As one physician manager discovered when he reported to a regional vice president for the insurance company that owned his HMO, even a bad physician-boss shares some basic values and a view of the world understandable to a physician. Dealing with a "lay" boss-even a good one--demands a different orientation.
From Identity as a Physician to Identity as a Manager. Physician managers describe physicians as fiercely independent, acting in their patients' or their own interests, and only tangentially a part of the particular institution in which they are embedded. As one put it, "Doctors are looking at personal agendas rather than department agendas." Another physician manager noted with frustration that "it's hard to understand why physicians are so hard-headed--why they do things for themselves and not for the group (or even the patient)." For those who manage physicians, a physician's identity is tied up in personal professional agendas, or in individual patients. It is difficult to get physicians to make sacrifices for the good of the institution. In contrast, the heart of the manager's job lies in building the unit or institution, and managerial effectiveness requires increasing identification with organizational goals and systems rather than personal or professional ones. Concomitantly, achieving managerial goals increasingly requires long time frames and interaction with external bodies (such as boards and legislatures).
As the institutional demands of leadership increase, it is increasingly difficult to commit the time and energy required to meet them and, at the same time, maintain the professional intensity of the physician. In fact, the tough side of this transition is that effectiveness increasingly depends upon institutional commitment and time spent on institutional objectives; yet this is psychologically and physically at the expense of clinical practice. As many told us, they "feel fear because they are giving up their lives as a doctor." Thinking of one's self as a manager first, and learning to identify with and embrace the goals and challenge of management, is no small accomplishment.
From Naive to Pragmatic. Few dynamics affect the professional entering management as much as the startling shift in the nature of rationality. For a professional, and especially for a clinician, the world has one kind of order, based on fact, linearity, and logic. An engineer can analyze pressure points on a bridge and predict within specified parameters where and under what circumstance it might give way. A physician can diagnose on the basis of symptoms and tests, and, once diagnosed, most diseases will follow a predictable path. Treatments are, within limits, predictable in their effects.
The world of management and organizations seems to have a different basis for its rationality.  One of the first shocks any new manager faces is that logic and rationality, as defined in other professions, are not the same in management.  Finding a technically satisfactory solution, for example, is sometimes the easiest part of a managerial job--getting people to accept and act on the "right" answer is the real challenge. In the managerial hierarchy, technical expertise is sometimes only a minor driving force in what happens. Many physicians and other professionals enter management profoundly naive about what it takes to make things happen in a complex organization. It is a jolt that facts alone don't always triumph, that people don't automatically rally around logic, that power and position and differing perspectives all influence outcomes.
In response to this jolt, some new managers begin a transition from their naive view to a cynical one. When rationality as previously known doesn't hold, some conclude cynically that there is no rationality. "It's all politics." "It's who you know, not what you know." "You've got to play the game." This is a very dangerous intermediate stage in the overall transition. Cynical reactions, while perfectly understandable, define problems as irrational, unapproachable, unsolvable. Thus the manager is left with an unassailably self-righteous position upon which he or she cannot--or need not--act. As one put it, "I didn't want it or need it [management] as a job, and there was power in that."
In an organizational world of conflicting interests and power differentials, to ignore or disdain "politics" is to resign from organizational leadership. To view "people problems" with disgust is to abandon the very heart of management. The transition is not complete until the physician can move from the naive through (or past) cynical into a pragmatic approach to how organizations work.  As long as there are hierarchies, power differences, and different views of the world, people will disagree and work to have their views prevail. To the pragmatist, politics simply is. It is another issue to be dealt with, another thing, like ambiguity, to learn to manage effectively. Unlike the cynic, who dismisses the apparently nonrational, the pragmatist tackles it as another problem to be solved. Larger goals require mastery of new skills, and the pragmatic manager learns to "do whatever it takes" to make the organization work. 
This movement from one rationality to another can be very difficult for the professional. In our interviews, for example, many clashes with "lay" managers centered on what physicians believed were moral and ethical value issues. In many cases, however, the real dilemma lay in pragmatic organizational choices that simply looked different from the two perspectives. One example, given by a senior medical executive, showed the dramatic differences in perspective even among physician managers at different hierarchical levels. It involved a dispute over the purchase of a million dollar piece of equipment--an extremely sophisticated, high technology apparatus that would save a relatively small number of lives and would put the organization on the cutting edge of care in a particular field. The lower level manager, based largely on his physician's values for a single life, saw the equipment as essential for patient care and the reputation of the specialty area. For him, not allocating the funds was indicative of fundamentally misplaced values in the administration. The senior manager, viewing the situation from the institutional perspective of limited resources and many needs, believed the million dollars could be used to significantly upgrade emergency preparedness, potentially saving hundreds of lives. The issue was perspective, not abandonment of values.
Development of Three New Skills
From Command to Persuasion. Accepting a boss's authority (the transition of dependence) is not the only issue of control faced by the physician in management. The physician manager's own ability to control situations seems to change in two unsettling ways. First, most physicians are used to calling all the shots in patient care and are decidedly unused to having their authority to do so questioned. As managers, they discover quickly that their "subordinates" (who are often physicians) are not always looking for direction and sometimes don't respond well to orders. The new requirement, as the doctors themselves describe it, is to learn to influence, persuade, and convince. As one physician manager described it, "Doctors only talk to God. They prescribe. They dictate. This works in the doctor-patient relationship, because the patient wants direction. In organizations, members are not necessarily looking for directives. We need to get executives comfortable with using persuasion to get physician managers to work with others in a fashion that they aren't always captain of the ship."
This control issue involves development of the skills necessary to influence (rather than order) others and to be effective in spite of the ambiguity of managerial jobs. Used to working with patients, physicians expect quick feedback (a treatment works or it doesn't; a patient gets better or not) and tangible results. The contrast they find in managing others is stark. Because achieving change through others may take a long time, gratification, if any, is delayed. Feedback on how well one manages others is slow to emerge and often misleading; rewards are not immediate. It is a world of ambiguity in which the impact of decisions may be slow to emerge, and credit is often diffused.
The control transition, then, requires learning patient, the skills of negotiation and persuasion, to act comfortably in spite of ambiguity and long time frames, and to accomplish things through others rather than hands-on.
From a Physician-Peer to Managing Diverse Relationships. Most successful managers, regardless of technical background, eventually end up promoted over their former peers (or even bosses). Handling this situation is inherently difficult, because interacting as a peer is dramatically different than interacting as a boss who influences another person's evaluation, objectives, salary, and even employment.  For physicians who become managers, the normal difficulty of this situation is apparently exacerbated by the loss of peer support. Association with other physicians is more central for physicians because it has professional as well as collegial implications.  In addition, promotion over one's peers is both less common among, and viewed with greater skepticism by, physicians. Professionals in general and physicians in particular seem to have little respect for authority based on hierarchy, being far more impressed by professional credentials and accomplishments. 
Physician managers were often surprised at the magnitude of the change in their relationship with their former peers. After accepting a serius managerial role, some were viewed by their former colleagues as having "sold out" or abandoned the values of the profession.  The impact of finding himself in the out group was reflected by one physician manager, who said his peers considered him "second class." Another reported that his former peers "think I'm goofing off."
Adding to the hurt and loss are the difficulties associated with relationships that the physician manager now finds central. Depending on the nature of the job, these may include "natural enemies" of physicians--nurses and administrators. Even when the physician manager still deals primarily with physicians, there is often a totally new perspective from the managerial side. As one frustrated physician manager of physicians discovered ironically, it is "hard to work with physicians. They are very difficult to manage." Another found that, "When I tried to use authority, no one took me seriously."
Even family life can be affected by the move into management, because the social network and status in the community are often tied to the role of physician. As one physician manager recounted, when people found out he was a manager, invitations tapered off and his wife was treated differently in organizations she belonged to. Another physician said that deciding to accept a managerial role almost led to a divorce, his wife was so upset.
The transition in relationships, then, entails a change from in group to out group, a fundamental change in the relationship to a central professional peer group, and the initiation of new central relationships. It things on the development of a host of interpersonal skills relevant to these changes situations. Like other managers who are promoted over peers, physician managers must learn to deal effectively with the changes relationship with their now-subordinates (in essence learning to manage professionals as opposed to being a professional), as well as develop the skills needed to deal with other kinds of people (e.g., nonphysician) who are now central to managerial success.
From Competence as a Physician to Competence as a Manager. Another painful transition was precipitated by the return to ignorance faced by many physicians as they took on increased responsibilities in managerial roles. It was one thing to be conversant with microsurgery, magnetic resonance imagers, ventricular assist devices, and biotech miracle drugs, but the arcane language and complex content of medicine didn't help much in the equally arcane and complex world of business. They found themselves confronted with undreamed-of esoterica--cost of capital, return on equity, spreadsheets, EEOC legislation, tax law, market segmentation, customer service, labor shortages, cost containment, union work rules, etc. Not only were the language and concepts baffling, but most of the crucial players with whom they had to work already knew the rules. As one medical general manager observed, not understanding finance and accounting made him helpless in influencing crucial organizational decisions.
If the content of business weren't difficult enough, the process of getting things done added yet another dimension to the managerial "TwilightZone." Instead of making decisions within a limited domain of professional expertise, physician managers found themselves forced to make decisions on things they didn't fully understand and about which they hand insufficient information.
The magnitude of these changes was, for many physicians, enormous. Before, they were expected to be an expert in medicine and know diseases and treatments. Now they were expected to be experts in business, knowing people and budgets. From fighting for and spending money as part of a cost center, they were propelled into controlling costs and earning revenue as part of a business unit or profit center. From relying on specialists when they were ill-informed, they were now expected to adjudicate disagreements among experts in a vast array of areas well outside their expertise.
At the core of this transition is competence. Psychologists have long known that a feeling of personal competence is central to individual selfesteem and self image.  It is no small matter to move voluntarily from mastery to ignorance, essentially starting over the learn a new set of skills. Yet this is exactly what a move into management asks from a physician. And to the extent that taking on a new profession results in giving up mastery of the old--through decreased time spent in practice or gradual obsolescence--the challenge of learning is compounded by significant personal loss.
In the May-June 1992 issue of Physicians Executive, the authors will develop some of the specific obstacles that physician managers encountered in their transitions into management.
 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. Special thanks go to Ron Pickett, formerly with ACPE, Robert Spears, MD, and David Moltrop Jr., MD.
 Carroll, L. The Annotated Alice. New York, N.Y.: Bramhal House, 1960, p. 67.
 For examples of the managerial challenges in the new health care "battleground," see "Can You Afford to Get Sick?", Newsweek, Jan. 30, 1989, pp. 44-50, or Herzlinger, R., "The Failed Revolution in Health Care--The Role of Management," Harvard Business Review 67(2):95-103, March-April, 1989.
 "Can Insurers Nurse the HMOs Back to Health? Business Week, Jan. 16, 1989, pp. 80-81.
 McCall, M., and Clair, J. "Why Physician Managers Fail." Los Angeles, Calif.: Center for Effective Organizations, Technical Report T 89-14 (157), 1989.
 For insights into physician manager failures and challenges, see McCall, M., and Clair, J., op. cit., and Ottensmeyer, D., and Key, M. "They Unique Contribution of the Physician Executive to Health Care Management." In Curry, W. (Ed.), New Leadership in Health Care Management: The Physician Executive. Tampa, Fla.: American College of Physician Executives, 1988, pp. 50-64. But the process is not unique to physicians--executives rarely derail for lack of technical knowledge (McCall, M., and Lombardo, M. "What Makes a Top Executive?" Psychology Today 17(2):26-31, Feb. 1983). Research on scientists and engineers also documents the difficulties they face in learning to manage, few of which have anything to do with their professional or technical accomplishments (McCall, M. "Leadership and the Professional." In Connolly, T. (Ed.) Scientists, Engineers, and Organizations. Monterey, Calif.: Brooks/Cole Engineering Div., pp. 328-45, 1983; Raelin, J. The Clash of Culture. Boston, Mass.: Harvard Business School Press, 1986; Von Glinow, M. The New Professionals. Cambridge, Mass.: Ballinger, 1988).
 More than most other professions, becoming a physician requires an unusually lengthy period of training and intense socialization. Giving it up for a career in management is that much more wrenching a loss.
 To get an idea of what some of the differences are, see Kurtz, M. "The Dual Role Dilemma." In Curry, W. (Ed.), New Leadership in Health Care Management: The Physician Executive. Tampa, Fla.: American College of Physician Executives, 1988, 65-73; or Ottensmeyer, D., and Key, M., op. cit.
 The 15 people interviewed included 14 physicians and 1 hospital administrator who was not an MD All but one of the physicians held managerial positions at the time of the interview. Titles represented included Medical Director (4), Associate Medical Director (1), Chief of Staff (2), Associate Dean (2), Department Head (1), Director (1), and Chief Executive Officer (1). Organizations represented included four hospitals (private, community, public, and university), two national managed care organizations, three group practices, and a medical school.
 For a report on some of the other result, see McCall, M., and Clair, J., op. cit.
 Approximately 26 major transitions were described by the physicians in the sample, and many of these contained multiple parts. The authors independently sorted their responses into themes, compared the results. On the one hand, many of the transitions could be described ad job changes, such as the first supervisory job or promotion from one level to another. More meaningful to us were the kinds of things they had to cope with in making the transitions, and it was these elements rather than the jobs themselves that finally emerged from our analysis.
 Unless othrwise notes, all quotes came from participants in the study and were reconstructed from interview notes. In some cases they have been altered slightly to protect confidentiality.
 Sayles, L. Leadership: What Effective Managers Really Do...and How They Do It. New York, N.Y.: MgGraw-Hill, 1979.
 See the sections on early work and first supervisory experiences in McCall, M., Lombardo, M., and Morrison, A. The Lessons of Experience. Lexington, Mass.: Lexington Books, 1988.
 This process as it plays out with physician managers is not unlike the model of individual reaction to change found in Strauss, A. Mirros and Masks: The Search for Identity. New York, N.Y.: Free Press, 1959.
 McCall, M., and Kaplan, R. Whatever It Takes: The Realities of Managerial Decision Making. Englewood Cliffs, N.J.: Prentice-Hall, 1990.
 Hutchison, E., and others, Key Events in Executives' Lives. Greensboro, N.C.: Center for Creative Leadership, Technical Report 32, 1987.
 Kerr, S., and others. "Issues in the Study of "Professionals" in Organizatins: The Case of Scientists and Engineers." Organizational Behavior and Human Performance 18:329-45. 1977.
 See Kerr, and others, op. cit., 1977; Rubin, I. "The Management of Professionals." In Curry, W. (Ed.), New Leadership in Health Care Management: The Physician Executive. Tampa, Fla.: American Collega of Physician Executives, 1988, pp. 121-8; Von Glinow, op. cit. 1988.
 This can turn to scorn or disdain, with devastating results for the organization. See Herzlinger, op. cit.
 Bass, B. Stogdill's Handbook of Leadership. New York, N.Y.: Free Press, 1981.
Morgan W. McCall Jr., PhD, is Professor of Clinical Management and Organization in the Graduate School of Business Administration, University of Southern California, Los Angeles, and Judith A. Clair is a PhD candidate in management and organization at the university.
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|Title Annotation:||Career Management|
|Author:||Clair, Judith A.|
|Date:||Mar 1, 1992|
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