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In transit from physician to manager - part 2.

In the March-April 1992 issue of Physician Executive, the authors described the six transitions that are required for a successful management career. In the second part of the two-part article, the authors describe some of the obstacles to successful transitions that were disclosed in their research.

Physicians who move into management face significant transitions that would be difficult to achieve under the best of circumstances. Failing to make any of these six transitions successfully hurts both the physician and the organization: Being unable to adjust to working in a hierarchically driven context, failing to identify with the managerial role, inability to accept the realities of organizational life, failing to learn how to exert influence in ways other than command, inability to handle changed and diverse relationships with a variety of people, and failing to learn the language and content of business.

Obstacles to Transition

It is crucial, then, to understand what helps physicians make the necessary transitions and what gets in the way. We asked physician managers about these issues, and, not surprisingly, they tended to focus on how their organizations helped or (more often) hindered them in making changes. From the interviews, our richest database is on how organizations contribute to the difficulties faced by physician managers. However, reading between the lines, capitalizing on the candor of a few, and drawing our own conclusions lead us to believe that there are three major forces in addition to the organization's failings that hinder physicians in making the necessary transitions: the physician manager's own defenses, especially denial, which get in the way of dealing with realities; the unsuitability, for motivational or ability reasons, of some physicians for a managerial role, reflecting an error in selection; and the physician manager's inability to build a new support system to replace the loss of physician peers. Apparently both individual physicians and their employing organizations can contribute to making transitions more difficult.

No One Else to Blame

It's a well established psychological fact that people have difficulty accepting or admitting their shortcomings, frailties, and failures.(2) It is also well-established that people sometimes have trouble dealing with significant losses--it is hard to let go of either people or situations that have meant a lot to us.(3) Physicians are not immune to these basic processes. On the contrary, physicians may have a harder time with both of them because other people are more likely to defer to or be intimidated by a physician, further restricting available feedback and challenges to the physician's behavior.

Both inability to accept shortcomings and inability to accept loss result in denial, which translates into behaviors such as acting as if nothing has changed, downplaying the significance of the change, refusing to accept the new situation (and, in some cases, fighting anyone or anything that tries to force change), or continuing habitual behavior in the face of contradictory information. Each of the six transitions represents a loss to the physician manager. Whether it is a loss of freedom, control, important relationships, mastery, or identity or naivete, it can be significant and elicit counterproductive responses. Denying a transition can be compounded by perceived inadequacy when feedback is available. Thus, both processes may work together to create a serious block to change. Failing to recognize the need for change, or persisting in behaviors that were useful in the old situation but are inappropriate to the new one, seriously hinders making a needed transition.(3) When such responses persist over time or exacerbate an already prickly situation, the organization may respond by removing the physician manager.(4)

Poor Choice in the First Place

Psychological defenses are not the only reason physicians fail to make needed transitions. Some are simply not suited to become managers. They may not want to manage, or they may not be willing to make the investment required to manage well. One physician manager was quite candid about it, saying, "It have an aversion to administrative-type activities. I have others represent me. I want to be involved in my research." Still others may not have the skills required, even if they try very hard. Regardless of the underlying reason for the failure, the organization has made a selection error.

Physicians become managers for a variety of reasons, including gradual increases in responsibility within a narrow specialty area, reputation as a clinician or researcher, shortage of viable candidates, desire to get out of practice, and as a result of a takeover or buy-out.(4) Neither the presence of needed managerial skills nor the ability to learn those skills is ensured by any of these mechanisms, and the needed motivation for change is not ensured by most of them. To the degree that the six transitions require both skills and motivation to change, poor selection plays a major role in eventual failure.

Loss of Support at a Crucial Time

A third reason for difficulty with transitions is the loss of a primary support group and the failure to replace it with another. Physicians seem to associate primarily with other physicians, both at work and socially. Physicians we interviewed confirmed this, suggesting that it was a logical result of the time they spend together, professional identity, and common interests. However, becoming a manager fundamentally changes the relationship between the manager and the former peers. To the degree that physician managers spend time exclusively with other physicians, this change can eliminate the major source of personal support at precisely the time it is most needed--to help with a major transition. Because the change in the nature of relationships with peers is often a surprise, the impact of loss of support is confounded by the personal loss.

Lousy Design, Poor Preparation

Finally, but in physician managers' minds most significantly, the organizations that employ them contribute to the difficulty of transition. The physician managers we interviewed described a litany of mistakes their organizations made, including failing to set clear objectives or specify the responsibilities of the job; failing to provide adequate or timely feedback; failing to train or otherwise prepare the professional for the role; neglecting to provide experiences for physicians to develop needed managerial skills; assigning new physician managers to bosses unable to coach or mentor; surrounding the physician manager with troubled or incompetent staff; and failing to reward or recognize exceptional performance. The general pattern of responses suggested that health care organizations were uncertain of how to use physicians in managerial roles, how to structure the managerial roles in terms of reporting relationships and responsibilities, and how to prepare their professionals for the demands of the roles. Combined with the errors of selection described earlier, it appears that the organization is a substantial obstacle to successful transitions.

Toward an Understanding of Transition

This exploratory study provides a framework for understanding the transitions required in moving from a full-time physician to an effective full-time manager. At least three clusters of variables need to be considered: the events that trigger transitions, the transitions themselves, and the obstacles that prevent or retard progress. The postulated relationships among these clusters is displayed in the figure on page 17.

For these physician managers, the events that triggered transitions were almost all related to job changes. The most frequently mentioned were:

* The first professional role after medical school, where as a resident or fellow they wound up playing some kind of leadership role.

* The first managerial position, which for many of them involved taking on a little bit of managerial responsibility in addition to their primary role as a physician.

* Significant job changes, usually promotions but sometimes lateral moves, that substantially increased managerial demands (involving such things as managing managers or people other than physicians, responsibility for different functions or departments, and being in charge of increasingly large units or institutions).

* Evolutionary processes, in which transitions were slowly pushed along by gradual increases in responsibility rather than by a single trigger event.

We postulate that the specific transitions faced and the pressure to complete them depend largely on the degree of change required in moving from one job to another. On one end of the continuum are managerial jobs involving few major changes, such as supervising a small group in a narrow medical specialty. While a physician assumes some supervisory and managerial responsibility, such "low change" jobs involve continued focus within patient care or medical specialty, working with bosses and subordinates who are also physicians, and taking little responsibility for revenue production, budgeting, community relationships, marketing, and other functions foreign to the physician. These kinds of managerial jobs may create stress and difficulty, but we hypothesize they are unlikely to serve as major triggers for any of the serious transitions. In fact, these kinds of jobs may make later transitions more difficult by reinforcing the illusion that managing is a secondary activity that can be handled with minimum investment while continuing one's clinical or research commitments.

At the other end of the continuum are major job shifts that demand significant changes: dealing with non-physician bosses and subordinates, alien functions and disciplines (for example, food service, maintenance, contracts), and institutional responsibilities (e.g., strategic planning, finance). These, we hypothesize, are the major triggers for transitions that must be accomplished successfully (and sometimes quite quickly) if the physician manager is to succeed.

The idea that significant changes in job demands accompanied by high pressure was documented in studies of high-level corporate executives(5) and is consistent with the experiences of the physicians in this study. We hypothesize that those physician managers whose careers consisted of a slow accumulation of modest increases in managerial demands had encountered fewer of the transitions and made less progress in those they did face. Thus, we suggest that transitions are driven by:

* The magnitude of change in managerial job demands, with increasing demands creating more pressure for change.

* The specific demands made on the individual to handle new situations, such as different kinds of key people, different functional or technical areas, or different strategic perspectives.

The second element of the framework is the transitions themselves. Of the six we have described, three are primarily centered around personal psychological adjustment to change (dependency, identity, and acceptance), and three involve the development of significant new skills (control, relationships, and competence). We do not believe that the six transitions are independent of one another, although they may be. It is entirely possible, for example, to go through a crisis of dependency and identity at the same time or at different times. It is likely, however, that the three transitions involving psychological change are more similar to each other than they are to the transitions involving skill development, and vice versa. In that respect, the learning processes involved are likely quite different, and people are likely to differ in their ability to achieve one kind of change or another.

We hypothesize that the transitions requiring psychological adjustment are more dependent on the overall magnitude of a job change (from physician to manager or from physician-supervisor to higher level manager or executive) than they are on the specifics of it. The skill-based transitions, while clearly affected by the magnitude of a change, may be driven more by the specific elements within the job change (for example, when bosses and subordinates are not physicians, the "relationships" transition is likely to emerge as central).

Finally, the third cluster of variables involves obstacles to successfully achieving a transition. Two of these are primarily personal, in the sense that they are largely under the control of the physician: psychological defenses and lack of supportive relationships outside of the former physician peer group. The other two obstacles are largely controlled by the organization: the ways people are selected for managerial roles, the ways managerial jobs are designed, and how people are prepared for them.

This framework suggests that physicians are similar to other professionals when it comes to taking on managerial roles. The factors that trigger a need for change, the transitions that face them, and the obstacles to success seem relevant regardless of the particular professional specialty. It is likely, then, that the same organizational initiatives useful for moving other professionals or technical specialists into general management (for example, engineers or accountants) should work for physicians as well. Organizations employing physician managers might profit from paying more attention to their selection processes and to job design and managerial development. Criteria used for selecting physicians for managerial jobs should reflect managerial (as opposed to professional) skills and attributes and should tap potential to develop the skills and attributes needed for higher level managerial jobs. Selection might also be improved by helping physicians make realistic choices for themselves by providing job previews, feedback, and options for those who do not succeed or decide they prefer life as a professional.

Physicians could be better prepared for significant managerial roles through systematic use of on-the-job experience and other developmental opportunities, in much the same way that high-potential candidates are developed in better-managed corporations.(6) Managerial jobs destined for physicians might be designed so that the scope of responsibilities, objectives, and goals are realistic and clear (many of the physician managers we spoke with felt their jobs were illdefined or that expectations were unrealistic) and structured so that organizational support is available to help new incumbents as they take charge (for example, coaching from an experienced boss, training programs, or needed learning resources).

Becoming an effective manager is no easy task. Even for individuals whose entire careers build logically toward general management, developing the intimidating array of skills and attributes is a daunting task. Professionals who have already progressed down one career path face the added burden of starting over on a new career. In the case of physicians moving into management, both the physicians themselves and their organizations can make a substantial difference by recognizing the kinds of transitions that must be made and by taking steps to successfully make them. It is not magic.


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. Special thanks go to Ron Pickett, formerly with ACPE, Robert Spears, MD, and David Molthrop Jr., MD.

2. An interesting example of this unrealistic self-appraisal was a survey of American's expectations about heaven and hell. 77 percent believe there is a heaven; 76 percent think they'll end up there. 58 percent believe there is a hell; only 6 percent think they'll end up there ("Visions of Eternity," Newsweek, March 27, 1989, p. 53).

3. Bridges, W. Transitions: Making Sense of Life's Changes. Reading, Mass.: Addison-Wesley, 1980; Kubler-Ross, E. On Death and Dying. London: Collier-Macmillan Ltd., 1969; and Viorst, J. Necessary Losses. New York, N.Y.: Fawcett Gold Medal, 1986.

4. McCall, M., and Clair, J. "Why Physician Managers Fail." Los Angeles, Calif.: Center for Effective Organizations, Technical Report T89-14 (157), 1989.

5. McCall, M., and others. The Lessons of Experience. Lexington, Mass.: Lexington Books, 1988.

6. Kotter, J. The Leadership Factor. New York, N.Y.: Free Press, 1988); McCall, M., and others. The Lessons of Experience. Lexington, Mass.: Lexington Books, 1988.
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Title Annotation:Career Management
Author:Clair, Judith A.
Publication:Physician Executive
Date:May 1, 1992
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