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With a new name for its professional organization (the American College of Physician Executives) and a new certifying organization (the American Board of Medical Management), the profession of medical management is in the throes of significant and far-reaching change. At the College's National Conference in Washington, D.C. in May, we talked to two leaders of the profession, Michael B. Guthrie, MD, MBA, FACPE, and Robert H. Hodge Jr., MD, FACPE about what the future holds for physician executives and what physician executives can do to position themselves for success. Dr. Guthrie, the immediate Past President of the College is Vice President for Business Development, Penrose/St. Francis Healthcare System, Colorado Springs, Colo. Dr. Hodge, the new President of the College, is a Program Director, W.K. Kellogg Foundation, Battle Creek, Mich.

As the medical management profession enters a more mature stage in its development, it is useful, perhaps even wise, to examine it more closely. What is this profession? What qualifies one to claim membership in it? For what reason does the profession exist? Can such a diverse group be called a profession at aH? Are there lessons to be learned from other professions?

Medical management can be usefully compared with any number of other professions or careers, but engineering management leaps to mind. There are startling differences in the two careers, of course, but there are also some useful similarities. Both engineering and medical managers are responsible for professionals with strong senses of independence. In both cases, the managers come from the same background as those they now manage. And both must add management skills to an existing skill base and balance the inevitable conflicts in the two roles. Those still providing medical care, or engineering, will become suspicious of the colleague who "has gone over to the enemy." Both professions rely substantially on less formal educational and training techniques for practitioner development.

If engineering management is a profession, and by the looser modern definition of that term it certainly is, then there can be no doubt that medical management also qualifies for professional status. And like engineering management, medical management exists to ensure that the interests of the larger profession, medicine, are observed in the operations and policy making of the overall organization in which the manager operates. But what, beyond the acquisition of an MD or a DO degree and some suitable time spent in clinical practice, qualifies one to be a medical manager? For most current practitioners of medical management, the road was serendipitous. They were in places that needed strong leadership, and their fellow practitioners tapped them for the jobs. In many, perhaps most, cases the jobs came because of strong clinical credentials, not because of any demonstrated management skills. Those had to be acquired later. While medical management has grown from a clear need, individuals have entered the profession largely without preplanning.

That is changing. Drs. Guthrie and Hodge both see medical management professionals as needing more management skill at the beginnings of their careers. The election of a management career will be made earlier in the medical career, they say. And, they say, more concrete and proven credentials will be required not only for success but for entry itself. What will be required for success? Will the MD degree be enough? Dr. Hodge believes that, "For success in management, something beyond the medical degree will be required. I don't want to suggest that this means a formal degree, but there needs to be some type of postgraduate education process. Whatever advanced education is finally offered, it will have to be specifically for physician executives, and it will have to be flexible," he says.

Dr. Guthrie says that advanced management degrees are neither "necessary nor sufficient." He says that the profession needs to be reminded that many managers in this and other industries have made significant contributions without advanced degrees. Some, he says, have done so without college degrees at all. In medical management, he says, many physician executives "were in the right place at the right time. They were intelligent, resourceful, and capable, and they were rewarded." He says that this type of transition to medical management can also be expected to take place in the future. But, he says, "It will be increasingly difficult for young physicians to make the transition without credentials." The credentials will have to be demonstrated competence and contributions, he says. "The novelty will have worn off. When you are looking for a job, the management degree is interesting but insufficient. What will count is what you have accomplished. To succeed, physician executives will have to be able to point to a solid record of performance." Dr. Guthrie emphasizes that the intellectualization that characterizes medical education does not apply well to management. "Physicians come from a traditional orientation of achievement through mind power. Most management training is results- or skill-oriented. Companies expect future managers to learn their skills on the ob. When the skills are in place, a promotion into management is possible. But management training is an ongoing process. You never 'fil up' for life. Skills have to be updated to accommodate changes in organizations and in their environments."

Dr. Hodge agrees. A danger is that we will overintellectualize management. In medicine there is a maxim: When the test results are in and you still don't know what's wrong, you need to go and see the patient. In management, the corollary of that, hands on practice, is important." Dr. Hodge believes that some combination of learning and application will prove to be the best way to develop physician executives. He points to the University of Wisconsin Administrative Medicine program as an example of the approach that he believes will succeed.

"Physicians will have already spent a large amount of time in education when the management bug hits them," he says. "They will have gone through medical school, residency training, and board certification. When they become interested in management, they will seldom be able to afford the luxury of a return to college for a few years. There has to be another process for the acquisition of the knowledge. Programs such as the University of Wisconsin's, where the student can spend a short period on campus and then do the remainder of the program while on the job, is an excellent approach. It combines learning and application of learning in a way that can create successful managers."

Dr. Guthrie applies the intellectualization curse to the MBA. "One of the objections to the MBA is that it trains its recipients to be analysts rather than persons who roll up their sleeves and do something practical. If physicians are not careful, they will make great MBAs and lousy managers."

The newly formed American Board of Medical Management is another way for physician executives to gain credentials, but Drs. Guthrie and Hodge warn that there are risks in this. Neither sees board certification in medical management as a panacea. "It is a trap to believe that medical management can be achieved through an examination," Dr. Hodge says. "The exam is a necessary evil. It is an indication that the physician executive who passes it understands medical management knowledge, but it is not a reflection on the quality of that physician executive's performance or skills. The test doesn't tell people what to study. It tells them what they must learn."

Dr. Guthrie has another concern. "There is a risk that members of the College will view diplomate status in the American Board of Medical Management as a way to be acknowledged as a physician executive. But they are apt to be disappointed at the end of the exam. They will have run the race and cleared the hurdles, and there will be no audience at the end to applaud them. Nobody out there cares other than other physician executives. There is a risk that they will believe that the exam has a value beyond the intellectual exercise of taking it. The fantasy is that passing the exam will intrinsically elevate you above the rest. I cannot emphasize to much that the real measure of the physician executive, as it is for all executives, is proven performance."

Dr. Hodge adds that what separates the good physician or physician executive from the not-so-good counterpart is a motivation to keep up with the field. "You can't take a pill to be a better manager," he says. "It's not possible to get a piece of paper that says you're certified and can now manage. The effective physician executive will acquire management skills and will be motivated to update them continually."

Dr. Guthrie says that the College should not promote the ABMM as a panacea. "We should not promote wishful thinking," he says. "Board certification doesn't mean that you set yourself apart from others for the rest of your life or that people will hire you because of your certification. I have to say it again. Physician executives, like all executives, will be judged on the basis of their contributions to an organization."

Dr. Hodge receives a number of calls from clinicians who are interested in moves to medical management. They think that they need to acquire management skills and then go for a management position. I would reverse the process. The best approach is to go for the most challenging position you can find and then use the educational and skill building processes to make the best of the position. What's more," he says, "those positions are frequently within the clinician's organization, so a track record is being built upon. Industry looks at track records. Then it looks at how the educational process has been used to augment skills."

"The risk for the College and the profession," Dr. Guthrie says, "is that we will all huddle around and congratulate ourselves that we're physician executives and have passed a board. The real challenge will be determining what the hell difference it makes. What difference does it make to society? We have to remember that those of us who have two advanced degrees have asked society for a double investment. And someone probably has one or no degrees as a result."

Dr. Hodge has a dream for the College. "I see the membership driving the organization. They will ten us that they need certain things, and we will provide them. For instance, when should management training and education begin? I don't think that it should begin in medical school, but at that point an awareness of medical management should be instilled. Medical management needs to be identified as a track option that they can select later. The College can play a role in seeing that the option is presented in medical school. It can also be made a part of residency programs. Residents can spend some of their time with a medical manager preceptor."

Dr. Hodge believes that role models and emulation can be an effective way to learn about medical management and to learn management skills. Dr. Guthrie is not so sanguine. He says that he suspects that Dr. Hodge's experience, in academic health centers makes him overly optimistic. He says that the theory works less well in the world of community hospitals. "It's the luck of the draw. If the student is lucky enough to be in a Mayo Clinic, there may be some terrific executives to watch. In most community settings, there are few such models."

Dr. Hodge considers this a real challenge for the College. "We need to determine how to establish preceptorships where the uninitiated can view medical management leadership. This applies not just to students but also to physician executives who are just beginning their medical management careers. Unfortunately, you can't bring a leader to a National Conference, point to the person, and say these are the qualities that are important for leadership."

Dr. Guthrie expects to be a preceptor in the University of Wisconsin program in Administrative Medicine. And he is enthusiastic about the responsibility.

"Mentoring is a critical issue in management," Guthrie says. "How do you train people to be leaders? A lot of management has nothing to do with what goes on between your ears. Most of it tends to be adaptive behavior. So there is a limit to the effectiveness of the didactic approach in management training. Seeing a successful physician executive in action can be a powerful experience for the young physician for whom medical management is an option."

The two physicians agree that epidemiology, although a "boring part of medical education," serves as a ready-made leadin to medical management. They say that the lessons of epidemiology can be very useful to the manager and would make a good bridging mechanism for the physician who aspires to management. This science, they say, can help the physician executive understand the interrelationships between elements of the business world, such as the role of marketing. "The training of doctors is largely one on one," Dr. Hodge says. "The physician executive has to be concerned about community. The challenge lies in making the transition from that one-on-one orientation to group considerations."

Dr. Guthrie calls this "getting your nose over the lip of the teacup" to see the world outside the organization. The real difference between clinicians and managers, he says, is the perspective on group dealings. "Physician executives have to understand that they are dealing with a number of forces. After they decide what they want as a service, they have to decide who will buy it. Physicians are good problem solvers, but they aren't used to dealing with that buying decision."

Dr. Hodge says that "we get lulled in medicine. We take a history and get as much data as possible. Then technology is used to give us an answer. There is no such technology on the horizon in management. How managers deal with people determines their success." What is the role of the College in the profession? How can it continue to contribute to the growth and development of the profession? "The good physician manager will do well in spite of our organization," Dr. Hodge says. "Our goal should be to help them do well in a shorter time." Dr. Guthrie says that we have to help them "understand the strengths that they bring from medicine. We need to help them build on their. strengths and overcome their weaknesses." Both physician executives believe that the College has an important role in the process by which physicians are identified for management roles, encouraged to move into them, and helped to become leaders in the industry.

"One has to be a caregiver to really understand what the health care industry is all about," Dr. Hodge says. He says that it's a matter of sensitivity. "If you own a restaurant and don't eat there, much is said about the restaurant. If you own an airline and travel by train, the airline is suspect. In health care, there is also a credibility factor. Physicians enjoy a credibility with their peers that others lack." Dr. Guthrie questions how far this can be taken in a community hospital setting. "When a physician becomes a manager, he is judged as a manager. And you have to act like a manager. Medical knowledge and experience are important as memory traces, but you're now a manager."
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Article Details
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Title Annotation:medical management profession
Author:Curry, Wesley
Publication:Physician Executive
Article Type:Interview
Date:May 1, 1989
Previous Article:Buying managed health care services.
Next Article:Outcome management issue tops conference agenda.

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