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Prescription for physician executives: take care of your doctors.

Prescription for Physician Executives: Take Care of Your Doctors

Most of the physicians in our clinic are more irritable, clearly annoyed, or outright angry than in years past. There have been more petty disputes and significant arguments among our members. Criticism without confrontation that never would have been tolerated in the past takes place in front of other physicians even at our teaching and work conferences. There is loud grousing about income, often by our highest producers.

It is difficult to explain these conditions unless the problem is one of unhappy doctors and not really the various targets of complaint. The following is a menu of suggestions that physician executives might follow to foster nurturing of their physician colleagues and to overcome disgruntlement.

Malpractice Help

The physician executive must be alerted by the organization's insurance administrator at the first mention of a malpractice suit. Generally, no physician will volunteer that he or she is being sued.

Form a support team made up of older, respected members who have experienced the misery of malpractice suits. Almost always, they will be eager to sit down with younger members newly involved in such legal mayhem. They can discuss the embarrassment, frustration, anger, resentment, worry, and insomnia that accompany the malpractice experience. Because defense attorneys generally instruct the physician not to discuss the facts of the case, limit the discussions to feelings, not medical matters.

Physicians' spouses sooner or later become emotionally involved in malpractice cases. It may be helpful to have separate support groups for these people, for the sharing of their intense experiences is often helpful.

There are numerous sources of information on the emotional aspect of malpractice. In her book Defendent, Sarah Charles, MD, a psychiatrist, tells the story of her malpractice trial in progressive stages and of her emotional reactions to the events as they unfold. Her spouse, a journalist, follows each stage with his own description, particularly of the accused physician's emotions. [1] There are also numerous videotapes on the subject of malpractice. [2-5]

Look at Work Habits

Check on-call schedules. Are they realistic? Do some of your surgical specialty people work so many consecutive on-call nights that perhaps the third night up means that their surgical quality is poor? What is the quality of their care if they practice at outlying centers or outlying hospitals? Are their acquisitions of new partners unrealistic? Sometimes the very vocal, workaholic, dominant member of the department may keep others from seriously considering taking on a new partner that the department may need. Occasionally checking waiting time, both for appointments and for surgery, or asking other departments about the timeliness of referrals and consultations may provide important information.

Encourage Time Off

Physicians in general are very compulsive about work. In most groups, this is considered an admirable trait, but physicians worry about their colleagues who are working too hard. I find that few physicians listen to analytic comments about their own work habits. Even when a medical group has liberal vacation and studytime policies, some physicians do not take advantage of them. Generally, these same physicians take minimal vacation time throughout the year.

A medical director should at least point out the abnormality of work compulsion, emphasizing the possible undesirable consequences. In some cases, frequent reminding by the medical director and by the physician's peers may effect some change in such work habits. Sometimes it is convenient to point to older colleagues who have demonstrated either good or imprudent work habits as appropriate examples.

Burnout is a very real problem for all professionals, especially for physicians. [6] One of the medical director's tasks is to try to prevent overwork but also to recognize burnout when it has occurred. Again, most physician victims will not recognize burnout, nor will they seek professional help even if they do. Generally, a question about how a physician feels about getting up in the morning and addressing the day enthusiastically may elicit an answer that merits further inquiry. It helps a troubled physician if the subject of burnout--its causes, its prevention, and various activities that may help to treat it--are discussed.

Financial Help

A useful service, to young physicians in particular, is advice about financial planning. Local accounting groups, banks, and investment brokers are delighted to offer such help. Older physicians, and particularly the financial officers of the administration, will know of such services.

Women Physicians

Be alert for sexual chauvinism, both subtle and grossly overt, directed toward women physicians. Women do not get committee appointments or elective offices as soon as their male counterparts. They often are not treated cordially and occasionally not even fairly. Their medical knowledge and ability are criticized more readily and often in an arbitrary fashion. Even on-call assignments may not be equitable.

Examples of male chauvinism toward female partners that surfaced have been unequal numbers of on-call nights, new women physicians being called when they are not on call, loud criticism about maternity leaves, and indiscreet complaints about diagnosis and treatment by an on-call doctor, particularly when it is a woman. Such attitudes may cause difficulties in recruiting women and may result in significant danger of lawsuits lodged by female candidates not hired by the group. This matter must be tackled in an open, frank manner in discussion groups.

Start Support Groups

Physician wellness groups, in which members meet regularly to openly discuss their emotions, fears, disappointments, and successes, can be effective. Begin with a small circle of physicians who seem more emotionally perceptive than usual. Women physicians may be particularly helpful to such groups, because women more readily express emotions than men in our culture. The inclusion of women physicians in a support group at our clinic enabled them for the first time to openly discuss the chauvinism directed toward them. Heretofore, we really had been unaware of this problem.

Support groups require a facilitator, who may be the medical director, to encourage the frank expression of feelings and to direct traffic in those instances when emotions get too volatile or when one doctor dominates the session. Occasionally, an outside, more skilled facilitator is needed.

Many physicians find the care of dying patients very stressful. Hospice organizations do a very effective task of preventing staff burnout by encouraging open expression by their staff members in frequent, regular meetings. Physician support groups can also provide this type of outlet.

Physician Mentors

Make sure that every new physician has a mentor within his or her specialty. A so-called political mentor, not necessarily in the new physician's department, also can introduce the new physician into the so-called political life of the clinic. New members usually are ignorant of the history of their institution and its members and need someone with whom to discuss these matters. Mentors should actively seek out new members who are assigned to them. Mentoring prevents new people from feeling that they are isolated, helping to increase their loyalty to the group.

The social needs of new physicians and their spouses, particularly couples from outside the local area, should also be addressed. Generally, new physicians do better with contemporaries than with older members in their specialty. Some physicians and their spouses are not interested in social aspects of the community, but these opportunities should be offered. Attendance at social events hosted by established members and/or their spouses should be encouraged for new members but certainly not be compulsory. Medical institutions might even be interested in providing babysitting services or day care for new physician families.

Learning to Sell Oneself

Most physicians pay no attention to the advertising aspect of marketing except to openly state that it is repugnant to them. If the medical director gives one-on-one instruction about effective marketing, patient satisfaction surveys, new service ventures, and the like, the group benefits.

The clinic may introduce new members to the community through local service organizations, parent-teacher groups, and senior center associations that are receptive to offers of physicians' speaking on medical topics. Help young physicians to become good public speakers. Audiotapes on public speaking may be of benefit. Colleagues' objective criticisms and suggestions are always helpful. Even better is arranging for videotaping of talks for subsequent review and improvement.

An awareness of the need for appropriate publicity is generally well received by members unfamiliar with marketing. With some coaching, it is easy to advocate meetings with friendly business people who are equally interested in obtaining information on what they see as their important medical needs. Business advisory groups are very advantageous, often helping physicians understand better how the business community perceives medical care. Encouraging young physician to join service organizations or to serve on United Way campaigns is another method of making friends and building practices.

Advocating Postgraduate Efforts

Doctors' personal and professional pride and their presence in a group practice may ensure adherence to good, continuing medical education, but gentle reminders may be helpful. We urge doctors to keep records of their continuing medical education simply because it continues to be a requirement in many states. It also serves as a record of an individual's efforts and provides an opportunity for the medical director to inquire about them. You should also encourage the use of motivational and post-graduate education tapes.

Annual Interviews

The medical director should regularly visit each physician and many of the support professionals, particularly psychologists, audiologists, and administrative personnel. An annual appointment in the individual's office, with unobtrusive appointments made by yourself or by your secretary, are flattering to the individual and of considerable value. Members should be queried about their health status and habits. Too many physicians not in primary care are simply unaware of what is included in an annual medical exam, in exercise prescriptions, and in proper dietary habits, including concern about fats and cholesterol. Generally, no one questions doctors about these issues or about their smoking or their alcoholic consumption. Questions about habits often will serve notice of the organization's concern for those who are habitually overindulging. Another question is where the physician anticipates being in five years. This may give a troubled person an occasion to discuss concerns about the future.

As you make these interview rounds, you may learn of colleagues' concerns about one of their partners in regard to quality of care, personal life, or emotional health, all things that may lead to significant problems of quality of practice or of life satisfaction. Such visits often provide opportunities for partners to confide about their concern about a partner's losing expertise or being ill. Problems with substance abuse may surface, especially if the medical director asks general, open-ended questions about colleagues in general.

Some physicians need nudges about their under- or overcharging and, perhaps, their tardiness for office hours. You may find that some younger physicians need help from older, skilled partners in becoming efficient providers of care. After-hours meetings in physicians' homes are great occasions for exchanging philosophies and methods of practice. By frequent exposure to physicians and to their nurses during office hours, you also may learn to identify compulsive physicians who may become so inefficient that they clearly need counseling.

The anonymity of colleagues who discuss their worries about their partners must be respected. We have a device called the "yellow sheet" on which any physician or employee of the clinic who is worried about quality of care will merely write the name of the patient on a yellow form and submit this to the medical director's office or to the quality care committee. This notice is reviewed without anyone knowing the source.

Anticipate Retirement

Many physicians, particularly in the specialties, fear that consultations and referrals will stop if their colleagues find out that they are going to retire. They prefer that no one know their plans. As retirement nears, the more secretive they get. Even more ticklish is the fact that some physicians need to be advised that they are up for retirement. The medical director can be head off these problems by prominently advertising the availability of package retirement plans, such as the one offered by the American Medical Association.

Learning by Walking

A medical director learns about individual practice patterns by making frequent rounds through the institution. Appearing in the medical intensive care unit, and the emergency department at various hours of the night and day is helpful. The nursing staffs of those sites, as with head nurses of many departments in hospitals, may provide quiet comments that really represent a loyal interest in your physicians and in their patients' welfare.

Be Familiar with Office Employees

Regular visits to departments allows the medical director to become acquainted with physicians' nurses. Nurses generally are very interested and very protective of their physicians' welfare. However, when a doctor's behavior concerns his or her nurse, the may drop a subtle hint about personal habits or practices that would bear scrutiny. Concern about physicians' prescribing habits, particularly in regard to tranquilizers and narcotics for long-time patients, will lead a nurse to casually mention the fact.

Allow the chief of pharmacy to know that the medical director is interested if there seems to be an unusual prescribing habit by a physician in the group for him- or herself, for members of the physician's family, or even for particular patients.

Reserve a Lounge

Specialists in organizational patterns are aware that common meeting rooms, e.g., lunch rooms, are of great help to the camaraderie and to the morale of the professional institution. Avoiding or eliminating such amenities for cost-cutting reasons may be shortsighted. Maintenance of the morale of groups often depends on the exchange of experiences and emotions. In addition, such sites facilitate the meeting of spcecialties that often are sequestered geographically. These meeting places initiate curbstone consultations and keep the exchange among departments open. They help keep the institution a group practice and not simply a group of separate camps.

Attend Department Meetings

A helpful practice for a medical director is to regularly attend department meetings. Communication from the organization's board of directors is facilitated, and this is another source of information about members. It serves to keep peace if there is friction among department physicians, particularly in a small department. An outside figure may prevent an older physician, particularly a chairperson, from dominating the agenda and the discussion within a department.

Be a Physician Advocate

Frequently, younger staff physicians need help in encouraging hospitals to look after their needs, particularly in the equipment area. New physicians often feel that they are disenfranchised when it comes to requesting attention from hospital administrators. Medical directors can intercede quietly and diplomatically.

A medical director should learn to confront problems presented by gossip, particularly when it damages a physician's professional or personal reputation. The ability to confront without hostility is an art that should be cultivated. Frequently, misunderstandings among physicians are easily resolved. An unpleasant incident is magnified simply by the repetition of a tale, especially as the medical group gets larger.

It is important to isolate the troublemaker by running down the sources of complaints or gossip. Because the surgical lounge is the nerve center of the institution, the medical director should make that area a daily stop in order to keep abreast of local gossip.


Medical directors should keep diaries of their activities. They need not be extensive, but they document attention to accountability Also, a diary helps the medical director keep a schedule so that all physician members are visited regularly.

The nonremunerative services to the community that many group members provide needs to be applauded. In the absence of financial reward, recognition, either in meetings or in newsletters, is important. A source of poor morale is often the fact that some members do a great deal outside the clinic to increase the clinic business while others confine their efforts to personal gain.

Physicians need lots of caring, and they rarely ask for that attention, at least overtly. a good medical director seeks ways in which to help colleagues. Practicing medicine is tough enough in this new world of intense accountability, public scrutiny, professional review organizations that seem to be looking to find fault with physicians, malpractice, and forecasts of lower income. We need to help physicians to be as happy and collegial as possible.

Judging from conversations with medical directors from other group organizations, compensation is an ongoing source of discontent in most organizations. However, it is a discontent that is largely unwarranted; physicians have relatively high incomes. Most physicians are in the 90th percentile of income in the country, and many of our surgical specialists are higher. Many complaints about money may actually represent unhappiness in areas described in this article. For that reason alone, these concerns must be addressed by medical directors and boards of directors.


[1] Charles, S., and Kennedy, E. Defendant: A Physician on Trial for Medical Malpractice. New York: Free Press, MacMillan, 1985.

[2] "The Malpractice Suit: A Survival Guide for Physicians and Their Families." Boston, Mass.: Eidetics, Inc., 1988.

[3] "Family Stress During Malpractice Litigation." AMA Publications. Videotape No. 46. Chicago, Ill.: American Medical Association.

[4] "Witness Preparation Film Re Giving Deposition." New York, N.Y.: Matthew Bender & Co., 1884.

[5] "Your Day in Court." New York, N.Y.: Info by Management Forum, Inc., 1975.

[6] McCue, J. "The Effects of Stress on Physicians and Their Medical Practice." New England Journal of Medicine 306(8):458-63, Feb. 25, 1982.

William Rock, MD, is Medical Director, Dean Medical Center, Madison, WI. He is an associate member of the College's Society on Group Practice and Forum on Bioethics. The author acknowledges Professor Standish Henning, University of Wisconsin-Madison, for editorial assistance.
COPYRIGHT 1991 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1991, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Rock, William
Publication:Physician Executive
Date:Mar 1, 1991
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