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The chief of staff and the medical director.

The Chief of Staff and the Medical Director

To understand the roles of the medical director and the chief of staff, it is important to consider the environment in which they operate. If both the environment and the roles are designed for collaboration and cooperation, these physicians can contribute to the success of the institution.

The modern hospital is a complex institution that operates with limited resources. Many groups compete for economic and psychological dominance, including the board of directors, the medical staff, and administration. Both the medical director and the chief of staff have a relationship with the board of directors. The chief of staff is viewed as the representative of the medical staff. The medical director is viewed as a medical advisor representing primarily management. The board of directors is composed, for the most part, of successful individuals with limited time to devote to the operation of the hospital. In addition, they do not have detailed knowledge of current trends affecting health care and the hospital. Members of the board have personal physicians with whom they have professional and social relationships. These physicians, many of whom are members of the medical staff, frequently offer advice or attempt to advance their own interests. In addition, board members often seek advice about the hospital from these physicians, who are assumed to be knowledgeable and objective. The typical community hospital has at most a limited teaching program and few salaried physicians. The members of the medical staff of such a hospital are engaged in private practice. They generally have privileges at more than one hospital and have little commitment to one institution. The goal of physicians is to have an institution that provides facilities for the best possible care of each of their patients, irrespective of the effect upon the survival of the institution. In addition, physicians seek to maximize their economic return, which may adversely affect the hospital. They operate with a great deal of autonomy and view with great suspicion any attempt to interfere with their dominant position in the hospital. If they perceive a threat to their goals or position, they will move their patients to another institution or threaten to do so. Physicians look to their peers as their reference group and have little respect for the opinions of nonphysicians, no matter how experienced or capable. For the most part, they have limited organizational skills and little time to spend on hospital matters. As a result, problem solving by the staff is ineffective. The medical staff operates under bylaws that are structured to limit action and to maintain the status quo by diffusing power. The chief of staff is generally a popular and competent physician who is politically astute and has a power base on the staff. Such individuals have generally been moderately effective, but the too-effective leader is often viewed with suspicion. The chief of staff, who frequently depends on other members of the staff for referrals, is often very busy with practice. Time spent on medical staff affairs reduces the time available for practice. Furthermore, actions required by the chief of staff may interfere with that individual's referral base. Most commonly, because of long-standing professional and social contacts, the chief of staff has direct access to individual members of the board. The administrator is usually trained in management, with a great deal of experience obtained through a progression of lower level positions. The position is very difficult, requiring mediation between the goals of the medical staff, the board of directors, and the employees of the institution. Because of economic constraints, the position is one of high stress. Many administrators, who have a lower earning potential than most physicians, are ambivalent in their feelings toward physicians and regard many of them as arrogant and demanding. Traditionally, when there has been a major conflict between the medical staff and administration, irrespective of the cause, the administrator has been sacrificed. The position of medical director has evolved during the past generation. Initially medical directors were physicians who, for one reason or another, wished to limit their activities. Currently, some physicians are preparing for the position of medical director early in their careers. Many medical directors, perhaps because of insecurity, continue to practice on a part-time basis. This introduces the potential for a conflict of interest between the medical director and the practicing physician, particularly when referral practice is involved. A major advantage the medical director has vis-a-vis the chief of staff is continuity. The medical director generally occupies the position for a number of years, whereas the chief of staff generally serves a limited term. Because of continuity, and by virtue of the time devoted to the organization, the medical director is more knowledgeable about hospital affairs and is in a position to control information flow to the chief of staff. The chief of staff is elected, subject to the approval of the board, by the medical staff. To prevent concentration of power in a single individual, tradition or bylaws frequently prohibit consecutive terms for the chief of staff. This, together with a short term of office, limits the opportunity for a chief of staff to become effective. The medical director, on the other hand, is appointed by the hospital administration or the board of directors and is expected to occupy the position for some time. Increasingly, the medical director is selected from a pool of trained and experienced physician executives. In many hospitals, a search committee composed of representatives from the board, administration, and the medical staff is utilized as part of the selection process. The medical staff frequently perceives the position as a threat to its autonomy. The primary constituency of the chief of staff is the medical staff. In some institutions, the medical staff pays the chief of staff a stipend. The medical director, on the other hand, reports to the administrator and ultimately to the board of directors. As a result, the medical director is often perceived by the medical staff as a tool of administration. This causes problems in the relationship of the medical director to the medical staff. The chief of staff is responsible for leadership of the medical staff and formal direction of meetings of the general staff, executive committee, and, on occasion, other key committees. The chief of staff appoints chairs and committees and represents the medical staff to the board, administration, and the community. The medical director acts as staff to the chief of staff. The medical director is responsible for the flow of information to the chief of staff and ensures that the chief of staff is not publicly surprised because of lack of information. In addition, the medical director is responsible for assisting in the effective functioning of the medical staff. In many hospitals, the medical director is responsible directly to the board for quality assessment. The medical director also mediates between members of the medical staff and represents the medical staff to the administration and board. The medical director acts as staff to administration and the board regarding medical affairs, technology assessment, and strategic planning. The chief of staff has great credibility with the medical staff but is handicapped by a lack of management knowledge. The medical director, on the other hand, has been a member of a medical staff and is aware of its problems. Furthermore, many medical directors have been medical staff officers. Usually the medical director has had experience or formal training in management. It is important for the medical director to introduce the chief of staff to management concepts so that the chief can convey management's problems to the medical staff. In addition, it is advisable to include medical staff officers in hospital management training programs and conferences. A medical director should work with members of the medical staff who show potential for leadership to develop a cadre of physicians trained in management and knowledgeable about medical staff problems. It is becoming increasingly apparent that medical staff affairs are too complex and time-consuming for the chief of staff to continue to function effectively on a voluntary basis without training. As mentioned, many medical staffs have dealt with the problem by paying the chief of staff a stipend. In this way members of the staff can expect the chief of staff to spend the time needed to represent them adequately. Also, a few medical staffs require that a chief of staff have some training in order to be effectively represented. A one-or two-year term of office is too short to learn to function effectively. This problem has sometimes been solved by lengthening the term of office. Hospital affairs have also become too complex for the medical aspects to be adequately represented by a voluntary chief of staff who is untrained in management and has goals that may not be congruent with those of the institution. Most hospitals with at least 200 beds are hiring medical directors to manage medical affairs. Further impetus to this development comes from risk underwriters and quality assurance programs. As of January 1, 1989, all hospitals in New York State are required under the health code to designate a medical director, paid or unpaid, who will have responsibility for quality assessment and for effective functioning of the medical staff. Undoubtedly other states will follow this pattern. In the turbulent atmosphere of current health care, the relationship between the medical director and the chief of staff is critical. The two roles operate symbiotically and together are vital to the successful functioning of the hospital.

David M. Bloom, MD, MBA, FACPE, is Vice President for Medical Affairs, Sarasota Memorial Hospital, Sarasota, Fla., and a member of the Board of Directors of the American Board of Medical Management.
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Title Annotation:medical leadership
Author:Bloom, David M.
Publication:Physician Executive
Date:Jan 1, 1990
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