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The making of a hospital physician executive.

The Making of a hospital Physician Executive

Management has not always been foreign territory for the physician. There always has been a need for salaried physician executives in the hospital, and in the not-too-distant past it was commonplace. The important medical centers of the world have been influenced by great doctors who were also great executives. The Mayo brothers and Drs. Lahey, Kreil, Ochsner, and Lovelace immediately come to mind.

Before World War II, it was quite common to have a chief surgeon and a generalissimo-like chief nurse who kept law and order in the hospital. After the war, the advent of subspecialty boards in surgery broke up the power structure and caused the medical staff to "divide the territory." Management in this environment made a specialized curriculum for hospital administration necessary. Several universities began to offer master's degree programs in hospital administration, led by the University of Chicago in 1934. The first wave of graduates arrived in the early and middle fifties. With the passage of }e icare and Medicaid in the mid-1960s, the expertise and powers of the lay administrator expanded.

Until the early 1980s, there was unlimited growth in the "all you want" period of Medicare's cost-plus reimbursement. There was no need for physicians to participate in management. Frankly, the economic opportunity in medicine during these "golden years" kept most physicians tied to the clinical grindstone. Then, in 1982, the situation changed. First, there was the the Tax Equity and Fiscal Responsibility Act (TEFRA), followed by the present system of prospective, DRG-based pricing.

Prospective pricing has changed the rules of medical practice. high-quality, appropriate, and cost-effective care has become the standard. With this change has come a need for physicians to work more closely with or even join the management team. At the same time, compensation for executive positions has increased to a level that is competitive for the recruitment of management talent from the ranks of medicine.

In response to this opportunity, numerous physicians are participating in both formal and informal educational experiences to equip themselves for careers in hospital management. But there is considerable difference between the perception of an executive's job and what in reality it proves to be. If I were asked to name the most significant human characteristic in being a manager, it would be a good sense of humor.

Management is hopelessly and incurably repetitive. hospital executives have to accept listening, waiting, and serving roles on a continuum. They cannot ask what is the new problem today. Rather, they wonder which of several common problems will recur. Without a sense of humor, they could not survive.

In clinical medicine, problem are generally attacked one at a time. One cannot treat an epidemic of the flu by offering a generalized prescription to the public. The clinician treats on a one-on-one basis, dealing with subtle differences in individual need and response. Physician executives must adapt their experience in dealing with individuals, learn to read group response quickly, and tailor their words accordingly. Sensing a question or misunderstanding in one individual, the physician execute can quickly translate to mend that deficiency, knowing that there is clarification for the entire group. It becomes a kind of intuitive ability to react quickly to a group.

A significant contribution that can be made by a physician executive is sensitivity, if not empathy, with the clinical situation, providing a bridge to the management need for quality assurance as quality becomes the standard by which medical performance is judged. The manager who has a feeling and an empathy for bedside care can more effectively gather what is necessary to represent quality in the institutional product.

There are some cautions, however. Going toward management cannot be an escape from bad medicine or bad society or bad anything. But if a physician is good at anything in medicine, there is an excellent chance of being a top-of-the-line manager. It has to be remembered that physicians carry a lot of clout. The simplest way to illustrate this is a generalized anecdote. Two total strangers meet, one a physician and the other a patient in need of care. The physician has such power that, in this first meeting of total strangers, the physician can command the other individual to take off all of his clothes, and the patient willingly does so. In management, the physician executive does not have the privilege of saying, "Take off all your clothes." Management is a participatory process. Eventually, the new manager will earn the right to lowered resistance from his colleaques, but it is by no means automatic.

Medicine is hierarchical; management is participative. To trust members of a team requires a shift in the natural consciousness of a physician. At first it is alien, but the relationship gradually mellows to a legitimate group process.

For some physicians, the team process will never be anything but contrived, but it must be carried out. It soon becomes abundantly clear that one cannot run the ship alone. A hospital is a large and unwieldy mass that must be brought under control through a team effort.

Perhaps the most important management experience I have had is in forming an expert administrative tean and, with their advice and assistance, creating an administrative policy manual. The administrative policy manual--our bible--required over two years of effort, with the participation of all division directors and the supervisory personnel within their jurisdictions. It tells how we are organized and how our work should be governed. The process of bringing this information together has been my major task as CEO.

Can a physician bring a vision of a better health care system to this role? There is a myth that a physician has access to superior knowledge of what the system should be. It isn't always true, but the chance to communicate works to the physician's benefit, if he or she communicates truthful and believable information. Points are won, at least in the initial stages. However, there also is a negative potential, because in time this advantage can be perceived as unfair, or even as an ability to manipulate. If a physician manages by manipulating people, it will be a weakness that soon will cause a falling away. Instead of having a new crop of patients with new problems, the physician executive works with the same people over and over. One can play games in one-on-one encounters, but in dealing with a group, one will be caught.

When the physician executive presents a vision for change or improvement or a proposal for an exciting new program, there are special hazards. One must be very careful with entrepreneurial or visionary dreams that one does not sell them beyond their ability to benefit the individuals who have to make the dream a reality. It is relatively easy to sell a dream and its rationale to a governing board, where visions and new opportunities are always welcome. But if they but it, they properly expect that the lower level of administration and the medical staff will function to make it a reality. The physician executive must go all the way to the grassroots to be certain that everyone knows and shares the vision before it is sold at the board level. If one builds a dream before everyone knows about it or buys into it, the people in the organization will not perceive a need for it, even though it could benefit them, and it will fail.

The physician tapped for management should be a good clinician. A bad physician will be a poor manager and a worse executive. The candidate should have or be willing to acquire training in personnel management, finance, marketing, and other aspects of business management. Most definitely, the physician executive should be computer literate. The curricula of the American College of Physician Executives and the american College of Healthcare Executives can be helpful in this regard, adn the candidate should express a willingness to join the organizations and, when qualified, sit for their certifying examinations.

Working with the medical staff is a process that calls out the best of behavioral management training and experience. Each conflict is an opportunity to develop win-win relationships. It is important to remember that the manager--physician or not--will be a target for the many frustrations that physicians are feeling with their professional practice. The anger and grief that many physicians feel can cause them to strike out at the traditional "enemy"--the administrator--as a local representative of all that is repressive and difficult in the new atmosphere of managed care.

The employment of a qualified physician executive is never a substitute for active medical staff input and involvement in hospital decisions. The CEO should be present at medical staff executive committees, and the medical staff should participate at hospital board and committee meetings. The physician executive should encourage members of administration to be available and of assistance to the medical staff.

The physician executive should help the medical staff organize its own clinical review and quality control process. This will require employing a physician part time to be captain of team, along with utilization review, quality assurance, nursing review, and clerical staff. These needs usually cannot be met by a volunteer group, and it is a mistake for the physician CEO to sit in judgment.

If the hospital CEO is not a physician, and this is most frequently the case, it is important that a full-time, career-minded director of medical affairs be found. This physician executive will work closely with the CEO to coordinate all the hospital-physician relationships and functions. However, legislation to mandate a medical director in every hospital seems to me a poor move. Onve cannot mandate good medical direction or good hospital administration

The physician executive can be of great assistance to the hospital board and administration, but one must always remember that patients are interested in medical care, not a pile of bricks or equipment. They could not care less who or what the accomplishments of the physician CEO might be. Keeping this in perspective may be the hardest--and most valuable--lesson of all.

I have been asked from time to time, "Why have you chosen to work in hospital administration? Is it really satisfying, as compared with laboratory or clinical medicine?" The answer is "yes," but involvement in hospital administration could not have preceded clinical practice and department management. One must achieve excellence in the technology, art, and science of health care in order to grow toward a management role. If one is to be a physician executive, one must be a competent physician first. The jury is still out on the future. Health care changes quickly, and individual priorities change as well. But change would not result from impossibility of the task or lack of satisfaction in performing it. The role of physician executive is an established reality in the health care field.

James B. McCormick, MD, FACPE, was President and Chief Executive Officer of Swedish Covenant Hospital, Chicago, Ill., from 1983 to 1990. He is now Chairman of the Board, Life-Center on the Green, adn President and CEO of Pelam Laboratories, both affiliates of the hospital.
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Author:McCormick, James B.
Publication:Physician Executive
Date:Sep 1, 1990
Previous Article:Economic feasibility of a primary care practice.
Next Article:Behavioral quality assurance: a transforming experience.

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