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The many paths of physician executives. (Careers: Special Report).

IN THIS ARTICLE:

Discover some of the many career paths physician executives are taking and learn how they achieved their current positions.

Take a minute to consider a sampling of the job titles found in the American College of Physician Executives' database:

Chief executive officer

President

Executive vice president

U.S. Surgeon General

Chief medical officer

Chief operations officer

Dean

Agency director

Chairman of the board

Management consultant

Congressman

Councilman/Mayor

Editor

Commander

Department chair

Today's physician executives are leaders in Fortune 500 companies, insurance companies, large and small group practices, medical equipment companies, hospitals, software firms, medical schools, pharmaceutical companies, all branches of the military, medical research organizations, managed care companies and integrated health systems.

In this special issue of The Physician Executive, examine some of the many careers physician executives are pursuing and perhaps take some time to evaluate your own career path along with way.

Veterans Health

Lawrence H. Flesh, MD, CPE, FACPE Interim Network Director/Network Medical Director VA Healthcare Network Upstate New York Albany, N.Y.

Larry Flesh remembers the moment vividly. He was standing over a patient in an operating room in Albany, N.Y., a second-year surgical resident with retractor in hand, when it suddenly struck him, "I don't want to do this every day for the rest of my life."

Flesh, 55, had gone into medicine Out of filial obedience: "I was a typical child of refugee parents who said, 'You have to be a professional."' By that they meant, in hierarchical order, becoming a doctor, a lawyer or an engineer. He aimed for the top.

As a student at the prestigious Bronx High School of Science, Flesh had better grades in physics than in biology. So his next step as he walked out of that operating room was 'a no-brainer," he says. He turned to nuclear medicine.

The Veterans Administration in 1976 was "an old, stodgy, bureaucratic organization where patients were kept in bed as long as possible and it was so far from private practice it was staggering," Flesh says. "But even then it had the best equipment in the country, because the government had the money for it."

And so, having completed his boards, Flesh went to work at the VA hospital in Albany. Two years later he was named its chief of nuclear medicine (in a department of two). He has been a VA doctor with increasing administrative responsibilities ever since.

Today Flesh is medical director, and for the past year acting director, of a five-hospital, 27-clinic VISN (for "Veterans Integrated Service Network") in upstate New York, one of 22 nationwide.

"Being that the VA is a self-contained health care system, it lends itself to letting people go out of their specialty into areas of administration," he says.

In 1981, he was asked to serve briefly as acting chief of staff at the Albany medical center and he "found it fun. Nuclear medicine tends to get a little routine and boring, especially the lab stuff," he explains.

Three years later he got the chief of staff job (the top clinical post at the hospital), and 12 years later was named director. In 1998, he became the clinical manager of the network, which has involved him much more broadly in VA affairs and oversight nationally. Clinical practice gradually fell by the wayside.

"When I first became chief of staff and spent a lot of time in meetings, my initial reaction was that I'd stopped doing anything productive," he recalls. "I was complaining about that to my wife at dinner once, and she said, 'No, going to meetings is your job!' It gave me new perspective."

Surprisingly, Flesh's wife is an internist in private practice.

"She doesn't want to be on hospital committees and make budget decisions," he says. But she can appreciate that while "she can make that special difference for one particular patient, I can see to it that nuclear medicine is delivered to three sites in my network and 100 sites around the country with quality. The underlying theme of my career," he muses, "has been broader and broader scope of involvement. And the wider your focus, the less insular you are."

Meanwhile, the VA has itself undergone a transformation.

"We've become a modern health. care organization," Flesh declares. "We have the best patient safety, some of the best outcomes and the best computerized patient record system in the world. And one of the seeds was in Albany, in my department."

Software Development

David Kibbe, MD, MBA

Chairman and Founder

Canopy Systems

Chapel Hill, N.C.

During his first 10 years as a family practitioner in the Rio Grande Valley of south Texas, David Kibbe racked up more than 70,000 patient visits. So he figures he's done his share of hands-on doctoring. Now, he says, "my skills are being appropriately used helping others in the health care system improve the quality and efficiency of their work."

Kibbe's main instrument is a company he co-founded in Chapel Hill, N.C., in 1997, Canopy Systems. It offers secure Web-based utilization, case and discharge management software application services to big health care system clients.

At the same time, he's director of health information technology for the American Academy of Family Physicians (AAFP) and president of the North Carolina Health Information Communications Alliance. That's a nonprofit consortium of over 280 organizations (now transcending state boundaries) dedicated to improving health care through information technology and secure communications.

Kibbe, 52, grew up in northern Ohio, son of a schoolteacher father. He went to Harvard, then studied at the Jung Institute in Switzerland, intent on becoming a lay analyst.

"I realized you had to be a physician to get anywhere in psychiatry," he says, so he enrolled at Case-Western Reserve University School of Medicine in Cleveland. There, his career trajectory changed under the tutelage of Jack Medalie, the charismatic founding chair of Case's family medicine program.

After internship, Kibbe went off on a National Health Service Corps assignment ("they'd paid for my medical education") to sweltering Mission, Texas. He stayed even after his stint at a migrant farm worker clinic ended, running an office, serving as the borderland city's health officer, founding hospice and home health programs and doing peer review at area hospitals. He was fluent in Spanish.

But managed care was sweeping the country. For-profit Columbia-FICA was becoming a powerful force, he recalls. "It was very clear to me that corporate America was making most of the decisions about our health care system. And I knew nothing about business. I didn't understand the language, finance..."

So once again Kibbe went to school. Every two weeks for two years he flew 350 miles north to Austin to spend 2 1/2 days as the only physician in a class of 64 at the University of Texas Executive MBA program. He came away with a degree, a dean's award for academic excellence and the hard-core business skills he thought he was missing.

In 1990, Kibbe sold his practice to pursue a Robert Wood Johnson academic fellowship at the University of North Carolina School of Medicine and complete his board certification in family medicine. Two years later he founded his first company, a hospital quality improvement and data management consultancy called Future Health Care.

"As we got more and more involved in the problems associated with IT in hospitals, and more familiar with the issues of data exchange and data standards, we started focusing on the software opportunity," he says.

In 1997, with funding from the physician-owned Medical Mutual Insurance Company of North Carolina, he developed Canopy Systems. The backing from Medical Mutual, he notes, "is the reason we could weather the dot-corn storm."

Although he no longer sees patients, Kibbe talks regularly with his brother, an internist. "That," he says, "helps me stay on track."

Consulting

Bryn J. Henderson, DO, JD, CPE, FACPE Founder/Principal ITA, Inc. (International Trade Affiliates)

Orange, Calif.

Bryn Henderson modestly styles it "staying flexible." His resume suggests that he would be a formidable opponent in the game of Twister.

Henderson, 56, graduated from Iowa's Luther College and went to work for Colgate-Palmolive, which sent him to graduate school at California State University-Fullerton. Selective Service soon plucked him away into the Army, which made him a forward observer in Vietnam.

When his tour was up, Henderson attended medical school in Guadalajara, Mexico. He completed his studies at the College of Osteopathic Medicine in Des Moines. Then he migrated to Southern California, where he worked in emergency rooms, fell into family practice and began teaching at the College of Osteopathic Medicine of the Pacific, in Pomona. There, his dean insisted he get management training, which led him to ACPE. He also found the time to pick up a law degree from Fullerton's Western State University College of Law.

In 1985, California Governor George Deukmejian appointed Henderson to the Osteopathic Medical Board of California. He eventually served as its president. A Spanish speaker, Henderson coordinated and participated in medical missions to Latin America and developed an interest in comparative health systems internationally. He's compiled a comprehensive CD-ROM on the subject, as well as co-authored books on legal terminology and on managed care and cardiac patients.

His cosmopolitan interests led Henderson to incorporate a company, International Trade Affiliates, to import and export vaccines and medical devices. ITA serves as an umbrella for a variety of consulting activities in which Henderson applies expertise accumulated during various positions with a venture capital group, New York financial houses and health insurers.

"Today," he says, "I advise health plans and physician groups on how to enhance revenue and institute evidence-based medicine in their offices.

"I was with a startup last year," he continues, "where I automated their office from the ground up. It was a homerun from the clinical perspective." What's more, it allowed him to interact with patients.

"I was hugging old ladies and patting old men. You miss the personal side," he admits. "Most physicians don't understand that in medicine the deliverable is caring."

There's a downside to that, though, Henderson says. Clinical income is dependent on patient throughput. 'You've got to create strategies to provide for you when you're sleeping," he counsels.

Which is what has motivated him in his dedicated multi-tasking.

"I make my own time. I don't work for anybody. And I'm always learning," he exclaims. "I love it!"

Health Policy

Carolyn M. Clancy, MD

Director, Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services

Rockville, Md.

As the oldest of seven children, says Carolyn Clancy, "being in a big crowd was part of my upbringing."

She's really in her element now. Last February, Clancy, 49, was named director of the federal government's bustling Agency for Healthcare Research and Quality--the world's leading sponsor of patient safety and medical outcomes studies.

A serious injury to a family member when she was in high school reinforced Clancy's interest in medicine. She graduated from Boston College and went to medical school at the University of Massachusetts, where she gravitated to primary care.

Counseled by a mentor during residency in internal medicine to consider an academic track, she accepted a Henry Kaiser Family Foundation fellowship at the University of Pennsylvania. There she met John Eisenberg, MD, a distinguished health services researcher. Under his direction she began studying the effect of decision analysis--"a qualitative technique for breaking down decisions into discrete parts"--on patient responses to treatment options.

Appointed to an assistant professorship at the Medical College of Virginia, Clancy turned her attention to the influence of financial incentives on physicians' behavior.

In a study reported in 1988 in the Archives of Internal Medicine-one of 66 publications under her name listed in PubMed--she reported that HMO patients at that institution got fewer discretionary diagnostic tests than fee-for-service patients. They were not, however, scanted on preventive services.

Findings like that, along with her work as director of a primary care clinic serving poor patients (she continues to volunteer one evening a week at a local public clinic)--further whetted her interest in access to care and health policy issues.

In 1990, she joined what was then called the Agency for Health Care Policy and Research, or AHCPR. It was then only a year old and flush with Congressional authorization to apply scientific rigor to the determination of how doctors and the health system ought to treat people with greatest efficacy and economy.

"This was a very exciting place," Clancy recalls. "It was a new agency, with a new mission. There was no script but we clearly had a mandate to conduct research that would lead to change. It was just fabulous. People were around at all hours of the day and night and on weekends... it was a very heady time."

So much so that the two years she'd initially thought she'd give the job turned into three, then four. She was named director of the Center for Primary Care Research, then director of the Center for Outcomes Research.

"Our whole purpose was to look at the impact of health services on end results that are important to patients," she says with enthusiasm.

In 1997, her old friend John Eisenberg was appointed AHCPR director. But the climate had changed in Washington. Republicans were in control of Congress and a controversial back-pain guideline issued by the agency alienated many surgeons. Plans were afoot to choke off the AHCPR's funding.

Eisenberg proved a masterful tactician. Working with Tennessee Senator Bill Frist, MD, Eisenberg doggedly revived the agency's fortunes and its direction. Then, in 2001, he was diagnosed with a brain tumor. Within a year he was dead, age 55. Toward the end, he asked Clancy to step in as his interim replacement.

"People pulled together incredibly," she says of the months following his death. Clancy overcame her shock and, aided by widespread concern about reducing medical errors, helped keep AHRQ on target.

Now that HHS Secretary Tommy Thompson has handed her the agency reins unequivocally, Clancy looks forward to a batch of new initiatives. They include:

* Training an interdisciplinary Patient Safety Improvement Corps to help the examine data

* Launching Web M&M, an online analysis of medical errors submitted anonymously

* Numerous information technology initiatives to be announced in 2004

* Releasing two new annual reports, one on the quality of health care in the United States and one on disparities in health care

Once again, she exclaims, "this is a very, very exciting time."

Insurance

Deborah Y. Smart, MD

Medical Director and Vice President Trustmark Insurance Company Lake Forest, III.

Deborah Smart enjoys watching the occasional professional basketball or ice hockey game on television. You'd think her first thought when she sees a player go down with an injury would be, "Ooh, poor guy." But it's, "Uh-oh... how much is that going to cost us?"

Heartless?

That's a claim she would deny.

Since 1993, Smart has been vice president and medical director of Trustmark Insurance Company. Smart, 49, oversees payments for medical expenses under the company's health policies. Trustmark caters to small and medium-sized employers, covering some 2 million lives. Notable among them are the hazard-filled careers of the stars of the National Basketball Association and the National Hockey League.

In fact, says Smart, those talented young men are no more eager to run up medical expenses than Trustmark.

"They're incredibly motivated," observes Smart, "and they know that some 22-year-old is looking to take their job. They're out there on the court playing with injuries that would have you or me flat on our backs in a hospital bed."

Scanning the morning's sports pages for bad news is only a minor part of Smart's job, though. In addition to reviewing medical necessity on all non-routine claims under Trustmark health policies--40 to 50 a day, she estimates--Smart:

* Assesses new technology ("figuring Out what we should cover based on how the government classifies them")

* Advises PPO and pharmacy benefits managers

* Supervises 15 case managers who handle catastrophic situations ("helping the insured navigate through the health care system at probably the most vulnerable time of their lives," she characterizes it)

* Directs a staff of 17 sniffing for fraud in Trustmark health, disability and life insurance lines

A graduate of the University of Michigan and Michigan State University's Medical School, Smart was practicing family medicine in a group that was part of the Henry Ford Health System in the Detroit area when her husband took a job in Illinois. Through a headhunter she found the Trustmark position, which was "serendipitous.

Smart continues to see patients as a volunteer at a free-clinic. "I do it because I'm a doctor. I love medicine," she explains. "Bureaucracy has its place, but it's not what I trained for."

As a result, she says, "I think of myself as a physician's advocate. Oh, I've had my fill of nasty letters and run-ins. But because I wear two hats, I can understand that,"

She empathizes with her clinical peers' resentment of managed care constraints. And, she declares, she will never overrule another doctor's treatment decisions. But that's not to say she won't weigh in forcefully when they seem inappropriate or inadequately documented.

The latter is a key element that is often lacking, she says, because "they're too swamped, or too lazy, or didn't learn to do it or all of the above.

"What my colleagues don't understand," she adds, "is that when we deny a claim, it has to do with what's in the medical record and what's in the contract."

Pharmaceuticals

Daniel Teres, MD, FCCM, CPE, FACPE

Senior Field Medical Officer

AstraZeneca

Needham, Mass.

Most physicians would find themselves uncomfortable in his job, Daniel Teres believes.

"The physician's role is leadership," he explains, "but it's not based on being a team leader. And change is not something most doctors are comfortable with.

"Hospitals," he adds, "don't drop a lot of programs. They have a rigid structure. And working doctors to the bone is part of the culture."

By contrast, he says, the pharmaceutical industry--certainly as exemplified by the organization in which he's a senior field medical physician, AstraZeneca--requires an ability to work as an equal with many people of varied credentials and to be at ease with rapid change.

Teres, a critical care specialist, spent 22 years as a division chief in charge of a Level-1 intensive care unit at Baystate Medical Center in Springfield, Mass. He was also the director of Baystate's Center for Health Services Research, where he did pioneering work to develop the Mortality Probability Model, a severity scoring instrument for ICU and surgical patients. Baystate is the western campus of the Tufts University School of Medicine where Teres also is a professor of medicine.

In 1999, Teres attended a meeting at the London headquarters of Zeneca, a leading British pharmaceutical manufacturer with whom he had participated in several clinical trials. One of its major products was Diprivan (propofol), an anesthetic commonly used in ICUs.

"I was clearly phasing out my career at Baystate," he says. "I wanted to do health services research full-time, but I was not bringing in millions of dollars in research grants."

Moreover, a merger was pending between Zeneca and Astra, a Swedish company that had developed the popular anesthetic Xylocaine (lidocaine). Teres expressed interest in job opportunities that might arise and a year later he was hired.

Teres is one of 11 senior physicians at AstraZeneca in the medical affairs section, working with product directors, brand managers, team physicians, advisory boards, key opinion leaders and researchers conducting phase IV clinical trials in six primary therapeutic areas, Teres' responsibilities are pain, anesthesia and infection control agents (specifically, Cefotan, Diprivan, EMLA, Merrem and Naropin.)

AstraZeneca's U.S. operations are headquartered in Wilmington, Del. Teres maintains a "virtual office" there, but visits only periodically. His main base is his home in Boston, which is equipped with a T1 line for high-capacity data transmission.

"This is a career path that is probably growing," muses Teres, "a new role for physicians who've established reputations for clinical and academic excellence. But they have to be able to fit in with organizations where 'Doc' doesn't mean anything. At AstraZeneca, the fact that you're a physician carries no special benefits,"

Working from home allows him to continue meeting weekly with a pulmonary-critical care fellow at Tufts whose MPH thesis he's supervising.

"Pharmaceutical companies--especially those making money--really understand the work-life balance, too," he says. "I'm certainly enjoying what I'm doing."

Hospital Administration

Ronald Deering, MD, FACPE

Medical Director

St. John's Hospital

Springfield, Ill.

Medicine has become a much broader field than it appeared to Ronald Deering when he checked into his first meeting of the predecessor organization to the ACPE in Hilton Head, S.C., in 1981.

A pediatrician at the Christie Clinic Association in Champaign, Ill., Deering was encouraged to enlarge his horizons--"build relationships, network"--by Jack Pollard, CEO of the neighboring Carle Clinic and a founding member of the American Academy of Medical Directors.

Deering had dipped his toes briefly into administration as a young officer in the Navy Medical Corps. Born in Covington, Kent., in 1941 he attended Vanderbilt University but completed his undergraduate studies back at home at the University of Cincinnati "to be close to my intended."

He married, went to the University of Louisville School of Medicine and served his internship in Cincinnati before joining the Navy, which made him senior medical officer on an airbase in south Texas. He returned to Louisville for a civilian pediatric residency and then joined the Christie Clinic as one of its 25 physicians.

Deering would ultimately spend a quarter of a century at Christie, 10 of those years as its medical director and two as the group practice association's president.

At the outset, the job of medical director was supposed to involve a mere 20 percent of his time, he says. But as the organization grew in size and complexity--among other accomplishments it brought heart surgery to the community and ultimately grew to 100 doctors-the real breakdown of his time allocation was 100 percent administration and 100 percent patient care.

"They had to decide what they wanted me to do," he says. "And at the time the culture wouldn't allow for a doctor to be medical director full-time. People thought you were no longer productive. You had to be doing something to reduce the overhead."

As it happened, he continues, "right down the road was a big hospital looking to replace a gentleman who been there for 20 years. And they were willing to allow me to spend some time on at least academic medicine."

In 1994, Deering relocated 85 miles southeast to the state capital to become medical director of Springfield's St. John's Hospital, licensed for 750 beds and boasting Illinois' largest heart program, along with thriving orthopedic, pediatric, cancer and trauma services. It is also the teaching institution for the Southern Illinois University School of Medicine.

To his disappointment, Deering was not able to join the hospital's clinical faculty. "There was a problem with malpractice insurance," he explains, "and maybe there were some people who weren't exactly anxious to work it Out."

In any case, he had to give up clinical medicine--and, he admits, "I do miss dealing with individual patients. But to go back after an eight-year hiatus and at my age, it would have to be in a very structured environment and probably only ambulatory. I'd never, ever go back to managing patients in a hospital. And I'm not very excited about having to take night call any more."

ACPE Resources:

The College is, committed to helping you advance your career as a physician executive. We will continue to profile physician executives and highlight the many, career options in upcoming issues of The Physician Executive. For more information about ACPE career services, please visit www.acpe.org/Career.

David Oilier Weber is a frequent contributor to this journal and 2002 winner of the eighth annual award for trade journalism presented by the National Institute for Health Care Management Research and Education. He can be reached in Mendocino, Calif., at doweber@kilasprins.net.
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Author:Weber, David Oilier
Publication:Physician Executive
Geographic Code:1USA
Date:May 1, 2003
Words:4017
Previous Article:Internet use for health advice is low. (Short Takes).
Next Article:Wandering in the desert: lessons from a life in health care. (Careers: Special Report).
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