Healthcare executives have routinely questioned how best to manage their physicians, when the better question would be how to best engage and partner with physicians.
Amid today’s healthcare challenges, the ability of organizations to develop strong, cooperative, focused relationships with physicians is a key element toward success.
Managing physicians has long been compared to “herding cats” by those in the know. There’s a reason for that analogy. Cats are typically independent, autonomous creatures, resistant to owner efforts to establish behavioral conformity. They tend to be self-sufficient, seeking attention when they want it rather than when the owner wants it – often at the most inopportune times. They also have a strong escape response and react aggressively when cornered. Finally, cats are unpredictable when other cats are brought into their environment. Perhaps this analogy reminds you of what you face in your physician network.
Many administrators wish their physicians exhibited more typical canine characteristics: loyal, easily-trained and eager to demonstrate owner-instilled behaviors. However, dogs also require higher maintenance. They crave quality time and require more attention to meet their basic needs. Dogs can also behave aggressive when cornered and can revert to their hostile pack mentality. While some breeds exhibit predictable, stereotypical behaviors, temperaments and behaviors can always vary. Same can be said for physicians (think neurosurgeon compared to family physician).
Animal kingdom analogies aside, how should executives best engage with physicians? Clearly, there is no one correct way to address all situations and circumstances. However, there are certain underlying principles that can help guide us.
First, do not treat employed physicians as “employees.” Some administrators think that employed physicians should just do their bidding – after all, they are employees. This strategy never works well. Employed physicians will uniformly resist being treated as employees who should simply follow directives. Interestingly, we do not expect other employees in our healthcare systems to passively follow directives. Significant time and effort is expended to engage these other employees and measure their levels of engagement. However, we often do not extend that same effort to our employed physicians. In fact, instead, we frequently lump them in with the other employees to diminish their differences out of a fear of promoting any kind of elite status.
Second, we should recognize and embrace the professional character of physicians and actively partner with them to help move the organization forward. In this, we have the best opportunity to successfully engage physicians and maximize their contribution to organizational success. This can be a disquieting thought for administrators influenced by the scars of past physician conflicts, of the traditional all-or-none concept of physician leadership, or concerns of relinquishing a portion of organizational control, or being perceived as “giving in to the doctors.” For those not accustomed to incorporating physicians in the leadership hierarchy, trepidation about the unknown can be a significant barrier to overcome.
A mechanism that can help bridge this chasm is a physician advisory council. These councils capably augment the scope and effectiveness of a formal physician leader, enhance organizational performance by incorporating broader physician involvement in operational activities, promote effective, two-way communication, and enrich physician leadership development. The council provides a valuable forum to:
· Solicit strategic and tactical input from direct care physicians early and often.
· Establish metrics to review practice performance in a dashboard format which permits replication of positive practices and identification of potential areas for improvement.
· Present and vet new initiatives.
· Promote physician “ownership” of practice function and projects.
· Educate and groom future physician leaders.
· Leverage an organizational perspective and promote a collective, rather than individual focus.
Advisory councils can foster significant physician engagement and alignment, leading to substantial organizational benefit – in a less menacing manner for the faint of heart.
Third, we should develop physician leaders – lots of them – and embrace them in our leadership hierarchy. Some administrators hope that, by creating or cultivating a single physician leader, physicians will fall in line and be more open to management. This approach begins to involve physicians in leadership, overcomes administrator trepidation of directly involving physicians in operational leadership, and minimizes administrator exposure and perceived risk. There is value from creating this type of position when done well. However, this alone will not likely reap the degree of control administrators desire. To truly be effective as a standalone control mechanism, physicians would have to exhibit lemming-like behaviors and follow their leader without question.
Science has proven that this type of lemming behavior does not actually exist, much as experience dispels the lore of physicians blindly following a single physician leader’s direction. Even in a pack mentality, in which the acknowledged leader demonstrates significant influence, the leader is regularly challenged and can be displaced. The ultimate disconnect with the desired outcome does not diminish the value of a designated, formal physician leader in an organization, but highlights that creating this position alone is not a panacea.
Organizations must identify, develop and mentor physician leaders who understand clinical, market and economic issues, are committed to improving all facets of quality, are willing to model and drive the organization’s culture and will hold peers accountable. These leaders portray a philosophy that balances individual autonomy with system expectations, advocates for both the patient and the system, adeptly promotes team participation and leads by example. They help to establish direction, buoy the vision and align and motivate others to follow.
Physician leadership exists on three basic, progressive levels in a continuum – from front-line leadership to middle management and senior management. As physicians progress along this leadership continuum, additional management skills must complement developed leadership skills.
• The front-line leadership role is exhibited in the trenches of direct patient care. All practicing physicians have a role in working with and leading a care delivery team that is aligned with organizational objectives and driven to achieve the safest, highest quality, most efficient and effective patient care. This form of leadership is key to organizational success.
• The middle management role depends on system size and can vary from positions such as office-based leads to department chairs or service line leaders. These individuals assume some degree of management activity and often spearhead specific roles related to performance improvement in clinical quality and patient safety.
• The senior leadership role includes Chief Medical Officer and Medical Director positions. This level comprises the highest degree of management activities in conjunction with direct leadership capabilities.
Successful progression of skills does not happen by chance, the growth must be cultivated. Formal didactic programs, self-learning adjuncts and active mentoring all contribute to skill enhancement to effectively plan, organize, empower and problem-solve.
Just as incorporation of physicians into the organizational hierarchy must be a strategic concept that is actively executed, the identification and development of outstanding physician leaders must also be an active process.
If we follow these leads, we can develop mutually beneficial physician alliances that will help meet the challenges ahead. However, time is of the essence since we have a lot of animal instincts to overcome and it won’t happen overnight.
By: Terrence R. McWilliams, MD, MSJ, FAAFP
Chief Clinical Consultant, HSG
tmcwilliams@HSGadvisors.com