Migrating to Physician-Leadership: An Introduction
In a recent Forbes article, the authors observed that shaping the future of health care depends on physician-leaders (Price and Norbeck 2017). They stated that physicians stand at the intersection of the often-competing cultures of patient care and business. They added that physicians are increasingly moving into titled leadership positions. However, it is often the case that physicians are ill-prepared to move into these high-level positions. In fact, the very skills that are required for a physician to be a great clinician often compete with or undermine the skills required to be a great leader. Further, the historical tension between clinicians and administrators compounds the challenge of physicians moving into leadership roles. In fact, transitioning into health care leadership is sometimes referred to as “going to the dark side.” That said, physicians can successfully transition into health care roles. The physician-leaders who successfully make this transition are among the most effective leaders in health care. We have found that there are certain critical skills that physicians must learn to become most effective as they consider transitioning into leadership roles. This is the foundation for this book.
The Business of Health Care: From Bedside to Boardroom
Physicians spend years in medical school and residency learning how to take care of patients. Through this education and continuing into practice, physicians are taught essential medical knowledge and trained how to think clinically. They are the leaders of the clinical health care team, but most physicians were never taught basic administrative and leadership skills. They understand almost every facet of the health care system from the clinical perspective, yet most do not understand the fundamental business models of health care.
During their careers, many physicians will have the opportunity to be medical directors or department chairs. These leadership roles are usually part-time and often rotate from one physician to another. Balancing these administrative positions with a busy clinical load creates significant stress. This often leads physicians to leave these leadership roles in favor of pure clinical practice. Some bounce back and forth between the clinical role and the hybrid clinical/administrative role multiple times, especially early in their careers. Those physicians who have both a passion for leadership and are able to acquire the necessary nonclinical leadership skills often progress to full-time administrative roles such as chief medical officer (CMO) or chief executive officer (CEO). At this stage, physicians usually do not migrate back to clinical practice because it is very difficult to maintain or regain clinical competency (Figure 1.1).
Figure 1.1 The parallel paths of the physician-leader
Although the paths of the clinical physician and the physician-leader are parallel, the roles in each path require vastly different skills. The skills necessary in a clinical setting do not require the same level of relationship management, strategic thinking, or business acumen as do leadership roles. We provide the tools and insights required to make this transition successfully, broadening the skill sets learned in either medical training or clinical practice.
Leadership Transition: From Star Player to Team Captain
Although the patient is always the ultimate decision maker in their own care, the physician is at the center of the health care team’s decision making and execution. Despite recent work in the area of crew resource management and shared decision making, most physicians still practice as the authoritative leaders of the clinical team. This is not surprising because physicians are taught that the ultimate responsibility for the patient rests on their shoulders. This is reinforced by the clinical health care system, which looks to the physician as the final authority as well as the medical liability environment, which is highly focused on the physician. In the clinical setting, the physician is the quarterback of the health care team. The quarterback, although surrounded and supported by the rest of the team, is the one who calls the plays in the huddle and often has to make the play work once the ball is snapped. The quarterback is often the hero when the game is won and the goat when the game is lost.
In contrast, when physicians move to broader leadership roles, like medical director or department chair, the very behaviors that made them successful in the clinical role can be their undoing. The role of the physician-leader is less that of a doer or commander. It is more about influencing and leveraging others. Physician-leaders need to learn how to inspire, develop others, and align those under their management around a common cause. This requires that they learn how to think longer-term, develop the art of persuasion, and have a broader view of the business. This is illustrated in Figure 1.2.
Figure 1.2 Migrating to leadership
John Kotter, well-known Harvard professor and business consultant, has noted that moving from managing to leading requires a new way of thinking and behaving. In clinical practice terms, it means moving from seeing patients and entering orders to planning, collaborating, and motivating. In other words, it requires transitioning from short-term tactical behavior to longer-term strategic thinking and keeping broader organizational objectives in mind. It entails transforming from being the star player to being the team captain or the coach. Applying Kotter’s model to health care and physician-leadership, a clinician managing patient care (the myriad of issues and decisions that surround physician–patient interactions) must evolve to coping with the complexity of health care operations and processes as they move into management roles such as medical directors. As physicians continue to progress on the leadership path and become CMOs or CEOs, their focus must turn to strategy and change management. In the chapters to follow, you will learn the skills required to make the transition from clinician to leader, learning new behaviors, while diminishing old, competing behaviors.
Managing Relationships: From Authority to Influence
In a clinical environment, relationships are focused on healing or ameliorating the symptoms of the patient. While it may sometimes feel to physicians that they spend most of the day convincing and cajoling patients, insurance companies, and health systems to follow their recommendations, the physician is still the primary authority in the clinical setting. The roles are clear, and all involved look to the physician for direction and commands.
However, in a physician-leadership role, it is not the physician that is the center of the decision-making universe. Rather, the focus is the function or organization that the physician serves. The physician-leadership role is further complicated when a physician has to manage other physicians in addition to nonphysicians. In these larger roles, where they are managing other physicians that were once peers, the command and control style so effective in the clinical setting is likely to be met with great resistance in a leadership role. Physicians, like all people, by nature, do not like to be managed. A natural consequence of the physician’s training and the historical functioning of the clinical health system is the expectation that the physician’s judgment should rarely be questioned.
When moving into a physician-leadership role, the new leader must learn a different way of dealing with others. The leader’s role is one of using influence over authority, in order to get compliance or cooperation in service to the benefit of the overall organization. This role is much more nuanced and subtler than giving orders. The misconceptions of how much power or authority accompanies a title or position is one of the first issues new physician-leaders need to address. In a leadership role, the leader is on much more of a collegial level with whomever they lead than one might expect. Accomplishing major organizational initiatives requires the full cooperation and the greater resources of a team. In subsequent chapters, you will learn how to use influence over authority in creating a high-performing team.
Setting the Vision: From Microscope to Telescope
By design, the practice of the clinician is one that focuses primarily on short-term solutions, especially in the acute care setting. Although physicians are observant of longer-term problems, such as the sequelae of chronic medical conditions and end-of-life considerations, their practice predominantly focuses on the here and now. In referring back to Figure 1.2, the far-left column shows that physicians tend to spend their time and focus on short-term tactical issues.
The practice of medicine is one that is deep and narrow. This is especially true in the era of increasing medical subspecialization. This tapering scope of practice, coupled with the focus on detail and task orientation that is required to produce the best patient outcomes, actually hinders clinicians from thinking more comprehensively and seeing the broader landscape as they transition to leadership.
Although there is complexity with respect to all the considerations involved in making clinical decisions, physicians generally tend to see presenting problems with which they have become familiar and have, or can develop, a standard and consistent protocol. Evidence-based medicine is founded on the use of best practices that have been scientifically demonstrated to be effective. Of course, innovation is required to create new ideas, but the vast majority of physicians spend their days applying the evidence base as opposed to creating it.
However, in a leadership role, the leader is required to think much more strategically, considering implications for the function, organization, or system. The leader is required to think further ahead and identify possible challenges and opportunities that can impact both the organization and those who work in the organization, both clinicians and nonclinicians. No longer can the focus of attention be solely on the interaction with the patient. A physician-leader has to balance the needs of patients and the sometimes competing challenges of payers with those of the organization. Thus, these leaders need to consider innovative and untried ways to change and transform the enterprise.
The physician-leader must learn to embrace the upper right-hand quadrant of Figure 1.2, the strategic and longer-term. This focus includes major issues such as program development, evolving clinically through new models of care, the identification of new trends in treatment modalities and technology, and considerations of the implications of payer and patient mix. In addition to these business and medical considerations, the physician-leader needs to think about setting a vision, talent acquisition and development, succession planning, and how to inspire for maximum productivity and profitability.
Creating a High-Performing Team
The concept of a team for physician-leaders is vastly different from that of the physician in practice. Particularly in the acute care setting where shift work is the norm for many members of the health care team, physicians are often working with constantly changing teams and have little input in the selection of team members. In such environments, there is a predetermined group of health care professionals who have narrowly defined roles and clear expectations. They are a team in the sense that they all work together for a common solution under the direction of the physician for the relatively narrow patient issues usually presented. The “team-ness” of the group only exists in the presence of the patient and in reaching the prescribed conclusion. Duties are segregated, and the physician delegates tasks to other members of the health care team. However, this delegation exists primarily to facilitate task completion as opposed to development of new skills or succession planning. This tends to be a hub-and-spoke approach to leadership, with the physician being the hub, giving orders to those on the spokes (Figure 1.3).
Figure 1.3 Hub-and-spoke leadership
The physician-leader is faced with a similar structure applied to a much bigger scope, with the added requirement that those on the team have much broader roles than in the operating room or clinical practice. Having a clear vision or charter for the physician-led team is critical for the success of the team, and subsequently the organization. However, the constitution of the team is one of fellow physicians, nursing leaders, nurses, and, in many cases, administrative professionals. The physician-leaders must change their model from that of hub-and-spokes to one of more equal collaboration (Figure 1.4). Delegation must occur to both complete tasks and to develop team members (see Chapter 7). Because they are in a leadership position, they will have some latitude in the selection of their team members and the qualifications required to address the current and future needs of the organization. The time frame is much longer, and the problems the team will face can be more complex, unique, and unfamiliar (see Chapter 6).
Figure 1.4 Collaborative leadership model
In the clinical setting, all team members are aligned to create the best possible outcomes for their patients. From the perspective of the clinical physician, this is the premise on which they function, and there is seemingly control over little else. The physician-leader will need to factor in team incentives that include remuneration, quality, patient care, and intangible rewards like doing the right thing for the organization. The physician-leader will lead the team members in establishing goals and aligning them with the vision, while creating processes for executing on goals that include ownership, time frames, accountabilities, rewards, and recognition. These physician-leaders and their teams will face multifaceted issues that, at times, compete with one another, such as managing cost while maintaining quality, meeting expectations with limited resources, holding team members accountable without alienating them. These complicated and challenging issues can be daunting for physicians transitioning into leadership. Fortunately, in the chapter on effective team building, you will find the kind of processes and structure required to create a high-performing team in the face of difficult challenges.
Communication and Negotiation
The reality of clinical practice requires communication to be quick, concise, and typically one-way. Even when not making life-or-death decisions, the role and expectation of “the doctor knows best” requires a type of communication that does not invite extensive dialogue. Most cases that physicians manage are routine and do not need a great deal of analysis or discussion to determine both an accurate diagnosis and treatment regimen. In addition, the pressure physicians are under to see as many patients as possible, without compromising quality, adds another dimension to brief, top-down communication.
As physicians move into leadership roles, the kind of communication they are required to have changes. Relationships change as the physician transitions from being a solo decision maker to being a leader having a team of professionals who often see themselves as peers and want to have input into major decisions. Those whom the leader now manages prefer, and may demand, to have their voices heard. This is a far different set of dynamics than in an operating room, hospital ward, or outpatient clinic. In addition, the issues faced by the physician-leader are very often unfamiliar and complex, requiring discussion with others to make the best decisions or find the best solutions. If physician-leaders maintain the same kind of unilateral communication that they employed in their practices, they run the risk of alienating their new teams and, ultimately, suboptimizing their roles or even failing.
Physician-leaders will also face a very different level of expectation with respect to managing others. In response to the top-down, authoritative (and sometimes authoritarian) communication in their practices, employees or ancillary staff typically follow orders and comply. In these circumstances, those who do not acquiesce tend to self-select out, considerably reducing the need for having difficult conversations.
However, the leader-led team is expected to be collaborative and to contribute to problem-solving initiatives. As a result, the physician-leader will often face challenges from those on the team who, by virtue of their positions, have a right, and even an obligation, to speak up. Learning how to conduct these difficult conversations is a new challenge for physicians, who, in their practices, have been the sole expert. The successful physician-leaders will be required to adapt their styles to include discussion, debate, and disagreement, in order to arrive at the best possible solution for the team, function, or organization. The constituents are varied, and the expectations differ greatly from those in their prior role.
When there are performance discussions, the effective physician-leader will want to understand when and how to intervene, the best approach to take, and how to create outcomes that are beneficial to the individual, the team, and the organization. This requires learning a process to have difficult conversations so that when a situation demands it, the physician-leader is prepared to have the discussion in a timely manner and with a positive outcome in mind. These difficult discussions require a very different approach than those for which the physicians’ practice has prepared them. We provide tips, tools, and a process for the physician-leader to have a positive outcome for such difficult conversations (see Chapter 8).
Another type of difficult conversation comes in the form of negotiation. Physicians are frequently interested in how to sharpen their negotiation skills. In fact, as clinicians rise to more formal leadership positions, the ability to effectively negotiate becomes critical to their success. Too often, negotiation is thought of as a win–lose situation in which one person is trying to get the best deal either at the expense of, or at least without regard to, the other person. Think about your last car-buying experience! These adversarial dealings can be stressful and can end in suboptimal outcomes. We present a negotiation context that considers both the value of the outcome with the value of the relationship. When negotiation is done within this context, the possibility of having an outcome that is mutually beneficial is heightened. We provide you with tools to help in these situations. We are also aware that in some difficult negotiations, the most desirable outcomes cannot be achieved. We provide you with a proven method, and tools, to know when to walk away from difficult negotiations. Look in Chapter 9 for these tools.
Physician, Heal Thyself: Looking in the Mirror
Moving from being a physician to being a physician-leader is not an easy path. Here is why. Most physicians struggle while moving from clinical roles to administrative roles, from short-term to long-term thinking, from operating as solo decision maker to shared decision making, from giving orders to collaboration. In fact, all of the training of physicians has charged them with having ownership of, and responsibility for, patient health and outcomes. The very nature of this training is essential for developing effective clinicians but can be very detrimental to the development of physician-leaders.
Research on those who go into medicine has found that personality traits such as competitiveness, perfectionism, and even, at times, obsessive-compulsive behavior are common physician traits (Lipsenthal 2005). Other physician personality traits that can be detrimental in leadership positions include risk-aversion, safety-seeking, and difficulty finding a safe place to discuss stresses associated with their jobs. Physicians moving into leadership roles find challenges that include planning and organizing, the need for highly developed emotional intelligence, adaptability, managing change, conflict management, and holding others accountable (Warren 2017).
In short, moving from the physician role to that of physician-leadership is a big jump. In fact, it is jumping two levels at once. Typically, leadership roles are filled with people who have aspired to being in them and who have prepared by being in previous leadership roles. Usually, their education and career paths have aligned with moving into leadership positions. However, the expectation of the physician’s training has focused on moving into a clinical role for their entire career.
Sometimes, physicians seek leadership roles to escape the pressures and ongoing difficulties associated with clinical practice. In this sense, they are “moving from” rather than “moving to.” The weight of the many challenges they face is the driving force. Increasing workload, constant time pressures, chaotic work environments, declining pay, and endless bureaucratic tasks required by health insurance companies contribute to physician burnout. It is often this burnout that causes physicians to consider moving from clinical practice into leadership positions (Grinspoon 2018).
We believe that when physicians begin to consider moving into leadership positions, they should ask themselves why they want such a change. Are they “running away” or “running to?” If they are running away, particularly if they still enjoy working with patients, have they considered all of the possible solutions to address the issues that interfere with their clinical work? Have they sought out the advice of colleagues, mentors, or therapists?
If they are “running to,” have they considered the many changes they will have to make in order to become effective leaders, such as developing business acumen, changing their communication and leadership styles, becoming collaborators and not simply order-givers, developing additional interpersonal skills, dealing with a completely different set of problems than they have found in clinical practice? We believe that before physicians move into leadership roles, even temporarily, a thorough self-examination will help them come to terms with why they are leaving clinical practices and to be realistic about the challenges ahead in a leadership role (see Chapter 3).
In spite of all these challenges, physicians can successfully transition into physician-leaders, and we believe that physician-leaders are the future of successful health care systems. By understanding and facing these challenges head-on, effective physician-leaders will be able to harvest the synergy created by combining clinical acumen and experience with administrative leadership skills. We hope that the observations and tactics contained in this book prove useful to you.
Coach’s Corner
Moving from being a clinician to being a physician-leader is a huge step. In this chapter, we have introduced you to some of the challenges inherent in that transition. For physicians to make this transition, they must realize that their thinking, behavior, and way of interacting will have to undergo modification and change. Here are some considerations for making the transition.
- 1.Internal motivation for change
- •Physicians must truly understand why they want to move into physician-leadership. Are they “running away” from clinical practice or “running to” physician-leadership? Some combination of both driving forces is often at play, and a successful transition plan requires a personal understanding of this balance.
- 2.Identify your strengths
- •Clinicians bring unique and valuable perspectives and skills to leadership positions. Recognizing precisely what perspectives and skills will be most productive in leadership is essential so that emphasis can be placed on preserving these while developing new skills.
- 3.Identify your opportunities
- •New perspectives and skills are required as physicians transition to leadership positions. Although some of these opportunities will be identified during the transition and through the use of external resources, such as this book, there is incredible value in introspecting and in personally identifying developmental needs.
Grinspoon, P. June, 2018. “Physician Burnout Can Affect Your Health.” Harvard Health Publishing, Harvard Medical School. https://www.health.harvard.edu/blog/physician-burnout-can-affect-your-health-2018062214093 (accessed September 15, 2018).
Lipsenthal, L. Fall, 2005. “The Physician Personality: Confronting Our Perfectionism and Social Isolation.” Holistic Primary Care 6, no. 3. https://www.holisticprimarycare.net/topics/topics-o-z/reflections/200-the-physician-personality-confronting-our-perfectionism-and-social-isolation.html (accessed September 15, 2018).
Price, G., and T. Norbeck. September, 2017. “Physician-Leaders Will Shape the Future of Medicine.” Forbes.com. https://www.forbes.com/sites/physiciansfoundation/2017/09/06/physician-leaders-will-shape-the-future-of-medicine/#18a2c2012766 (accessed September 8, 2018).
Warren, B. March, 2017. “Top Physician Personality Strengths and Challenges.” Healthcare Hiring Perspective Blog. http://www.selectinternational.com/healthcare-hiring-blog/physician-personality-strengths-challenges (accessed September 15, 2018).