Building a framework to transform health care

Advances in information technology are helping clinicians to realize the promise of evidence-based medicine, which includes benchmarking, outcomes monitoring, predictive modeling, and clinical pathways. By integrating individual clinical expertise and the best available research, physicians can apply the disciplines and techniques of clinical research to their practice of medicine, one patient at a time. Evidence-based medicine also allows organizations to move forward with continuous clinical quality improvement programs. Standards, open systems, data warehouses, and evidence-based medicine help a health care delivery system obtain the technical infrastructure, decision-making processes, analytical skills, clinical databases, predictive models, and clinical pathways. With this information technology (1) physicians can practice evidence-based medicine and (2) the delivery system can profile clinicians' practice habits for managed care contracting and continuous clinical quality improvement.     

Care management challenge is the toughest yet.

The newest health care trend involves changing the core business--health care delivery and the resources involved--through better care management. This impacts every practitioner all day, every day. This issue truly belongs to the physicians, and thus to physician executives. Care management is the latest frontier, the place where the delivery of quality care, in the most efficient way, at the best possible cost, all come together. And physician executives are being challenged to make it happen, to change the way medicine is practiced and health care is delivered across the country, to move from treating episodes of care to a true preventive mindset and population-based methodologies. This column outlines the skills in care management that systems-based physician executives will need to develop or enhance to remain competitive--effective communication skills and team-building capabilities are critical attributes for those who hope for success.     

Getting started as a physician executive

In clinical practice, technical skills often outweigh interpersonal and leadership skills as success factors--you can be a great doctor and a so-so person. But the reverse seems to be true in the physician executive role; it is precisely the intangible leadership skills that contribute to and determine potential success. And they can be tough to master, especially when you focus on them for the first time, partway through an already-successful career. Practicing leadership is like practicing medicine. It's not just a matter of learning some new things--if it were only that, physicians are known to be excellent learners. Nor is it just a matter of determination or application--this is not a battle that sweat and effort alone can win. Most physicians will want to "try on" the executive role before making strategic moves in that direction. But be clear about what you want to get out of any project or activity before you jump in. If you're seeking a management degree, the best approach is to tie together developing your technical and interpersonal skills, as well as the formal credentials.     

Administrative fellowships in emergency medicine

Physicians today need to be effective managers, as well as clinicians. In previous years, physicians gained managerial experience either through on-the-job training, degree programs, or continuing medical education courses. The specialty of emergency medicine began its first administrative fellowship in 1990 in California. Currently, three administrative fellowships exist nationally in emergency medicine. This article will describe the purpose of the fellowships and their curricula. Each fellowship has a different emphasis, with the goal to educate physicians who are interested in developing administrative skills to manage emergency departments or management groups or accept roles in hospital leadership. The existence of these fellowships will ideally influence the establishment of administrative fellowships in other specialties.     

The value circle. A profile of J. Richard Gaintner, MD.

This article describes how the arrival of CEO J. Richard Gaintner, MD, at Shands HealthCare signaled a time for refocusing the organization's direction and helping physicians to cope with the changes buffeting the industry. He saw angst and disenfranchisement, sentiments that characterized not only Shands and the University of Florida Health Science Center, but also the entire establishment of American scientific medicine. Gaintner believes--and continually preaches--that practicing medicine in a cost-effective manner will improve, not harm, the quality of care. His willingness to face reality objectively is perhaps his greatest asset in helping physicians deal with managed care. He conveys heartfelt empathy with the day-to-day conflicts they face. But he does not allow himself the temporary luxury of cynicism, and he refuses to accept negativity and pessimism in others. Rather, he asks that physicians and managers understand the system and develop the capacity to work within it and take responsibility for improving it. Beyond exhorting physicians to be accountable for the success of the enterprise, Gaintner creates mechanisms for meaningful physician participation in enterprise management.     

After the revolution: the physician executive of the future

There is a revolution in health care occurring in our midst. The roots of this revolution are explored. The physician executive of the future will need a new set of skills because the health care system will change. This new, evolving set of skills includes being: Savvy about business; simultaneously employer- and customer-focused; and technologically driven. This manager must be a team builder rather than a lone ranger. These skills are learnable, just like piloting a plane or doing a surgery. None of us was born with the skill to practice medicine any more than we were born with business skills. While many physicians are depressed by the present health care climate, feeling a loss of power and a loss in spirit, the vision of the physician manager must carry them and the organizations they build forward through uncharted waters to a future which is every bit as exciting as our past.     

The angry physician-Part 1. The temper-tantruming physician

Angry physicians create problems--for the people they treat and work with, for their administrators, and for their loved ones. Addressing negative emotions is one of the most prevalent organizational and personal challenges facing physician leaders. Solving this problem starts with taking an honest look at the factors and processes that shape physicians' coping patterns. Learning effective emotional management skills is underscored by a simple fact: Emotions are contagious. The Type A behavior pattern (TYABP) refers to an aggressive coping mode. Cross-cultural research suggests that, compared to the general population, physicians show elevated scores on TYABP measures, and that women physicians are at particular risk of developing TYABP. In Part 2 of this series, interpersonal anger management strategies will be presented.     

Suggestions for management training of residents

In addition to having medical expertise, physicians must possess managerial skills to deal with the ever-changing business environment of the practice of medicine. This article addresses the need for management training of physicians and calls for management training during residency and medical school. It also describes one residency program's efforts to provide comprehensive management training to its residents in pathology.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

Physician executives: managers first, clinicians second

The literature is replete, many would say depressingly so, with accounts of the changes that are rocking the health care delivery system. The demands on the system's leadership increases with every change. And the future holds even more changes, with a level of uncertainty that will makes today's demands seem childplay. Physicians, especially physician executives, will surely be key factors in helping the system maintain its fundamental charge of high-quality patient care provided at reasonable cost, but what exactly is expected of them? One point is clear: While their clinical backgrounds will continue to arm them well for reaching the executive suites of health care organizations, physicians who hope to fully succeed in management will have to acquire and master a widening range of management skills. An indication of just how demanding the health care management job will be is provided in this report, based on interviews with physician executives and the people who seek and sell their services.     

Impact of managed care on physician organizational behavior.

This article examines how physicians act, react, and organize when managed care forces them to consolidate into larger groups and business corporations. Physicians have experimented with ownership by hospitals or business corporations to gain capital, management skills, and information systems. Now they're moving toward physician-owned groups with "outsourcing" of administrative and information system functions. The mood, movement, and momentum of physicians, in short, is toward integrated physician organizations bound together by information that amplifies on their core competencies and capacities to deliver care.     

The physician glut: a different view. Interview by Donna Vavala

An interview with nationally known futurist Leland Kaiser, PhD, on the changes physician executives are likely to face as a result of the coming dislocation in the health professions. Or will there be a shrinking career pie at all? The real question is: What new mental models are we going to use and as a result of the new models, what new jobs are going to be created that will ameliorate some of the surplus we've created in the old model? Dr. Kaiser predicts a model will soon emerge that will open a myriad of new career opportunities for physicians. The new model he foresees is community-based medicine.     

Development of a local Physician Executive Leadership Program

Dramatic changes are occurring at a rapid pace throughout the United States in virtually all aspects of health care delivery. Physicians, hospitals, consumer groups, and others are thus facing new and greater uncertainties and are forced to adapt to a continually shifting environment. Fundamental change of this magnitude has and will continue to result in the formation of new alliances and organizations within which physicians and others will be forced to function. To participate effectively in these processes of change and to maintain influence within these new organizations, physicians will need leadership and management skills. To address the challenges facing current physician leaders and the need to develop more effective leaders, Sharp HealthCare developed its Physician Executive Leadership Program. This article describes the program and summarizes some of the lessons learned regarding the training of physician executives and leaders in today's changing health care environment.     

Conflict management, prevention, and resolution in medical settings

Everything about conflict is difficult for physicians, who are by nature and conditioning quite confrontation adverse. But conflict is inevitable, and conflict management skills are essential life skills for effective people. The keys to conflict management are prevention, effective communication, and anger management, skills that can be learned and polished. Conflict management skills can enhance all aspects of life for physicians, as well as those who work or live with them.     

Economic feasibility of a primary care practice

To make informed career decisions, the new physician must acquire basic skills in medical management and health care economics and learn how to evaluate the potential survival and growth of a primary care practice. The authors have developed a model designed to aid physicians in determining the economic feasibility of establishing a practice in a specific community or joining an established practice.     

Purchasers and the impact of managed care on physicians

In much the same way that demands by managed care organizations are shaping the way physicians practice, health care purchasers impact how managed care organizations operate. Corporations purchase managed health care through their employee benefits programs, and understanding the language, objectives, and limitations of these purchasers is essential to grasping the forces influencing managed care organizations and the modern practice of medicine. The emergence of value-based purchasing as a strategic corporate approach to health benefits programs will dictate the forces on physicians, hospitals, and managed care organizations for years to come. These forces have already led to price reductions, health plan accreditation, employee-directed report cards, outcomes management, and organized systems of care, and they will determine the broad outlines of the emerging U.S. health care system.     

A new industrial order for physicians: a talk with Jeff C. Goldsmith, PhD. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Jeff C. Goldsmith, PhD, President of Health Futures, Inc. on October 12, 1999 to discuss how the Internet will affect health care delivery in the millennium. One of the most profound changes that he sees is how the relationship between physicians and patients will be altered. Empowered consumers are where the real revolution is happening--a trend sometimes overlooked by physicians. Goldsmith says, "The key thing physicians have missed is that the patient is in charge of the process.... The Internet has enabled patients to aggregate their collective experience across disease entities." But there is too much information. "It is almost universally acknowledged by patients and physicians that there is a terrible quality problem. Getting from information to knowledge is a huge commercial opportunity for somebody." He doesn't think that people have put enough emphasis on the collective learning part of this new technology.     

The physician executive in a changing world.

Physicians are losing their historic franchise as sole and primary providers of medical care. In addition to eroding moral and scientific authority, physicians are also losing income and status. It is no wonder that physicians are retrenching--confused and angry about the increasing marginalization of their profession and about society's changing expectations. Physicians are caught in a transition zone between the world that was and the one that will soon be. This is destabilizing and causes great anxiety. Rather than being buffeted by changing social and cultural definitions of health care, physicians must become proactively involved in the future of their profession. Physicians can only do this by offering a better mental model of health, medicine, and the community. This cannot be a defensive retreat from engagement. Rather, it must be an imaginative vision, vigorously set forth--a vision that will enlist the support of all constituencies involved in the effort to improve the health and well-being of all members of our society. The physician executive needs to work with physicians to orchestrate this effort to create a new vision of health in the 21st century.     

The courageous follower

With the recent changes in the delivery of medical care in the United States, physicians are being thrust into new and unsettling roles. Many are finding themselves for the first time in the role of the follower, subject to myriad types of leadership. Leaders frequently complain that leading physicians is like "herding cats." What are the characteristics of followers? Do physicians make good followers? This article examines the role of the "cats"--what is effective followership, why physicians may fall short in followership skills, and how physicians might become better "followers."     

Health care trends, Part 2. The new health care team. Panel discussion

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.