Re-forming the traditional organization medical staff

The traditional, two-bylaws-model organized medical staff was created in another age (1919) to serve a simple health care system, controlled by physicians, in which the only players were patients, doctors, nurses, and small hospitals. This medical staff model does not meet the needs of the U.S. health care system of the 1990s. The purpose of this article is to provide the physician executive with a resource to use when he or she is called on to help determine what, if any, changes are needed in his or her organization to make the role of physician leaders more effective. Finding the right answer to this question is part of discovering ways to reduce health care costs without reducing the funds available to pay for direct delivery of health care services. Maintaining traditional, bureaucratic, legalistic organized medical staff activities is a very expensive game that we can no longer afford to play.     

Physician executives: where they are and what they do

As hospital operations become increasingly complex, so does the institution's management and organizational structure. Physician executives with titles of medical director, vice president for medical affairs, medical administrator, chief of staff, medical staff president, etc., are playing more important roles than ever before. This article will briefly review some recent literature describing physician executive profiles. The results from a survey of ten university teaching hospitals are also presented as supplementary information regarding current staffing models. Finally, several physician executive staffing-related issues will be discussed in light of the literature and the survey results.     

Physician leadership. Physician executives share insights

Senior physician executives were asked to share their insights about how the medical management field has evolved. The Physician Executive Management Center, a Tampa, Florida-based search firm, has been surveying senior physician executives each year for the past decade. This year's report on physician executive compensation and duties in hospitals, managed care organizations, and group practices provides an excellent picture of the growth of the profession, as well as a broad perspective of anticipated changes for the future of medical management. The respondents addressed the following questions: What are the skills necessary for success? How have their jobs changed over the years? Have they made the right choice in pursuing medical management careers?     

Compensation for elected hospital medical staff leadership

As physicians' practices become more complex and their practice incomes more difficult to maintain, hospitals concurrently require more physician input into organizational, utilization, and strategic planning matters. Physicians and hospitals across the country are discussing the question of financial compensation to physicians for the time they spend performing these hospital administrative tasks. It is already common practice for hospitals to pay a salary for medical direction of hospital departments such as intensive care units or pulmonary laboratories. The question has become whether this practice should be extended to elected medical staff leadership.     

Elected medical staff leaders: who needs 'em?

Authority, influence, and power are not synonyms. In working with elected medical staff leaders, a physician executive who chooses to exert authority may soon find him- or herself relatively powerless. But one who chooses to downplay authority, to influence through persuasion, and to coach leaders to lead effectively soon generates support for his or her ideas. The need to coax, cajole, explain, persuade, and "seek input" frustrates many leaders in all kinds of organizations. It would be much easier just to order people about. It's so tempting to think: "Who needs 'em? I'm the 'chief physician.' I know what needs to be done. Let's weigh anchor, take her out, and do what it takes to sail those rough, uncharted seas." If you really enjoy sailing a large ship in rough seas without a crew, go right ahead. Or if you think it makes sense to run an organization with only an executive staff and no knowledgeable middle managers, by all means let clinician leaders know that, now that you're aboard, they're just window-dressing. If you can make this approach work, well and good. Your life will be much less complicated, each day will have far fewer frustrations, and progress toward established goals will be much faster. However, given the reality of traditionally thinking physicians, it would be best to keep an up-dated resume in the locked lower left-hand drawer of your desk.     

Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.     

CEO behavioral pattern expectations for physician executives

This is a report on the second part of a two-stage survey. The first part of the survey, reported in the Nov. 1994 issue of Physician Executive, dealt with physician executive behavior tendencies as viewed from the perspective of physicians, largely in hospitals. In the follow-up portion of the survey, the views of hospital CEOs on this subject were sought. CEOs were also asked for their views on the roles of physician executives and on what they were seeking in physician leaders. CEOs were asked to assess these issues in terms of the ideal physician executive, not the persons currently holding such positions in their organizations. Finally, this second report draws on the results of both parts of the survey in order to make comparisons between the views of the two groups of managers.     

Boards want leadership and decisiveness.

Regardless of whether they aspire to the top executive spot, physician managers are likely to benefit from insights into what hospital boards want in their chief executive officers. Many of the attributes board chairs desire in hospital CEOs involve how they handle medical staff matters. In general, board chairs want leadership and decisiveness--attributes they likely would covetin any physician manager who has hospital management responsibilities.     

Hospital medical directors, quality of care, and financial returns

You are a physician executive working very hard within a hospital on all sorts of medical staff issues and quality of care. You answer to the board. The latter, through its administrators, may still have difficulty documenting the precise value of a full-time physician executive. Your hospital is losing money or not making enough profit for capital expenditures and salary raises. It is considering or will have to consider staff cuts. What can you do that will influence the bottom line, produce a quality image, and quantify your value?     

Making a match: inexperienced physician executives and the job market

Hospitals and other health care organizations are adding physician executives at such a rate that demand is outstripping supply-there are more opportunities for seasoned physician executives than there are physicians with track records as medical managers. It is possible that hiring management will have to consider the employment of a physician who wants to be in management but has no track record as a physician executive. In some cases, it may even be preferable to employ a neophyte physician executive, especially when the physician is a respected clinician already on the organization's medical staff. In selecting such a physician, however, an evaluation must be made of the probability that the physician will be successful in the new role. The author points to 10 criteria that the hiring organization should observe in hiring inexperienced managers.     

Physician executives report high job satisfaction. Summary of findings from a survey of senior physician executives

The role of the senior physician executive is well established in American hospitals and health systems. There is little research, however, on overall physician executive job satisfaction, their perceptions of their organizational role and job performance, or their views of the medical staffs with which they work. A recent survey of physician executives examined these and other areas. It found physician executives to be quite satisfied with their jobs. What follows is a summary of the findings. An article based on the survey will be featured in a future issue of The Physician Executive.     

Quality management remains top medical manager responsibility

Earlier this year, the Physician Executive Management Center conducted a survey of physician executives in management positions in hospitals, group practices, managed care organizations, and industry. Information was obtained for physician executives in both full-time and part-time roles. In addition to gathering compensation information, the survey sought to define the scope and intensity of the responsibilities of physician CEOs and senior medical managers (medical directors or the equivalent) in these organizations. In this article, the authors summarize the findings on responsibilities for senior medical managers in hospitals, group practices, and managed care organizations.     

Wanted--seasoned veterans. Diamonds in the rough need not apply

Health care organizations looking for physician executives prefer seasoned veterans--doctors who have already done the job. They want job-specific experience. Most organizations do not provide training grounds and orderly career ladders for aspiring physician executives. The Permanente Medical Groups, Family Health Plans, and some very large group practices are exceptions, but, for the most part, rising medical directors in these organizations stay with them. Most hospitals are not large enough to have associate or assistant medical directors or an environment that could provide a training ground for rising physician executives. On the other hand, hospitals, larger group practices, health insurance companies, and managed care organizations provide ample opportunities for nonphysician managers to train, gain experience, and climb the ladders. How can the novice physician executive break into the world of management and begin establishing management credentials? The author provides some key steps that can lead to success.     

What skills do physician leaders need now and in the future?

The role of the physician leader is moving beyond traditional medical staff issues. A recent national survey of physician leaders shows a growing need for education on specific technical, leadership, and practical skills. The results reveal the medical leadership skills that physician executives consider important today, and provide a window to the future about the skills that will be important tomorrow. Physicians say they need training now in quality assurance, clinical benchmarking, decision-making, and strategic planning. And when they gaze into the future and see the rapid changes throughout health care, they say they'll need more training in communication, organizational change, effective listening, and systems thinking.     

Should the physician executive be the physician's advocate?

Medical staff commonly want to know if a prospective physician executive will serve as their advocate to management. A successful physician executive must like and respect physicians. But the question of advocacy must be answered thoughtfully, because the candidate must not imply that he or she will defend any action by any physician. A three-part conditional response is advisable.     

An approach to the impaired physician

The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention.     

Medical staff handling of concerns with physicians' performance

Medical staff organizations and their leaders are frequently confronted with concerns about physician knowledge, performance, or behavior. Dealing with these concerns is a serious and time-consuming task. Poorly handled issues may result in serious legal consequences. In highly structured organizations, authority for responsibilities, income, and employment rests with individuals who must manage these problems, but medical staff structures do not always lend themselves to dealing with these issues. Introduction of quality improvement processes into medicine has been received as a panacea for physician problems. Certainly the majority of physicians understand quality improvement and work toward common goals to improve patient care. Unfortunately, a small minority remain problem physicians. Steps that can be taken to deal with problem physicians, particularly for issues of quality management, are described in this article.     

The evolution of the VPMA (vice-president, medical affairs)

In the past, the VPMA's role was clearly defined. So were the skills required to do the job. Initially VPMAs served an inside role in an organization as the liaison with the medical staff and the hospital administration. That role has matured and is currently evolving. Ultimately the expansion of the VPMA role will provide alternative career directions for physician executives. The wise physician executive learns from those who have knowledge--or who are in the process of acquiring it. That means keeping an eye on active managed care markets nationwide for trends that may be coming to his or her locale. The physician who does not do this kind of professional introspection and evaluation of the national market may find him- or herself professionally behind the curve.     

Health care applications of complexity science. Life at the edge of chaos

The authors explore complexity science, a relatively new field of inquiry, which holds for both clinicians and health care leaders the real possibility of stimulating fresh insights and approaches to health and medical care-both its provision and its organization. Two case studies are presented to illustrate how complexity theory can provide health care leaders with a new perspective on how to address the myriad challenges they confront daily: (1) a patient with dissociative identity disorder; and (2) a physician task group charged to advise on hospital medical staff reorganization and governance. These case studies help clinicians and leaders of health care organizations understand how complexity: (1) may be relevant, even helpful, as they consider difficult challenges in both patient and organizational management; and (2) might emerge as a synthesizing force as they face the extraordinarily complicated task of jointly creating integrated health care systems. A resource section is provided for those who may wish to further pursue the topic.     

Part 2, Conflict management. How to shape positive relationships in medical practices and hospitals

Managing workplace conflict is one of the most important, stressful, and time-consuming tasks faced by today's physician leaders. In Part 1 of this article series, the authors describe how to assess an organization's interpersonal dynamics. True change comes from interventions that help an organization to become a positive interpersonal culture, one that fosters cooperation and collaboration. Part 2 offers seven steps to solving the disruptive physician problem: (1) provide protection to complainants; (2) listen, empathize, and avoid communication triangles; (3) confront offenders with data, authority, and compassion; (4) if needed, get outside help; (5) offer workplace training and experiences that foster positive relationships; (6) follow-up; and (7) practice what you preach. The self-assessment and intervention guidelines discussed in this series of articles can help physician executive move beyond struggling with episodes of conflict to shaping stress-resilient medical organizations.