Confronting the disruptive physician

Ignoring disruptive behavior is no longer an option in today's changing health care environment. Competition and managed care have caused more organizations to deal with the disruptive physician, rather than look the other way as many did in years past. But it's not an easy task, possibly the toughest of your management career. How should you confront a disruptive physician? By having clearly stated expectations for physician behavior and policies in place for dealing with problem physicians, organizations have a context from which to address the situation.     

Spirituality and the physician executive

The "s" word can now be spoken without flinching in health care organizations. Spirituality is becoming a common topic in management conferences around the world. Many U.S. corporations are recognizing the role of spirituality in creating a new humanistic capitalism that manages beyond the bottom line. Spirituality refers to a broad set of principles that transcend all religions. It is the relationship between yourself and something larger, such as the good of your patient or the welfare of the community. Spirituality means being in right relationship to all that is and understanding the mutual interdependence of all living beings. Physician executives should be primary proponents of spirituality in their organizations by: Modeling the power of spirituality in their own lives; integrating spiritual methodologies into clinical practice; fostering an integrative approach to patient care; encouraging the organization to tithe its profits for unmet community health needs; supporting collaborative efforts to improve the health of the community; and creating healing environments.     

The evolving role of the primary care physician

In today's climate of health care reform, the title of this article might more appropriately be "Is the Role of the Primary Care Physician Evolving or Going the Way of the Dinosaur?" According to Koop, primary care is in trouble. Whereas only 29 percent of U.S. physicians are primary care physicians, in Great Britain, 72 percent of physicians are primary care physicians and in Europe and Canada the average is 50 percent. Many U.S. primary care physicians are in the later stages of their careers and nearing retirement age. Unless the supply increases, this number will dwindle further. However, in 1992, only 14 percent of U.S. medical school graduates were headed for primary care careers. Even if the supply of primary care graduates were increased to 50 percent of the graduating medical school class, it would be well into the next century before the ratio of primary care physicians to specialists would be equal. Primary care is at a critical juncture and the next few years will decide the fate of the primary care physician. Given the state of primary care today, I believe that a fundamental look at the assumptions regarding the role of primary care physicians is in order. The current health reform movement has placed a major responsibility on primary care to solve many of the problems in health care delivery today, such as cost, utilization, and prevention. Many health care organizations are planning strategies involving primary care providers, and physician executives can play a key role in these decisions.     

The physician executive and the future.

In summary, physician managers have a bright future. They are working on one of the most exciting professional interfaces--medicine and management. The future of medicine is both high-tech and low-tech. It will challenge all physician executives. For a few years, health care organizations will experience turbulence and stress. The name of the game for physician managers will be organizational survival. The nation will then move into an era of abundance in medical care, and the management game will switch from survival to thrival. Managers are key players in the world of tomorrow. The physician executive is a manager and therefore a key player. One of the best things about the future of the physician is that he has one.     

Haunts on the Web for physician executives

Listed here are some medical management and health care related Web sites on the Internet worth visiting, as well as favorite search engines and how to use them. From health care systems and hospitals, to health plans and insurers, the industry is using Web technology to promote programs and outcomes, and to provide information on health and wellness.     

Managing the mixed physician practice.

In general, utilization of health care resources translates into physician income. In both a capitated and a fee-for-service environment, the physician is reimbursed for patient care. The reimbursement structures of these two systems is quite different, however, and this difference creates a perplexing reward system for the physician. This article has two goals: To focus on the decision-making process of physicians in a mixed fee-for-service/HMO environment and the potential for cognitive dissonance in this system. To propose an approach for physician leaders in this setting to not only manage and minimize cognitive dissonance, but also strategically position their group for a successful future.     

Integration of quality assessment and physician incentives

The ultimate challenge in dealing with any type of risk incentive system is to be able to integrate the quality of care and the cost of care into an equitable system and to monitor the system and detect either barriers to care or the withholding of appropriate services. We believe it is possible to do this and have based our incentive model upon this premise. At U.S. Healthcare, we have been successful in developing some measures of quality in the ambulatory setting and have tied the measurements to our payment mechanism.     

Leadership for the next millennium: the physician executive

We continue to muddle through using tourniquets and bandaids on a health care system that is in dire straits. And the future is even less promising. There will be millions without basic health care, let alone basic health care coverage. Rural and inner-city hospitals will close, with progressive public apathy, as we focus on the marvels of expensive technologies that serve only the few. Costs will continue to rise at double digit rates, and our nation's employers will fall further behind in the global marketplace. Preventive care will be uncommonly provided and only more rarely reimbursed, while a couple more children die of measles in Mississippi. It's not a pretty picture, and it simply doesn't have to come to pass. "What we really need is leadership," the public cries. That leadership can and should come from medicine through physician executives.     

Lessons from the trenches in physician integration

Beyond the theoretical basis for integration, three core considerations stand out as the primary reasons for pursuing integration from a physician's perspective. In the authors' experience, the ability to make a case for physician integration stands or falls based on the ability of the integrated delivery system to address these considerations: Gain greater access to capital; develop human resources with talents in managed care and the full spectrum of care services; and sustain an information infrastructure. This article explores the lessons learned in pursuing physician integration.     

The physician exodus from hospitals

Physicians are spending increasingly less of their work week in the hospital. This is true of surgeons because they are performing more ambulatory surgery, often off the hospital premises, and for primary care physicians because they are delegating hospital care of their patients to others. What are the effects of this physician exodus on hospitals, patients, physicians, and medical education? Some of these consequences are explored, from disruptions in the continuity of care, to increase in practice productivity, to preparing undergraduates for the realities of medical practice.     

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.     

Changes in physician and non-physician relationships

At the end of World War II, one-third of the nation's hospital administrators were physicians. During the 1950's through the mid-1980's a new breed of masters'level administrator, with well-honed coordinating skills, orchestrated a major expansion of new programs, services, and facilities. With the advent of the Medicare prospective payment system (PPS), more governing boards restructured their administrative staffs with corporate titles. Meanwhile, physicians sensed that trustees were becoming far more concerned with bottom line performance to repay a mounting debt that hospitals had incurred to remain technologically competitive. Since mergers and integrated health systems by themselves will be unable to generate significant operating efficiencies, governing boards will be forced to change direction and shift back to recruiting physicians as their CEOs or in other senior positions to assure themselves of the clinical leadership required to implement the managed care concepts of reducing utilization and cost, and simultaneously enhancing quality of patient care.     

Trends in managed care organizations: implications for the physician executive.

The rapid change in the managed health care industry is placing substantial demands on the managerial and leadership skills of physician executives. These changes are forcing a reevaluation of the fundamental principles of managed care organizations, specifically in terms of patient satisfaction, cost containment, and quality health care. Additionally, the physician executive will be confronted with substantial issues concerning future staffing needs. This article assesses the health care industry's environment to suggest where managed care is going and how physician executives should position themselves to optimize their position in the marketplace.     

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.     

A pivotal role for physician executives

Physician leaders are needed to fill a pivotal role in the health care industry of the '90s. Medical education based solely on traditional scientific methods will continue to produce physicians with excellent clinical and research skills. However, study of science alone will not produce physician leaders. Effective leaders will also need to understand the tools and concepts of organization and management. These leaders will need to participate in the process of formulating and implementing policies to promote the development of economical financing and delivery arrangements while simultaneously improve the quality of care provided.     

Managed care. Preserving the quality of physician work life

The cost reduction imperative of managed care represents a formidable challenge to the culture of medicine and the values of physicians. The unpredictability of practice has culminated in widespread disenchantment--medicine has lost some of the allure which previously attracted the "best and the brightest." To achieve the goal of increasing the work force of qualified primary care physicians, we must ensure that the practice of medicine remains intellectually challenging, personally gratifying, and that its demands are reasonable and realistic.     

Designing the future: physician poll rates the trends

A recent interactive electronic poll of 160 physicians attending an educational conference at ACPE's Future Forum reveals some opinions physicians have about the transition of medicine into the 21st century. Emerging issues include capitation, quality, law, and how to manage integrated delivery systems. Overall, respondents are concerned about remaining solvent is a capitated managed care environment.     

Health reform bridging gaps between physician executives and CEOs

Recently, Hospitals & Health Networks reported the results of a study it conducted, in conjunction with Premier Health Alliance, Inc., and among hospital CEOs and COOs to gauge their preparedness and level of concern about various health care reform issues. Because administrators and physician executives are not always in agreement, we wondered how physician executives would rate the same issues. To find out, the American College of Physician Executives polled some members and posed the original survey questions. The results and subsequent interviews revealed that health care reform appears to be a catalyst in bringing the two factions closer in their thinking.     

Serf or citizen: physician status and organizational structure

For more than a decade, dynamic changes in the health care industry have created new organizations for physicians. The major change for physicians has not been the organization itself, but the principles by which it is governed. This fundamental shift is studied with its impact on physicians, by analogy, becoming more like serfs or more like citizens. A review of the general organizational direction and results of non-physician health care organizations is made followed by the statistical trends of physician groups. Historical comparisons of non-health care industries are made with current organizational choices of physicians and physician groups. Observations of physician decisions are made identifying the direction they send physician status along the continuum from serf to citizen. Physicians are unknowingly making decisions regarding the principles by which they will be governed in new organizations. The choices they are making give them less autonomy and less opportunity to make future choices. The seductive invitation to spend less time in administrative matters and more time practicing medicine is a siren's call that will diminish the status of physicians and the autonomy by which medicine is practiced.     

The physician condition: the age of economic medicine

A university professor believes the combination of Generation X physicians, who assert different expectations about work and home-life compared to Baby Boomer physicians, and the influx of female physicians over the past three decades, has profound implications on the structure of the health care industry.