Negotiating. Biases physicians bring to the table

What are some of the obstacles that physicians face as they seek to become more effective at the bargaining table? The author's thesis, based on experience in both the classroom and the front lines of medical practice, is that physicians face a set of systematic "biases" derived from physician training and professional culture that make negotiation especially difficult for them. They outline the biases they have observed, explore some possible explanations, and suggest solutions for physicians who wish to negotiate more effectively.     

Is there a physician union in your future?

Physician unions are in the news. Patient management and patient care decisions are increasingly being taken out of the hands of physicians and put into the hands of "The Suits." To take their case for a return to physician-driven patient care to the people, some physicians are joining unions. Some are even collectively bargaining for salary and other issues that are historically more closely associated with unions. The simple fact is that physician unions exist and the number of physicians joining them is expected to increase. What are the pros and cons of unionization? What motivates physicians to join unions, and what potential negative and positive factors are associated with physician unionization? This article reviews the pros and cons and the issues related to physician unions, for physicians attempting to answer the question, "Is there a union in my future?"     

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.     

Part-time medical director: way station or end of the line?

This article is mostly directed to physicians who are contemplating a career change into management. You may be one of those persons who is contemplating taking a part-time position and continuing part-time clinical practice to see if you might enjoy management. It is important to understand that a part time medical director is there primarily because management perceives a need for a physician's skills and license. When a physician is hired on a part-time basis, it is unlikely that management realizes the larger benefits that can accrue to the organization from the physician manager's knowledge of health care and unique approach to the problems and opportunities in the delivery of that health care. Part-time medical directors seldom have an opportunity to be exposed to real management issues and activities and are usually sequestered and limited to functions that a naive management team thinks are most appropriate to a physician's skills and temperament. Be cautious in extrapolating a part-time experience to a full-time role. Consider taking the plunge to full-time management without a part-time transition phase.     

The emerging role of the physician in administration

Physicians often find it difficult to determine the type of training needed to prepare themselves for administrative roles in health services organizations. Without extensive knowledge about organizations and how they function and how administrators contribute to organizational performance, physicians tend to view management roles as either overwhelmingly complex, or, conversely, simply a matter of using good judgment. In an attempt to help clarify this issue, we have outlined six management problems that an entry-level physician executive should be able to deal with successfully without asking for help. If physicians find that they are unable to deal with these issues, they should seek additional training before considering a management role.     

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.     

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.     

The physician's alternative career transition model: a stepwise approach

The recent intense focus on marketplace reform has stimulated a reassessment of career planning options for some physicians. These socioeconomic changes have created unique opportunities beyond the traditional arenas of clinical practice and medical management for physicians to leverage their medical degrees and experiences in the business world. This paper presents three case reports of physician executives who have successfully pursued medically related business career options, each following different motivations at various stages of their medical careers. It then discusses the Physicians' Alternative Career Transition (PACT) model developed by the authors to assist other physicians who are considering making transitions into business-related careers. The PACT model is based on four critical steps for practicing physicians to make these transitions successfully: an internal self-evaluation process, an external environmental evaluation process, seeking the best "career match," and securing the career match.     

Operations network development: internationalisation and externalisation of value chain activities

Considering the increased significance of both internationalisation and externalisation of manufacturing, this paper aims to provide an integrated understanding of internationalisation and externalisation and seek to identify further development trends. First, this paper investigates and summarises the existing literature in order to examine what has been done on internationalisation and externalisation. An adapted matrix is further presented in order to illustrate a roadmap for the manufacturing system evolution. Claiming that conceptual insights tell only one of the two worlds (i.e. research and practice) of operations management, this paper successively explores what is actually happening in practice on the basis of three case studies selected from the global operations networks (GONE) project, which is a joint-effort between several Danish universities and aims to deepen the understandings on GONE. The empirical findings suggest that the discussions on internationalisation and externalisation need to be extended from manufacturing activity to other value chain activities. Two development trajectories are further identified and combined. Their similarities and differences are correspondingly compared. Based on these findings, some managerial recommendations are given at the end.     

Physician leadership. How do physician executives view themselves?

Most physician executives today have acquired substantial management training and experience, and many have worked with and relied on the expertise of mentors for their career guidance and development. Physician executives are actually becoming executives who happen to be physicians. They view themselves first as leaders, then as physicians, and finally as managers. That is a remarkable transformation in perception. To chronicle this process, Witt/Kieffer, Ford, Hadelman & Lloyd conducted a national survey this spring among senior physician executives in both payer and provider organizations. The data provide a "snapshot" of their role, and may also suggest some future scenarios for the industry. The primary reasons for choosing to pursue a management role noted by most participants include a desire to be part of the health care solution and an interest in management and leadership challenges.     

Legal issues in accepting capitation

The effort to reduce the cost of medical, hospital, and ancillary services increasingly focuses on shifting the financial risk for the cost of these services to those who provide them. Shifting arrangements include capitation for physicians classified as "primary care" physicians; capitation arrangements that include primary and specialty services; risk shifting to medical groups, IPAs, and other physician organizations; as well as the packaging of physician and hospital services on a "full risk," "per case," or other basis. Accepting financial risk for the cost of medical and other health care services, as well as the responsibility for managing the provision of services, may very well be the only remaining opportunity for providers to maximize reimbursement and maintain administrative and clinical self-direction. However, physicians must work with managed care organizations (MCOs) through negotiation of contracts and throughout the relationship to make sure: Unnecessary financial and legal risks to the MCO and physicians are eliminated. Risks that cannot be eliminated are apportioned between the MCO and physicians. All risks are managed in a coordinated fashion between the MCO and physicians.     

The new breed

Structural changes within the health system--particularly in the organization and financing of services--have made new and different opportunities available to physicians interested in management. What types of physicians are currently going into management? How do they compare to others who have been in management for a longer period of time and to the "traditional" portrait of the physician executive? The author profiles the emerging, contemporary physician executive and explores the implications for the viability of the field of medical management as a whole.     

A physician's view from the Hill

Rarely do physicians have the opportunity to participate in our political system on a day-to-day basis. The Robert Wood Johnson Health Policy Fellowship, a one-year program for mid-career medical professionals, provides just such an experience. The Fellows begin with a two- to three-month orientation phase before selecting a congressional work assignment. As a member of a congressional staff, a Fellow has the opportunity to learn from, as well as contribute to, the legislative process. The health policy experience provides another tool to complement the clinical and management expertise of the physician executive.     

From medicine to management: the female physician executive

In a 1988 article in Physician Executive, Bonbrest recorded the number of women members (74) of the American College of Physician Executives (then the American Academy of Medical Directors) and urged senior managers to facilitate the entry of women physicians and minorities into management positions. This article relates historical trends for women in medicine and medical management and calls for increased attention to the slowness with which advancement for women has been achieved.     

Hirer, hiree, beware: new hiring trends

What are the three hiring trends that trouble both human resources people and top management? From the "exploding job offer," to new hires who renege on their acceptances, to "front loading," these trends are predicted to continue, so where does this leave you in the salary negotiation process? From communicating often to interviewing more carefully, some suggestions are explored to help physician executives address these disturbing trends. There's still a sub rosa theory that only undesirable candidates back out of an offer. But that's no longer true and that attitude may make you short-handed!     

Navigating the job search superhighway

The recent Cyberforum on "Navigating the Job Search Superhighway" gave 131 American College of Physician Executive members the opportunity to discuss the job search process, addressing questions and sharing what they've learned through their experiences in the medical management job market. Several comments that convey the essence of the discussion are listed, representing the various viewpoints of the participants. The words are from physician executives who have gone through the job search process and from some who have been involved in hiring decisions. The topics range from the value of experience to the importance of having a management degree to tips on networking to preparing for the interview. The final section on contract negotiation is a composite of comments on the subject during the Cyberforum.     

Rethinking Risk Assessment for Public Utility Safety Regulation

To aid in their safety oversight of large‐scale, potentially dangerous energy and water infrastructure and transportation systems, public utility regulatory agencies increasingly seek to use formal risk assessment models. Yet some of the approaches to risk assessment used by utilities and their regulators may be less useful for this purpose than is supposed. These approaches often do not reflect the current state of the art in risk assessment strategy and methodology. This essay explores why utilities and regulatory agencies might embrace risk assessment techniques that do not sufficiently assess organizational and managerial factors as drivers of risk, nor that adequately represent important uncertainties surrounding risk calculations. Further, it describes why, in the special legal, political, and administrative world of the typical public utility regulator, strategies to identify and mitigate formally specified risks might actually diverge from the regulatory promotion of “safety.” Some improvements are suggested that can be made in risk assessment approaches to support more fully the safety oversight objectives of public regulatory agencies, with examples from “high‐reliability organizations” (HROs) that have successfully merged the management of safety with the management of risk. Finally, given the limitations of their current risk assessments and the lessons from HROs, four specific assurances are suggested that regulatory agencies should seek for themselves and the public as objectives in their safety oversight of public utilities.     

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.     

Get real: what will draw physicians to the Web?

What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems? How can health care leaders and physicians help the technology innovators and the executives of technology firms understand the components necessary to assure physician acceptance and utilization of new tools? (1) Don't underestimate the personal nature of a physician's practice. It really isn't a "business." (2) Most physicians are not Luddites; they are just extremely pragmatic and practical. (3) For the majority of physicians to adopt a new technology in their private office practice, it must address three major issues: money, hassle, and patient care. There are many obstacles to adopting the new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. Some technological innovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.     

A rational approach to career change

Recently, the number of physicians who have been interested in alternative careers has vastly increased. Many physicians express dissatisfaction with clinical practice, but they are uncertain about which nonclinical options are appropriate for them. Pursuing a different career after many years of studying and practicing medicine can seem like an overwhelming task. In this article, the author briefly outlines a decision-making process that can be used in analyzing career options and suggests some careers that have provided challenging opportunities for physicians.