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.     

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 process for objective review of physician performance

How do you objectively evaluate physicians at reappointment. How do you establish a common ground for the evaluation process that still acknowledges acceptable differences in performance? Perhaps one physician has some difficulty with documentation and attendance at meetings, but has no quality problems clinically. Another physician may have good documentation and meeting attendance, but has some quality problems. Another physician has a behavior pattern that is disruptive, a few documentation problems, but excellent quality. Yet another physician is a marginal practitioner with major problems in several areas, including quality. Reappointment of these physicians might be extremely difficult, especially if the credentials committee is recently appointed and not familiar with the details of the performance data.     

Physician organizations. Part 1: A report from the trenches of a start-up PO

How has Community Health Partners, a physician organization based in Kansas City, turned the corner as it rolls into the second year of operation? The biggest indicator is that CHP hammered out the city's first professional risk contracts and the PO has grown from 23 to more than 50 physician member/owners. Looking back, there are at least 10 reasons why CHP made it this far. These are not reasons you learn about in medical school or an MBA program. There is no one-size-fits-all template for building POs. No fixed organizational chart. No neon signs pointing to the best capital partner. Part I explores five reasons for success, such as having a strong board and physician leadership, as well as educating participating physicians about capitation and affiliating with any hospital or payer that really knows how to partner with physicians. Part 2 will focus on five more lessons learned from the trenches of a start up PO.     

Why it matters

Physicians everywhere are facing changes in the ways they are paid, and in their relationships with their patients. In the United States, an increasing number of physicians are being confronted with the choice to join their practice to a physician service organization (PSO) or some other capitated financial structure in which they collectively put themselves at financial risk for the health of their patients. In all these decisions, the biggest handicap is fear. Some physicians let fear keep them from changing. Others let fear drive them too quickly into change that turns out to be unwise. The fear of change-the fear of the unknown, of things that, deep down, under the professional veneer, we wonder whether we can handle-is quite real. It is immediate and nearly constant. How can you drive out the fear? There is no simple answer. The complex answer starts with daily practice, with taking the practice deeper, taking it wall-to-wall. Here are some ideas for dealing with the fear of change, from owning up to your true feelings, to acknowledging failure, to breaking the change down into its smallest components.     

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.     

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.     

Negotiate the salary you want

How can physician executives negotiate the salary and terms that they want for a new position? The idea of negotiation raises the anxiety level of all but a few people, those who thrive on the thrill of competitive bargaining. Most physicians do not relish the process and view it as a type of conflict. But without knowing what you want to accomplish and preparing to ask for it, you may well leave the meeting frustrated and unhappy with the offer. Determine what you want before you get into an important negotiation. You will get clear on what you want much quicker and you will remember the points better when you talk to the other person.     

Managing diversity in the workplace

Recognizing and dealing with cultural diversity has become a critical issue in health care because of the growing numbers of women, minorities and foreign-born physicians and patients. To avoid a culture clash, physician executives have become more aware of the differences and are working to find ways to help the staff interact more effectively with each other and with patients.     

The ideal physician entrepreneur

How does the sometimes elusive and high-stakes world of venture capital really work? How can physician executives with innovative ideas or new technologies approach venture capitalists to help them raise capital to form a start-up company? These important questions are explored in this new column on the physician as entrepreneur. The ideal physician executive is described as: (1) an expert in an area that Wall Street perceives as hot; (2) a public speaker who can enthusiastically communicate scientific and business plans to a variety of audiences; (3) a team leader who is willing to share equity in the company with other employees; (4) a recruiter and a motivator; (5) an implementer who can achieve milestones quickly that allow the company to go public as soon as possible; and (6) a realist who does not resent the terms of the typical deal. The lucrative world of the venture capitalists is foreign territory for physician executives and requires a great idea, charisma, risk-taking, connections, patience, and perseverance to navigate it successfully.     

A great position before a great 'package'

Should employment agreements (EAs) be the deciding factor in considering a new position? EAs are details--important details, but background just the same--to the key issue: Do you want the job? And because of the way many health care organizations create their EAs, there really is little room for negotiation. Perceptions persist that this is an entirely open area, a blank canvas upon which each physician executive, in each situation, must don his or her battle gear and fight fiercely for the best possible deal. And yet, this is an area in which you are unlikely to have control.     

I can't believe they think I'd...

Many physician executives experience a personal jolt as they move to work in a very different relationship with their colleagues. What happens? How can we understand this phenomenon? What can we do to minimize the personal toll so often exacted by the transition to leadership? This paper will focus on these essential questions. The inevitable discomfort encountered during this learning curve, which can last from two months to two years, often comes as a surprise. Many physicians who have been elevated to leadership positions because of their success and interpersonal acceptance, have not had to struggle with this sense of being "a fish out of water" since very early in their professional careers. Unless there is someone in place to reassure and mentor, the resulting confusion can be quite unnerving, resulting in reflex defensiveness.     

Don't be an accidental physician executive

How can physicians begin crafting a career with intention and careful thought? Before you go leafing through The Physician Executive or the New England Journal of Medicine's Positions sections, you'll need to conduct a thorough career evaluation of where you are and where you want to go. There are more career tracks in more types of organizations available to you as a physician executive than ever before. There is also considerable turbulence, creating unexpected opportunities. The times have never been better for aggressive, energetic physician executives who want to move up and out.     

Attitude adjustment

How can you motivate physicians so that their decisions and behavior reflect what is best for the group practice, instead of themselves or their department? By clearly stating expectations and goals, physicians can learn that the priority must be the success of the group practice. Presented here is an example of how the Orlando Health Care Group (OHCG), a primary care medical group with 85 physicians in four specialties, addressed this challenge and the physicians' positive response to the change. To survive as a group, the OHCG had to abandon old ways of managing conflict and agree upon a list of core values around which it could evaluate all future physician behavior. The list became known as the "10 Commandments." They were meant to give every individual a sense of place and purpose within the group, knowing that the best way for an individual to prosper was to be part of a successful group.     

Thriving in change

The turbulent state of health care and the rapid changes that show no sign of abating point to many career-related challenges for physician executives. How can you predict the impact of these changes on your career? What measures can be taken to prevent any negative impact of change? And how can you prevail when dealt a negative blow like job loss? The signs that foreshadow the unraveling of a physician executive's career are described. The warning signs are: Not keeping up with change, losing your influence; getting negative feedback; turning your "concerns" into complaints; the economy working against you; and being blindsided because we think leaders operate logically. Being proactive puts more control in your hands and leaves less to chance. You can prevent being blindsided if you: develop your people skills; get comfortable and involved with e-business; stay abreast of health care trends; pick up the pace; and develop "You, Inc." There is a final component to prevailing over adverse circumstances--find your work-related passion and apply it to your career.     

The future of health care, Part 2. The PPMC debate. Panel discussion

In Part 2 of this second annual panel discussion, Jeff Goldsmith, Barbara LeTourneau, Uwe Reinhardt, and physician executives from three physician practice management companies (PPMCs) examine this burgeoning new industry. They grapple with questions (and occasionally with each other), such as: Are PPMCs delivering what they promise? What will separate successful PPMCs from the rest? When PPMCs win, who loses? What value do PPMCs add to health care? What lies ahead for this industry? Could Wall Street pressure cause PPMCs to put profit ahead of physicians and patients? And, what roles will physician executives play in PPMCs?     

Risk alignment in health care quality and financing: optimizing value

How should health care best consolidate rational cost control while preserving and enhancing quality? That is, how can a system best optimize value? A limitation of many current health management modalities may be that the power to control health spending has been expropriated from physician providers, while they are still fully responsible for quality. Assigning responsibility without authority is a significant predicament. There are growing indications that well-organized, well-managed groups of high quality physicians may be able to directly manage both types of risk-quality and financial. The best way to optimize responsibility and authority, and to control financial and quality risks, is to place such responsibility and authority within the same entity.     

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?     

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.     

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.