Most patients would be surprised by how little involvement their physicians have in running healthcare organizations.
The vast majority of U.S. hospitals are led by non-physicians, but it wasn’t always that way. A century ago, about one out of three hospitals were led by physicians, a number that has now dwindled to less than two percent.
According to a HealthLeaders survey, more than one-third of hospital and health system CEOs said they had no physicians on their senior leadership teams, which includes titles from senior vice president and higher. About half said one to 20 percent of their senior leadership team was composed of physicians.
Despite this, there is a movement afoot to put physicians into leadership positions because delivery reform law is changing the healthcare landscape. Healthcare organizations now must focus as much on quality as financial performance. Patients and policymakers are demanding greater transparency, patient safety, cost effectiveness, and accountability.
For all this to happen, physicians need a strong voice.
“Doctors are a highly educated group of people,” said Baylor Quality Alliance president Carl Couch, M.D. “But their education and career is mostly technical and clinical. The whole subject of physician leadership training has only received attention in the last 10-15 years.”
Baylor has invested in extensive training programs and created “physician champions” who encourage colleagues to adopt evidence-based methods. Established in 2000, the program has an annual $3 million budget and includes 40 champions who either operate systemwide or are based at individual hospitals.
Baylor created a Best Care Committee in 1999 that has established about 300 protocols and best practices using evidence-based medicine for use by physicians systemwide. Implementing guidelines and quality improvements requires time and persuasion, especially because physicians often are not directly employed by the hospital. The champions do most of the heavy lifting.
Baylor also has a quality improvement course called “ABC Baylor,” which has graduated about 350 physicians, along with more than 1,000 nurses, hospital administrators, and employees to accelerate progress and reinforce a corporate culture. The program is modeled after that of Intermountain Health Care/Latter-Day Saints Hospital in Salt Lake City, Utah. The full training program is four and a half days, but ABC also offers a one-day “fast track” program for front-line caregivers and a half-day program for practicing physicians.
In addition, Baylor has sent about 150 physicians through a six-day, two-year course at the Cox School of Business at SMU. Physicians learn about healthcare finance, negotiation and communication skills, and conflict resolution.
Texas Health Resources recently created three geographical zones, each led by a clinical and operations executive at the same level. With an eye toward advancing clinical quality and operational excellence, Texas Health Resources appointed Daniel Varga, M.D., as chief clinical officer and senior executive vice president in December.
THR and UT Southwestern created a custom-made healthcare management master’s degree program that includes physicians who have been tabbed as potential system leaders.
“Advancing physicians in key leadership roles alongside operations leaders at all levels of the system brings together a depth of clinical and operational expertise that will help us understand and address all aspects of patient care,” Texas Health Resources CEO Doug Hawthorne said. “This approach will enable us to connect the dots along the care continuum—from wellness, prevention and primary care to acute care, rehabilitation and end-of-life care.”
Russell Dickey, M.D., former chief of staff at USMD Hospital in Arlington, said USMD identifies 4-6 promising candidates each year for weekend training geared to cultivate physician leaders. A physician working in a hospital cannot “just show up for work anymore. You have to participate There is a lot of work behind the scenes for the hospital to be successful. The government requires physicians be much more involved than they used to be. And that’s a good thing.”
The need for physician leadership has trickled down to medical schools as well. The combined enrollment in MD/PhD, MD/JD and MD/MBA programs has increased by more than a third from 2002 to 2011, according to the Association of American Medical Colleges, with the vast majority enrolling in MD/PhD programs.
Business training for physicians has been growing steadily, too. More than 50 percent of medical schools now offer a joint MD/MBA program joint degree, Maria Chandler, M.D., head of UC-Irvine’s Medical School and president of the Association of MD/MBA Programs told Kaiser Health News. Physicians comprise about half of the enrollee’s in the school’s healthcare executive MBA program.
The Affordable Care Act has fueled the demand for executive MBAs as well. One out of five of those enrolled in MIT’s Sloan School of Management program is either a senior-level physician or healthcare professional.
A 2011 study by a British researcher found that hospital quality scores were about 25 percent higher at hospitals led by physicians, compared with those that were not. Scores for cancer care were even higher at physician-led hospitals. The same researcher conducted a similar study on National Basketball Association coaches, which found that teams coached by former star players improved substantially during the first 12 months of being hired.
Like star athletes, physician leaders can be role models for the medical staff and clearly have an advantage when recruiting clinical talent. They have instant credibility because they have “walked the walk” as a healer.
Physicians are responsible for about 75 percent of the costs incurred by healthcare organizations. Physicians deliver the product—patient care—and control service quality. Physicians who combine clinical and managerial skills are best equipped to run health facilities.
Traditional physician training emphasizes individual performance and evaluation. Doctors are taught to be autonomous thinkers. As medical residents, they spend long apprenticeships as subordinates usually under command-and-control mentors. They are trained for individual contribution. Collaboration and teamwork are foreign concepts.
Physicians by nature are fiercely independent. Most are in solo or small practices, with little outside accountability. The teamwork required in integrated care organizations is a foreign concept. Doctors are highly trained scientists used to having the final say on how they treat their patients. Many see the study of leadership as weak and lacking the rigor of science.
“Physicians have a unique position in the health-care arena,” said Jim Jacobson, M.D., an Arlington physician and consultant for large medical groups and insurance companies. “They are at the center of patient care. They can look at patient care from the inside out. If they are a physician leader, they can also look at it from the outside in, taking into account both the clinical and business aspects of the organization.”
Some healthcare executives simply believe physicians cannot lead. Jacobson said a hospital association executive spoke to a graduate-level course he was teaching and joked that physician leadership was an oxymoron.
But others think physician leaders can take patient care and advocacy to a higher level, transforming their professional ethics and compassion into institutional policies and affecting far more lives. Evidence indicates that physician CEOs have higher job satisfaction than those who spent their careers treating individual patients. To maintain credibility and keep clinical skills fresh, many physician leaders continue to see patients. According to a survey of chief medical officers at health systems and hospitals, about 15 percent continued clinical duties despite heavy administrative responsibilities. A separate survey found that more than 2 out of 3 physician executives continue to practice medicine, with nearly half saying it is a job requirement.
Steve Jacob is editor at large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at [email protected]