Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Career Resources Editor’s Note: In the context of escalating health care costs and regulatory reform, there is a high demand for health care leaders with clinical experience and the desire to facilitate systemic change. Physicians who have the drive to lead, the willingness to test their skills, and an interest in an initial part-time management role and who augment their real life experiences with formal management education are the perfect candidates to lead the business side of medicine. Seeking advice and constructive feedback from successful medical leaders can also enhance leadership skills.
— John A. Fromson, MD
In the health care sector, physicians are assuming an ever-increasing range of management and leadership positions.
By Bonnie Darves, a Seattle-based freelance health care writer
As health care dynamics shift at an unprecedented pace, with health reform unfolding and traditional funding sources shrinking, the industry is seeking new leaders in what was once a rarely tapped pool: practicing physicians. Today, organizations at the center of the delivery system, and apparently many on the periphery, are coming to the conclusion that physicians ought to be in top management roles, observes Barry Silbaugh, MD, CEO of the of the American College of Physician Executives (ACPE) in Tampa, Florida.
“This is what we’re hearing from recruiters: ten years ago, hospital boards wanted one physician candidate on the roster for a potential CEO, and five years ago, boards would consider a physician candidate for the post. Now, it’s becoming a preference that the CEO be a physician,” Dr. Silbaugh, an internist and hematologist, said. “And this is all happening fairly quickly.”
This development is not to suggest that physicians necessarily want — or ought — to set their sights on the corner office, Dr. Silbaugh admits, but it’s a strong indicator of where things are going on the business side of medicine. As pressures to improve financial and clinical performance in tandem mount, he explains, physicians must be more integrally involved in devising solutions.
“That’s the key issue. We need individuals who can link the financial results of a health care organization to clinical outcomes — who can see how clinical processes impact the bottom line. Physicians know how to do that,” said Dr. Silbaugh, who previously served as medical director of a New Mexico Blue Cross/Blue Shield plan and vice president of medical operations for Catholic Health Initiatives in Denver, Colorado. “That’s why they are being asked to step up to the plate.”
The demand for that particular physician perspective is growing in several areas beyond the traditional chief medical officer role. Today, organizations seek physicians who can assist with information technology (IT) implementation, particularly electronic medical records (EMRs) and systems that link clinical and financial data.
“They’re looking for individuals who not only know technology, but who also know how to implement it with clinicians of all different age groups,” Dr. Silbaugh said. “Because when a physician is hired on as a chief medical information officer (CMIO), an associate CMIO, or project manager for technology initiatives, it’s really about change management — not so much about the technology, but about working with the people who use the technology.”
Organizations also are in dire need of physicians to commandeer physician integration and alignment and to help their colleagues work through the cultural changes such strategies entail. This area is growing very rapidly, with the trend toward more employment of physicians as change agents in hospitals, Dr. Silbaugh said. “As physicians become employees of organizations, it’s very important that there are physician leaders who understand how to move the organization forward with these two very different cultures,” he said.
Management Roles, Options Expanding
Grace Terrell, MD, MMM, CPE, longtime CEO of CornerStone Health Care, a large physician-owned delivery network in High Point, North Carolina, concurs with Dr. Silbaugh’s view. She says opportunities abound for physicians with an interest in and aptitude for management, and that the range of career options will increase in the coming years. In addition to the opportunities Dr. Silbaugh cites, the health care system needs physicians to lead population management and cost-reduction initiatives, Dr. Terrell notes, and to work in both clinical and actuarial aspects of risk management as well as informatics.
“This is the absolutely best time ever for physicians interested in management and executive roles,” Dr. Terrell maintains. “As we look at where we need to go — with the country broke, a disproportionate amount of resources going into health care, and the baby boomers hitting Medicare age — we’ll have to work through that in ways that are good for patients without plunging the country into crisis. We need physicians to lead the way — and for those who answer the call, it’s a time of great opportunity.”
To illustrate her point, Dr. Terrell, whose book on physician leadership is due out next spring, somewhat jokingly cites a 1972 Forbes magazine article that declared that management in medicine was “too important” to leave in the hands of physicians. “Now it’s clear that health care management is too important not to leave in the hands of physicians,” she said.
For physicians interested in trying their hand at management while remaining in clinical practice, part-time opportunities exist as well, and not just in the hospital. But that’s a likely place to look initially, advises Mark Browne, MD, MMM, CPE, a principal with the Knoxville, Tennessee, health care consulting firm Pershing, Yoakley & Associates who trained in internal medicine and pediatrics. Taking the lead on a quality-improvement initiative, for example, chairing (or even launching) a committee, or serving as medical director of an intensive care unit can give physicians a sense of their ability and interest in management.
“These kinds of middle-management positions offer physicians a good way to try out leadership roles, and then see if they could lead in a more formal way,” said Dr. Browne, whose work focuses on quality and health reform, physician executive support, and physician alignment for groups and hospitals. “You don’t have to be in the C-suite to be an effective leader.”
Sheri Phillips, MD, MPH, FACPE, whose diverse background includes senior management positions in health care systems, pharmaceutical firms, and insurance, advises young physicians to look to the community at large for management opportunities. “There are a growing number of collaborative physician roles in the community, from oversight of ‘mini-clinics’ and hospice programs to lead physician roles in county and state health projects and initiatives,” said Dr. Phillips, an Illinois occupational medicine physician who also uses her skills to serve educational institutions and numerous health care foundations. “Many of these opportunities are very part-time and often flexible, so physicians can test the waters while they pursue their clinical careers.”
Dr. Phillips points to another growing avenue for budding physician leaders: the advocacy arena. Physicians can serve in lobbyist roles not only within medical professional organizations, but also for public health issues, locally and nationally. She is the newly appointed spokesperson for Susan G. Komen for the Cure, a foundation dedicated to advancing breast cancer education, research, and treatment. “It just spoke to me — and I am very excited about being the first physician to hold the position,” said Dr. Phillips, who is a breast cancer survivor.
Career Paths As Diverse As Physicians Themselves
Some physicians decide to make a wholesale switch from clinical practice to management roles, but for many, it’s a slower process that involves “trying on” various roles before leaving clinical practice.
Hoda Asmar, MD, MBA, a fellow of both the ACPE and the American College of Healthcare Executives (ACHE), exemplifies the incremental — and interesting — career paths that lead physicians into executive roles. The newly hired senior vice president and chief medical officer (CMO) of Presbyterian Health Care Services in Albuquerque, New Mexico, started “training” for physician leadership early on.
A few years into her infectious disease practice, Dr. Asmar was asked to serve as medical director of a public health district in rural northwest Michigan — in a part-time position. At the encouragement of the district’s administrator, she pursued an MBA, and just days after she earned her degree in 2000, the CEO at Trinity Healthcare’s 97-bed Mercy Hospital in Cadillac, Michigan, tapped her to become their vice president of medical affairs (VPMA).
“They wanted to create a more structured VPMA role, and they appreciated the way that, as an ID consultant, I took on activities in quality and infection control and built relationships with the medical staff,” Dr. Asmar recalls. “So I ended up doing both jobs — a half-mile apart on the same street. I was literally running between one and the other!”
She moved on to become the full-time CMO at 394-bed St. Joseph’s Healthcare and Medical Center in Michigan in 2005, and later, CMO/VPMA at Edwards Health Services Corporation in Naperville, Illinois.
“Fifteen years ago the opportunities for physicians besides seeing patients were limited; now they’re virtually limitless,” Dr. Asmar observed. “You can assume quality improvement roles, combined operations and QI roles, general management roles — and now, informatics, too. The CMIO role will become huge, I think.”
Mark Zeidel, MD, MS, chief of medicine at Beth Israel Deaconess Medical Center in Boston, also took a somewhat convoluted path en route to his current position. In the 1990s, while pursuing a research career in epithelial biology, he was asked to take over the renal service at the West Roxbury VA, his first encounter with managing a budget. From there, he went to the University of Pittsburgh to run the renal division, where he received a request to serve as interim chair of medicine when the chair left the post somewhat suddenly.
Dr. Zeidel recalls with humor starting that chapter in his career. “I said I would take over based on two conditions — that I be able to make decisions as if I were the permanent chair, and that it was understood I didn’t want the job,” he said. While in the interim post, Dr. Zeidel found himself being recruited from institutions elsewhere to chair their medicine departments. “Just as I was preparing an offer for someone else to come in as chair at Pittsburgh, they decided it was me. So I spent two weeks negotiating against my own offer.”
Today, in Dr. Zeidel’s self-described “dream job,” he continues to teach in both a traditional faculty role and in Harvard University’s MD/MBA program, and he even takes morning report several days a week. He says young physicians can carve out their leadership paths more readily now than at any other time in the history of medicine — and that solid clinical experience remains their most valuable asset.
“If you are going to lead a clinical enterprise, you need to have been a successful clinician — and physicians can lead from that role,” he says, by taking on increasing responsibility in their own institutions. “The opportunities are there, and if you evolve and develop management experience, that’s of enormous value. Hospital CEOs are absolutely desperate for physicians to step up and make high-quality health care happen. If you do that well, you will be asked to do more.”
Management Education, Aptitude Essential
Precisely because health care has become such a complicated, financially complex business, physicians who hope to move into management or executive roles will require some targeted training and education, sources agreed. Knowledge of accounting principles, budgets, and finance are fast becoming essentials, as is familiarity with health care quality, safety engineering principles, organizational development, and possibly matrix management. Although it’s not necessary to pursue an advanced degree initially — such as the MBA or master’s in medical management (MMM) — physicians who plan to seek top jobs in any health care industry sector will likely require such credentials.
“Even though the way we learn often isn’t the old way university-centric or degreed model anymore, in the typical hierarchy we have now, there will be a glass ceiling for physicians if they don’t get a credential, I think,” Dr. Terrell said. “And to really pursue CEO roles in large systems, some kind of degree will be required because of the nature of those organizations.”
Fortunately, it’s now easier than ever before to obtain education in management through growing online, distance-learning, and weekend offerings. Many universities offer basic or even health care-specific courses, as do some medical professional organizations. Entities such as the ACPE, the ACHE, the Institute for Healthcare Improvement, and the Medical Group Management Association offer more robust education in either targeted training or master’s- or credential-track programs. Among those interviewed, most gave the ACPE the top marks for offering the broadest range of educational programs and learning venue options (see Resources). In addition, combined MD/MBA programs, once a rarity, are now offered by 65 institutions.
The need for leaders in health care is clearly illustrated, Dr. Silbaugh says, by the increasing enrollment in ACPE courses. “Our ‘evergreen’ Physicians in Management series continues to sell out, and the online distance-learning products sell themselves, regardless of the economy, because they’re convenient. What we know now is that many physicians who work in shifts — hospitalists and emergency physicians, for example — when they’re awake and not seeing patients, are learning,” he said.
Physicians eyeing management roles are understandably curious about what it takes — in the personality traits and people skills realm — to make the jump. There’s no one “package,” all sources agreed, but there are desired attributes. Dr. Silbaugh says that frustration with inefficiencies in the current delivery system coupled with a strong desire to devise solutions is a good starting place. “If you want to fix it, or you’re starting to think that way, and you tend to read a lot about what’s happening in health care, you may see a career change coming,” he said.
Several physician executives also cited the importance of being a broad thinker and a good listener who is respectful of others’ opinions, however diverse. All thought that being able to deal with conflict without becoming ruffled is a definite prerequisite.
Dr. Terrell puts empathy near the top of her list. “Physician leaders must have empathy — not only for patients, but also for their fellow physicians and all those being impacted by the health care system,” she said. “And that’s a hard thing for some doctors to do sometimes outside the role of clinician, because we tend to get jaded.”
For her part, Dr. Asmar cites personal flexibility and an ability to collaborate as key qualities. “Especially in this age of health reform, you have to be flexible and able to move outside your comfort zone — and you must be someone who can do the ‘we’ by nature instead of the ‘I’,” she said.
The ability to lead can be cultivated, Dr. Browne suggests, but the requisite willingness and drive must be innate. “Those prone to lead will lead, but many of the skills needed in leadership roles can be learned,” he said.
Dr. Zeidel concurs. “There are two pieces to this. Physicians can learn the management craft — the technical pieces like accounting. But I’m not sure that leadership can be taught,” he observed. “Leaders emerge.”
On another level, he thinks that even physicians with demonstrated leadership ability and years of experience still need refresher courses. His own “brush up” entails rereading, every few years, the collected speeches and writings of Abraham Lincoln (Library of America, Vols. 1 and 2). “If you look at what he does in those writings — he’s articulate, he’s forthright, and he uses humor — all qualities that are important in leadership,” Dr. Zeidel said.
All physician executives interviewed agreed on one point: physician leaders emerge from many settings, from private practice to academia, from the laboratory to the operating room, to MD/MBA programs. “And all who exhibit the willingness to lead,” Dr. Silbaugh maintained, “will surely be welcomed.”
Physicians who shared their perspectives for this article offered useful advice for physicians contemplating a management role or making a career change out of clinical care and into the executive realm. Some of their tips follow.
Seek out mentors — and constructive critics. “It’s important to learn from leaders and to look for mentors who can advise you,” Dr. Asmar said. “But physicians also must be willing to ask for feedback on how they’re perceived, and they should start in their own shop. Say that you’re interested in doing more, and ask for an honest assessment of your strengths and weaknesses. Then be ready to receive the feedback.”
Don’t look for greener grass. “Ensure that you’re running to, not away from something, because being a physician executive or assuming a management role isn’t an easy job — it simply requires a different set of skills,” said Dr. Browne. “I think it’s also important to have a calling for a different way of caring for patients.”
Always be a physician first. “When I first got into this I asked one health care legend who hadn’t seen a patient for years, ‘what’s your secret?’ ” Dr. Silbaugh said. “He didn’t hesitate, and said, ‘never forgetting what it’s like to be at the bedside of the patient in the middle of the night.’ I think that you can never forget that. If you do, you won’t be an effective manager or leader as a physician.”
For physicians who want to learn about management or boost their leadership potential, the following organizations offer a wide range of options:
American College of Physicians Executives (ACPE)
American College of Healthcare Executives (ACHE)
Association of Professors of Medicine (APM)
Institute for Healthcare Improvement (IHI)
Medical Group Management Association (MGMA)