Medical Practice in the C-Suite

We physicians enjoy the privilege to practice in diverse settings doing work that is highly varied in its substance and style. We occupy central roles in many organizations whose cultures and missions are as different as the range of medical specialties that are available to us. Physicians who elect to join the senior administrative team of a healthcare organization practice a kind of medicine that differs greatly from the myriad of specialties, practice settings, and care delivery models available to clinicians today. In this article I will characterize the physician’s unique role in healthcare administration, comparing and contrasting the administrative medicine practice with the more traditional roles of physicians in the complex modern healthcare sector.

I completed my training and joined the primary care faculty of UMass Medical School in 1980. From the outset, I sought to take a position that would allow me to combine practice with teaching. It was the penetration into the Worcester market of highly organized managed care and ultimately an experiment by Memorial Hospital to accept large-scale full-risk capitation that led me to accept increasingly senior administrative positions and to concomitantly ratchet back my clinical practice. In 2002, I left practice entirely to accept the position of Chief Medical Officer at Saint Vincent Hospital.

Choosing to abandon clinical practice for a C-Suite position was, in the day, viewed by many as “going to the dark side”. Medicine was largely a private enterprise, with solo practitioners and small groups dominating the scene up until recent decades. Corporate types, a.k.a. “bean counters”, were there to run the institutions but clinical matters were the sacred and exclusive domain of physicians. There was a dogs vs cats antipathy between these groups and the burgeoning administrative physician often endured some not-so-friendly ostracism from one-time colleagues. Fortunately, this is much less the case today as corporate models of practice and consolidation of the massive healthcare sector have made the small medical practice seem almost quaint and physicians’ presence in leadership is recognized by clinicians to be necessary and desirable.

Arguably, the skills, focus, and challenges of senior physician administrators differ in fundamental ways from those of clinicians. In most cases, the physician executive is charged with managing some critical aspect of a healthcare organization’s clinical performance, whereas the clinician, almost by definition, is concerned with the unique person, the “patient”, to whom they are providing care and guidance. Macro issues of strategy, financial and clinical performance data, regulatory compliance, and group dynamics/communication dominate the professional world of the senior administrator. In contrast, the clinician is chiefly concerned with matters of physiology, diagnosing disease, and therapeutic options for an individual. The differences between these two roles for physicians cannot be overstated. However, the skills developed by excellent clinicians, empathy, active listening, clear communication, and a relentless insistence on considering a broad set of diagnostic possibilities transfer readily to the C-Suite. Thoughtful interpretation of data and context is as crucial in toptier management roles as it is in sound clinical practice. Professionally we all inhabit psychological spaces that interact with the work we do and how it affects us as individuals. The contrast between administrative medical practice and typical clinical practice extends into these spaces as well. I will highlight three areas where the practices differ:

• Conflict: Clinicians are generally conflict-averse in their professional roles usually functioning as fiduciaries for the patient. Administrative work often requires physician executives to manage people and, in that regard, to deliver difficult feedback, and to take disciplinary action.

• Reward and recognition : Patients and their families generally hold us in high regard and offer praise and/or gratitude for the efforts we make on their behalf, especially when the clinical outcome is good. Organizations rarely provide the kind of positive regard for our personal efforts that energizes our efforts in the same way.

• Decision-making: Clinicians retain substantial decision-making authority in managing their patients. While medical practice is increasingly a team effort, usually the final decision maker is the physician in concert with the patient. Most physician executives operate in a complex organizational matrix of responsibility and authority. Key decisions are rarely made by the administrative physician alone. Organizational culture plays a large role in the professional world of the physician executive. Overbearing emphasis on financial performance can undercut the focus on clinical quality and patient safety in the positions often held by administrative physicians. Heavy-handed, top-down decision-making can be an affront to the physician more accustomed to collaborative working relationships with peers. The clinician contemplating a career in senior management needs to understand the importance that culture plays in how work is done and in how satisfying the position ultimately will be.

Clinicians considering a move into administrative medicine often wrestle with the question of whether to get additional training to better work with non-clinical peers. The days of promoting the best senior medical staff into administrative positions are, for the most part, gone. In the corporate medical world, physician executives need a set of skills and a language common to contemporary management to most effectively bring their unique perspective into the C-Suite conversations. For clinical leadership positions, in addition to an MBA, the MPH and the Masters in Medical Management (MMM) are very helpful pathways for leadership positions.

Medical practice in the C-Suite is a sea change from most clinical practice. Our unique training and experiences dealing with patients and diseases allow us to bring a dimension to the senior administrative team that is both rewarding and critically important as the delivery of healthcare becomes increasingly corporate in its character and complex in its scope. Aspiring physician administrators should understand the contrasts between clinical and administrative practice and the degree to which cultural attributes can affect their professional satisfaction and the attainment of the mission and goals that motivated them to move into management.

Harvey Kowaloff, MD, MMM Retired Chief Medical Officer