This 2019 article from the Journal of Hospital Administration tells us that only 5% of US hospitals have physician CEOs today. This is down from 90% in 1935. Interestingly, the article also points to studies showing that hospitals with more physicians in leadership and management have better operational and quality performance than those without. So why aren’t there more physician leaders in healthcare?
Most physicians choose a medical career because they want to be healers, not leaders and businesspeople. Medical schools do a great job helping them become diagnosticians and healers. By the time medical students are done with medical school and residency training, they usually internalize the morals and ethics of the professions and always learn to put patients first. Many do this even at the cost of their physical or mental health.
Yet, with hardly any leadership and business training, doctors are thrust into leadership roles from the day they finish their training. They start leading clinical teams, running departments, or managing private practices. The skills required to be an effective leader – decision-making, strategic and systems thinking, team building, interpersonal communication, persuasion, and conflict resolution – aren’t usually taught in medical school. Some physicians have a natural talent or interest in leadership. They seek out leadership learning experiences and try to find the right mentors. Eventually, through trial, error, and reflection, they become better leaders than they were at first. Most others don’t.
They are unprepared to realize that medicine is ultimately both a noble profession and a business. Maintaining a financially sustainable organization is essential to delivering on its mission. Physicians have difficulty accepting the tension between those two realities of medicine. Yet, they must not just get that tension but use it to drive improvements in their spheres of influence. Because most medical education and training ill-prepares them for this, they end up having mistrust of healthcare administration. This mistrust percolates through the entire clinical organization within healthcare.
One day, fifteen years ago, I told clinical staff at the hospital where I worked that I had accepted the chief medical officer role at a state psychiatric hospital. One of the nurses asked me with genuine curiosity and reproach, “You are such a good doctor. Why would you go over to the dark side?” I couldn’t think of any other way to respond other than to inquire, “Are you saying we should only encourage bad doctors to go into healthcare administration? How can we then expect ever to trust healthcare administration?” She laughed but didn’t answer the question.
Since then, in various leadership roles, I have contributed to improving the care of individuals in multiple ways. I didn’t create anything new. I helped clinicians and administrators in organizations see patients’ best interests in particular contexts. Then I showed them how those improvements suited the organization and the people they served.
In a residential treatment program where I worked, the team used to immediately discharge anyone who relapsed. I persuaded them to modify their approach. We started helping individuals who relapsed overcome their shame and process their relapse with their counselors and peers. In the state hospital where I started my administrative career, I worked with physicians’ and nurses’ unions to implement evidence-based protocols for treating opioid and alcohol withdrawal. At a large payer, I helped build a data-driven case to drop prior authorization requirements for a medication for opioid addiction. I helped develop an algorithm that predicts the risk of adverse health outcomes related to opioid and alcohol use. I then helped develop and implement a case management program to help individuals avoid those predicted outcomes.
None of these ideas are rocket science. Every doctor in America has similar ideas on how to improve the care of patients. But without physicians’ leadership skills, most of these ideas remain but seeds. Taking the germ of an idea from a seed to a tree or even a forest in large organizations takes skills that most physicians have not learned. And that’s a problem because an increasing number of physicians are working in large organizations.
Physicians bring invaluable clinical insights into decision-making processes, leading to decisions that are more in tune with patient needs and clinical realities. They understand the intricacies of patient care globally better than almost anyone else in healthcare. Their familiarity with clinical processes gives them a potential advantage in leading quality improvement. Without leadership skills, all this potential remains untapped.
US healthcare is squarely in the middle of a consolidation phase. Health insurance companies continue to consolidate. Hospital and clinic systems also continue to consolidate. A study commissioned by the Physicians Advocacy Institute shows that hospitals, health systems, and corporate entities of one kind or another now employ 74% of US physicians. Very soon, small independent practices will become not just rare but anomalies that will exist to serve only niche patient populations. Significant improvements in US healthcare will not come from them. Without effective physician leadership in large organizations, the task of improving US healthcare will progress gradually with occasional fits and starts.
The medical school curriculum is packed with all the medicine that budding doctors need to learn. As a result, I don’t foresee medical education ever taking the lead on ensuring solid leadership training before graduating doctors. Ultimately, two groups must take responsibility for developing physician leaders. First, physicians themselves. They must seek learning experiences that will improve their leadership skills. Secondly, and perhaps even more importantly, on those large consolidating health systems and health insurance companies employing ever increasing proportion of American physicians.
Engaged physician leadership ensures that the tension at the heart of medicine – noble profession vs. business – is maintained. Otherwise, it will tend to resolve towards the business end of that tug of war. And that does no one any good.
