Published in the May 2013 issue of Today’s Hospitalist
FOR THOMAS MCILRAITH, MD, one of the lowest points in his early years leading a hospitalist program came during a very public meeting.
“A physician who reported to me stood up in a very dramatic fashion and handed in his letter of resignation in front of the entire department,” Dr. McIlraith says. “Sometimes, you get moments like that.”
And because so many hospitalist program directors are so young, leaders say, the specialty can expect a lot of moments like that. Hospital medicine is rife with examples of doctors just a year (or a few months) out of residency being tapped to lead their groups.
With no management training or experience, these young hospitalists have to figure out how to “manage up” “working effectively with the new bosses above them “and navigate the bureaucracy that surrounds them. But they must also learn how to “manage down,” directing physicians who until very recently were their colleagues.
Young leaders suddenly find themselves the boss of doctors who may be older, have more clinical experience, and have been steeped in the culture and politics of the group and hospital for much longer.
“Young leaders are going to be challenged by doctors who are now working for them,” says Dr. McIlraith, now the chair of hospital medicine for Mercy Medical Group in Sacramento, Calif. “Just because you have the title does not mean you have the credibility.”
A recipe for burnout
Jairy Hunter, MD, MBA, who’s associate executive medical director for case management/care transitions at the Medical University of South Carolina in Charleston, S.C., led several different hospitalist groups for many years. He likewise has painful memories from those early years and says those are par for the hospital medicine course.
“When highly paid professionals are managed by someone who’s ill-equipped,” Dr. Hunter says, “that person is resented and makes bad mistakes. You go on your instincts, but those will take you only so far. It’s a recipe for failure, and leaders keep burning out.”
Dr. Hunter is even more blunt about young leaders’ odds for success. “It’s difficult to become a leader of people your own age or skill level,” he says. “You simply don’t have the maturity to be the boss.” That problem is compounded by what he calls “a blind spot” for hospital administrators: They don’t invest in training physicians in leadership.
But the reality is that there’s simply no way around inexperienced group leaders. Because hospital medicine has grown so quickly in such a short period of time, leadership paths from other specialties don’t apply.
Take the tried and true route to leadership in a specialty like emergency medicine, where the most senior doctor takes the lead. That path is an anomaly in a specialty like hospital medicine, where “senior” is a very relative term. For many young hospitalists, the first time they ever run a meeting, create a budget or mediate conflict is when they take over as group leader.
Problems managing both up and down
That was the situation that Patience Reich, MD, found herself in several years ago in her first leadership role as director of a troubled academic group. Dr. Reich quickly learned to “find her counsel” and get advice “from other leaders who were not necessarily in my field.”
While nonphysicians were able to offer her some guidance, Dr. Reich says that some management challenges that physicians face are unique to medicine. Take, for instance, the need to learn how to manage up, a dilemma she says young doctors don’t know how to handle.
“Doctors don’t work their way up, like people starting out in business do,” says Dr. Reich, who is now between jobs but was previously medical director of Wake Forest Inpatient Physicians in Winston-Salem, N.C. “Once you’re through training, you’re the one giving orders that need to be carried out.” Filling a role toward the bottom of an organizational hierarchy, she says, is very different from being a doctor on the wards.
For Dr. Hunter, the initial experience of managing up was far from pleasant. “I’d be excused from the table of C-suite individuals when it was time for them to talk finance,” he recalls. “It was insulting “but I really didn’t know what they were doing, and I couldn’t speak that language.”
In response, Dr. Hunter was motivated to first take online management and business classes from the American College of Physician Executives, then attend all the Society of Hospital Medicine’s leadership academies, then finally go ahead and get an MBA.
That degree brought him some much-needed credibility with administrators. “It signifies to them,” he says, “that here is a person who’s serious about his or her career in leadership.”
But the reaction to a leader getting a business degree among the doctors being managed can be decidedly mixed. “Some recognize your commitment, but others don’t understand why you’d ever want to do something like that,” says Dr. Hunter. “A lot of the responses I still get are, ‘Are you still seeing patients? Are you still a real doctor? Are you one of us, or are you one of them?'”
Us vs. them
Sources say the “us vs. them” trap is particularly pernicious for young leaders. That’s especially the case when doctors find themselves heading up troubled programs that need to be turned around.
Dean Dalili, MD, who’s now a regional medical director for Hospital Physician Partners and directs groups at several community hospitals in Florida, was only six months into his first hospitalist job at a different community hospital when he was named program director.
“Age was an unstated but obvious issue,” he now says. “I was 32 and by far the youngest member of the team.”
Heading up a group of extremely frustrated physicians, Dr. Dalili says he was able to rack up some quick wins for the practice in terms of better staffing and resources. “But because I was successful at the beginning advocating on the group’s behalf,” he recalls, “I began to view my role exclusively as their advocate instead of also being the administration’s advocate to the group. Over time, that became my biggest challenge.”
Dr. Dalili found that he couldn’t motivate the group toward greater productivity when it was needed, for instance. He has since matured away from the dangerous “us vs. them” dichotomy.
“Now, whenever somebody tries to couch an issue in terms of ‘it’s us vs. them,’ I completely diffuse it,” Dr. Dalili notes. “I say, ‘No, it’s all of us focused on what’s good for patients. It can’t be two different goals. It’s different viewpoints that we need to figure out how to bring together. ‘ ”
For Dr. Dalili, the “us vs. them” trap in his first leadership role fed into another major challenge he faced in that position: what he calls the “psychological contract.”
“You’re being asked to lead a team that’s already been built, but you’re the last person to join,” he explains. “Everyone there had a pre-existing psychological contract that predated your arrival.”
That “contract,” Dr. Dalili notes, is unwritten, but it defines any group’s (or company’s) culture, expectations and work ethic. “People always feel the need to enforce that contract,” he says, “and it’s very hard to change over time.”
One of that group’s unwritten expectations, for instance, was that ED physicians would continue to manage codes. When the hospital tried to reassign that responsibility to the hospitalists, says Dr. Dalili, the doctors “pushed back very hard. They resisted taking on that higher-risk service without any corresponding change in compensation” “a
change that he, as a young leader, wasn’t able to deliver.
According to Dr. Reich, that kind of psychological contract can be even more iron-clad in academic settings. “Unlike private practice, academic culture is one in which people practically have to commit a crime before you can get rid of them,” she points out. “It’s the attitude that, ‘I’m faculty, you can’t touch me.'”
When Dr. Reich first became director of an academic group that likewise needed to be turned around, she was one of the youngest doctors and unfamiliar with the center’s politics and culture. Her troubles really began when new faculty hired by the previous director started showing up for work, feeling completely unbeholden to her as a leader.
One particularly memorable experience was a new hire who, along with antagonizing all the nurses, patients and families, wouldn’t accept the idea of any woman, including Dr. Reich, in a leadership role. Over the next six months, she notes, he continued to refuse to take any feedback or direction from her.
For Dr. Reich, dealing with that physician served as a crash course in how to reach out to management resources she’d never used before: human resources, the dean’s office, even the academic center’s attorneys. She ended up having senior physicians sit in with her during her series of meetings with the new hire, who was eventually suspended and then left the program.
While the experience was searing, it gave her newfound confidence. And “wielding that huge hammer,” as she puts it, also gave her some much-needed credibility with the other members of her group. The doctor’s behavior had been so egregious that it was affecting group morale, and the fact that she engineered his exit “definitely helped me a lot.”
That raises what Dr. Reich points out is often one of the trickiest dilemmas for young leaders: deciding what their role will be vis-a-vis the doctors they’re now managing.
“Some people try to be what I call a ‘super peer,’ the same colleague they always were with just more authority,” says Dr. Reich, “but I don’t think that works. At the same time, you don’t want to turn it into an ‘I’m the boss’ situation.”
What you do need to do, she adds, is proceed carefully “and not let too much time pass without establishing some authority. She recommends using what management author Michael Watkins calls the consult-and-decide approach, which she says is particularly useful for leaders in their first few months.
“You listen carefully to the input of your former peers, which shows that you value their thinking,” says Dr. Reich. “But the ‘decide’ piece also shows them that you’re now in a different place.”
Not a democracy
Dr. Hunter agrees, urging young leaders to quickly “if diplomatically “establish that their relationship with the physicians in their group has changed.
“If you don’t clearly define your role as leader,” he says, “doctors assume that it’s a democracy, and many times it should be.” But there are other times “making scheduling decisions, taking on new service lines “where individual doctors simply can’t have the same vote as you. If you give them that vote, he adds, be prepared to be challenged on every management issue that crops up.
“To be a leader, you can’t be one of the guys, so you have to put yourself above that fray,” Dr. Hunter says. “You still want to be one of them, but you can’t be the clubhouse champion while also being the boss.”
Dr. McIlraith from Mercy Medical Group characterizes the dilemma as a delicate balance: “You have to be able to stand your ground, without always itching for a fight.” But the rub, he points out, is that leaders will have no credibility with physicians, regardless of their executive style or prowess, if they don’t maintain their clinical edge.
He also realized when he first became a group leader that he was being scheduled to work days only, Monday through Friday.
“I said, ‘Wait a minute, you’ve got to stop this. You need to schedule me for weekends and nights,'” Dr. McIlraith says. “You have to see the challenging shifts to know what the problems are first-hand, and you can’t get any special treatment.” He also notes that while his job was officially 50% administrative and 50% clinical, “in the first three years, I was about 150% clinical and at least 100% administrative.”
“The game slows down”
The good news, say veterans, is that young leaders who don’t crash and burn go on to develop new skills.
“Athletes say when they first turn pro, that everything comes at them really fast, like out of a water hose,” Dr. Hunter says. “But eventually, the game slows down and they start to see things. It’s the same thing: You start seeing things you didn’t catch before and know how to get something done.”
In Florida, Dr. Dalili “who’s also pursing a master’s in health care management “says he’s learned to avoid the “psychological contract” trap he fell into before by leading groups that he starts and hires for. Now, he’s able to set the terms of that contract himself. He’s also learned that “it’s amazing how a change in compensation affects people’s motivation.” In his first leadership position, he had a tough time spurring physicians on to more productivity because they were paid a flat salary. In the groups he’s led since, Dr. Dalili has insisted on a compensation package that includes at least 15% of income tied to individual productivity.
“You can spend a lot of time and energy trying to understand conflict and behavior,” Dr. Dalili points out. “Then you realize that you just have to align incentives, and you don’t have to necessarily get in there and manage. It’s much more difficult to administer a program where people aren’t incentivized on the things you need them to do.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
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