Published in the May 2011 issue of Today’s Hospitalist
For one hospitalist, stepping up as program director meant learning to act as her group members’ boss, not just their colleague. For another, it meant knowing when to take the lead and make the tough calls. And for yet another, running a program effectively meant being guaranteed the authority to hire and fire as he sees fit.
Because hospital medicine is such a young specialty, it comes as little surprise that the average age of its leaders is a mere 41. Directors of hospitalist groups are “a young group of physicians leading a younger group of physicians,” explains hospitalist O’Neil Pyke, MD, chief medical director of Medicus Consulting LLC, a consulting firm associated with Medicus Healthcare Solutions, a staffing company.
But the reality is that the mean age of hospitalist directors overstates the experience that many doctors bring to the table. Much younger physicians are stepping up to the plate, many of them only months out of residency or taking on a director’s role right out of training.
Dr. Pyke, who consults for hospitalist groups and helps facilitate leadership training, says that being a young hospitalist director has some benefits. Young leaders, for instance, have been trained in an era when quality and accountability are an integral part of patient care. That gives young leaders a leg up on the clinical and corporate attributes “core measures, teamwork and care coordination “that hospitals are looking for.
But the downside is that young leaders typically have little to no training in making critical management calls. And their relative youth may be the reason why some young directors aren’t given the autonomy they need to really lead, even after they get some experience under their belt.
“They’re sensing that, ‘OK, I have this position, but it’s a powerless position,’ ” particularly when it comes to shaping other doctors’ behavior, Dr. Pyke says. “The bigger leaders like the VPMA aren’t willing to give that up yet.”
So how do young leaders learn on the job? And how do they get the clout they need among medical staff? Here’s what several young leaders had to say about how they work around their age “and how generational differences can make their job harder.
An incremental approach
When she first moved into a leadership role, Greta Boynton, MD, was a mere 30 years old. She first became assistant director of the program she’d joined in the hospital where she had trained, then was promoted to co-director. In her case, being given responsibilities in an incremental manner helped her adjust to having to lead.
“I started off with some scheduling responsibilities and then protocol development and communication issues, and it all came at a time that we were heavily recruiting,” Dr. Boynton recalls. “I felt like I didn’t have quite the grasp of all the business and politics that were involved.” In that first job, she notes, her age and familiarity with the medical staff probably worked against her. “They forever see you as a resident in your original institution,” Dr. Boynton recalls.
Three years later, when she switched jobs and became chief of the hospitalist services at Eastern Connecticut Health Network in Manchester, Conn., she dove in with both feet. “I got handed the whole package,” Dr. Boynton recalls. While she had to quickly learn “how to speak the language of the C-suite,” she says that her age hasn’t been a barrier to gaining influence.
How has Dr. Boynton overcome the perception that she’s too young for the role? In addition to running a program with 20 FTE physicians, she sits on “on every major leadership committee.” That includes the medical executive committee, as well as the IT steering, QI, and patient safety committees, and the Lean teams. “They see me so involved and our own staff so engaged that I have garnered their respect,” she explains. “I don’t feel like I have any difficulties with upper-level management.”
When asked to name the toughest leadership lesson she’s faced heading up a program, she says that it’s been how to walk the fine line between being a boss and a colleague.
“At times, you need to discipline your own staff and yet work side by side with them as colleagues,” Dr. Boynton says. “That can be a very difficult transition.”
The autonomy to hire and fire
Brian Kendall, MD, who’s now 41, started working at the Regional Medical Center in Orangeburg, S.C., as one of four original hospitalists in the group in 2002. He became assistant director in 2004 and program director in 2007. In directing a group that now has 18 physicians, Dr. Kendall also found that an incremental approach to learning the ropes helped greatly.
“I was more detail-oriented,” he says, “so I started off managing things like billing, scheduling and recruiting.” Seven years later, he is responsible for much bigger-picture items like “driving culture and setting the correct long-term objectives.”
A big lesson early on was the value of having control over the staff who report to him. When he took the job as director, Dr. Kendall points out, he had enough experience to insist on one condition: “I had to have autonomy over hiring and firing. If you don’t have good control and can’t manage personnel independently, you can run into a great deal of frustration.”
As an assistant director, Dr. Kendall says he learned the hard way that having to kick hiring decisions up through a bureaucratic process usually meant waiting six to 12 months before a new doctor could come on board.
“By the time we’d get permission for extra FTEs, the hospitalists were again behind our own growth curve,” he says. “That’s very frustrating as a director and very demoralizing to the team.”
Another lesson he’s learned is to make sure he has direct communication with the powers that be. He’s taken the step, now that his hospital is recruiting both a CMO and a COO, of asking the CEO to change the organizational structure.
“I now report directly to the CEO and meet with him weekly,” Dr. Kendall says. “We’re the largest service line in the hospital, and we have the most employed physicians in our department, so I would rather have a dialogue directly with him.”
The biggest challenge he still faces in directing a program is how to effectively manage other physicians’ behavior. But Dr. Kendall points to another lesson learned: Groups often create their own performance problems by “hiring the wrong people.”
“That’s because of the specialty’s growth,” Dr. Kendall says. “The No. 1 lesson is learning to be disciplined in terms of your hiring practices, even though it’s tempting to hire any warm body when you’re seeing 20 to 25 patients a day.”
Maintaining a democracy
Thea Dalfino, MD, who directs the hospitalist program at St. Peter’s Hospital in Albany, N.Y., took on that role two years ago at age 31.
When it comes to relationships within the hospitalist group, Dr. Dalfino says that the boss/colleague dichotomy is particularly hard to finesse, in part because she likes to maintain a democracy. But she’s learned that there are times when a democracy just isn’t possible.
“We make decisions together,” she points out, “but then sometimes we can’t. Some things, if they were left to the group, just wouldn’t change.”
Dr. Dalfino had to step in and decide on her own, for instance, that the group would take on endocrine patients as a service and that each group member would work four weekend days a month, instead of three, to keep the group within its budget.
“That’s what we had to do, and now we’re not scrambling to fill shifts like we were” says Dr. Dalfino. “But if I left it up to the group, nobody was going to say, ‘Please give us more weekend shifts.’ ”
Another challenge has been learning how to delegate so that she can make the most efficient use of her time. She’s now put one group member in charge of billing and documentation, and another in charge of patient relations, dealing with difficult patients and with family complaints.
As hospitalist director, Dr. Dalfino says that she’s always sitting down with other medical staff members, all of whom are men and, typically, 20 years older. But far from being patronized, she has found a warm reception. “They welcomed me with open arms,” she says. “I was young, energetic, and willing to change and compromise.”
Like many other young leaders, she’s found that older physicians are extremely pleased to find doctors willing to help steward the hospital. Where she’s run into resistance, she says “which she doesn’t chalk up to her age but to her group’s willingness to try innovations “has been more with case management and nursing. That’s made changing the hospital’s current system of multidisciplinary rounds more challenging.
“This was really a nursing-led hospital,” says Dr. Dalfino. Now that hospitalists are sitting on every hospital committee, she adds, “We’re having a lot more physician involvement and input.” That’s another new development that senior physicians in her hospital are happy to see.
But that doesn’t mean that young directors in general don’t need to navigate generational dynamics with older members of the medical staff.
“Medical staff members toward the middle or end of their careers are used to a work ethic that goes back 20 or 30 years, when physicians worked all day, all week, all the time,” says Mark Rudolph, MD, chief medical officer for the Northwest Region of Sound Physicians, a national hospitalist organization based in Tacoma, Wash. Those expectations can clash when older physicians ask young hospitalist leaders for help establishing a new admission service or comanagement line.
According to Dr. Rudolph, who serves as chief training officer for Sound Physicians, different lifestyle expectations among generations can be a real challenge for hospitalist leadership. A good example is the seven-on/seven-off schedules that mark so many hospitalist programs ” and that are completely foreign to older colleagues.
Going beyond lifestyle concerns
To provide credible leadership, Dr. Rudolph adds, hospitalist directors can’t keep “being viewed as simply trying to protect their quality of life whenever they’re asked to change or participate.” When approached to start a new service line or solve a logistical problem, for instance, even if the hospitalist group doesn’t immediately have the staff to ramp that service up or solve the issue, hospitalist leaders should explore ways to eventually accommodate the request.
Hospitalist leaders also have to be sure that lifestyle doesn’t stand in the way of effective committee work or quality improvement efforts. “If you want to gain credibility in the hospital community,” Dr. Rudolph says, “you cannot apply the hospitalist schedule and go to every other meeting. You need to go to every meeting.”
Part of the problem for very young leaders, he adds, is that they are still so close to residency “a mindset that’s very different from the one they need to provide hospital-wide leadership. For one thing, residents are typically immersed only in their one department, while directors have to quickly learn “how to interact with all the moving parts of these facilities, like surgery and case management, to accomplish what’s needed,” he says.
Another problem, explains Dr. Rudolph, is that “people don’t usually ask residents to problem-solve,” yet problem-solving is the hallmark of an effective director. He says that one of the most effective ways to demonstrate leadership at any age is to show up with solutions ” not just complaints “for whatever problem is on the table.
“Do not,” Dr. Rudolph advises, “just be the squeaky wheel.”
Changing of the guard
While generational differences can be a challenge, young directors are getting a boost from the rising star of hospital medicine.
Dr. Boynton, for example, says that the power shift going on in hospitals now favors hospitalist groups, regardless of how young their leaders may be. As hospitals struggle to improve quality and master information technology, she explains, hospitalists’ influence within facilities is only going to grow.
“Everybody senses that there’s a disconnect between the inpatient and outpatient services,” Dr. Boynton says. Her group’s visibility “and success “within the hospital correlate directly to its deep involvement with quality improvement and IT.
In South Carolina, Dr. Kendall also believes that “an age of data transparency” naturally favors hospitalists. “Younger physicians tend to be more trusting of evidence- based protocols and more open to administering care in a more uniform fashion,” he points out.
As he and the other hospitalists have introduced order sets, bundles and clinical protocols, “it’s the younger doctors who have been more willing to adopt those,” he says. “The older physicians are more likely to say, ‘No, I’m going to do it my own way.’ ”
That has taught Dr. Kendall another key leadership lesson: It’s sometimes better to let things go that you can’t control. “I don’t have the authority of a CMO or VPMA to manage those private physicians,” he explains.
That doesn’t mean, however, that he won’t eventually win the argument. If older physicians aren’t willing to follow protocols or collaborate, “their outcomes are going to show up on data-tracking systems,” Dr. Kendall says. “What we bring to the table as hospitalists from a quality standpoint will be even more of an asset.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.