Published in the September 2009 issue of Today’s Hospitalist
WHEN ADA C. RAHN, MD, agreed to become director of a start-up hospitalist program two years ago, she realized that she would need several new skill sets “and that she would need them in a hurry.
Right off the bat, Dr. Rahn had to become adept at marketing and community relations. The concept of hospital medicine was new to the community, and many of the physicians refused to use hospitalists.
Because she had worked as an internist for more than a decade, Dr. Rahn was able to work quietly behind the scenes in one-on-one meetings. She was eventually able to change enough minds to get the program “Elmhurst Clinic Hospitalists in Elmhurst, Ill. “off the ground.
Soon afterward, Dr. Rahn realized that she needed to also become much more conversant with finances and gauging the value of the program. “I didn’t have a clue what people were talking about sometimes,” she says. “You start saying to yourself, ‘How are we doing? Why are we valuable?’ And you realize very quickly that you need to get educated.”
Dr. Rahn also realized that she needed to get up to speed in management. “You have to manage a group of doctors who all have ideas, personalities and varying levels of confidence in their own skills,” she says. “You have to make them work together and keep them happy, and that’s one of the biggest challenges.”
With the explosion in hospital medicine, nothing has been in shorter supply than leaders, all of whom, like Dr. Rahn, were woefully untrained in leadership skills in medical school. And because hospitalist groups are changing so quickly, physicians who direct them are finding that they need to constantly update their leadership skills.
“We have been inventing the specialty on the fly,” says Ron Greeno, MD, co-founder and chief medical officer of Cogent Healthcare, a national hospitalist management and consulting company. “We are often taking relatively young physicians with little or no formal leadership training and putting them in positions where they have a great deal of responsibility.”
As a result, some programs find that they no longer have the right leader to take the group where it needs to evolve “or those leaders realize they don’t have the authority or infrastructure they need to succeed.
Getting comfortable with risk
Since founding Cogent in the mid-1990s, Dr. Greeno has seen his fair share of hospitalist leaders. The best, he says, are comfortable taking risks and making decisions when there isn’t necessarily a right answer. Unfortunately, he adds, those attributes are almost anathema to practicing medicine.
“You don’t walk into a patient’s room and say, ‘I feel like being creative “let’s take some risk today!’ ” says Dr. Greeno. “If physicians are not 95% sure that they’re making the right clinical decision, they don’t make that decision. But ‘first, do no harm’ doesn’t work when you’re heading up a sophisticated program.”
One challenge that leaders of hospitalist groups face is needing to continually adapt and take on new skills as the needs of their programs change. What groups need from leaders when they’re just getting started and when they’re maturing can be two different things.
When hospitalist groups are first getting off the ground, says hospitalist and consultant Kenneth Epstein, MD, MBA, of KRE Consulting LLC, “Hospitalist leaders at first are often the senior physician in the group or a nice person liked by both the administration and the clinical staff. It’s usually someone who’s respected clinically or has seniority.”
Or new programs tend to go with what Eric Rice, MD, MMM, a hospitalist at Methodist Hospital in Omaha, Neb., calls “heroic leaders.”
“The heroic leader fights all the battles and establishes the group’s culture and standing in the hospital,” explains Dr. Rice, who directed his program for its first six years before stepping down (in part to consider other leadership options). This leadership model is popular with the other hospitalists because they get to focus on clinical care, and with hospital administrators, who have one point of contact for the hospitalist program.
Then there’s the fact that many hospitalist programs in their first years opt for the business model and culture that physicians know best: the small private practice. When many groups are first getting their bearings, “physicians are almost working independently of each other,” Dr. Greeno says. “All they’re doing is rounding on patients every day.”
In such groups, he adds, the autonomy of each physician is at a premium, so “leaders are primarily consensus builders,” he explains. “Group members look to that leader to advocate for them to the hospital and to be the first among equals.”
When programs start to grow and enter what some call the “maintenance phase”, however, these leadership models can begin to break down. Some directors who relish the challenge of a start-up, for example, get bored.
“The chronic, stable condition is not the same as the acutely unstable,” says Aaron Gottesman, MD, director of hospitalist services at Staten Island University Hospital in Staten Island, N.Y. “It’s much the same way with physicians: Some enjoy critical care and emergency medicine while others abhor such acutely ill environments.”
Other hospitalist leaders fail to understand that as their organization grows in size and importance, they need to start partnering with the hospital. Dr. Epstein, who’s now based in Boulder, Colo., and who spent five years as director of medical affairs and clinical research for IPC The Hospitalist Company, says that many first-time directors make the mistake of continuing to represent only hospitalists’ views.
“They have to learn that the reverse is just as important,” he says, “which is representing administration’s opinions to the physicians. You have to evolve to become part of the hospital’s management team, and physicians often don’t have a comfort level with that.”
And while new hospitalist leaders often take a “first among equals” approach, larger groups just have too many personalities and potential conflict to look for consensus any longer. Mary Frances Barthel, MD, who directs the hospitalist program at Gundersen Lutheran Medical Center in LaCrosse, Wisc., prides herself on her ability to build consensus among hospitalists and other departments when examining critical issues. But when push comes to shove, she knows that she’s the one who needs to act like an executive.
“If you’re going to be a manager,” she says, “at some point you need to make a decision. I’ll do my best to explain that to the group, but not necessarily open it up to a vote.”
Martin B. Buser, MPH, a co-founding partner of Hospitalist Management Resources LLC, a consulting firm based in San Diego and Colorado Springs, Colo., says that that move “from being a colleague to a boss” is one of the toughest transitions a physician can make.
“When you go from five to 25 physicians, leadership becomes much more impersonal,” says Mr. Buser. “You have a lot more friction among the hospitalists, and you need to maintain much more consistent practice patterns.”
When it comes to leadership, Mr. Buser adds, medicine is just like many other industries. “You hear about the person who makes the invention in the garage and then the one who takes it out of the garage and grows it,” he says. “You need higher levels of leadership expertise.”
Victims of bad design
Occasionally, says Mr. Buser, leaders have personal issues that make it impossible for them to lead, such as the program director who so tightly micromanaged the physicians in his group that he’d go through and change their care plans during rounds. Another director of a program that Mr. Buser consulted on was so averse to conflict that he’d punt any situation involving a difference of opinion to the group’s secretary.
But in many troubled programs, a mismatch between a group’s needs and its leadership may have nothing to do with the director’s skills and everything to do with the flaws in the way the hospital (or another larger entity, such as the hospitalists’ multispecialty group or an outsourced provider) has set up and maintained the program.
Program directors often “don’t have permission to do the things they need to do to change the program,” Dr. Greeno says. Or they’re asked to steer the group in a certain direction but given no incentives to get there. Or their reporting structure to senior administrators is so convoluted that the director is accountable to no one person. “You may have the right person,” he explains, “but structural and functional inconsistencies don’t allow the person to succeed.”
In other situations, hospitals may undercut leaders by not giving them enough time to do the job “or by off-loading responsibility for every new project onto the hospitalist director. “Leaders may be given the same amount of time to run a 25-person group that they had running a five-person one, without a budget to expand their administrative hours or hire assistants,” says Mr. Buser.
And there are hospitals that don’t really want leaders, Mr. Buser explains, but messengers. “The CEO tells the director, ‘Tomorrow, your group is going to take over neurology admissions, then nephrology on Friday and oncology on Monday,’ ” Mr. Buser says. “If the director isn’t at liberty to come back and say, ‘No, this is the way it’s going to work so we don’t burn my people out,’ the group is in trouble.”
Changing the guard
As if all of these challenges aren’t enough, hospitalist leaders also need to keep an eye on developing leadership in the rank and file. Without that, consultants say, succession becomes a problem. In Illinois, for example, Dr. Rahn says that she will be delegating responsibilities for scheduling and hospital-committee participation among the physicians in her group. She is also involved in creating a succession plan by encouraging group physicians who are interested to take on leadership roles.
For groups experiencing problems with their director, Mr. Buser says that there is such a lack of well-trained leaders that his company tries to salvage the current person. When he is called into these situations, he says, he encourages leaders in trouble to get outside leadership or management training.
Sometimes, however, the best remedy is to replace the director. In some instances, Mr. Buser explains, program directors are acutely aware that they’re not able to fill the bill and “are relieved” to step aside.
In other cases, rank and file hospitalists may have to exercise leadership of their own and move to replace the director. “There’s a right way and a wrong way” to go about that, Mr. Buser explains. The wrong way is to loudly air the group’s complaints among the medical staff “and incite a riot, get the mob mentality of the medical staff going.”
The right way entails having an intervention with the group leader and talking frankly about the problems the group is facing. Or, if the leader is not approachable and other remedies have been exhausted, group members may need to go over the director’s head and explain their frustration to someone higher up, typically the chief medical officer.
“That is very sensitive because you have only one shot,” Mr. Buser says. “If the CMO says, ‘Forget it, we like the way things are, so get back there and row,’ you may just have to start looking for another job.” Sometimes, Mr. Buser adds, it’s “the fact that many are leaving that gets the attention of hospital leadership and results in some change.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.