Notes on the Future of Physician Leadership and Medical School

To begin with, there is an urgent need for physician leadership in the healthcare industry today. In an interview with Aric Sharp, Vice President of Accountable Care at UnityPoint Health states why:

Physicians must lead the changes, clinical and otherwise.  Of course the business folks and accountants still have to be a key part of the process, but clinicians will drive the change.  The days of physicians just treating patients is over. To meet the disruptive challenges of our industry, physicians will have to step to the forefront and lead the change.

The very success of your healthcare organizations depends on the quality of your physician leaders. The Iowa Clinic’s C. Edward Brown explains:

Physician leadership has allowed us to make strategic moves that required extraordinary courage.  We have been bold enough to do things that otherwise might appear unattainable.  We have made these changes very rapidly, without the typical emotional stress that such changes cause. We have added many physicians to the organization, and the physician leadership institute is a mentor to them, helping them grow in our culture, nurturing the next generation of leadership. That is one of our cultural differentiators. Our physicians make the organization better for the future.

Question: how should medical schools and residencies integrate physician leadership into their curriculum? 

In our opinion, they should use a two-part approach:

One, use the physician leadership model to define and educate medical students and residents on what it means to be a physician leader.

Two, use the physician model and 360 assessments to determine the strengths and weaknesses of the individual student. Provide feedback that creates awareness and engage the learner in the development.

Three, use 360 data to customize curriculum and focus the learning and efforts on highest impact development areas of cohort. Select the appropriate time for which topic to teach. Teaching medical students about business negotiations may not be appropriate in year 1 and 2, but perfectly timed for 3 year residents. Alternatively teamwork and collaborative problem solving is very appropriate in year 1 and 2 for medical students.

Four, use coaches to help students and residents with self awareness, developing learning plans and growing as a leaders.

Five, use action-learning projects during medical school and residency to operationalize and apply physician leadership and create collaborative problem solving opportunities on team.

Of course, this is easier said than done. Nevertheless, it is the only way forward. Why should medical schools change their time-worn traditional methods to include physician leadership? Because without it, they are doing a disservice to their students. Without physician leadership, they are not building a core competence of the future. We need more Leader-ists. The framework for transformation of medical school curriculum will have to be similar to this framework for transformation.

The Loss of The Creature: The Patient is Your Mother

The medical profession is getting a bad rap. Hardly a day passes without an article or blog post “exposing” the underbelly of failed health care.  A recent article in The Atlantic is no exception.  The writer - Meghan O’Rourke, is also a patient:

…this essay isn’t about how I was right and my doctors were wrong. It’s about why it has become so difficult for so many doctors and patients to communicate with each other. Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes “patient-centered care” as a mantra, modern medicine is startlingly inattentive—at times actively indifferent—to patients’ needs.

O’Rourke is onto something.  Why is it that in this day and age of modern medicine, we fail our patients in the most basic ways?  Have we become so efficient that we have forgotten how to communicate with the patient? 

Again, here’s O’Rourke:

Terrence Holt, a geriatric specialist at the University of North Carolina at Chapel Hill, describes the situation in Internal Medicine, fictional fables based on his residency:

Any patient in a hospital, when we take their clothes away and lay them in a bed, starts to lose identity; after a few days, they all start to merge into a single passive body, distinguishable … only by the illnesses that brought them there.

The subjective experience of illness has always been all but impossible to convey. But systemic changes have intensified a disconnect between patients and doctors that was less glaring some 40 years ago, before technological advances and corporatization began to transform the comparatively low-tech, localized postwar medical system. The broad contours of the situation are familiar. Health care in the United States operates predominantly on a fee-for-service basis, which rewards doctors for doing as much as possible, rather than for offering the best care possible. This didn’t matter much in the 1950s, when a general practitioner coordinated most of your care and not many treatment options existed. But sophisticated new surgical techniques, and tools like the CT scan and the MRI, led to a surge in high-tech specialization. Rising costs in the 1970s were the catalyst for “managed care”—basically, our current system, in which insurance companies like Aetna and United Healthcare negotiate with networks of doctors to determine how much care patients get, whom we can see, and at what price. But along with new checks and balances came added bureaucracy, and frustrated doctors and patients. Comprehensive oversight has never been in shorter supply, as specialized “consults” proliferate and no one gets paid to coordinate care (problems the Affordable Care Act aims to fix).

This is a phenomenon that I call the “Loss of the Creature” after an essay by Dr. Walker Percy - the late southern writer.  According to Percy, the very way we are taught about science devalues the individual:

…a shift of reality from concrete thing to theory which Whitehead has called the fallacy of misplaced concreteness. It is the mistaking of an idea, a principle, an abstraction for the real. As a consequence of the shift the specimen is seen as less real than the theory of the specimen. As Kierkegaard said, once a person is seen as a specimen of a race or a species, at that very moment he ceases to be an individual. Then there are no more individuals but only specimens

To illustrate: A student enters a laboratory which, in the pragmatic view, offers the student the optimum conditions under which an educational experience may be had. In the existential view, however-that view of the student in which he is regarded not as a receptacle of experience but as a knowing being whose peculiar property it is to see himself as being in a certain situation-the modem laboratory could not have been more effectively designed to conceal the dogfish forever. The student comes to his desk. On it, neatly arranged by his instructor, he finds his laboratory manual, a dissecting board, instruments, and a mimeographed list:

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Exercise 22 Materials:

1 dissecting board 1 scalpel
1 forceps
1 probe

1 bottle india ink and syringe
1 specimen of Squalus acanthias

The clue to the situation in which the student finds himself is to be found in the last item: 1 specimen of Squalus acanthias.

The phrase specimen of expresses in the most succinct way imaginable the radical character of the loss of being which has occurred under his very nose. To refer to the dogfish, the unique concrete existent before him, as a “specimen of Squalus acanthias” reveals by its grammar the spoliation of the dogfish by the theoretical method. This phrase, speciment of, example of, instance of, indicates the ontological status of the individual creature in the eys of the theorist. The dogfish itself is seen as a rather shabby expression of an ideal reality, the species Squalus acanthias. The result is the radical devaluation of the individual dogfish.

In my view, there is a simple yet effective way for the physician to restore the sense and dignity of the individual patient. That is by viewing each patient as a relative. The physician simply asks herself - if the patient was my mother (or father) what would I do for them? This simple thought experiment brings the patient back to being an individual – restoring the humanity of both the doctor and the patient.

O’Rourke also talks about how overworked physicians lose their empathy for their patients:

Yet empathy is anything but a frill: not only is it crucial to doctors’ humanity and patients’ dignity, it can be key to medical efficacy. The rate of severe diabetes complications in patients of doctors who rate high on a standard empathy scale, Ofri notes, is a remarkable 40 percent lower than in patients with low-empathy doctors. “This is comparable,” she points out, “to the benefits seen with the most intensive medical therapy for diabetes.”

What can be done?  Are there examples where the patient is still viewed as a sovereign individual?  Of course there are.  Let’s look at these cases to learn what it is that makes them different.  Here’s Ed Lopez (from an interview we did earlier on this blog):

Today physicians are recognizing that there is a dearth of physician leadership at almost every level. The physician leader must understand today how the business works, what the outcomes are, how to lead and inspire teams, and fix problems – all from the perspective of the patient. The government has stepped in as well – forcing the hospital systems to measure outcomes not just costs. This is changing the business dynamic by forcing a sense of accountability for all of us – Doctor, Patient, payor, administration. We ALL now own this thing called the American Healthcare system – You can run but you can’t hide.

To compete, our medical practices must nurture real, authentic physician leaders. Men and women who understand that before we can lead others, we must search our souls and learn to lead ourselves in order to become the leaders we need to be. Leaders must inspire followers through servant leadership – by example and by service. No job is too small or too insignificant when it comes to the patient experience.

 Lopez is all about regaining the doctor-patient relationship. He says:

My commitment is to do the right thing to help the patients and their families receive the finest experience they can have. No detail is too small. And we teach this to all – from the physician to the janitor. If a patient needs something, we do our best to get it for them. We tell them: “If anything isn’t working for you, please let us know, so we can help.”

There is science behind this. When a patient experiences a feeling of trust and faith, endorphins kick in, and they begin their journey of healing with a positive frame of mind.

The difference is physician leadership.  And that’s the only way forward. How do we make sure that physicians are engaged in the healthcare revolution? In the end, as we stated earlier, it all boils down to trust. Far too many physicians do not trust their organization’s administrators. We believe the techniques we use to engage physicians and administrators allow them to build trust and see the world from a shared perspective. It’s the age-old alignment conundrum. Purpose drives strategy, and strategy must be linked to operations.

A final quote from O’Rourke:

I used to think that change was necessary for the patient’s sake. Now I see that it’s necessary for the doctor’s sake, too.

Well said.

In Memoriam: Dr. Doug Butzier

We express our condolences and deep sympathy to the family, friends, and co-workers of Dr. Doug Butzier from the Mercy Medical Center for their sudden great loss.

Our feelings echo the sentiments of Mercy President and CEO Russell Knight who said in a statement:

“Dr. Butzier was one of the pillars of the emergency department for the past 17 years. His influence was felt throughout the hospital, as he led one of our key quality-improvement teams with skill, knowledge, and enthusiasm, helping to produce the outstanding results Mercy has become known for. He was a leader among his peers, and we will all miss his strong, intelligent, thoughtful presence, and we express our collective condolences to Doug’s family, friends, and colleagues.”

In our work with Dr. Butzier, we were always struck by his passion to make the work a better place.  This was evident in his everyday work at in the emergency room, as well as in his run for Senate office in Iowa. He was also the chairman of the Iowa Emergency Medical Services Advisory Council and had served on the council since 2006.

Dr. Butzier was an inspiration for us in our work, and will continue to be in the future.  We will all miss his passion and indomitable spirit.  He was a wonderful colleague and friend, and will be missed greatly.

The Future of Physician Leadership: An Interview with Aric Sharp

Aric Sharp was appointed Vice President of Accountable Care at UnityPoint Health in 2013. Prior to that, he served as Chief Executive Officer for Quincy Medical Group (QMG) in Quincy, Illinois. Under his direction since 2007.  Aric serves as the Chair of the American Medical Group Association Public Policy Committee.  He has 17 years of physician group practice leadership experience and was  , named one of Modern Healthcare’s 12 “Up & Comers under 40″ from across the United States. Aric is a Fellow in the American College of Healthcare Executives and a Certified Medical Practice Executive with a Master’s degree in Hospital and Health Administration from the University of Iowa.

What are the biggest challenges facing healthcare organizations today?
In terms of organizational challenges, I would start by saying we are in a stage of transformation, with three clear challenges that have to be met at the same time. It’s as if the healthcare industry has to move through the industrial age, the information age, and the consumer age, all at the same time.  It’s a time of disruption with our clinical care processes undergoing radical change.

In terms of the organization, the biggest challenge is culture. How do we go from individual silos to working as teams?  How do we use these teams to reduce variation in clinical care processes?  There are great opportunities ahead for those who are willing to change.

A second challenge is data analytics. We are learning to extract real insights from the data providers have been collecting.  Traditional measures have been driven by financials or by clinical data and safety. Now we need to use data as a tool for knowledge discovery – to learn about quality and cost, dig deeper to the root cause of issues, and learn more about how and what.  The new knowledge we gain from data is going to be critical going forward.

Finally, there’s the consumerism wave that is sweeping healthcare as consumer technologies are accepted and embraced.  And cost information is becoming more and more transparent.  Even insurance companies are sharing their cost info to benchmark and monitor cost, quality, and patient satisfaction.  Data on cost, quality, and satisfaction will be readily available for all.  The disruptive innovators are here to stay – from eHealth to retail-based solutions.

So all three challenges are bearing down on us simultaneously.  It’s not a time for timidity or faint-heartedness.  Our revenue streams will change, and we need to understand how to serve the patient using these disruptive technologies and processes.

How is the role of the physician leader changing?

Increasingly, the role of the physician leader is at the clinical core.  The old financial models don’t work. Physicians must lead the changes, clinical and otherwise.  Of course the business folks and accountants still have to be a key part of the process, but clinicians will drive the change.  The days of physicians just treating patients is over. To meet the disruptive challenges of our industry, physicians will have to step to the forefront and lead the change.

How does your organization create alignment between strategy and execution?

We invest heavily in the development of physician leadership. We have change agent leaders across the organization – people who know how to manage and drive change forward. We have institutionalized the process of change so that we have a common vocabulary and understanding of how change will happen. It makes change more acceptable and recaptures the entrepreneurial spirit.  The space of change is accelerating as well. This alignment between what we want to do and want we do is possible through collaborative thinking – a shared mindset of how we get there.

How has your leadership role changed over the past few years? What advice to you have for other healthcare executives as they face the organizational challenges of the future?

The players in the industry – from providers, to insurance companies, the employers, are all much more vocal.  Total cost of care  efficiency is becoming key toward decision making while quality and safety are prerequsites.  When margins are tight, we have the potential for adverse effects.  That is why “change leadership” is so critical.  These leaders are remaking the business model, even as the ground is shifting under them.  We are experiencing a sea-change in healthcare, and the challenge can sometimes be viewed as an exponential challenge.  As leaders in these tumultuous times, our job is to create and nurture a culture that is both agile and resilient.  These may sound like buzzwords, but I assure you they are not.  Long term we have to build the talent base for the challenges of tomorrow – even if it at times it means bringing in new talent from the outside.  And of course we have to develop our people on the inside.  We have to be outward looking and inward focused at the same time. This is not the time to be myopic.  Look beyond the obvious.  Challenge your team to lead.  And most of all, empower them to do so. Embrace the disruption ahead.

Leadership in a Time of Crisis: A Checklist for Ebola

Fearbola…  According to Richard E. Besser, chief health editor at ABC News:

Infectious disease often leads to irrational behavior. It’s a primal defense. We saw this during the early days of the AIDS pandemic, as infected children were barred from schools and some health professionals wouldn’t provide care. We are seeing it again now with Ebola.

RoseAnn DeMoro, executive director of National Nurses United, analyzes the situation:

Ebola is exposing a broader problem: the sober reality of our fragmented, uncoordinated private health-care system. We have enormous health-care resources in the United States. What we lack is a national, integrated system needed to respond effectively to a severe national threat such as Ebola.

 In many ways the U.S. Ebola crisis is a crisis of leadership. So, what does a leader do in a time of crisis?

In addition to the CDC provided Ebola information for hospitals and providers, here is a CRISIS LEADERSHIP CHECKLIST from the Physician Leadership Institute. Based on our physician leadership model, we’ve developed 5 key areas that must be addressed based on the physician leadership model:

» Leading with Purpose:

“Efforts and courage are not enough without purpose and direction.” – John F. Kennedy

In times of crisis, leaders anchor their teams in both the purpose of the organization and their individual purpose.

- Have we clearly articulated our organizational purpose of serving others?

- Are we connecting with individual’s burning ambition versus burning platforms?

- Have we clearly articulated our organization core values such as compassion, care, and service to others?

- Have we clearly articulated our goals and capabilities for the crisis at hand?

- Have we shared these goals with all our internal stakeholders (employees, staff, physicians, patients)?

- Have we communicated these goals with all our external stakeholders (citizens, local institutions, press, public agencies)?

- Are our actions timely?

- Are we trusted?

- Am I trusted as a leader?

- Do we have the right communications team in place?  Do they know what to do and when?

- Does everyone know who is in charge and responsible across the entire process?

» Leading Self: 

“It is said that one who knows himself and knows others will not be endangered” – Sun Tzu

- Have I communicated clearly my core principles and values such as courage, duty and service to others?

- Have my actions been consistent with my core values thus inspiring trust?

- Am I authentic in my actions and behaviors? Do I lead by example?

- Do I demonstrate the courage required by the situation?

- Am I forthcoming and timely with my communications?

» Leading People:

“It is better to lead from behind and to put others in front especially when you celebrate victory when nice things occur. You take the front line when there is danger. Then people will appreciate your leadership.” - Nelson Mandela

- Do we put our people first?

- Have we showed empathy towards our team’s concerns for safety and wellbeing?

- Are we actively listening to our teams and they feel heard?

- Are we providing our people with the best training required?

- Are we coaching our people on all critical tasks and priorities?

- Have we built the appropriate teams – at every level of the organization?

- Do we have a collaborative mindset?

- Are there any leaders whose crisis management leadership we are concerned about and for whom we need to provide special guidance?

- Are we present and visible? Are we leading by walking around ?

- Do our teams know standard protocols on when, and how to escalate potential concerns, issues?

- Do our teams know standard protocols should they be approached / questioned by the press outside of work?

- Is the communications team trained to be proactive?

- Do we have a FAQ document distributed to our employees?

 » Leading with Strategy:

“The effective strategist (leader) only seeks engagement after the victory has been won, whereas he who is destined to loose first fights and afterward looks for victory.” – Sun Tzu

It is useful to reflect on Sun Tzu’s advice to “learn and do the orthodox, but win with the unorthodox.”

- Have we assessed the impact of the crisis on the organization?  The community?

- Have we planned for how can this situation escalate?

- Is my “river of information” sufficient to provide me swift access to critical information/ breaking news internally and externally from which to make appropriate decisions?

- Have we benchmarked and learned from other best practices?

- How do we manage fear and panic?

-  Are we executing our strategy effectively with a plan–do–check process?

- What will be our own unorthodox best in class strategy and actions? What innovative actions, processes can we develop to manage the crisis?

» Leading for Results:

“The pinnacle of excellence is not marked by number of the victories, fame for wisdom or courageous achievement, it is about flawless execution.” – Sun Tzu

- What are our measures of success? And do our teams know them?

- Are we focused on key activities?

- Are our processes tried and tested?

- What systems thinking models are required?

- Are our decisions based on evidence and best practices?

- Have we taken all possible safety precautions?

- Are we optimized for productivity and effectiveness?

- Have we published a regular communications frequency and are we communicating to our teams per that schedule: our progress towards our goals, any concerns and responses, updated FAQs, reminder of linkage between purpose, actions and results, etc ?

For more information on our crisis leadership program, contact us >>

Change Management: No Pun Intended

The literature on “change management” is clear: over 70% of change initiatives fail.  In 1995, John Kotter published research that revealed only 30 percent of change programs are successful. In 2008, a McKinsey & Company survey of business executives indicates that the percent of change programs that are a success today is… still 30%. The field of ‘change management’, it would seem, hasn’t changed a thing.

The IBM Institute of Business Value recently published a report titled: Making change work…while the work keeps changing: How Change Architects lead and manage organizational change.*

Similar to the Big Shift from Deloitte’s Center for the Edge, the report finds that companies no longer have the luxury of expecting day-to-day operations to fall into a static or predictable pattern interrupted only occasionally by short bursts of change. Instead, constant change has become the new normal.

The report also identifies the important aspects of successful change, which, not coincidentally, includes “soft factors” so often overlooked by organizational change initiatives:

Our Model of Physician Leadership includes these hard and soft factors and is centered around organizational purpose:

Organizational culture can and must be designed to meet the challenges ahead.  It would not be too much of a risk to say that culture is the reason why 70% of change initiatives fail.  This is reflected in the findings as well:

This sort of understanding is critical to gauge where your organization is on the transformation journey. At the Physician Leadership Institute, we formalize this process through a institutional framework for change and the embedded Physician Leadership Academies or Institutes that become the engine for transformation from within. As we stated earlier, we help organizations through the journey of transformation through continuous coaching over time.

Leadership Delivery Model

Organizations cannot address the increasing pace and magnitude of change today by reinventing activities and roles ad hoc or on a project-by-project basis.

In our work, we find that if an organization is already suffering from change fatigue, the cure is not easily administered. Rather, it begins with the fundamental rethinking of who you are  and who you want to be – at both a personal and organizational level. Your story is all-important (remember CVS Health?).

Learn more about how to use our change expertise and systematically build enterprise-wide change capabilities >>

* Making change work…while the work keeps changing: How Change Architects lead and manage organizational change, IBM Institute for Business Value, IBM Corporation, August 2014

A Framework for Change: What Works

If your organization follows specific steps change will happen. Wrong!

A very dangerous assumption in organizational change initiatives is assuming that cause and effect can be managed in a linear manner.  Change is never a static linear process.

What we observe at the Physician Leadership Institute (PLI) is that often leaders fail to make a clear assessment of the terrain.

All change initiatives must begin by understanding the various stakeholders – their perspective: needs, motivations, goals and incentives.

We teach leaders the importance of knowing “the terrain” by mapping the stakeholders and where they stand.

But the most critical part of change is the change agent.  We help organizations through the transformation journey by developing and certifying Physician Leadership Change Agents.  How  your organization selects, engages, and nurtures a coalition of change agents will make the difference between success and failure. Our change framework focuses on cultural and soft skills as they apply to physicians, a key issue often overlooked by organizational development specialists not familiar with the healthcare industry.

Physician Leadership Change Agents must have or develop the following qualities and skills:

- Face uncertainty with courage and adaptability.

- Intellectual curiosity

- Forward looking

- Communicate effectively with their peers

- Understand the change process and its dynamics

- Build coalitions – the sponsorship and stakeholder support necessary to effectively implement change

- Constructively challenge the status quo

- Facilitate and nurture innovative ideas that make a difference.

- Seek out and listen to input from others.

- Influence and motivate others even when not in a position of authority (garnering commitment and support for change)

We create action-learning programs that engage these change agents to work on impactful projects.  They are supported through leadership coaching and by applying their learning to their organizational change project or initiative. Without the right mindset, framework, and execution, change initiatives fail.  In fact, as we will see in the next blog post, 70% of change initiatives fail.

Rebranding CVS Health: Building the Corporate Narrative

As we mentioned earlierCVS Caremark Corp announced that it would stop selling tobacco products at its 7,600 stores by October, becoming the first U.S. drugstore chain to take cigarettes off the shelf.  Now we get the rest of the story.

CVS Health, as the new entity is called, halted sales of tobacco products almost a month ahead of schedule and started a smoking-cessation campaign all in a bid to to position itself as an advocate of better health for consumers. This is in line with the consumer engagement wave, one of the three waves disrupting the healthcare industry.

In my view, this repositioning is a sound strategy, made even stronger by the power of CVS’ corporate narrative. The new brand has a story to tell:

The change of our corporate name to CVS Health is an important milestone in the history of our company. It reflects our broader health care commitment and our expertise in driving the innovations needed to shape the future of health.

For our patients and customers, health is everything and CVS Health is changing the way health care is delivered. We’re committed to increasing access, lowering costs and improving the quality of care. Each year, CVS Health touches more than 100 million people by playing an active, supportive role in each person’s unique health experience and in the greater health care environment. 

 It may be one of our pharmacists counseling a grandmother on why it’s important for her to take her diabetes medication as prescribed by her doctor, or a nurse practitioner at one of our MinuteClinics being there on a Saturday afternoon to diagnose and treat an earache for a seven-year-old so an unnecessary trip to the emergency room can be avoided, or CVS/specialty addressing the needs of a newly diagnosed young mother with rheumatoid arthritis, to understand how to take the potent medications that will make a difference in her life.

Millions of times a day, close to home and across the country, we’re helping people on their path to better health.

As a further demonstration of our commitment, we’ve removed cigarettes and tobacco products from our  CVS/pharmacy stores. By eliminating the sale of cigarettes and tobacco products in our stores, we can make a difference in the health of all Americans.

We also launched a comprehensive and uniquely personalized smoking cessation campaign to help millions of Americans to quit smoking.

As CVS Health, we are tobacco-free, reinventing pharmacy and taking our place among leaders in the health care community.

Well said.

What is critical is the speed with which CVS Health has gone to market with the message.  CEO Larry Merlo leads the way with the “message”:

The smoking cessation program adds an active community initiative that aligns brand purpose with the good of the community.  The goal: establish a brand based on trust.

There is one other dimension that adds credibility to the new brand: a concerted effort at collecting and disseminating research data and insights – a consumer-centric shift that signifies more transparency.  By featuring the CVS Health Research Institute, they are positioning themselves as a “trusted” guide, a good neighbor in the community.

How is your healthcare organization positioned to meet the challenge from CVS Health?  Are you doing enough to disrupt yourself? What’s your organizational narrative?

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