Hospitals' new physician leaders: Doctors wear multiple medical hats

When emergency physician Chris Thomson, MD, arrives in the emergency department at Centra Health in Lynchburg, Va., to care for patients, he sometimes feels as if he needs a sign that says, "I am not an administrator today."

That's because on other days, he is an administrator, looking to improve care, staff performance and the patient experience.

"There are a lot of physician administrators who do leave clinical practice completely and do a great job," said Dr. Thomson, medical director of the Centra Emergency Services Group. "But I really love the combination of the two. I think continuing in clinical practice is incredibly valuable. You can see the real problems that you are trying to solve."

Dr. Thomson is an example of a new phenomenon in health care. Both clinical and leadership duties are part of his job. He took the position of medical director about a year ago after spending several years as assistant medical director. He works 80% of the time as an administrator and 20% providing direct patient care. His previous position was more of a 50-50 split.

"It keeps your credibility when people see you working a night shift and struggling like everybody else," Dr. Thomson said.

Having physicians in some form of executive or leadership role in the health care setting is nothing new. There are quite a few executives with MDs or DOs after their names but no clinical component to their professional lives. What is new is that physician leaders -- the word "executive" is falling out of favor -- are more likely to have a clinical component to their jobs. There are more of these positions as hospitals and large health systems prepare for the implementation of health reform and recognize the need for greater alignment with physicians.

"Executive implies more of a corporate role," said Deedra Hartung, executive vice president and managing principal of Cejka Executive Search in St. Louis. "Organizations are really talking about leadership."

Bridging a gap

Physicians leaders are viewed as more important than ever to closing the divide between clinicians and the administration as they try to create accountable care organizations, reduce readmissions, improve care and implement electronic medical records.

"The health system has become much more complex," said Chal Nunn, MD, chief medical officer and president of Centra Medical Group in Lynchburg. "There are more employed doctors, and integration means the need for physician leadership has certainly grown."

A survey of 200 chief medical officers at health systems and hospitals released Feb. 24 by the Physician Executive Leadership Center in Tampa, Fla., found that 15% had clinical duties in 2010, up from 12% in 2009.

A survey by Cejka Executive Search found that 68% of physician executives reported that they continue to practice medicine, with 42% maintaining clinical hours as a requirement for the position.

"Maybe not for the CEO and maybe not for the physician COO, but for the majority of the other positions, physician leaders often retain some level of clinical activity," Hartung said.

Physicians who fill these positions say they enjoy affecting the health of a large number of people as an administrator, and seeing how various initiatives change the care of individual patients when they are in front of them.

"Your range is far greater," Dr. Thomson said. "If you do a good job, your range of positive influence can be broad."

For example, Drs. Thomson and Nunn implemented an EMR system at Centra. This included choosing one that would appeal to multiple physician groups and customizing it when it arrived. They have worked toward setting up an ACO by incorporating quality incentives and efficiency metrics that make sense for all involved.

Along with others in Centra's emergency department, the two physicians were instrumental in getting a computerized physician order entry system that works for both doctors and the hospital system.

At Centra, patient satisfaction scores for the ED have improved from a very low level to the 90th percentile. The staff improved emergency department efficiency, reduced waiting times and increased patient volume by 30% to 40%. Years ago, the ED was losing money, but it is now turning a profit for the hospital.

"Hospitals have been very poor employers of physicians, which is another reason physician leadership is important," Dr. Thomson said.

That employment issue is another reason hospitals and large health systems are creating these positions to improve alignment with doctors and address long-standing trust issues.

A report, "From Courtship to Marriage, Part I: Why Health Reform Is Driving Physicians and Hospitals Closer Together," issued in December 2010 by PwC found that 56% of the 1,009 physicians surveyed did not trust hospitals as partners because of a lack of physician leadership or representation on the board.

"Physician leaders are uniquely positioned in today's world to help identify business and clinical needs of organizations that have a greater emphasis on clinical quality, clinical outcomes and health system performance," said David A. DiLoreto, MD, executive vice president and chief medical officer of Resurrection Health Care in Chicago.

The change takes getting used to. When Dr. Nunn went into a leadership role more than a decade ago, the physician group he left wouldn't talk to him anymore. Other physicians referred to him disparagingly as an administrator.

"To them, I had joined the enemy," Dr. Nunn said. "After two years, they realized that I was actually trying to help them, and this was not so bad." He now sees patients a half-day a week and is on call one weekend every few months.

Filling new needs

The chief medical officer remains a common leadership position, but hospitals are creating positions such as chiefs of physician relations, integration and medical informatics.

Banner Health in Alaska, Arizona, California, Colorado, Nevada and Wyoming recently promoted three physicians to new positions of regional medical officer. The doctors were chief medical officers for their hospitals in the Banner system and kept these roles. Banner Health is developing associate medical officer jobs that would be more of a blend of clinical and administrative work.

"And we're working to identify future physician leadership roles that we are going to need in our organization," said John Hensing, MD, Banner Health's executive vice president and chief medical officer. "We need physician leaders close to the practice of medicine, not in a corporate office somewhere. There's no question that physician leadership in general is being increasingly viewed as an essential requirement for excellent performance for health systems."

Some physicians are taking jobs not previously filled by MDs or DOs. For instance, Joel Lafleur, MD, a general surgeon and chief medical information officer at Pen Bay Healthcare, a hospital and health care system in Rockport, Maine, recently was elected board chair. Other physicians occupy several spots on the board, but Dr. Lafluer is the first practicing physician elected chair.

"As we move towards more integration, you cannot do this without the cooperation and involvement of physicians," Dr. Lafleur said. "There's still a little bit of skepticism as to how well this is going to work, but we're all going into it in good faith. And physicians are recognizing that in order to have some influence, we have to have a seat at the table."

These new positions incorporate some duties that until now physicians traditionally would have carried out as volunteers as part of the medical staff or various committees. But there is an increasing sense that relying on physicians to volunteer time to help run an institution is not sustainable.

"The model of voluntary work on a committee is not going to be the best way to get this work done in the future," Dr. Lafleur said.

But some volunteer work may be the best way for physicians to position themselves for significant leadership jobs, experts said.

For instance, before Dr. Thomson moved into an administrative position, he worked on initiatives such as establishing an ultrasound program at the hospital. He also volunteered with local medical societies.

New opportunities

Doctors who have transitioned successfully into administrative positions say the first step is to approach the health system's CEO to talk about opportunities.

Recruiting for physician leaders sometimes needs to happen outside the organization, but most hospitals prefer to grow leaders from within. Dr. Nunn got his start in the early 1990s by telling hospital leaders what he wanted to accomplish.

"Participate, participate, participate," Dr. Hensing said. "There are lots of opportunities -- some traditional, some less so."

He was a practicing internist for 17 years and took leadership positions on the medical staff and the health system's board of directors before becoming CMO at Banner 15 years ago.

Some physicians may find it worthwhile to receive additional training, such as an MBA or other advanced degree. But on-the-job mentorship or training could be sufficient. Other physicians may want to take advantage of training programs offered by medical societies.

Before signing up for a course, experts say it is important to think about whether a leadership role would be a good fit. The required skills can be very different from the ones that make a good clinician. Leadership roles require team and consensus building, while providing clinical care tends to be more independent.

"Physician leaders need to have the ability to work collaboratively and build teams," Cejka's Hartung said. "That's not necessarily taught in medical school. Physicians are taught to think autonomously in medical school, but getting some level of consensus is really important."

People who work in these roles say physicians who are uncomfortable with change or prefer to work autonomously may not find a leadership position a good fit.

"If you, as an individual, value your autonomy above virtually anything else in your life and you have to make all the decisions, you probably should not be going into a management role," said Barry Silbaugh, MD, CEO of the American College of Physician Executives.

Doctors who have taken on leadership roles said such a move should not be made in response to being burned out by clinical work. The pay may not be greater, the hours may not be fewer and the stress most likely will not be reduced.

"It can be an incredibly long workweek," Centra's Dr. Thomson said.