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Don't Expect Physicians to Lead Change

 |  By Philip Betbeze  
   October 04, 2013

Unless you take steps to equip them to do so, physicians will continue to be unprepared to lead changes in clinical guidelines critical to performing under healthcare reform.

A huge amount of change is in process within the American healthcare system, and physicians will play a huge part in whether or not healthcare costs will moderate and quality will improve. Trouble is, in most cases, they're unprepared to play a leading part. That's because the large majority have no leadership training.

Team-based care, which is at the foundation of reimbursement based on added value, is foreign to many of them, says David Nash, MD, MBA. He is dean of the Jefferson School of Population Health, based at Philadelphia's Thomas Jefferson University.


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I'm not revealing anything revolutionary here, but Nash says that's not necessarily their fault, because physicians are trained to lead themselves, not others. "Imagine a football team of docs," he says. "They don't know each other's names, they don't practice together and they all want to play quarterback when they play on Sunday and they want to play well. That's where we are in physician leadership."

Underlying the attempts to push for and deliver value on the insurance/employer/patient side and the provider/physician side, respectively, is a belief that physicians will work together with other physicians as well as their colleagues in nursing, case management, and with medical technicians, among others, to deliver efficient, coordinated care to patients.

"We want doctors to be the leader of the team, but we don't teach them how," Nash says.

The physician is supposed to be the leader of this teamwork approach to delivering healthcare. But financial incentives alone won't necessarily deliver the expected outcome, says Nash. Physicians have to be trained to operate this way, because it's the opposite of how most were trained in school and in residency.

"Some people consider physician leadership an oxymoron," says Nash. "That's sad and totally not fair, but I've actually had doctors say to me there's no such thing [as physician leadership]."

Yet physician leadership as a concept or area of scholarly inquiry has received a lot of attention in the past decade. The school Nash leads in Philadelphia is ample proof of that in itself. But Nash says Jefferson's School of Population Health is far from sufficient to achieve the lasting change and value in healthcare that nearly all players in this game profess to want to achieve.

If value and higher quality are really the goals, Nash says, hospitals and health systems must take the lead on providing that training to their physicians. That's easier said than done; this training is expensive.

It often takes doctors away from their practice for periods of time, many doctors who need this training most are not employees of the hospitals and health systems where they practice, and many leaders and board members worry that an investment in physician leadership training may train doctors only to have them compete with the health system.

Yet the evidence that physicians need this training is ample.

"The average board certified internist has had seven years of post-college training," says Nash. "In that seven years, she may have had only two hours of classroom-based leadership training. And we expect these people to lead the development of the patient-centered medical home?"

Of course, there's a problem in painting an entire diverse group of 600,000 practicing physicians across the country as deficient in leadership skills. Physician leadership is not an oxymoron. Many of the most well-known proponents of evidence-based medicine, infection and quality control, clinical integration, and many other groundbreaking innovations in patient care are physicians.

They're heading up ACO programs. They're chief medical officers. They are leaders in promoting and developing clinical informatics. More and more hospitals and health systems are tapping physicians as their CEOs. So they are out there. There just aren't enough of them, says Nash.

You simply can't practice population health without physician leadership and physician integration.

The American College of Physician Executives has been training physician leaders for 30 years. Members of that organization, including Nash, self-identify as spending more than 50% of their work time in a leadership role.

"But we only have 11,000 members," says Nash. "So you're talking about 2% or less of practicing physicians who are in a leadership role. For success under reform, we need 10-15% of physicians in that role."

There's also been an explosion of graduate training programs exclusively designed for docs that are exclusively online. But funding and time is a huge issue. Organizations, and more particularly their boards, need to take charge, Nash argues.

"Funding physicians to go to ACPE and various master's programs is a great start, and is one strategy, Nash says. "Another one is to bring ACPE faculty to their institution.That's the on-site program. Third, you can grow your own physician leadership program, and there are several outstanding ones."

Nash mentions physician leadership programs at Texas Children's Hospital, Ochsner Health System in New Orleans, UnityPoint Health in Des Moines as examples.

"At those, docs fight to be included," he says.

But those organizations commit significant institutional resources for physician leadership training, making their creation a board-level decision.

"Hospital CEOs don't want to do this," says Nash. "Boards have to do it. I counsel them that it's their fiduciary responsibility to demand the commitment of resources to physician leadership training."

Nash says CEOs are understandably reluctant to pay to train leaders from the physician ranks when they reason that the physicians may at some point use that training to compete against the hospital or health system.

"I don't subscribe to that worldview, but I understand its appeal," Nash says. "But I could make a strong economic argument to the cost of free training if you believe health reform means we're headed to bigger systems that are risk-bearing, integrated across sectors, boast seamless coordination, and that there are leadership challenges to implement the new measures coming our way."

He says healthcare will require a small army or leadership-trained physicians to run the core components of health reform from ambulatory quality to patient-centered medical homes. After all, your hospital or health system's PQRS [Physician Quality Reporting System] score is going to be online in 2015, so the hospital error rate will be researchable, he says.

"Who's running that store?"

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Philip Betbeze is the senior leadership editor at HealthLeaders.

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