Managing Physicians May Be Impossible

I realize the headline above is provocative.

In fact, most physicians I know probably don't even appreciate the insinuation that anyone could even ask the question, never mind whether it's possible or not. And I get that. No one who learns and trains as long and hard and goes into debt as much as physicians do is much in the mood to be told how, when, or where to practice medicine once they're past that personal finance nightmare.

You read that headline, and all the tropes about managing physicians come to mind—that it's like herding cats, it's a thankless job, and, best of all, that it's impossible.

If it is, we're all in for trouble, because healthcare is bankrupting us. Everyone needs to be managed, whether they're the president of the United States (managed, at least in theory, by the voters, and checked by Congress and the courts) or a country doctor. If not, we get what we have now in some cases, which is management without data; management without evidence (incidentally, that's probably one reason physicians have historically so hated to be "managed").

I doubt if he would appreciate me attributing this quote to him—so I won't—but as a good source told me in a recent conversation, "the era of the "M-Deity" is over," referencing the abbreviation for the term medical doctor.

Strong words. I asked him what he meant.

He couched his answer in the context of how hospital and health system CEOs should see the physician-administration relationship. In his view, the idea of hospitals and health systems treating the physician as a customer is exactly what's gotten healthcare in trouble financially. Because in the end, treatment orders, in most cases, are written exclusively by doctors. He suggests CEOs develop structures where the hospital or health system is sharing risk with physicians as partners and not as customers to whom you pander.

Lest physicians reading this column think this is a case of "blame the doctor" for all of healthcare's woes; it's not. Physicians want to be treated as adults anyway, he says. But any way you cut it, for both physicians and administrators, you have to "go big or get out."

Consolidation is already progressing steadily. In every community of 500,000 people, he predicts we'll see healthcare owned and controlled by a couple of $2.5 or $3 billion (revenue) enterprises instead of six hospitals and 1,500 independent practices.

That means managing physicians. But managing physicians takes far more skill than managing, say, a factory shop floor. Or maybe it doesn't, but that's another story.

In this narrative, physicians have lots more education, and lots more power, than that. The question is how to do it well.

Many physicians, being prior victims of management failures, could probably tell you, if you let them. If management's about taking better care of patients (and critically nowadays, taking better care of populations), physicians are for the most part a ready audience. If it's about money and costs, they tune out. Yet it's all linked.

If you've been covering healthcare as long as I have, your notes and stories over the years are full of comments from and about hospital and health system leaders who tried to manage their physicians, and failed spectacularly. Speaking of tropes, managing physicians over the years has come to be seen as a "career-limiting event" among CEOs. Often, the last event in their tenure boiled down to a vote of no-confidence from the medical staff.

Whether or not they've been successful, or even correct in the way they've chosen to manage their physicians, senior leaders have the right idea: Physicians need to be managed like everyone else. Even leaders need management.

But many physicians are recognizing that their ability to influence healthcare, for the good of the patient, can be more fully realized by a management role of their own. I've had as many as a dozen CMOs tell me they had no idea what they were getting into when they were named CMO, which entails more and more these days, actually managing patient care, and by proxy, managing physician behavior.

Ditto for the burgeoning ranks of physician CEOs in hospitals and health systems. That doesn't mean they regret it. For the most part, they are exhilarated. They appreciate the scale on which they can influence patient care, which, after all, is why the vast majority of them got into medicine to begin with.

This month in HealthLeaders magazine, I write about several organizations that are putting their physician management skills to the test. Perhaps they'll succeed, perhaps not. Physicians have always been leaders in their organizations, whether or not they wanted the role. But that leadership role has been far from multidimensional.

That's changing rapidly. Physicians are leading the development of clinical protocols and managing their financial repercussions as never before.

But they can't do it alone.