It is a mutually agreed and acknowledged fact that health service organisations often find it difficult to manage their senior medical staff. It is also fact that it is the senior doctors in a health organisation who determine costs of care, who can support or stymie the ability to make change in the organisation and who can influence organisational success far more potently than any other professional group. It is these facts that have given rise to the concepts of the importance of medical leadership and medical engagement in a way that far exceeds any discussions and strategies related to other professional groups.
The importance of getting medical staff more intimately involved in organisational matters was first openly discussed in Australia in the late 1980s when a well-known consulting firm travelled the country with their panacea to be introduced at considerable cost. This involved structural change in organisations with more accountability and authority to be provided to clinical directors who would form a key part of the organisation and be prepared to take action to spend resources wisely and work with their peers to support organisational goals. This purported outcome of this strategy was to save substantial amounts of money in health services and it was stated that that these savings would far exceed the costs of the consultancy.
A significant number of health organisations subscribed to this theory and then employed the consulting firm to assist them with restructure. Over time many other organisations also went down the clinical director route and this has now become the most common organisation structure for medical staff in Australia. Whether this has actually improved health service finances is debateable. In many organisations, it has probably cost more rather than saved any money. Whether it has engaged medical staff and fostered more involvement in organisational goals is also debateable.
So why is this so? Why is it that a strategy to improve engagement of doctors, something that is regarded as a “good thing”, has not delivered the outcomes promised by the consulting firm?
To answer this question, one needs to dig much deeper than the superficial approach adopted by the consulting firm referred to. One needs to understand that the complexities involved do not lend themselves to a panacea and one needs to also understand that while there is a degree of truth in the theory, practice rarely perfectly mirrors theory, even though some of the principles are sound. This is a good example of not clearly identifying the problem before adopting a solution. In addition the consulting organisation was very good at selling what it regarded as “the” solution to health services, but the health services themselves at the time had little real understanding of their medical staff and were naïve to imagine that there was a panacea for health service problems.
2. Understanding the problem
Whilst it is true that senior medical staff are a major determinant of health service costs, it is a fallacy to assume that simply putting them in charge of managing these costs, will make a difference. This assumes that they actually have the knowledge and skills to do this, they have the skills to influence their peers to manage costs, they have the time to carry out management obligations whilst continuing with a considerable clinical workload and that they are fully committed to the health services’ strategies and goals.
The assumption is that once they are provided with a substantive position that gives authority and accountability for resource management and leadership, that they will become both successful leaders and managers overnight. There is the assumption that being a good technician i.e. a competent and respected clinician, will translate without any support or education into a competent and respected resource and people manager and leader. There is also the assumption that as soon as a senior doctor is employed in a substantive leadership position that not only will he or she function in partnership with the organisation, but so will all of the other senior medical staff who report to this position.
Unfortunately, these assumptions do not hold water. If one is serious about having senior doctors work in partnership with health organisations, considerably more needs to be done. There are two specific areas where this effort should focus.
Firstly health service executives require a better understanding of what makes a good medical clinician and how this differs from a clinician manager/ leader is needed by health organisations. As part of this, health services need to understand what motivates medical staff to get involved in organisational activities and what health service executive management needs to do to foster this involvement.
The second important issue is that what we want from this partnership is far broader than cost containment. What health services need is for the partnership to enhance strategy, enhance patient care and service delivery and ensure that relationships between medical staff and management are robust and supportive. This is a two way street. Both parties need to demonstrate ongoing leadership and both parties need to work at continuously nurturing the partnership so that it will flourish.
These two tenets will be discussed in more detail below so as to understand not only why they are important, but what needs to be done to work successfully with medical staff and further organisational goals.
3. Developing partnerships with medical staff
3.1 Understanding partnership
This section has purposely used the term “partnership” rather than “engagement” and there are specific reasons for adopting this terminology.
The assumption is that if we work assiduously at engagement it will deliver us the holy grail of the efficient, effective, high quality care and safe health service that we are seeking. In addition, if we spread leadership education to all doctors, they will take up the baton with enthusiasm and become true organizationally minded people.
That’s how the theory goes, so why hasn’t it happened after decades of talking and trying? Why is it so difficult?
From executive management’s point of view of course, it’s “them”. “They” (the doctors) are difficult. They won’t toe the line. They won’t attend the important meetings even though they are invited. They don’t manage their departments well. They don’t control costs. They don’t care about the health service as a whole. It’s a common litany of complaints about how difficult and unyielding doctors are.
From the doctors point of view it’s also “them”, but a different them. It’s executive management. “They” don’t understand how we manage patient care. They only care about the bottom line. They only invite us to meetings in a tokenistic way as the meetings are always at the time of clinic or operating theatre sessions. They don’t provide us with appropriate data so we can manage our costs. They don’t really care about our opinions.
So we have our parallel universes. And yet patients still receive quality care, often not as efficiently or effectively as possible but nevertheless, from a professional and clinical point of view, care on the whole is safe and appropriate. Executive management believes it is genuinely trying to engage with doctors and being knocked back and doctors continue to be unaware of, or unwilling to accede to, the overtures that management is trying to make.
3.2 Applying first principles
To try to make sense of this situation it is worthwhile going back to first principles. What is engagement? What drives engagement? Do we really understand what it is we are trying to do and what outcomes we want to achieve?
True engagement is emotional as well as intellectual. An engaged employee cares about the future of the organisation they work in and is prepared to invest discretionary effort into this organisation 1. They do not come just to do a task but to be part of the organisation and contribute to its success. They do this because they are emotionally invested in this success. They want to work in an organisation they are proud of.
Considerable research on drivers of engagement has identified a variety of factors, some of which are particularly pertinent to doctors in health services. These include:
These drivers provide the key to engagement or in reality provide the key to why using the term “engagement” can actually work against a health service trying to get doctors to invest emotionally and intellectually in its success. The drivers clearly identify that this investment is a two way process. This means it is actually a partnership where if the health service wants doctors to invest, then the health service must in turn demonstrate that it also invests both emotionally and intellectually in its medical staff. This is not a one-way street, where one engages doctors so that they will do whatever the health service wants. There are responsibilities and obligations on both sides and a partnership should develop based on trust. Trust is what is most often missing and this is what stymies the engagement process. In this way, the drivers are often negative and work against a true partnership.
Perceptions of the ethos and values of the organisation
Regular feedback and dialogue with superiors
Quality of working relationships with peers, superiors and subordinates
Effective internal communications
All health services have developed values. They sit in the annual report, or up on a wall. They may have been developed collaboratively with staff. However, very few health service organisations use these values consistently to underpin decision making and strategy. In some organisations decisions appear to be made in clear contradistinction to the values. As a result of this, medical staff have a perception that executive management is hypocritical. They often feel that the only thing important to executive management is the bottom line or maintaining good relationships with government. They see this as working against good patient care. This has an impact on trust between executive management and medical staff.
Perceptions of the ethos and values of the organisation
Often the organisation does attempt to consult medical staff, but only does this when there are key strategic decisions to be made. There is the lack of an ongoing open dialogue that builds the relationship and engenders mutual trust and respect. Building the relationship assists with understanding each other’s issues and problems and assists with more willingness to be flexible with meeting times for both parties, for example, when significant input is required from medical staff.
Regular feedback and dialogue with superiors
In health services, relationships with peers and subordinates are usually robust, although this is not always the case, when strong individuals come together in one unit. Nevertheless, these are usually the strongest relationships for medical staff. However, for the reasons given above, for senior medical staff in particular, relationships with superiors may be fraught, particularly if superiors are not medical. Again lack of trust and mutual respect contribute to this.
Quality of working relationships with peers, subordinates and superiors
Emotional and intellectual investment depends on knowing what is happening in the health service organisation and understanding how it impacts on individual doctors and patients. Internal communication also helps medical staff to understand the constraints and pressures that affect the health service and executive management. Poor internal communication can be highly detrimental with mixed messages and misunderstandings that alienate doctors and confirm their views about perceived organisational values and executive management’s underlying agenda. Successful communication with doctors is a complex issue as it requires many different approaches to capture a critical mass of the workforce. This takes consistent and continuous time and energy that management is not always prepared to invest.
Effective internal communications
3.3 Changing the language
It is clear that the underlying barrier to building a partnership is a lack of mutual trust and respect. Using the term “engagement”, I believe strengthens this barrier by confirming with executive management that although getting the doctors engaged means some work on their part, this small amount of involvement should satisfy medical staff and bring them fully on board with organisational goals. Once this happens, health service management may believe that their work is done and that from now on the medical staff should continue to maintain their involvement.
However, if the language is changed to “building a partnership”, this completely transforms the way that we look at relationships within the health service. Partnership means that we work together for the greater good.
There is no partnership without:
Medical staff perceptions are that they can perform the task they see themselves employed for i.e. the provision of good patient care, without any real involvement with the health service as a whole. As most senior medical staff in health organisations throughout Australia remain part time or visiting, it is usual for them to complete the task then move on to another work place. To a large extent, medical staff are comfortable with this. It is less distracting to focus on what they enjoy and where their areas of competence lie. Most will not feel that they are an integral part of a partnership unless they are actively and continuously involved in health service matters by management, so that trusting relationships develop and continue.
Mutual trust and respect
Clear common goals where both partners work together and support each other to achieve these
The culture of the organisation providing the context in which these mutual obligations and supports can flourish
Continuous nurturing from both partners to maintain mutual trust and respect
However, if we remember that as well as being professionals medical staff are also human beings who want to feel valued and respected, then partnerships can be fostered for the benefit of the health service, the medical staff and management. In those health services, where management does continuously work on this, I have seen partnerships develop, but these continue to remain fragile unless continuously nurtured and they are always at risk if management changes.
3.4 Barriers to building partnerships and overcoming these
There are numerous barriers to building partnerships in health services and these have prevented the overall engagement strategy being successful. Barriers include:
So to engage our medical staff, we first need to engage our executive managements and have them acknowledge that the key to success is building a partnership. We need our non doctor management colleagues to admit that a good health organisation cannot become an outstanding health organisation unless doctors are fully involved. We need to include in this that getting doctors invested in the success of the health service will impact on the bottom line. There needs to be a genuine effort to get to know medical staff as people and to respect them not just for their professional expertise but for the other qualities and skills that they can bring to a health service. Individuals will all bring something different and management will not know what this is unless they build the relationship and find out. This needs to be a genuine effort and it needs to be ongoing, respectful and consistent. It needs to involve listening to medical staff’s views and being prepared to be flexible. Over time, this will be repaid by the medical staff as partnerships are built and medical staff invest emotionally and intellectually in the organisation’s future.
The time and investment needed on both sides to strengthen relationships, particularly by executive management which has the most to lose if doctors are not on board. Meeting organisational goals is more difficult without doctor involvement
The rapid turnover of executive management in many health service organisations, so that if even if the process begins, it becomes fragmented as relationships need to start from scratch again at regular intervals
A lack of understanding by management that to initially engage doctors, a clear value proposition of “what’s in it for me” needs to be developed. There is no overriding need for doctors to get involved in non-clinical activities as they can still look after their patients competently without this. Indeed, getting involved means taking time that they could spend on direct patient care
The laissez faire way that we orientate senior doctors to our health services, which confirms to them that all we want from them is that they do the task that they were employed for. Even then, we rarely define the task well and assume that they know what is needed. We take a lot of time ensuring that they are fit and proper professionals to work in our health service, but no time to really integrate them into the health service and make them feel valued participants in care and service delivery.
In parallel with this, medical staff need to be treated like all other staff in relation to orientation to and integration with the health service at the time of initial employment and throughout their employment. This will require Medical Administration to work with department and divisional heads to develop systems that support senior doctors to feel part of the whole health service and to find discretionary time for contributing outside their hands on professional tasks. Developing these systems at grass roots level, will act as a protective mechanism where changes in executive management occur and the partnership at this level needs to be rebuilt.
Like any other investment in business, the strategy needs to clearly define outcomes, be carefully planned, comprehensively implemented and continuously evaluated. Like any other business strategy that is worthwhile, development and implementation will be challenging and time consuming with many hairpin bends along the road that will need to be carefully negotiated. However, without executive management taking the lead, partnerships will never be built. In Australia the influence of health service FRACMAs is key to ensuring that at executive management will understand why building partnerships with doctors is so important and what are the best ways and means to achieve success in this.
So if we really want to get the best out of medical staff in health services, we need to change the language that we use. We need to stop talking about engagement with its connotations of a one way process and work on developing, implementing and nurturing partnerships based on mutual respect and trust between those who lead health services strategy and the doctors who deliver key services to patients.
4. Making the transition from clinician to clinician manager and leader
4.1 Clinician values and professional expectations
Building partnerships is one side of the equation. The other side relates to understanding what leads to medical staff being perceived to be “difficult to manage”. This goes back to understanding how doctors are trained and what values and professional expectations are instilled in them as make the journey from medical student to junior doctor to senior doctor. This also explains why the professionally trained medical manager has a distinct advantage when working with medical staff as he or she has had the same training and understands the impact of this on behaviour.
The differences between medical trained and other clinicians can be explained by an understanding of the 3 A’s of patient care:
Authority: Just becoming a doctor with its initials, is enough to have patients listen, and in general take whatever advice and treatment is offered with little if any argument or challenge. The doctor title immediately engenders trust in a patient that the doctor has their best interests at heart and therefore their management plan is acceptable. This authority is much more than for any health professional and in fact, it is almost always the doctor who devises the plan of care that provides the blueprint for all other professionals to follow or at least fit in with.
Autonomy: doctors often don’t need anyone else to become involved in looking after individual patients. They develop a management plan which is unchallenged and unless the patient comes to hospital, it is likely that no-one else will be involved with their patient. They have absolute autonomy in this area. This can become a problem if a patient needs more comprehensive care, second opinions or another medical specialist as not all doctors can overcome this autonomy to recognise that they do not have all of the answers.
Accountability: doctors in general feel very accountable to their patients and feel little accountability to anyone else. Their aim is to do the best for their patient in the area in which they have been trained and to advocate for the best treatment for their patient. Patients are considered as individuals and each patient deserves the best care. There is no consideration of the implications of this if for instance the best care for each patient is unaffordable for the community as a whole.
Understanding this training, can assist an organisation with the perspective of doctor behaviour and how it needs to assist doctors to behave differently once they are in management and leadership positions. Doctors in management and leadership positions need to make a mental transition if they are to become successful in these roles and to understand themselves and the 3 As implicitly.
Authority: a doctor in a management and leadership position is no longer regarded as having authority just because he or she is a doctor. Medical knowledge and skill do not lead to expertise in management. Staff do not take heed of what the manager needs to do unless it makes sense to them both as a strategy and in its implementation. In fact, others may ignore opinions, advice, orders and refuse to do what they are requested to do. Or they may agree to do things, but not follow through. They may be disrespectful and continuously challenge. This may be not only foreign to the doctor involved but upsetting and lead to inappropriate behaviour if there is no awareness and he or she does not have the skills to manage working with other people in this way.
Autonomy: instead of dealing with an individual, the manager and leader deals with individuals, groups, communities and diverse stakeholders all of whom work in systems and complex inter-relationships. Any decision is likely to have unexpected effects if the complexities are not carefully considered at the outset. In addition the clinician manager/ leader exercising autonomy in decision making is likely to damage relationships and trust with many stakeholders including colleagues and executive management.
Accountability: similar to authority the manager and leader has an extended range of accountability to individuals, groups, community and for systems. The stakeholders who are part of these accountability systems are diverse in nature and for patients, accountability is related to what can be done within a set of parameters for a group rather than the best for an individual. A doctor in a substantive position with leadership and management responsibilities will be held accountable for results, even when situations may conspire against being able to deliver. There may be ongoing pressure to deliver what seems impossible and these stresses need to be managed, often with no consideration for the clinical load that the doctor needs to manage at the same time.
4.2 Assisting doctors to make the transition
Awareness of the 3As can assist executive management of health organisations to understand why doctors appear difficult. In general, doctors will approach all problems with a clinician mindset. This means, they try to fix things themselves and to do this as quickly as possible, their solutions are usually simple as they often don’t consider systems and diverse stakeholders. They become upset if someone in executive management does not believe them about the seriousness of the problem, disagrees with their solution and wants to collect more data or consult more people and then take what seems inordinate amount of time to get to a solution, as this is not how it works in their own clinical practice.
Once a doctor does get into a leadership and management position, they find exactly the same frustrations working with their peers. Peers who might be very happy to seek and take their advice on a clinical issue, suddenly behave very differently when this advice relates to something that affects their work environment, service or hip pocket. The doctor leader and manager also needs to be able to unpick the 3As so that he or she can develop the skills to work with his or her peers in non-clinical situations.
All over the world it has been recognised that to get the best out of any person moving into management, specific knowledge and skills are required. More recently, it has been recognised that doctors taking up manager/ leader positions also require knowledge and skills and a multitude of courses have been developed specifically for this group. However, the mindset transition and the differences for the medical clinician have been to a large extent ignored. In fact the mindset transition relates very closely to the psychological aspects of change management and the work of Bridges2 can be effectively applied to this.
If we apply this to the medical clinician moving into a manager/leader position, then the first step needs to be the understanding of the change in mindset and the resultant behavioural changes that are essential in order to be successful in the role. Generally it is much easier for the new manager leader to understand the destination i.e. what needs to be done, but the difficulty is how to get there. How to get there requires not only the acquisition of the knowledge and skills provided by the multitude of courses available but also a clear understanding of oneself including values and professional expectations and an unlearning of clinical behavior when functioning in leader/manager situations.
“Change is situational: new site/ new boss/ new team role/new policy”
“Transition is the psychological process people go through to come to terms with new situations”
People responsible for planning and implementing change often forget the first task of change management is to understand the destination and how to get there.
The first task of transition management is to convince people to leave home.
As management involves getting things done through people and leadership involves influence, the approach to meeting goals set by the organisation must be understood at the outset. An understanding of medical values professional expectations will assist the clinician manager and leader in his or ability to influence medical peers to align with organisational goals. In addition an understanding of how medical values and professional expectations impact on their own behaviour will assist clinician manager/ leaders in their ability to work with and influence the other diverse non-medical stakeholders they will come into contact with. Likewise if executive management also has an understanding of this, building relationships will be easier to accomplish.
5.The way forward
All over the world the process has begun in that it has been recognised that for health service organisations to be successful, then medical clinicians need to be involved not just as people performing the task of patient care but assisting in developing strategy, improving quality, managing risks, becoming team players and assisting with cost containment. The path to achieving success through medical leadership and management however has many obstacles and not all of these have been recognised. In particular the ongoing role that needs to be played by executive management based on real understanding of and investment in its medical staff has not been well understood and therefore not sufficiently promoted. In addition, the term “engagement” has at times worked against this depth of understanding required by executive management as this seems to indicate that getting doctors involved is a task that can be completed rather than a long, arduous and continuing journey to a destination that is not necessarily fixed.
Where a true clinician leader and manager culture has been achieved, this is usually due to an enlightened executive management in a health service, with a focus on partnership with its medical staff based on mutual trust and respect and a continuing process of education and communication. In this type of organisation there is clear emotional and intellectual investment by all in the success of the health organisation as a whole, for patients, for staff and for the community in relation to patient care, service delivery and financial achievement.
Dr Lee Gruner
1 Rutledge T, Getting Engaged: The New Workplace Loyalty. Mattanie Press 2005
2 Bridges W. Managing Transitions 1995
The Royal Australasian College of Medical Administrators
Dr Lee Gruner, , p701