Several years ago, an article appeared in the journal, Physician Executive, with the title, "Caducean Ceiling" Blocks Docs from CEO Posts. The article suggested that, like the more commonly described (and real) "glass ceiling" that female executives face, there are unseen organizational barriers and biases that prevent physicians from being hired or even considered as candidates for top executive positions in hospitals. The article goes on to cite statistics showing that the number of physicians in hospital CEO positions has declined by more than 70% between 1972 and 2002, when the article was written. Juxtaposed with the statistics that show that hospitals that are led by physicians or nurses tend to perform better, both from a quality of care standpoint as well as a financial standpoint, one has to ask why there is such a thing as a "Caducean Ceiling."
There is a common perception that physicians and hospital administrators just don't get along - and there is a certain amount of truth to this perception. Almost every health care administration book that I have read (and I've read a number of them) has a chapter on how administrators can get along with physicians. There's a countless number of journal articles on how to "bridge the gap" between a hospital's leadership and medical staff, and this particular topic is almost always covered at health care administration conferences. But why is there such a disconnect between physicians and administrators? Why can't the "white coats" get along with the "blue suits" and vice versa? Bias, both implicit and explicit, plays a major role here.
Larry Mathis, former CEO of the Methodist Healthcare System in Houston, Texas, wrote a book about health care leadership following his retirement in 1997 - the book is called "The Mathis Maxims: Lessons in Leadership." One of his maxims states simply the following: "Physician executive: an oxymoron." Wow. If that's not bad enough, his rationale is even more offensive.
"There's nothing in a physician's education and training that qualifies him to become a leader. And that's what executives are - leaders, persuaders, team builders, communicators, and organizers."
Mathis goes on to explain, "The physician is challenged throughout his education and training to be an outstanding individual performer. But leadership is not an individual action. It's a participatory process."
While continuing to discount the fact that women can be physicians too, Mathis finishes, "I respect and admire physicians. They are consummate professionals, the best and the brightest of the best and brightest. But when they leave the confines of medicine, they can be a danger to themselves and others."
"A danger to themselves and others..." Larry, Larry, Larry. Unfortunately, this kind of thinking is not uncommon. Physicians - even those who have gone on to pursue additional education and training in business - continue to be pushed aside and have their opinions discounted when it comes to the non-clinical aspects of our modern health care industry, such as marketing, finance, and strategy. I wish that I could say that my experience has been different, but I can't.
During my professional career, I have been told that there's no way that I, as a physician, could write up a legitimate business plan (just for the record, there's very little difference between a formalized business plan and a research grant proposal). I have been told, more than once, that there's no reason that I need to attend certain meetings because they were "all about finance." I have even been told that physicians just don't understand the business aspects of health care. While it may be true that I don't have the level of experience that my administrative counterparts have when it comes to finance, strategy, and marketing, I could argue that I have a much greater understanding for taking care of patients than they will ever have. The simple fact is that they will never take care of a patient. While I can learn finance, marketing, strategy, and operations, they can’t learn to take care of patients at the bedside (not to say that they aren’t capable of learning to be able to do so, it’s a simple matter of being legally prohibited from doing so).
It's frustrating, but my experience tells me that the so-called "Caducean Ceiling" is still prevalent. Health care administrators are missing out on an incredible opportunity here. Clinicians (I use that word instead of "physician" as I firmly believe that nurses and allied health professionals should be strongly considered for executive-level leadership positions in hospitals too) have a unique perspective on the business of health care - it is a business, but the fundamental purpose of health care should be (and is) taking care of patients. At the very least, clinicians should be involved in leading any health care organization whose mission is truly focused on patient care.
I am reading a book right now by Carson Dye and Jacque Sokolov called, "Developing Physician Leaders for Successful Clinical Integration", which is published by the American College of Healthcare Executives. Dye and Sokolov specifically call out the difference between "physician involvement" and "physician input" - it's an important distinction:
Physician involvement means:
1. Physicians are always at decision-making meetings.
2. Physicians are viewed as partners.
3. Executive leadership sees physicians as aligned.
4. Physician involvement is ongoing.
5. Physicians remain in the process.
6. Seeing physicians at the table is common.
Physician input, on the other hand, means:
1. Physicians are always invited.
2. Physicians are viewed as tokens.
3. Executive leadership seeks alignment from physicians.
4. Physician input is sporadic.
5. Physicians are occasional players.
6. Seeing physicians at the table is rare.
Far too many health care organizations focus on seeking clinician (again, physicians, nurses, and allied health professionals) input, when what really matters (and what will transform health care) is clinician involvement. There is no place in today's health care for the opinions and beliefs that Larry Mathis shared. The relationship between clinicians and health care administrators needs to be collaborative, and it needs to be based on trust, mutual respect, and a shared understanding of what it means to be in the business of patient care. We can do better. We have to do better. Our patients deserve it.
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