I will occasionally listen to XM Radio's "Radio Classics" on the drive to and from work - one of my favorite shows is "Doctor Kildare", which aired from 1949 to 1951 and starred Lew Ayres in the title role as Dr. James "Jimmy" Kildare and Lionel Barrymore as his mentor, colleague, and friend, Dr. Gillespie (you will likely recognize Barrymore as the villainous Mr. Potter in the Christmas classic, "It's a Wonderful Life"). The radio show was based upon characters created in the 1930's by the author Max Brand (a pen name). Over the years, the same characters have been used in a novel, several movies (starring both Lew Ayres and Lionel Barrymore), a comic strip, comic book, a 1960 television series (starring the actor, Richard Chamberlain), and a short-lived and relatively unsuccessful 1970 television series. One of the recurring themes in all of the stories is the relationship between the physicians and the hospital administrator, Dr. Carew.
Last night, I listened to an episode "Benjamin Barkley", which originally aired on February 15, 1950. In this episode, Dr. Gillespie is sick and unable to care for one of his frequent patients, an elderly (presumably) and wealthy patient named Benjamin Barkley. Barkley presents with abdominal pain, fever, and an elevated white blood cell count, and Dr. Kildare makes the diagnosis of acute appendicitis. Barkley refuses to undergo surgery, and of course asks to speak to the hospital administrator, Dr. Carew. The first half of the episode calls to mind the issue of the "VIP patient" (see my previous blog post, "Every one of my patients is a VIP"), as Barkley demands special treatment because of his status as a wealthy patient who personally knows the hospital administrator. I don't want to focus on "VIP patients" today. Rather, I was interested in the recurring theme on the relationship between the physicians and the administrators, which was further highlighted in this episode.
The relationship between the medical staff and hospital administration is an important one, but it is not always a good one. There are countless articles in trade journals and chapters in textbooks on health care administration about how to build better relationships between physicians and hospital administrators. One would think that administrators and physicians mix like oil and water (i.e., they don't). One proposed solution is for physicians to assume a greater leadership role in hospitals by becoming administrators. I have certainly written about this issue in previous blog posts. However, at least in the case of Dr. Kildare's hospital, having a physician-administrator (in this case, Dr. Carew) doesn't necessarily help.
There are just as many articles and textbook chapters about how physician-administrators can help bridge the divide between the medical staff and hospital administration. Considering the case of Dr. Kildare and other, real-world examples, this is not always a successful solution to the problem either. Most physician-administrators will tell you stories about how colleagues told them that they were "going to the other side" or "becoming a suit" when they became physician-administrators. Personally, I have never been told that, though to be honest I continue to treat patients in the hospital on a relatively frequent basis, and I suspect that helps. However, if I were to be completely honest, there are times when I feel that I am caught somewhere in the middle - I am not necessarily viewed as an administrator, nor am I considered as one of the physicians.
I raise all of these points in light of an article I recently came across entitled "First and foremost, physicians: the clinical versus leadership identities of physician leaders". The authors of this article conducted a series of interviews with 25 physicians from 4 different hospitals (though all 4 hospitals were from the same larger health care organization). Approximately half of the physicians were full-time administrators and were not actively practicing medicine, while the remaining half were part-time administrators. The latter group held different leadership positions within the hospital - Medical Director, Head of a service line, etc and maintained an active clinical practice as well. The study's findings were incredibly thought-provoking and highly relevant to the current discussion:
1. All physician-administrators (whether full-time administrators who were not actively practicing medicine or part-time administrators who were) self-identified as physicians first and administrators second.
2. Physician-administrators in a part-time role (e.g., Medical Directors, Heads of service lines) subjugated their leadership roles and prioritized their roles as physicians to the point that they created a self-fulfilling prophecy. Typical statements included, "What am I? Vice-something..." or "It's really not that big of a role" or "I have a nominal title of executive director, but I am not really sure what that means." These part-time physician-administrators claimed that they were motivated to advance organizational priorities and goals but were reluctant to address issues that were not fully supported by their medical staff colleagues.
3. While full-time physician-administrators felt supported (and respected) for their leadership role, part-time physician-administrators did not. In most cases, part-time physician-administrators did not receive protected time or additional compensation for their leadership role. Hence, they often felt that their colleagues were "picking up the slack" when their leadership responsibilities took them away from their clinical duties.
I can think of a couple of potential solutions to some of the issues identified in this particular study. First, I think it is important that full-time physician administrators spend at least a portion of their time in active clinical practice. If these physician-administrators are going to bridge the gap between the medical staff and hospital administration, they need to spend time in both worlds. Maintaining an active clinical practice builds trust, establishes credibility, and will help assure mutual respect for the roles that the different sides of the organization play. Second, leadership training is critically important, especially for part-time physician-administrators. Being a good physician does not mean that you will be a good leader and manager (being a successful administrator requires both). Third, part-time physician administrators need to be provided protected time to devote to their administrative duties and recognized throughout the organization for the important role that they play.
We can certainly learn a lot from Dr. Kildare. Oh, and by the way, in the end, things turned out just fine for Mr. Barkley. Dr. Kildare removed his inflamed appendix, and everyone was happy by the end of the episode!
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