My Twitter profile used to state that I was a physician first and health care administrator second. I don't mean to be controversial or offensive here, I am proud of what I have accomplished both as a physician and as an administrator. However, I've devoted a lot of time and energy into my education and training to become a physician (four years of medical school, three years of residency, and three years of fellowship training). I've been a physician much longer than I have been a health care administrator. So, while I identify with both groups, I self-identify as a physician first and foremost.
Social identity theory states that individuals categorize both themselves and others into different groupings based upon their social identity. A person's sense of identity ("who they are") is based upon their group membership. Identification with a group incites loyalty to that group. It may even inspire competitive (and unfortunately, at times discriminatory) behavior towards individuals who are not part of the group.
Building upon what I described above, I self-identify as a physician and as a health care administrator. I also self-identify as a pediatrician (based upon my residency training and ongoing professional certification) and as a pediatric intensivist (again, based upon my fellowship training and ongoing professional certification). If you take a close look at my professional network, most of my colleagues and collaborators are also pediatric intensivists. Therefore, if I were to rank my social identity, at least from a professional standpoint, I would classify my identity in the following order:
1. Pediatric intensivist
2. Pediatrician
3. Physician
4. Health care administrator
I do wonder if most physicians who hold administrative positions would self-identify as a health care administrator. Several studies have noted that physicians and health care administrators don't always see eye to eye. Physicians, as a group, often view administrators through a lens of distrust, often perceiving that administrators place financial considerations over patient care. For this reason alone, I suspect that some of us would rather identify as a physician executive. Not all health care administrators are physicians, and many, if not most, health care administrators don't have a clinical background.
Studies suggest that when physicians move into administrative leadership roles, they may lose some of their sense of identity as physicians. It is with this in mind that I wanted to talk about a recent study published in the Journal of Healthcare Management ("Engaging physicians in leadership: Motivations, challenges, and identity-based considerations"). The investigators interviewed 27 physician leaders to determine why they chose an administrative position, how they experienced their roles as leaders, and what challenges they faced as physician leaders. The findings of this study are not necessarily new and have been reported elsewhere. Regardless, the investigators highlight important issues that deserve a broader discussion.
Of the 27 physicians interviewed, the majority (17/27, or 63%) were medical directors, directors, or C-suite level executives. When the interviews were analyzed further, four main themes emerged. First, the physicians stated that they accepted their leadership roles out of a desire to make a necessary change that would benefit patient care. Several physicians voiced frustration with the status quo, and rather than ignore or complain about the problem, they chose to be part of the solution. As one physician stated during the interview, "I can't stand it when I see things not running the way they should. I'd rather participate than grumble. I'd rather take a leap." Another physician said, "I couldn't stop because I felt I had a point and I needed to fix this problem." Importantly, all of these sentiments are consistent with the more general motivation of practicing medicine - that is to help and serve patients.
The physicians also expressed a desire for professional growth and development (second theme). However, the majority also felt that "learning the ropes" of an administrative or leadership position was not easy, and juggling clinical practice with administrative responsibilities took a lot of time and effort. As one physician stated, "I think my life would be smoother and easier if I had chosen to just be a pure clinician." Unfortunately, a number of studies have revealed similar findings. Moving into an administrative role requires a commitment to learn a different and additional discipline, and whether that occurs through graduate-level coursework or "on the job" training, it takes time and effort.
The third and perhaps most important theme centered around the difficulties with transitioning from being a pure clinician to a physician/administrator. Most of the physicians surveyed still maintained a clinical practice, but those who did not expressed the sentiment of missing patient care. These physicians often felt lost in their new role, particularly during the initial transition, and most felt that their relationships with colleagues changed. Both the research and my own anecdotal experience has found that when physicians accept an administrative role, colleagues often say that they have "gone to the dark side" or "exchanged the white lab coat for a dark blue suit." One of the physicians was told by a colleague, "It's like you're no longer a real doctor." This is of course unfortunate - our physician colleagues should recognize the value of having a clinical person in a hospital leadership position. Perhaps we need to do a better job of demonstrating our value to both the business side and the clinical side?
The fourth theme was related to the third and dealt with the change in identity associated with a change in professional responsibilities. Most of the physicians surveyed felt that taking on a leadership role changed the way that they perceived themselves as professionals. One physician stated, "I think it [identity] took a hit. There's nobility and there's status of being a physician...that I had to give up."
There's another important point that the investigators didn't mention that is related to the their third theme. Physicians in administrative roles often find themselves in a strange middle ground where their physician colleagues feel that they are no longer true physicians (they've "gone to the dark side"), but they are not fully accepted by their administrative colleagues either. Recall my earlier discussion on social identity theory, when I stated that one's social identity inspires both loyalty to the in group and competition with the out group. Physician administrators often find themselves caught in the middle of this loyalty/competition (for more discussion on this topic, see the articles "The Paradox of Legitimacy: Physician Executives and the Practice of Medicine" and "Physicians as Executives: Boon or Boondoggle?").
There is a growing body of evidence that suggests that hospitals perform better, both from a quality of care standpoint as well as a financial standpoint, when they are led by physicians and nurses. Our nursing colleagues seem to have figured out the transition from clinical practice to administrative leadership, at least in my opinion. Regardless, we can certainly learn from their experience. Given all of the issues presented above, we clearly need a better and more defined pathway for physicians who want to make a difference and choose to become administrators. I like to call it the "Wards to Boards" pathway.
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