Physician, Lead Thyself!

It is funny to me that after all these years, there are still so many doctors who question whether they want to have a role in leadership or administration. Certainly, it was not part of the curriculum that was presented at my medical school, and hardly anyone goes to their medical school interview saying that they are applying to medical school to become a chief medical officer. Still, it seems odd because who doesn’t want to be named captain of their hockey team, or move up the ladder from mail room to CEO? Why are physicians any different from other professions?

A possible reason is that our training is scientific, clinical, and often fiercely independent. We are taught that we hold our patients’ health and lives in our hands and need to do everything we can to help them. We are told that we are the “captain of the ship” and that when we make a decision, we stand alone with it. Physician practice was historically a private enterprise with little oversight and tremendous individual autonomy. Many physicians today long for those days.

My viewpoint was changed in the course of studying for my master’s in public health, during which I learned about the reality of insurance companies, the moral hazard of physician and hospital payment systems, and the checks and balances that exist for the less scrupulous. That is when I first realized that physicians must participate in the administration of health care or risk becoming merely pawns in someone else’s strategies.

Health care is the juggernaut of this century. It consumes almost 20% of our gross domestic product, and in January of this year The Atlantic reported that health care has become the largest source of jobs in the United States.^[1] It is no wonder that it is highly regulated and that every year there are more challenges to the practice of medicine and the payments made for services. As more and more people claim pieces of the health care pie, payments to physicians shrink while the responsibilities, obligations, and expectations grow. This is not the time for physicians to step away from leadership roles in the house of medicine. No one else can speak for us nor articulate the challenges we face.

Leadership has many faces, and you can easily find one that suits your interests and availability. Are you new to medicine, or simply ready to lift the mantle of leadership? You can do so informally by tackling a common clinical conundrum for your department with a journal club. Alternatively, offer to review cases that have been identified as problematic or work with another department to define best practices for shared patients—maybe you can be the one to define a smooth pathway for admission of patients with hip fractures! If policy is an interest of yours, consider working with your local congressperson, city, or county public health board on health care issues. Join a bylaws revision committee at your hospital, and craft rules that affect hundreds of your colleagues while educating yourself about the terms that govern your practice. Offer to guide your group through the MIPS/MACRA maze that governs the CMS pay-for-performance plan and learn about quality measures while earning yourself and your group your fair share of Medicare payments.

For a formal leadership route, join the medical executive team of your hospital by running for office or becoming chair of your department. Most bylaws allow for vice-chairs or section chiefs if you want to test the waters. Almost every hospital has a peer review committee and a quality department. You can be the quality lead for your department, the electronic health record super-user, or the formally designated “new products and equipment” go-to. There is a leadership position for just about every interest that you could have in medicine, and it will give you control over your practice and more happiness in your clinical work.

Formal leadership roles, like medical staff president or department chair, will open doorways into the administrative side of medicine and hopefully whet your appetite for these positions. Having physicians lead health care organizations is essential to the survival of our profession. As department chair, your life will involve some of the more painful and thankless tasks, like responding to complaints, but even these provide insights. As chair, you will be able to build the department of your dreams by hiring the right people and ensuring they have a smooth transition. Your collegial conversations that have crossed a line reveal the fragility of your colleagues and are humbling experiences. You get to be tested and grow in character and charisma.

If you move on from the medical staff to the administrative side as a physician executive or chief medical officer, the burden of responsibility shifts dramatically. No longer do you advocate solely for the physician or the patient, but you must also consider the health of the hospital as an organization and any corporate directives if you are part of a larger health care system. Riding this line can be difficult, so it becomes even more important that the physician in this position acts in a fair, consistent, and honorable fashion. The larger the organization, the more important it is that the physician in the role of chief medical or chief clinical officer maintains their connection with the practice of medicine and their relationships with physicians.

The physician-patient relationship is a sacred one, and our leadership within the business of medicine is essential to the survival of our profession and for the best care of patients. As emergency physicians, our relationship with other physicians and the hospital gives us a broad perspective and we are well-represented in hospital administrative positions across the country. We are uniquely skilled to hold leadership and executive positions, and our work schedule is such that it is easy to carve out time to build our skill set in as small or as large a way as we want.

Working in quality is what drew me into my leadership roles, as I have been fascinated by the question of why it is that any single patient with the same presentation would have a different evaluation and treatment depending on which physician they see when they come into my department, and even sometimes between visits with the same physician. While I have not solved that conundrum, those type of questions formed the tractor beam that pulled me into full time administration. I never stopped enjoying the practice of emergency medicine, but I did not enjoy working within dysfunctional health care systems. My goal as CMO is to help more patients have better outcomes by advocating for both patients and physicians alike, by creating policies and procedures that make sense and support the practice of high quality medicine, and by being fair in the inevitable conflicts that arise.

I hope by now you are convinced that not only can you be a leader, but you want to become a leader in emergency medicine. You will be in service of both your patients and your colleagues. Being a part of the solutions at your hospital will lessen the feeling that you are simply another cog in its machinery. The right leader can move mountains. Be that mountain-mover and lead the change that is still desperately needed within health care!

[1] Thompson D. Health care just became the US’s largest employer. The Atlantic January 9, 2018. Learn More - Accessed October 14, 2019.

By Keri Gardner, MD, MPH, FACEP