Leadership and Medical Finance

A quick look at a newspaper will tell any doc just how important physician leadership has become, and increasingly so, in having a say in our economic futures. But our titular leaders are in a historically weak system complicated by being only one group of voices struggling to be heard in the rush to deal with national health care reform. There are many docs in title roles in our affinity groups working hard, but none are really positioned to be as effective as changing times require.

Why are our organizations weak? Primarily because our medical system is a hold over from the changes made after the Flexner report a century ago, and with roots long before that. Docs have always been selected and trained to be the Lone Ranger, practicing in splendid isolation, accountable only to our consciences, our patients, and in the last century, those pesky state license people. Just in the last 50 years have lawyers have been added to the list of accountability and in the last 25 years, managed care insurance companies. So the medical community has had only sub-optimal inclination to join or get involved and certainly not to surrender authority to any level of organization.

Our freedom to act and maintain our personal prerogative have been traditionally paramount. Thus our representative affinity/guild organizations (see my October 2009 column on this subject) have long existed largely to maintain the external status quo, primarily in a defensive posture. And they are losing ground.

Let's digress for a moment to identify what a leader can be, other than a title holder. There is the traditional role in medicine, where the grizzled veteran sliding towards retirement takes a victory lap with an honorific. He occupied a title, did what he could, but had no formative training, just like his peers, (my on-going theme/complaint/suggestion) and, because of the independent character of docs and their practices, had no real power to represent them and therefore to achieve much of substance.

One working definition of a true leader, by contrast, is someone who initiates and directs endeavors in the pursuit of consequence. Someone who acts, not holds, position; a change agent in pursuit of progress.

Real leaders tend to have high EQs, emotional intelligence, not just IQ. People who have a vision for their group, who can listen, who don't overreact in emotional situations by showing anger or defensiveness. He/she keeps a cool head in personal and group situations, not just medical ones. How does that square with the stereotypical grumpy doc who has a tantrum in the OR or openly gets mad at his office staff in public, or the opposite, just shuts down and becomes remote? We recognize more of the latter than the former, I'm afraid. But medicine selected us, and we selected medicine, both heavily leaning towards skills characterized by the numerized norms of IQ, not so much the softer, subjective interpersonal skills necessary to building and running a team.

Just like any human endeavor, everyone can benefit from training, but there are few natural leaders, born with talent, and molded by life experience, just like in any other human activity...the King Arthur/Excaliber thing. For example, in a quartet, how do you decide who sings tenor? The tenor does! It just helps if they have been trained. You tend to see this type of polished natural at the top, where, like cream, they rise.

The problem with this type of leadership is that there are scant few, especially in medicine, and we have need of many more at all levels. So we need to start training young docs to fill this newly rising, non-traditional role for physicians. You could also argue that every doc has leadership responsibilities right in his/her practice, whatever the size, aside from titled positions in organizations. So we all could benefit in a significant way from deliberate, focused training to lead, from the outset of our careers.

I have made this pitch to various titular leaders in medical training, but their attitude about concerns outside of immediate patient affairs is too often passive (or you could substitute "I'm too busy" or "It's not my job" or the like). This stance from our mentors not only makes the profession look even more out of touch, but abrogates the potential of our influencing in what direction our economic interests will go. Our focus lies here.

There are a profusion of medical organizations, with the consequent dilution of currently available strength and voice. We are not only not trained to be leaders, but there is a strong bias against being followers, too. So we have many not particularly representative voices clamoring in the din. But you can count on the fewer voices representing Big Pharma, Big Insurance etc, being well trained and speaking with powerful authority. Guess who dominates?

Look what happened to physicians' economic interests when managed care came in; being organizationally weak and acting largely as powerless individuals, we rolled. We weren't prepared personally or collectively to assert our leadership very effectively, and we still haven't done much to adjust at the basic intellectual level, even after the fact.

So, bottom line, we need to modify our training curricula to acknowledge the need for teamwork, leadership, and better business understanding. But we do not have the people or structure poised to get ourselves and the profession there. It's a paradox (double pun intended). Yet we must have these changes to stabilize our economic futures. Which, in turn, will impact and improve our ability to fulfill our mission of leading healthcare progress in our communities. Like it or not, they are directly related.

You know, sometimes I feel like my alma mater's (Dartmouth College) motto, Isaiah 40: "...a voice cries out in the wilderness...."