The story is told of the brash young physician who applied for an administrative position at the local hospital. Asked on the job application whether he was a team player, he confidently wrote in reply: "Yes--captain."
The comparison of the physician's role to that of the captain of a ship is a timeworn one. During medical training, for example, the senior attending gives orders that others either carry out or pass down the chain of command. The head nurse often plays the part of chief petty officer, ready to carry out orders or, if necessary, discreetly make suggestions as to how others (such as residents or students) might do so.
On closer inspection, however, the analogy springs a leak. While an individual doctor may have command authority in the office or as part of a surgical team, the number of individuals directly under his or her purview could fit comfortably into a moderately sized sailboat.
Richard Afable, M.D., executive vice president and chief medical officer of Catholic Health East, is trying to change that picture. As the cover story discusses in detail, Afable is recruiting physicians to oversee medical management and managed care for the system's hospitals. The position will require the kind of in-depth skills that distinguish senior-officer material.
These "Renaissance doctors" must have clinical experience, familiarity with business office functions, quality measurement expertise, general management training and a demonstrated ability to lead.
As in selecting naval captains, a record of real-world experience and savvy will be at least as important as paper credentials.
A key reason Afable is creating this high-profile job is his belief that managing the processes of care in a hospital has become even more important than managing the physical facilities. In the light of that change, a physician manager is uniquely suited to address the problem of important care process "inefficiencies."
Afable's use of the term "inefficiencies" has an interesting resonance. The same term was used some 90 years ago by another physician to justify the first hospitalwide outcomes management and reporting system. Boston surgeon Ernest Amory Codman argued that the "efficient" hospital was one that did a good job of curing patients. Measuring patient outcomes, he continued, was a kind of "inventory of the goods delivered."
This was very different from the hospital as physician workshop, where the implicit "product" is satisfied doctors.
For a while, it looked like Codman's ideas about clinical efficiency would become common practice. In New York City, for example, the Harvard Medical Society sponsored a joint meeting with local industrial management experts. More broadly, the regents of the American College of Surgeons sent a copy of a Codman-authored report on efficiency to every hospital in North America.
Unfortunately, the clinical efficiency initiative ran out of steam. One reason was the absence of an economic incentive for doctors and hospitals to measure their outcomes.
As Codman put it: "For whose interest is it to have the hospital efficient? Strangely enough, the answer is: No one . . . There is a difference between interest and duty. You do your duty if the work comes to you, but you do not go out of your way to get the work unless it is for your interest."
In the structure envisioned by Afable, there will be at least one powerful physician in every hospital whose interest, as well as duty, will include a commitment to clinical efficiency. Moreover, as the healthcare system as a whole evolves into one where performance measurement becomes the norm, Renaissance doctors can serve as navigators for other physicians who also wish to set the practice of medicine on a new course.
As important as their duties are, the new CHE physicians won't be CEOs. Having a physician at a hospital's helm was once common, but even putting a doctor in the top position provides no guarantee of success.
Most recently, one need only look at the much-publicized travails of William Kelly, M.D., and James Reinertsen, M.D. Each is a talented visionary with an abundance of street and book smarts.
Unsatisfactory financial results, however, caused the former to be pushed out of the University of Pennsylvania Health System and the latter to be relieved of command at Boston's CareGroup Healthcare System.
Still, for those who believe that the greatest challenge facing hospitals today is clinical transformation, bringing more doctors on board as leaders in the struggle has to be seen as good news.
"For the individual physician executive," says Afable, "this is a message of hope."
Michael L. Millenson is a longtime healthcare analyst and author.