As a hospital administrator for most of his professional life, C. Kevin Goodwin was enjoying another career milestone in the spring of 2001, when he was promoted to vice president of clinical services at St. Joseph's Regional Medical Center in Milwaukee. But less than four years later, Goodwin decided to make a dramatic midcareer change after growing disillusioned with the sometimes harsh economic realities of the U.S. hospital industry.
So long, hospitals
He bid adieu to hospitals and moved to a job as executive director of Radiology Associates, a 21-doctor medical practice in the Milwaukee suburb of Wauwatosa -- not too far from his old office at St. Joseph's.
The new business environment isn't exactly a bed of roses, Goodwin says, but it's a lot more comfortable than the tough and often unforgiving business climate at many acute-care hospitals. He finally had had enough when St. Joseph's underwent a series of layoffs and job consolidations that involved about 200 full-time positions, some eliminated entirely, after the system failed to reach certain operational benchmarks, Goodwin recalls.
"As a hospital administrator, your life involves having to deal with less money and increasing expenses -- it just becomes a real grind," says Goodwin, who began his hospital career in 1988 in strategic planning with St. Bernardine Medical Center in San Bernardino, Calif. "When the (cardiology group) approached me and asked me if I was interested in running the practice, I told them at first that I wasn't. I was a hospital guy, after all. I'd worked my entire career to be a hospital operations person.
"But you can only lay off hundreds of people for so long" before it takes a toll on you, Goodwin adds.
Goodwin's professional transformation is far from unique. Many healthcare executives have made the transition from hospitals to one of the estimated 20,000 group practices across the nation. No one is certain how many have made this career change, or whether the number exceeds those who are moving in the opposite direction, but anecdotal evidence suggests that it has occurred with more frequency in the past year, perhaps as a result of the growing financial pressures hospitals are facing, among myriad reasons.
"I think there are more hospital administrators who are realizing there is a career opportunity in medical practices," says William Jessee, president and chief executive officer of the Medical Group Management Association, whose 20,000-plus members represent about 12,000 groups, most of them smaller practices. "It's becoming a much more challenging job that's attracting a lot of top professionals."
Until recently, some outsiders considered the job of a group-practice administrator to be little more than that of a glorified office clerk. That stereotype has receded rapidly, giving way to the reality of a complex job that requires all the skills of a top hospital administrator -- or more. Jessee, who might be a little biased, thinks that practice administrators need "a broader skill set and more depth in more areas than hospital administrators."
"A group-practice administrator may have five or six areas he's responsible for," Jessee says. "The hospital guy can be more of a high-level generalist. And when you get into group-practice administration, you generally don't have the depth of staff to support you. So you have to have both in-depth knowledge and very broad knowledge. A lot of hospital people find it shocking how much they don't know when they get into medical-group practices."
Why do executives suddenly relinquish long, successful careers in hospitals? Some are seeking a little more independence -- the chance to run the entire show -- even if it typically means becoming a big fish in a smaller pond. In some cases, especially with high-margin operations such as orthopedics and cardiology, group practices can provide better salaries and overall benefits. Others who have made the switch to the world of group-practice management are looking for refuge from the many headaches so often associated with the job of running big, complex institutions like hospitals.
To some recent converts, the differences are pretty stark, especially in size and scope.
"The best analogy I can provide is that it's the difference between the Titanic and a small sailboat," says Michael Fuselier, an erstwhile hospital executive who is administrator of Anesthesiology and Pain Consultants, a nine-physician group practice in Lafayette, La. "It may not be easier working in a group-practice setting, but it's different. The dynamics of management are very different. Decisions are made quicker. You deal with strategic-planning issues more quickly."
Fuselier, a registered nurse who is a fellow of the American College of Healthcare Executives, joined the group practice in March after 2½ years as CEO of Vermilion Hospital, a 52-bed acute-care psychiatric hospital in Lafayette. As a former nurse, he lamented that a top job in hospital administration often meant lots of bureaucracy, meetings and paperwork -- a mix that prevented him from spending more time "on the floor" dealing with patients and clinical professionals.
"When you're administering the operations of a hospital, you tend to be further removed from where the care actually occurs," he says. "Your interaction with patients becomes very limited."
Jan Hundley, who has spent the past 10 years as administrator of the orthopedic surgery department at the University of Arkansas for Medical Sciences, Little Rock, provided another good reason for making the switch: government bureaucracy. She left state government earlier this month, becoming chief operating officer of the 14-physician Arkansas Otolaryngology Center. She notes that bureaucracy was only one factor in her decision.
"I've had to deal with layers of bureaucracy for a long time," Hundley says. "You always had to get lots of approvals for doing anything, fill out certain state forms. Out there (in the private arena), if you decide you want to hire someone and you can find the money, you just do it. I'm excited to see how the world of private practice operates."
Of course, coping with demanding doctors and the various complications of even a modestly sized group practice can present its own state of tension and trauma, says former hospital administrator Mykl Garrett, who began his career as the assistant director of pharmacy services at St. Joseph Medical Center in Bloomington, Ill. Like so many of his colleagues, Garrett slowly moved up through the ranks in a series of jobs at several hospitals, finally rising to COO of Phoenix Memorial Hospital, an acute-care facility affiliated with Nashville-based Vanguard Health Systems.
Yet after almost two decades in hospitals, Garrett underwent his professional rebirth less than a year ago, when he moved from the comfortable familiarity of hospital administration to the foreign terrain of group-practice management, taking a job as CEO of Tri-City Cardiology Consultants in Mesa, Ariz.
Now, after just 11 months in his new job, Garrett -- another ACHE fellow who left that group's traditional fold -- says the weight of his responsibilities hasn't eased much since the transition. In fact, he feels more accountable than ever before because he is the one making almost all of the key decisions. Unlike the multilayered bureaucracies of large hospitals and healthcare systems, many group practices, particularly smaller ones, subsist with a slimmed-down organizational chart that often features only one highlighted name: that of the top administrator.
"This job has added pressure because the decisions I make directly affect the livelihood of my physicians," Garrett says. "It's not the same as working for a large company where you don't have daily contact with the owners or investors. It makes the risks considered in each decision much more real and significant."
Despite the added pressure, Garrett says he's happy with his decision.
As far as Fuselier is concerned, his new job isn't necessarily more challenging than a similar administrative post in a hospital -- it just takes more of his time. "I wouldn't say it's tougher," he says. "It's more demanding from a time standpoint, just by nature of the operation."
If hospital administrators are wearing a hole in the carpet as they move to group practices, the same thing may be happening in the other direction, Jessee says. "I see movement the other way, too," he says. "More hospitals are starting to hire practice administrators because they bring a skill set that hospitals find useful."
For his part, Don Fisher, president and CEO of the American Medical Group Association, which represents most of the nation's large group practices, says it's logical that the world of hospital administration seems to have such a close connection to practice management. In some cases, Fisher says, the two are almost interchangeable. Indeed, many of the MGMA's larger members are medical groups that encompass entire integrated hospital systems, including well-known names such as the Cleveland Clinic and the Mayo Clinic.
"The demarcation line between hospitals and medical groups will become even more blurred in the future," Fisher says. "It just makes sense."
Yet some long-entrenched hospital administrators look down on those who have left their ranks for the world of group-practice administration, Fuselier says. He recalls attending a recent ACHE-sponsored executive program at which he was the only individual in the audience who was not employed by a hospital. When Fuselier identified himself as a group-practice administrator, he says, he was surprised at the moderator's sarcastic references to his transition.
"He frequently made the comment that I had switched to the `dark side,' " Fuselier recalls with a chuckle. "And that, I think, is one of the tacit, unspoken beliefs that are held throughout hospital administration. It's unfortunate that in some facilities, hospital administrators and physicians are almost adversaries. In my case, we're collaborative."
"Under current reimbursement methodologies, the hospital administrator's primary reason for being is to cut costs or control costs," he says. "For the physicians, their key concern is the quality of care. And so you're put in that adversarial relationship."
For Goodwin and his new employers at Radiology Associates, the definition of "dark side" is completely different from the one presented by the ACHE moderator. The doctors in his group, Goodwin says, jokingly refer to him as a "recovering hospital administrator" who came to them from the "dark side" -- the big, bad hospital industry.
In fact, at the time he was considering moving to the radiology group, Goodwin was simultaneously mulling over an offer of the top administrative job at an acute-care hospital about an hour's drive north of Milwaukee. Even with the chance to "run his own shop," Goodwin says, he opted to remain in Milwaukee and make the pivotal switch to the group-practice environment.
"The reality," Goodwin says, "is that life (as a group-practice administrator) is much more controllable, reasonable. The lifestyle is just better. I would never go back to hospitals."
He also points out that the job of a group-practice administrator is more "hands-on" than the often detached role of a top hospital administrator, and that the job allows him to use every skill he has developed over a long career in healthcare. "Business skills, operations skills, political skills -- they're all so important," he says. "Especially the political skills. You really need that to gain consensus in a group of doctors."
While the multifaceted role of a top hospital executive is often markedly different from that of a group-practice administrator, the two roles do require many of the same proficiencies in areas such as leadership, communication and financial acumen, says Deborah Bowen, executive vice president and COO of the ACHE. She notes that there is an "amazing amount of similarity" in the competencies outlined by the Healthcare Leadership Alliance, an association that includes the ACHE, the MGMA, the American College of Physician Executives and the Healthcare Information and Management Systems Society, among others.
"There's a kinship there in skill sets," Bowen says. "First, there are the more intangible things: Communications and relationship management. Clearly, they're critical no matter what setting you're in. And leadership. How do you not only motivate and organize a vision, but also measure performance? Of course, there's also the knowledge of the healthcare environment, responsibility to patients and the community, business skills and a commitment to lifelong learning. There's quite a bit of synergy across the professions."
With all of those complicated issues, the top jobs in big hospitals have often been described as among the most demanding and difficult in corporate America, according to some longtime industry observers. So, which job is tougher -- hospital executive or group-practice administrator?
"I don't know that either is very easy," Bowen says. "Healthcare is stressful and healthcare-executive jobs are stressful across all settings. We're all dealing with problems of the uninsured, reimbursement levels, malpractice insurance, workforce shortages. I wouldn't consider people working in multispecialty groups to be on easy street. It's tough all over."
One of the most difficult roles in either job, of course, might be dealing on a day-to-day basis with healthcare's most unrelenting taskmaster -- the physician.
Now firmly settled into his new career at Tri-City Cardiology, Garrett says the key difference between the two milieus is meeting the lofty expectations of his 13 bosses -- the independent physicians who own the group practice and collectively sign his paycheck. The scrutiny from these exacting professionals makes the job of group-practice administrator very difficult at times, he says. He's the human lightning rod, accountable for all aspects of the business -- everything from finance and contracting to human resources and long-term planning. In other words, if things go wrong, the bosses know precisely where to turn to vent.
"The biggest transition issue is what I call the Tri-City paradox," Garrett says. "It's where you have a group of doctors who want all the advantages of a group practice, but they also want to practice autonomously. My job is to get them to consensus. That's the hardest part. This is the toughest job I've ever had."
Garrett says that "managing relationships," particularly those involving physicians, takes about twice as much time now as it did when he worked in hospitals. "I think, for that reason, it's a lot tougher job," Garrett says.
Indeed, coping with tough-minded doctor-bosses is likely the most important job of all for a group-practice administrator, observers note.
"Obviously, if you're not successful dealing with doctors, you won't be a practice administrator for very long," says the MGMA's Jessee, who, as a physician himself, should know.
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