Clinicians in Management

• Introduction
• 14 (+1) Truths About Medical Management
• References

Introduction

I have spent the majority of the last 15 years of my life thinking about the role of clinicians, particularly doctors, in the management of health care and working with individuals who choose to take on that role. What follows is an attempt to find, from my reading and listening over those years, emergent themes about medical management. In some cases, academics have developed and put forward framework models for medical management, which I have observed in practice; in some cases, issues of practice have become clearly defined and crystallised and conceptualised as models. Whilst this paper contains some direct references and credits it nevertheless will inevitably fail to give appropriate credit for many of the ideas contained within it. To that extent the paper is really authored by the British Association of Medical Managers; but more particularly from that Association’s membership and extended family – that is the many doctors who somehow, within the narrow confines of 24 hours a day and 7 days a week, manage not only to develop and deliver clinical care of the highest standard, to engage with the health care system itself and play a role in its management and continue to have fulfilling and rewarding personal lives and relationships, but also seem to manage to always find time to talk to me about what they do. It is with respect that I dedicate this piece to them. I use the term "medical managers" throughout this paper to refer to doctors who engage in management, not those who manage doctors.

14 (+1) Truths About Medical Management

1. Medical management can be the best of both worlds
   Medical management is not doctors who manage, nor is it management conducted by doctors; it is, rather, the convergence of medical training, background, orientation and socialisation with the skills and knowledge of the management domain. Those educators who set out to train doctors to understand and participate in management are missing a trick. Management has as much to learn from medicine as medicine does from management. The most effective management technique I was ever taught came from medicine. One day, complaining about my in-tray, a doctor said to me "Why don’t you triage it?" This classic, robust and proven clinical technique is incredibly effective when applied to paperwork. A third is "dead" or unsaveable and needs to go in the wastepaper basket; a third is urgent and can, with immediate attention, be saved; and a third should be put to one side to see whether it "manages itself" or becomes more acute. Similarly, the well-embedded notion of medical audit – a cycle of action, reflection, change and review – is equally applicable to management and more managers need to become "reflective practitioners".
   
   
2. Once a doctor, always a doctor
   Some notable doctors have ceased to practice medicine and started to work full-time in management. Interestingly, however, a large percentage of these choose to remain registered as practitioners and, in some way at least, to maintain their medical skills. I am embarking on no great crusade that all medical managers should continue to practice medicine. But I do think they must remain members of the profession, and continue to work within a professional ethic and culture and to bring a professionalism to bear on their management role which is, perhaps sometimes sadly, lacking from mainstream management.
   
   
3. Medical managers are bilingual
   Both medical professionals and health care managers complain about the other group’s jargon. Jargon is no more and no less than an elaborate and convoluted acknowledgement of the special nature of each profession. It is sometimes said that the Eskimos have 33 words for snow – not surprising since snow plays such a central and important role in their lives. Their way of thinking about the environment is reflected in the very language that they use. To see management jargon (or indeed medical jargon), as purely common sense expressed in deliberately obscure terms is to miss the point – one needs to be able not only to speak and understand a language but to think in it, in the same way that a linguist living abroad may learn to think, to some extent at least, in their non-native language . Language’s nature and structure is such that it frames people’s thoughts, and so it is with both medical and management jargon.
   
   Medical managers need to be able to speak and think in both languages, and act as translators for others.
   
   
4. Stereotypes are not archetypes
   The profession of medicine is broad enough to accommodate all personality types. Some with a medical degree may choose to be general practitioners, others pathologists or anaesthetists and others surgeons. Indeed some may choose to be journalists or scientists. Health care managers however tend to be drawn from a narrower spectrum of the population, with some three of the sixteen Myers Briggs types very strongly represented amongst the full-time managers within health systems. (Winkless 1999). Medical managers should recognise that their own personality type may not be one with which most health care managers are familiar or comfortable or indeed see as part of a management community.
   
   The stereotypes, "doctors" and "managers" are not helpful. Nevertheless each group embraces a wide range of different personality types and medical managers need to recognise this.
   
   
5. Clash of paradigms
   Doctors bring an exciting and interesting perspective to management – that of the researcher. Doctors are professionally accustomed to looking for evidence and reviewing research and are skilled at reading research papers and taking views on the quality, robustness and rigour of research. What they sometime fail to recognise, however, is that they work within an essentially scientific paradigm where the randomised control trial is the "gold standard". The more cynical amongst doctors find it hard to accept that management has any sort of academic base, let alone that it has a robust, if young, academic tradition. The fact that there are more than 500 refereed scientific journals in management comes as a revelation to most doctors. They have difficulty sometimes, however, with the sociological research paradigm. Disciplines such as sociology, anthropology and psychology seem to them to be "soft" and lacking in rigour. Medical managers will need to understand the full range of research methodologies applied in such disciplines, and to be constructively critical of such research.
   
   
6. Learning about learning
   Doctors have generally had a very particular educational and socialisational experience. Competition to get into medical school is fierce and the academic environment is usually highly competitive. Many of the social rituals that doctors are involved in are based around this fierce competition and doctors pride themselves on their ability to "mug up" for an exam or otherwise learn in an intense fashion. They have, at least in the past, had less respect for learning through experience or engaging with a community of practice (Lave & Wenger, 1991). For most medical managers, ie doctors engaged in management, the key to development is to learn about learning; that is, to be able to consciously think about their own approach to learning, recognise their learning habits in this area and seek a wider range of learning techniques and opportunities. Doctors’ initial approach is to learn about management But while they have some simple skills to acquire in this area, the deeper issue is to learn about learning.
   
   
7. Doctors must improve their writing!
   Rather than a jibe at the supposedly poor handwriting skills of doctors, I am rather referring to a spectrum which, painted to the extreme, has at one end the doctor writing abbreviated truncated notes and at the other the manager (with a degree in classics) writing beautiful and lucid prose. Of course, the reality is much more variable and there are many doctors whose prose style is far better than that of their management colleagues. Nevertheless, there is an underlying grain of truth – much of clinical medicine and, in particular, the information shared between clinical professionals working in teams, is rendered in extreme coded brevity – not least for reasons of speed. By contrast, the management world seeks to convey complex and ambiguous ideas and much management "work" is done through the written (or electronic) word. Interestingly, the advent of electronic literacy and the increasing use of e-communication may reduce some of the verbosity typical of the lengthier management style. An author is less likely to render mellifluous prose when typing than when dictating into a machine!
   
   
8. It’s not just us and them!
   Any clinically trained medical practitioner who begins to take on management roles has a tendency to see a polarity between managers and their own clinical profession. Doctors in particular will talk about the doctors’ world and the managers’ world. Health care systems employ professionals from a wider variety of backgrounds than any other industrial area. Typically, any acute care hospital will have more than 50 different professionals working within it; each with their own professional society, codes of practice, registration and examinations. One of the characteristics of health care systems is the endemic tribalism that comes with such a professional mix. A key to having effective teams and to team building in this environment is for each group to develop a better understanding of all the other professions’ specific contribution and area of work. It is often illuminating to sit down with a doctor/nurse/physiotherapist/occupational therapist/optician and get them to describe what they believe the others do. Few will paint the full rich picture that the members of each profession would wish to hear. One of the interesting facts that follows from this is that any decision-making body anywhere, in any part of the health care system, is unlikely to contain an individual from each of the professional backgrounds. Nevertheless, decision-making groups must acknowledge and take account of professional perspectives and, therefore, many of their discussions will require either the involvement of specific professions or, at least, that those present have a clear understanding of those particular professions and their ways of working. Many of the problems of change in health care arise from one or other professional group feeling "left out", "ignored" or, worse, "misrepresented".
   
   
9. Rituals
   Mintzberg (1975) pointed out that a considerable element of what managers actually do is best described as "ritualistic". To those not conditioned and brought up within an area of practice such rituals always seem archaic and unnecessary. It is important as a doctor/manager to begin to think about the nature of and need for ritual. To a non-clinician much of what goes on in the operating theatre or indeed in a general practitioner’s practice appears ritualistic, as indeed it is. Nevertheless, there are often good reasons underpinning such ritual, not least so that people new to a particular location or group may still look for the certain basic commonality that they gained during their "apprenticeship". It is usually important to understand not just what the ritual is overtly about but also what it is covertly about; that is what value it actually has for those who participate in it. In the end, if it had no value to participants it would probably "wither on the vine". It is rare indeed for tradition to become so ossified and yet so compulsive that we find ourselves forever bound up in it, although as Mervyn Peake reminds us in Gormenghast, this can always happen!
   
   
10. Organisations live (and die)
    There are a variety of management views about organisations. Any organisation is made up of individuals and from some theoretical standpoints it seems inappropriate to look at organisations as other than clusters of individuals. Yet, in many ways, organisations do have lives of their own and, certainly, momentum. The story goes that, in the 1960s, the National Health Service (NHS) adopted a strategic planning model which was simply expressed as: "Where are we now, where do we want to get to and how will we get there?" This simplistic model neglected to consider, "and where is the momentum of the system currently taking us?" The in-built direction that an organisation has already adopted will require some form of correction if a change of course is agreed upon. The NHS in England has, not infrequently, been compared to a super tanker ; it is huge and has enormous momentum and moves a long way before a change of direction takes effect. Organisations, institutions and specific buildings (particularly hospitals) have a life and momentum of their own.
    
    
11. Organisations are more than buildings
    I support a soccer team, Charlton Football Club, who last won a national trophy in 1947. I don’t support the current board of directors, I have my doubts about the current team and even the current pool of players and my club has played at different "home" grounds over the last twenty years. What I support is an institution! Americans who have in the past been fans of the Cleveland Browns have been even more abstract in their support. Their team not only moved physically several hundred miles but also changed its name and was only recently re-established as a franchise. To that extent a Cleveland Brown supporter has, for some years at least, not had a team or even an institution to support, but has been supporting a concept!
    
    
12. Accountability
    Those working in health care find themselves constantly involved with issues of accountability. Whatever funding arrangements are in place, in any country, there is always some accountability to government. This will either be because government is the single payer of a national health system or because government provides a regulatory framework within which a system operates. Given the relative percentage of gross national product that every country spends on its health care (anywhere between 3% and 15%), it is inevitable that government will take a role. Health care is always high on individual citizens’ agendas and an issue on which governments can fail or succeed. To that extent, management of the components of health care systems will always involve some sort of political accountability and managers will need to recognise this. There is clearly accountability from individual practitioners to their patients (and each professional body will have strong views on this). More difficult, however, is a notion of local accountability. Health care is, inevitably, one of the largest employers in most locales. As a service industry with, typically, 60% of its budget spent on people, it is often the largest local employer. This brings with it some form of local accountability, both as an employer and also as a provider of services. Medical managers in particular are used to the notion of personal accountability but find it a perpetual struggle to reconcile that with organisational or health care system accountability. There is no easy answer and it is essentially the continued review of the relationship between those accountabilities, and the delivery of them, that constitutes governance in its widest sense in health care.
    
    
13. Global Medicine and Local Management
    Medicine, and indeed health care, are increasingly global activities. The knowledge base of clinical practice is constantly increased; a recent article in the BMJ pointed out the potential explosion that integrating access to the Chinese language into western culture would provide. Current search engines do not access Chinese medical research which is nevertheless 20% of all reported research. Knowledge management is an active issue for health care professionals and a variety of emergent techniques, such as systematic review, are acknowledgements of the huge issues that the explosion of clinical knowledge brings with it. Most professional clinical areas have knowledge transmission mechanisms that are global – through journals, conferences and so on. Medical managers increasingly need to strike a balance between generalisable and global knowledge and the particular and specific local implementation of it. They must ask whether the wider field of knowledge of practice suggests a necessary fundamental questioning of local patterns of provision.
    
    Inherent in this issue also is the "general versus specialty" debate. Medicine, and clinical practice more generally, is increasingly seeing the response to the knowledge explosion as being specialisation and sub-specialisation. An emergent managerial role is clearly to actively and positively manage the balance of access to general advice and therapy and specialist advice and therapy. The patient who has an emergency in the middle of the night, needs the best kinds of generalist knowledge to determine their specific and special problem but then needs access to those specialists, and any health care system needs to consciously find balances between generalism and specialism. One aspect of the UK health care system, often mentioned in foreign commentary, is the role of primary care as a "gatekeeper" to secondary care; other countries tackle this issue in other ways. There is no right answer but acknowledgement of the need to review and monitor this balance is an essential part of the world of the medical manager.
    
    
14. Ethics
    There is considerable evidence to suggest (Scott, 1996) that an increased area of concern for managers in health care systems in the third Christian millennium will be an ethical one. In particular, the human genome project and others that focus on genetic building blocks will pose a range of clinical managerial ethical issues. Only a small number of professions, including doctors, have, as part of their basic training, some understanding of ethics. The practical implementation of this in everyday life is often neglected and forgotten. Medical managers of the future are likely to have to think hard and long about support and development of the ethical components of their local health care system.
    
    

References

• Lave J and Wenger E. Situated learning: legitimate peripheral participation. Cambridge, UK: Cambridge University Press; 1991
• Mintzberg H. The manager’s job: folklore and fact. Harvard Business Review 1975; July: July/Aug; Reprinted in Harvard Business Review - on leadership. Boston, MA: Harvard Business School Press; c 1998
• Scott TJ. The future. In Lees P, ed. Navigating the NHS - core issues for clinicians. Oxford: New York: Radcliffe Medical Press: British Association of Medical Managers; c1996. p. 137-147
• Winkless AJ. The Myers-Briggs type indicator and NHS doctors and managers. Unpub. Pers.Comm