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Physician Leadership: An Idea Whose Time Has Come?

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Lately there have been articles in journals like JAMA and Health Affairs discussing the need for physician leadership in reshaping the system. It isn’t that there hasn’t been this need before. Because of the central role granted to physicians by law and by culture, we have always needed physicians to agree, explicitly or implicitly, to changes to the delivery system. Indeed, I call the last model of physician accountability for health care the “infinite power for infinite responsibility” model. Because we had no way of measuring physician performance in the last age, how else were we going to deal with matters that were literally life and death? If you are dealing with a phenomenon that frightens us all, you want to give your agents all the power you can.

But in the Age of Information That Is Cheaper Than Zero and massive computing power, suddenly we can measure physician performance. With the knowledge that all physicians are not created equal (much less perfectly), we are left with a disturbing reality: physicians, like everyone else, need to be engaged in continuous improvement, simply in order to stay even with consumer expectations. I realized the other day that one reason this is so is that we are increasingly expecting human performance to be like computer performance. Computers are performing highly complexity and nuanced tasks, and doing them with greater reliability and reproducibility than humans can. What do you think is more reliable, asking a stranger for directions to a restaurant in a strange city, or Google Maps? Me, I like the app. So is it any wonder that we get annoyed when someone can’t remember if it’s ten or twelve blocks to the CafĂ© Boeuf?

Meeting ever rising requirements requires change and change management, and lots of it. Some theories of leadership state that leaders are really only necessary when dealing with change. When everything is stable (I remember a time once when I thought things were), leaders have limited utility. If I can get by doing tomorrow what I did yesterday, who needs leaders? I’m on autopilot. But in a time when people are radically changing what they want, how they pay me, with whom they expect me to work, and most importantly, how they judge my work? Yikes. And thus, physician leadership is the topic of the day.

I personally think physician leadership is a hot topic now because we’re quite simply out of other options. As Jerry Garcia said, “Somebody has to do something, and it’s just incredibly pathetic that it has to be us.” We’ve tried every option that doesn’t involve physician leadership and buy in, and none of them work. Health plans and mother-may-I managed care failed. Why? Because studies show that 40% of physicians admit to lying to get services for patients. That’s 40% who admit it; who knows how many it really is? Hospitals acquired physician practices thinking buying accounts receivable is almost like buying buy in, but find out, not so much. Way back when in the 1990s, practice management firm like Phycor did the same thing, and with the same disastrous results.

Okay, to brass tacks then. What will it take for physicians to do the Nixon-to-China about face, and actually embrace the Medicine of Limited Resources, the end of society’s blank check, and the upward slope of increasing accountability? Here are some suggestions:

  • First, embracing limits cannot be primarily about making people money, even for the docs themselves. Fundamentally docs have to look themselves in the mirror in the morning, and no one likes to see someone who hurts other people for money looking back. If money is the sole appeal to changing to a population health approach, it will not be sustainable as a motivator.
  • Second, there must be a positive reason to learn new skills and engage in the process. These positive reasons are different for different people. For some, it is the recognition among peers that they are the highest value provider in the land. For others, it is the sense that by making the system more efficient, they are preserving resources that allow other patients to get decent care. But for the largest proportion of providers in my experience, it’s when they see that things like coordinated care are actually better for patients. When someone comes back to the office and says, “My mother looks so much better with the additional help that Karen (the care manager) is giving her. Thank you so much for getting her that.” How do you stop doing that, even if it is a little more trouble for you as the doc? How do you refuse to offer it to every patient out there whose life is strung together with baling wire?
  • Third, docs are like other humans. We like things like a sense of our own competence, autonomy, and relatedness. In many ways, external coercion works against these basic human sources of satisfaction. But if docs can feel like they have the tools to lead well, the ability to really make a difference, and the support of peers, this is a much different proposition that the bad old days of managed care. It reminds me of the saying, “People don’t resist change—they resist being changed.”

In essence my hope is that in order to avoid being changed, we physicians will own the change ourselves. None of this is easy or simple, because nothing involving humans and emotional processing is. But now is the moment we must test these theories, and as a physician community, either own this challenge or turn over the reins to someone else. I know which option I prefer.

About the Author: Dr. Jay Want is CIVHC's Chief Medical Officer. Contact him at

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