Abstract
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To mark this occasion, we offer some tips that no one taught us along that road from outcast to O-zone. Yet, for those physicians from our field who will follow, we offer these pearls.
Relationships First
It does not matter what you know. If people do not know you and trust you, you will have no influence and you will be frustrated. As you will take one of these jobs after you have reached mid-career, you need to expect to start from scratch to build your new reputation in your new role. You will know you are successful when you hear your ideas espoused by others advocating for what you want. In other words, social power is more important than your title, training, or publication record. Be willing to compromise today to continue to advocate another day rather than trying to be right or win any specific argument. Although everyone talks about data-driven decision making, data largely have rhetorical power and decisions are based on beliefs and impressions before there is any data. Three things follow: (1) smile more, talk less, (2) relationships (and culture) trump data. Even a story or two trumps data. (3) Be the person to whom others come to solve their problems. Do not say no. Tell them what you need to accomplish both their goals and yours as part of accomplishing their goals.
Resistance to Change
Even if you build a stellar reputation, there will be resistance to change. Even if everyone agrees that the status quo is not right, or even if it is downright hurting people, there will still be resistance. Large organizations move slowly. Community health systems and academic health systems move differently, because of different power structures. Some “hurting patients” issues are handled very quickly, but they tend to be very discrete medical events, like “sentinel events.” Do not be surprised when the resistance comes from within hospice and palliative care staff. It is better to have little successes than try something really big and complicated. Engage with those who resist like you engage with a patient and family in a palliative care consultation. Those abilities to understand the motivations and emotions around the table during a family meeting work just as well, discerning institutional and administrative “goals of care.”
Doctors Do Not Do Clinical Operations
Administrators who have reputations as “operators” do. Nurses are favored in many institutions as operators because it is traditional and because hospitals were built on the structure of nursing care. Physicians were outsiders who came in and used the hospital services to care for patients. Hospital and health system culture is hierarchical and military in structure and function. In contrast, doctor culture is horizontal, less clear, and more or less a meritocracy. Consequently, even if you were recruited to “lead,” you will want to work to be known as someone who is a “team player” and who follows instructions, pays attention to chain of command, and does not embarrass superiors in the chain of command.
Matrix Relationships Are Key
Doctors in the o-zone have influence, but have no direct power. However, our indirect power, through matrix relationships, is considerable. Learning how to use influence rather than “doctor's orders” and to have patience for prolonged time lines are challenging skills to learn. Medical school and residency do not train us for any of this. The value of one on one direct patient care is supplanted by the value of building systems of care that are functional and repeatable. Learning to delegate and get the best out of the people who work with you is a core skill. It is analogous to the skill of a resident learning to trust and delegate to the intern. You have to let people do stuff even if they do not do it exactly the way you would have done.
Outcome versus Process
Physicians are fundamentally outcome focused. “Who cares about process as long as my patient gets the right care” is a common rant. In contrast, health system cultures focus on process as a method of improving outcome. This can seem very indirect to physicians. This also has implications for time lines—which are always long in process-focused places when a doctor wants an outcome now. Each of us has a more developed respect for process than formerly. A well-designed process is how everybody gets good care every time. It helps to remember that physicians are generally “fact utilitarians.” Everything can be up for negotiation and change in light of the facts of the case. Nurses and most others in healthcare are “rule utilitarian.” The rules matter.
Fear
Fear, although related to resistance to change, is its own entity. Fear of not making budget, or running afoul of the regulations (not what they say, but what people think they say) and worrying that a wrong judgment will cause the whole organization to fail are frequently just below the surface. Most basically, fear of losing one's job. As a group, physicians are afraid of different things like not getting the diagnosis or treatment right, or adverse actions of the medical board, or being sued. Fear is conquered through trust. Demonstrate that you can hear what they do not like about your plans or ideas. View mistakes or missteps as opportunities of learning and improvement rather than opportunities to deride or denigrate. These are the same active listening and negotiation skills you use with patients and families, just applied in a different context.
No Margin, No Mission
No margin, no mission is an essential mantra for any business. Sadly, it conflicts with the “damn the torpedoes, full speed ahead” model that frequently guides physician training and practice—where no information about the financial consequences of physician decisions is made available to the physician, and is explicitly or implicitly implied to be less important than the infinite value of a patient's life. We have learned to own the margin and the financial components of our role. This, in turn, permits others to demonstrate their commitment to doing the “right thing” for patients and families. Therefore, it goes back to the relationships, and letting them matrix their way to an outcome.
It Is Lonely at the Top
Do not expect thanks or adulation. People come to you with their problems and complaints. Your job is to ask them what they can do to make it better themselves, hold their anxiety, and remove barriers. Job satisfaction comes from making a difference on a big scale, not from being credited with making the difference. In addition, do not be surprised when your every move and utterance is observed carefully by others. You are on a very visible platform to which others look for signs of your true intent. We find it helpful to communicate, collaborate, and kibitz with colleagues in similar roles in different institutions as a way to get advice and support; we have met monthly for several years. In addition, as others in leadership are similarly lonely, take every opportunity to thank your administrative colleagues, including your bosses, when they do things that make things better.
In summary, 20 years is a generation. In that generation we have seen extraordinary growth and development in our field. As we continue on a rapid growth trajectory, it seems quite likely the next 20 years will be just as eventful. Journal of Palliative Medicine will continue to report its progress.