Working hospitalists frequently find themselves leading quality initiatives, writing care protocols, sitting on a variety of committees, or engaged in other activities aimed at improving the hospital environment as a whole—not just the care of individual patients. Some even direct their hospital medicine group.
For many hospitalists, such activities may be auditions for progressively greater management responsibilities, eventually leading to physician executive positions, perhaps even leaving clinical practice behind. Experience as a hospitalist can be helpful when moving up the career ladder, say those who have followed this path, but advances also pose trade-offs in their working lives.
Hospital medicine can offer some of the best opportunities in all of healthcare for physicians to transition into administrative or executive positions, says SHM CEO Larry Wellikson, MD, FACP. “I believe that in 15 years or less, a quarter of hospital CEOs and half of hospital chief medical officers will have started their careers as hospitalists,” he predicts.
Such demand for hospitalists-turned-executives raises important implications for the field, and for SHM because many who make the transition will lack formal management training, says Dr. Wellikson.
“I keep hearing from 37-year-old hospitalists who are sitting at the table with healthcare management types,” he adds. “They feel they are at a distinct disadvantage because they never learned the essential management skills.”
SHM plans to explore collaborations with other healthcare organizations to develop a comprehensive management curriculum that could be completed by working hospitalists during one weekend a month over the course of several years. SHM already offers a four-day intensive Leadership Academy. (See “Society Pages,” p. 8.)
Some of those who have made the transition say management is the last thing they expected to do when they entered medicine. One of these hospitalists is Russell L. Holman, MD, SHM president-elect and senior vice president and national medical director of Cogent Healthcare, Irvine, Calif.
“I believe my career has been marked by a series of defining moments, with one opportunity following another,” he says. “If you had asked me 15 years ago if I would be in this position, I’d have said, ‘Hell no!’ I had absolutely no interest in the business side of medicine and, frankly, I found it boring.”
Dr. Holman was initially drawn to internal medicine for the opportunity to establish long-term relationships with his patients, but then found that his residency training had really prepared him more for working in the hospital.
“I also found myself drawn to the challenge of the hospital environment and its very ill patients, with the opportunity to establish rapport and trust in a short period of time and achieve significant improvements in their care quickly,” he explains. He was also drawn to the environment. “I viewed the hospital as a complex setting to navigate, and I saw a lot of opportunities for improvement overall—which was also an opportunity for professional growth and accomplishment.”
During Dr. Holman’s year as chief resident, he realized that meetings with administrators and non-physician clinical personnel could be vehicles to accomplish larger goals. “I also began to experience the vicarious rewards that can be achieved from the accomplishments of others through the administrator’s role of making it easier for them to do their jobs,” he says.
Along the way, Dr. Holman’s mentors encouraged him to recognize an aptitude for management and seek additional opportunities to practice it. On his own, he recognized his need for professional development opportunities to acquire management skills. He took weekend seminars and attended conferences to help him learn how to run effective team meetings, communicate with colleagues, and approach financial reports. Combined interests in teaching and management led Dr. Holman to the chair of the SHM Leadership Development Task Force. He became course director for its Leadership Academy, first offered in 2005.
The Ideal Hospitalist Program
Stacy Goldsholl, MD, president of the Hospital Medicine Division of TeamHealth, Knoxville, Tenn., was a working hospitalist for 11 years before making the move.
“Along the way, I started to develop a real sense of what my own ideal hospital medicine program would look like, not just in terms of clinical excellence, but also physician professional satisfaction,” she says. Dr. Goldsholl worked in several hospitalist groups in different parts of the country, running one group and later setting up an 11-member hospitalist practice from scratch in Pennsylvania, with a 50% time commitment for administrative work.
“How did I prepare for that role? A lot of it is seat-of-your-pants, although a mentor had pointed me toward a physician management training course,” she said. Last year Dr. Goldsholl joined TeamHealth and became 100% administrative. “It’s a double-edged sword, giving up the clinical piece. Part of the success of any physician executive is having a passion for patient care. Clinical work is something I definitely miss. But the higher goal is to impact larger health systems.”
Dr. Goldsholl’s current job includes standardizing TeamHealth’s hospitalist practices nationwide, providing leadership for regional directors, and reporting on quality indicators. “But the biggest piece of my current job is business development—going out to meet with clients,” she explains. Those clients include hospital executives and potential acquisition partners.
“Is this a path for other hospitalists?” asks Dr. Goldsholl. “Absolutely. Not necessarily my exact role, but jobs like vice president of medical affairs for a hospital, patient safety officer, CEO, or medical director of a medical company. Those positions will be filled by hospitalists. Physicians who choose to be hospitalists already see themselves as change agents, so many will gravitate toward a leadership role. Young hospitalists with that same passion, once they come to understand the health care system, it ignites their passion to make things better on a larger scale.”
Hospitalist David Bowman, MD, has been executive director of the Tucson, Ariz., Region of IPC—the Hospitalist Company since 2000, after playing major roles in establishing medical practices and a physician’s organization. Today he is the only physician among the company’s executive directors. “Those guys are smart,” he says. “They look at medicine from a higher level.”
Dr. Bowman, like Drs. Holman and Goldsholl, sometimes thinks about pursuing a master’s degree. But he is reluctant to take the time away from what he is now doing.
“I don’t think I could go further than I have without the letters MBA after my name,” he speculates. “But I’m happy enough where I am and, if need be, I could still go back to hospitalist work.”
Dr. Bowman found his initial foray into administration as head of a five-member group practice. “At 7:30 at night I’d be signing checks,” he recalls. “If there was any money left over, the last check would be my own salary.”
Today his position is 75% administrative and 25% clinical. He has been able to get his fill of clinical work by taking hospitalist shifts evenings and weekends. “I don’t want to lose my medical skills, but I like administration much more than I thought I would,” he says. “What I have learned is just how much it takes to support the physician who walks up to the patient’s chart, opens it, writes an order for an MRI of the brain, and then closes the chart again. It’s mind-boggling how complex the system is in supporting that 30-second action—how many other people are involved in making it happen, all of the areas for potential error. That’s why we work so hard on patient safety—which has to start at the top and flow from there.”
Finding a significant administrative role is not an all-or-nothing proposition for working hospitalists, although directors of group practices sometimes struggle for their colleagues’ recognition of their need for dedicated administrative time.
Doctors face two significant crossroads as they gain progressive administrative responsibilities. For those with demanding executive positions, it may become necessary to give up clinical practice—a painful choice for doctors who have devoted years to mastering medical care. Physician executives eventually may also face the need to obtain a management degree such as an MBA or a master’s of health administration—or else find other, less time-consuming ways to learn essential management skills.
Patrick Cawley, MD, is a hospitalist who has not given up clinical work, even while his administrative responsibilities have grown. In his current position as executive medical director of Medical University of South Carolina (MUSC) Medical Center, Charleston, clinical duties take up about 30% of the job. He is just a couple of courses short of completing an MBA from the University of Massachusetts.
“Basically, I’m the hospital’s chief medical officer,” says Dr. Cawley. “A chief medical officer attends a lot of meetings. Most of my day is spent interacting with different people in the hospital—other administrators or one-on-one with physicians. My purview is quality, patient safety, and clinical effectiveness—providing the strategic vision for those activities and some level of detail in working projects through the system.” The role is part cheerleader and part task-master, he says, requiring skills in communications, negotiations and conflict management.
“There’s no doubt that I’m having trouble carving out 30% of my time for clinical work,” admits Dr. Cawley. “You end up missing a meeting here and there, and that’s not good. I know I’ll have to decrease my clinical time eventually.”
For now, however, Dr. Cawley is able to find clinical time in two- to three-hour increments, primarily for teaching and rounding with residents.
“Chief medical officers argue about this all the time: Should you be practicing medicine or not?” he says. “My personal take is that I prefer to do some clinical work. It keeps me involved in the day-to-day problems of physicians and the operations of the hospital. I don’t think I’ll ever give it up completely. For physician leaders, it’s important to be respected clinically, and it gives you a step up in professional relations.”
Dilemmas and Downsides
Research by Timothy Hoff of the University at Albany, N.Y., and others suggests that physician executives who continue to see patients part-time are happier in their jobs, says Winthrop Whitcomb, MD, a hospitalist at Mercy Medical Center in Springfield, Mass. Dr. Whitcomb is a member of SHM’s Career Satisfaction Task Force, which is also studying the issue. Also, when clinical commitments shrink, it can be a challenge to remain current with clinical skills, medical literature, and advances in healthcare technology and computerization.
“There is a danger in dropping out of medicine and pigeonholing yourself too early in your career—especially if you are taking an administrative job for the wrong reasons, such as temporary job frustrations,” warns Dr. Whitcomb. “It’s very hard to come back to clinical practice after giving it up.”
SHM’s Career Satisfaction Task Force is developing a career satisfaction self-assessment tool that would help working hospitalists make clearer assessments of the dilemmas of considering a career change.
Physician executives need to be clear on their loyalties as well as their stakeholders, adds Dr. Wellikson, who gave up his clinical practice in 2000. “At the end of the day, my value to my company was not in taking care of patients,” he says. “Yes, you need to keep yourself real in your relations with other doctors—but seeing patients is not the only way to do that. We don’t need Lee Iacocca building the cars he sells, even though he started as an automobile engineer.”
Dr. Wellikson reminds hospitalists that management “isn’t all fun and games. Your group expects you to fight for them. Not everybody sees you in the best light. Sometimes leadership can be lonely, and there’s no road map. You can’t always say ‘yes.’ Sometimes you need to fire colleagues.”
How to Get Started
When working hospitalists get exposed to administrative or quality improvement projects and opportunities, some of those projects will be successful and satisfying, while others will not. But even if their goal isn’t to become the CEO of a national organization, they can gain a sense of their interests and aptitudes. Other part-time administrative roles include associate medical director of a group practice, quality officer for the hospital, or medical director of informatics.
Just look around the hospital and see what’s broken, suggests Dr. Cawley. “Or else go down to the quality department and volunteer your services,” he advises. “There are innumerable tasks that need to be done. I would recommend starting small. Do projects that involve small groups working together. As the projects get bigger, they will involve more people, more resources, more measurement tools. This will then give you a sense of whether you want to continue in management.”
When a hospitalist gets appointed to a quality committee, it is important to be an active contributor. “Take a forward stance. Prepare for the meetings,” adds Dr. Holman. Go back to your constituency and have an active discussion about the project. By that very experience you will be viewed as a leader—and recognized leaders are the people who are given larger-scale opportunities.”
Dr. Goldsholl insists, “The way to be successful as a leader is to continue to be passionate about patient care. At the same time, continue to develop yourself with the tools and skills needed to make the case for hospital medicine. If you can do both, your chances of success are higher.”
It is also important to develop people skills—some of which can be learned. “Did I have all of those skills in the beginning?” asks Dr. Goldsholl. “Absolutely not. A certain maturity and ability to be flexible were acquired over time. At first I did not know how important it was in the first five minutes of a business conversation to ask the person I’m talking to about their children. That’s something else I didn’t learn in medical school.” TH
Larry Beresford is based in Oakland, Calif.