Medicolegal Issues

Beat the Boss Blues


A sour relationship with your immediate superior can ruin an otherwise fulfilling job. When you report to someone you continually disagree with or simply don’t understand, just showing up for work can become a misery. If you’re in a situation like this, don’t despair; there is a possible solution.

Power Struggle

Whether the conflict you feel with your boss is over care decisions, personal style, or scope of work, it really boils down to who gets control over your time and your patients.

“For physicians especially, autonomy is very important,” says Tosha B. Wetterneck, MD, associate professor of medicine at University of Wisconsin Hospital/Clinics in Madison. “Physicians are people who work hard, are very smart, and like to control what they do. There is obviously a lot of complexity and variation to the job, which adds to the workload. Plus, decision-making processes need to be happening all the time. This creates stress—and the way to control that stress is to have control over what they do.”

No one ever tells you this, but you need to spend time managing up.

—Russell L. Holman, MD, chief operating officer, Cogent Healthcare, and immediate past president of SHM

A hospitalist who continually butts heads with a superior over issues—or one who subjugates his or her opinion and decisions to the boss’s—is not likely to be satisfied with their job.

“Certainly, an individual’s autonomy is influenced by what they want to have control over and they’re allowed to have control over,” says Dr. Wetterneck. “If there’s a discrepancy between the two, that’s definitely going to have a negative effect on that hospitalist. If there’s a mismatch between what they want control over and what their boss wants, that’s going to be a problem.”

Manage Up

Russell L. Holman, MD, chief operating officer for Brentwood, Tenn.-based Cogent Healthcare and immediate past president of SHM, has worked his way through problems like this—both as the reportee and the boss. He worked out some particularly valuable lessons in a past job where, as medical director, he had trouble connecting with his boss.

“There seemed to be a tremendous communication gap, and there was a mismatch between what I felt was important and what my superior felt was important,” he recalls. “It seemed really hard to get on the same page.”

So he set out to solve the problem: “What I learned was that it’s not sufficient in a leadership role to just focus on who is reporting to you and manage in that direction,” says Dr. Holman. “No one ever tells you this, but you need to spend time managing up.”

Managing up primarily means initiating conversations to get information you need to better work with your boss.

“You need a clear understanding about the priorities and hot buttons of the person you’re reporting to, what they’re personally invested in, how they’re being managed, and what their incentives are,” advises Dr. Holman. “In my situation, I felt that I needed to understand my superior’s background—his career progression, areas of interest, things he felt were important in the organization.”

How do you uncover these facts? It’s simple: Request a one-on-one meeting with your superior and have a direct conversation where you ask those questions.

Next, continues Dr. Holman: “Have what I would call a translational conversation … ‘How do your priorities translate to me and my daily work?’ Again, ask this directly.”

But be warned. “This can be a very productive conversation, but it’s not an easy one to have,” he says. “The reason it’s hard is because whether you’re a frontline hospitalist or a group leader of some kind, you’re a highly educated, highly paid professional. Why would you want to redirect yourself to someone else’s priorities?”

That is the crux of the problem in working for a boss you don’t agree with—you need to relinquish some control to make the situation work.

“This may be difficult for some people but by giving up a little bit, you’ll get a much more productive relationship,” says Dr. Holman. “It also helps you understand how your daily work fits into the broader organizational vision, and you build political capital. You’ll build trust, respect, and equity. If there’s a project you want to engage in and you want support for it, you can trade on that equity.”

Career Nuggets

Palliative Medicine Subspecialty Recognized

The American Board of Medical Specialty is recognizing hospice and palliative medicine as a subspecialty. Qualified physicians can register and take the certification examination in hospice and palliative medicine with their own specialty boards, such as the American Board of Internal Medicine. The exam will be offered this fall and every other year and there is a grandfathering period until 2012, after which only fellowship-trained physicians will be eligible to take the exam. For more information, visit your own specialty cosponsoring boards.

Malpractice Primer Published

Published this April, Avoiding Medical Malpractice: A Physician’s Guide to the Law by William T. Choctaw, covers everything from basic malpractice law and how it’s interpreted to how to be an effective witness in your own defense, along with how to manage malpractice risk and the importance of good communication and documentation in daily practice. The book also focuses broader issues including the relationship of law, medicine and politics and its effect on physicians. Avoiding Medical Malpractice is available on—JJ

Learn their Style

Even as you’re practicing the art of managing up, you may face barriers in dealing with the boss. Consider whether it is a matter of understanding their personal and professional style.

“Maybe you’re just having trouble connecting,” Dr. Holman suggests. “Learn their style, how they communicate. Invest a little time to get a better understanding of their personality style. One way is to ask about their preferences—do they prefer e-mail, phone, or in-person conversations?—and to observe.”

You may discover that the boss is brusque with everyone, not just you, or that they don’t reply to your e-mails because they never check their in-box. The better you understand them, the less stress you’ll suffer from interactions.

The Last Resort

If you’re not getting along with your boss, or don’t like the answers you’re getting, should you consider going over their head to the next level up?

“The temptation may be to use workarounds or back channels—what I call leapfrogging—until you get the answer you want,” Dr. Holman says. “But there’s a lot of damage you can do in leapfrogging. I typically do not recommend that someone going over or around their supervisor unless the circumstances are egregious.”

Ultimately, if you’re still at odds with your boss and the conflict makes you unhappy with your job, you may need to consider finding a better environment.

“If your superior’s personal priorities are in conflict with yours, you owe it to both the boss and yourself to try to converse and reconcile those priorities,” says Dr. Holman. “You should still use the steps, but you may end up leaving anyway. [Managing up] doesn’t guarantee success, but it stacks the deck in your favor.”

He recalls an example where he was the superior to a dissatisfied hospitalist: “There was a hospitalist working for me who had a priority of working in an environment where he could use subjective judgment to make patient decisions. My priority was to standardize care as much as possible. The individual viewed [guidelines, checklists] as an encroachment on his autonomy. This came down to a very fundamental issue. I knew he’d be unhappy in this environment, and we agreed that he would be better off working for another group.”

Perhaps the best advice for coping with a difficult hospitalist-boss relationship is to avoid it in the first place. By recognizing what’s most important to you—what areas you need autonomy in—you can ask questions and perhaps negotiate during the interview or promotion stages. Dr. Wetterneck suggests that hospitalists take the control/autonomy survey included in the SHM white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction,” which she co-wrote. (The white paper is available under “Publications” on TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.

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