To learn more about the unprecedented challenges facing physician leaders all over the globe, we spoke with Laurie Pascal, lecturer in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and Institute for Healthcare Improvement (IHI) Director Cindy Hupke. They serve as co-directors for the International Leadership Development Program for Physicians in Boston, MA.
There are many different cultures and types of health care systems around the world. What are some of the common issues that physician leaders often face regardless of where they practice?
Laurie Pascal (LP): Physicians everywhere — irrespective of country and culture — have to manage complexity to provide the best care. They deal with patients, multiple other providers, health care institutions, and care networks outside their organizations, for example.
Also, health care costs in many countries are rising at a pace that most people feel is unsustainable. Many clinicians are trying to provide more care while spending less. Providing the best care at a cost that the patient, the organization, and the country can afford is a global challenge for physicians.
Cindy Hupke (CH): In the past, health care focused its attention inside the four walls of a hospital, doctor’s office, or clinic. But so much of what makes the biggest impact on health occurs outside those four walls. Health care leaders now have to focus on systems thinking and collaboration across boundaries, which adds complexity and demands the development of new and innovative ideas and approaches.
LP: Another challenge is the use of technology. Both developed and developing countries have become much more sophisticated in their use of cell phones and apps in health care. But how do we use them effectively?
CH: Here in the U.S. health care leaders need to focus on financial payment models, ACOs, fee for service, capitated payments, etc. It is often completely different outside the U.S.
LP: In places like the UK that have nationalized health services, one challenge is working within budgets that have been set centrally because changes in political leadership and focus can affect hospital budgets and priorities. Other countries may have private systems that are nationally organized, while still others have a collection of completely independent care delivery mechanisms. Regardless of the system, however, it’s critically important to focus on quality, care coordination, integration of services, and how to get better value.
Organizations often promote physicians based on their clinical expertise and skills. Why is it important for physicians to get additional specialized training in leadership, management, and quality to effectively lead their organizations or systems?
LP: Many physicians come to study at the Harvard T.H. Chan School of Public Health where I teach. When I ask what brings them here, I often hear something like, “I learned how to be a doctor in medical school, but I have no idea how to manage people. I have no idea how to lead them. When I think I’m leading them, I turn around and nobody is following me! In medical school and in practice, I got extraordinarily skilled at something narrowly focused. And now I need to influence people who have a wide variety of backgrounds and specialties, with different desires, different needs, and different orientations. I have teams that include nurses, social workers, physical therapists and on and on. My medical training didn’t teach me to do all this.”
CH: Medical training focuses almost exclusively on clinical skills. Physicians spend years learning and practicing diagnosis and treatment. And then they graduate and find out that they need a whole team of people to care for patients and deliver a treatment plan. Now physicians have to be a team leader or an organizational leader, but what they often learned in medical school was to give orders. And that “top down” leadership style turns the team into sheep instead of skilled, collaborative team members.
LP: Also, once physicians move up and become division or department chairs, all of a sudden they’re responsible for a budget. That’s not part of medical training. How do you make good decisions about money without understanding underlying cost structures and marginal cost? How do you make trade-offs? Budget decisions require a certain financial acumen that doesn’t necessarily come naturally. It’s like trying to do biostatistical research without having taken biostatistics!
Physicians also may not understand how organizations work politically, structurally, or culturally. As physicians move into leadership roles, and need to bring about change, they spend more and more of their time influencing people inside and outside of their organizations. Being able to see beneath the surface and understand what’s driving people’s behaviors and priorities is critical in one’s ability to influence them.
Much like medicine, leading and managing are a mix of art and science. You need to know where and how to gather and use evidence, and then apply intuition and creativity. These skills can be taught and honed through practice. Perhaps one of the greatest differences between clinical medicine and leadership and management is that in the latter roles, you often won’t know for six months, or two years, or five years whether the path you chose was the best path, or the right path. To be an effective leader means learning to live with ambiguity.
CH: When you’re a physician leader, you have to accept that you’re not going to have all the answers. [IHI President Emeritus and Senior Fellow] Don Berwick embodies the valuable attribute of humility. He admits that when he was appointed to head up the Centers for Medicare and Medicaid Services (CMS), there were many things he didn’t know about his new agency and the experienced staff with whom he was going to work. But he learned from the staff. He asked questions. He didn’t dictate orders. He respected that others had expertise that he didn’t. If someone like Don Berwick can admit that kind of vulnerability, I think any physician leader can.
What are the benefits of training with physicians from around the world?
LP: Peer support and networking opportunities are some of the best aspects of a good program. People training with you have tried things, failed and succeeded, and learned from them. Everyone in the group can share their experiences. They may work in health care systems very different from your own, but that helps widen your scope of experience. Maybe there are ideas from other countries worth trying in yours. It increases the potential learning exponentially.
There’s also some comfort in learning away from your home organization. At home, you may not feel you can be vulnerable. A shared learning experience means coming to a safe place with other people who are facing many of the same challenges you are and admitting, “I don’t know how to do this. What I’m trying isn’t working, and I don’t know why.” That kind of camaraderie and mutual support creates a richness that is indescribable.
Note: This conversation was edited for length and clarity.
The Harvard T.H. Chan School of Public Health offers the International Leadership Development Program for Physicians, which provides training in leadership and management, focused on the clinical and operational challenges senior physicians face as executives. To learn more about this opportunity, click here.