Academic Medicine Medical Economics

Why Are There So Many Asian Physicians In The U.S.?

People of Asian descent comprise 5.6% of the American population but Asian Americans comprise 19.8% of all U.S. physicians. Two things happened this week that led me to think about this statistic and why Asian Americans are so disproportionately represented in American medicine. First, I listened to the America’s Test Kitchen podcast, Proof, about why there are so many Chinese restaurants in the U.S. (quite fascinating and worth a listen). Second, I listened to this week’s MedNet webcast on Racism and Racial Bias in Medicine that included an exploration of why African Americans are under-represented in U.S. medicine. Part of my interest is because of my own Chinese heritage (albeit only 1/8th).

Several years ago, there was a lawsuit against Harvard University by a group of Asian students who were denied college admission and claimed that the University discriminated against Asian applicants who had superior admission test scores and grades than applicants of other races. The allegation was that Harvard made it harder for Asian applicants in order to keep the percentage of Harvard students who were Asian from becoming too high. The press surmised that Asian American students have a culturally-driven higher study ethic than students of other races. But I think that the reason for the high percentage of Asian students at elite U.S. universities and the high percentage of U.S. physicians who are Asian American has a deeper and darker cause that has its roots in immigration laws that paradoxically were created to keep Asians out of America. As the law of unintended consequences dictates, those laws ultimately resulted in Asian Americans being more academically successful and more overly-represented in American professions such as medicine.

The Naturalization Act of 1790

One of the first laws of the new U.S. government was the Naturalization Act of 1790 that limited naturalization to “free white person[s] … of good character“, thus excluding Asians (as well as anyone else who was not from Europe). This law essentially banned Chinese from immigrating to the United States but this was in many ways a moot point since travel by ship to the Eastern seaboard of the country from China via the Atlantic Ocean was very difficult and expensive. Not until the country’s westward expansion opened California to development did travel from China to the U.S. via the Pacific Ocean become feasible.

The next major event that affected immigration and naturalization of Asians was occurred in 1868. That year, the first section of the 14th amendment to the U.S. Constitution stated: “All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside.” The implication was that even if a non-white immigrant to the U.S. could not obtain citizenship himself or herself, their children could become citizens if born in U.S.

The Chinese Exclusion Act of 1882

The California gold rush attracted many Chinese to the west coast of the U.S. where they worked in mines and then when the mines played out, they worked in railroad construction. But soon, these laborers were competing with American citizens for labor jobs and often accepting much lower wages thus making it harder for white Americans to find work. This created a lot of hostility by many Americans toward Chinese immigrants. Notably, 140 years later, that same hostility would be directed against Latin American immigrants who are perceived as “stealing” jobs from other Americans.

The Chinese Exclusion Act of 1882 was enacted to appease this hostility. The act barred Chinese laborers from immigrating to the U.S. and also made Chinese immigrants ineligible for citizenship. The only exceptions were for Chinese merchants and teachers. At the time, Chinese were subject to racial discrimination equal in many situations to Blacks. In fact, in in 1896 Supreme Court case, Plessy v. Ferguson,  Justice John Marshall Harlan wrote in his dissent: “…the Chinese race is a race so different from our own that we do not permit those belonging to it to become citizens of the United States.”.

Because the Chinese Exclusion Act limited immigration to merchants and teachers, the act essentially barred Chinese women from immigration since at the time, the vast majority of merchants and teachers were men. Indeed, by the end of the 19th century, Chinese men in the U.S. outnumbered Chinese women 27 to 1. Many of these Chinese store owners and teachers married white women since there were so few Chinese women in the country. One of those men was my great-grandfather, who came to the United States from China in 1873, opened a Chinese laundry, married a white woman (my great-grandmother), and ultimately became the president of the Chinese Merchant’s Association of America (but that is another story).

The unintended consequence of the Chinese Exclusion Act was that it selected out only educated Chinese men from immigrating to the U.S. And when these men married and had families, they instilled the importance of education into their children. The unwritten message was that if you were Chinese in America, you had to have an education to economically survive. Racism against Chinese created a more educated and middle class Chinese population in the U.S. In contrast, racism against Blacks in the U.S. resulted in Africans being brought to America as slaves and education of their children was suppressed in order to maintain a population of unskilled enslaved laborers.

Many of these Chinese merchants opened restaurants. Chinese restaurants proliferated because their owners had to sell better food at a lower cost than other American restaurants since they had no other employment options than to be a merchant, even if it meant making a lower income by selling inexpensive food.

The Immigration and Nationality Act of 1965

After World War II, the Chinese Exclusion Act was repealed, in part because China had been a U.S. ally during the war. However, immigration from China was limited to only 105 Chinese immigrants per year. The Immigration and Nationality Act of 1965 eliminated national origin, race, and ancestry as basis for immigration. Importantly, it created a “special immigrant” category that was not subject to quotas – included in this category were foreign medical graduates. The implication was that if you wanted to immigrate to the United States, you had to go to medical school first.

Currently, 25% of U.S. physicians are foreign medical graduates. The more medical schools a given country has, the more physician immigrants that country can send to the U.S. There are 348 medical schools in India offering an MBBS degree. There are 154 medical schools in China that offer an MBBS degree and 50 of these teach in English. In contrast, there are only 160 medical schools in the total of the 48 countries in Sub-Saharan Africa; consequently, India and China are capable of producing more medical graduates that can then immigrate to the United States than other countries can.

One of the best predictors of whether or not a person will become a doctor is whether their mother or father was a physician. In the United States, 20% of doctors have a parent who was also a doctor. I’m a perfect example, a third-generation doctor, with my physician-father a descendent of one of the Chinese immigrants affected by the Chinese Exclusion Act. Medicine is the family business.

The counter productivity of Chinese racism

For a century after the inception of the United States of America, Chinese were usually disdained and immigration from China prohibited. For the second century of our country, some Chinese were tolerated, but only those who were well-educated and entrepreneurial. As a result of policies and laws to keep Asians out of the U.S., we now have a disproportionately high percentage of Chinese and other Asians occupying the ranks of physicians. And given the propensity for children of doctors to become doctors, the percentage of doctors who are Asian American will likely grow in future decades.

Racism is always morally wrong. And racism is always bad policy. There can be unanticipated consequences of racism that result in exactly the opposite of what racism intended… your doctor is likely going to be someone like me, a son of a son of a daughter of a Chinese immigrant.

October 30, 2020

Academic Medicine Physician Finances

Optimizing RVU Production In An Academic Medicine Practice

The work RVU is the current medium of exchange in clinical practice for all physicians, both private and academic. And as the numbers of physicians employed by academic medical centers swells at the same time as the percentage of these physicians’ time dedicated to clinical practice grows, academic physicians in particular are under increasing pressure to maximize their RVU output. Consequently, many academic physicians find themselves struggling to produce their required numbers of RVUs. Historically, private practices were built around efficient RVU productivity but academic practices were not and consequently, the academic inpatient and outpatient practice environment and practice culture is not conducive to RVU maximization. Failure to meet annual RVU targets can result in loss of bonuses, salary reduction, career disillusionment, and general unhappiness. On the other hand, consistently meeting or exceeding RVU targets can provide job security and the freedom to chart one’s own career path in academic medicine. Here are some of the ways that academic physicians can optimize their RVU production.

In The Inpatient Setting:

  1. Don’t forget to submit your bill for your clinical services. This seems so simple but a few years ago, I did an analysis at our own hospital and found that 7% of inpatient services and procedures that were documented in the electronic medical record went unbilled. This was not because of a conspiracy by the physicians, it was simply because they forgot to enter a charge for a given day’s clinical work. It is easy to forget to submit a bill (often called the “charge capture” application in an electronic medical record). If you are busy trying to save a patient’s life, the lowest priority in your day is to put in a bill for that service. I consider myself pretty compulsive when it comes to billing and even I found times when I forgot to enter a bill for a consult, a return hospital visit, or a bedside procedure. Two strategies can help minimize forgotten charges: (1) work with your electronic medical record to create charge entry prompts when completing progress notes or procedure notes to make entering those charges easier and (2) develop a personal strategy to ensure that all services are billed each day – I print out a rounding list of all of my patients each day and note my E/M service & procedure charge on each patient as I enter charges; at the end of the day, I can take a quick look at the printout to confirm that every patient had a charge entered.
  2. Don’t avoid submitting a bill for your service. A number of years ago, one of our very best clinical educators stopped signing resident inpatient notes and inpatient charges. The excuse was that there just wasn’t enough time in the work day and it got in the way of bedside teaching. No note meant no bill for service. No bill meant no income. No income meant no job.
  3. Don’t under bill. Most large academic medical practices do billing audits by billing compliance personnel. These audits are largely defensive, designed to prevent over billing. This is because large medical practices (and particularly academic practices) are subject to billing audits by Medicare or other insurance companies. The bias from compliance audits is that it is better to err on the side of under billing than over billing. Over billing jeopardizes the organization but under billing jeopardizes the individual physician by making him/her do more work than is necessary to meet annual wRVU targets.
  4. In academic medicine, RVU production is like running a series of sprints but in private practice RVU production is like running a marathon. The academic physician has weeks of being really busy interspersed with weeks of “academic time” with relatively little clinical activity. This is particularly true for internal medicine specialties that provide inpatient care where inpatient service blocks can pack a lot of RVUs into a short period of time. In private practice, RVU productivity is more consistent from one week to the next. Over the course of a year, the total wRVUs by an academic physician will be close to or slightly less than a private practice physician in the same specialty. The academic physician has to prepare for the fact that on the weeks that he/she is on service, he/she is likely going to be generating more wRVUs than a private practice physician but when off service, the wRVUs will drop.
  5. Maintain an adequate consult census size. In order to generate a typical academic internal medicine specialty wRVU target, the physician has to have enough patients on the consult census to generate those wRVUs. The inpatient consult service will have a mixture of new patient consults and return visits and this typically works out to about 1.75 wRVUs per daily encounter. If that physician works every day of the week for 46 weeks a year and does 1 weekend coverage per month, then the physician needs to keep an average daily consult census of about 13 patients. However, if (as is more often the case), that physician has some academic time when he/she is writing papers, teaching classes, preparing lectures, and doing research, then when covering an inpatient consult service, he/she has to have a considerably higher daily consult census in order to generate the proper target of wRVUs to make up for the lack of wRVUs during academic time. So, if the physician wants 5 months of academic time (“release time”) per year, then when on the consult service, that physician needs to maintain a daily census of about 25 patients. There is a limit to how many inpatients a consultant can see per day – there will be times when, by necessity, the consult census gets up to around 35-40. This size of inpatient census cannot be sustained for very long because after a few days of this high of a census, it is too easy to start missing things like key changes in patients’ physical exams, key lab tests, conversion of IV to PO medications, etc.
  6. A consult is a gift. Historically, academic physicians often tried to keep their inpatient census down as low as possible and often tried to dissuade primary services from getting consults. The successful consultant will express gratitude for all consults, regardless of when they come in. So, if you get a 4:00 PM consult, you should not be throwing a tantrum, you should be sending the referring physician a fruit basket at Christmas. Actively avoiding consults results in career death by wRVU deficiency.
  7. There should be no such thing as a curbside consult. The curbside consult is when an admitting physician (or more likely a resident) asks an “off-the-record” clinical question of a consultant. There is no entry into the medical record by the consultant and there is no bill generated. If a consultant’s expert opinion is sought, that consultant should be paid for it. I was once an expert witness in defense of a university medical center. One of the residents had called a pathologist to ask an opinion about an inpatient case and made the mistake of documenting that conversation (and the pathologist’s name) in the medical record. The pathologist was named as a co-defendant in the malpractice suit. Even an off the record opinion can result in legal liability so you should bill for your expertise and opinion.
  8. Don’t sign-off too quickly. For many consulting physicians in academic practice, a major goal of the workday is getting the consult census list shortened as much as possible. Consult follow-up visits are beneficial to patient and the primary service because the consultant’s expertise can be applied to new test results and changes in the patient’s condition. This can reduce inpatient hospital length of stay. Those follow up inpatient encounters do not pay as much as initial consult encounters but they often take very little time and on a per-hour basis can generate more RVUs per hour than initial consults. Most initial inpatient consults require at least 2-3 follow-up visits and many will require daily follow-up visits until the patient is discharged. In academic practice, there is a strong tradition of being a “one and done” when it comes to consults. For a consultant, those follow-up visits take far less time than a follow-up visit by the admitting service (hospitalist, etc.) so you can perform a lot of follow-up visits in an hour. I believe that this is the #1 low-hanging fruit in academic medicine for increased wRVU generation.
  9. Your goal should be to generate an yearly average of > 2.5 work RVUs per hour. For a pulmonologist, such as myself, in order to generate your salary, you should spend 24 minutes or less per work RVU, when averaged over the course of a full year (assuming a 55 hour work week and working 46 weeks a year). In reality, no physician does 55 straight hours a week of purely clinical care, especially in academic practice. Therefore, during the time that you are actually taking care of patients, you need to generate more like 4-5 wRVUs per hour. If it is taking you an hour to place a central line (1.75 wRVUs), then you are losing money.
  10. Mundane tasks generate a lot of wRVUs but can melt your brain. EKGs and pulmonary function tests are commonly performed in large medical centers. On an individual basis, neither generates very many work RVUs. However, they take very little time to interpret and document and consequently, the cardiologist or pulmonologist can generate huge numbers of wRVUs very quickly. The problem is that reading PFTs and EKGs is boring and are often seen as an unpleasant necessity of specialty practice. My brain would melt if the only thing I did all day was read PFTs but by reading them for an hour or two a week, I can generate enough wRVUs to free me up to do the uncompensated things that I really like to do.
  11. You can often generate more RVUs on a weekend than you can on a weekday. Weekdays in the hospital are full of non-clinical stuff: meetings, phone calls, emails, grand rounds, etc. On the weekend, those non-clinical activities largely do not exist, leaving more hours in the workday to see patients on a consult service. For many physicians, the goal for a Saturday or Sunday is to get out of the hospital as early as possible, preferably before noon. As a consequence, there is a different level of care provided on weekends: patients are often not seen as regularly and tests/procedures are often put off until Monday. This is often reflected in the “weekend checkout list” when the doctor covering on the weekday hands off the consult service to the doctor covering on the weekend. I have my own translation of the weekend checkout list.
  12. Make your EMR work for you. Investing a little time developing disease-specific note templates, order sets, and order preference lists can pay enormous long-term benefits by creating time-saving shortcuts in your electronic medical record charting. I have different new consult templates for the inpatient conditions that I most commonly encounter: COPD exacerbations, pneumonia, asthma exacerbations, abnormal chest x-ray, pulmonary embolism, etc. I incorporate my own self-designed “smart lists” into the physical exam portion of my notes that default to the expected findings; for example, for an asthma consult note, the lung exam smart list defaults to “diffuse wheezing” whereas the pulmonary embolism consult lung exam smart list defaults to “normal breath sounds bilaterally”. This allows me to rapidly click through the physical exam and saves me precious keystrokes when creating my consult note. Copying and pasting can also shorten your documentation time but it can be hazardous if you are copying too much data from a previous day’s progress note because of the danger of importing out-of-date information (like vital signs, lab results, NPO status, etc.). By using templates for notes that automatically import new data into the daily note, you can avoid this. I limit my copying/pasting to just my “impression and plan” list so that I can remember what problems I am actively following and what my previous day’s recommendations were – I then edit the impression and plan as appropriate.
  13. Medicare’s gift to pulmonologists is CPT code 94003. As a pulmonologist making inpatient rounds, particularly in a long-term acute care hospital (LTACH), I often see 5-10 patients a day who are on a ventilator and my primary role is ventilator management. CPT code 99003 saves me many minutes of unnecessary documentation keystrokes every day. The advantage of the ventilator management codes is that they require very little documentation – just the current ventilator settings and your plan for any ventilator changes. They are not regular E/M codes but instead are procedure codes; therefore, there is no requirement for a certain number of physical exam points, history elements or complexity of decision-making. Normally, when seeing a new ventilator management patient, for me the decision is between billing an initial day ventilator management code (99002) or a level 2 or 3 new inpatient E/M code. In this situation, it is usually better to bill the E/M code and pay the time cost of the additional documentation. However, for the subsequent visit ventilator management charge, it is generally a decision about whether to bill a level 1 or level 2 subsequent visit E/M or the 94003 ventilator management charge. Because the wRVUs associated with a level 2 subsequent inpatient visit E/M and a subsequent ventilator management code are about the same, you are better off using the ventilator management code and reducing your progress note from one page to one or two sentences.
  14. Organize your rounding strategically. As a pulmonologist, I start off my morning looking at any new x-rays and chest CT scans to see which patients need a bronchoscopy. That way, I can get the bronchoscopy team mobilized early and ensure that the patient is made NPO before the breakfast trays arrive. For a cardiologist, that might be checking to see which chest pain admissions need a stress test or which heart failure admissions need a cardiac echo. For an infectious disease consultant, it may mean checking to see which patients need a new CT scan or MRI to guide therapy. I will pre-chart the outline of my progress note before I see a patient so that I know what new information I need to know about when I am talking to that patient and what problems I am actively following. I then try to complete the inpatient encounter note as soon after I see the patient as possible so that I don’t forget about important data. 
  15. You will get more efficient producing RVUs with age. There is a Starling curve of physician productivity. It takes about 7 years after finishing residency or fellowship to get proficient in getting clinical work done. Not only do physicians continue to learn new knowledge but they get more efficient in getting their daily work done with everything from history taking to progress note writing. For most physicians, productivity peaks in their mid-50’s. After that, they often start dialing back the amount of time they spend in clinical practice.

In The Outpatient Setting:

  1. Pre-chart your patient encounters. Each outpatient encounter will require a certain amount of time in the patient exam room and a certain amount of time outside of the exam room. You can either finish your charting at the end of the day, after the patient leaves or you can do that additional charting before the patient arrives in the clinic. Either way, it will be the same amount of time – either before clinic or after clinic. But by pre-charting and preparing for the patient’s visit, you can often shorten the amount of time spent during actual clinic hours – this can free you up to spend more time communicating with individual patients and allow you to see more patients in a given period of time.
  2. Utilize CPT code 99358. This code is for “prolonged service without patient contact”. It requires documentation that you spent at least 31 minutes doing the service and I primarily use it (1) when reviewing a lot of medical records in advance of a new outpatient consult or (2) after an initial consult when I receive a lot of requested records and radiographic images. In my own practice, most new outpatients come with lots of chest x-ray & CT images that I need to review and interpret, office notes that I need to review, lab results I need to review, and pulmonary function tests that I need to review and interpret. About half of my new patients have > 31 minutes of records to be reviewed and documented. This CPT code is worth 2.10 wRVUs and when combined with a level 5 new outpatient visit (3.17 wRVUs), you can generate a whopping 5.27 wRVUs (7.91 total RVUs) for that visit. I use this code 2-3 times a week. Also, if that new patient does not show up, I still am able to generate some wRVUs for my efforts.
  3. Utilize the other CPT codes that you forgot to bill. The common ones are 99497 (advanced care planning, 30 minutes: 1.50 wRVUs), 99406 (smoking cessation 3-10 minutes: 0.24 wRVUs), 99495 (transition care management, moderate complexity: 2.11 wRVUs), and 99354 (prolonged services > 30 minutes: 2.33 wRVUs). I wrote about these and other often-overlooked CPT codes in a previous post.
  4. Cultivate a referral base. For specialists, new patients can come from self-referrals, emergency department referrals, or physician referrals. Self-referrals and ER referrals are notorious for being no-shows and for having no insurance (or having Medicaid). You are better off filling your schedule with referrals from primary care providers and other specialists because those patients are more likely to show up for their scheduled appointment and generally constitute a better payer mix. The best way to cultivate those referrals is by human contact, either introducing yourself in person or by the occasional phone call. Those referral physicians will remember your name the next time they need a consult if they have shaken your hand or heard your voice. This is especially true for nurse practitioner or physician assistant primary care practices – NPs and PAs don’t have the same opportunities to network with specialists at medical staff meetings, the hospital’s physician lounge, or CME events. A phone call to a primary care NP can endear you to him/her for life. Referral letters are also a good way to cultivate referrals. Each referral letter is an advertisement opportunity for your practice: a poorly constructed letter that consists of 4 pages of electronic medical record documentation will create animosity but a 1-paragraph readable note in prose form will create goodwill.
  5. Make the outpatient EMR work for you. Reducing keystrokes saves you time that you can spend seeing more patients and generating more wRVUs. Just as in the inpatient setting, by creating note templates for common conditions that you use, you can reduce your documentation time; in my pulmonary practice, I have different templates for COPD, interstitial lung disease, asthma, abnormal x-ray, and bronchiectasis office notes. Pre-designed order preferences and smart lists can streamline your practice. Outpatient EMR optimization is a huge topic and I’ll devote a post just to this in the future.
  6. Schedule your patients strategically. I see many academic physicians schedule 20 or 30 minute return visits. By pre-charting those visits, you should be able to cut that return visit time down. I schedule my return visits every 15 minutes. In the long run, this can increase your wRVU output by 33% compared to 20 minute return visits. The increase in net revenue can be even greater because the overhead expense of 4 patients per hour is not very different than 3 patients per hour and that means that after you pay off the base clinic overhead (rent, nurse salaries, etc.), the physician ends up keeping more of the total revenue for his/her own salary.
  7. Convert patient phone calls into wRVUs. There are two ways to do this: get the patient into the office or use the new CPT code for telephone/EMR encounters. CPT code G2012 is for phone or EMR patient encounters that last 5-10 minutes for patients that are not seen for 7 days before or 24 hours after the phone/EMR encounter. It pays 0.25 wRVUs. The other strategy is to get those patients into the office – either at the end of the day or to fill in holes in the office schedule created by late cancelations. Alternatively, keep a open 15 or 30 minutes at the end of the day for add-on sick visits. I prescribe way too much steroids/antibiotics over the phone for COPD exacerbations, etc. that could at least be billed as a G2012.
  8. Be sure that you have the right number of exam rooms. Exam room space in most academic practices is both costly and scarce. Often, a physician will get 2 exam rooms so that the nurses can be rooming one patient while the physician is doing the encounter in the other room. But some specialties need 3 or 4 rooms per physician to create optimal efficiency. Getting the right number of exam rooms to generate the most RVUs without creating too much overhead clinic expense can be challenging and needs to be individualized to each physician based on their specialty, efficiency, extent of point of care testing, etc.
  9. Use the entire day.  I often see physicians start their morning schedule at 9:00 even though the nurses and registration staff all arrive at 7:30. Similarly, I see physicians schedule their last patient at 3:30 or 4:00 even though the staff are paid to be there until 5:30. Time = wRVUs. Be sure to fill the entire day’s clinic time with patients.
  10. Double book strategically. In my practice, there are almost always late cancelations and no-shows. By double booking a couple of slots in expectation of those cancelations and no-shows, you can ensure that the schedule stays full. I often see physicians double book at the beginning of their schedule – I think this is hazardous because if both patients show up, then the physician is behind the schedule for hours, creating exasperation for the physician and dissatisfaction for the patients. I think you are better off double booking a slot in the middle of the morning (or afternoon) and at the end of the day. this is because there are inevitably patients who show up 30 or 45 minutes early for their appointments so if there is a late cancelation, you can slip an early arriver into that slot, thus creating an opening in the middle of the afternoon (or morning) or at the end of the day that the double booked patient can fill.
  11. Make up canceled clinics. There should not be an expectation for making up clinics canceled for vacations and scheduled CME time off. However, in academic practice, there are always things that come up that conflict with the regular clinic times: academic retreats, medical staff meetings, visiting lecturers, new faculty candidate interviews, medical student lectures, etc. These activities fall under “academic time” (release time) and when those conflict with regular clinic time, necessitating canceling that afternoon’s clinic, then a make-up clinic should be scheduled. If your academic time temporarily displaces your usual clinic time then you should have an equal displacement of your usual academic time by make-up clinic time in order to keep your total weekly academic:clinic time ratio constant.
  12. Do point of care testing. For me, this means having an office spirometer (0.17 wRVUs per test). For others, it may mean an INR machine, an EKG machine, or a hemoglobin A1C machine.  In order to determine if you need a piece of equipment to do point of care outpatient testing, you have to do a pro forma that compares the cost of the equipment to the estimated income generated by that piece of equipment. It takes about 44 spirometry tests to pay for the cost of a spirometer, after that, all of the income generated by spirometry is profit.
  13. Partner with advanced practice providers. Everyone wants an NP/PA/LISW/pharmacist in order to make their practice more efficient and generate more wRVUs. But everyone also wants someone else to pay for that NP/PA/LISW/pharmacist. In a healthy clinical environment, the physician should work synergistically with advanced practice providers so that the total RVU productivity is greater than the sum of what that physician & advanced practice provider could generate operating individually. Examples are a physician assistant who does the post-op office visits so that the surgeon can do more surgeries or a nurse practitioner who sees routine follow-up heart failure visits so that the cardiologist can see more new patient consults that in turn lead to more cardiac stress tests and echos.

June 8, 2019

Academic Medicine

How To Interview For A Medical Leadership Position

In academic medical centers, deans, department chairs, and division directors are almost always filled by doing a national search. Even if there is an inside candidate at the institution that is the heir-apparent for the job, a search is done to adhere to preserve the integrity of the hiring process. Sometimes, the medical center will hire a professional search firm to seek out and vet candidates (often at a high expense) and sometimes the medical center will perform the search with internal resources. The first step is generally the establishment of a search committee which will consist of a diverse number of physicians and administrative leaders both from within and outside of the particular specialty of the person being sought. Candidate names are compiled from responses to advertisements in professional journals, requests for nominations sent to deans, department chairs, and division directors at other medical centers, and first hand knowledge of candidates by search committee members. Candidates are asked to submit a CV and usually asked to submit a letter of interest in the position. There is an initial screening of candidates by the search committee with elimination of those candidates that clearly do not fit the position’s requirements. The search committee chair (or the search firm or the dean/department chair)  will then have a phone conversation with each candidate to discuss the position in more detail and assess their level of interest.

When the candidate list is down to 6-10 people, the so-called “airport interviews” are done. During airport interviews, 3-5 candidates are brought in per day, one after another, for a group interview with the search committee and often a second interview with the dean or department chair. These are called airport interviews because they are typically held at a hotel close to an airport so that candidates can fly in and fly out on the same day. At this point in the interview process, the candidate names are kept confidential; this is one of the reasons for not having these interviews done on-site at the institution. Most of these candidates do not want their own institution to know that they are out interviewing, otherwise, it could hurt their career at their current institution if they do not get the job. The confidentiality is to protect the candidates, not to create a shroud of secrecy for the medical center that is looking for a new leader.

The search committee will then narrow the list down to 4-5 candidates who are brought for a second interview. This second interview is a much longer interview – typically lasting 2 days or more – and the names of the applicants then become more public knowledge. Each candidate is asked to give a lecture, there are interviews with many different physicians and administrative leaders, there is typically a lunch and a dinner with members of the faculty. For many second interviews, spouses are also bought along for dinner, meetings with real estate agents, etc. After the second interviews, the search committee will generally meet a final time to recommend finalists to the university president, dean or department chair. Importantly, the search committee does not choose the final candidate – that is the job of the university president, dean or department chair. The search committee’s job is only to present a final slate of candidates to the individual who will make the final decision.

At this point, a job offer will be extended by the president, dean or department chair to the top candidate and there will be negotiations about resources (start-up packages, office/lab space, administrative structure promises, etc.) as well as salary. If terms cannot be agreed upon, then the president, dean or department chair will go to the next candidate on his/her list.

Over the years, I’ve been on dozens of search committees and have chaired several. I think I’ve seen every mistake a candidate can make and have seen candidates who excelled and knew how to hit the interview process out of the park. Here are some of the points I’ve learned. First, about the initial submission of your CV and letter of interest:

  1. Read the RFA (request for application) carefully and be sure that you send in the materials requested. If the RFA asks potential applicants to send in a CV and a letter of interest, then don’t just send in a CV without a cover letter.
  2. In the letter of interest, check your grammar and spelling 3 times. The search committee members are mostly going to be people outside of your specialty and most of them are not going to know anything about you. So, the first impression you make on them will be the letter of interest. If the search committee members find spelling or grammar mistakes, then they are going to judge you as sloppy, no matter how many awards you have obtained, grants you have received, and papers you have published.
  3. Make the right impression in your letter of interest. The letter should not just state why you want to be a leader (dean, department chair, chief medical officer, division director, etc.) but it should clearly state why you want to be a leader at that particular institution. That will require a little bit of research about the institution. If you have ties to the region or the institution make sure that those ties come through in your letter.
  4. Organize your CV. Many academic medical centers will require faculty to use an institutionally-approved CV template. These are often terrible and generate CVs that look fine in the CV template computer program that they are generated in but are a mess when they are printed up. Make your CV easy to read and organize it logically. If you have grants, separate them into current active grants (that are actively funded) versus submitted grants, versus completed grants. If you have publications, number them and separate them into categories of peer-reviewed articles, non-peer-reviewed articles, book chapters, and abstracts. If you have national/international presentations, organize them by date. Do not editorialize about yourself in your CV – it should just be the facts.

The airport interview is the next big step in the process. This can be a high-stress time because the candidate will typically be surrounded by a dozen strangers who will be asking all sorts of questions.

  1. The best preparation to do an airport interview is to have previously been on a search committee. Many physicians avoid being on search committees because they can be very time-intensive and it can seem like a lot of work for very little reward. But the education you get from being on a search committee will give you insight into the process that you just can’t get in any other way. You will also get a first-hand look at how successful candidates present themselves. So, if you are a junior faculty member, let your division director, dean, or department chair know that you’d like to participate on a search committee to familiarize yourself with the process.
  2. The second best preparation to do an airport interview is a good night’s sleep. Think of doing the interview the way you would think of taking a board examination. You are going to need to think on your feet and be as mentally sharp as possible. Being well rested is critical. If your interview is on the east coast early in the morning, taking a red-eye flight from California to arrive that morning is a really bad idea.
  3. Do your homework. Learn as much as you can about the institution before the interview. Draw from on-line sources, colleagues with first-hand knowledge, and alumni. But be careful in the interview – you don’t want to come across as bragging about how much you know but you do want to avoid sounding like a dummy when you are asked questions about institutional organizational philosophy, etc.
  4. Google search committee members. You may or may not get a list of the search committee members before the airport interview. But if you do, then do your research on them. There is nothing worse than to make a joke disparaging endocrinologists, when unbeknownst to you, one of the search committee members is an endocrinologist. The interview room may be set up with the committee members’ names on name tags but if they are not, there is no way you are going to remember everyone during a brief introduction so if you know their names/faces/backgrounds ahead of time, you can personalize your comments to them.
  5. Dress the part. If in doubt, over-dress rather than under-dress and be relatively conservative. You should be at least as well-dressed as the most-dressed search committee member – if only one other person in the room is wearing a tie, you need to be wearing a tie. Avoid flamboyant or provocative – all it takes is offending one search committee member and your prospects for the job are dead. You won’t know ahead of time if you are going to be seated at a large table or at an open desk so if you are a woman, avoid wearing too short of a skirt and if you are a man, leave your socks with pink bunnies on them at home.
  6. Expresso, not coffee. The interview may only be for an hour or hour and a half but you are already going to have an adrenalin-fueled diuresis going on and the last thing your bladder needs is to be hit by the effects of a 16 ounce double mocha vanilla latte half way into the interview. Expresso will give you the caffeine you need without the fluid volume. Also, remember that the last thing you do before you go into the room is to make a trip to the bathroom. A wise man once said that you should always start a lecture, a presidential debate, a rush hour commute, or an airport interview on an empty bladder.
  7. Everyone is either Dr., Ms., or Mr. Even if 9 committee members introduce themselves by their first name and 1 introduces themselves as Dr. so-and-so, address everyone equally and like clothing, it is better to be formal than risk being too informal. This is particularly true when it comes to gender. If you address all of the men as Dr. or Mr. and then address one of the women by their first name (or gender vice versa), then you have created a perception of gender discrimination that you likely will never get away from.
  8. Make eye contact. Every search committee member is evaluating you on your communication skills. When one member of the search committee asks you a question, make direct and continuous eye contact with that specific individual for at least 20 seconds. If you look at the floor or the ceiling, the person asking the question will think you are aloof and if you look at someone else, they will think you don’t like them. If possible, try to work the questioner’s name into your answer to them so that you can make your response more personal.
  9. Use your hands strategically. There are certain things you should never do with your hands during an interview: sit on them, drum your fingers with them, twirl your pen with them. Avoid crossing your arms or your posture will appear closed and defensive. Most of the time, keep you hands loosely folded on the table. But your hands can be great adjectives to emphasize key points you want to make. You don’t want to point or project your arm with the palm down. When you do want to use your hands for emphasis, position them as if you were holding an imaginary basketball in front of your chest.
  10. There are certain questions you are always going to be asked. What attracted you to this job? What is your leadership style? What is your approach to improving diversity? What would others say about you? Tell me about a time that you failed at something? Tell me about a time you dealt with a disruptive physician? At many airport interviews, the questions will have been pre-scripted ahead of time so that each candidate is asked the same questions (often by the same person) in order to better compare one candidate to another. Think about these ahead of time – you don’t want your answers to sound rehearsed but you don’t want to have uncomfortable pauses while you think of something to say.
  11. Be willing to acknowledge your shortcomings. There are a lot of pathways to becoming an effective leader – a successful researcher, a prolific publisher, an award-winning educator, a profit-generating administrator, an outstanding clinician. But few people, if any, are ever excellent at all of these. However, if you don’t have an RO1 grant, do make it clear that you value research and will be supportive of those who do research.
  12. Skype effectively. Some of the initial interviews are done by Skype. I think in many ways, these are more challenging than an in-person interview. When Skyping, your tendency is to look at the video picture of the other people on your computer monitor and not at the camera. As a consequence, the people interviewing you never have eye contact with you. In other words, you think you are looking at them but they see you looking away at something else. Resist the temptation to look at the other people on the monitor and instead look directly into the camera. Also, be sure that the back-drop is appropriate, tidy bookshelves or walls with artwork work well. Think of yourself as an actor and everything behind you is the stage that you are setting. When you are Skyping, your movements are going to seem amplified so don’t sway or rock back and forth. Also, position yourself appropriately in front of the camera – too close and your nose will look fat and your head will appear weirdly shaped. The best thing to do is to practice with a family member so that you can get feedback on your appearance and camera presence and you can also have your family member in front of the computer you will be using so you will know the best way to position yourself and the room background for effect.
  13. Avoid saying stupid things. A couple of examples from candidates I’ve seen in the past: “I like critical care because it is like internal medicine on crack.” Or, “As division director, can I put my name on the author list of all of the manuscripts that come out of the division?”. Or, “I’m debating on whether to retire or take on a new leadership job.”
  14. Don’t be a potty mouth. Most people swear (with varying degrees of intensity of vocabulary) but during an airport interview, your swear words should be limited to “gosh”, “gee”, and “wow”. The only thing that will blow up when an F-bomb is dropped is your chances for getting the job.
  15. Humanize yourself without self-aggrandizing. When asked about yourself, don’t come across as pompous or boastful but do present yourself as an interesting and well-rounded person.
  16. Pace your answers. Limiting answers to just “yes” and “no” is ideal for giving court testimony but you will want to expound a bit more than one word answers during the interview. On the other hand, you do not want to make your answers so lengthy that some of the search committee members feel cheated if there is no time for them to ask their questions.
  17. Project emotional intelligence. EI is all the buzzword these days in academic medicine. It turns out that this is a very difficult thing to teach or to prep for but it seems like some people naturally have it and others don’t. In an airport interview, questions that probe emotional intelligence often are grouped as questions that ask how you handle yourself and how you handle relationships with others. Examples are how you handle disputes, how you manage conflict, how you identify and overcome weaknesses in yourself and in others, how you handled a setback, and how you interact with others.
  18. Shake everyone’s hands… at least once. The handshake often seems like a formality of social etiquette but the human touch can help establish a connection between 2 people that words cannot. But there is an art to the handshake – it should neither be too limp nor too firm. For search committee members who use their hands for a living (surgeons, gastroenterologists, anesthesiologists, etc.), an excessively firm handshake is a direct threat since even a small injury to the hand can derail their professional career. On the other hand, a flaccid handshake can make you come across as timid and a pushover. Use the same amount of force that it takes to pick up a glass of water with your hand.
  19. Don’t clean out the hotel minibar. The institution will usually be paying the hotel bill if you stay overnight and that includes everything that you take from the minibar. Once, we had a candidate take everything from the minibar as she left the hotel, leaving the bill to the hospital. Needless to say, she was not asked back for a follow-up visit. What you take out of the minibar can reflect on your personality so if the institution gets a bill for 2 Snickers bars and 3 Budweisers, that is going to say a lot about you. If you order the lobster Thermidor with beluga caviar sauce and a bottle of champagne for a midnight snack from room service, that also tells a lot about you. If you want a beer the night before your interview, go downstairs to the hotel bar and pay for it in cash.
  20. Send a follow up email. I get these all of the time, from medical students interviewing for internships, from physicians interviewing for jobs, and from leaders doing airport interviews. Most of the time, I ignore them but I do think that a follow-up email can sometimes make an impression. The ones that impress me the most are those that incorporate some personalized information. For example, a reference to something that we discussed or a reference to something unique about me or my career. In other words, avoid sending the same generic “Thank you for interviewing me” email to all of the committee members.

Once finalist candidates are selected from the initial airport interviews, there is a whole new strategy involved for the next round of interviews. I will write more about that in a future post.

April 19, 2019

Academic Medicine Inpatient Practice

Setting Achievable Hospital Quality Goals

All across the country, hospital quality departments set goals for the upcoming year. For academic medical centers, that fiscal year is starts July 1st. And every year, at every hospital, those goals are set a little higher and hospital leaders get frustrated when a year from now, those goals are not met. The tactic that should be used to avoid all of this frustration is setting realistic goals.

In an academic medical center, there are all sorts of goals that are set for the physicians to achieve:

  1. Quality goals set by the hospital quality department
  2. Productivity goals set by the practice administrators
  3. Educational goals set by the medical school
  4. Efficiency goals set by the hospital finance department
  5. Research goals set by the department chairmen
  6. Citizenship goals set by the medical directors

For the physician with relatively limited time and emotional energy, all of these various goals compete with each other. The hospital finance department gets frustrated when the physician’s efficiency measured by getting all of the hospital discharges completed by mid-morning is affected by the physician doing too much teaching on rounds. The department chairman gets frustrated when the physician’s research output is affected by the physician spending too much time in the hospital trying to meet RVU targets. And the quality department gets frustrated when the physician is spending too much time in citizenship activities such as attending committee meetings and not focusing on spending more time with individual patients in order to improve patient satisfaction scores.

For the physician who is faced with the expectation of achieving a 75th or 90th percentile for all of these various goals, it is overwhelming and not realistically achievable. It is human nature to direct one’s limited time and energy to those goals that are achievable and then effectively ignore those that are not achievable.

As an example, lets say the quality department sets a quality goal that all physicians will do bedside rounds on every patient 3 times a day and the practice administrator sets a productivity goal of 4,000 wRVUs per year. If a physician currently rounds on every patient once a day and had a productivity of 3,500 wRVUs last year, then to both increase the number of daily visits by 2 additional visits with each patient each day AND increase the wRVUs by 500 in the next year, the only way to achieve both goals is for the physician to work more hours every day (the physician has to bill the patient the same amount whether he/she sees that patient 3 times a day or just once a day). From the physician’s standpoint, he/she will have to choose between meeting the quality department’s goal by increasing the number of daily encounters with each patient by 200% or meeting the practice administrator’s productivity goal by increasing the number of patients that the physician sees by 14%. Given these competing demands, most physicians will choose to go after the wRVU goal and ignore the quality goal because the wRVU goal is more achievable.

So, how should we set quality goals?

  1.  Recognize that most physicians cannot be above average in everything. The physician who wins all of the teaching awards get them because he/she is spending a lot of time doing bedside teaching rather than trying to knock the wRVU targets out of the park.
  2. Expect small annual incremental improvements and evelop long-term, aspirational goals. My favorite NFL team, the Cleveland Browns were winless last season at 0-16. Next year, I’m not expecting them to go to the Super Bowl but I’d be happy with 2 wins next season, 5 the following season, and then make the playoffs in 3 years. Setting long-term goals with incremental increases every year over a several year period is more realistic.
  3. Realize that the physicians can’t go it alone. Increasing productivity may require investing in more outpatient exam rooms per doctor, or geographically locating all of a hospitalist’s patients to one nursing station, or staffing up the case management department to facilitate discharge planning. Achieving higher goals requires giving the physicians the tools they need to meet those goals.
  4. Get the right benchmarks. For example, if you are tracking hospital mortality and are at a large tertiary care medical center that has a high percentage of complex, critically ill patients, then using a crude mortality rate will not be useful because your patients are sicker and have a higher expected death rate than those at a smaller community hospital. In this situation, using the mortality index would be a more appropriate way of comparing how well your hospital is doing in patient mortality. The mortality index adjusts the crude mortality rate by the severity of patient illness. For the tertiary care hospital to achieve the same crude mortality rate as a small community hospital or an orthopedic specialty hospital is unrealistic.
  5. The best theoretic result is not always the best achievable result. In an ideal world, there should be zero hospital-acquired central venous catheter infections. However, that is not going to happen, the bacteria always finds a way in the sickest patients and central lines are mainly used in the sickest patients. Therefore, setting a hospital goal of zero central line associated blood stream infections is not realistically achievable and if every year the doctors and nurses feel demoralized because they could not achieve a goal of zero, staff morale will suffer.
  6. Don’t create a storm of goals. There are 300 different merit-based incentive payment system (MIPS) measures. If you hold your physicians responsible for achieving all of these, their heads will be spinning and they will likely just give up. Focus efforts on a limited number of goals that are of highest priority for the hospital. Five or six goals for each physicians is a good target.
  7. Publicize next year’s goals before the start of next year. This seems so common-sense but many hospitals procrastinate on getting goals finalized and then getting those goals publicized to the physicians on time. A hospital that disseminates the annual quality goals 3 months into the year is doomed to failure since by the time the physicians and hospital staff know what their annual goals are, 25% of the year has already gone by. It would be kind of like a head football coach not telling the other coaches and the players what the game plan is until after the first quarter.
  8. Provide timely regular feedback. If one of the hospital’s quality goals is to reduce readmissions for heart failure patients, then report the 30-day readmission rate on a monthly basis, as soon as the data is available. People usually can’t remember what they did differently 6 months ago, let alone a year ago. Regular and timely feedback allows physicians and hospital staff to determine in real time what is working and what is not working and then adjust behavior and practices accordingly.
  9. Achieving a ranking is not achieving a quality goal. I’m probably going to get into trouble for this one because every hospital focuses on the U.S. News and World Report annual ranking of hospitals. Boards of Trustees, CEOs, Deans, and medical directors all define success as “moving up in the ranking”. It is true that in many situations, a higher national ranking by rating groups such as  U.S. News, Leapfrog, etc. do incorporate quality in the determination of ranking. However, the goal of the hospital should be to get the quality right and not just to get the ranking. Medicine is not like NCAA football where the highest ranked team at the end of the season wins. We win when our patients get the best care for their condition possible. The rankings and awards can come later.
  10. But… set goals that are achievable but not too achievable. To be successful in getting NIH research grants, research scientists know that they have to have half of the work already done before they submit a grant so that achieving the goals of the grant (and continuation of funding) is assured. Similarly, it is human nature for hospital leaders to choose goals that they know that they can achieve so that they are assured of looking good at the end of the year. For example, if I, as a medical director, set a quality goal of reducing Clostridium difficile infections by 20% next year and I know that the hospital just purchased an expensive ultraviolet light C diff decontamination system that the literature says reduces C diff rates by 50%, then at the end of the year, my quality goal scorecard is going to look great – it is like benefitting by insider trading.

The hospitals’ ultimate goal is to match the healthcare resources of the hospital to the healthcare needs of the community in a way that maximally benefits the patients. In most situations, a hospital cannot change overnight to perfectly match these needs and the alignment of hospital resources with community healthcare needs is a long-term journey. Setting achievable quality goals is a critical part of this journey.

July 11, 2018


Academic Medicine

How To dismantle Your Legacy As A Physician

Brett Favre was one of the greatest quarterbacks in NFL history. As physicians, we can learn a lot about the legacy we leave and about how we will be remembered from Brett Favre. After a rookie year with the Atlanta Falcons, Favre joined the Green Bay Packers where he spent the next 16 seasons amassing one football record after another. In Wisconsin, he was a hero: parents named their new-born sons Brett, Green Bay jerseys with #4 quickly sold out, and he was awarded the NFL’s most valuable player three years in a row. On March 4, 2008, he announced his retirement but then a few months later, he changed his mind about retirement and asked to be traded so he went to the New York Jets for a year and then announced his retirement (again). A few months later, he signed with the Minnesota Vikings, the arch rivals of the Green Bay Packers. And Brett Favre went from being the most beloved man in Wisconsin to being the most hated man in Wisconsin.

So, what does this have to do with physicians? We do not have the fame of a Brett Favre, but we do build up a reputation in our hospitals, our communities, and our medical schools. If you look around at medical centers and colleges of medicine, buildings are named after those locally famous doctors who stayed at their institution for years or decades and then retired from that institution. They don’t name buildings after doctors that practice at a hospital for 25 year and then leave to go practice somewhere else.

It is because our brains are wired to dislike someone more if we initially thought that they liked us but then later disliked us. As an example, think about the last ugly divorce that a neighbor, co-worker, or family member went through and how the former spouses now see each other. It also works the other way: we like someone more who we initially thought disliked us but then later liked us. As an example, think about every military sergeant and every high school coach that ever existed.

When a senior colleague, a mentor, a department chairman, or a division director leaves for a similar job elsewhere, they become a persona non grata. We perceive that the physician is leaving because he or she no longer likes us. Consequently, we no longer like him or her. Institutional history is always written by those who remain and not by those that leave and so those physicians who leave are remembered by institutional history not for all of the good that they did while they were here, but rather remembered just for leaving.

There are exceptions. For example, for a bona fide promotion, such as a division director who leaves to become a department chairman elsewhere else. Or for family reasons, such as a physician who moves to a different city because his/her spouse’s job got transferred. Or for internal transfers, such as a physician in a large multi-hospital medical system who is asked by the corporate leadership to transfer to fill a clinical void at one of the other hospitals.

But it is the physicians who depart for seemingly lateral moves who we perceive as rejecting us and thus we in turn reject. And the longer a physician has been at one hospital before leaving for another, the more strongly we reject him/her. We tend to erase and forget all of their accomplishments. We find other physicians to elevate to the level of celebrity to replace those who left. The students, residents, fellows, and junior physicians who came to the institution because of them feel as if they were lied to. The physician’s patients feel betrayed. To all, the departing physician becomes a pariah.

You can measure the qualifications of a physician by how he/she is recruited for a job. You can measure the integrity of a physician by how he/she leaves a job. It is better to leave an institution after only a few years than to leave after a few decades when you have become the face of that institution.

I want to be remembered not like Brett Favre but like Cal Ripken. He was born in Maryland and played every one of his 21 seasons with the Baltimore Orioles. His player number was retired by the Orioles in 2001 and the in the state where he was beloved as a player, he is still beloved.

July 2, 2018

Academic Medicine

The Value Of Shared Values

Leadership change in a healthcare organization is inevitable but every time it happens, it can be a bit unsettling to the physicians. If there are a lot of changes that occur simultaneously with sweeping changes in multiple leadership positions, then it can shift from being a bit unsettling to being a lot unsettling. And much of that arises from uncertainty of values.

In medical centers, leaders such as Deans, Department Chairmen, CEOs, and Division Directors can be roughly divided into two groups: those that are recruited from within and those who are recruited from outside. Those that are recruited from within are physicians and leaders who have worked at the institution and are “known entities” to the rank-and-file physicians and other employees. Those that are recruited from outside are largely unknown to most of the physicians. There is an often-overlooked difference between these two groups of leaders: The former are known whether they have shared values with the rest of the physicians and the latter are not.

Those shared values can mean many different things in different institutions. They can be dedication to clinical excellence, dedication, to educating the next generation of physicians, dedication to organizational financial health, dedication to creating new knowledge through research, dedication to improving diversity, dedication to care of the underserved, dedication to improving public health, etc. With leaders who are recruited from within, you know what you are getting because those leaders have shown what their values are as they have risen from one of the rank-and-file physicians to leader. And therefore, you know from personal experience and history whether that leader shares your own values.

It is harder to know what values are held as most important to leaders who are recruited from outside. You can get an idea from their curriculum vitae and from what they say in presentations and meetings. But you never really know until you experience that leader’s actions first hand.

Sometimes, new leaders are recruited specifically because they hold different values than what the existing institutional culture holds. Maybe a board of trustees wants to “change the culture” of the medical center – this really equates to changing what is valued by the medical center. This can be particularly difficult if the medical center is constantly trying to be something different than what it actually is. For example, a medical center that historically prides itself on care to underserved patients that tries to reinvent itself as a research powerhouse is going to face a lot of challenges. Nevertheless, such value disruption is often necessary to correct perceived institutional deficiencies.

The half-life of medical institution leaders is relatively short, particularly for deans and department chairmen in academic medical centers. An organization that primarily recruits its leaders from the outside can find itself in a state of perpetual value uncertainty, leading the physicians wondering whether or not the values that they hold and that brought them to that medical center originally are the values that will be used to define institutional success in the future. Such efforts to “change the culture” too frequently can result in a sense of on-going value disruption can result in non-alignment and disengagement by the physicians.

On the other hand, recruiting leaders exclusively from within the medical center can result in maintaining a sense of shared values but can also result in stagnation of values. For example, if a hospital in poor financial shape brings in a medical leader who values improving clinical productivity over everything else, then over time, the institutional shared value will become one that fosters high productivity; recruiting successors to that medical leader from within the organization will perpetuate that emphasis on high productivity rather than other values, such as education, enhancement of diversity, research, etc.

A healthcare organization can afford value disruption only so often. Too frequent of leadership changes with leaders recruited exclusively from outside the organization leads to uncertainty of institutional values that then results in high physician turnover. A goal of a healthy healthcare organization should be to create a pool of potential future leaders that have a track record of shared values with the rest of the physicians. These shared values can result in the physicians having a sense of security that what they personally value will be aligned with the values held by the next healthcare organization leader.

Hospital leaders recruited from outside are often aspiring leaders that want to be a leader somewhere and your hospital had an opening coincident with when that person was looking for a leadership job; these leaders are often effective when you need institutional value disruption. Hospital leaders recruited from within are usually aspiring leaders that want to be a leader at your hospital specifically; these leaders are often effective when you need institutional shared values. Therefore, it is on each hospital and health system to create leadership training programs to ensure a steady pipeline of future physician leaders from within who are known by the rest of the physicians to have shared values. This gives leadership search committees the luxury of being able to decide whether at that moment, what is needed is value disruption or shared values. A health system that relies too heavily and too frequently on recruiting leaders from outside of the organization will have a difficult time developing and maintaining a culture of shared values.

The true value of shared values is in improved physician alignment/engagement and in institutional stabilization.

April 5, 2018

Academic Medicine

Choosing Academic Medical Leaders

I think that every search committee assembled for nominating academic medical center leaders should be required to watch the movie The Replacements before starting their search.

In the movie, Gene Hackman is the coach of the Washington Sentinels, a fictitious professional football team. In the midst of a player’s strike, the team has been repopulated with a group of has-beens and want-t0-be football players, led by Keanu Reeves. Reeves plays the character Shane Falco, a former All-American quarterback from the Ohio State University whose football career crumbled after playing a horrendous Sugar Bowel game and who ends up living on a houseboat and doing boat repair work rather than playing professional football. What makes Falco successful with the Sentinels is not so much his quarterback skills but the fact that he brings out the best in all of the other replacement players, making the team win games as a consequence.

In the last game of the season, the Sentinels’ regular quarterback, Eddie Martel, crosses the picket line to return to the team, sending Falco back to his regular job as a boat mechanic. Martel is one of the best quarterbacks in the country but is a bit of a prima donna and looks down on rest of the team’s replacement players, who he considers rejects and inferiors. Meanwhile, the all of the regular players on the opposing Dallas team have crossed the picket line and returned to work. The first half of the game is a disaster for Washington because even though Martel is an all-star, he can’t relate well to the rest of the Washington players and consequently, they do not play well as a team. As the team is walking into the locker room for half time, Gene Hackman is asked by a reporter what it would take for Washington to get back into the game and he looks at the reporter and says:

“You’ve gotta have heart. Miles and miles of heart.”

That was a verbal signal to Falco, who was watching the game from his houseboat, that the team needed him and so he suited up and returned to the locker room where the rest of the players kick Martel out. Falco and the rest of the Washington replacements then go on to win with a touchdown in the final seconds of the game.

So what does a sports comedy movie have to do with selecting academic medical leaders? Over the past 30 years, I’ve seen good leaders and bad leaders. I’ve seen effective leaders and ineffective leaders. I’ve seen leaders with a long tenure and those with a short tenure. And all too often, I’ve seen leaders selected for the wrong reasons.

We often select our leaders based on their previous personal successes – because they’ve become famous doctors on their own right, because they’ve gotten a lot of research grants, or because they’ve published lots of papers in medical journals. And often what we get is the Eddie Martels of the academic world, people who have had enormous individual success but no track record of making those around him or her successful.

Former Ohio State quarterback Shane Falco was successful with the replacements not because he was the best quarterback himself, but because he brought out the best in all of the other players around him. Or, as his coach said, he had heart.

I think that is what is often missing when we select academic medical leaders. We overlook their passion for the institution and their passion for those who work at the institution. The rank and file faculty and physicians at any given academic medical center are mostly “lifers” – women and men who spend all or most of their careers at that single institution. They take pride in being a part of their university. They’re die-hard fans of their university’s athletic teams. They have jackets, ties, sweatshirts, scarves, and hats with their university’s mascot on them. They bleed (name your school colors). And if they are asked what they do by someone sitting next to them in a bar, they’re more likely to say “I’m on the faculty at the university” rather than “I’m a cardiologist”.

For a leader at an academic medical center to be truly successful, she or he has to have passion for that university. And I think that passion is the overlooked quality that leadership search committees overlook when they are evaluating candidates. A successful leader has to have more than just passion but passion is the catalyst that brings out the best in all of the rest of us. Passion doesn’t show up on a CV. Passion isn’t something that a hired recruitment company looks for. Passion isn’t something you can measure by number of grants or publications.

The best leaders are not the ones who accept your job offer because it was the best of the 4 or 5 that he or she has at the moment. The best leaders are those who accept your job offer because it is what they have always aspired for. Skills are what makes us succeed as individuals; passion is what makes those that we lead successful.

February 17, 2018

Academic Medicine

The Chief Petty Officers Run The Ship…And The Hospital

A few years ago, I took a tour of the USS Midway, an aircraft carrier that is now a museum anchored in San Diego. One of the things that I learned was that the Chief Petty Officers are the people who really run the ship from an operational standpoint with the Captains making the tactical and strategic decisions. There are a lot of analogies with hospital leaders.

Two weeks ago, we had some turmoil at Ohio State when the Vice President for Health Sciences and CEO of the Medical System resigned under pressure from the physician faculty. It caused me to examine who our medical system leaders are and I realized that there are really two tiers of leadership, a lot like the Chief Petty Officers and Captains.

At the top, are the executive leaders: the Chief Executive Officer of the Medical Center, the Dean, the Chief Financial Officer, and the Chief Operating Officer. These are professional leaders; by that, I mean that they are either leaders with a business background who have specialized in overseeing large health systems or they are physicians who have evolved into  leadership roles and no longer are doing clinical care. These are like the Captains. Of note, at Ohio State, all of them are people who were recruited from outside of the University.

In the middle, there are all of the operational medical directors: The Chief Medical Officer, the Medical Directors of each of the hospitals in our health system, and the Medical Directors of every procedure area and clinical program. Every one of these individuals are physicians who have been at our Medical Center for many years who started off as regular clinicians and then were home-grown into their leadership roles. I’m one of them – we are like the Chief Petty Officers.

In academic medicine, the captains have differentiated themselves so much that about all they can do is be full-time leaders. The chief petty officers are generally a lot less differentiated and they typically are also doing clinical care or teaching; in other words, they are not full-time leaders.

Because so many of the captains come from outside of an institution, they are by definition geographically mobile. Because they are mobile, you are always at risk of them leaving to go to some other academic institution, much like the Medical Rock Stars that I wrote about in a previous post. On the other hand, the chief petty officers tend to be geographically fixed, loyal to a single institution, and are less mobile.

In the navy, the chief petty officer is the highest rank that an enlisted sailor can achieve. Because they started off as regular sailors, the rest of the ship’s crew knows and trusts them – the chief petty officers have “been there” and the crew considers them to be one of their own. In medicine, the chief petty officers are the same – they started off as regular doctors and at their core, they still identify themselves as clinicians. They hold the institutional memory of the past years and decades and they are the ones that the rest of the physicians know and trust. They also know all of the bad things that have happened in the past that were swept under the carpet; in other words, they have institutional wisdom.

An academic medical center needs both captains and chief petty officers. For me, I’m very comfortable being a chief petty officer.

June 12, 2017