The Physician Culture and Resistance to Change. Part III

Physician Leaders Who Have Effected Change

The original version of the this article appeared in Healthleaders News</span> on June 4, 2003

Finding, developing and coaching physician leaders is a growth industry. Hospitals, HMOs, large clinics, and medical companies constantly hunt for physician leaders to help overcome physician resistance to change. Consultants who can spot and nurture these leaders are in demand.

Dr. Brian Campion, professor of Health Affairs and Medical Affairs at the University of St. Thomas in St. Paul, Minnesota., says:

"As a former CEO and practicing cardiologist I know the need for medical leadership in today's healthcare organizations. The practice of medicine has evolved from a cottage industry where physicians in small practices were their own bosses to large, complex healthcare organizations that employ physicians.”

These new organizations require leadership if processes of care are to be developed to provide care at a lower cost.

First-generation physician leaders have failed at an alarming rate due in part to lack of traditional leadership experience and training. We believe that as doctors become more educated and experienced their contribution will enhance their organization's ability to succeed. We badly need to entice more physicians into leadership."

But how can one spot physicians destined to be effective leaders?

In The Effective Executive (Harpers, 1956), Peter F. Drucker saiYW leaders igniting fundamental change share these traits:

• They rely on courage rather than analysis to dictate their priorities.

• They pick the future rather than the past.

• They focus on opportunity rather than problems.

• They chose their own direction, rather than climbing on someone else's bandwagon.

• They aim high, for something that will make a difference, rather than something that is "safe" and easy to do.

• They seek fundamental contributions to improve society.
Over the last five years, I kept these traits in mind as I interviewed 100 physician leaders for my book, A Managed Care Memoir: A Physician's Whistle-Stop Journey and for two nationally distributed newsletters.

What follows are sketches of physician leaders who exhibited these traits.

Dr. Ed Fotsch, CEO of Medem Inc.

In the 1980s, Ed Fotsch, a San Francisco emergency room physician, watched uneasily as medical societies suffered an identity and clout crisis as managed care rose to dominance. The societies' impotence in dealing with HMOs, legislators, and big business contributed to Fotsch's unease. Then, while running a 250-person San Francisco IPA and later an Internet communications company, Fotsch became acutely aware that physicians possessed no communications infrastructure.

In 1999, he became CEO of Medem Inc., an Internet company funded by the American Medical Association and specialty medical societies. In leading Medem, Fotsch set about filling two gaping defects in American medicine:

1. Communication systems linking physicians and patients, and,

2. Computer networks connecting physicians and hospitals.

To fill the first hole, Medem developed two core products – free physician web sites and online consultation services. To plug the second hole, Medem recently agreed with Cerner, a major hospital data systems supplier, to build systems to allow physicians and hospitals to talk to one another. Fotsch's contribution? Uniting physicians around the country by encouraging them to employ information technologies to make leaps in clinical and business efficiencies; achieve revenue increases through these efficiencies, and facilitate communication between physicians, patients, and hospitals. The road to the future, he maintains, is paved with concrete uses of information technologies.

Dr. Harris Berman, former CEO of Tufts Health Plan

Harris Berman is an internist who retired in 2003 after 17 years as CEO and chairman of Tufts Health Plan in Boston, a 900,000-member nonprofit HMO. When he joined Tufts, it had 40,000 members. Tufts now regularly ranks among the nation's top 10 HMOs. Tufts works closely with physicians to help them practice high-quality, cost-effective medicine. He explains:

“Our roots are very much in working with doctors and local hospitals. There is a real advantage to being a local organization instead of a national organization."

Tufts treads lightly on doctors by routinely asking them to evaluate new products. As an example, Berman notes:

"We are developing a state-of-the-art system for operating an HMO. The new system will enable us to collect information from doctors over the Internet and pay them electronically, thus eliminating the paperwork that delays payments. The system will auto-adjudicate claims, speeding payment to providers. Our aims are to increase revenue, reduce overhead and eliminate HMO hassles."

Berman's contribution? As a leader, Berman has always cultivated and asked for the consent of the governed – practicing physicians – before initiating change.

Dr. George Isham, medical director and chief health officer for HealthPartners

Dr. George Islam, internist, represents a new breed – a systems doctor. Systems doctors believe teams of health professionals applying systems to prevent and manage chronic disease can dramatically improve care.

Since 1995, Isham, as medical director and chief health director of HealthPartners, a 670,000-member HMO in Minneapolis, has developed systems approaches to care, resulting in significantly reduced complications and deaths from various diseases. Of diabetes, he says:

"There is a huge opportunity to improve the quality of care for diabetes. We now know what to do and how to do it. The American Diabetes Association has recognized HealthPartners Medical Group as a model for diabetes care. Our program in Partners for Better Health includes deployment of multidisciplinary care teams, a diabetes registry that provides clinicians with automated reminders for needed services, and several educational and counseling programs on self-management, diet, and exercise."

The Institute of Medicine recently appointed Isham to serve as chairman of its Committee on Identifying Priority Areas for Quality Improvement. The committee issued their report, Priority Areas for National Action: Transforming Health Care Quality, in March 2003.

Among areas the committee examined were: asthma, diabetes, evidence-base cancer screening, frailty associated with old age, high blood pressure, depression, end-of-life with organ system failure, children with special health needs, ischemic heart disease and immunization of children and adults. Isham's contribution? Showing that physician-led teams improve outcomes.

Dr. Allen Wenner, Founder, Primetime Software, and Dr. John Bachman, Saunders Professor of Primary Care, The Mayo Clinic

Werner, a family physician in a four man group in Columbia, S.C., and Bachman, a professor of family medicine at Mayo in Rochester, Minn., have worked together for eight years – in their own practices, at physician conferences, and at TEPR (Towards the Electronic Medical Record) meetings in the U.S. and abroad – to perfect and test a patient-generated medical history based on a computer interview. Their work has fundamental importance for four reasons:

1. Taking a patient history is the single most time-consuming aspect of physicians' workdays.

2. Engaging patients to relate their histories to a computer makes them feel like partners in their care. \

3. A patient-generated record produces an accurate, documented and structured record that helps facilitate coding, referral letters, billing, and protection against malpractice.

4. Patient-generated histories enhance productivity, patient satisfaction, and physician revenues.

The typical physician now spends an average of 18 minutes with a patient. To make ends meet under lower Medicare and managed care reimbursements, computer interviews can shorten that time by four to eight minutes.

For 15 years, Wenner has been developing software that makes patient-generated computer history a relevant reality. For eight years, Bachman has tested the computer-aided patient interview in his daily practice at Mayo.

Wenner's and Bachman's contribution? They have shown a computer-aided medical history improves care and documentation, and patients will embrace the idea of having a computer conduct the initial interview before seeing the doctor.

Dr. James Nuckolls, Medical Director of Carilion HealthCare Corp.

Expanding and consolidating medical groups into large practices has become common in recent years. Physicians seek to affiliate with large organizations to provide wide geographic coverage and to leverage their ability to negotiate with managed care organizations. Yet many groups have experienced significant growing pains associated with expansion, mostly due to difficulties in communicating and in maintaining common procedures.

Under the leadership of James Nuckolls, Carilion HealthCare Corp., in Roanoke, Va., has kept its physicians linked by using a multifaceted information system. The group includes 165 primary care physicians and 50 nurse practitioners and physician assistants in 54 locations. Through a common billing system, an Intranet, and electronic patient records, the group has enhanced practice efficiency, facilitated communication among physicians, provided continuing education, improved patient care, and demonstrated value to its constituencies.

Nuckolls has demonstrated that you don't need to be a big-city practice, or to be centered on some large central group, or to have a squadron of big-time specialists offering tertiary care, to make a difference in healthcare. The 165 physicians who make up his practice are largely primary care physicians in the rural Southeast, spread over 250 square miles in southern Virginia and eastern Tennessee.

Nuckolls makes sure his approach works by staying in daily contract by e-mail with his dispersed physician troops.

Nuckolls’ contribution? He has demonstrated an information system can lend coherence to what is often believed to be a "fragmented system," defying rational organization.
New physician leaders are surfacing who share common traits:

1. they have rich clinical backgrounds

2. they have the courage to say frankly that medical care can be vastly improved

3. they endorse physicians working as members of professional teams

4. they believe information technologies offer major opportunities

5. they are willing to spend years of hard work and resources to make their dreams of a better system become reality.