MANAGED CARE November 2003. ©MediMedia USA
She's in the forefront of efforts to define the unique domain of doctors who become managers. One thing she knows for sure: Trustworthiness is everything.
Appropriately, for someone whose research includes looking at physicians who cross professional boundaries to become executives, Kathleen Montgomery, PhD, is something of a boundary buster herself. As her professional affiliations attest, she has an active interest in health care, management, and sociology.
An associate professor of organizations and management at the Anderson Graduate School of Management at the University of California, Riverside, where she also chairs the department of management processes and systems, Montgomery has written extensively on the hybrid phenomenon of physician executives that has sprung up in response to the need for leaders who combine clinical and business expertise.
Successfully negotiating — while seeking to narrow — the chasm separating clinicians from executives requires an ability to gain and hold the confidence of both sides. That ability often hinges on an ancient virtue: trustworthiness. It may be difficult to quantify, but trustworthiness can be distilled to a few key characteristics, notably competence, benevolence, and integrity.
Montgomery earned a bachelor's degree from American University in Washington, D.C., and master's and doctoral degrees in sociology from New York University. Her perspective has been deepened by stints as a visiting scholar in Australia and France. She spoke recently with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: Why do physicians decide to become executives?
KATHLEEN MONTGOMERY: There have been so many changes in health care over the last 25 years, changes that have only accelerated in the last 10 to 15 years. Decisions about what health care treatment one should have traditionally had been based on a physician's own unique experience and training. Those decisions now reflect evidence-based medicine and clinical protocols. There have been great changes in how care is accessed, monitored, paid for, and financed. Each of those changes brings an additional layer of management and administrative oversight. So it's almost been inevitable that some physicians, when confronted with additional layers of administration, would decide to get involved in a more hands-on way rather than just having change imposed on them. A physician I interviewed very early on in my research said, "Well, if we can't beat 'em, let's just join 'em and lead 'em." It's worth noting that many physicians who have gone over to the management side have gone in as leaders at the top from the beginning, rather than having to start at the bottom and work their way up. The MD credential carries so much cachet that I have encountered a number of physicians with virtually no management education and very little management experience who took on extremely important executive positions.
MC: Physician executives cross a boundary between two professions. Talk about the concept of boundaries and what it takes to cross them.
MONTGOMERY: In health care, the issue of boundaries is longstanding, primarily with regard to different clinical specialties. These boundaries define the domain that various clinical specialties are responsible for and who can have entry. Often, these boundaries are based on credentialing and are self-established. Specialty certification is a self-established boundary set that serves as a signal to people inside and outside the group. We don't even think about negotiating those boundaries until they become challenged or until we engage in some boundary-spanning activities. For example, obstetricians have worried about their boundaries from encroaching occupations like midwives. When you have professionals like physician executives, whose job is explicitly to cross boundaries, it becomes especially challenging to try to figure out what is it that they do that is unique so they can be recognized as a distinctive unit. Their core work is much more boundary spanning than, say, someone in a clinical specialty, so they wrestle with the issue of boundaries every day.
MC: Is there a typical path that physicians take on the way to the executive suite?
MONTGOMERY: No, there doesn't seem to be any one normative path of education that we're seeing the physicians follow.
MC: Is there one that tends to be a predictor of success?
MONTGOMERY: That's a good question and I don't have an answer to that. Partly it's because it's difficult to measure success. It's very difficult to say how much of an organization's performance is affected by the fact that it has physicians in executive roles. Organizations seem to assume when they decide to bring physicians into high-level management positions that they need someone who will be a liaison to help articulate the organization's strategic direction and decisions to clinicians and communicate the views of clinicians back to management. That doesn't always work. A lot depends on the individual capabilities of the person in that role. We have some evidence that indicates that clinicians become quite distrustful of physicians who have gone over to the other side.
MC: Over to the dark side, as some physicians would see it.
MONTGOMERY: We know from a number of case studies that people who are still on the clinical side aren't particularly happy dealing with those whom they now consider former colleagues. Much of that is a function of the individual and of the trustworthiness of the person in this very difficult hybrid professional position. Much depends on individual capabilities and interpersonal skills. Does the person act with integrity? Has the person demonstrated a history of competence as a physician as well as competence in management? It is an extremely difficult set of skills to maintain.
MC: Do physician executives need to continue to spend at least part of their time in clinical practice to maintain credibility with other physicians?
MONTGOMERY: People in this hybrid profession wrestle with that all the time. My research has shown that they ultimately end up intensifying the amount of time in management partly because it's such a challenge even for full-time clinicians to stay on top of the latest research in their field. Physicians recognize this and don't want to put themselves in a position of not being able to be at the top of their specialty as clinicians. So ultimately, as they get into their management career they eventually stop doing clinical work. Part of it depends on their specialty, but for the most part physicians themselves acknowledge that it is an extremely difficult balancing act to try to do both well.
MC: Have you seen any evidence that physician executives have a hard time gaining the confidence of executive colleagues who have come up through the ranks, earned MBAs, and spent their careers in management, just to have people who have been trained in a very different line of work come in and say, "I can do what you do, too."
MONTGOMERY: Sure. That's been a challenge and probably more than anything is what prompts physicians who are going into management to go back and get a formal management degree. They need that credential to appear credible to their nonphysician colleagues. The phrase "selective signaling" describes how sometimes physicians will emphasize their MBA or the graduate management education they've had when they're talking to nonphysicians and emphasize the MD credential when they're talking with clinicians. They walk an interesting tightrope. Another colleague of mine has referred to this as the paradox of legitimacy. You use different credentials to appear legitimate depending on your audience.
MC: Is there a particular specialty of physician that tends to end up in these hybrid roles?
MONTGOMERY: More come from the primary care specialties and fewer from other specialties. Internal medicine was perhaps most represented.
MC: You write that trustworthiness is crucial to the success of a physician executive. What traits make someone trustworthy?
MONTGOMERY: Trustworthiness is especially important when you're dealing with situations of uncertainty because trust is most important when people feel vulnerable. Trust is necessary when you can't control the actions of someone else that may have an impact on you. It's hard to think of many other industries where people feel more vulnerable than health care, both on the receiving and delivery ends. A model of trust development that has been synthesized from a lot of the research suggests that trustworthiness falls into three categories: competence, benevolence, and integrity. Competence has to do not only with one's credentials, but also with how one has performed in one's job. For physician executives, not having an MBA may not be critical if the individual has done a superb job leading a medical practice or hospital. The credential isn't the only signal. Benevolence is a reflection of compassion, of how much the person truly seems to care about others and not be self-interested. Integrity is a wonderful word that people throw around, but what does it mean? It has components of honesty, follow-through, and fairness. Do you do what you say you're going to do? Realizing, for example, that missing deadlines can erode someone's perception of your trustworthiness may help people to realize that letting deadlines slide can have more far-reaching implications than they realize. Fairness is tricky as an aspect of trustworthiness for physician executives because people define fairness in different ways.
MC: If you're fair to me, you're fair.
MONTGOMERY: Yes. It's important to be able to articulate the assumptions that drive your perceptions of fairness and recognize that not everyone perceives fairness the same way you do. This is at the heart of many clashes between the medical profession and the management of health care. Are we looking at fairness at a micro level, as it affects an individual patient, or from a macro level, and what's fair for the population? Either definition can be justified intellectually.
MC: You have identified three areas of focus for physician executives: quality assurance, communication, and conflict mediation. What skills are needed to be effective in those areas?
MONTGOMERY: You've got to be able to be perceived as a trustworthy person by all sides involved in the mediation or the negotiation. That requires integrity and the perception that the person can speak convincingly for both sides.
MC: To what degree are physician executives recognized as a profession?
MONTGOMERY: Efforts in that direction over the last 15 to 20 years have sputtered. The main association for physician executives is the American College for Physician Executives, made up exclusively of physicians. There's also the very large and very long established American College of Healthcare Executives, but physicians constitute a much smaller percentage of its members. ACPE initially hoped to achieve medical specialty certification similar to the American College of Physicians or American College of Obstetricians and Gynecologists, but that didn't work. The difficulty is that, unlike with OB/GYN or other medical clinical specialties, defining the unique domain of physician executives has been elusive. It's been very difficult to say, this is exactly what we do and no one else can do this.
MC: Do you have any insights into the personal toll that's being exacted on people who work in the buffer zone between two sometimes-conflicting groups of clinicians and executives?
MONTGOMERY: I began this research with a working hypothesis that they were fed up with the intrusion of management, and were grudgingly going into management. I was pleasantly surprised to find that many of the physicians I interviewed were embracing this career shift because they wanted to be leaders of health care. They had been leaders all along, from their earliest times in medical school and through their residency training. So maybe they had been frustrated because they weren't able to have a larger policy making and leadership role. One wonderfully optimistic perspective on these physicians is that we're seeing the cream of the crop of leaders among clinicians who are finding ways to use those talents more directly.
MC: Thank you.