Can physicians afford not to get involved in hospital administration? Peter P. Morgan, MD, DPH Lynne Cohen

P hysicians used to run hospitals. Now they run into a lay administrator's office with impossible demands, each wanting more space and staff, more money for research and training. That's the stereotyped image of the hospital-based physician held by many hospital administrators, who insist that doctors don't see the big picture, the needs of the hospital as a whole, the budgetary constraints. Can a physician be taught to see this big picture and to become an effective hospital administrator? Today, the major question appears to be: Can they afford not to be taught? The administrator's job description has little in common with the physician's. The ideal administrator is a professional trained to communicate with governments, media and other health agencies, is familiar with product and program evaluation, knows about the roles and rights of patients and employees and is skilled in conflict resolution. Above all, the ideal administrator will appreciate a reality most physicians deny - the impossibility of providing optimal health care to everyone. Hospital administrators' and physicians' objectives differ as much as their job descriptions, and hospital executive offices have become the venue for skirmishes between the two groups. "Blackmail," exclaims Jacques Labelle, president and chief executive officer of the Ottawa General Hospital, "is not too strong a Peter Morgan is a CMAJ consulting editor. Lynne Cohen is an Ottawa-based freelance writer. MARCH 1, 1992

word to describe how physicians deal with administrators." Physicians' demands for space, personnel and research funds seem to be insatiable, he says. "We've increased the number of doctors here by about 35% in 7 years, and still we have new department heads coming into medicine, surgery, obstetrics and gynecology, ophthalmology, and they are all coming here with a desire to bring in a high complement of doctors. In spite of the amount we build, we're never on top of the situation. Where the money comes from, that's my problem. I say, 'look, we've got a bunch of money, if we spend it on bananas, we won't have any for oranges.' The doctors couldn't care less. They want both the bananas and the oranges." Labelle believes the misunderstanding developed because physicians are paid from what are ostensibly money trees - government health insurance plans while he is supposed to keep to a fixed budget. The Ottawa General's chief of medical staff, Dr. Jean Maroun, is one of the doctors feeling the resource pinch. "The pure administrator can't appreciate the needs in patient care," he says. "The doctor's function is to treat patients and to address the needs of the community in terms of illness. To do that we need resources. If you give me the mandate to deliver care, I need the right resources to do it." Dr. Catherine McCourt agrees. "I see administrators as setting the stage for doctors to do their work," says McCourt, a physician who holds a master's degree in health administration (MHA)

and is former associate director of the CMA's Department of Health Services. "That's how the two [groups] should complement each other." Labelle admits his physicians' preferences for favoured programs and facilities still carry a lot of weight. Why? Competition. "As a teaching hospital, our mandate is to stay at the leading edge of technology and research. We want to have the most skilful, the most advanced doctors. So if we say 'No' to the chief of medicine, there is always the chance that he will go across the street and develop his program there." Nevertheless, the imperatives of Canada's health care system have toughened today's administrators. "Historically, it was [the administrator's] job to keep the peace with the medical staff, supply the doctors with resources so that whatever the doctors chose to do got done," observes Dr. Ralph

Sutherland, a general practitioner

who used to be a faculty member with the University of Ottawa's health administration program. Now an adviser to Ontario's minister of health, he says today's administrators have to be tough if they are "to disappoint a dialysis group or a battered-women's group or an emergency-care group, saying to them, 'I'd love to care for you but I don't have the money. I've examined your need and I don't find it to be as great as the needs I'm already meeting.' " Sutherland notes that nonphysicians usually decide on the allocation of resources. "Doctors . . . can only make decisions at the low, technical levels . . . when it's already been established how much money ought to CAN MED ASSOC J 1992; 146 (5)

751

be spent in a particular area." Overall, physicians' clout in hospital administration seems to be dwindling in the face of global health planning and increasing budgetary consciousness. However, it is timely that physicians appear to be returning to hospital management, this time as trained managers; some keep their clinical positions, while others serve as full-time executives. In his 1991 presidential address to the Association of University Programs in Health Administration, Gary Filerman, PhD, maintained that "the changing role of physician managers will be one of the most significant developments in - and potential contributions to - health care management in the 1 990s." There are numerous reasons for this resurgence: protection of professional turf, expansion of personal competence and fascination with the wider world of policy and administration. McCourt summarizes doctors' evolving interest in hospital management this way: "Physicians make better health care administrators than nonphysicians because they have a feel for the bottom line in health care, which is the provider-consumer relationship. Their training is rigorous, they're taught self-learning and self-motivation."

"There's no question about the need. -As soon as the physician gets any administrative responsibility, he or she should start training." Dr. Alan Hudson

752

CAN MED ASSOC J 1992; 146 (5)

However, a physician without appropriate training may have difficulty coping with today's administrative hurdles. Dr. Alan Hudson, who was recently appointed president of the 1220-bed Toronto Hospital complex after serving as its surgeon-in-chief, observes: "There's no question about the need [for training]. As soon as the physician gets any administrative responsibility, he or she should start training." Jim Pealow, president of the Canadian College of Health Service Executives (CCHSE), doesn't feel that physicians are necessarily better administrators than nonphysicians. "It's whoever has the better training," he says. However, Pealow does see "increasing pressure on doctors to play more administrative roles, to understand finances and the impacts of utilization patterns. Medical school doesn't prepare them for that." By far the most popular training program is the Physician Manager Institute (PMI), a joint program of the CMA and CCHSE. The latter group represents 3100 senior health executives from government, hospitals and universities, and has been certifying health administrators through a tough fellowship program. The

PMI programs were introduced in 1984 after the CMA General Council passed a resolution calling for increased physician involvement in management both in hospitals and within the health care system generally. Some 1500 doctors have taken PMI courses, which Hudson strongly endorses. Physicians, usually ones who already hold management positions, take the courses in various locations. "We cater mainly to chiefs of staff, department heads and medical program directors," says Pealow. "We teach physician managers who are doing administrative jobs for a term and those who are in it for the long term. When they arrive doctors are missing a lot of the fundamentals of management because they never took them as part of their medical training - they never even thought about managing." Alexandra Harrison, the CMA's director of educational services, says the PMI courses have a big advantage over other types of administrative training: "Physician managers get the opportunity to meet with their peers. PMI courses provide a chance for physician managers to share their struggles. The PMI is a particularly valuable service to physicians in small towns and community hospitals because they may not be able to access other management programs." "When we started the management program in 1984, it dealt with the basics, like the foundations of management," says Maria Reardon, CCHSE's vice-president of professional services. "The demand for the course was so strong we added more modules." Reardon thinks physicians' attitudes shift after a few days in the PMI program. "When they come in, they have the idea it's 'us versus them.' When they leave, they see there's more to health administration than money." However, some educators from the health administration LE Iler MARS 1992

field are against PMI-type programs. Jean-Claude Martin, coordinator of the Canadian arm of the Association of University Programs in Health Administration, and the executive in residence for the University of Ottawa's Faculty of Administration, feels strongly that doctors must be trained in administration, but alongside everyone else. "There is definitely a great need for doctors properly trained in management," he says. "Because doctors are responsible for big budgets, like other departments they also must be accountable. All managers should be educated together - lay, physician and housekeeping managers. When we go into real life to manage an institution, we don't say 'I'm here as a doctor.' Rather, it's 'I'm here as a manager.` Martin believes that university-based MHA programs "are terrific training grounds ...

there is nothing else, really." McCourt, one of the small number of Canadian physicians to have completed an MHA, says the University of Ottawa program offered her everything she wanted, and exposed her to the expertise - and points of view - of other medical and nonmedical professionals. Initially, she admits, she was put off by the "almost tangible atmosphere of challenge toward the doctors' historical role as top dog in the health care system." Sutherland, a full-time faculty member in the Ottawa MHA program for 22 years, disagrees vehemently with the idea that doctors should take MHA degrees. Frustrated with the program, he and health policy analyst Jane Fulton resigned their positions in the MHA program in 1987 and transferred to the university's Department of Administration. "Not many doctors want to

take 2 years out of their life for a master's degree," he notes. "Time and cost are real factors, unless someone is subsidizing them. Also, most doctors know they will never be low-level managers directors of purchasing, for example. They're hired into management and put in charge of departments or hospitals. The first years of the MHA programs are very basic - they teach low-level accounting and a lot of other primitive courses. Doctors don't need or want to take a full year of accounting and other stuff they'll never use.", Indeed, even Martin sees problems with the MHA that won't go away because "you can do very little with people who have tenure." All universities and all programs face the same problem - they would like to have a higher staff turnover. "At one time, you could just hire more people, put the older professors in

BECONASE Metered dose aerosol (intranasal beclomethasone dipropionate)

BECONASE Acj Nasal Spray And l~_w

^d

INDICAFION1S: tment of perennial and seasonal allergic rhinits poorly responsive to conventional treatment. To delay recurrence of nasal polyps following polypectomy. Prevention of increase in size of recurring polyps. CONTRANODICANONS: Patentswith active or quiescenttuberculosis or untreated fungal, bacterial, and viral infections. MRNINGS: In patients priously on high doses of sWtemic steroids, transfer to BECONASE may cause withdrawa symptoms such as tredness, aches and pains, and dep on. In severe cases, adrenal insuflidencymay occur, necessitatingthetemporaryresumption of systemicsteroids. Safe of use in prgnancy has notbeen established. Administration of drugs during pregnancyshould only be considered ifthe expected benefittothe mother is greater than any possible sk to the ftus. PRECAUTIONS: Repladng a sysbmic steroid with BECONASE has to be gradual and carefully supervised. Guidelines under "Administration" should be foll~d. Corticosteroids may mask some signs of infection and new inifections may appear Decreased resistance to localiz infection has been observed dudng coricosteroid therapy. During long-term therapy, pituibary-adrenal function and hematoogical status should be perodically assessed. There is an enhanced effect of corticostorids on patients with hypothyroidism and in those with cirrhosis. ASA should be used cautiousy in conjuncion with corticostoroids in hypoprothrombinemia. Advise patents to inform subsequent phyicians of priorcorticosteroid use. Durng BECONASEtherapy, the possibilityofatrophic rhinitisandlor pharyngeal candidiasisshould be keptin mind. Fluorocarbon propellants may be hazardous if deliberately abused. lnhalaton of high concentradons of aerosol sp"r has brought about cardioascular todc effcts, and even-death, especially under conditions of hypoxia. However, evnie atteststo the relative saty of aeross when used intranasallyw tth adequate venilatlon. ADVERSEREACflONS:Side flecshavebeen primailyassociatedwiththe nasal mucousmembranesandareconsistentwlthwhatonewould expectfromapplyingatopca medicaliontoanalreadyinflamed membrane. Other less fruent adverse effects include sore throat, cough, headache, dizziness, nausea, ltargy, and stomach pains. When patients are transferrd to BECONASE from a sstemnic steroid, allergic condffions such as asthma, conjunctivs, or eczma may be unmasked. DOUSE AND ADUINISORATION: Patents wth no preous systemic steroid use - Two applicatons (100mcg) in each nostril twice daily. Maxnim - Adults: 12 applicatons/day; children: 8 applicatons/day. When used concurrenty with BECLIIENT, combined total daily dose should not exceed maximum daily recommended dose of beclomethasone dipopionate (1000mcg). Safety and efficacy of BECONASE in children under6 years of age has not been established.. Since the effect of BECONASE depends on regular use, patients maybe instructed to take inhalatons at rgular intervals and not, aswith other nasal sprays, as they feel necessary. They should also be instructed In the metod which is to blow nose, insert nzzlefirmly into nostnl, compress opposb nostnl and actuate acrosol orspraywh k insprng through nose, with mouth closed. In the presence of ecessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of action. in such cases, use avasoconstrctor for 2 to 3 days prortoBECNASE. Careul attention must be given to patnts prevnouslytreated for prolonged pedodswith systemic corticosteroidswhen transferredtoBECONASE. Initally, BECONASE andthe sytemiccorlicosteroid mustbegivenconcomitanty, while the dose of the latteris gadualydecreased. Usual rate of withdral ofsstemic steroid in adultsIs t1O mg of prednlsone (orequvalent) at no less than weeklyintervs if paent is under close supsion. In children er 6 years of age, the rte of withdraal is 1t mg of prednbone (or equivalent) every 8 days under ciose SUpervsion. If continuous supervision is not feasible, withdwal of the systemic steroid should be slower. approxmately 1.0 mg of prednisone (or equivalent) every 10 days in aduls and every 20 days in children. If wihdrawal symptoms appear, the previous dose of the systemic steroid should be resumed for a week before further decrease is atempted. AILAINILITY: BECONASE - Metered-dose aerosol deliverlng 50 mcg beclomethasone dipropionate wifth each depion ofvalve. 200 dosescontainer. BECONASE Aq - Suspension in amberglass bottle fitted with a metered atomiing pump and nasal applicatordeliverng Smcg beciomethasone dipropionate per spray. 200dosesoe. Product Monograph available to phystcians and pharmacsts on request. For additonal information on BECONASE Aq Nasal Spray, call Glaxo Medical Information at 1-80046684051, Mondayto Friday between 8:30 a.m. and 4:30 p.m. EST REFERENCES: 1. Resratory Dise Trmcidng Study, Data on Rle, Glmo Canada Inc, May 1991.2. Beconase Product Monogph, Ghaom Canada Inc., 1991. 1 Juniper E.F, Kin PA., Hargr, FE., C Dolovitch, J., "Conpafson.of b tsne dipmoonate aqwous nasal sp#, asmio e and the combinabon in the pro w haft~ of d polknsinducd rliqu "vids", JAr -E. An knmu .: vo183, Na a March 1989, pp. 627633 4. Beick, KI.J.. ienon, GS, Cherry, l R., "A compae tstudyfbecoetasonedi onate aqueous nasal sprywfith teenadine tablets in seasonalallergic rhinits CtrrMedRes OpIn;9(8) pp. 560567 1i. BECONASE@ and BECOO Aq@ are registered traedmarl of the GWaxo group of companies. Glaxo Canada Inc. Product monogrph ailable to physicians and pharmadist upon request. (indicated for the treatment of perennial and seasonal alle*ic rhinitis unresponsive to conventional treatment)

£/axo MA-AM I

T

I TS

'E L- I E F RE L IE F,

..R

:.ttv. N 'L Y

O N LY

YO

U

Y OU

C

A

N

C AN

(beclomethasone dipropionate aqueous suspension)

P

R

E

S.

C

R

I

B..

..

PR E SC R IBE.

the corner. But now there is no money to hire extras. As a result, the curricula are not as cutting edge as some would like." In Sutherland's eyes, MHA programs fail because professors fail to stay on top of healthadministration issues. "I think the most telling statement about MHA programs in Canada is this: if you think of one centre in the country where health policy and cost-effectiveness are being studied, you would think of McMaster University in Hamilton. McMaster doesn't even have an MHA program, but it is where health economics is looked at and studied. It has an annual policy conference which is the most prominent in the country." Jeffrey Lozon, who was president of the Glenrose Rehabilitation Hospital in Edmonton until he was named executive vicepresident and chief operating officer at St. Michael's Hospital in Toronto last summer, is a 1978 graduate of the University of Alberta's Health Services Administration Program. "I didn't think [the program] was particularly useful from the perspective of learning how to lead or manage people," he says. "We spent too much time on things I have not used regularly - I haven't used the statistical work to the extent it was taught." He also felt the Alberta program, at the time probably the best of its kind in the country, focused too much on finances and economics, and too little on ''some core management and leadership skills that could have been taught in greater detail." Public health administration, a field that physicians still dominate, may be another jumping-off point for physician training in hospital administration. Dr. Stephen Corber, the medical officer of health for the Ottawa-Carleton region, says he and Dr. Robert Spasoff, director of the epidemiology and community medicine res754

CAN MED ASSOC J 1992; 146 (5)

idency program at the University of Ottawa, will be adding material to that academic program. New topics will include "strategic planning, setting goals for an organization, looking at different organizational models as the best way to deliver programs, team building and communications, personnel management, such as hiring, union agreements, disciplining, performance appraisals, and how to budget." He says these areas are not covered in medical school. Corber explains that even though the additional teaching will focus on running health departments and health units, while the MHA program focuses on running hospitals, he and Spasoff will be borrowing the expertise of professors from the MHA program. Regardless of how training programs evolve, physician managers will be confronted with the same problems as lay administrators. They, too, will wince at the seemingly incessant demands of department heads for money, space and staff, while supervising an increasingly complex operation on a shrinking budget. What will physician administrators be able to achieve that lay administrators cannot? Filerman

thinks they have three advantages: shared interests with other physicians, insight into doctors' motivations and a high level of trust. The physician administrator will interact with other doctors in such practice-related areas as improving the quality of care and technology assessment. Since organizational policy will increasingly take precedence over individual decisions in health care, Filerman thinks it is vital that physicians have immediate input into, and some sway over, those organizations. Robert Evans, a University of British Columbia health economist, emphasizes the importance of rationalizing services by defining appropriate care, a job he feels administrators are not qualified to do. "Patients with basically the same conditions are in hospital for very different lengths of time, and there are different criteria for surgery, with different outcomes, including different infection rates, mortality rates, et cetera, for patients with the same condition. It seems to me it's the responsibility of the medical profession collectively to establish that these [unjustified treatment differences] are happening, rather than just close its eyes." Physicians themselves, Evans argues, need to standardize methods of care by assessing patient outcomes and mortality rates and then policing individual doctors to make sure they conform to standards. There should be "appropriate penalties" if standards aren't met. These proposed tasks for the hospital-based physician may seem overwhelming. Hudson, fresh from his practical experience in reorganizing the Toronto Hospital's surgical services, sees it this way: "Each physician down the line is acting as an administrator. The tools are budgetary. Physicians must get themselves into the Lozon: more focus needed on leader- budget game, and then prove themselves."m ship LE ler MARS 1992

Can physicians afford not to get involved in hospital administration?

Can physicians afford not to get involved in hospital administration? Peter P. Morgan, MD, DPH Lynne Cohen P hysicians used to run hospitals. Now the...
2MB Sizes 0 Downloads 0 Views