Ronald Feinstein, DMD, MD, FACS
Clinical Professor of Surgery, Keck School of Medicine, USC
Adjunct Professor, Healthcare Systems Engineering Program
Loyola Marymount University
Assistant Medical Director Surgical and Support Services Emeritus KP-WLA
Regional Chief of Plastic Surgery Emeritus, Southern California Permanente Medical Group
The COVID-19 pandemic has acted as a catalyst and accelerant for both cultural and economic changes in the delivery of healthcare in the US. At the same time a light was being shined on the issues of inequities in care and provider well-being, the diverse systems of healthcare delivery were in the midst of large-scale change. The traditional Fee-for-Service model with many different provider groups and independent physician practices continued trending to a Value-Based model driven by the need to be more competitive as reimbursement rewarded measurable outcomes. This change pushed the healthcare marketplace toward major consolidations and mergers with the majority of physicians (up to 70% in one study1) working as employees of hospitals, group practices, or healthcare systems. Recent data from the American Medical Association2,3 supports the trend of mergers and consolidation continuing and prompts the need to understand how best to adapt and succeed as a physician employee or member of a large medical group, hospital, or healthcare system.
What follows is a brief discussion of a few of the important reciprocal behaviors for professional success and fulfillment in a large healthcare organization or group practice where the culture and leadership need to be collaboratively aligned with physician ethical values that place the needs of the patient first.
An appropriate place to start describing how physicians and their organizations can act collaboratively in the pursuit of delivering excellent care is with the physician compact, as described by Silverstein and Korenacki.4 This description is followed by thoughts on the relationships and mutual expectations between leaders and the people they hope to lead and continues with a mention of the value of organizational citizenship behavior, physician engagement, and the important roles of mentors and sponsors in contributing to a successful career.
Jack Silversin and Mary Jane Kornacki, in their teaching module4 on how to lead physicians through change, described the physician compact as the traditional and implicit understanding of reciprocal expectations between physicians and their organizations as the gives and gets between them. The physician gives quality care when treating patients without much focus on the cost while adhering to standards of professionalism. In turn, the physician gets from the organization respect for clinical autonomy, protection from market forces, and certain entitlements commensurate with their status.4 In a recent update to their thinking, which they referred to as the new compact,5 Silversin and Kornacki promote the recommendation that this relationship be outlined in a written document that specifically mentions what had previously been implied. It adds more to the gives and gets between organizations and physicians to reflect current market forces and societal changes that affect the business of delivering care. For example, there is a greater emphasis on stewardship of limited resources and the need for more physician engagement in the organization’s nonclinical activities that align with a shared vision for the future. In return, organizations must provide competent leadership that is collaborative, fosters excellence, and provides stability and security plus the resources needed to pursue the mutual mission of high-quality care.
The realization that the mission of an organization cannot be fulfilled unless the business is successful is an important but sometimes contentious interface between a physician and the organization’s leadership. In this regard, the adage of “no margin, no mission” rings true and needs to be a part of any physician’s perspective on how best to be a partner in the business. It also requires that if the mission is not fulfilled, the business will fail, and if the business fails, the mission becomes moot. A reciprocal relationship is central to individual and organizational success.
The basic qualities of emotional intelligence best described by Daniel Goleman, expounded on in his book Primal Leadership: Unleashing the Power of Emotional Intelligence,6 are an essential part of an individual’s success as both a team leader and in positions of greater responsibility. The principles of self-management, self- awareness, social awareness, and relationship management he describes are essential to being effective as a team leader, which is a requirement of all physicians. Leaders at the organizational level must exhibit these principles to be successful as well. Organizations like the Mayo Clinic7 with its large group practice model recognizes the importance of emotional intelligence and reinforces the development of these behaviors with physicians starting with the onboarding process and continuing with the development of point-of-care leaders. A further validation of this approach is described by Adam Grant from the Wharton School in his book Give and Take: Why Helping Others Drives Our Success,8 which emphasizes that givers tend to be more successful than takers in organizations. Being a giver is a quality that is embedded in the principles of emotional intelligence and in the tenets of servant leadership as describes by Robert Greenleaf 9 where a culture of trust is imbued with unselfish behavior. It is not enough to deliver excellent care, there must be a broader sense of how best to interact with individuals within an organization.
This can be further expanded by the reciprocal interactions and expectations between a senior leader of the organization and the individual physician. Larry Bossidy in his Harvard Business Review article “What Your Leader Expects of You and What You Should Expect in Return”10 goes through a list of expectations that could also be categorized as a part of organizational citizenship behavior as first described by Dennis Organ.1 They both emphasize all the positive and constructive employee actions and behaviors that aren’t part of their formal job description. It is anything that employees do, out of their own free will, that supports their colleagues and benefits the organization as a whole. Bossidy mentions in part that individuals should stay current, drive their own growth, get involved, generate ideas, collaborate, lead initiatives, and be a player for all season. In other words, when things may not be going well, stay in the game. At the same time, individuals should expect their leaders to provide clarity and direction, set goals, give frequent feedback, be accessible, be honest, and provide fair compensation. Dennis Organ describes in detail why the citizenship behaviors of altruism, courtesy, sportsmanship, conscientiousness, and civic virtue are important for being a positive contributor to both organizational and individual success.
These reciprocal expectations of leaders and the people in their organization should be a fundamental element in the organization’s culture. If they are not part of the culture and the physician compact, then the business will not succeed and the mission will not be served.
Part of organizational engagement and citizenship behavior that has reciprocal elements is the activities involved in mentoring and sponsorship. They are reasonable and beneficial ways of helping others be successful and should be cultivated whenever possible. Seeking out a mentor and sponsor should also include, when the opportunity presents itself, filling that role for others. Mentors, for the most part, should be chosen, and sponsors should be sought out to further enhance the work experience and contribute to both individual and organizational success. The current approach to mentoring12 that suggests the mentee choose the mentor is relationship driven, often long lasting, and focused on support and guidance with reciprocal elements that benefit both individuals.
Sponsors and their protégés also have reciprocal relationships where the protégé delivers performance, loyalty, and value and the sponsor invests and advocates while supporting the big picture mission for the group or organization. Both of these reciprocal relationships are essential to foster advancement and often contribute to opportunities to champion or lead organizational change efforts.
The trend toward larger healthcare organizations is continuing, which makes the importance of learning how to successfully adapt to their cultures and leadership an important element of achieving a satisfying and fulfilling career. It starts with choosing the right organization that realizes the business mantra of “no margin, no mission” must be viewed through the lens of a physician’s credo that the mission to care for patients both humanely and compassionately must be integral to its business model to be successful. If the only motivation is to make a margin, the enterprise will fail. Additional elements of their business model must include a systems approach to the well-being of healthcare providers13 and the embracing of equity, diversity, and inclusion.
Physicians should understand the reciprocal relationships between themselves and their healthcare organization. Being emotionally intelligent, engaging in activities beyond direct patient care, exhibiting desired organizational citizenship, aligning with leaders’ expectations, and seeking out mentors and sponsors will contribute to the best chance for a successful and rewarding career.