Do physician executives make a difference

The role of the physician executive was effectively and accurately highlighted in 1989 at a symposium sponsored by the Association of University Programs in Health Administration (1989), and the article by Barbara LeTourneau and Wesley Curry offers a timely, important update on this issue. I fully agree with most of what they have written-including their basic thesis that the field is growing both quantitatively and qualitatively, and that this growth will potentially add value to the performance of the healthcare system in the United States. Let me instead comment on several aspects where I draw different, perhaps sharper, conclusions. The Definition of the Profession There is evidence that the numbers and types of physician executives are increasing, but what exactly qualifies one as a physician executive? Membership in the American College of Physician Executives is one indication, and its growth rate is impressive, but membership is open to whomever chooses to join. In the "Physician Characteristics and Distribution in the United States," the American Medical Association listed 15,684 physicians in 1994 whose primary professional activity was in management, 2.53 percent of all active physicians. The percentage, which was 3.9 percent in 1970, declined from 2.8 percent in 1980 to 2.6 percent ten years later. Many more physicians indicate administration as a secondary or temporary activity, as shown in Table 1 (Kindig 1991). Based on this data, it was estimated that there were 27,635 full-time equivalent physician executives in 1986, an increase of 38% since 1977, mainly in younger age groups; these figures clearly need to be updated to reflect current trends and practices. Is the Physician Executive's Role Unique? The authors seem unclear on this point, using this term several times, but they also indicate that others in the health management team can do many of the tasks as well. Certainly, we can all think of nonphysicians-managers or other clinicians-who excel at different components of the medical management role. I prefer to think in terms of comparative advantage: In a differentiated management team, the physician executive brings an important specialized expertise to the management table, as do others in, say, finance and marketing. I like Paul Ellwood's idea that "medical management is a clinical science," based on such core competencies as medical information systems, medical decision theory, social psychology of organized medical care, and health promotion and disease prevention (Ellwood 1989). Add to these the competencies of managing other physicians and medical ethics, and an important role, full of potential, begins to emerge. Is Clinical Experience Required? To this question I clearly answer "yes," because much of the physician executive's comparative advantage comes from clinical experience-not primarily for the respect of physician peers, as the authors suggest-but mainly the deep and experiential understanding of the medical care process, of the physician-patient relationship, of physician values and culture, of the hidden subtleties of medical ethics, and of the difficulty of the quality/cost trade-off at the individual patient level. This is why the American Board of Medical Management requires clinical board certification and substantial clinical experience in order to sit for the board exam, and why the Administrative Medicine Program in Wisconsin has adopted a similar standard for admission. The comparative advantage disappears if the physician executive has only-or has nevercompleted residency training, even if that manager has an MBA. For this reason I have reservations about the authors' suggestion for management training for medical students and residents. Some understanding of health economics, health outcomes and quality, and trends in managed care is certainly vital for those still in medical training, but more indepth managerial training should wait for this second career in management after an initial one in clinical practice. …