Transitional leaders for transitional times.

In responding to the mandates of an evolving industry, physicians interested in the management aspects of healthcare delivery have taken on entirely different characteristics from their forebears. In the past the populationhealth-oriented physician was a public health officer (and some of these still exist). However, in an era of megamergers and megasystems and groupings of enrollees driven by managed care contracting, population health issues are being addressed by provider systems in the context of the healthcare delivery needs of populations, usually as part of a discussion around costs. The climate of scarcity in resources has seriously heightened the stakes. Against this backdrop, the physician executive has been identified as a management team member who potentially brings value around better cost effectiveness in care delivery. Dr. Guthrie's comprehensive exploration of the core issues and developmental challenges of this new managerial team member is thorough and lays out subtle though important nuances. Dr. Guthrie's sphere of reference is the management team that has not always included physicians-mostly the hospital/ system forums that now commonly include vice presidents of medical affairs or the equivalent. (Large group practices have always had physician executives in management, and in most instances these institutions have required high-level physician leadership to continue with a practice presence as an important way to maintain credibility in a physician-driven organization.) Hospitals and healthcare delivery systems until recently relied on the elected rotating leadership of the medical staff for key medical affairs and medical staff issue resolution; naming and compensating physician executives as core dedicated senior management members is a reflection of the perceived and real complexity and challenge of the medical leadership function. Rarely do physicians attend medical school to become a vice president of medical affairs. In most instances a physician's intent is to care for patients; the executive move is a career add-on, nowadays spurred by the individual's interest in being part of solutions for an industry in turmoil and transition. Thus this is a group of hybrid physician leaders who have been deflected from a traditional clinical career track. At some level all clinicians are inevitably part of a struggle to regain control of healthcare resources, and this group is the vanguard of that movement. The goal is to be part of setting, not just accepting, the terms of engagement in healthcare delivery, and to drive the negotiations and agreement as to where, how, and at what price healthcare needs are met. In today's hospital-centric system, hospitals and healthcare systems are engaging in vigorous ongoing discussions about who is in charge, and the answer is still not entirely clear. Hospitals and systems (at least to the present time) have had the wherewithal to fund initiatives, and have been willing to partner with physicians to work toward shared goals. Therefore, many hospitals and systems have added physicians to the senior management team and have looked to them to drive the care management side of the healthcare discussion, which, from the vantage point of the system, is where their greatest value lies. Although physician executives are appointed, the identification process typically includes serious input and thus buy-in from the physician constituency, and has some of the aspects of a political election. At some level, this "leading with the consent of the governed" is a unique aspect of the largely not-for-profit U.S. healthcare delivery system. Such an approach reflects the fact than a sizable percentage of the physician segment remains economically independent of the healthcare system, even though the two are highly interdependent through shared resources and services. Through joint decisions-selecting physician leadership being one of the most important-physicians and healthcare systems hope to work toward synergistic relationships. …