Why Physician Leaders of Health Care Organizations Should Participate in Direct Patient Care
Venue: Annals of Internal Medicine

Physicians assume a variety of leadership positions in health care. The most common ones are heads of clinical divisions, chiefs and chairs of clinical departments, and deans of medical schools. Some ultimately become chief executive officers of hospitals or health systems. Others lead national medical organizations like the American Board of Internal Medicine or the Royal College of Physicians and Surgeons of Canada. Physician leaders profoundly affect the way health care is delivered. They influence and sometimes determine working conditions; professional standards; training programs; research environments; payment schemes; certification requirements; and the quality, safety, and type of care that patients receive. Before becoming leaders, physicians often demonstrate success in research or education. Many arrive at their positions by taking on the leadership of successively larger and more challenging entities. But all of them start out training as physicians to deliver front line patient care. Physicians who become leaders must decide whether they should continue to participate in direct patient care. We believe that they should. Our opinion is based in part on our involvement in direct patient care while we held leadership positions; thus, we are biased because of that experience (1) Many leaders who are former clinicians believe that they already have sufficient understanding to be effective. We have a different view. Everyone who leaves clinical care, even for a short time, quickly loses the emotional intensity and detailed clinical knowledge that allow full understanding, just as elite athletes lose their competitive edge when they interrupt training. The clinical environment changes constantly and rapidly, so memories are no substitute for continuous participation (2) You understood yesterday's electronic health record, but today's version requires new security measures, limits your drug choices, and allows different options. Yesterday's patients asked you for advicetoday's patients expect something more, and it is not clear what that is. You used to work late at the office and then go home to your family; now you work late at the office and go home to finish recordkeeping and clinical communication on the Internet. Walk around experiences are effective for gathering information and showing commitment to such issues as patient safety (3) but they cannot substitute for taking care of individual patients in real time. Each physician leader will need to determine how to provide safe and effective clinical care by selecting a specific type and scope of practice that match his or her experience and comfort level. Some will work in outpatient settings, some on inpatient units, some in the emergency department, and some in the operating room. Consider the advantages when physician leaders participate in direct patient care. Information is critical to an organization's success, and being on the frontline of the core activity provides information that cannot be learned any other way. For example, nothing helps a leader understand how a medical organization functions as much as being with patients through diagnosis, treatment, and counseling; watching them struggle to improve their health and maintain their dignity; and sharing their frustration when a well conceived plan goes wrong. Also, resource allocation and efficiency in the operating room are central concerns of most hospitals, and surgeons and anesthesiologists who do not work in this setting on a regular basis are at a disadvantage when they make decisions that affect operating room policies and productivity. Another advantage is credibility. There is no better way to establish credibility than for leaders to do the job of the people they lead (2) Being in the emergency department at 8:00 on a Sunday morning or in the intensive care unit at 10:00 any evening will go a long way toward establishing credibility. People can tell what leaders value by observing how those leaders spend their time. It sends a powerful message when physicians who lead the health care organization place clinical care high enough on their priority list to spend time doing it. Still another advantage is personal fulfillment. In our experience, physician leaders actually enjoy taking care of patients because it balances the job. Working one on one helping a patient, as we all were trained to do, diverts attention away from the frustrations that arise when everyone constantly expects their leaders to deliver more and are outraged when they don't (2) Providing direct patient care gives leaders the satisfaction of helping others, connects them with their own humanity, and reminds them to marvel at the wonder of being alive. Working with students and trainees while providing direct patient care is nothing short of inspiring. They help us remember what it was like to be young, and their skill and commitment reassure us that someone will be there to take care of us when we need it. Finally, maintaining clinical skills while being a physician leader provides another opportunity once the term ends. The value of this option should not be underestimated. For example, we have observed that terms for chairs of basic and social science departments are shorter than those for chairs of clinical departments. We speculate that some of this difference arises because clinical chairs lose their clinical skills as leaders, have fewer options after they step down, and thus delay doing so. Physician health care leaders have been given a gift that is unavailable to health care leaders who are not physicians or to leaders of most businesses. The president of a car company can hardly work on the assembly line or sell cars at a dealership. Although some leaders may consider patient care a burden or a distraction, we firmly believe that participation in patient care is time well spent. We expect that our position will resonate with physician leaders who practice medicine. We also expect that it will resonate with clinicians who complain about decisions made by leaders who have lost contact with the realities of day to day clinical practice (4) We recognize that not everyone will agree, and we welcome your comments (5)