Viewpoint
Physicians in Governance: Their Unique Learning Curve
By Joseph S. Bujak, M.D.
Lay members of health care organization boards value physician membership/participation. The nonclinician trustees understand that they lack firsthand knowledge of patient care processes and rely on physicians' insights to help guide decision-making. This is especially true on issues that address clinical quality, patient safety, credentialing and privileging.
Why might physicians be attracted to serving in a governance capacity? It is with the goal of preserving the physician's preeminent role in health care delivery that they first approach the task of governance. Physicians characteristically have a linear and narrowly focused view of the health care enterprise. They want to have input into decisions that have a clear impact on their capacity to deliver care and to continue to earn a living free of excessive or unfair competition. Moreover, they want to defend themselves from infringements on the free expression of individual physician prerogative.
It is important to appreciate that there are aspects of physician culture that present barriers to their ability to serve the governance function. Above everything else physicians traditionally value their personal autonomy. Each physician views himself or herself as the captain of the ship. As members of an expert culture they make decisions from the personal perspective of what impact this will have on them. Physicians rarely speak in the collective we. Rather, it is the I perspective that dominates. By virtue of their authority, physicians make pronouncements with the expectation that their orders will be followed.
Often seen as being all-knowing on issues of patient care, too often physicians see that authority extended beyond the narrow limits of their own practice. They are frequently accorded deference on matters well beyond their expertise. This expectation makes it exceptionally difficult for physicians to openly express vulnerability, something essential to the capacity to learn.
To govern effectively, physician trustees must come to appreciate the necessity of assuming a "big-picture" perspective on health care. This is dramatically opposite to the practicing clinician's perspective. David Eddy, M.D., a thought-provoking writer on health care issues, has described this as a "problem of the apostrophe." The physician's ethic demands that he or she serve as the patient's advocate, doing everything short of harm, to benefit that patient regardless of the patient's ability to pay. The governance ethic demands that trustees serve as patients' advocates, seeking to create the greatest good for the greatest number. Each of these positions is supported by a distinct and equally valid set of ethics. However, no individual can operate in both systems simultaneously.
Another challenge for the physician trustee is the need to unequivocally support the consensus judgment of the group. Because the physician's professional world values individuality, it is difficult to set aside personal opinion when it might be in conflict with the view of the majority. And yet, that is demanded of those serving in governance.
Generational differences further complicate the issue of physicians in governance. Older physicians have a value hierarchy different from physicians under the age of 40. Older physicians are dominated by a commitment to professionalism and the need to be in control. Younger physicians see having a balanced lifestyle as preeminent and are much more willing to disengage from the physician role when they are not formally "on-call." This significantly colors their respective views and priorities, making it all the more difficult for the board to plan strategically. Younger physicians have neither the time nor the inclination to seek a governance role. The older physicians, who might be attracted to governance, bring with them a view that isn't shared by 40 percent of their colleagues.
What can physicians gain by participating in governance functions? The most significant deliverable is an appreciation for the complexity of the enterprise and the difficulties that attend maximizing performance of the whole. The cost of labor, supplies, training, information systems, and other operational components will astound them. The burden of regulation, accreditation, and effective communication will overwhelm them.
They will become frustrated by having to acknowledge the often self-serving behaviors of their physician colleagues. Review of data that challenges the quality and safety of patient care in their own institution will prove quite sobering. They will come to appreciate and value the talents and commitment of those who serve in administrative and governance capacities. Additionally, they will come to value even more the commitment, compassion, and caring that are demonstrated every day by nonphysicians who are laboring in the service of their patients.
They will begin to see the enormity of the challenge of trying to maintain a community asset that seeks to serve everyone and come to appreciate that the ability of this asset to continue in such a capacity is most challenged by the needs of their physician colleagues. Identifying with the community brings a totally different perspective to the challenges of creating access and providing safe, quality care to those in need, irrespective of their ability to pay.
Physicians who would serve as trustees are presented with unique challenges and opportunities. In exchange for overcoming the barriers that are imposed by their professional culture, they will be rewarded with an opportunity to serve at a level that transcends and multiplies their capacity to serve individual patients.
Joseph S. Bujak, M.D., is vice president of medical affairs at Kootenai Medical Center, Coeur d' Alene, Idaho, and a frequent speaker, facilitator and consultant on issues related to health care organization-physician relationships. He can be reached at (208) 666-2014 or jbujak@attglobal.net.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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