Suits and Coats: Administrators and Physicians at Baylor College of Medicine

In the Spring and Summer of 2017, the Doerr Institute for New Leaders at Rice University awarded the HRC a leadership development grant to advance the center's medical humanities programming and promotion of undergraduate research, specifically in the area of "Medical Leadership." With supplemental support from the HRC, the HURC 306 course on "Medical Leadership" was complemented by a speaker series on the subject, bringing in experts on the topic from Houston and beyond. Read more on the speaker series here. In the Summer, the HRC awarded three research fellowships to non-graduating undergraduates, to pursue their own research projects on the topic. Working with medical faculty at Baylor College of Medicine, Augusto De las Casas worked with Dr. Ricardo Nuila to study leadership in the context of medical translators' work, Sarah Lasater worked with Dean Jennifer Christner's office to study leadership in the context of physician professional education, and Shaian Mohammadian worked with Robert Trieu's office to study leadership in the context of hospital administration.

Healthcare literature often speaks on the relationship between administrators and physicians as markedly tense, sometimes referring to administrators as “obstacles” to physicians and acknowledging rifts in the relationship between the two parties due to their differences in work priorities.  While administrators often focus on maximizing profits and efficiency, physicians typically focus their efforts towards patient care and experience.  This summer, I set out to learn more about how these two parties coexist at Baylor College of Medicine (BCM) and attempt to identify characteristics that I observed that strongly molded this coexistence.

Through the help of Robert Trieu, Director of Clinical Affairs at BCM, I was able to interview a number of prominent administrators and physicians from a medley of different departments at BCM about their day-to-day work lives and their thoughts on the subject.  These interviews ranged from 15 minutes to about 90 minutes in length, and were extremely helpful in giving me insight on the subject.  I was presented a lot of information, much of it useful, but I homed in on three specific topics that I felt were the most significant and ubiquitous in the interviews: collaboration, communication, and professionalism.  These three subjects, to me, are the pillars of the foundation of the relationship between the two parties at BCM, and I believe that success in each of these facets of the foundation helps to explain why the administrator-physician relationship at BCM deviates from the literature.

Collaboration comes hand-in-hand with any partnership.  Whether it be a conversation, a team project, or a committee, working with others is inevitable in the workforce.  John W. Gardner, a former U.S. Secretary of Health, Education, and Welfare, wrote many novels on his thoughts on leadership, many of which clung onto his idea of collaborative leadership.  He details that collaborative goal-setting and problem-solving are his most important leadership “truths.”  Throughout my interviews, I was constantly reminded of the importance of collaboration at BCM.  Terri Lee, a former Director of Front Desk Clinical Operations at BCM, describes a lack of collaboration as missing out on an opportunity to achieve the best result.  Because she was in charge of numerous front desks spread across all of the clinical departments at Baylor, collaboration and consistency were essential to her.  Not only did she have to work on normalizing all the front desks to increase patient satisfaction, but she had to make sure that the physicians in each department were on the same page as their administrative counterparts at the front desk about how their department wanted patients to be treated and served.  Dr. Ellen Friedman, a renowned Pediatric Otolaryngologist and the Director for the Center of Professionalism at BCM, agrees, stating that a “mistake” physicians make too often is not involving themselves with their administrative counterparts more.  Ironically, this “mistake” was described to me on numerous occasions during the interviews: a general tendency for the two parties to purposefully handle their own responsibilities in an isolated fashion and let the other party take care of their responsibilities, limiting collaboration and interaction due to their unfamiliarity with the other party’s work and meaningful intention to dissuade conflict.  Although this intentional isolation allows for the evasion of potential tension, it prevents the opportunity for both parties to better understand the other side’s responsibilities and daily work.

Dr. James L. Reinertsen, an esteemed rheumatologist and prolific writer on health care leadership development, wrote an article entitled “Physicians as Leaders in the Improvement of Health Care Systems,” a guide on how to be an effective physician-leader in today’s healthcare world.  In the article, he claims that some administrators may look down upon certain physician-leaders as “amateur administrators” who are incapable of doing administrative work due to lack of training.  Conversely, he claims physicians typically point their fingers at administrators as their most significant “obstacles.”  This thinking, coupled with the tendency for both parties to stay tightly bound to their own work circles, can severely decrease the likelihood of collaboration between the two parties.  In an effort to promote and facilitate collaboration at BCM, Dr. Friedman is implementing a program that involves taking an individual and allowing them to shadow another individual of the different party for an entire work day, allowing them to observe first-hand the actions and responsibilities of their colleagues.  This program was mentioned by a few of my interviewees with positive anticipation, as they believe it will greatly enhance relations between the two parties at an institution that already seems to have an impressive attention to and appreciation of collaboration.  Karla Heath, Director of Clinical Operations, mentions another process that, in her opinion, has helped facilitate collaboration as well as improve understanding at least from the physicians’ point of view: the acquisition of an MBA or MHA degree in addition to their MD.  Mrs. Heath claims that this allows the physicians to better understand the administrative world, as they learn about the skills necessary to perform and reasons for carrying out administrative work in their MBA or MHA programs.  They also can work more collaboratively with their administrators and suggest more realistic solutions to problems that their department faces as a result of their enhanced understanding of the business and managerial sides of healthcare.

Examples of where lapses in collaboration could come about were detailed to me in various interviews.  Mrs. Lee explained that each party can get agitated when they feel as though an “agenda is pushed onto them.”  She also describes that a method to get out of this situation is to call out the other party when the work seems disproportional.  She describes that many administrators that have worked for her have felt intimated to call out physicians.  She believes that she has gained credibility and respect from physicians by not being afraid to counter a physician’s wishes, especially if she feels as though their ideas are unrealistic or their proposed work is excessive.  Dr. Laila Woc-Colburn, an Associate Professor and Director of Medical Education at the National School of Tropical Medicine at BCM, described to me a train of thought that many physicians hold that may explain why a heavy load of work is pushed onto their administrators.  In a healthcare system, physicians generate money while administrators do not; the administrator’s main objective is to manage money and increase efficiency.  Because of this thinking, accompanied by the massive rise in healthcare administrators when compared to physicians in the past 20-30 years (see graph below), physicians feel as though they are already spread too thin to be “bossed around” and perform extra work for the people that they provide salaries for.  Thus, they may feel comfortable putting a greater work load on their administrators, especially if they are unaware of an administrator’s already-heavy work load.

Dr. R. Clay Burchell, an OB-GYN and writer on physician leadership, wrote an article detailing his viewpoint that physicians should take on more leadership and administrative positions to avoid the potential for an imbalance of work load.  But by following this way of thinking, the already-overcommitted physician must tackle more on their plate, all while limiting collaboration between the two parties.  And, as many of my administrative interviewees mentioned when asked about their thoughts on Burchell’s point of view, many described a lack of business and administrative training on the physician’s part would actually be a detriment to that department.  Although work experience can act as a replacement for formal schooling, many noted that promoting collaboration between the two parties rather than having physicians attempt to do it all would be much more effective in limiting work imbalance, issues, and tension.  However, to accomplish this and get both parties on the same page, communication must be steadfast and clear.

Basic communication is necessary in any field for operations to run smoothly and be checked upon routinely.  As social creatures, communication cultivates our curiosity, allows us to learn from and teach others, and allows us to create and maintain our relationships with others.  Herbert Simon, a Nobel Prize winner in Economics, once described organizational communication as one of his key facets to focus on to improve an institution.  His definition of an organization is a “complex pattern of communication and relationships in a group of human beings”—essentially simplifying the concept down to a group of people who communicate.  Communication in his eyes was a “two-way process,” one that moved up-and-down and side-to-side throughout the organizational hierarchy of the institution.  He even details that the only case in which communication is not needed in an organization is when the person who is best fit to “carry out a decision” is the same person who makes the decision, explaining that in this “exceptional case” there is then no need for organization.  After speaking to Mandy Sowell, administrator for the small, yet prosperous department of Neurosurgery at BCM, I was able to get a better glimpse of what organization and communication mean to an administrator at the clinical department level at BCM.  She raved about how effective and constructive the communication between her and her clinical co-leader (the head of the Neurosurgery department) was.  She also acknowledged that, at other institutions, it is common to observe scenarios where lapses in communication can be detrimental to both parties involved, which benefits the argument of most literature.  In her experience, however, the foundation for her success as a department administrator rests on the trust, communication, and collaborative mindset that she and her department head share.  She professed that at times she may serve as a “challenge” to the physicians in the department, but in no way an obstacle.  She qualified that statement by explaining that many times the physicians’ wishes cannot be granted due to certain administrative rules and regulations that the administrators are more aware of than the physicians.  While this does pose a threat to their autonomy, she explains that her job is to respect BCM’s expectations and ensure that every aspect of the department is running to the highest degree of the College’s standards.  In essence, she must act as a road-block of sorts, but only because that is what her job requires of her when she needs to play that role.  Through communication, though, she and the physicians are able to work out solutions and compromises that benefit both parties.

One particular way communication can be improved, according to Simon, is the inclusion of informal communication in daily work banter.  By combining informal and formal communication, relationships improve and both parties are more likely to feel comfortable working with each other.  Unfortunately, the “elitist” thinking of some physicians can hinder the desire to communicate informally, according to Lily Shih, Associate Provost of Academic Affairs at BCM.  I surmised that this thinking arises due to the rigor and demand of medicine and the path to obtaining a medical degree.  Because medicine is extremely difficult, it typically attracts extremely high-achieving people who probably have experienced nothing but success their entire lives.  She explained that this unchecked success makes them think they can control any situation and feel as though they know how to perform and excel in every task, even if they do not necessarily have the proper training or work experience to complete it.  She further explained that because of a lapse in or lack thereof of communication between the two parties, relations could worsen and tensions could rise (even though they are not constantly communicating).

From what I gathered, communication is key to success in the healthcare world, especially between administrators and physicians. Without constant communication, one party has no awareness of what the other party is doing or in charge of.  Through increasing formal and informal communication between the two parties, relationships and the organizational effectiveness of the institution can be improved simultaneously.

Furthermore, the topic of various types of formality within communication merits a conversation on professionalism in healthcare.  Bill James, a renowned statistician, once said “Professionalism in medicine has given us medical miracles for the affluent but hospitals that will charge $35 for aspirin.”  What James attempts to highlight in this quote is the difference in a patient’s healthcare experience based on their socioeconomic status due to the autonomy that professionalism has given medicine.  Paul Starr, a sociologist and prolific writer, noted in one of his most well-received novels, The Social Transformation of American Medicine, that professional authority in healthcare is linked to a “distinctive” form of dependence: one that lies on the professional’s superior competence.  For quite a long time, physicians have been regarded as the most trustworthy professionals of any field.  Whether it be the arduous path to becoming a physician, or their power over the well-being of loved ones, many find physicians to be wizards of sorts, often romanticized as angels or benevolent guardians who possess special healing powers.  This perception of the physician is not starkly wrong—their job description entails facilitating the healing of individuals in any way possible.  However, this perception could have harmful side effects, such as further supporting the notion that physicians are at the most elite position in the healthcare field, completely circumventing the other pieces of the puzzle involved (administrators, among others).  Ironically, Starr mentions that the professional autonomy of physicians is continuing to decrease as the years pass due to the rise of for-profit corporations in healthcare.  The physician who once was entirely in control of their market, now becomes a unit of commodity at the whim of the corporation that now owns the hospital that the physician works at.  And, as James highlighted, Starr claims that these corporations do not aim to favor those who are of particularly low socioeconomic status, or put more frankly, of low profitability.

As has already been mentioned, the interviews that I had the privilege of performing involved a wide variety of administrators and physicians from various departments at BCM.  However, I must acknowledge that the scope of this study, even in the context of BCM, is narrow.  With the immense diversity in roles for both administrators and physicians in healthcare, it would be incorrect of me to state that this is a completed study.  However, I do believe that it presents a firm infrastructure for either a continuation of this project or its implementation into a study of a different institution.  One other advancement of this study could involve looking at the relationships between the two parties and the other parties involved in healthcare, such as physicians’ assistants and nurses.

With that being said, I am content about the results of my summer study.  I greatly appreciate the mentorship of Dr. John Mulligan, Robert Trieu, and Steve Winder, all who have made a lasting impact on my career path and who have allowed me to explore and enrich myself on the necessity and complexity of healthcare administration.  There is no doubt in my mind that more pre-Medical students should be made aware of their administrative counterparts’ work and what it entails, especially if they are to have a successful working relationship with them as physicians.   Through an emphasis on and awareness of collaboration, communication, and professionalism, the current generation of students who eye either administration or medicine as career paths can learn to better understand the holistic intricacy of healthcare.