Now That I Am a Hospital Executive
A few years ago, I deviated from my pathway as a research-focused academic cardiologist situated in a traditional medical school organization chart to begin a new career as a senior executive at one of the two academic campuses of the largest hospital in the United States, NewYork-Presbyterian Hospital in New York City. As the chief operating officer of Weill-Cornell Medical Center, I have primary responsibility for the strategic direction and management of a campus with nearly 10 000 employees who treat 1 million outpatients and admit 60 000 patients into 910 registered beds each year, in collaboration with 2600 physician partners from our sister organization, Weill-Cornell Medical College. Now that I am past the point of settling in, I have had a chance to think about what I wish I could tell my former academic self and what challenges and opportunities I see for medical school–hospital partnerships going forward.
My list of “shoulda knowns” that would have made me a more productive academic and administrative cardiologist is lengthy. I would have been better prepared to advocate for my faculty members, trainees, and especially the patients we cared for if I had been more comfortable with the nuances of hospital finances, healthcare reimbursements, and the regulatory environment. I wish I had had a better sense of the fully loaded costs of education in an academic medical center environment. I probably would have stepped on fewer toes if I had understood the entire scope of unsupported activities most academically affiliated hospitals shoulder, and I could have been more compelling in articulating the unfunded mandates borne by my academic department. I wish I had pushed for sharper conversations to explain to my hospital partners the nearly inscrutable interplay of clinical and research productivity that makes being an academic physician so rewarding.
The most impactful piece of advice I would give my former self—this is a big surprise to me—is far less specific to health care and also far less obvious than it needs to be. I would say to pay a lot more attention to the structure and function of the teams that I supervised and participated in. This surprises me because I have spent my entire career thinking that I was engaged in team-based activities, many of them I thought to be highly functioning; I saw myself as a “team player”; and I have spent plenty of time talking about the importance of teamwork in clinical care and biomedical discovery. Nevertheless, it is only since I have taken a more top-down view of teamwork in action that I have appreciated how complicated, difficult, and ultimately rewarding formal team building can be, and how far off the mark about teamwork I often was in the past.
In their seminal article, “The Discipline of Teams,” Jon Katzenbach and Douglas Smith point out that “committees, councils, and task forces are not necessarily teams.”1 I would extend this list to include research laboratories, clinical divisions, and what we euphemistically refer to as medical teams, groups from different disciplines that round together on inpatients. Under optimal conditions, these groups coalesce as a true team with shared purpose and mutual accountability, yet all too often members of working groups in the healthcare environment operate in silos with individual goals and responsibilities.
Teamwork matters a lot more to me now, as I imagine how to advance our hospital mission with staff who not only have different (although complementary) skills, but also who have affiliations and alliances and reporting relationships that are completely unaligned. Creating and nurturing productive teams is critical to an innovative endeavor such as a precision medicine program, where laboratory personnel work alongside academic physicians, bioinformaticists, programmers, ethicists, and genetic counselors, but the same issues arise in an inpatient medical unit or an operating room.
How we work together matters even more as we confront the shift to value-based payment models, pressures to reduce healthcare costs, threats to graduate medical education funding, and myriad challenges to academic healthcare systems looming on the horizon.
Given their many unfunded mandates, research endeavors, and educational missions, academic systems will increasingly be required to justify their cost structures. I am convinced that the academic medical centers that consider their research and educational missions as entities separate from clinical program development, regional network development, and physician and hospital alignment and acquisition strategies are going to struggle. We cannot consider the forces impacting our enterprises, changes in the research funding environment, healthcare reform, pressures to consolidate, in isolation, or else we will lose sight of how interrelated our missions are. We cannot, for example, make decisions about regionalization of care without mapping out the impact this will have on graduate medical education or clinical research. Marginal strategies may appear more robust (or vice versa) when the all-in costs and consequences are considered.
At a broader level, I believe strongly that we will need to accelerate the introduction of business education and practices into academic medicine. This will cut in both directions. Physician leadership in the executive suite of hospitals is demonstrably associated with improved
quality and performance,2 and, in my experience, there is no doubt that hospitals that have physician leadership function with more carefully calibrated service to the multiple academic missions. We must do a better job of providing professional ladders for physicians to be primed for hospital leadership positions, because the skill sets and experience of divisional and departmental leadership in medical school hierarchies provide little preparation for the operational and strategic demands of hospital leadership.
The need to blend business and medicine runs in the other direction as well. I occasionally say that the MD/MBA is the new MD/PhD, and, although this is a provocative statement, I believe there is truth to it. Medical school and graduate medical education provide minimal to no training in leadership, innovation, managerial acumen, change management, and numerous other skills that will be necessary for academic physicians to measure and improve clinical quality, provide health care at the population level, foster innovation to develop next-generation diagnostics and therapeutics, and create a foundation to accelerate improvements in healthcare delivery. From my current vantage point, what are proposed as new paradigms for medical education do not venture nearly far enough from the traditional Flexnerian model3 to prepare our next generation of physicians for the challenges we are facing, not just in the near future, but right now.
The opinions in this article are not necessarily those of the editors or of the American Heart Association.
Circulation is available at http://circ.ahajournals.org.
- © 2016 American Heart Association, Inc.