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Fam Pract Manag. 1998;5(1):72-84

Have you heard the one about how many doctors it takes to screw in a light bulb? The answer is only one: The doctor stands on a ladder and holds onto the bulb while the whole world revolves around him.

At one time, the world of patient care did revolve around the practicing physician. But today, especially for physicians who are salaried, many patient care decisions are subject to organizational restrictions.

Even so, physicians must demand the respect due professionals. You're no assembly-line laborer! When employees have unique knowledge and skills without which executives and managers would fail, the employees can have as much influence on management decisions as those with greater organizational authority. You don't believe it? Remember that Michael Jordan receives a salary, too. Do you think he might have had something to do with the Chicago Bulls' decision to extend coach Phil Jackson's contract for another year?

To command respect among organizational leaders and influence their decisions, learn and practice the following six principles of organizational behavior.

1. Realize that authority and power are not synonyms. The Michael Jordan example is dramatic, but here's an everyday instance of a person controlling a situation in which the ultimate decision-making authority belongs to someone else. Beth, my administrative assistant, walked into my office and asked, “Do you have a minute? Next Wednesday is your talk to the physician group in Michigan, and I just wondered how you will be getting there and back.”

“Oh, yes, sit down and let me tell you what travel arrangements to make,” I said, as though I'd been thinking of travel arrangements all along. And just to make sure we both knew I was the boss, I added, “And you better make them today.”

Note the often-helpful technique of “wonderment” that Beth used (“I just wondered ...”). And note her skill in allowing me to feel that I had actually exercised executive authority.

For more examples, think of the times your nurse has asked you something like, “Doctor, I just wondered if you'd like to call Mrs. Jackson back now, since her child has a fever of 105 degrees and she called two hours ago.”

2. Give up the notion that only the devious and dishonest “manipulate” people. It's common to think that manipulate has only a Machiavellian meaning. Not so. Did my assistant manipulate me in the example above? Yes. Did your nurse manipulate you? Of course. Is there anything sinister, devious or self-serving in their behavior? Absolutely not.

An employed physician recently told me, “I don't know how you ever got interested in teaching organizational behavior. It's all smoke and mirrors!” That physician has absolutely no impact on organizational decisions that are controlling his life and practice. If he learned how to work through the organizational system — to manipulate in beneficent ways those who run his organization — he would begin to gain more control over his destiny and strengthen his ability to work for his patients' interest.

3. Recognize the source and extent of your power within the organization. It really isn't true that you have no power. You are the chief executive officer (CEO) in the context of caring for an individual patient. Your organizational power derives from your professionalism and your dependable performance as a skilled, cooperative and respected clinician. (Note, therefore, that as soon as you unionize and strike, you lose your power within the organization. An executive who is manipulative in the Machiavellian sense would love to tell the press that “his doctors” are using patients and the public as pawns in a power struggle.)

4. Learn what makes executives and managers tick. People with clinical backgrounds and people with management backgrounds bring very different training, experiences and perspectives to issues they confront together. (“Characteristics of executives and physicians” lists some of these differences.) Being aware of them can help you find the best way to make a suggestion or discuss a problem with a member of your executive management team.

For example, when I was chief of pediatrics in a 500-bed medical center, I received a call at home one night from the emergency department (ED). A 2-year-old had ingested furniture polish. The ED physician wanted to follow the established policy of admitting the child for observation. However, the child was indigent, so the admissions office balked. I telephoned the CEO at home and explained the situation. “I have to side with the admissions office,” said the CEO. “Transfer the baby out.”

“OK,” I said. “But I wonder if you realize that we fear aspiration pneumonia from the oils in the furniture polish. If we do transfer the child and something bad happens to him, the hospital will probably be sued, and the lawyers will try to show that our dumping the baby was related to the bad outcome.”

The CEO called admissions. The child was admitted, developed aspiration pneumonia, was treated by the family practice residents and recovered nicely.

That illustrates the “smoke and mirrors” of organizational behavior to which many physicians object. They might wonder why the CEO couldn't understand the danger to the child, and simultaneously to the hospital, if the child weren't properly cared for. The answer to that question is, see “Characteristics of executives and physicians.”

Characteristics of executives and physicians

Use this comparison of the training, perspectives, expectations and habits of executives and physicians to better understand how to approach someone with organizational authority about problems or suggestions.

ExecutivesPracticing Physicians
Trained in and concerned with financial matters (budget, acquisitions, marketing, etc.), group process, personnel management, legalities, and external regulations.Trained in and concerned with disorders in anatomy and physiology of the human body as well as diagnosis and treatment of illness and injury in a chosen, limited clinical field.
Understands that executive privilege is limited by higher authority, such as organizational policies and goals.Often appears to believe that there is no higher authority — even, in some instances, the law.
Data-oriented. Is justifiably concerned with what happens to groups of patients and the impact of decisions and actions on the goals of the organization for which the executive has been made responsible by the governing body.Case-oriented. Is justifiably concerned with what happens to an individual and the impact of decisions and actions on the welfare of patients for which the practitioner is responsible. May or may not appreciate the value of accumulating and using data over time.
Responsible for implementing change.Many with the “doxology mentality” — as it was in the beginning, is now and ever shall be.
Must manage to stay within budget or control costs to maximize profit, depending on the specific health care setting.May have little experience with planning and limiting expenditures because of (up to now) largeamounts of expendable income.
Delegates responsibilities; “Go do it and report back.”Fears being disenfranchised; “Don't do anything without asking me first.”
Expects to be evaluated.May view suggestions about how to practice medicine, or even about other matters, as “interference” with a physician's “prerogative.”
Allegiance is primarily to the organization employing the executive at the moment, secondarily to others in the same field through colleges, congresses and associations.Allegiance is primarily to patients and to other practitioners through practice arrangements, specialty societies and local, state and national associations.

5. Identify the person or people in charge, and work through organizational lines to reach him, her or them. Here's an example. Dr. Will Kilbourne, a family physician and a salaried member of a large group practice, has a special interest in pharmacology. He notes that some drugs on the outpatient formulary have questionable effectiveness and that safer alternatives are available.

Will asks Dr. Stella Barnes, the director of family practice and his immediate supervisor, to meet with him over coffee for 20 minutes, at her convenience. Will asks Stella some carefully prepared wonderment questions. “Stella, I wonder if you might be interested in the side effects listed in this insert that accompanies product X, compared with the safety of this new preparation that's now available?” Having captured Stella's attention, Will then asks, “Who's in charge of the formulary? I'd like to get involved in revising it. What's the best way for us to approach them?”

Note that Will doesn't ask, “May I?” He asks, “What is the best way for us to ...?” That way, he doesn't steal Stella's thunder. In fact, he offers her an opportunity to exercise her authority.

6. Take the right approach. Taking the right approach includes three components:

  • Plan ahead. Decide what should happen before you approach anyone about the problem you see. Then determine how to express this goal in as few words as possible. Practice explaining how the change you favor will benefit the organization as well as its patients (“customers”).

  • Keep your expectations reasonable. When you ask an organization to change, don't ask for the moon — a couple of asteroids, maybe, but not the moon.

  • Don't assume your way is the only way. When you propose change, you may be told, “What you want us to do can be done, but not the way you have in mind.” Understand that this is a positive response. Your next move should be to ask, “Then how can it be done?” With this question has begun a planning and implementation phase in which you most likely will be involved.

And with the beginning of planning and implementing the change, you've won! I wonder if you really know how good such an experience can make you feel.

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Copyright © 1998 by the American Academy of Family Physicians.

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