Administration

Clinical Service Lines

A training ground for the emerging physician leader

Daniel K. Zismer. Ph.D

Experience with the Health Care Administration Program, University of Minnesota identified growing interest from younger, practicing physicians in developing competencies in a parallel career; healthcare management. By the third year of the newly launched Executive MHA program, it was clear that physicians at mid-career and less, whether domestic or international, came to the program with unapologetic enthusiasm for their desire, as one young physician put it “to develop a different part of my brain”. Another, a young interventional radiologist, by his mid thirties, had already decided that he “did not want to go through the rest of his career wearing a lead apron”, and a third interviewed for admission to the program had stated that “I want to provide myself options as my medical career unfolds”.

As physicians consider a career in organizational leadership there are typically two questions that loom large. Both are addressed here. The first is “will I need to eventually give up the practice of medicine to succeed?”, the second “is there a reasonable, more measured way to get started on the path?” The answer to the first is easy. No! There are a number of leaders who effectively navigate roles as clinicians and as leaders in health systems and medical practices, while some do decide to hang up their stethoscopes in favor of an alternative way to contribute to patient care, and healthcare delivery more broadly. 

The leadership dyad is not two people doing the same job.

The second question presents the centerpiece of this article: “is there a manageable way to get started on the path of becoming a physician leader?” The answer to this question is represented by a fast expanding opportunity for physicians who wish to get their feet wet with a meaningful role in leadership without jumping into the deep end of the pool. That opportunity is serving as the physician member of a “leadership dyad” in charge of a clinical service line within a health system or medical clinic. 

In a chapter written for Mechanick and Kushner’s 2020 book titled “Creating a Lifestyle Medicine Center” (Zismer, D.K.) a clinical service line is described as “a grouping of defined clinical services and programs dedicated to an identified constellation of related diagnoses, and clinical conditions, designed and dedicated to produce superior course of care, over time, based upon evidence-based, best practices for defined clinical populations”. Clinical service lines are often, but not exclusively, dedicated to the management of chronic diseases and conditions. The clinical service line “leadership dyad” pairs a practicing physician leader with a trained administrative services partner to oversee the design, leadership and management of the clinical service line. The physician partner in the dyad has a defined, part-time job. The position is typically responsible for providing the clinical guidance to how, and how well, the clinical service line functions and performs its obligations to patients served, including how providers work as teams to enhance clinical outcomes, and how clinical and staff resources are applied to create optimal outcomes. To be clear, the leadership dyad is not two people doing the same job. The physician and administrative dyad partners bring unique skill sets and competencies to the leadership of the service line.

A Model for Shared Leadership

But are clinical service lines a real and sustainable strategy worthy of redirection of a physician’ career path? In a survey of 47 health systems conducted by Wegmiller and Zismer, 85% of systems in the sample stated they had already launched, or expected to launch one or more clinical services as principal components of an overall organizational strategic plan. Most health systems in Minnesota have long since decided to compete based upon what are easily identified as clinical service lines including; “heart and vascular centers”, “sports medicine”, “mother and baby hospitals”, “pain management centers”, “behavioral health programs”, “lifestyle and wellness centers” and “diabetes management programs” to name a few.

So if starting on the path of physician leadership can begin as member of clinical service line dyad, what does the emerging physician, with little or no real leadership or management experience have to offer? The answer hides in plain sight; it is what they already know, or know how to know, as an experienced clinician. The value of the dyad, and the clinical service team, is best described by the old bromide, “two heads are better than one”. With dyad leadership, the physician member of the team brings the clinical experience and understandings. This includes, but is not limited to, knowledge of the following:

• Expected clinical outcomes.
• Evidence-based standards of practice brought about by an integrated and coordinated team care.
• How to understand variation of practice style and the effects on clinical outcomes and related resource use variation.
• How various combinations of clinical program inputs (diagnostic and therapeutic services) can enhance or sub-optimize clinical efficacy, efficiency, and total cost of care performance.
• How specific patient characteristics, and traits, may interact with care protocols to affect program adherence, clinical outcomes and value derived from established care models.
• Identifications of practice style markers that may serve as useful sources of clinical service line operating productivity performance metrics; e.g., types of provider work relative value units, types of diagnostics applied, care model team configurations, interactions with related patient care providers, and use of pharmaceuticals.
• Expected rates of hospitalizations and re-hospitalizations.
• Identifications of the provider behaviors that are counterproductive to the mission, goals and objectives of the clinical service line, including how to identify them in related service line performance metrics.
• The construction of useful, applied service line performance scorecards.
• Ongoing analyses of how the incentives created by provider compensation plans align (and misalign) with service line mission, goals and objectives.

Pursuit of these goals provides for more than a sufficient part-time job for any physician member of a clinical service line leadership dyad. The physician leader in the dyad carries at least half of the responsibility for encouraging high-functioning team care. Virtually every clinical service line promises patients an integrated and coordinated experience. Those that succeed deliver on that promise.

Physician leaders don’t need to compete with the non-physician executives.

Developing Advanced Skills

The leader interested in “moving up the leadership chain of command” in health systems, and in larger medical group practices, will need to develop advanced skills and competencies. Here the expectations of the physician leader expands, and more formal, graduate-level healthcare administration or “B-School” education and training may be required. But beware the trap, and trust this bit of advice. The trap is physicians who pursue graduate degree training in an attempt to compete with the seasoned, non-physician executive. Physicians can fall prey to the belief that “if I earn an MBA, I’ll know everything that every other MBA knows”. Translate that thinking to medicine. Does the new med-school grad know everything a physician with 20 years of experience knows? The answer is obvious. Physician leaders don’t need to compete with the non-physician executives. Remember, physician leaders have a special knowledge and experience foundation that can’t be replicated by non-physicians; it’s the knowledge of the practice of medicine! The other MBAs or MHAs in the room can’t bring that. Never try to play another person’s game. Too many physician leaders fail as leaders, or quit as leaders, because they tried to compete with the wrong “competitors”. Many-a-physician in the C-Suite has told me “I don’t even understand the language the non-physician executives are speaking. The best response is always, “turn the tables”. Step-up with what you know and what is always relevant; the effective “manufacturing” and delivery of the right patient care, at the right time. Your job is to bring the medical care and relevant patient care aspects of the service line business plan to the table. The successful physician leader learns to integrate the language of clinical care and the practice of medicine with service line business planning, management and performance evaluation. Clinical service line strategies often fail because the practicalities of clinical practice were missing during the developmental stages of business planning and service line implementation.

For the physician clinical service line leader who has designs on being the next CEO of the health system or medical group, formal, graduate “business school” training may be required. If pursued, be mindful of the curriculum design provided. The curricular offerings need to complement the role of a physician leader. A portfolio of syllabi representing general business courses can be useful, but may not be specifically relevant to the needs of a physician with leadership experience under their belt. When examining the curriculum of a graduate level degree program, look for the opportunities to acquire skills and competencies in the areas of:

• Organizational culture and its effects on clinical process and patient experience performance.
• How the right clinical processes will bear upon service line staffing composition, business operations and financial performance.
• Analyses of clinician practice style variation and the potential effects on service line productivity and operational and financial performance.
• Continuous quality improvement.
• Continuous process improvement.
• Clinician and staff behavior effects on the patient experience.
• Understandings of how the clinical processes implicate other clinical care requirements of patient served; i.e., the integration of clinical care beyond the identified service line.
• Organizational psychology and the effects on culture and performance.
• The discipline of innovation and business practice.
• Change management.
  

Completing the Circle 

Now let’s return to the beginning. Almost everything an emerging physician leader needs to know about the “business of medicine” resides with the design, leadership and management of a single clinical service line. Every large health system and complex medical group practice is composed of a combination of clinical service lines. Even the complexity of the clinical enterprise that is Mayo can be distilled to an aggregation and integration of multiple clinical service lines. There practicing physicians who are the next generation of health system and medical group physician leaders have a practical path and training ground to test the waters of leadership in a way that doesn’t put their clinical career at risk. 

Another bit of counsel for the emerging physician leader is set in an established social psychological theoretical framework (Julian Rotter, 1975); “A person’s behavior is a function of their expectation for rewards that are valued, and the prevailing social psychological dynamics that apply.” Change one, two or all three variables, and motivation and/or actual behavior changes. For physicians, thinking about venturing into the world of organizational leadership, some introspection is required. Four challenging, but practical issues are faced by virtually all physicians as they consider pursuing leadership career opportunities: 

• What is it that pulls me toward leadership; what are the expected rewards that are more compelling for me than dedication of my professional time and talents to full-time direct patient care?
•  How will I best apply a reduced clinical service schedule for the good of the organization and to ensure a satisfying and worthwhile clinical practice for me?
• Will the opinions of my peers matter as I make the decision to pursue a full or part-time career change?
• Can I reconcile the two roles as being equally valuable in service to an integrated mission of patient care, and thereby minimize the risk of seeing myself being caught between distinct and opposing forces (differing missions and obligations) as I make an important decision?

One final consideration; those most likely to succeed, discover sooner rather than later that success as a leader is less dependent upon their abilities to make all the right decisions for those they lead, than guiding those led to make their own right decisions based upon a clear vision and system of shared beliefs and mission. Physician leaders who fall in love with making all the decisions soon find themselves heading down an entropic professional path; the need to control all decision-making leads to a shrinking sphere of effective influence.

Daniel K. Zismer, Ph.D., is Co-Chair and CEO of Associated Eye Care Partners, LLC, Also, Endowed Scholar, Professor Emeritus and Chair, School of Public Health, University of Minnesota.