Competing Clusters and the Physician Leader

Each of the 7 “clusters” is impacted by both internal and external forces that affect physicians as they grow into leaders.

How health care will be provided in the future may be markedly different than how it is provided today, as information infrastructure and resource constraints move health care out of facilities and into the homes and workplaces of people. The enormous investment in capital resources in large hospital systems cannot continue to accelerate at its current pace. The boundaries of the health care delivery system will be redefined radically and rapidly. For physicians and those in leadership throughout the industry, the expansion of these boundaries results in a need for greater cognizance of morally ethical conduct to avoid conflicts of interest. Physicians are expected to navigate their way through many issues amid external and internal forces that influence critical decisions. The diverse environments in which physicians’ practice must be understood within definable professional identities that transcend industry boundaries and traditional medical disciplines such that their professional role remains true to its traditional roots as healer/shaman from a sociological, ethical, and fiduciary perspective.

Hafferty and Castellani developed a model defining a seven-cluster system of medical professionalism based upon their work in complexity science due to their difficulty in accepting he efforts within organized medicine over the last 20 years to re-establish an ethic of professionalism. (1) In their study of the medical profession from a sociological perspective and through the lens of complexity science, they delineated the ways physicians seek to establish their own identity in their profession and society. They argued that these seven clusters of medical professionalism emerged as a direct response to the historical forces of decentralization in which organized medicine has been situated for the past 30 years. They viewed the historical forces of decentralization within the medical profession and within the complex system’s distinction between organization and dynamics, such that the values, orientations, beliefs, specific skills, and ways of controlling the position within the larger bureaucratic structure are dynamically at play with one another in 10 key aspects of medical work that create competing clusters of professionalism. They identified 10 key aspects of medical work as autonomy, commercialism, social justice, social contract, altruism, professional dominance, technical competence, interpersonal competence, lifestyle ethic, and personal morality. Castellani and Hafferty use the complexity science agent-based processes such as emergence, evolution, adaptation, feedback, autopoiesis, perturbation, self-organization, and operating far from equilibrium as terminology to understand medical professionalism as a complex system. They identified the seven clusters as different ways of organizing medical work that uniquely combine and practice the 10 aspects of medical work in the complex system.

The element of complexity Hafferty and Castellani apply is network analysis. Each cluster is impacted by both internal and external forces that affect physicians as they grow into leaders or deeper in their clinical practice/research and the peer group they are engaged with over time. External forces such as managed care, consumerism, and health policy reform and internal forces such as health information technology, and evidence-based medicine approaches to care processes, and challenges to authority and autonomy within complex organizations impact the development of professional identity.

Lifestyle. Physicians who identify with this cluster place strong values on family life and achieving balance between their time at work and devotion to family, spiritual needs, and other interests. There is also a greater tendency to seek part-time or employed physician salaried positions.

Entrepreneurial. Physicians in this cluster focus their efforts on improving the business model for health care service delivery. Innovations that lead to reductions in the cost of care and the waste of resources, improvement in quality, or expansion of services or products offered are of high importance to these physicians. While autonomy is important to this group, they recognize the transformation under way in health care, the need for greater collaboration, and shared authority in organizations. They will also identify more closely with clinically integrated care delivery models and those that affiliate with the corporatization of medicine.

Unreflective. The focus of this cluster is on the day-to-day work that typifies episodic patient care. They may be somewhat disengaged from reform efforts, business model transformations, or research. The unreflective segment of the physician community tends to make no distinction between their personal and professional identity and may be particularly vulnerable during times of change. Salaried employment models such as those offered by hospitals may be attractive to those who simply want to hunker down and see patients.

Academic. The academic cluster attracts physicians who are the majority in the medical teaching ranks. Within this cluster there are challenges to be reconciled. The presumed value placed by the academics on teaching is not reciprocated in financial compensation or tenure. The need to generate revenue from research competes with responsibilities of clinical practice within the academic environment, especially as the regulation in resident work hours and overall shortage in general surgery and general internal medicine squeeze the time to teach even further. In the field of general surgery the industry has experienced a 4.2% reduction in the general surgeon workforce between 1981 and 2005. (2) External forces or stressors (e.g., financial pressures, changes in status, etc.) may increase the likelihood of verbal abuse of subordinates.

Activist. A group that is clearly focused on advancing the ideological needs of health care on local, national, and global scales is the activist cluster. The physician activist embraces the challenges of motivating peers and other stakeholders to support grassroots movements that can improve public health or the health of a population in general. These altruistic efforts may detract from time in the practice of clinical medicine, which may in turn create a conflict between financial stability and leadership development.

Empirical. Physicians attracted to the empirical cluster are typically academic physicians who are research orientated in contradistinction to those in academia having a teaching focus. This group values the creation of new medical knowledge. The pressure to bring in research revenues to establish tenure may lead to a focus on safe, incremental approaches to science that lag in advancing evidence-based medicine practices, innovation of new medical technologies or therapies, or innovation in patient and population health models. This group may be less concerned with idealistic movements in society but may still be marked by a strong sense of benevolence that must be balanced by their realistic by their realistic need for grant-based revenues that often restrict radical approaches to scientific inquiry.

Nostalgic. The last clusters in nostalgic. Hafferty and Castellani consider this group to be the most dominant of the seven clusters. This cluster tends to serve as a locus for those physicians operating at leadership levels across the industry in academic medical institutions, in medical societies, and in the production of medical publications. As a collective this group is focused on maintaining levels of autonomy and, while historically seen as fighting the commercialization of medicine, may have championed national movements such as the need for a transition away from the problematic fee-for-service model of reimbursement for care in exchange for a culture more driven by value-based purchasing initiatives, shared savings programs, and pay-for-performance incentive programs. Although they perceive that there may be problems or unintended consequences to work through in this transition (3) as a whole the aristocracy of medicine recognizes the need for change.

Although professional ethics should keep the interests of patients at the forefront of decision-making by physicians working in each of these seven clusters. The aspects of medical work that are most emphasized within an individual cluster are distinctive and therefore varying in leadership development implications. Hafferty and Castellani identify key values in each of the seven clusters that define the professional behavior of physicians operating within the constructs of that cluster. The clusters can therefore be used to identify implications for leadership for physicians operating in each of the clusters.

For the nostalgic cluster, viewed as the ruling aristocracy of medicine, self-reflection regarding their idealized notions of the profession’s past versus the dynamic changes of the contemporary professional will be useful.

For the entrepreneurial physician, self-reflection on the impact of disruptive innovation on complex adaptive systems as it pertains to their ideal of improving care will be useful.

Those in the academic cluster must parse their role in training future physicians with curriculum and culture change that prepares physicians for the changing health care system.

Physicians in the lifestyle cluster must reflect upon the potential limitations to their personal leadership growth and development as they pursue the work/life-balancing act that is increasingly complicated in contemporary American medicine.

The empirical physician cluster offers the opportunity for physicians to lead by helping to define what, how, and why resources are used for research. Pertinence of effort becomes the guiding principle for leading in this group, such that research in system redesign and comparative effectiveness are emphasized. The potential for strong engagement in health reform campaigns/public health grass roots movements for activist physicians is paramount, as long as physicians in this cluster understand the importance of bringing other physicians along in their efforts. Leadership development for activists involves skills in influencing others rather than simply fighting for pet causes.

Finally, the leadership for the so-called unreflective physician may involve engagement in those aspects of health care delivery that most influence their day-to-day work, such as care coordination, patient safety efforts, and workflow redesign. These physicians should not be overlooked as leaders, for their willingness to work on system improvement at the micro level will improve the likelihood of success in clinical integration efforts and population health management strategies.

The seven clusters described by Hafferty and Castellani have interesting implications for the physician leadership development. The obligations physicians have not only for to their patients but in their wider professional roles with peers, clinical teams, students and other in the industry necessitate self-reflection as to the pitfalls and potential opportunities implicit in the values embedded in each of the seven clusters.

1. Hafferty FW and Castellani B. The increasing complexities of professionalism. Academic Medicine. 2010;85(2): 288-301
2. Kavic M. Professionalism, passion, and surgical education. JSLS. 2010 Jul-Sep;14(3):321-4.
Mehrotra A. Sorbero, ME, Dumberg CL. Using the lessons of behavioral economics to design more effecting pay-for-performance programs. Am J Manag Care. 2010 Jul;16 (7):497-503.

Excerpt from: MD 2.0: Physician Leadership for the Information Age by Grace E. Terrell, MD, MMM, FACP, CPE, FRCPE and J.M. Bohn, MBA,

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