As independent medical practices have grown in both size and complexity, so have the roles and responsibilities of their physician leaders. Because physician leaders in independent medical practices do not benefit from the complex organizational framework found in large hospitals and medical systems, their duties may not be as clearcut as those of their peers. However, it is clear that independent practices benefit from having a physician leader whose role is both formal and visible, and who often has paid time for nonclinical and administrative responsibilities. Examples of duties that are best performed by a strong physician leader include: setting the culture of the practice; providing annual reviews to, and evaluating coding patterns of, their fellow providers; and communicating with the staff on a consistent basis.
Independent medical practices traditionally have been led by their senior physicians. Most of these practices started as one- or two-doctor affairs with a handful of employees, led by a physician whose shingle was hung on the door. As the size of most groups increased over the last 50 years, most continued with the tradition of being led by one of the physician owners. Some groups set up a rotating system where each partner took their turn in order. Others had a partner with either the skill set or desire (or if they were lucky, both!) to wear the mantle of physician leader for many years or even decades.
Regardless of the size and shape of the practice, or skill set and experience of the management team, the practice will run better if at least one of the physicians takes on a visible leadership role.
As groups have grown in size, so have they also grown in complexity, and the number of business models is myriad, with no group looking exactly like any other. It is not uncommon to see a single group with over fifty doctors, for one super-group to be made up of what was once a collection of smaller independent practices, or for one umbrella company to own groups in multiple states. However, regardless of the size and shape of the practice, or skill set and experience of the management team, the practice will run better if at least one of the physicians takes on a visible leadership role.
It is important that the leadership role be formalized and recognized by the other doctors and the rest of the staff. A title should be chosen—President, Managing Partner, and CEO are three of the more common ones—and used consistently. Some groups will pay their physician leader to take on this role, whereas others will not. Like-wise, some leaders will spend some of their time doing dedicated, non–revenue-generating administrative work, whereas others will be expected to do this work before clinic, after hours, or during weekends, without cutting down on clinical time. There are many different models, and each group should create the one that works best for them. A description of some of the key roles that physician leaders are best suited to take on follows.
SETTING THE CULTURE
Every business has a culture, and if leaders do not intentionally create the culture, the staff will. When thinking of culture, we always like to use a restaurant analogy, where the doctors are like the chefs working in the kitchen, creating the product that brings the customers in. Our ancillary staff are like the restaurant staff. Their actions often define how popular a restaurant is, at least as much as how good the food is. Is the hostess friendly? Is the waiter knowledgeable and attentive? Is the dining room clean? Did the food come out hot and in a timely manner? If the answer to any of these questions is” no,” then the diner risks having a bad experience, even if you, the chef, made a great-tasting plate of food. With rare exception, if the answer to those questions for a particular restaurant are all “yes,” it is because leadership created a culture that demanded a high level of service and then held staff accountable.
The independent medical practice is similar to the restaurant analogy. It is common for a doctor to walk through the waiting room and clinic with their head down, not noticing what is going on around them, until they get to their exam rooms to work for the day. Likewise, many doctors do not like to correct staff members who make easily correctable errors, treat a patient poorly, or, for example, fail to pick up a used tissue from the floor. When staff members are not redirected, they will assume that their sub-standard performance is acceptable, and will not improve. Thus, in this situation, the culture of “we do not expect the best from our employees” will develop organically.
The physician leader is best situated to establish the culture and hold everyone accountable to it. Staff look to physicians to lead, and they hold strong opinions on how we all contribute to the culture. They know when we show favoritism among the staff, and they hear if we say negative things about our patients. Because they know that we, as leaders, set the culture, they believe that this type of behavior is the culture we want, and will either model their behavior on it, or will leave for a clinic whose culture is more in line with their internal belief system.
Leaders also must understand that organizations do not typically have one single, all-encompassing culture. Rather, an organization is more likely made up of composites of subcultures. There may be one culture among technicians, and a second one for front desk staff. Likewise, the culture of one clinic site may be different from that of another clinic site. Leaders must be attuned to all the different sub-cultures within their organization and work to ensure that they are all consistent with the fundamental culture they are trying to build.
PROVIDER ANNUAL REVIEWS
In most businesses, employees and managers undergo a formal annual review process. Despite everyone’s understanding of the importance of this process, it is rare for physicians, themselves, ever to be formally reviewed. One quirk that is common among providers is that they may believe that their clinic work is unique compared with that of other providers (i.e. their patients are older, or sicker, or needier than those of the other doctors). Regardless of this belief, most clinicians do respond to being compared to other physicians if objective data are the means of the comparison.
We have found that objective reviews help break through some of the counterproductive beliefs that keep providers from being receptive to receiving feedback.
If practices collect Net Promoter Scores on each provider, these are the type of data that are useful to share at an annual review. Likewise, coding patterns can be discussed at an annual review. This practice is especially helpful in determining where the provider may be an outlier compared to other providers within the group. It also may be helpful to perform a “360,” in which a small (10 to 12) number of staff members from around the company are asked to anonymously answer a number of objective questions through a survey site such as Survey Monkey (www. surveymonkey.com) or Survey Planet (www.surveyplanet. com). Some examples of questions we use for our reviews are these:
- Does this provider display leadership in front of staff?
- Does this provider respect patients’ time? and
- Does this provider finish tasks in a timely fashion?
A frank discussion of all these results helps each partner not only recognize the one or two areas where they are outliers, but also shows them the importance of changing their behaviors (if necessary) to bring them to the same level as their peers.
We have found that objective reviews help break through some of the counterproductive beliefs that keep providers from being receptive to receiving feedback. Some examples include “I am an owner, so I can do what I want,” and “You can’t compare how my clinic runs compared to Dr. A’s because she always gets the best staff.” At the start of each review, we ask each partner whether or not they agree to these four statements:
- I understand the importance of the culture here.
- As a physician, staff and patients look to me to define the culture more than they do to others.
- How my actions are perceived by our patients and employees is at least as important as what the actions actually are.
- I understand that the information that has been gathered for this review is made up of direct comments from patients and coworkers.
Reading and confirming that they understand these statements at the start of the sit-down review should help the provider understand the importance of receiving this feedback and making whatever changes that may be required for the sake of the well-being of the practice.
Providers learn how to code properly in a number of ways. We can have exposure in school or training, can attend conferences devoted to the topic, learn on-the-job from our partners or internal coders, or—hopefully—a combination of all-of-the-above. Once we become established in practice, it is important that our coding be evaluated from time to time to ensure that we are coding appropriately. It is likely that most doctors do not receive significant feedback on their coding patterns once they begin practice. The physician leader can have important insight into how each of the providers in the group is coding.
It usually is easy for the business office to run reports of coding utilization for each provider. By evaluating the results of these reports, the physician leader can look for anomalies among coding patterns of the different providers. That physician leader can then speak with any doctors about where they may be outliers when compared with the other doctors in the group. Examples of coding patterns that may be discussed include underusing modifiers, and using lower-paying codes in place of higher-paying ones when the coding requirements are otherwise comparable. These discussions can take place during either the formal annual review, or during a separate session.
Unmanaged interprovider coding variation should be thought of as more than just a potential source of decreased revenue. For instance, it can also put organizations at undue risk for governmental audit of Medicare and Medicaid reimbursements. Evaluating coding patterns can also uncover clinical deficiencies among providers. For example, the physician leader can evaluate the utilization of certain tests, and in this way determine if there are outliers in some aspect of clinical care.
COMMUNICATING WITH STAFF
Communication is important for the smooth operation of any business. Front-line workers must be able to communicate with their supervisors and managers, and managers must be able to communicate not only with those working under or over them (vertical communication), but also with other managers in the practice (horizontal communication). One critical tool that is grossly underused by most practices is direct communication from leadership to the entire workforce.
Employees want to be kept abreast of what is going on with the company, and also want to be reminded that they are part of a well-functioning team. There are few better tools to accomplish both these goals than a weekly email from leadership, especially from a physician leader. These communications can update staff on new policies or procedures one week; fill everyone in on the success of reaching a goal the next; lay out a strategic initiative the next; and be filled with feel-good stories and compliments from patients the next. In this way, the physician leader continually reminds their staff that they are all part of a single high-functioning team, one that is working together to fulfill the mission of the company within the framework of its culture. Here, again, our work with culture in medical groups has shown us that the employees’ perceptions of the culture of the organization are affected by how leadership presents the mission, vision, and direction of the organization.
Formal physician leadership is necessary for any small medical group practice’s success, because the physicians ultimately are responsible for the core mission, vision, and values of the practice. Physicians understand both how business decisions will affect clinical ones, and how clinical decisions will affect business ones. It is not unusual for physicians to be persuaded more by a colleague in an administrative role than by a non-physician in a similar one. Likewise, physicians often are looked at favorably by staff beside whom they work in ways that help foster the acceptance of new policies and programs.
Leaders rarely are born; rather, leadership is more often an acquired skill. Some physicians have a very dynamic style, whereas others are quieter. Some always think they are right, whereas others question every decision that they make. Every medical practice should benefit from having a physician in a formally recognized leadership role, regardless of the size of the practice or the individual physician’s leadership style.
Gary S. Schwartz, MD, MHA, President, Associated Eye Care; Co-Chair and Executive Medical Director, Associated Eye Care Partners; email: email@example.com
Daniel K. Zismer, PhD Managing Director, Associated Eye Care; Co-Chair and CEO, Associated Eye Care Partners.
This article appeared in the November/December 2021 issue of The Journal of Medical Practice Management.