What does a physician hear when you speak?

Understanding what resonates

The perspective of Laura Avakian's book "Helping physicians become great managers and leaders: Strategies that work" is from a human resources professional. And that is because Avakian worked as vice president of human resources in health care for about 25 years at Beth Israel Deaconess and MIT. But the thrust of the book, she says, which is evident for anyone who works with physicians, is that physicians have had very little training in management activities such as running meetings, supervising people — "those things we think of as good business and organizational process," she says.

"In fact, almost everything in their training runs counter to that. They have learned that they are exceptionally brilliant people as solo practitioners, and that's how they've been rewarded and acknowledged," she says. In making decisions, she says, physicians see facts, analyze them, come up with a diagnosis, and give orders to others on how to deal with it, she says. That often runs counter to what administrators, specifically you in your role, are looking for.

She compares physicians' decision-making process to that of a quality improvement committee undertaking an initiative. "First of all, it's collaborative. Secondly, the outcome may not be known but there is a lot of talk about process... You can just envision the physician sitting there chafing, looking at his watch, thinking, 'What is this about? Why am I here? This is a waste of my time.'"

Several things have to happen, Avakian says, to get physicians to embrace what you need them to embrace:

• Acknowledge that physicians do not approach things the way you do.

"He or she comes from a different mindset, a different way of thinking about problems and their outcomes," Avakian says. What makes something resonate or meaningful for them to embrace is what is going to be good for patients and what is going to be good for outcomes.

She recommends framing a project with this question in mind: Where is the patient served here, rather than putting the emphasis of your project on goals such as the economic advantage or the regulation or law we need to comply with. Administrators, she says, think about cost, improving quality outcomes, metrics, and measurements. What the physician thinks about is "the difference for the patient he just saw in the emergency room in the morning."

"It isn't just that these physicians should be coddled... I believed it is, for the most part, a matter of what the motivation is for the work." And it's not that cost cutting or efficiency aren't important to physicians, she says, but "those aren't the motivations that will inspire them."

• Engage physicians in the early stages of the project at hand.

Avakian says this is important to do this rather than "assuming we'll figure out all the nitty-gritty and the details, and then we'll take them the results of our work and tell them how we need them to be involved." Involving them in the early, early stages doesn't mean demanding attendance at endless committee meetings. But involving them takes advantage of something she says physicians are good at — taking a problem and thinking about it in an analytical way.

As an example, she says, let's say the initiative at hand has to do with delays in getting patients from the unit to the X-ray department. And nursing sees the delays affecting the whole sequence of care, and it disrupts the transporters' jobs, and the system is bogged down due to these delays. If it's determined that the cause is the radiologist not being satisfied with the film quality and asking for things to be redone and someone tells him or her, "You're taking too long," or asking physicians to change behaviors, you'll get no buy-in, she says. "Instead, they'll come back with all kinds of defensiveness about the quality of their work."

If, however, radiologists had been approached and talked about the delay issue and the quality implications, you have a much better likelihood of getting buy-in on the resulting changes in work flow, she says. "If [a project is approached] as a question, and with engagement, there's a very high likelihood of success," she adds.

• Recognize the importance of partnering with your physicians.

But not in a parent-child dynamic, she says. So now administrator and physician are working together to make decisions. Dialogue may begin with, "'OK, this is the part of the project I'll do, this is the part you'll do,' playing to different skills and expertise," she says.

Physicians' education choices changing

Author of "Helping physicians become great managers and leaders: Strategies that work," Laura Avakian, acknowledges there can be differences among physicians from different generations. For example, those who have been in the field a long time may not have had much life experience as younger physicians using technology. Younger physician in general may be more gung-ho on learning to use a new electronic medical record system, for instance.

"Part of it, too," she says, "is that the educational models are changing somewhat." She has found there are more than 50 joint MD/MBA programs available in the United States, with more growing, she says. There also are joint programs for MDs and the master of public health (MPH) program, as well as MD and MHA (master of health administration) programs.

Younger physicians, she says, see the value of being business-savvy and learning about budgeting, strategic planning, and health care finance and reimbursement. "I found, though, that most of these programs still didn't teach them a lot of what I would call the 'people skills' they need, but they are learning the business skills and seeing that as making a difference. And those things are growing by leaps and bounds," she says.

At Beth Israel Deaconess, where Avakian formerly worked, doctors are being taught Toyota's Lean model as a fellows program. "There's more of that going on, and I think we'll continue to see that increase," she says.