Being a leader is difficult. Being a physician leader? Even more. Aside from taking care of your patients, you have to focus on your team and how standard procedures are done. You need to find people who are going into medicine for the right reasons. Join your host, Kanhai Kapadia, and his guest, experienced physician leader, Dr. Donald Lurye. After retiring, Donald became an independent consultant. He wanted to share his expertise in healthcare leadership with other physician organizations. Join in the conversation to know what it takes to be a leader in the healthcare industry. Learn how to focus on the patient and how reduced variation can help your team achieve success. Listen now if you want to be a leader in your industry.
Listen to the podcast here:
Leading A Patient-Centric Physician Group With Dr. Donald LuryeOne of the first questions I have for you was you went from being a physician to being a physician group leader, I was curious, what were the personal skillsets or circumstances that pushed you in that direction? It was an accident. You have to go back to 1990. I was in this group in Atlanta and our medical director was a colonel in the Army Reserve. When the first Gulf War started, he got called to Fort Benning in South Georgia to relieve the active-duty people going overseas. There was a need to divide up his job because we knew his absence was going to be temporary. He went around to a lot of the administrative leadership and I presume the board of the group. I was still new. He said, “Here are the duties we need to distribute. Who do you think would be good at handling utilization management?” We had delegated utilization management from HMO, which was unusual for that time, but we did. My name floated up and my cell qualification was that I was the first person who joined the group, who had participated in an HMO previously and understood how it worked. I was always cooperative and team-like with the UM nurses. When they would approach me about an inpatient or so and so, I said, “I’ll do that.” I discovered somewhat to my surprise that I liked it. It used to be any way, a fairly common portal of entry into position leadership and it’s frankly somewhat thankless job. I got good at it. I was surprised. I never thought much about doing anything in leadership but I could see there was a potential for me to add value in other areas. I agreed to do it. When this gentleman came back from his duty as a reservist, he asked me if I would stay and retain that role, which I agreed to do. To be honest, I was probably better at it than he was. His skillset was elsewhere. That’s how it started and it became an associate medical director role within the group that fluctuated in size over time, but at its peak, it was about 80 physicians and other professionals. That’s how that started and then the rest is history. If you’d like, I can get into more of that. You say you enjoyed it somewhat surprisingly. I’m curious, why somewhat surprisingly? I never thought about a role of that sort. I’m a fairly vocal and outspoken guy. Department meetings and committees, I would talk a lot and things like that, but I never thought much about taking it further. When you’re in medical school and residency, it’s not the first thing that comes to mind. Particularly when I trained in school in the late 1970s and residency in the early 1980s, things were different then. Independent practice was still the norm and so on. Meridian was about 80 physicians? This is getting to be a fading memory. I saw you went to Wellborn Clinic and were Chief Medical Officer there and thereafter went to Elmhurst Clinic. How did you come into the role at Elmhurst Clinic? When I was at Wellborn, we were going up on an electronic medical record at roughly the same time as Elmhurst. This was in 2003 or 2004. I met some of Elmhurst’s people at training and learned a bit about the place. We ultimately sold Wellborn to a local health system. At that time in mid-2008, it was best for me to move on. I was fully in support of the transaction and worked actively to make it happen but I knew it probably was going to lead to me needing to seek other employment. That’s a long story but it was a cordial process. At the time, the Elmhurst Clinic CEO was getting ready to retire. He’d been with the clinic 37 years and the last 11 years as CEO. He felt it was time and one thing led to another. I got the job and it was a wonderful experience. I feel lucky to had three major leadership positions in my career, each one exceeding expectations, and in their own way, both enjoyable and challenging. What did Elmhurst Clinic look like when you started there? Give us a little bit of color in terms of how it evolved over the years.
You can’t operate a busy organization that caters to everyone’s individual quirks.When I got there, I found a group of about 74. It was almost entirely physicians. There were few nurse practitioners and male physician assistants. I found a group of physicians committed to their patients and to each other. They got along well and genuinely liked each other, something you don’t see in all medical groups. I knew I’d inherited something great but I also observed that while they were collegial, there was still a lot of what we sometimes call practicing alone together. Help each other. There was a lot more opportunity for sharing patients in cases of urgent care, teamwork, and so on. I also liked the relationship between the Elmhurst Clinic and Elmhurst Memorial Hospital at that time, which for Chicagoland was unique. They still have a long-term professional services arrangement with the hospital. It tied our success to that of the hospital and vice versa, but it stopped short of full employment. I thought that it was a sweet spot for us and there is unlikely always and will be a little bit of tension in that relationship, but also that breeds a lot of creativity because we got things to the point where everybody wants the same thing. Over time, the practice grew during my tenure to about 130 professionals and there were some departures and retirements, and so on. Recruiting was always a big thing. I looked for people who would fit well with the culture. I figured that was my job and whatever part of the practice I was recruiting to add to. It was up to them to tell me if they were comfortable with the physician or other professional’s knowledge of medicine and their attitude, and so on. We evolved into a patient-centered organization. We had a mantra, patients first, organization second, and the individual third, which somewhat countered with that practicing alone together rubric. We were able to be successful in terms of increasing our popularity with patients, growing the practice in an extremely competitive environment, and providing a place that people wanted to work. We had a little voluntary turnover and little involuntary turnover. Most of the people who were there when I started are still there except for a couple of age-appropriate retirements or for whatever the personal circumstances took them out of town or whatever. What I liked about was the ability to bring young physicians along. I found that satisfying because I could see myself from twenty or so years ago. I also enjoyed fostering a real sense of teamwork and also mentoring leaders under me in either committee chair roles or department leadership roles. We were in a number of locations of various sizes. Some of them were small and operated. Not on their own because we all approach things the same way but the hyperlocal leadership I’ll call it. I had a chance to work with some of those people and help them grow some communication skills, assertiveness, and so on. I found that it was fine and now the group’s done well. You mentioned the organization evolved into a patient-centric organization. It’s not that it wasn’t previously. It’s just that that became our mantra. To some extent, Elmhurst Hospital in particularly following the merger with Edward Hospital into the system that’s now called Edward-Elmhurst Health, that was something that was articulated well at both institutions. It was only strengthened when they came together. When that philosophy becomes part of your daily language, it ends up suffusing everything you talk about. That’s what you have to do to succeed these days. The public has gotten more sophisticated. They’re more apt to ask questions. We physicians aren’t worshipped any longer, frankly, never should have been. The nature of the doctor-patient relationship has evolved over the decades. I’ve been in the game for the better. From a business standpoint, creating a sense of purpose in this case and being patient-centric is key. Can you talk about the key success factors for a physician group? One of the things that’s important to do these days is as much as you can, be evidence-based and reduce unnecessary variation. For example, back in Indiana, we had people and this was before electronic records. Dr. X wanted his charts organized this way, Dr. Y wanted his charts organized that way, and Dr. Z wanted her charts organized yet a third way. You can’t operate a busy organization like that, particularly, because that catering to individual quirks that don’t accomplish anything other than satisfying somebody’s particular itch. It’s error-prone and it’s extremely expensive. Extinguishing variation that isn’t based on variation and patience is key because that way, you have a way you do certain things. For instance, if you have a set of things that you always want to do for diabetics or if you can standardize a colonoscopy prep, there are certain dermatologic medications that you need to manage with blood tests. I was in a situation in Indiana where the three dermatologists wanted to do with three different ways and it became a push and pull among them. Honoring more the old values of autonomy and individual heroism that many of us were trained in rather than what’s the best way to do this so that we can accomplish the task we need to accomplish. It also allows you to interchange staff from location to location if you need to for some reason because you do things the same way. It can be as simple as, let’s say in family medicine or internal medicine or perhaps all primary care, we’re going to put these supplies in this drawer and these supplies in the drawer underneath it. We’re not going to do it one way for you. You can clear away a lot of physical clutter and process clutter that way. I suspect in the work you do, you spend some of your time doing that as well. To the extent that we were able to do that, it made us a better organization, it was more efficient to run, and it allowed us to focus more on what patients needed as opposed to catering to people. One of the big questions for me and potentially one of the challenges for you in leading Elmhurst Clinic was bringing some of those common practices that exist in the business world in large to medicine and practice management.
Establish trust with people. You need to do that one relationship at a time.Many of us, particularly people my age, thought we were going to be an independent solo or small group practice. In those settings, it’s easier to have your way, my way, and somebody else’s way but you can’t in a group besides the Elmhurst Clinic. The thing would grind to a halt. How you do that is over time. I was new there, but they didn’t know me and I didn’t know them other than passing familiarity from the interview process. The first thing you have to do is establish trust and you do that one relationship at a time. You have to meet everybody and hear what it is. That was the first thing I did. I sat down with everybody and I made a lot of notes about, “What brought you here? Why do you stay here? What do you see as the biggest challenges? What do you think are the greatest strengths of the organization?” I was able to put together a picture of things for myself that allowed me to have people be comfortable to me and know that I would listen to them and always them the truth whether it was good news or not. Once you establish that credibility, which by the way, you have to keep doing partly because you have to keep doing it and because they’re always new people coming in and so on. Consequences like a merger of two health systems, there you have another culture you have to adapt to or attempt to change to a limited extent that seems best. Being able to communicate well both orally and in writing and standing up in front of a group is key because you have to show that you’re on a mission, on vision, and you’re entirely trustworthy and honest all the time. As I used to tell less experienced leaders, “You get to lie exactly once and you shouldn’t even do that because if you do that, you’re done. You might as well step away.” Building those relationships was key. Here’s an example. In one of our larger departments, we had probably a 1- or 2-inch-thick book of people scheduling preferences. “I want to do this many physical exams a day. I want to see this many new patients a week. I don’t want these two types of appointments back-to-back and I don’t do this procedure, that procedure, and the next procedure.” Some of that’s okay. If there’s something you don’t do, don’t put it on the dock schedule. That’s relatively easy. The most ridiculous one I ever heard, and this was not in Elmhurst, this was many years ago in Atlanta, is, “Don’t give me two back pains in a row after 3:00 PM on Thursdays.” I swear to God that was an actual scheduling demand from the physician. Multiply that specificity by 14 or 15 people, it will take somebody on the phone fifteen minutes to make an appointment because they got to go read through everything and then find an appointment slot. What happened is the physician then complains, “Why do I have empty appointments?” I said, “It is because your rules are screwy that we can’t arrange things in a way. What you need to do is trust the people who do the schedule to understand that you have two types of appointments, long and short. Here’s what goes on a long one and here’s what goes into a short one. Let’s try to have a few other individual variables as possible beyond that.” That requires physicians to let go of a lot of control over people whose expertise is in talking to patients on the phone or by email and getting them scheduled. Every time we got somebody to do it, ultimately, they thanked us. That becomes a rolling stone going down the hill, gathering moss. The more people say, “The so-called open schedule works better for me. My appointments are filled. I’m not getting jammed up with two things that shouldn’t be back-to-back. You’ve got the longs and the short straight and I’m happier now.” It takes a long time to convince some people even in the face of overwhelming. That’s an example of the thing that when you get it working, it’s gratifying because it helps everybody wins. They usually make more money because their schedule is running more smoothly. They can maybe add on a patient or two a day which sounds like a dripping faucet but over time, that’s meaningful from a revenue standpoint. One of the challenging parts of running a clinic is balancing those two agendas, the medical objective and the business operational objective. Things like scheduling are seemingly trivial but they have a substantial effect on the performance of the business. It’s not at all. It’s the front door to the organization. It’s most people’s first contact with medical practices. “Let’s call and make an appointment and do it online if that’s how you’re doing it now.” What that experience goes like often defines whether somebody will stay with you or not. If it’s too hard to get to you, they’re going to go somewhere else. You described your entry into the organization as this exercise, meeting people, building trust, and listening to them. How much of what you looked to improve and evolve in the business was driven by that versus by data? The data is a tool that you use to implement change. The other thing that we haven’t talked about is there are a tremendous number of external forces that come to bear on medical practices. Some of it is national regulatory and you can’t do a lot about that. You have to roll with it. Some of it was self-imposed. One of the things you wanted to talk about is what are some of the more challenging things we had to do. At one point, the physician practice remained a separate entity but the facilities for reimbursement purposes under Medicare became part of the hospital. What that did was it brought those facilities, which I mean an ambulatory office, under the hospital’s joint commission, regulations, and requirements. That was not something that we were used to. One of the things I wish I had done better was prepare us more for making that transition because we got involved with everything from infection control to how we clean the rooms, who entered orders, closing loops on referrals, physical safety in the office, and adopting the hospital’s high-reliability service in the ambulatory setting. We had to deal with some round pegs in square holes but there were a lot of back-end business processes that we thought were set up correctly that weren’t. This is probably the most difficult time I faced in the organization because the decision to do wasn’t entirely under my control because the facilities had always belonged to the health system. I was still the leader and I felt that I owned communicating that, “This is going to be okay. We can do it.” It turned out we could. It was a lot more involved than I thought it was going to be. That taxed the trust and communication and so on. At the back end of it, it made us better in a lot of ways. It was somewhat more inconvenient for patients and some of them depending on their insurance was a little more challenging financially for them. We became much more scrupulous about infection control and verifying people’s identities. You may have noticed if you go in, you get asked your name and your birthdate fifteen different times by different people. We started implementing stuff like that. There were potential errors that may not resulted in harm, but we caught them and we tried to celebrate those things. The organization is much more disciplined, safer, and the cleanliness is monitored. It’s a better place to get care. We all chafed at some of this a bit but overall, it was painful but positive. Was this one of the challenges that emerge from the merger with Edward’s? No, this predated Edward’s. This was something that the senior leadership at Elmhurst wanted to do partly because there were some reimbursement advantages to it. Also, because some of the individuality that we were struggling with had to be extinguished to come into regulatory compliance. It helped us with risk, cost management, and safety. One of the other things you mentioned as a key success factor was being more evidence-based. Can you expand on what you mean by that? You would be surprised at the amount of stuff that physicians, hospitals, and other entities that provide healthcare do. There aren’t a million medical studies that support every single move that we make. We try to respect clinical guidelines that are either driven by our professional societies. In the hospital, they have goals for reducing infection rates in various settings and there is solid evidence behind those sorts of things so where we can, we try to implement that and base what we do on the best science available. It changes over time as we’re seeing aptly demonstrated with the COVID-19 epidemic. Did that translate into more usage of diagnostics? Is that in line with this idea of reduced individuality? When I say reduced individuality, I prefer the term reduced variation unless it’s a variation that helps a patient in some manner. For instance, going back to appointments, our positions now have an opportunity to say, “Mr. So and so is coming in. He always needs a long appointment because he’s complicated and he likes to talk.” That is a patient-centered variation that helps. A variation that doesn’t help is, “I don’t want to do Pap smears after 4:00 PM.” Where were tried to be more uniform was in the area of the process. We started screening people at annual visits and even sometimes on the phone. There are some basic screeners you can use for depression. It’s a way under-diagnosed problem. We set up a relationship with Linden Oaks Behavioral Hospital. It’s the mental health hospital of the Edward-Elmhurst System. If we detected somebody in trouble, we can make a fairly rapid connection to someone who could assess them and decide what level of care they needed fairly quickly.
Data is a tool that you use to implement change.We were sensitive as everyone is to the twin epidemics of opioid abuse and suicide, that both have been exaggerated in the COVID-19 era. Being able to catch people in more of a contemplative phase than when they’re ready to act is far preferable. Systemizing screeners of that sort by saying, “These are the things we will always make sure we pay attention to when we’re treating diabetics and here are the lab parameters we’re going to set.” In the past, it used to be criticized as a cookbook or overly oppressive or antithetical to physicians, heroism, and autonomy, but it’s better for patients. Particularly with physicians being trained now, they’re far more accustomed to working in this manner. It’s an exciting time to be a physician and to be coming into the field because of all the advantages not in technology, but in the process and improvement that are available now. COVID-19 upended everything, but I don’t think the pandemic is the only reason med school applications are on the rise. I wonder though, from an outsider’s perspective, it’s creating a level of complexity that is tremendous. Being on the end of the individual leader in an organization having to adopt these things, I’m curious, to what extent can you continue to scale the complexity of some of these procedural things versus relying on knowledge workers or people who are experts at their craft? It is a complex field. Remember, when you are trying to do things your way, my way, and in someone else’s way, you’re just pushing the complexity onto somebody else. It has to cope with the lack of uniformity. By no means does everybody practice the same way or schedule the same way but they make uniform what makes sense to make uniform. That is a way of attacking complexity and what it does is reduces errors in scheduling and care. When you think about what it took to get from 70 somewhat professionals to 130, in addition to ferreting out variation, what were some of the other challenges of growing a group to that level? The most important thing is finding people who are going to work in the culture well. The way things were set up, the final decision whether to hire was mine. I rarely disagreed with input from those who would be the direct colleagues. I would want to know things like, “How did you get interested in medicine? What is it that you wanted to do? What is it about a multispecialty environment that appeals to you? Why does that seem like a better thing for you?” Some people had answers and some didn’t. I would also ask, “If you take a blank sheet of paper and sketch out to me, what’s your ideal practice look like? How many hours a week do you want to work? Do you want to do hospital care? Do you want to rely on hospitalists?” Through those behavioral probing, you can develop a good idea of what working with someone will be like and how likely they are to be enthused about improving the processes of care so that everyone is better served. I can give you a couple of examples. This was not in Elmhurst but I once asked that question of somebody in medical specialties, “Why would you like to join this multispecialty group?” His answer, which I’m sure you didn’t think about but it came out was, “It’s a good place to start.” That was the end. The worst example was the guy who said, “I can work anywhere. Just tell me what you’re going to pay me.” I said, “I don’t even know if he wants to be a doctor.” Usually, what we would hear are things that are, “I like being able to have colleagues to bounce things off. Particularly since I’m new, I’m coming out of training.” I like the idea of having multispecialties under one virtual roof with a common medical record where we can communicate easily. I don’t want to have to start my practice which people still do but it’s extremely daunting these days. We didn’t even use that as a Litmus test because it’s uncommon, particularly in an urban and semi-urban environment like we’re in. The way to have a stable group is to make sure you hire the right people in the first place who seem to be going into medicine for the right reasons. They are group-oriented. They’re collaborative and like a team culture. The ones who didn’t, we either chose not to work with or they went somewhere else. You said retention was high, and turnover was quite low. Was there ever a point where people became a challenge? Most of that, you can work with because I’ve always felt, and I did not coin this turn or phrase either, positions are decent but imperfect people like everyone else, and I include myself. You have to approach people respectfully but also the end in mind saying, “Here’s either a behavior or a practice habit we have observed. We all agreed that the way we should do things. Let’s talk about why there’s a gap and how do we overcome it.” That’s treating professionals with the respect they deserve, but also making clear that as a group, we had certain expectations of people. It almost always worked out. We did have some involuntary separations and a few where I was able to help people see that it was either time to retire or they might be happier somewhere else. That’s something I particularly enjoy. I was good at it, as it turned out, and I found it personally difficult. It should be because it’s not a change you ever want to make lightly. It’s not like somebody who works in a limited job where you can easily take them out and put someone else in and the job keeps getting done. Even people who are difficult in some sense, however you want to define that, either they may not fit in the culture, they don’t get along with staff, or whatever the issue might be. Despite that, they generally have significant followings of happy patients. When you displace a physician or other professional, you leave a whole bunch of patients that you have to do something with. Some of them will leave but you have to work hard to retain them and usually can’t explain what happened. That’s difficult. I’ll put it this way, my predecessor on the way had said to me, “This is a fun job. It just isn’t fun all the time.” That was the not-fun all the time part and it didn’t happen very often. What I finally learned after a few of these is that we’re better off. A couple of these people maintained relationships with me. I bumped into them periodically and they realized that it was probably better for them, too. Not the gratification you want sometimes is what happens. On the way to growing the clinic, twofold approximately, were there points at which the organization got stuck?
When you are trying to do things your way, you’re just pushing the complexity onto somebody else.Yes, but not because of growth. When you add people, you need time for the practices to fill in but some other things held us back that once addressed, led to further growth. Let me give you an example. When I came, it was a team of six hospitalists. Most people know what a hospitalist is. For any readers who don’t, physicians generally, general internists, family physicians, and pediatricians who practice exclusively in the hospital. Other outpatient-only physicians will send in their admissions in the hospitals to take care of them. It became obvious over time that we needed too much better align them with both the hospital’s goals as well as the patient care they were doing. The hospital has a lot of regulatory needs to satisfy. They have quality goals and metrics they need to meet for governmental and other reimbursements. They were getting paid per shift. They were great people. They work hard but there was no personal stake for them in getting some of these other things done. They were the first group that we moved into what’s commonly called the value-based compensation method where some of their pay got held back and tied to their achieving a certain readmission rate. Some of the goals were tied to blood usage, patient service parameters, and a couple of other quality metrics that were easily measured and well within their control. That was a big culture change and it was controversial. There were a lot of long, sometimes unpleasant meetings about it but once we did it, it brought the team together, particularly once I put a new leader in for that team. When I left, it was a team of 15 docs on its way to becoming 17. They were busier and they were happier. The hospital was much happier with them. The patients were getting good care and they’re all making more money. If you’d ask any of them at the end of it if they want to go back, they would all tell you no. It’s not perfect. There are problems with it but it gave us an opportunity to look at what other things could they be doing other than being passive recipients of admissions. For instance, we asked for volunteers, “We’d like you to develop some expertise at opioid management and in helping people reduce their use of opioids.” A couple of them pursued that and the other 1 or 2 pursued expertise in the management of medical issues that come up in labor and delivery because that was an area that needed a little more support. Some of them did that. Part of it was, “If you were willing to do that, we would replace some of your bonus credit that you otherwise had to earn because you were helping yourself, patients, and the hospital.” The team probably cares for more than half the patients in the hospital right now. I’m not sure. I’ve been gone for years. That was an example of a real cultural and philosophical struggle we went through that led to something that turned out to be good. That team had a low turnover. If you look around this city or other cities, hospital’s teams turnover a lot. Physician Group Lead: The way to have a stable physician group is to make sure you hire the right people. They have to be going into medicine for the right reasons. They are group-oriented, collaborative, and have a good team culture. Whether it’s value-based compensation or better alignment of incentives at the doctor level to the clinic level or to the organization’s objectives, was that also a change that you made organization-wide? If we were getting there at the time that I retired, one of the things I was a little bit sorry about was I wasn’t going to be there to bring that one home but I was confident that the gentleman who replaced me would be able to do so. They’re still working on it. This process got waylaid by COVID-19. What I am gratified about is that the organization I left behind was one that has adapted brilliantly to the new demands of overnight becoming telemedicine experts. Completely reorganizing priorities in the way the hospital is staffed and a whole bunch of other things. I’m not even familiar with all the details but I have feedback both from physicians in the group and from the hospital leadership that the clinic has been helpful and adapted well. I’m sure that’s true over at Edward’s as well but having an organization that could see a sudden and brutally different vision of the future, to me, is a healthy one. I miss some of the action and the people. I wish I was there helping on the other hand. It’s nice to know that I left behind an organization that could remain resilient under these circumstances. What are the challenges of a mid-size group as opposed to an even larger one or one that’s smaller? Being in the middle can sometimes be the toughest spot. You don’t have at least a deep a bench as you might. If you have a specialty with 3 doctors and 2 of them get COVID-19, that’s a real stressor. It doesn’t even take COVID-19. We had a scenario during my tenure where there is one guy who was on vacation in Italy and the other one suffered a severe injury to his hand and couldn’t operate for a while. This one poor guy was left by himself, not that we were able to arrange some other coverage for him. Depth can be a problem. One thing that is going on is that the Edward-Elmhurst Health System has a variety of relationships with both employed and contracted entities like ours. One of the things we were working on was in figuring out how we could all collaborate better together and create a virtual physician organization of 500 to 600 people even if we had, to some extent, remained in our silos. That was part of the evolution that we were working on and what might the model look like. I don’t think any of us knew. What was nice was that both the medical professional side of things and the hospital side were open to whatever that might be as long as we focus on certain common goals that we would be able to provide patients the care they needed, when and where they needed it. Our processes would be fairly uniform across the organization for the reasons I explained and that people had a similar experience regardless of whatever door or window they entered the entity through. I imagined that would raise the bar quite a bit higher for standardization. You try to take a bang for the buck approach to that. Where are you going to most advantage yourself by trying to standardize? Devote your resources to doing that. Try to catch every little thing. If you want to use a Band-Aid that’s the size and I want to use, we’re not going to waste a lot of time arguing about that. That’s seemingly commonplace in some specialties in medicine to have a service organization of some sort behind it and then to some degree, everyone is, sometimes literally, a free agent of sorts. Physician employment has become far more common over the last decade or so, then it was almost unheard of when I finished training. You would go to work for a hospital and hospitals weren’t into employing positions at that point. There have been a couple of waves of that. Some people come in and come out. It’s being done in a smarter way and driven by more timely and reliable data this time around. It’s going to stay plus. I came out of medical school with $11,000 of debt. I remember talking to one gifted young female OB-GYN physician in our group. She married an orthopedic surgeon and they were starting their life and their practice together. Between them, they owed over $800,000 in education debt. It’s a mortgage on a nice house without having the house and they still needed to live somewhere. They’re great people and talented physicians. They’re working hard and they’re doing well financially. The thought of having to put up what it takes to start from zero and then knowing little about the business side of things and put up a practice is not feasible these days. I would have to keep reminding myself that if a physician sounded to me a little what’s in it for me focused, I remember I’ll get this person probably owes mid-six figures in education debt. We’re going to try to work with that a little bit and help them be successful enough so that they can manage their lives. That’s a challenge involved in this if you’re going to be in this profession. How did you personally come to learn some of the non-medical things that go into leadership, even beyond the individual coaching and being able to relate as a physician yourself? I had a couple of good mentors, but I also recognize that leadership is a discipline and a set of skills that come naturally to a few people, and the rest of us can develop. It’s an academic field of study like gastroenterology or brain surgery. All physicians are leaders to some degree. They’re usually operating a clinical team. It doesn’t mean that they’re in any way shape or form prepared to operate organizations. You learn a lot by making mistakes but I’ve been a member of what’s now called the American Association for Physician Leadership since the mid-‘90s. They have a certificate program completed. I went to a Master’s degree in Medical Management. There are a few of them in the country, mine is from Carnegie Mellon. That thing is helpful as long as you put it into practice. I still remember a guy I reported to early in my leadership career who every time I brought him a problem, he would say to me, “What do you think we should do? What’s your recommendation?” I stopped bringing him problems and recommendations because what he was saying to me is, “I trust you to make this decision.” “I can treat heart failure and high blood pressure, but now he wants me to decide. Do we need to hire somebody into this role?” How can we better reduce our length of stay? How are we going to model how we take care of this type of patient? Once you start a system thinking approach, it becomes a little easier but there’s formal training for them. Some people find it isn’t for them and it isn’t for everybody. It doesn’t have to be nor should it be. You need great, hardworking physicians, nurse practitioners, PAs, nurses, and staff. That’s where they get their energy and that’s what drives them. Back to the trust part, they have to know that they can rely on you to look out for their best interest to some degree, but also to make sure that they’re working in a system of care that does what it says it’s supposed to. This idea of systems thinking is one that you mentioned to me before. The phrase you used was, everything affects everything. That is the hardest part of operating a business to grasp and you can’t learn from a textbook, or even from a case study. How did you conceptualize this? You’re the first person to verbalize it in quite that way. Some of it was from experience and probably doing a few dumb things myself. My background originally is I was an Astrophysics Major in college. I’m used to thinking, “You want to talk about thinking broadly.” There’s a flip side to it, by the way, because when I’ve had 360 reviews and other feedback, it’s not negative but sometimes you think about things a little too hard. You’re not going to make everybody happy. Make what you think is the best decision. My response is the guy who’s working all by himself on the other side of the building, I don’t have to worry about him and everybody else 24/7. I can do what’s right for the organization. I’ve come to appreciate the value of being driven by a mission and a vision. Those are somewhat overused terms and it’s something that can be done badly if it’s hidden from the C-Suite. Without a feeling of investment and buy-in from the people doing the actual work, it’s meaningless but if you involve them in crafting it, which one of the other things I did on the way out is we reformatted that. You can point to those things and say, “These are our values. This is where we said we want it to be in five years. This is the set of strategies and goals we set to get us there. I understand what you want to do, but it’s not consonant with what we said we were going to do so we can’t do that.” It becomes not an interpersonal contest and, “This is about what we all at some level agreed we were going to do.” Our activities and initiatives have to be consistent with that. It doesn’t mean mission and vision can change over time. It’s worth a look every couple of years but while it’s in place, you have to always ask yourself, “Is this consistent with our vision for ourselves or is it not?” If it isn’t, you have to have the courage to say no.
Know where to put yourself at an advantage and then devote your resources to doing that.Were there times where you had to do that? Frankly, not often. What we wanted to do was not quite mom and apple pie but it was about the values that define the organization and the workplace about doing things that are right for patients. Not getting bogged down in bureaucratic minutiae to the extent that it interfered with our ability to do that. Making sure that the resources for people that do go to work are available and that they had compatible staff supporting them. Through that, we moved through most things pretty smoothly. We get little turnover. There are plenty of other places in this area that people could have gone to. Chicago is home to five major medical centers if not more, and a variety of community hospitals. There are opportunities for people to go elsewhere and they didn’t. When you ran into business changes like bringing the Elmhurst Clinic under the hospital designation where you have a lot more regulation and operational constraints or requirements, to be a little broad, there are reimbursement benefits to that. Money in the pocket of the clinic is more money to invest in the medical quality of care amongst other things. Does that scenario present a conflict of values of sorts? It did because it was perceived as a further impeding autonomy. It did sometimes in a good way and sometimes not in a good way. Some things didn’t translate well from a hospital setting to an ambulatory setting that we still had to find a way to honor. We worked through those things one at a time. Now, it might have been a little different in ENT than it was in pediatrics or gastroenterology but we did it. It was a matter of communicating and putting the patients first and having physicians realize that I wanted what was best for them but I also couldn’t ignore if there was a practice underway that either had a safety risk or potential for an infection control problem or something of that nature. We had to address it. Just because something had never happened doesn’t mean it couldn’t. We’re typically dealing with fairly low-volume adverse occurrences anyway. It’s the reason airplanes don’t fall out of the sky all the time because of maniacal attention to detail, double-checking, verifying communications, and taking steps out of processes that don’t add value. If you had to do it all over again, what might you have done differently? I probably would have asked a lot more questions before tying us to the hospital regulatory model. Not that we wouldn’t have done it but we would have been better prepared. We’d have understood our workflows better and done a lot more preparation. I was a little too resistant to enter the world of value-based compensation. Not because I thought it was a terrible idea so much as I wanted to be sure we had the data we needed to manage it well. We didn’t entirely let the insurance companies define quality for us that we would be able to do some of that ourselves. That is the path that the group is moving down. We’re a little behind the eight ball. We did things like improving outcomes for diabetics and so on. When we initially came into the merger between Elmhurst and Edward, we were doing it about as well as Edward Medical Group. They had a value-based comp plan. I give them a lot of credit for going at it long before anybody even thought about it. Our argument was, “We’re doing about as well as these guys. Why do you want to rock this boat?” They kept getting better. That gave us an opportunity to take advantage of physicians’ inerrant belief that they’re all above average. There are great people out there. I’ve met and enjoyed many of the Edward-employed physicians and became friendly with their leadership. We would help each other quite a bit but we couldn’t let those guys ahead of us. That outdrives some of this. Plus, the opportunity to self-design such a program prior to having one way or another imposed was appealing. I wish I’d started that process a bit sooner. The group would have adapted then as well as they are now. That’s one thing I wish we’d done at work. It works quite well with the hospitals. It was a lot harder to spread out to the rest of the group because there was quite a bit of resistance to it. It got to the point where I could say to the doctors, “If you think you’re going to see something different anywhere else, I invite you to go take a look because you won’t.” There has been an endless series of rumors that Edward-Elmhurst was going to merge with some bigger entity. It has not happened. It may yet it may not, I have no idea. My message always was, “If you think that your current comp plan is going to survive anything like that, it isn’t.” It’s a combination of recognizing reality and some concerns about various potential future scenarios that might impose something that the docs would prefer to design themselves. That’s where I believe they are right now. I like to stay in touch a little bit. Once you leave, you can’t hover. The guy who replaced me, he’s the leader and this is his job to carry forward. I know he’s doing it quite well. I had the opportunity at Edward-Elmhurst to work with a talented group of professionals as we implemented a lot of change. I developed a lot of trust and added to group cohesiveness. The opportunity to mentor new physicians and future leaders was extremely gratifying. As I look back both over the last eleven and a half years that I was there and my two prior roles, each one exceeded my expectations in different ways. Each one was challenging in different ways. I look back over 37 years and I’m amazed at how fast that all went. It’s been a professional life well spent. I’m grateful for it. What’s interesting is you could go out there and help midsize groups better manage themselves. Consistent with what you’ve shared here, you’ve chosen to go off and mentor up-and-coming physicians. Can you talk a little bit about what you’re doing now? I was hoping to do both but the pandemic has obviously restricted a lot of discretionary dollars for things like consulting. The one thing I am involved in right now is a program called Ascent Physician Leadership. It has a mountain climbing theme to it, though I don’t know how many of us involved would end up in a real mountain. It’s a product of the Interstate Postgraduate Medical Association, which is the oldest organization nobody’s ever heard of. It’s been around since the Mayo brothers. It’s based in Madison, Wisconsin. They do a lot of CME programs. They certify other people’s CME programs. Some people pulled this together. What I like about it is that it’s grounded in peer group learning and individual coaching. It’s about the personal side of leadership and developing yourself as a leader. Most of the other leadership training for physicians ends up being about helping someone else be successful. It might be your practice, an ACO that you’re part of, or a health system. It’s about helping something other than you becoming a big success. What it focuses on a lot is the personal development side of leadership, a lot of stuff that I wish there have been an Ascent program around to teach me. That’s been nice. The other thing that’s been fun, fun is one word for it, is it was modeled on three in-person meetings a year in various locations around the country and then monthly conference calls in between with a peer cohort. That all got completely upended. We’ve been busy continuing the program as best as we virtually can while completely redesigning it for a relaunch in a way that we could return to the old model but we’re also ready to pivot quickly back to an old virtual model if we need to. I’m certainly making myself available to do other consulting projects. I’ve had some conversations with other people. I’ll keep doing that, keep networking if something comes to fruition, fine. If it doesn’t, I’ll enjoy what I’m doing or play the clarinet more. Donald, thank you very much for coming on the show and sharing your experience and your insight. It’s very kind of you to have me.
- Edward-Elmhurst Health
- Linden Oaks Behavioral Hospital
- American Association for Physician Leadership
- Ascent Physician Leadership