Cancer Economics: Dilemma of the Contemporary Physician - The Nobel Prize or the Business Prize?

Albert B. Einstein, Jr, MD

Oncology practice and economic realities are inexorably linked today. Developments in cancer economics are explored in this regular feature.

Recently, I was fortunate enough to receive the Physician Business Leader Award of the Medical Business Healthcare Awards. I am stating this not to boast about my business acumen, but rather to reflect on the conundrum this has created for me. Why am I --a physician who received his Doctor of Medicine degree 30 years ago, who commenced his career conducting basic immunology research, who devoted 17 years to caring for cancer patients -- being acknowledged for my business activities rather than for my quest for the holy grail, the Nobel Prize in medicine? The mere presentation of a business award to an academic physician is, I believe, a clear statement of the intrusive dominance that the business aspects of health care has assumed today. With the recent economic changes, the physician executive has emerged as a valued, respected member of the health care team in both academic and community health care organizations. While potential Nobel laureates pursue the cure for cancer, physician executives help to navigate their organizations through the hazards of today's health care environment and help to ensure that the scientists have the resources they need to accomplish their jobs.

Throughout my medical education, my role models were the academic clinical scientists who were superb caring clinicians, well-published researchers, and inspiring teachers. Their days and evenings were consumed in seeking the answers to important questions regarding the natural history of disease and potential treatments. They sought to bring new laboratory discoveries into the clinical arena to be tested in carefully planned clinical trials. One of my mentors and role models, Dr E. Donnel Thomas, deservedly was awarded the Nobel Prize in Medicine for his pioneering work in bone marrow transplantation. His work, which extended over a professional lifetime, has led to numerous patients being cured of otherwise fatal diseases. His important contribution to the medical profession and the health of society is without question.

While many of us grew up admiring and hoping to emulate the great professors of medicine, we recognize that contemporary medicine now offers many varied professional opportunities beyond the more traditional roles of teaching, patient care, and research. Health care reform, the rapid growth of managed care, and the resultant consolidation of the health care providers have transformed medicine from purely a profession to very much a business. In turn, new opportunities for physicians with the necessary administrative and business skills have emerged to provide leadership in shaping the future of health care in the United States. Physicians are assuming broader and more influential administrative leadership roles as CEOs of hospitals or medical groups, presidents of medical staffs, and vice presidents for medical or clinical affairs. In the insurance industry, physicians apply their clinical knowledge to the systems of payment for health care as important members of senior management teams and as medical directors. In government and academic circles, physicians help to shape public policy regarding health care in an era of shrinking health care resources. Most major health care consulting groups have physicians in key roles on their consulting teams.

The role of the physician executive is emerging prominently in the academic medical center. Traditionally, medical school leaders and academic department chairmen were chosen for their clinical and research reputations. With the scarcity of resources, the emphasis on clinical productivity, and the need for cost containment, academic leaders now need leadership and team-building skills coupled with a knowledge of business principles to maintain solvency and manage their faculty. Academic clinical enterprises are finding themselves competing for the same business as their community colleagues at much reduced reimbursement rates. Physician executives are being hired to manage academic practice plans, reduce costs, develop networks, and interface with managed care plans. These leaders are being selected on the basis of their leadership skills, their management ability and experience, and their willingness to expand their current skills. As an acknowledgment of the value of the role of the physician executive to the academic organization, academic promotion in some institutions is now driven by administrative skills and leadership in recognition of the value of the role of the physician executive to the academic organization. The ideal physician executive needs to be respected as a physician with clinical knowledge and experience, skilled in managing people, and educated in the basics of business management. Desirable personal qualities include being focused, driven, open, decisive, fair, politically astute, quality-oriented, and collaborative. The individual must possess skills in visionary leadership, effective communication, listening, negotiations, and conflict resolution. The person must be willing to promote and uphold quality standards and ethics above individual considerations. The physician executive should have some degree of knowledge and understanding of basic business skills, including strategic planning, accounting, budgeting, human resource management, organizational theory, marketing, managed care, and negotiations. Critical to success is the ability to work collaboratively with other members of the management team, while respecting each individual's contributions, unique skills, and experiences.

Today, a physician interested in administrative medicine can easily acquire the necessary skills. Formal master's degree programs, short courses, specific topic seminars, books, and journals are readily available for continuing education on management issues. The University of South Florida's College of Business Administration enrolls approximately 35 to 40 physicians each year in its MBA program for physicians. Some medical schools are adding courses on health care management to the curriculum. Professional societies such as the American College of Physician Executives (ACPE) now offer certificate and fellowship programs for physician executives. The ACPE membership has grown to 90,000 physicians. The American Medical Association reports that in 1994, more than 15,600 physicians claimed to work primarily in administration. Physicians who used to be in the examining room or the research laboratory can now be found in the meeting room learning business skills and discussing business and management strategies.

The unique contribution of physician executives to health care organization is their understanding of the clinical issues surrounding patient care and disease management. As a health care provider, the physician executive can also serve as a strong patient advocate. While many talented administrators and managers operate health care organizations, they lack the education, training, and experience in the diseases and the clinical processes that they manage. As disease management replaces simple provision of services, clinicians will have to be involved in the design of the systems and the evaluation criteria. While the patient has become the pawn in the managed care game, the quality of their clinical care and their satisfaction will become the ultimate measurable outcomes. The definition and evaluation of quality outcomes need to be determined by clinicians who are trained in the management of disease rather than by managers and accountants who are oriented principally to the bottom line. The physician's responsibility in management is to try to balance quality issues with economic issues in ultimately serving the best interests of the patient.

From the perspective of the health care organization, the senior management team needs a physician executive in a major leadership role in order to be optimally effective. This physician in turn needs to work collaboratively with nonclinical administrative colleagues to provide balanced management for the organization. The physician leader also may serve as a credible link between the administrative structure and other physicians. Physicians' respect for one of their own helps build bridges and create bonds with the organization.

Is this diversion of physician talent and skills into the business field worth it? Are we, the physicians, being distracted from our ultimate goals of curing disease and caring for patients? We certainly can argue about whether the consumption of human and financial resources in this effort to cope with the changes in health care delivery is ultimately in the best interest of humanity. However, I submit that given the economic and political forces at play, we have no choice. Appropriately skilled and interested physicians need to step forward to provide the administrative leadership necessary to direct the future of health care and to ensure that other physicians and scientists will have the necessary resources they need to make Nobel-Prize-winning discoveries that lead to the prevention and cure of cancer. Today's physician executive plays a new legitimate role in the attainment of the traditional professional goals of medicine.

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