Dilemmas of Physicians in Administrative Roles Dealing with the Managerial Other Within

Health care settings have been characterized as 'church-state' organizations in which physicians and administrators collaborate to produce the organization's services (Gilmore, Hirschhorn and Kelly, 1999). Historically these two groups were loosely coupled (Orton and Weick, 1990). The hospital was regarded as the 'doctor's workshop' and the mere administrative mortals took up their role in support of the priestly work of healing the sick. Their work took on the character of 'parallel play' with each in different realms, with different distinctive competencies. Physicians, especially in academic medical settings could remain blissfully ignorant of the cost implications of all their decisions (admissions, level of care, tests, medications, etc.). Administrators stayed clear of the issues of quality and medical decision making. (Gilmore and Krantz, 1990) The organization of health care is changing dramatically with most of the significant issues requiring much greater collaboration between the church and state sides of the house (Starr, 1982). This is especially true in academic medicine. In any of the three missions of education, research and clinical care, the complexity and costs require advanced substantive thinking and sophisticated organizational and managerial knowledge to invent and implement the new systems. In academic medicine, within the medical school, the leadership roles of dean, chairs, center directors and section heads were always filled with physicians. Now, in academic medical centers many of the significant administrative leadership roles are being taken by physicians. As the issues become more complex and the boundaries between their substantive knowledge (basic science, clinical care or education) and managerial issues becomes more intertwined, they face the challenge of building their competence in the business and organizational aspects of the work. Additionally, many more business leaders are taking up roles within senior leadership, such as chief financial officers, chief information officers, directors of technology transfer, etc. This creates a double challenge. First, the top team of the organization needs to integrate across the professionally and administratively trained members due to their increased interdependence. Second, for physician executives there is a particular challenge to integrate within themselves the clinical and administrative aspects of their roles, what Argyris and Schon (1974) have termed their first- and second-order professional skills. This paper will explore the dynamics of the 'managerial other' within physicians as they take up significant organizational leadership. Many colleagues, on the occasion of a physician's 'promotion' to a leadership role, express some variant of, 'You are no longer one of us. You are one of them.' Physicians wrestle with this dual identity'some becoming completely caught up in the world of organization and management, others holding firm to their core professional identity, often at a cost to their effectiveness. If the challenges increasingly require the integration of first-rate medical knowledge with advanced skills in leadership and management, then the working alliance across physicians and administrators needs to be productive. Physicians need to discover ways to value both aspects of their leadership roles, rather than holding the managerial at a distance. Heifitz (2001) has distinguished between technical work and 'adaptive leadership work'. Adaptive work is value-laden, clarifying and addressing what matters most, surfacing conflicts in values and gaps between values and reality. Unlike technical work on routine problems, adaptive work requires changes in people's values, attitudes or habits of behavior. Sometimes those changes are within themselves, sometimes they are within their fellow professionals, but increasingly they require changes in the working alliances with non-physicians.