Management Training for Doctors

[Ibid]

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Inspired by another thread. I think this issue is particularly relevant to psychiatry.

What are peoples opinions of the current state of management training for Doctors where you are?

Specifically should management training be part of the curriculum at all?
When would it become relevant? At what level would you pitch it or offer it, after qualification?

Is their not a good case for Doctors to be even more involved in management?

Would you favour the development of a more formal career structure for people with the interest and aptitude?

Or are you against it? Do you see it as hybridisation of the profession, not relevant or helpful in someway?


The issue of training in health economics and accounting are similar questions and I would be interested in what people think about those issues as well.

My own view is that Doctors in management are helpful and more attention should be given to developing a career path where one does not exist outside just putting ones hand up.

 

[nitemagi]

As a chief-resident, I think it's useful once at the chief resident position, as well as formal training as an attending in any multidisciplinary setting.

 

[whopper]

IMHO most doctors, as a whole, are poor managers.

In most of the fields of medicine where we practice, doctors are considered at the the top of the food chain. Yet, instead of leading, I noticed several doctors expect their team to cater to their whim as if the staff are servants, and the doctors are masters.

Being in an executive position should yield some benefits. As a leader, the doctor does need some catering to keep their mind on more important matters, but at the same time, it's supposed to have added responsibilities, including listening to the concerns of the team as a whole.

IMHO, doctors, starting from pre-med up, the training is too focused on grades and performance on multiple choice exams, not on leadership. For example, would experience running a company with over 100 employees with a GPA of a 3.6 give someone a leg up over someone with a 3.7 or 3.8? From my experience no. In this case the difference in GPA is insignificant, yet the experience of running a large organization, that IMHO is too significant to overlook, yet it often is.

The issue of managerial skills is very important in psychiatry if you want to run your own private practice, are the attending of an inpatient unit, or in any aspect of administration of a psychiatric department.

 

[Manicsleep]

I was a clinical chief in PGY3 and helped out the admin chief/covered him when he was out. In PGY4 I was the Admin chief. It was very useful.
Our program also had courses on 'How to be a Senior' 'How to Mentor' and 'How to Run a Service' as part of didactics. Each course was about 6 hours each.

I have considered going the route of the MMM degree but don't know if it is necessary.

 

[hippiedoc13]

Our program also had courses on 'How to be a Senior' 'How to Mentor' and 'How to Run a Service' as part of didactics. Each course was about 6 hours each.

That sounds so useful. I wish we had something like that at my program. Were those courses taught by your program faculty? If so I would imagine you also got some good modeling of those skills in day-to-day operations?

One of our former chief residents had an MBA, which seemed invaluable. It was really interesting to see how his approach to administrative & management problems differed from that of other chiefs and even attendings and program administrators.

 

[Manicsleep]

Our chair had an MPH and an ex program director had an MBA. On of the other attendings was very heavily involved in the medical school program and ran the mentorship program.

I think i learned most of the information on the day to day level. This is why I am considering the MMM. The immersion is really helpful.

 

[notdeadyet]

The American Management Association has a series of seminars that are top notch. In tech, we sent a lot of folks to these. They're ideal for subject matter experts (programmers, docs, etc.) who need the foundations of leadership/management skills but for whom a full-fledged MBA would be overkill. They're pricey, but you tend to get what you pay for with this kind of thing...

 

[Ibid]

Whopper

Yes, I wouldn't like to guess at how many managers are bad managers. Being a good Doctor and being a good manager don't go hand in hand as you imply. Oddly enough even psychiatrists won't necessarily be good people managers which of course begs the age old question, are leaders born or made.

As you say you need certain management skills to run a practice, probably farmed out to a practice manager if it has enough partners. Running a service, unit of some description again requires another skill set. The skills required being dependent on the job at hand.

The big picture is what really interests me and that is how whole service systems get commissioned and designed and in the case of mental health, psychiatrists input. Obviously design, the way the system will look in the end, no matter who inputs what, always boils down to how the system is funded. So the funding mechanism controls the bigger rationing mechanism.
In a socialised system where the service is paid for out of general taxation there is going to be a huge political dimension with respect to what is provided. Concerning the specifics, a host of stakeholders come into play. In the UK that means the Department of Health setting strategy, local bodies (circa $1.5 billion to play with each on average) buying services from local providers and strategic bodies in between refereeing the contracts. (all these bodies being part of the NHS) Obviously psychiatrists are significant stakeholders so feed into all these bodies by different mechanisms along the way. Cue bitter complaints this is untrue and that they are marginalised and hand wring about government targets distorting clinical priorities..

In the US as I understand it the federal government is putting in place legislation that state governments don't want to pay for as it will affect their bond rating and given they have to balance the books and can't just sell another shed load of T-bills to pay for it all I can see their point. (It all seems to have gone through on a technicality after the election of a senator with a previous stint as a model got elected?? I digress, even I have limits as to how closely I can follow foreign news.) The bigger question seems to me that all the service design is done by HMO's through insurance companies and similar mechanisms. So how psychiatrists feed into the design is unclear to me although I am sure they do one way or another. It seems that questions of equity and fairness wouldn't come into play.

In either of the cases above its going to be a good understanding not just of mental health but of health economics as they apply in the respective systems. Obv an MBA is an excellent generic qualification but given health systems are fiercely complex, particularly mental health systems, an MA or Msc in Health Service management is imo probably a better bet. Exposure to a debate over Total Quality Management v Business Process Re-engineering for improving health services being a tidily example. Again I digress. I should say at this point that I am just setting the scene as I see it and it's not as if it is news to you.

Clearly a good psychiatrist could disappear and spend their entire lives in "management" in either system. A waste of a good doctor? That's the question for me, among others.

I have just used those two countries as proxies. Clearly cultural biases come into play. In the UK depending on the complexion of the ruling party the wellbeing and happiness of the population is a matter for the government. In contrast in the US I believe the cultural disposition is that happiness and the well being of the population is something for consumers to pursue, aka the constitution, at Macys or K-mart depending on disposable income. That's a joke not a dig btw. Anyway it's not meant to cause offence but it is relevant. No?

 

[whopper]

I get your point, and actually agree with you on several levels.

Several positions, however, IMHO, such as running an inpatient unit do require some management skills that I see doctors lacking. Doctors are considered the head of the treatment team, and as the leader, should have the leadership skills of someone running a group of what would be at least 10 people (social worker, head nurse, all nurses, psychologist, etc). Others, you don't need it as much.

 

[Manicsleep]

I think physicians, particularly psychiatrists, actually do make excellent managers however there is a need for them to be properly trained. The major reason for this is because there is a tendency to behave in the 'do no harm' model. In management, this behavior has to be subdued, especially when there is a destructive element in the workplace. This can cause problems in the resolution of conflict because many are unwilling to take a hardline approach. Where psychiatrists do excel is in the nurturing of talent and making a good team better.

Interestingly, I have seen the different disciplines often play the archetype role. I know a great surgeon who is excellent at attacking and eventually cutting out "the problems" as she calls them.

 

[Ibid]

I get your point, and actually agree with you on several levels.

Several positions, however, IMHO, such as running an inpatient unit do require some management skills that I see doctors lacking. Doctors are considered the head of the treatment team, and as the leader, should have the leadership skills of someone running a group of what would be at least 10 people (social worker, head nurse, all nurses, psychologist, etc). Others, you don't need it as much.

Whopper

Agreement on several levels must be even better than one level. If you fleshed it out I would be interested.

I agree what you have posted above is true. Bearing in mind not to mix up clinical leadership with line management. Obviously those are two different things but there is an interplay between them and the inpatient unit is a really interesting example. Broadly there being two models:

Model one - One psychiatrist with overall responsibility (Responsible Medical Officer or equivalent) for the treatment of all patients on unit

Psychiatrists - divided opinion, decreasing interest in this sort of role, some enthusiasm for the model, promotes a sense of whole team working with the psychiatrist seeing the inpatient staff as their team.

Ward Managers - mostly prefer this model as until runs more easily from a bureaucratic perspective

Patient perspectives - uneven opinion tending towards a preference to see their community psychiatrist in the ward round rather than another psychiatrist

Model Two - Muliple psychiatrists with admitting rights seeing their own patient in ward round and keeping RMO status or equivalent.

Psychiatrists - see treating the patient along the whole pathway seen as positive. Handing over treatment during the acute phase unhelpful when they know the person best. Others don't see it as a problem as long as they have good communication with the inpatient psychiatrist. (strong feelings both way to be fair). Generally psychiatrists in this model don't see the inpatient unit as their team and this detachment causes problems as well.

Ward Managers- general dislike, the ward team constantly has to adapt to different practices. Demandon the staff team to respond to the differing dispositions of psychiatrist with varying dispositions toward the same scenario.

Patients - Generally a strong preference for seeing the same Psychiatrist in the community and during an acute phase.

Obviously variations on a theme exist and historical, cultural and demographic factor all play a part in which model is implemented. Not least the preference of individual psychiatrist.

Your point is highly salient though and I agree fully. Model one only works well, if at all, if the psychiatrist is committed to a multidisciplinary team approach. Lip service is not enough. If they are not signed up to a certain way of working it can be quite toxic. Most psychiatrist who would be well suited want to work in community teams imo.

I think Sweden is the country that is closest to achieving bed less services. Home treatment seems to be being embraced all over the world. With inpatient units losing beds and closing as resources are diverted away from expensive buildings. Of course pointless admissions for medication changes will still happen but the tendency to support people at home even during acute episodes is irreversible. My point being that service configuration in that context becomes relevant again.

Just my own thoughts on it.

 

[whopper]

Agree with you. I also agree with the models you brought up.

One business aspect I've noticed in inpatient units, is the bottom line. I've seen several doctors not practice in tune with that bottom line.

Now, several would argue that we should practice with no consideration of the money AT ALL. I disagree. Here's an example.

You've got a schizophrenic patient, and it's well known the patient is schizophrenic. There's no doubt. There's also previous records showing that on Risperdal 4 mg QBID and Depakote 1500 QHS, the person is fine. In fact the patient even wants to be on that medication.

In this particular hospital, given the patient's payment method, the hospital starts losing money on that patient on day 4. It's day 3 and the patient hasn't even been started on meds yet.

That's what I'm talking about. It's not in the patient's interest, nor the hospitals interest to keep this patient stewing around with no help that the patient wants. Yes, I'd disagree with the opposite extreme, starting the patient on Risperdal 4mg QBID and Depakote 1500 QHS on day one. You need to gradually taper up the Risperdal.

At least from my experience, doctors that understand the monetary aspects don't wait around on issues that cause the hospital to lose money that is not in the patient's interest.

And from my experience, when the money issue is brought up to the doctor, in this case, the doctor that's sitting on his butt, letting the patient stew, the doctor gets upset and starts pulling the "it's unethical" argument, even though the doctor's lack of medication treatment is the result of his laziness, not the result of something that is clinically in the interest of good patient care.

It essentially boiled down to a battle of egos between the hospital and the doctor. The doctor believed he earned an entitlement where because he was a doctor, he had the final say without living up to all his responsibilities.

That was a case I've seen in my training. There were other doctors that moved things along, and if they did get a patient that needed much more time than 4 days, the hospital was willing to give them leeway because they knew the doctor didn't sit on his butt. They had some trust that if this patient needed the extra time, given that the doctor moved things along at a better pace, then this really must be a case where this patient really needs the extra time.

I'm currently seeing the same problem in the state hospital I'm working, though instead of a margin of error of a few days, it's more on the order of months. I just got a unit 3 weeks ago, and within 3 weeks, 6 patients were discharged. Before I had that unit, it took about 6 months to get 6 patients discharged.

What was IMHO going on was it's actually easier for a doctor in the state to just let a patient stew around. We're only supposed to see patients once a week. If you discharge a patient, you'll get a new (and dangerous) patient. So some doctors appear to just want to keep someone who is not actively dangerous, but not discharge-able in that state. I've seen too many cases where someone is actively psychotic, then 6 months later the same doctor keeps them on the same medication regimen that needs major modifications (e.g. depakote at subtherapeutic levels---for months!).

The doctors with the adminstrative skills know what's going on with this game some of the doctors appear to be playing, yet with the shortage of doctors, they must keep them in the hospital.

 

[Ibid]

Whopper

Very interesting. The first scenario raises so many questions. With respect to the individual patient, in my minds eye, one way to resolve that situation generally would be if each patient had an advance directive that while not legally binding would have to be taken notice of.

With respect to using financial considerations as an instrument to address poor practice, I wouldn’t be against that as long as an accepted definition of what is good practice could be agreed while at the same time allowing for discretion. The other way to do it is to monitor individual doctors and services and give them targets with financial penalties. That is what has been tried in the UK but of course the penalty is paid for out of general taxation anyway so it’s a bit farcical in the end. Although the target culture is coming to an end in the UK, probably rightly, it has served its purpose. Wait times are down generally and bed blocking and delayed discharges have been addressed to some extent as well. I digress.

Back to the scenario, with respect to the ward, the situation you describe stinks. As will often happen two patients with identical profiles to the one you describe end up being treated differently by the same ward team. Hardly conducive to creating a therapeutic environment when the ward team don’t have acoherent way of working.

In the same vein you mention “not supposed to visit more than once a week”. I couldn’t tell what was driving that but I can’t think of anything more pernicious and against the interest of the patient. Weekly ward rounds just lead to a wave of incidents and “unrest” on the days leading up the to “the return of the almighty” followed by a tapering and another crescendo. All these incidents are viewed through the prism of the patients pathology when in fact when you look at it in detail it is blasted weekly ward rounds that are the root cause of nearly all the trouble. With multiple ward round days and different doctors it all looks like chaos but there is a pattern to it when you do the analysis. Another reason for dedicated inpatient psychiatrists who can see the patients as and when. Much more rational.

I recognise the game playing you mention. Clearly people are unpredictable when they are psychotic but keeping people in hospital under the guise of treatment when in fact a phoney risk management process is going on is truly unethical IMHO. Detaining people for months on end when their risk profile is never going to change during that time is absurd. The fact that it is never made explicit makes it all the more devilish. Not least because it prevents the patients ever being forced, or more correctly being given the proper opportunity with their psychiatrist and wider team, to address the real risks that they pose when they are in an altered state of mind. Psychiatrists need training to enable them to talk to patients about risks explicitly not just tangentially in discussions about treatment. Its just a change of emphasis really but I am sure you know what I am getting at.

I take it you are talking about doctors holding on to patients. Ward teams can and do play the same game by not selling patients as ready for discharge if they know they can have a quiet life or have a new person who needs more support.

You raise a lot of interesting questions. Instead of trying address them all I will save them up and start some threads in due course.

As an aside with respect to financial discipline being used as an instrument to inform practice the Orwellian sounding UK body, NICE (National Institute for Clinical Excellence) has recently bumped up one of its decision making rubrics for guidance to 30K per quality adjusted life year. (Hospitals have a duty to be NICE compliant). Nice to know what one is worth lol.

 

[whopper]

It's unfortunate we live in a world where doctors sometimes "play the game."

We are supposed to give the best treatment we can, given the opportunuties we have available to us.

A problem with utilization review is that if it becomes too much of a logarithm, there are too many exceptions to the rule.

But not having any structure leads to the opposite problem, that I mentioned above.

At the state hospital I've worked at, several doctors, IMHO, were not moving the patients along in a manner that was responsible. As much as you can point to the hospital as possibly being bad, I've seen this in almost every hospital I've worked in.

We're only supposed to see patients once a week.

Let me clarify. We can see patients more than once a week, but we, minimum, must see them at least once a week.

So if you have a unit full of patients that are not yet stable for discharge, but not actively causing a disturbance, you can get all of your work done in just 2 days of work. You'll then have an easy 3 days where you can watch DVDs of Hell's Kitchen in your office.

If you're actually doing your job, you're admitting, discharging, getting newer and less stable patients that could be dangerous, and you'll be working every moment with opportunities for some breaks here and there.

I cannot allow myself to be the former. To me, it's a sin. It goes against what I believe in and why I became a doctor, but nonetheless, IMHO, several colleagues of mine fit the above model.

 

[Ibid]

Whopper,

Thank you for clarifying, I thought perhaps it was some kind of byzantine rule imposed by state government or insurance companies to limit payment liabilities.

I suppose some sort of mandatory peer review or revalidation process could winkle out miscreants. It's only other psychiatrists who are going to be able to tell who the black hats are with any degree of certainty and critically credibility. Of course if the root problem is just laziness thats a pernicious problem, lazy people being prone to spurts of hyperactivity when it comes to formulating a defense of their working habits.

 

[whopper]

The hospital has something called "utilization review." In this process, one of the doctors in the administration, the head doctor in the county's mental health board, among several high ups in the mental health community in the county oversee patients that have been in the hospital for a long period of time.

I was probably one of the only doctors in the hospital that actually liked the UR process. The doctor has to be in front of a group of literally 15 or more people, all questioning why the doctor was in the hospital for an extended period of time.

Yet, some doctors don't seem to give a damn. I think they've figured out the hospital will not fire them because of the lack of psychiatrists.

Right before I started fellowship, the unit I was working
on, I had 4 patients set for discharge. They were doing well. When the new doctor took over, he changed all their meds, and they all became psychotic or manic. Those patients that were set up to leave the unit, 3 of them are still in the hospital to this day (over 1 year ago!). The doctor heading the UR committee, and the head county doctor approached me and almost begged me to come back.

The thing that bugged me about it was that aside from the obvious that I had them on a medication regimen that worked (it's all on print, why didn't a doctor just put them on the previous regimen?), I don't claim to have some sort of genius. I followed a simple rule....try to medicate with the least amount of meds possible that got the patient stable, if it didn't work, gradually go up the dosage as recommended by the manufacturer. Add or switch meds if you've reached the maximum dose that met the guidelines or the patient could tolerate. It's not much more complicated than that, but that's the bottom line.

If a patient is psychotic to the point where they still cannot be discharged, and has been on the same meds for 6 months, WTF? Just gradually go up.

But it seems some have no problem keeping the person on the same med for months.....and then when the person doesn't get any better, the doctor just continues to shlept around.

For you medstudents and residents, follow my advice. Always do a good job. Even if you're not happy where you are at, you ethically owe it to your patients, and the your rep in psychiatry spreads around fast. There are only a few dozen if even that many psychiatrists in most localities. I couldn't stand my state job my first year, but after 1 year of continuing to do work I was proud of, and 1 year of fellowship, I've got too many job offers. In fact, I've got too many, it's stressful. Several of the employers are calling me up and basically sounding so enthusiastic to hire me that is' uncomfortable for me to say no. It's to the point where everyday for about 1/2 an hour, I try to figure out what I'm going to do as a more permanent path, and I can't figure it out.

 

[Ibid]

Sound advice from whopper. To that sagacity I would add

Don't play poker when drunk.
If you do plan to drink and drive always reverse into the parking spot at the beginning of the night.
Remember 50-1 is a price you are being offered. Not a true reflection of a horses chance of winning said race.

As man of the world Whopper really should not have left these points out.