"The afternoon knows what the morning only suspects."
Question: What do a Department Chair in a medical center and a two-year old have in common?
Answer: They both wake up screaming at 2am.
I heard this quip from a former neurology department head about three months after I assumed a similar role in 1998. Funny then, but less so over time. In my case, I was usually still trying to get to sleep at 2am, clock-watching every 10 minutes instead, while knowing I’d be on the M-14/I-96 racetrack between Ann Arbor and Detroit a few hours later. There’s nothing like starting your day with a testosterone-charged guy in a pickup gesturing at you in your rear-view mirror because you’re only doing 80mph in a 70mph zone to fry up your nerve endings.
If you get to work unscathed you still have to have the right stuff to be a physician administrator. You should know that the average tenure of individuals in Department Chair or Dean positions in US medical schools is about 3 years. The real surprise is that it is that long, given how tough physicians can be on their peers who head for administrative posts.
Below is a recipe list, in no particular order of importance of ingredients. You need to have all of them at your own disposal - they may lie within you, be on your regular payroll such as your personal assistant or administrator, come ad hoc such as outside consultants or coaches, or come gratis such as the support provided by your spouse or partner, who, willingly or not become part of an intimate team that keeps the ship afloat. All ingredients are needed in bulk. Think Sam’s Club or Costco, not your local delicatessen.
There are others, I’m sure, but if you can say yes to all of these, you’ll be fine. Anything less and you’ll be one of those who keeps the mean duration in office at 3 years.
"....first ask yourself, can I take it emotionally? You will have to learn to be an outsider, to be on your own. The first three years will be rough. You’ll have a terrific lunch with a potential client and you’ll never hear from him again. It’s not the money that’s the crucial resource; it’s the ability to survive those first years of hopeful, promising leads that lead NOWHERE. If you have the emotional fortitude to last three years, you’ll succeed." - Peter Drucker on life as an independent consultant.
We all have days when, overexposed to patients, partners, or hospitals, we dream of striking out as an independent consultant and becoming our own boss. We imagine an ideal profession that reimburses us handsomely for our independent, thoughtful opinions and leaves time for our families and outside interests.
After three years as a self-employed physician-consultant, I can offer a more realistic perspective. To be clear, I’m talking about gainful self-employment—the type that puts gas in the tank and pays the health insurance premium—which requires more commitment than simply proffering opinions between daily rounds of golf.
There are good reasons why millions of Americans of all professional persuasions put on their institutional faces each morning and head to work. Some examples:
Being a successful consultant requires certain characteristics and a particular mindset. Examples of these qualities include:
Isn’t consulting what we ultimately do every day? A patient is someone with a problem who turns to the doctor-consultant for advice on how best to solve it. Formal training, detailed domain knowledge, and a careers’ worth of experience advising patients and colleagues have prepared you to make the leap.
Whether fleeting thought or sustained ponder, almost every physician has considered what life might be like working in "industry". This essay surveys the real world requirements for physicians wanting to break into the pharmaceutical, biotechnology or medical device industries.
I’ve known physicians move to industry straight from their graduate medical training, in mid-career usually after several years where working as an investigator on clinical trials was an integral part of their professional responsibilities, or more rarely after holding senior leadership roles as department heads or directors of clinical research centers. Some have been full time clinicians, others clinical scientists. Irrespective of background, I’ve seen great success or a complete bomb. Success in the end boils down to how well we blend certain personal characteristics with our background training and experience as clinicians and scientists. Strong qualities in the latter domain are insufficient on their own.
It costs about a billion dollars to bring a promising compound from earliest development stages through to the marketplace. It may cost as much as $50 million to advance a compound sufficiently to allow an Investigational New Drug [IND] application. As less than 10% of potentially useful compounds even get as far as applying for an IND it’s easy to see why the cash burn rate in industry is a frightening one, and, why great care and attention is paid to the selection of those individuals who will be shepherding a compound along the treacherous path to FDA approval.
What qualities will an industry staff member assessing the suitability of a physician candidate want to see?
You are fresh out of training and willing to step into a junior role and learn, have worked in clinical trials or basic drug development within a university or large private health system and possess deep domain knowledge, a record of published work, practical clinical trial experience and a network of colleagues of future use to your new employer, or are a senior clinician or scientist being hired to develop new programs, laboratories or because you have extensive experience managing physicians and scientists, and because you also bring your network of colleagues and potential future collaborators.
You have a familiarity with the range of roles physicians may play from early development of drugs or devices [suitable roles for physician/pharmacologists or physician/engineers], to phase II or III trials for past clinical researchers, to later stages like medical affairs, marketing, regulatory affairs, or drug safety or epidemiology, fields where a range of skills and qualifications like business acumen, an MBA or an MPH may be of value. You have a clear sense of which of these roles you’d be most suited to.
No matter how exalted your background, you will need to take a step backwards. All our worlds have their own culture and idiosyncrasies – those physicians blessed with those admittedly soft constructs of emotional and cultural intelligence, and who can articulate to an industry insider their awareness of same will be more likely to be recruited and more likely to succeed.
Teamwork crucial to business success is predicated on the fact that everyone around the table is an equal contributor to ideas and workflow. In the clinical arena, physicians tend to be the top dog. Thus, it can be disorienting to be in an environment where the physician’s opinion is given the same weight as the people from sales and marketing.
While some companies allow their physicians to spend ~ 10% effort at a local medical center, it’s improbable you’ll do more than that – my experience is that most pharmaceutical industry physicians who elect such involvement early on eventually abandon it as they become more senior. Can you demonstrate your readiness to forgo practicing medicine? Do you articulate positive reasons for leaving the clinic and joining industry or do you convey a sense that you are wanting to get away from something?
You should expect to travel as much as 30-40% of the time, and not infrequently at short notice. Are your spouse and children ready for this? There are inherent risks of job transfers in industry due to programmatic changes by your company or opportunities for promotion than you’ll ever encounter in clinical work.
Physicians in industry are often on the front line, one explanation for the travel requirements discussed above. Articulate physicians with strong interpersonal skills and an ability to write well are much in demand.
Pharmaceutical industry bashing is quite a popular sport these days whether on the business pages of your newspaper or within the walls of large health systems. Some of these criticisms are more an unthinking piling on than a constructive assessment. In my own area of clinical expertise, epilepsy, there have been numerous highly beneficial therapeutic advances in the past twenty years. The same is true for most other clinical fields. Our society needs healthy pharmaceutical and medical device industries. Just as these industries need a steady pipeline of compounds and ideas, they need a steady supply of talented resourceful physicians.
"Physicians traditionally have been considered poor entrepreneurial businessmen and investors. But the healthcare executive who takes this generalization too literally will learn some lessons the hard way. Physicians represent the largest group of successful small businessmen in the country and unlike restaurateurs, retailers or service people, physicians survive and make money over 95 percent of the time." - WR Spence in Healthcare Executive [1989;4:22-3.]
I doubt there’s ever been a physician who immersed in a ward round or inside an abdomen has not had an inspiration for some breakthrough in clinical care. For a moment we see ourselves at the helm of a startup in Silicon Valley – then, we emerge from our reverie and wonder if we have what it takes to be a physician entrepreneur.
Entrepreneurs are risk tolerant, creative, flexible, energetic and self-confident people who take the germ of an innovative product, procedure or service and convert it into a financially viable business. They have a propensity for working on their own or with small groups. Some derive their greatest satisfaction from the early development of their ideas, losing interest as the business become established and in need of more formal structure and management. Many of them are successful across a range of market sectors; Richard Branson of Virgin Records and Airlines comes to mind.
Intrapreneurs are people with entrepreneurial spirit and characteristics who perform creative work within the existing structure of an organization or business. Compared to entrepreneurs they have a lower tolerance of risk but greater tolerance for the bureaucracies and orthodoxies of established organizations and professions.
Two case histories illustrate the entrepreneurial spirit among physicians.
Dr. Tom Fogarty, the vascular surgeon of Fogarty catheter fame holds over 60 patents, which, knowing the work that goes into holding just one patent, makes me breathless. Fogarty currently directs research development in vascular surgery at Stanford University while also owning a successful winery.
Dr. Michael Lesh, a pioneering cardiac electrophysiologist, developed three startup companies in as many years to correct cardiac arrhythmias and cardiac valvular anomalies noninvasively. All his companies were purchased by large corporations like Johnson and Johnson or rolled up into ‘ev3', a company that develops catheter-based or endovascular technologies for the minimally invasive treatment of vascular disease. Lesh has since left medicine...for the movie and video business.
Here’s another issue where you can argue nature versus nurture over cocktails or coffee interminably. The current evidence from identical twin studies is that ~ 70% of our IQ is genetically derived, the remainder coming from our environment, percentages that to my mind could equally well apply to entrepreneurship. Recently I answered the doorbell to 5-year old Sylvia, whose father, my neighbor, is a serial entrepreneur. She was "selling" some of her drawings - no Picasso in the making, but a chip off the old block as she advised me "buy this one - it’s very artistic". For $1 I got an object lesson in how the gene pool is generating a new crop of entrepreneurs.
Writers have to write, painters to paint, entrepreneurs have to be entrepreneurial. To most of them, it’s the game or the chase that’s the fun; profit making is often a side benefit. Real entrepreneurs have often been that way since they organized paper delivery routes or ran lemonade stands as children. Most bona fide entrepreneurs are serial entrepreneurs in my experience.
Doctors, like most members of the population, are not especially entrepreneurial. Plenty of us are successful in business but our world is one insulated by virtue of educational demands, and the obligations of licensing and credentialing to be a largely closed one. Spence, cited at the beginning of this essay, has it half-right and half-wrong. Within our world of healthcare we do well. The more ambitious, risk tolerant, creative, flexible, energetic and self-confident among us, can carve out niches within clinical practice where we can innovate and achieve significant financial rewards – thus, be intrapreneurial.
The ‘requirements’ if we want to be entrepreneurs are no different for doctors than others.
Most physicians have some or all of the following characteristics which are beneficial in establishing successful ventures.
On the other side of the coin, we physicians tend to have several strikes against us which can be sizeable barriers to establishing successful ventures. I’ll assume here that many of the fundamental characteristics of an entrepreneur, thus, being risk tolerant, creative, flexible, energetic and self-confident are already in place.
If you can address the concerns detailed above and proceed with the full knowledge that most entrepreneurial ventures don’t take off you are at least in a position to consider starting a venture.
Successful entrepreneurs don’t ever think about failure. An unsuccessful venture is just one more learning experience, another notch in the belt, an opportunity to grow, expand their network and make smarter decisions the next time.
If you can have that attitude, you too can be a success; perhaps not on the first or second or third try, but perhaps thereafter.
"The American compulsion to take your identity from your profession with its corollary of only one trade to a practitioner may be a convenience to society but is burdensome and constricting to yourself" - Richard Gilman, American Dramaturge
Many physicians after years of busy clinical service seek fields of professional engagement that offer new experiences and greater flexibility. Financially secure, but not ready for endless golf or babysitting their grandchildren, they ask what alternative professional options exist?
While career choice drivers, i.e. autonomy, creativity, endogenous growth, external recognition, financial compensation, interpersonal contact, opportunity to mentor, security, taste for power, technical competency, and variety, remain unchanged as life advances, their relative value evolves. Physicians at later stages of their career or already retired usually focus on factors like endogenous growth, interpersonal contact, opportunity to mentor and variety, and less on financial compensation, external recognition and taste for power.
I have listed categories of professional effort for late-career or retired physicians to consider incorporating into their personal circumstances. Most are self-explanatory. I’ve added comments to several and also appended the URLs of some websites to allow further exploration.
The later stages of a professional career or retirement are states of mind, only. The world remains your oyster.
"Peace, peace, and give experience tongue.
They do abuse the king that flatter him:
For flattery is the bellows blows up sin;
The thing which is flatter’d, but a spark,
To which that blast gives heat and stronger glowing;
Whereas reproof, obedient and in order,
Fits kings, as they are men, for they may err"
-Helicanus to Antiochus, King of Antioch, in Shakespeare’s "Pericles. Prince of Tyre" Act 1 Scene 2.
I’m contacted periodically by retired physicians who remain interested in healthcare and want to make contributions beyond consulting projects or medicolegal work.
I also hear from individual or groups of physicians dealing with inter- or intra-group tensions that go well beyond the merely petty and have the potential of harming patient care, or adversely impacting the availability of particular clinical services at a hospital or health system. The frequency and the size of these problems is proportionate to the size of the organization.
When I look at these two needs, and reflect on the contributions that I’ve seen public editors (really a synonym for big picture ombudsmen) of newspapers like the New York Times make in the past few years since the roles were incepted, I propose that physicians holding posts like CMO or VPMA at medical centers consider appointing a Medical Staff Ombudsman.
Physicians holding posts like CMO or VPMA are often placed in invidious positions when adjudicating tension points between medical staff members. Their broad portfolio of responsibilities may not allow them the time to focus adequately on the matter, they are susceptible to lobbying or arm twisting, and they are at high risk of protagonists in the conflict doing end runs around them to higher levels within the organization such as the board or the CEO where they may be then pressured to make a decision that is in fact against their better judgment.
Enter, stage left, then, your newly appointed Medical Staff Ombudsman:
He or she is the following:
The Medical Staff Ombudsman, in turn, is provided the following:
The source of projects would include matters referred by individual physician staff members or practices, or come from the CMO or other executives. Issues would have to pass certain thresholds - these could include having a significant impact on the financial health or reputation of the institution, or where there seemed to be a clear divergence from the stated mission and vision of the organization. Whether the Medical Staff Ombudsman would have the freedom to select their own issues to address, as public editors do, remains an open question. While the scope of projects would likely be determined on an individual basis, certain end results should be consistent. These would include completing the analysis and written report in a defined time frame, say 8-12 weeks, and that the report be circulated to all members of the medical staff.
Serving as a Medical Staff Ombudsman would be challenging, exciting and add value to the work of any hospital or healthcare system. It could be a great opportunity for a retired physician to continue to contribute.
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