DOCTORS AND MANAGEMENT

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1 DOCTORS AND MANAGEMENT Atun Rifat 1 Abstract Many doctors are agiainst involvement in management. The cause of this may partly be the fact that management is seen to interfere with their professional duties. Some considers it as additional workload, others think formal training in management is necessary. The article describes the role of manager and compare job of the manager and that of the doctor to demonstrate that both jobs indeed consist of similar activities but with different names. It will show that doctor s role naturally prepares him/her to take on management roles. 8 Introduction In a previous article in the Journal Clinician in Management I argued that doctors should be involved in the management of their organisations (1) given the systematic shift of control from medical professionals to management in the health system. Many doctors seem opposed to being involved in management. This may partly be due to the fact that management is seen to conflict with their professional duties. Some see it as an additional and an unnecessary burden. Some feel that that a lack of formal management training precludes them from participating in management activities. The article is not intended to be a review of academic management literature on the role of the managers. It is intended, however, to describe and demystify the role of the manager drawing on a classic management article by Henry Mintzberg. The article will compare the job of the manager (as described by Mintzberg) and that of the doctor to demonstrate that both jobs indeed consist of similar activities albeit with differing names. Given the similarities I shall argue that the doctor s role naturally prepares him/her to take on management roles and describe how best to achieve this transition. 1 MBBS MBA DIC MRCGP MFPHM, Senior Lecturer & Director, Health Management Programme Imperial College Management School, Imperial College of Science, Technology & Medicine, 53 Prince s Gate, London SW7 2PG, tel , fax The Job of the manager The Mintzberg article, The Manager s Job: Folklore and Fact, was first published in the July-August 1975 issue of the Harvard Business Review (HBR) (2). It is one of the most quoted HBR articles and has won the McKinsey Award for excellence. It was republished in March-April 1990 issue of the Harvard Business Review. The article is as relevant and applicable today as when it was first published. Henri Fayol, the French industrialist, in 1916 described the role of the manager as consisting of planning, organizing, co-ordinating and controlling. Mintzberg, drawing on published research and his study of managers (3), demonstrates this not to be the case. Mintzberg highlights four myths about the managers job and compares folklore with fact (table 1). These facts mean that managerial work is rather complex and difficult. This work is characterised not by rigid routines and well defined problems but rather by fragmentation, unpredictability, brevity and discontinuity. As a consequence managers develop idiosyncratic styles, just like Gps and consultants. Mintzberg compartmentalised the managerial roles into three key areas, namely interpersonal, informational and decisional (Figure 1). Mintzberg argues that managers, by virtue of their position, are vested with formal authority over an organisation or a unit. This formal authority carries with it a status. It is this posi-

2 Table 1. Comparing folklore and fact Folklore Fact 1. The manager is a reflective, systematic planner 1. Many studies have shown that managers work at an unrelenting pace, their activities are characterised by brevity, variety, and discontinuity. They are strongly oriented to action and dislike reflective activities. 2. The effective manager has no regular duties to perform 3. The senior manager needs aggregated information, which a formal management information system best provides 4. Management is, or at least is quickly becoming, a science and a profession 2. The managerial work involves performing a number of regular duties, including ritual and ceremony, negotiations, and processing of soft information that links the organisation with its environment. 3. Managers strongly favour verbal media, telephone calls and meetings over documents. 4. The managers programmes-to schedule time, process information, make decisions and so onremains locked deep in their brains Figure 1 : The manager s roles Formal Authority and Status Interpersonal Roles Figurehead Leader Liaison Informational Roles Monitor Disseminator Spokesperson Decisional Roles Entrepreneur Disturbance handler Resource allocator Negotiator tion and status that allows the manager access to various interpersonal relationships, and access to information. These relationships and information then enables manager to make decisions and strategies for the organisation in question. Mintzberg identifies ten roles for the manager. The formal authority gives rise to three interpersonal roles, which in turn gives rise to three informational roles. These two sets of roles are then building blocks that enable the manager to play four decisional roles. By drawing on these ten roles and comparing managerial activities with those of a clinician we can see that a managers job is not very different from that of a clinician (Figures 2, 3 and 4). A comparison of managerial roles and activities with those of a clinician (Figures 2, 3, 4) highlights the similarities between the activities of a manager and that of a clinician. Therefore, clinical work shares many features with management. As a consequence clinicians have many readily transferable skills that enable them to become effective managers. 9

3 Figure 2. Interpersonal roles Role type Typical Managerial activity (According to Mintzberg) 1. Figurehead Chief executives spend 12% of their time with ceremonial duties 2. Leader This important role involves direct leadership (e.g. responsibility for selection and development) and indirect leadership (e.g. mentoring, coaching, motivating, encouraging). They have the responsibility for the unit or the organisation 3. Liaison Managers work in teams. They liase internally with peers (horizontally and with chain of command) and externally (outside the vertical chain of command) Doctors related activity Doctors regularly represent their organisations in meetings and inevitably in ceremonial occasions. Doctors act as leaders in their firms or directorates. GPs are leaders in their practices. They have the responsibility for the training, development and actions of their juniors, for the staff they employ. Doctors are involved both at a strategic level, particularly in planning, and operationally in terms of line management. They are the point of last resort for decisions. (often where the buck stops) Doctors liase with patients, relatives, their peers, other clinicians, managers, their seniors and juniors on a regular basis. Figure 3. Informational roles Role type Typical Managerial activity Doctors related activity Monitoring Managers are the centres for information flow. Processing information is a key role. Managers perpetually scan the environment for information from their internal and external networks. Although some of the information is formal, much of it is in informal form. Monitoring of information flow and content is hence critical. Disseminating The manager is a privy to sensitive information in the organisations vertical chain of relationships. S/he acts as a point of control to assimilate information and decide what needs to be disseminated, to whom and to what extent. Spokesperson The spokeperson role involves passage of information to stakeholders outside the organisation. Managers act as the representative of the organisation Doctors are constantly gathering data and information. There is new information that is brought to the organisation, and existing information that is analysed to help decision-making. Doctors are especially trained to monitor information in many different forms namely verbal, physical, visual, written, and varying data forms. Effective analysis and synthesis of fragmented but voluminous information is a key activity for the doctor A routine activity for a doctor is dissemination of privileged information, in a distilled form, to junior or more senior colleagues, to peers, patients, relatives, other health professionals and managers and stakeholders within and outside the organisation. Doctors are often involved in representing their profession or speciality either at meetings, or conferences, or in negotiations. 10

4 Figure 4. Decisional roles Role type Typical Managerial activity Doctors related activity Entrepreneur As an entrepreneur the manager seeks to improve the organization or the unit within which s/he works. Managers play a key role in identifying and encouraging the development of new ideas, and dissemination of good practice within the unit. Senior managers are able to maintain a large number of development initiatives at different stages. Many doctors have an entrepreneurial culture that encourages improvements in quality. They are not reluctant to show initiative and are often the voluntary initiators of innovation. There are examples in both the primary and secondary care sectors, ranging from innovations, made possible with fundholding, to developing new techniques for patient care eg minimally access surgery. GPs develop their units just as hospital clinicians try and build their clinical directorates. Disturbance handler Resource allocator Negotiator The manager has to be responsive to pressures and unforeseen problems. They act voluntarily or involuntarily to these high pressure disturbances and like a symphony orchestra conductor maintain a melodious performance of the organization. They have to ensure that appropriate contingency measures are in place to handle disturbances when they happen but also to prepare the organization to reduce the impact of the disturbance. The manager is responsible for allocating resources within the unit. This includes financial as well as human resources but also own managerial time. Effective - management is key to prioritization and optimal utilization of scarce resources. Manager also acts to co-ordinate the resources to ensure continuity with activities within the unit. Considerable managerial time and energy is spent in negotiations. By virtue of authority, and access to resources the manager can negotiate on behalf of the team members or the organization as a whole. There is little room for error in medicine. Any disturbance, deviation from the norm or quality standards has to be identified and acted upon immediately. The GP and the consultant (who have the ultimate responsibility for the patient) have to ensure very high standards in their units, manage risk and disturbances very effectively. This is a regular activity for clinicians. Disturbance management is not just in clinical work but involve people relationships, such as dealing with the unsatisfied patient or relative. Doctors operate within highly resourceconstrained environments. They have to allocate their own resources effectively for instance time spent with each patient, each intervention, and with each team member. By prioritizing interventions, (elective surgery, waiting times) the clinicians allocate financial as well as human resources of the unit on a regular basis. Clinicians negotiate regularly at every level within the organization but also in macro and micro domains. This may involve negotiating a budget for the clinical directorate or for the staff of GPs. At micro level clinicians negotiate within the organization to decide on outpatient times, juniors training, staff roles and skills. In practice most of clinical practice is in fact rather complex management. If clinicians are able to realise that they have these management skills that are readily transferable then involvement in management may be less intimidat- ing. Management is not as alien to clinical practice as one may assume. Perhaps clinical training does not allow enough exploration of the applicability of the clinician s skills or perhaps the semantics and management jargon 11

5 builds a wall around the management role. Hence, to many, management roles appear to be rather mysterious. If one is able to demystify management and the role of the manager then one will clearly see the inter-relationship and the inseparability of the managerial and clinical roles. This understanding requires an open attitude and a mental transition to overcome prejudices and misconceptions. The functional emphasis in managerial training at business schools, (such as finance, marketing, operations management, etc) reinforces the belief that management is very different to activities of a clinician. Functional skills are the scientific elements and he building blocks of management. This is collectively known as management science. Medicine is no different. Knowledge base in various specialities, an array of clinical and social skills and appropriate attitudes are the building blocks that are needed not in isolation but collectively before a clinician is allowed to qualify and practice. Likewise, for the managers, the knowledge of the functional areas and having an array of skills is not enough. These have to be present collectively to enable one to become an effective manager. The art of management is the application of these skills, just as good clinical practice is the art of application of medical science. Reference 1. Atun R. A. Should doctors manage or be managed. Clinician in Management Mintzberg H. The Manager s Job: Folklore and Fact. Harvard Business Review. March-April Mintzberg H. The Nature of Managerial Work Harpper & Row. New York eqimebi da menejmenti rifat atuni mravali eqimi winaarmdegia menejmentis processi monawileobis mirebisa. amis mizezs nawilobriv warmoadgens is faqti, rom menejmenti ariqmeba, rogorc mati profesiuli saqmianobis xelis SemSleli movaleoba. zogierti eqimi ganixilavs mas, rogorc damatebit samusao datvirtvas, sxvebi fiqroben, rom auvilebelia menejmentsi formaluri momzadeba. statiasi arwerilia menejeris roli da Sedarebulia menejeris samusao eqimis movaleobebtan imis dasasabuteblad, rom orive samusao martlac msgavs qmedebebs moitxovs mxolod sxvadasxva saxelwodebit. nacvenebia, rom eqimis roli bunebrivad amzadebs mas menejeris movaleobata SesrulebisaTvis. 12