(special communication ) The Need for Leadership in Hospital Respiratory Services· RomanL. Yanda, M.D., F.C.C.P.··
The duration of a position ai physician-director of respiratory services proved to be less than five years in 68 per cent of CMeS followed. Based OD available information, in the 50 such cases, the act of sepantion w. Dot elective in these instances, except • a final response to an otherwise intolerable situation. Further study revealed the prime cause to be ignorance of the basic essentials of m8llagement. Technical incompetence w. never an issue in cases of separation. The general appUcation of princi-
pies of management to the control of respiratory services is illustrated by a series of case reports and subsequent discussion. Presently, candidates aspiring to such p0sitions appear to rely almost entirely on their elaborate technical sldUs. Choice of such a career option, however, should carry with it an obligation to "learn the rules of the game." Logically, graduate training programs should provide this training.
Experience alone is a poor teacher. By the time you have accumulated enough of it, success or failure is no longer an issue. N.S. Dumas
mand. The majority of America's 6,314 full-service hospitals will have respiratory departments ranging in size from 3 to over 25 technicians, and in gross annual income from $100,000 to over $1,000,000. In order to maintain its competitive status, each of these hospitals will expect expert medical management to create and to oversee the development of a full array of respiratory services, particularly in areas where the demand is great but where services have been only rudimentary or absent altogether. In fact, hospitals will expect to meet the very costs of the new medical director by increases in the income generated by his department. At the same time that they demand expanded services, hospitals will expect management to limit departmental costs. Today's national outcry over rising medical costs may even lead to the kind of cost crisis that occurred in the aerospace industry in the sixties. That industry had for decades enjoyed the privilege of passing on to the consumer (usually the Federal government) any unexpected increases in costs. When the Department of Defense and others reversed this policy, the effect on aerospace firms ranged from crisis to disaster. As government agencies assume an ever greater share of health costs, a similar policy reversal probably awaits the hospitals. Disallowance of the current cost-plus formula, which permits hospitals to pass on extra costs to third party payers, will probably become a national policy. Ignorance of the pertinent economic and management elements involved in these costs will restrict the pressured manager to the single option of reducing the
Medical schools teach nothing of management. As a result, physicians newly appointed to the position of physician-director of respiratory care services often fail to develop managerial skills. This feature of their education must normally await a few years' experience in encounter with preventable erFor editorial comment, see page 1
rors, ranging in seriousness from mere mistakes to disasters. Such experiences reveal that the quality of care the director's department provides depends as much on his managerial skills as on all of his special technical abilities. These skills will vitally affect not only the patient but also the respiratory services department, the hospital as a whole, government agencies and insurance carriers, and the director himself, Although they frequently fail to realize it, all the participants in respiratory care suffer to the extent that the physician-director neglects his responsibility to manage. A large and growing demand for management skills in respiratory therapy will occur in the next decade for several reasons. The expectations of hospital administrators will form one source of this de°From The Valley Presbyterian Hospital, Van Nuys, Ca. Medical Director, Respiratory Services, Valley Presbyterian Hospital, Van Nuys; Clinical Associate Professor of Medicine, University of Southern California, Los Angeles. Reprint requests: Dr. Yanda, 15243 Vanowen, Van Nuys, Califomia91405 00
CHEST, 68: 1, JULY, 1975
NEED FOR LEADERSHIP IN HOSPITAL RESPIRATORY SERVICES 81
quality of services, even though this may entail a reduction in his own services and compensation. Skilled management is also essential to building and training teams of responsible technicians. The increased demands for respiratory therapy have outstripped the checks and balances common to other fields of medicine: today, for example, there are only about 4,000 registered therapists available for some 7,000 hospitals. Shortages of adequately trained technicians will require of the director creative, short-term adaptations that will significantly determine departmental policy and the quality of services offered. The problem of insufficient numbers of trained personnel is compounded by the magnitude of the forthcoming demand for services. HEWs Health Interview Survey of Chronic Respiratory Conditions! revealed 46,884,000 people suffering from 1 or more of 15 selected chronic respiratory conditions. This included some 13,870,000 cases of significant obstructive diseases (asthma, bronchitis and emphyserna), and 1,625,000 incidents of assorted restrictive diseases. These numbers, enormous as they are, refer only to chronic conditions. Data from an acute disease survey (HEW), 2 revealed 10,687,000 cases of acute lower respiratory tract diseases (pneumonitis, acute bronchitis, etc) of a total of 447,000,000 acute conditions reported in that year (19711972). The volume of significant acute and chronic pulmonary diseases approaches 10 percent of the nation's population, and so heralds a busy time for hospital respiratory services. The magnitude of the above numbers owes much to the success of both acute medicine and preventive medicine in promoting the startling growth in the number of people over 65 years of age. Between 1960 and 1969 a 17.6 percent increase occurred in this age group. This continuing trend guarantees a growing number of persons who are particularly prone to acute and chronic respiratory disorders. The need for a positive approach to development and expansion of respiratory services will gain further impetus from the success of chest specialists in reducing or delaying mortality among these heavy consumers of respiratory care. A number of forces, however, tend to obstruct this positive approach. Foremost among these are the general attitudes of physicians themselves. Since medical schools devote a relatively minor portion of their curricula to respiratory diseases, their students graduate with less than an optimal understanding of and familiarity with respiratory diagnosis and treatment. This policy, continued and reinforced during postgraduate training, is maintained by the physician in practice. The doctor displays an understandable
82 ROMAN L YANDA
reluctance to devote much of his attention to conditions in which his training and experience have been minimal. The very character of this chronic illness exacerbates this problem for no matter what the physician does, his patients with respiratory disease never seem to get better, an experience which robs him of emotional satisfaction in his work. The degree of utilization of respiratory care services therefore depends on a complex interaction between the physician-director on the one hand, and the attitudes of the medical staff and the standard of practice in the community on the other. The director's ability to educate physicians, key hospital staff and community leaders, and to help them take full advantage of available services, will be critical to the rate of departmental growth. If he is even modestly successful in this function, the potential numbers of patients with respiratory disease benefitted, will be several times greater than he could achieve through direct individual patient care. Effective leadership forms the foundation of this magnification of the medical director's success as a chest physician. Such leadership functions are the essence of management. They consist of a complex of medical and nonmedical responsibilities, including the following: ( 1) concrete planning, with provision for alternative courses, to meet immediate and longrange goals within the limits and resources of the institution; ( 2) assembling the components necessary to meet departmental objectives, including screening personnel, securing capital, and purchasing equipment and supplies; ( 3) organizing the department's team into an effective unit in the total health care team (hospital and doctors) ; ( 4) supervising the multiple levels of departmental activity, in particular, promoting the eHective use of personnel, facilities, and finances; and ( 5) controlling the growth and direction of services on the basis of an organized system of feedback, thus modifying the planning described in (1).
The medical director who comprehends the significance of the above functions, and who succeeds in their implementation, will probably encounter fewer obstacles than usual in this career. Merely analyzing and defining a problem often reveals an obvious solution to it. The majority of directors, however, lacking clearly stated goals or plans of action, merely react to current problems in an uncoordinated fashion over lengthy periods. During the past ten years, I have collected notes on a number of cases in which the careers of apparently competent directors have suddenly run into major obstacles, with derailments frequently the result Among 50 instances, 15 directors resigned because of work circumstances and 19 either had their contracts prematurely terminated or had their options to renew cancelled by the hospital. Six left or made other CHEST, 68: 1, JULY, 1975
arrangements for personal reasons; four transferred the position to a junior associate because of internal problems; and six are still negotiating either to maintain present arrangements, or to have a conflict resolved. And there are other problems, such as potential physician-directors unable to reach an agreement with the hospital, hospitals searching for a director for periods running into years, and in some hospitals, "revolving door" situations. Of 60 hospitals with respiratory service departments that require medical direction, only 15 have had the same director for more than five years. All concerned parties suffered from this instability (except perhaps the attorneys), including the medical director and his career, the hospital and its plans, the medical staff, and above all, the patients. Thus, in a community hospital the position of a physician-director of respiratory care services is evidently as difficult to maintain as to attain. The Small Business Administration (U.S.) reports that 50 percent of the new businesses established each year fail within five years. The survey results mentioned above indicate that the failure rate, among physician-directors, is 68 percent in five years. This is an astounding percentage, considering all the positive factors for success in the latter situation. Analysis reveals a common fault in both groups: the zero level of appropriate management training at the onset of the venture. The errors possible to fully explain such a disastrous statistic are legion. The reader may gain some appreciation of the specific problems physician directors encounter through the following case studies. (Obviously, details are kept to a minimum in order to preserve anonymity) . CASE REPoRTS
Case Study 1 (Implied Contractual Obligation Ignored)
Dr. Z signed an agreement with Hospital A to provide medical direction of respiratory services and a consultative service to the medical staff. After an initially satisfying period of service Dr. Z markedly curtailed his activities and availability due to other newer practice commitments. The provisions specifying coverage in his contractual agreement were sufficiently vague so that his actions were legally proper. Thus, the administration responded only belatedly after departmental income had precipitously fallen. (By this time staff physicians were hospitalizing their patients with respiratory disease elsewhere). Physician response to appropriate remedial efforts was delayed for several years. A potent factor was the defensive negative posture of the department's technical personnel as a sequel to the depressed departmental activity. The root of the problem was inadequate criteria of performance. Since the hospital's only yardstick was income, appropriate definitive preventive measures could never be taken.
CHEST, 68: 1, JULY, 1975
Case Study 2 (An Unwise Political AUiance) Clinic 123 recruited Dr. B as its chest consultant and arranged his appointment as physician-director of respiratory services at Hospital Y. Unfortunately, a sense of antipathy existed between the clinic group and the other staff physicians. Consequently, deparbnental activity and income did not grow (contrary to the administration's expectations) and the Hood of consultations never occurred. Since Dr. B's income (and hence interest) was tied to both of these factors, his visibility and deparbnental support function were essentially stillborn. Ultimately his contract was terminated and another chest physician, acceptable to all members of the staff, was recruited. Consequently, deparbnental activity and consultative requests grew rapidly, due to his drive, management and educational efforts. This more than compensated for the increased cost of his services to the hospital. Case Study 3 (Respirat01fl Therapy as a Business Instead of as a Profession)
Dr. X was recruited by an entrepreneur into offering a "package deal" to Hospital C. The sales campaign to the hospital relied on Dr. X's reputation and on the opportunity for the hospital to gain respiratory services without investing the time, the effort, and the capital necessary to develop the services itself. The proposal resembled many physical therapy arrangements. The hospital administration accepted the offer. The private agreement between Dr. X and the company provided that he would receive a significant portion of the profits. But the company soon encountered the same sort of cecapital squeeze" that the hospital had avoided, so that no profits accrued for a long time. This, however, did not relieve Dr. X of his professional responsibility to provide competent medical direction. Since he adequately honored that commitment, his opportunity to gain income elsewhere was severely restricted. The deparbnent was plagued by measures of expediency designed to reduce costs, but which unwittingly reduced quality as well. Further tensions between the doctor and the company arose over personnel policies related to the cash How problem. Finally the partners brought legal action against one another, and in the resulting uproar, Dr. X left the area. Another director was found who wisely refused to deal with the company, and who instead negotiated a contract directly with the hospital. Ultimately the hospital terminated the contract with the company. With the new director's help, it built a department from the company personnel assigned there. The result was a major improvement in services, utilization, and income to all. Case Study 4 (An Agreement Without Provision for Growth) Hospital W had a very active chest department, but the respiratory therapy section was under casual direction on a voluntary basis. Due to increasing demand, this was not adequate, so Dr. E was recruited as its formal director. With Dr. E's added abilities, the entire chest deparbnent program expanded into several new areas. The supervision of all of the new developments was delegated to Dr. E, whose original 40hour work week ultimately grew from 60, to 70 hours. While the scope of his responsibilities doubled over several
NEED FOR LEADERSHIP IN HOSPITAL RESPIRATORY SERVICES 83
years, his remuneration had not increased at all. Attempts to negotiate a new agreement not only were nonproductive, but undermined the working relationship of the parties involved. Consequently Dr. E resigned. It took the hospital more than a year to find an apparently adequate replacement. Dr. F assumed only two of Dr. E's four major duties, and he did so at twice the former salary. In the interval the programs suffered a decline from lack of direction from which they never fully recovered. Case Study 5 (Disadvantages of a Fixed Minimum Contract)
Dr. V took over the practice of another chest physician, including a contract with Hospital G that paid a fixed retainer in return for two departmental supervisory visits a week. The contract also carried an obligation to be available for consultation to the medical staff. On many occasions, Dr. V suggested to the administration and to the medical executive that departmental facilities were minimally adequate. The general response was, "If it costs more money forget it." Since Dr. V had growing commitments elsewhere, he did not press the matter. The next winter witnessed an unusually heavy admission rate of patients with acute respiratory disease. The swamped department seemed unable to cope with the load. Some of the very seriously ill patients died. In justifiable alarm Dr. V transferred the other critically ill patients to hospitals with adequate respiratory facilities. The department's reputation and self confidence plummetted; what impressed the administration was that revenues followed suit. When the shaken administration and medical executive asked what could be done, Dr. V produced the plan to expand coverage, responsibility and training. A new contract was negotiated which provided for compensation geared to departmental activity, recompense for effort and time invested. Since then, the department's capabilities and utilization have increased substantially. While some people work solely for the intrinsic satisfaction that a job well done provides, the majority are also stimulated by the prospect of an enhanced 6nancial return. In most cases a Bat, fixed, minimum retainer brings a corresponding return: flat, fixed, minimum medical direction. Case Study 6 (Promises and Politics)
When Dr. H was retained by Hospital U as physician director of respiratory care services, he was led to believe that the pulmonary function responsibilities would also be transferred to his department, as soon as certain "political problems" were ironed out. Since his commitment was only part time, the doctor developed his own practice and began to admit his patients to Hospital U. It was then that his lack of control over the pulmonary diagnostic facilities proved troublesome. Not only were there problems with the way these tests were done and with their quality control, but, more importantly, he could not agree with many of the "official" interpretations. He challenged the group doing the tests, but it could not be dislodged. Consequently, he resigned as physician-director, developed pulmonary function test (PIT) facilities in his own office, and affiliated with another nearby hospital. Two years elapsed before the hospital obtained a new medical director who also required control of pulmonary function.
84 ROMAN L YANDA
The prospective director of respiratory services who encounters anything less than a full complement of departmental services obviously needs a written guarantee that the missing elements will be supplied. Those elements may represent not the icing on the cake, but rather the cake itself. Case Study 7 (Gentlemen~s Agreement?)
Dr. T was recruited to act as director of respiratory diagnostic services and as chest consultant at Hospital H. Someone else would continue to supervise the respiratory therapy department. Contractual details, however, were vague, and were committed to writing only in the fonn of a letter of intent to Dr. T from the hospital. On his arrival at the hospital, the doctor found some surprises. The hospital had not planned to spend any extra money on' the pulmonary laboratory, and when it had to, it cut costs by reducing payments for services to the doctor by 50 percent. Dr. T also found that he was acting as the director of respiratory therapy a good part of the time. Finally, he was also being used as the "house officer" by influential medical staff members. With his income significantly reduced by these nonremunerative incursions on his time and by the reduction in his income, Dr. T took a part time salaried position at another hospital to maintain his financial position. His availability for stipulated duties only, led to numerous complaints and an ultimatum to drop the other position. Dr. T did not find his decision difficult: he dropped Hospital H. Several years elapsed before another physician-director of respiratory care services was recruited at six times Dr. T's initial compensation. Since his availability is not also six times greater, complaints are rolling in once again. DISCUSSION
The common denominator in all of these cases is frustration of expectations, by one or both parties. For those involved in the medical direction of respiratory therapy, the cases hold further implications. Problems commonly arise when the responsible agents for the contracting hospitals have little awareness of the director's functions and responsibilities. This lack of awareness also occurs, with equally deleterious effects, among the decision making levels of the medical staffs, and is compounded by the almost universal aggrandizing approach of the more senior hospital departments. The candidate must therefore take it upon himself to adequately inform these power holding components of the hospital of the magnitude of the problems he is attempting to solve and of the tools essential to doing the job correctly. The studies also demonstrate that the directors themselves contributed as much to mismanagement as did the administrators and key medical staff. In many cases the director totally neglected management functions because he had no clear idea of what the position actually entailed. This problem was compounded by the directors' lack of longrange personal CHEST, 68: 1, JULY, 1975
goals. Had their personal plans been more clearly worked out, many directors would not have accepted the position at all. In most cases, financial considerations were foremost in their minds. Yet respiratory skills are in such demand that even a modicum of planning insures financial solvency in this field. Factors besides potential income should therefore influence career decisions, including such factors as work satisfaction, potential associates, credibility and prestige in the peer group, political influence, stability and security, and the freedom to develop other interests within and outside of the profession. Managing one's own career is an essential element in successfully managing a department. Mismanagement of the terms of the initial agreement was probably the greatest factor in any financial hardship suffered in the cases cited. In other cases the lure of income from other sources encouraged the director to neglect essential management duties. In either case, the missing elements were the explicit details of each party's responsibilities to the other. It is worth noting in conclusion that the pulmonary specialist can afford to be complacent about deficiencies in his management skills, for his medical skills are: in a seller's market today. He may pick and choose among a variety of options. But if he chooses the physician-director option and yet neglects management, or if his managerial efforts are ineffective or
CHEST, 68: 1, JULY, 1975
even detrimental to the department, his hospital can only replace him or substitute a lower level of management. The latter course will relegate him to the status of an "on call technical advisor," and his reputation as the resident pulmonary expert will not be enhanced by the fumbling performance of a mediocre department of which he remains the titular head. Only a physician can provide top level respiratory management. His background alone supplies the potential for developing the best overall perspective on today's pulmonary problems. Development of this perspective, however, requires reordered priorities and new motivations, an added array of skills, and an expanded perception of the total health problem in which he is involved. It is time that respiratory training programs fostered the development of such a perspective. EDITOR'S NOTE: This article is being published simultaneously in the July issue of Respirat01l/ Care.
1 Prevalence of selected chronic respiratory conditions United States, 1970. Vital and Health Statistics (HEW) series 10, no. 84, pp 3-5 2 Acute conditions, incidence and associated disability United States, July 1971-June 1972. Vital and Health Statistics (HEW) series 10, no. 88, pp 12-13
NEED FOR LEADERSHIP IN HOSPITAL RESPIRATORY SERVICES 85
The duration of a position ai physician-director of respiratory services proved to be less than five years in 68 per cent of CMeS followed. Based OD available information, in the 50 such cases, the act of sepantion w. Dot elective in these instances, except • a final response to an otherwise intolerable situation. Further study revealed the prime cause to be ignorance of the basic essentials of m8llagement. Technical incompetence w. never an issue in cases of separation. The general appUcation of princi-
pies of management to the control of respiratory services is illustrated by a series of case reports and subsequent discussion. Presently, candidates aspiring to such p0sitions appear to rely almost entirely on their elaborate technical sldUs. Choice of such a career option, however, should carry with it an obligation to "learn the rules of the game." Logically, graduate training programs should provide this training.
Experience alone is a poor teacher. By the time you have accumulated enough of it, success or failure is no longer an issue. N.S. Dumas
mand. The majority of America's 6,314 full-service hospitals will have respiratory departments ranging in size from 3 to over 25 technicians, and in gross annual income from $100,000 to over $1,000,000. In order to maintain its competitive status, each of these hospitals will expect expert medical management to create and to oversee the development of a full array of respiratory services, particularly in areas where the demand is great but where services have been only rudimentary or absent altogether. In fact, hospitals will expect to meet the very costs of the new medical director by increases in the income generated by his department. At the same time that they demand expanded services, hospitals will expect management to limit departmental costs. Today's national outcry over rising medical costs may even lead to the kind of cost crisis that occurred in the aerospace industry in the sixties. That industry had for decades enjoyed the privilege of passing on to the consumer (usually the Federal government) any unexpected increases in costs. When the Department of Defense and others reversed this policy, the effect on aerospace firms ranged from crisis to disaster. As government agencies assume an ever greater share of health costs, a similar policy reversal probably awaits the hospitals. Disallowance of the current cost-plus formula, which permits hospitals to pass on extra costs to third party payers, will probably become a national policy. Ignorance of the pertinent economic and management elements involved in these costs will restrict the pressured manager to the single option of reducing the
Medical schools teach nothing of management. As a result, physicians newly appointed to the position of physician-director of respiratory care services often fail to develop managerial skills. This feature of their education must normally await a few years' experience in encounter with preventable erFor editorial comment, see page 1
rors, ranging in seriousness from mere mistakes to disasters. Such experiences reveal that the quality of care the director's department provides depends as much on his managerial skills as on all of his special technical abilities. These skills will vitally affect not only the patient but also the respiratory services department, the hospital as a whole, government agencies and insurance carriers, and the director himself, Although they frequently fail to realize it, all the participants in respiratory care suffer to the extent that the physician-director neglects his responsibility to manage. A large and growing demand for management skills in respiratory therapy will occur in the next decade for several reasons. The expectations of hospital administrators will form one source of this de°From The Valley Presbyterian Hospital, Van Nuys, Ca. Medical Director, Respiratory Services, Valley Presbyterian Hospital, Van Nuys; Clinical Associate Professor of Medicine, University of Southern California, Los Angeles. Reprint requests: Dr. Yanda, 15243 Vanowen, Van Nuys, Califomia91405 00
CHEST, 68: 1, JULY, 1975
NEED FOR LEADERSHIP IN HOSPITAL RESPIRATORY SERVICES 81
quality of services, even though this may entail a reduction in his own services and compensation. Skilled management is also essential to building and training teams of responsible technicians. The increased demands for respiratory therapy have outstripped the checks and balances common to other fields of medicine: today, for example, there are only about 4,000 registered therapists available for some 7,000 hospitals. Shortages of adequately trained technicians will require of the director creative, short-term adaptations that will significantly determine departmental policy and the quality of services offered. The problem of insufficient numbers of trained personnel is compounded by the magnitude of the forthcoming demand for services. HEWs Health Interview Survey of Chronic Respiratory Conditions! revealed 46,884,000 people suffering from 1 or more of 15 selected chronic respiratory conditions. This included some 13,870,000 cases of significant obstructive diseases (asthma, bronchitis and emphyserna), and 1,625,000 incidents of assorted restrictive diseases. These numbers, enormous as they are, refer only to chronic conditions. Data from an acute disease survey (HEW), 2 revealed 10,687,000 cases of acute lower respiratory tract diseases (pneumonitis, acute bronchitis, etc) of a total of 447,000,000 acute conditions reported in that year (19711972). The volume of significant acute and chronic pulmonary diseases approaches 10 percent of the nation's population, and so heralds a busy time for hospital respiratory services. The magnitude of the above numbers owes much to the success of both acute medicine and preventive medicine in promoting the startling growth in the number of people over 65 years of age. Between 1960 and 1969 a 17.6 percent increase occurred in this age group. This continuing trend guarantees a growing number of persons who are particularly prone to acute and chronic respiratory disorders. The need for a positive approach to development and expansion of respiratory services will gain further impetus from the success of chest specialists in reducing or delaying mortality among these heavy consumers of respiratory care. A number of forces, however, tend to obstruct this positive approach. Foremost among these are the general attitudes of physicians themselves. Since medical schools devote a relatively minor portion of their curricula to respiratory diseases, their students graduate with less than an optimal understanding of and familiarity with respiratory diagnosis and treatment. This policy, continued and reinforced during postgraduate training, is maintained by the physician in practice. The doctor displays an understandable
82 ROMAN L YANDA
reluctance to devote much of his attention to conditions in which his training and experience have been minimal. The very character of this chronic illness exacerbates this problem for no matter what the physician does, his patients with respiratory disease never seem to get better, an experience which robs him of emotional satisfaction in his work. The degree of utilization of respiratory care services therefore depends on a complex interaction between the physician-director on the one hand, and the attitudes of the medical staff and the standard of practice in the community on the other. The director's ability to educate physicians, key hospital staff and community leaders, and to help them take full advantage of available services, will be critical to the rate of departmental growth. If he is even modestly successful in this function, the potential numbers of patients with respiratory disease benefitted, will be several times greater than he could achieve through direct individual patient care. Effective leadership forms the foundation of this magnification of the medical director's success as a chest physician. Such leadership functions are the essence of management. They consist of a complex of medical and nonmedical responsibilities, including the following: ( 1) concrete planning, with provision for alternative courses, to meet immediate and longrange goals within the limits and resources of the institution; ( 2) assembling the components necessary to meet departmental objectives, including screening personnel, securing capital, and purchasing equipment and supplies; ( 3) organizing the department's team into an effective unit in the total health care team (hospital and doctors) ; ( 4) supervising the multiple levels of departmental activity, in particular, promoting the eHective use of personnel, facilities, and finances; and ( 5) controlling the growth and direction of services on the basis of an organized system of feedback, thus modifying the planning described in (1).
The medical director who comprehends the significance of the above functions, and who succeeds in their implementation, will probably encounter fewer obstacles than usual in this career. Merely analyzing and defining a problem often reveals an obvious solution to it. The majority of directors, however, lacking clearly stated goals or plans of action, merely react to current problems in an uncoordinated fashion over lengthy periods. During the past ten years, I have collected notes on a number of cases in which the careers of apparently competent directors have suddenly run into major obstacles, with derailments frequently the result Among 50 instances, 15 directors resigned because of work circumstances and 19 either had their contracts prematurely terminated or had their options to renew cancelled by the hospital. Six left or made other CHEST, 68: 1, JULY, 1975
arrangements for personal reasons; four transferred the position to a junior associate because of internal problems; and six are still negotiating either to maintain present arrangements, or to have a conflict resolved. And there are other problems, such as potential physician-directors unable to reach an agreement with the hospital, hospitals searching for a director for periods running into years, and in some hospitals, "revolving door" situations. Of 60 hospitals with respiratory service departments that require medical direction, only 15 have had the same director for more than five years. All concerned parties suffered from this instability (except perhaps the attorneys), including the medical director and his career, the hospital and its plans, the medical staff, and above all, the patients. Thus, in a community hospital the position of a physician-director of respiratory care services is evidently as difficult to maintain as to attain. The Small Business Administration (U.S.) reports that 50 percent of the new businesses established each year fail within five years. The survey results mentioned above indicate that the failure rate, among physician-directors, is 68 percent in five years. This is an astounding percentage, considering all the positive factors for success in the latter situation. Analysis reveals a common fault in both groups: the zero level of appropriate management training at the onset of the venture. The errors possible to fully explain such a disastrous statistic are legion. The reader may gain some appreciation of the specific problems physician directors encounter through the following case studies. (Obviously, details are kept to a minimum in order to preserve anonymity) . CASE REPoRTS
Case Study 1 (Implied Contractual Obligation Ignored)
Dr. Z signed an agreement with Hospital A to provide medical direction of respiratory services and a consultative service to the medical staff. After an initially satisfying period of service Dr. Z markedly curtailed his activities and availability due to other newer practice commitments. The provisions specifying coverage in his contractual agreement were sufficiently vague so that his actions were legally proper. Thus, the administration responded only belatedly after departmental income had precipitously fallen. (By this time staff physicians were hospitalizing their patients with respiratory disease elsewhere). Physician response to appropriate remedial efforts was delayed for several years. A potent factor was the defensive negative posture of the department's technical personnel as a sequel to the depressed departmental activity. The root of the problem was inadequate criteria of performance. Since the hospital's only yardstick was income, appropriate definitive preventive measures could never be taken.
CHEST, 68: 1, JULY, 1975
Case Study 2 (An Unwise Political AUiance) Clinic 123 recruited Dr. B as its chest consultant and arranged his appointment as physician-director of respiratory services at Hospital Y. Unfortunately, a sense of antipathy existed between the clinic group and the other staff physicians. Consequently, deparbnental activity and income did not grow (contrary to the administration's expectations) and the Hood of consultations never occurred. Since Dr. B's income (and hence interest) was tied to both of these factors, his visibility and deparbnental support function were essentially stillborn. Ultimately his contract was terminated and another chest physician, acceptable to all members of the staff, was recruited. Consequently, deparbnental activity and consultative requests grew rapidly, due to his drive, management and educational efforts. This more than compensated for the increased cost of his services to the hospital. Case Study 3 (Respirat01fl Therapy as a Business Instead of as a Profession)
Dr. X was recruited by an entrepreneur into offering a "package deal" to Hospital C. The sales campaign to the hospital relied on Dr. X's reputation and on the opportunity for the hospital to gain respiratory services without investing the time, the effort, and the capital necessary to develop the services itself. The proposal resembled many physical therapy arrangements. The hospital administration accepted the offer. The private agreement between Dr. X and the company provided that he would receive a significant portion of the profits. But the company soon encountered the same sort of cecapital squeeze" that the hospital had avoided, so that no profits accrued for a long time. This, however, did not relieve Dr. X of his professional responsibility to provide competent medical direction. Since he adequately honored that commitment, his opportunity to gain income elsewhere was severely restricted. The deparbnent was plagued by measures of expediency designed to reduce costs, but which unwittingly reduced quality as well. Further tensions between the doctor and the company arose over personnel policies related to the cash How problem. Finally the partners brought legal action against one another, and in the resulting uproar, Dr. X left the area. Another director was found who wisely refused to deal with the company, and who instead negotiated a contract directly with the hospital. Ultimately the hospital terminated the contract with the company. With the new director's help, it built a department from the company personnel assigned there. The result was a major improvement in services, utilization, and income to all. Case Study 4 (An Agreement Without Provision for Growth) Hospital W had a very active chest department, but the respiratory therapy section was under casual direction on a voluntary basis. Due to increasing demand, this was not adequate, so Dr. E was recruited as its formal director. With Dr. E's added abilities, the entire chest deparbnent program expanded into several new areas. The supervision of all of the new developments was delegated to Dr. E, whose original 40hour work week ultimately grew from 60, to 70 hours. While the scope of his responsibilities doubled over several
NEED FOR LEADERSHIP IN HOSPITAL RESPIRATORY SERVICES 83
years, his remuneration had not increased at all. Attempts to negotiate a new agreement not only were nonproductive, but undermined the working relationship of the parties involved. Consequently Dr. E resigned. It took the hospital more than a year to find an apparently adequate replacement. Dr. F assumed only two of Dr. E's four major duties, and he did so at twice the former salary. In the interval the programs suffered a decline from lack of direction from which they never fully recovered. Case Study 5 (Disadvantages of a Fixed Minimum Contract)
Dr. V took over the practice of another chest physician, including a contract with Hospital G that paid a fixed retainer in return for two departmental supervisory visits a week. The contract also carried an obligation to be available for consultation to the medical staff. On many occasions, Dr. V suggested to the administration and to the medical executive that departmental facilities were minimally adequate. The general response was, "If it costs more money forget it." Since Dr. V had growing commitments elsewhere, he did not press the matter. The next winter witnessed an unusually heavy admission rate of patients with acute respiratory disease. The swamped department seemed unable to cope with the load. Some of the very seriously ill patients died. In justifiable alarm Dr. V transferred the other critically ill patients to hospitals with adequate respiratory facilities. The department's reputation and self confidence plummetted; what impressed the administration was that revenues followed suit. When the shaken administration and medical executive asked what could be done, Dr. V produced the plan to expand coverage, responsibility and training. A new contract was negotiated which provided for compensation geared to departmental activity, recompense for effort and time invested. Since then, the department's capabilities and utilization have increased substantially. While some people work solely for the intrinsic satisfaction that a job well done provides, the majority are also stimulated by the prospect of an enhanced 6nancial return. In most cases a Bat, fixed, minimum retainer brings a corresponding return: flat, fixed, minimum medical direction. Case Study 6 (Promises and Politics)
When Dr. H was retained by Hospital U as physician director of respiratory care services, he was led to believe that the pulmonary function responsibilities would also be transferred to his department, as soon as certain "political problems" were ironed out. Since his commitment was only part time, the doctor developed his own practice and began to admit his patients to Hospital U. It was then that his lack of control over the pulmonary diagnostic facilities proved troublesome. Not only were there problems with the way these tests were done and with their quality control, but, more importantly, he could not agree with many of the "official" interpretations. He challenged the group doing the tests, but it could not be dislodged. Consequently, he resigned as physician-director, developed pulmonary function test (PIT) facilities in his own office, and affiliated with another nearby hospital. Two years elapsed before the hospital obtained a new medical director who also required control of pulmonary function.
84 ROMAN L YANDA
The prospective director of respiratory services who encounters anything less than a full complement of departmental services obviously needs a written guarantee that the missing elements will be supplied. Those elements may represent not the icing on the cake, but rather the cake itself. Case Study 7 (Gentlemen~s Agreement?)
Dr. T was recruited to act as director of respiratory diagnostic services and as chest consultant at Hospital H. Someone else would continue to supervise the respiratory therapy department. Contractual details, however, were vague, and were committed to writing only in the fonn of a letter of intent to Dr. T from the hospital. On his arrival at the hospital, the doctor found some surprises. The hospital had not planned to spend any extra money on' the pulmonary laboratory, and when it had to, it cut costs by reducing payments for services to the doctor by 50 percent. Dr. T also found that he was acting as the director of respiratory therapy a good part of the time. Finally, he was also being used as the "house officer" by influential medical staff members. With his income significantly reduced by these nonremunerative incursions on his time and by the reduction in his income, Dr. T took a part time salaried position at another hospital to maintain his financial position. His availability for stipulated duties only, led to numerous complaints and an ultimatum to drop the other position. Dr. T did not find his decision difficult: he dropped Hospital H. Several years elapsed before another physician-director of respiratory care services was recruited at six times Dr. T's initial compensation. Since his availability is not also six times greater, complaints are rolling in once again. DISCUSSION
The common denominator in all of these cases is frustration of expectations, by one or both parties. For those involved in the medical direction of respiratory therapy, the cases hold further implications. Problems commonly arise when the responsible agents for the contracting hospitals have little awareness of the director's functions and responsibilities. This lack of awareness also occurs, with equally deleterious effects, among the decision making levels of the medical staffs, and is compounded by the almost universal aggrandizing approach of the more senior hospital departments. The candidate must therefore take it upon himself to adequately inform these power holding components of the hospital of the magnitude of the problems he is attempting to solve and of the tools essential to doing the job correctly. The studies also demonstrate that the directors themselves contributed as much to mismanagement as did the administrators and key medical staff. In many cases the director totally neglected management functions because he had no clear idea of what the position actually entailed. This problem was compounded by the directors' lack of longrange personal CHEST, 68: 1, JULY, 1975
goals. Had their personal plans been more clearly worked out, many directors would not have accepted the position at all. In most cases, financial considerations were foremost in their minds. Yet respiratory skills are in such demand that even a modicum of planning insures financial solvency in this field. Factors besides potential income should therefore influence career decisions, including such factors as work satisfaction, potential associates, credibility and prestige in the peer group, political influence, stability and security, and the freedom to develop other interests within and outside of the profession. Managing one's own career is an essential element in successfully managing a department. Mismanagement of the terms of the initial agreement was probably the greatest factor in any financial hardship suffered in the cases cited. In other cases the lure of income from other sources encouraged the director to neglect essential management duties. In either case, the missing elements were the explicit details of each party's responsibilities to the other. It is worth noting in conclusion that the pulmonary specialist can afford to be complacent about deficiencies in his management skills, for his medical skills are: in a seller's market today. He may pick and choose among a variety of options. But if he chooses the physician-director option and yet neglects management, or if his managerial efforts are ineffective or
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even detrimental to the department, his hospital can only replace him or substitute a lower level of management. The latter course will relegate him to the status of an "on call technical advisor," and his reputation as the resident pulmonary expert will not be enhanced by the fumbling performance of a mediocre department of which he remains the titular head. Only a physician can provide top level respiratory management. His background alone supplies the potential for developing the best overall perspective on today's pulmonary problems. Development of this perspective, however, requires reordered priorities and new motivations, an added array of skills, and an expanded perception of the total health problem in which he is involved. It is time that respiratory training programs fostered the development of such a perspective. EDITOR'S NOTE: This article is being published simultaneously in the July issue of Respirat01l/ Care.
1 Prevalence of selected chronic respiratory conditions United States, 1970. Vital and Health Statistics (HEW) series 10, no. 84, pp 3-5 2 Acute conditions, incidence and associated disability United States, July 1971-June 1972. Vital and Health Statistics (HEW) series 10, no. 88, pp 12-13
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