Just how big IS the elephant in the room?

My previous post prompted a commenter of some pedigree Ben, to suggest it may be worthwhile trying to measure exactly how big the gap is between clinicians and management. Interestingly there is not that much in the literature of either medicine or management attempting to quantify this situation. After some searching however I unearthed this little nugget: “Views of doctors and managers on the doctor-manager relationship in the NHS” Davies et al BMJ 2003;326:626-628

The study was a postal questionnaire carried out in 2002 of Chief Executives, Medical Directors and a stratified sample of Clinical Directors randomly selected from 75 Trusts. Responses were received from 103 Chief Executives, 168 Medical Directors and 445 Clinical Directors. It is pertinent to explain that Chief Executives are purely from a management origin and Clinical Directors are Consultants heading up a clinical grouping known as a Clinical Directorate. Importantly, the latter group are clinicians, undertaking a management role in addition to their clinical role. These doctors will share most closely the opinion of the majority of clinicians although it should be noted that their role identifies them as having a bent towards management that other clinicians may not share. So they will have a more positive view of management generally than the majority.

A series of questions were posed and the answers assessed to see how much (or little) the respondents agreed with the question. The results of the study are clear and are summarised by the the authors,

” Clinical directors were easily the most disaffected, with many holding negative opinions about managers’ capabilities, the respective balance of power and influence between managers and clinicians, and the prospects for improved relations.”

I have uploaded a spreadsheet of the results here with the questions and the responses from the two groups discussed. I’ve also done a little additional work of my own calculating the distance between the answers of managers and clinicians. Allowing a 5% error each way (ie >10% difference is significant) it is intriguing to see that of  the 26 questions in only 4 was there any similarity of opinion.

So, how big is the elephant in the room? I think we need to address a few other issues now apart from its size…

Clinical Managers are like web sites.

The more I thought about the last post and Sue Llewelyn’s analogy of clinical managers as two way windows, the more I realised it was wrong. For me at least.

Certainly a clinical manager can allow and transmit vision (knowledge) to and from both sides of the “divide”, the insights one being more apparent to the other. But there I think the analogy starts to fail. Once again I accept that this may be due to my experiences but if an analogy is to be worthwhile it must work beyond simply those who describe it.

If one is inside a building looking out, no matter how big the window, the view is limited by the window itself. Similarly, no matter how close one gets to the window only one room inside the building will be visible. that is if the window is even on the ground floor! I’ll let you make your own translations into the experience of managers and clinicians.

My proposal is that clinican managers should be like a website.

It’s all about communication and information, accessibility, and development. And if the website isn’t working properly, or providing the right information, the appropriate support or communication portal, it can be upgraded and added to. It doesn’t have to be all singing and all dancing with java apps and downloads everywhere; it has to be personal and effective, professional and online.

What sort of website are you?

“…there’s something wrong, can you hear me Major Tom?”

Sue Llewelyn in her paper, “clinicians as medical managers,” addresses some of the issues of doctors in roles of management. At the centre of her thesis is the use of analogy; the clinician manager as a two way window. This she asserts allows each group to effectively view the other through the faciliation of the window. The suggestion is, that originating from a medical background the window will garner respect from clinical colleagues offering medical insight into the world of management and working within  management gain respect from managers and offer insight into the world of medicine from management.

The topic of the clinician-manager interface seems to come up a lot in conversation around me, even without me bringing it up. Doctors want to talk about it; most have strong opinions on the matter. There’s alway a lot of negativity and, a little respect here please people, I always try to turn the conversation towards positivity and solutions for the problem rather than simply allowing the routine regression to negativity and criticism.

Recently I think I have hit on the problem. It’s not about respect, it’s not about experience, it’s not about understanding or insight, authority or knowledge, hieracrchies, budgets, control or indepencence. It is not about departmental interactions, committees or working parties, cascaded emails or a newsletter stapled to your payslip. It’s not about looking.

It’s about communication.

Yes, it is a complex professional bureaucracy with multi-faceted relationships and interactions but at the very centre of them, and of course every relationship, is communication. Without effective communication every relationship is doomed whether that is between kids in the playground, star crossed lovers, governments or even between clinicians and management. And the key word here is between.

BINGO!

“Can you hear me Major Tom?”

Clinicians are from Venus, Managers are from Mars

It is encouraging that my failure to post on a regular basis stimulated a request for output from a loyal reader, thanks B. In response I posted yesterday; “Managers are from Mars, Clinicians are from Venus. Discuss.” Sadly, no-one did!

The book, from which the title is culled, discusses the difficulties and differences between the sexes within relationships essentially surmising that they are as beings from separate planets. The complexities of professional relationships within hospitals, which may (or may not) be the basis of my Action Research thesis, I believe mirrors this disparity. Managers and clinicians are as different as beings from another planet; Managers are from Mars and Clinicians are from Venus.

 

The academic literature is not awash with discourses on this matter. As I work through this I am grateful to various colleagues for their support and notification of individual papers and particular to Ed for unearthing this  article from Amer Kaissi: Manager-Physician Relationships- An Organizational Theory Perspective, The Health Care Manager Volume 24, Number 2, pp. 165-176

Although the paper is written from an American perspective it has a lot to say that is relevant to the almost diametrically opposite cultural stances of British clinicians and managers. The table below summarises some of those differences.

Area		Managers		Physicians
Central logic		Rationalization, efficiency		Collegial control, expertise
View of work		Make a living		Work is living
Values
Primary loyalty		To the organization		To the patient
Responsibility		Shared		Personal
Tolerance for ambiguity		High		Low
Patient focus		Broad		Narrow
Time frame of action		Middle-long		Short
View of resources		limited		Unlimited
Artefacts
Basis of knowledge		Social and management sciences		Biomedical sciences
Exposure to others while in training		Little		Great
Relationships		Hierarchical		Collegial
Career development		Hierarchical advancement		Achievement
Vocabulary		Cost, benefit, revenue		Quality, patient outcomes

Perhaps, like the book of the title, some of the findings and statements of this paper may appear somewhat obvious. These differences will clearly affect many clinician-manager interactions, even without ladders of inference. The ability to recognise and work effectively with (or despite) such differences requires insight, skill and patience. On both sides.

What do you think? Are managers from Mars and clinicians from Venus? Despite being so different can you see how the two can work effectively together?

Clinicians are from Venus, Managers are from Mars

discuss.

Hospital Consultants are like professional footballers…John.

I sometimes wonder if my use of analogy is counter-productive but as I was struggling to find comparisons and analogies to demonstrate the interaction and relation between Consultants and medical management I was drawn back to professional football and I think I’m onto a winner.

In hospital medicine doctors work in small teams under the supervision of a Consultant. Ultimately, most Consultants work as independent practitioners within the hospital. True they may be part of a Diabetic team or Upper GI surgery or the Acute Mental Health team but one of the goals and privileges of being a Consultant is that we work at the pinnacle of our profession attempting to deliver care to the best of our personal knowledge and ability.

Within hospitals these Consultants work as part of larger teams and that team delivers care for a particular problem; such as Diabetes or a geographical area such as central Nottingham or even for a specific age group such as newborn children. Ultimately there is a umbrella covering this whole varied group and this may be a Hospital or a Trust or a regional service ultimately managed by someone such as a Medical Director. The exact inticacies of this are not important but what you do have is highly specialised individuals working with others in a larger group directed towards one over-riding purpose for that uinified group. A Premiership football team.

Each “player” or Consultant is highly trained, highly specialised and often brought into the team at that level of maturity. They offer experience and knowledge that may be of international reknown in one specific area and whilst they can be developed that is only within this ability channel not generically. No more can you encourage the goalkeeper to take over as a winger than get a Vascular Surgeon to do some hip surgery even althoughugh in a previous junior “team” he may have taken on that role.

Clearly for the whole team to succeed there is a requirement for effective teamwork, communication and sharing of the ball. Some of the roles have glamour attached as media celebrities performing  Heart transplant surgeons up front receive the plaudits of the red-top press but there is no doubt that without the midfield solidity of General Medicine and the decisive tackling of the Casualty specialist at centre back that the team would fail overall.

Extending the metaphor towards breaking point it is clear that some teams play with no sense of common purpose. Glory seeking wingers rushing for the goal only leave gaps at the back that the goal hangers of negligence sweep past. Old fashioned tactics of brutal tackling and the high ball attract poor crowds and the finances dwindle away. Not every team performs on the day despite the ministrations of the manager as they just fail to gel and even an occasional sending off may actually bring out the best in a team as they draw together defensively.

Clearly, whilst the manager gives instructions and plans before the game, “when they cross the white line” every player is their own boss whether they hang back and make a mockery of the rush offside defence or leave the lone striker up front with no ball because of selfish showboating in the midfield it is all about effective leadership and communication.

I’m going to leave it there, John, give all credit to the boys, who held their hands up and played for the badge. It’s a marathon, not a sprint and if we keep our noses to the grindstone we can save ourselves from the drop. Myself and the lads’ll be back, you know, you know wif more analogies cos, you know, if we give 110% we can turn this around, regain the dressing room and, you know, do it for the supporters. all credit to them.

What do you think John? Did the lads done good? Is that an apt analogy or just another cliché?

I think the analogy is true.