John Gray's popular advice book of 1992, Men Are from Mars, Women Are from Venus, portrays the sexes as hailing from different planets. However difficult it is for men and women to communicate, at least they are of the same species. I'm not sure the same can be said for physicians and health care executives. I have believed for years that health care management programs have underprepared their graduates for the complexities of even understanding, let alone managing, medical professionals.

Previous generations of health care executives were conditioned by their elders and their training to view the physician as a special kind of "occupational hazard." Some older health care executives fantasized that if you could simply dispense with physicians altogether, the hospital would run much more smoothly. Failing that, if physicians worked for you, it would be clear who was boss; you could simply tell them what to do and they would do it. To them, the buzzword "aligned" means that physicians do what you tell them to do. These health care executives suffered from a mixture of envy, resentment and baffled misunderstanding in trying to deal with their physicians.

Contemporary managers have their previous generation's wish: More than 120,000 physicians now work for hospitals full time. Yet, the complexities of managing them remain. Even with an allegedly more pliant generation of physicians, the job of running health care organizations is no easier.

The Physician Mindset

Many future physicians select their professional trajectory in childhood, or are pointed that way by their parents. They spend middle school and high school at or near the top of their classes, wistfully watching their classmates having more fun. They are, and remain, intensely competitive individuals; were they not, they would never have made it to medical school. In college, they push through premed courses, often forgoing disciplines like the humanities and the arts that might have provided them with a broader understanding of their patients, colleagues or society, or perhaps their own motivations.

Once they reach medical school, they are crammed full of science and clinical lore from a curriculum that hasn't changed meaningfully in 50 years (with the notable additions of clinical computing and molecular biology). They are taught by clinical faculties who have been, until very recently, functionally illiterate in information technology — and often were demonstrably lacking in people skills. Then young physicians get the stuffing kicked out of them in their residency training.

By the time they emerge from their training, they are often damaged as human beings and are having second thoughts about their career choice. They leave their residencies full of knowledge and seriously short of practical understanding, scared to death by the $200,000 debt they are carrying and wondering when life begins, exactly. What they are not typically taught is anything meaningful about the practice world they are entering.

Nor are they taught anything about what you do or how to work with you. For their entire training, they've been supervised by other physicians: the faculty "officer corps" and the "noncoms," i.e., senior residents and fellows. They saw folks in suits in the halls, but had the dimmest notion what the "suits" actually did for a living. Now those suits are paying their salaries and expecting performance. It is not obvious to them what you want or how to meet your needs.

Here are some clues about this new class of physicians:

They remain fiercely competitive and empirical. This is a major selection factor at work in people who decide they want to become physicians. As mentioned, they had to be both competitive and empirical, or they never would have gotten into medical school. These traits were powerfully ingrained as they developed in childhood and adolescence. As a result, they care plenty about how they are performing relative to their peers, and they don't like to lose. Appropriately employed, these two factors may be the most powerful levers in motivating them. They also expect decisions that affect their professional lives and care of their patients to be defensible empirically.  
 
They actually care about the people they are taking care of. With some notable exceptions, for example, radiologists and pathologists, who fled direct patient contact in their residency selections, physicians entered the profession to work directly with sick people and help them. They despair over how little they can do to help sometimes. But, with the possible exception of the pediatricians, they will never (a word I don't use often) care about the people they are not seeing as much as they do about the patients in front of them. They will work hard to help their patients understand their role in their own health. But your physicians have been trained to take care of patients, not the rest of the community.
 
They have learned a lot from watching their elders. There is a lot of discussion in medicine right now about how Generation Y doctors are different from their workaholic elders. Most younger physicians don't want to practice 100 hours a week. To many of their elders, this smacks of a "lack of commitment to medicine." Younger physicians (and not just the half who are women) would not only like to have families, but also remember the names and significant life events of their children. Striving for work-life balance looks like wisdom derived from closely studying their elders, many of whom were burnt to a crisp by the time they reached their late 40s. If you wish to keep them once they've paid off their debts, you're going to have to be clever and understanding in scheduling their work hours.
 
Don't expect the best of them to stick around if you cannot adequately support their practices. Many of them chose to work with you to minimize their economic risk and to pay down their debts, not because they loved hospitals. The acid test will come when those medical school debts are reduced enough for them to be able to buy homes and join the middle class. If you struggle in managing their practices, you are not going to keep the best of them. They will have limited patience with excuses, broken promises, and poorly trained and focused practice managers and clinical leaders. The best of them will be picked off by aggressive, larger group practices in your area — or by specialty physician firms that staff hospitals — and you'll be left with the rest.

Don't expect a lot of help reducing patient care costs. An earlier generation of physicians had profound philosophical objections to "managed care." Younger physicians have a different problem. With them, it isn't "political." My spies tell me the new generation of employed physicians are cautious, risk-averse and prone — as they were taught in their training — to over-order tests and consults, and let the "suits" sort out the finances.   

If we expected employed physicians to actually reduce the cost of care, we're learning sadly that their training has pointed them in a very different direction. Even younger hospitalists and intensivists have had trouble with more resource-sparing clinical decision-making. They will need to be retrained, and that will happen only with effective physician leadership.

Younger physicians are, however, team players, and far more comfortable practicing as part of a team than all but a handful of their elders. This bodes well for their willingness to adopt and practice evidence-based, protocol-driven medicine. But don't expect them to practice protocol-driven medicine unless they feel the outcome is defensible based on available science.

Don't expect them to be your buddies. Physicians are different from you, in temperament, training and character. They are a different species. Even physicians who move from the practice world into the executive suite often find that their membership in the "tribe" is affected negatively. It is an extremely unusual lay health care executive who develops a physician peer group. That's OK, too. You don't have to be their buddy to work effectively with them, because they need high-quality administrative support to avoid compliance hassles, grow their practices, launch new programs and get them paid for.

Building Trust

The fact that so many physicians now work for hospitals virtually guarantees tension over how and how much they are paid. Moreover, an equally large number of physicians who are not employed by the hospital depend on the hospital for significant income through contracts. Negotiating these contracts always has exposed health care executives to a predictable number of land mines; conflicts with pivotal physicians like anesthesiologists and radiologists, who are widely connected to the rest of their colleagues, easily can flare up and affect medical staff relations as a whole.

Figuring out how you can help physicians be successful is the key to converting these potential conflicts into win-win situations. I learned early that for those physicians who make any clinical enterprise successful — whether it's a faculty practice plan, a new clinical program or service, or a group practice — if you can help them grow and clear away the barriers to success, you'll have their support when you need their help to do things that do not directly benefit them.

You will need to earn their trust, even if you sign their paychecks. Keeping that trust is a matter of transparency and integrity: Promise only what you can deliver, and be modest about what you don't know. That modesty will go a long way toward building lasting, successful partnerships.

Jeff Goldsmith, Ph.D., is the president of Health Futures Inc., and associate professor of public health sciences at the University of Virginia, Charlottesville. He is also a member of Speakers Express.