Lack of Role Clarity Damages the Physician, Manager Relationship

April 16, 2014

Clear and well-respected boundaries between medical practice managers and physicians are essential. Here's how to better define them.

Clear and well-respected boundaries are essential to the effective function of every relationship, business or personal. Roles define boundaries. The combination of these two facts explains why the relationship between physicians and practice administrators or managers in private practice is often problematic.

The physician has two roles: owner and income producer. In economic terms, the physician supplies both capital, e.g., assets the owner has decided to employ in the production of goods and services, and labor, e.g., the human effort required to produce goods and services. There is no conflict between the dual roles as long as the managerial pyramid is flat, and there is no intermediary between the top (the owner) and the bottom (the income producer) of the power hierarchy.

The office administrator/manager also has two roles: subordinate and superior. As a subordinate to the owner, the practice administrator has a duty to implement the policies and achieve the objectives of the owner. As a superior, the manager has an obligation to effectively utilize all practice resources, consistent with those policies. The rub is that the administrator takes orders from and is charged with maximizing the productivity of the same person: the physician.

I will assume that the reader is clear, in theory, on the perquisites and obligations of capital, labor, superior, and subordinate. The interesting question is how to successfully manage a relationship when both individuals can assume multiple roles.

The answer is simple and maddening: Since the physician has the potential for the highest role, it is up to the physician to declare the role he is assuming in any interaction. The only way to productive resolution and successful relationships is to be clear as to the current governing authority. An effective method may be for the physician's default role to be labor, unless he specifically assumes the role of owner. It's more effective to be explicit when pulling rank, rather than call attention to the physician's role as a worker.

For example: A physician has declared that staff must verify patient insurance and collect any copay before the physician sees a patient. The administrator has implemented procedures to ensure compliance.

The staff successfully verifies a patient's coverage, and the patient declines to tender the copay. The staff cancels the appointment. The patient leaves angry, and the physician has an empty slot in the schedule.

The physician is frustrated because a) no incremental cost would have been associated with seeing the patient, b) physician time went unutilized, and c) the patient was a good friend who has since called to complain. The office administrator supports the staff.

Now what? It all depends on what role the physician chooses to assume in the situation. For example: 
Labor. The physician might say, "Those are the rules, and I have an obligation to support their enforcement." The administrator is superior.
Capital 1. The physician might say, "Those are the rules I have mandated, and I support enforcement." The administrator is subordinate, faithfully implementing policy.
Capital 2. The physician might say, "This is a consequence I did not intend. I want to amend the rules." The administrator is subordinate and responds: "These are the consequences of the change you propose. The responsibility for the consequences is yours. I will support whatever you decide."
NOTE: The physician assuming the role of owner is never subordinate.

Clarity removes uncertainty, which is the biggest detriment to the morale and productivity of any office. If the administrator is secure in his role as the implementer of a stated policy, he has the confidence to give clear direction to staff.

If staff knows that the rules are the rules until the owner(s) direct a modification through the manager, they have confidence to enforce policy without fear of undefined special circumstances.

Clarity as to the physician's role removes doubt about who is assuming responsibility. If the owner gives a directive, any discussion is ended and the owner is responsible for the impact of the decision. If the physician, as a member of the labor force, disagrees, responsibility stays with the administrator.

All this clarity is not always attractive. Most of us like to get what we want when we want it. We also like to wait and see what happens before we decide who gets the credit or blame. That's a normal reaction, but it is not the path to high productivity and high morale.