Should Physicians Mind Their (Own) Business?

A contentious point of debate is the role of physicians in running health care organizations. Some argue that doctors should be in charge of hospitals, given their firsthand knowledge of the realities of clinical medicine and the day-to-day happenstances of caretaking. Others argue that physicians are hopeless at leadership activities in general, that outsiders sometimes have fresh perspectives that sweep away the inertia inherent in a hierarchically structured field like medicine, and point to high profile examples of how executives from other sectors/industries have swept in to save ailing hospital systems (they often refer specifically to Paul Levy, the former CEO at Beth Israel Deaconess in Boston).

So what does the evidence say? Unfortunately, there is very little in the way of hard data on this issue, except for this new paper by Amanda Goodall:

Although it has long been conjectured that having physicians in leadership positions is valuable for hospital performance, there is no published empirical work on the hypothesis. This cross-sectional study reports the first evidence. Data are collected on the top-100 U.S. hospitals in 2009, as identified by a widely-used media-generated ranking of quality, in three specialties: Cancer, Digestive Disorders, and Heart and Heart Surgery. The personal histories of the 300 chief executive officers of these hospitals are then traced by hand. The CEOs are classified into physicians and non-physician managers. The paper finds a strong positive association between the ranked quality of a hospital and whether the CEO is a physician (p<0.001). This kind of cross-sectional evidence does not establish that physician leaders outperform professional managers, but it is consistent with such claims and suggests that this area is now an important one for systematic future research.

As the author suggests, this is but a first step into understanding the returns to a physician versus a non-physician leader. Here are a few thoughts:

1. The main threat to inference in this study is selection into leadership positions. That is, physician and non-physician leaders are not randomly assigned. What if hospitals that are doing poorly, are more desperate, tend to "go outside the box" and hire non-physicians (supposedly, Beth Israel was in this position a decade or more ago). This would create the appearance in the data that non-physician managers do worse, when it reality it is not the case.

One way to push this point is to augment the regression slightly: add a measure of historical hospital quality on the right hand side. That is, regress current quality against current leadership and a measure of quality before that leadership went into place. This would control for selection into quality.

2. Of course, a better design would be to use longitudinal data on quality and leadership and track outcomes over time. A problem with implementing this is that effects only are identified off of those hospitals that change leadership regimes. In addition, rankings need to change over time, too. It's not hard to imagine inertia in both leadership and rankings, limiting the utility of this potential research design.

3. Everyone seems to refer to US rankings as gospel while at the same time denouncing them for their inaccuracy. I think better measures of quality (process elements, for example, like door-to-balloon time, patient satisfaction, etc) may be more informative in better delineating the effectiveness of different kinds of leaders.

4. Finally, there is a growing cadre of physicians who have obtained MBAs, MHAs, MPPs, MPHs. Are these dual-degreed souls better leaders than MD only physicians or non-MDs (I suspect the answer is yes)? I'd be interested to know.