'Caducean ceiling' blocks docs from CEO posts - Climbing to The Top - why physicians have trouble getting promoted to chief executive officer positions

Physician Executive, Sept-Oct, 2002 by David O. Weber

YOU MIGHT CALL IT THE caducean ceiling.

Like the famous glass ceiling that constrains ambitious women executives, the caducean ceiling is the unseen organizational barrier that repels physicians when they aspire to be chief executive officers. Despite the wings on their profession's symbolic caduceus, they can't fly through this final obstacle. Invisible it may be, but the caducean ceiling is up there. Look at the evidence.

In 1972, according to the American Hospital Association, there were 7,061 hospitals in the United States with 813-11.5 percent--headed by physicians.

Thirty years later in 2002, mergers and closures in a turbulent health care marketplace winnowed the total number of hospitals nationwide to 6,044. But doctors who are chief executives run only 200-3.3 percent of the total. That's more than a 70 percent decline in the proportion of physician CEOs.

Indeed, among its 23,065 current members, the American College of Healthcare Executives can count only 28 who are doctors and hospital CEOs. When the field is widened to include organizations of all types, not only hospitals, the ACHE's physician CEO corps rises to just 54.

To be sure, the American College of Physician Executives boasts among its 11,030 members many more doctors in top positions--711, according to the database. But by far the majority are CEOs of medical groups rather than more multifaceted health care organizations.

They constitute a tiny clique huddled in a lonely corner as the laughter rings out and the glasses clink at the big chief executives' ball.

What's going on here?

Oxymoron?

Larry Mathis, former CEO of the Methodist Healthcare System in Houston, took early retirement at the age of 54 in 1997 and wrote a book about what he'd learned in his 14 years at the helm of a major medical enterprise. (During that span, he also wedged in presidencies of the AHA and the ACHE.)

He titled it The Mathis Maxims: Lessons in Leadership (Houston: Leadership Press, 2001). One of his maxims: Physician executive: an oxymoron.

"There's nothing in a physician's education and training that qualifies him to become a leader," maintains Mathis. "And that's what executives Are--leaders... persuaders...team builders...communicators...organizers.

"The physician is challenged throughout his education and training to be an outstanding individual performer. But leadership is not an individual action.

"It's a participatory process.

"I respect and admire physicians," Mathis hastens to add. "They are consummate professionals, the best and brightest of the best and brightest. But when they leave the confines of medicine, they can be a danger to themselves and others."

Clearly, then, among some who have been in a position to look down upon them through the caducean ceiling, there's a prejudice against-or perhaps more accurately, a profound skepticism about--doctors as candidates for senior executive roles.

Not surprisingly, many who have worked under physician executives share those dim views.

"They just don't get it!" moans a woman executive who fled a professional organization headed by a physician. "They brag they don't have management skills. My boss just wanted to be the doctor's doctor. But that was not what was needed."

Other statistics are telling, as well. Consider a June 2002 study published in the American Journal of Nursing that found 93 percent of nurses, physicians and administrators at 84 VHA hospitals had witnessed or personally experienced "disruptive behavior" by a doctor.

The behavior was defined as inappropriate confrontation or conflict ranging from verbal abuse to physical and sexual harassment. Nearly a third of respondents said bad organizational karma--resignations of valued nurses, for example--followed.

So maybe it's understandable that many successful physician chief executives themselves join the chorus of negativity.

"Emotionally we're often like seven-year-olds, a little bit retarded," confesses Donald Hofreuter, MD, CPE, FACPE, chief executive officer of the Wheeling Hospital in Wheeling, W.Va. "Beyond that, our focus is one-on-one--one patient at a time. We want to be healers, loved and honored and respected. We've envisioned ourselves almost as God-like."

Ironically, though, he says, "we don't want to make the hard call. And that's what's necessary on the business side of medicine. Physicians, by nature, want to transfer the blame to other people because they need to be God-like. There are very few times that you'll hear a physician say, 'Boy, I blew that baby!"'

Hofreuter isn't convinced that physicians really want to take on the top post.

"Many say they want the CEO job, but I don't think they do. It's lonely at the top. They're fine as vice presidents of medical affairs and clinical administrators, keeping the medical staff in check and that kind of thing," he says. "But that's not running an organization. The CEO spot is where the buck stops. It's totally your call. And physicians are reluctant to be out there that way. Deep down, they'd rather be where they are, where they don't have to make the really hard calls."