Editorials

What doctors and managers can learn from each other

A lot

Doctors and managers have different cultures, which opens up possibilities not only of fruitless fighting but also of rich learning. I've belonged to both cultures. In 1989 I went to the Stanford Business School in California with a typical doctor's view of management: boring, uncreative, and best left to those incapable of doing anything better. I came back thinking the opposite. To be able to mix together ideas, people, and resources to makes things happen is creative, difficult, and a privilege. Generally, there is even more uncertainty in management than medicine. Having now inhabited both cultures it's clear that they have much to learn from each otherand where better to do that than within healthcare systems, where they work alongside each other?

Not everything is different between the two cultures. Both professions are full of highly committed people who work extremely hardoften to the point of damaging themselves and their families. The training of both is long, hard, and never ends. Contrary to what doctors may believe, managers think about ethics. Shocked by the scandals of the 1980s, business schools have been teaching ethics for as long as medical schools. This is not to say that all managers behave ethically any more than all doctors do.

Both professions respond to financial incentives. Doctors like to fool themselves that they don't, but there is overwhelming evidence that they dojust like everybody else. Managers and doctors are people of action. They are also used to taking risks. In both professions there are specialists: managers may specialise in finance, marketing, or human resources just as doctors may specialise in neurology or paediatrics. To be successful both professions need competence in communication, but both have poor reputations as communicators. Both have excessive jargon. Interpersonal skills are also crucial in both professions, and the hardest part of management is the "touchy feely" aspects. Doctors and managers have to break bad news and try to encourage people to changeyet many within both professions have poor interpersonal skills. Finally, both medicine and management have been dominated by ageing white men. Women and ethnic minorities have found it hard in both professionsbut both professions are learning to celebrate diversity.

One advantage that medicine has is a stronger intellectual base. Most doctors may not be scientists, but medicine is rooted in science and has learnt the importance of basing its actions on evidence. Management does draw on well established disciplines like economics and finance, but subjects like marketing or strategy lack academic rigour. There is no managerial equivalent of the Cochrane Library or Clinical Evidence, compilations of what the evidence shows. What, for example, is the evidence on the effectiveness of performance related pay? A related benefit is that medicine has much more of a written culture. Doctors are offered a much broader and better range of journals than managers, and too many management journals are, as the Americans say, "all sizzle and no steak."

Medicine benefits from being an ancient profession. It has assembled professional paraphernalia like licensing bodies, specialist societies, and royal colleges. Many doctors might see these as impediments, but having systems for creating codes of good practice, disciplining doctors, helping sick doctors, and promoting and monitoring continuing professional development are good things that managers should emulate. Professional accountability provides a counterbalance to accountability to employers.

Another great advantage that medicine has over many other enterprises, including management, is that its senior members work directly with patients (customers). Senior managers tend to preside over large organisations and concern themselves, rightly, with strategy, and so are a long way from the customer. Some time spent with customers is invaluable, and many senior managers find some way to build this into their working lives. But this difference in orientation is important: doctors think first about their individual patients, managers think first about organisations. For any hospital or primary care trust to succeed it will need both kinds of thinking.

Doctors probably have to learn from managers rather than the other way round. Increasingly doctors work in teams and large complex organisations. The ways of thinking and working that served doctors and patients well in much simpler circumstances are no longer enough. Doctors need to learn to think strategically. They and their organisations have not been good at thinking ahead.¹ Uncomfortable with the abstract, doctors tend to be reactivedriven by science and suffering. Doctors have also been uneasy about leadership, often designing unleadable organisations and then electing compromise candidates to lead them.² Leaders must set a path for organisations and then motivate people to want to follow that path. Doctors think it almost conceited to set paths and are uneasy with motivating peoplesomething that depends more on emotion than reason. Doctors are also uneasy with being led: they are too individualistic.

Doctors are learning from work on improving quality and safety in health care that it depends on thinking about systems rather than individuals.³ Managers are much more familiar with this than doctors, and the improvement that's so badly needed in health care will come only with managers and doctors working and learning together. Managers also tend to be more comfortable with working in teams. They understand that complex decisions are best made by effective teamsand effective teams are those where people are comfortable with disagreement and the team can work though conflict. Many doctors are too inclined to dominate teams. Managers are generally more comfortable with conflict and negotiation, recognising that the best strategy for negotiation is "win-win" not "win-lose." Doctors are too inclined to see negotiation as a process of extracting concessions from the other side.

Although I've argued that medicine has a stronger evidence base than management, managers are much more comfortable with economics and finance than doctors. Economics, whether we like it or not, drives the world, and is primarily concerned with the distribution of scarce resourcesa problem faced every day in healthcare systems. Microeconomics, invented essentially by Adam Smith, is a subject of bewitching beauty, and knowing nothing about economics leaves you almost as disadvantaged as somebody who is illiterate or knows nothing about history, science, or geography. Similarly, it's increasingly important in a world of large organisations to be able to read a balance sheet and an operating statement, something familiar to managers but unfamiliar to many doctors.

Doctors are, I believe, losing out in modern healthcare systems because of their discomfort with leadership, strategy, systems thinking, negotiation, genuine team working, organisational development, economics, and finance. Learning more about these things from managers, their colleagues, may make them not only more effective but happier, less lost within modern health care.⁴ Managers in their turn might learn from doctors more about creating an evidence base, encouraging research based debate, becoming a full profession, and staying close to patients. Mutual learning could lead to a harmony that would benefit both groups and, more importantly, patients.

Richard Smith, editor. 

BMJ (rsmith{at}bmj.com)

Footnotes

Competing interests: none declared.