What doctors and managers can learn from each other
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7390.610 (Published 22 March 2003) Cite this as: BMJ 2003;326:610
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Sir, - I read with great interest the article by Allen entitled ‘What
doctors can learn from Managers’ 23 February 2004. I am employed as a
dentist in a PCT and although I have no direct experience of the
relationship between managers and doctors, I feel that the same principle
described can be applied to dentistry.
I am amazed that management is not taught in dental or medical
training, particularly in dentistry. Around 80% of graduates will work in
the General Dental Services, which will lead ultimately to buying and
running a practice. The remaining graduates will work within the N.H.S. in
hospital services where an insight into management is essential. I can’t
speak for medical staff, but postgraduate fellowship exams in dentistry
have a module in law, ethics and legislation that affect dentistry but
management is not included. As well as the three suggestions that you
mentioned in the article perhaps a theme of management should be
introduced in undergraduate teaching and expanded in fellowship/ post
graduate training?
M. Cox
Manchester
Competing interests:
None declared
Competing interests: No competing interests
It may be a bad time to suggest that doctors can learn from managers
(1). “There has been a breakdown in the relationship between doctors and
managers” (2) and doctors’ morale has been sapped “by excessive, intrusive
audit and the imposition of Department of Health diktats”. (3) As even the
House of Common’s committee (4) found some of these targets to be
counterproductive, it is not surprising if many doctors feel unhappy about
their loss of clinical autonomy and power and that their distrust of
managers has increased.
The jobs doctors now have may not be what many had or expected, but
it is no good dreaming of a past. (5) The NHS costs too much, it has to be
managed. (6) If we disagree with Government policy we either have to try
to change the Government or find ways to cope.
If trust between doctors and managers is to be improved we must be
aware of the differences between the two groups. Just as many managers
have no first hand experience of the complexity of clinical practice, so
many doctors often do not understand about managing complex organisations.
However, medicine is not a factory and doctors rightly get offended if
medicine is treated as a “production line” (3). When there are medical
problems on the ward, it is the clinician who is the prime target of
complaints; patients know they see clinicians and not managers, but when
performance targets are not met, it is managers who must answer.
Medicine is not always a matter of life or death, but it is usually a
serious matter, especially to patients. Management, although it can be, is
rarely a matter of life or death. Managers can be sacked if they do not
meet a target, but if they make a management mistake, exceptionally they
might be sacked, but generally they try to correct it, hopefully learn
from it and carry on, while a bad decision may finish a doctor’s career.
The differences between medicine and management will inevitably produces
different pressures and actions. Just as managers need to learn more about
doctors’ pressures and priorities, so doctors need to learn more about
managers’ problems and methods
Managers can learn from clinicians, be more aware of their needs and
regularly spending time on the wards and in the theatre is formative.
“There needs to be considerable subtlety in the relationship between
doctors and managers”, (2) imposed changes in management requirements
without involvement saps morale, which can be demotivating and managers
need to be sensitive to this. Managers have to “show true leadership” and
“set a path for service delivery which everybody buys into” (2) and work
with doctors to develop a common approach to meet targets and improve
quality of care. It requires goodwill and skill, but discussion and
partnership is the key to improving morale and the Service. Doctors need
to contribute to this process as active partners. “With the right kind of
communication, you would get agreement (on targets) from many
doctors….Doctors are often very creative people and if their creativity is
unlocked they will find solutions “ (2) The NHS needs that involvement and
creativity.
Many doctors are too preoccupied with clinical practice to have time
for reflection on wider issues, but their training and experience enables
doctors to make a unique contribution to the management of the Service. It
is surely a professional responsibility of doctors to be involved in how
the system delivers care to their patients. Medicine must become more than
delivering care to patients it has to provide services to the population.
Doctors and managers do share some things in common. Both groups
serve patients and recognize that the guiding principle for actions should
be what is in the best interests of patients. Of course, although there is
agreement on ends it is how to find agreement on means, which is the
problem.
There are at least three ways doctors can try to improve agreement on
means.
1/ Doctors can engage in the debate about Health Service policy and
organisational structure. However, Government policy is difficult to
influence. The policy development process is complex and unpredictable.
2/ At a more immediate level, doctors can seek to improve relations
between themselves and managers. Why are managers bad? How can doctors
help? Or could it be that doctors do not always understand what managers
are trying to do or understand their methods?
3/ Doctors can become involved in management. Doctors already
practice management. Doctors face many of the same problems as managers.
Doctors deal with the personal managerial problems, also the general
managerial roles of leadership, developing their team, management of
change to improve their service, budgeting, quality management, etc.
Understanding managers’ methods could help doctors. Much of management
“theory” may be little more than common sense, but it is "systemised
common sense" and I would be surprised if, after studying management most
doctors do not change their practice.
When the Americans landed on the Moon, the New York Times published
an editorial saying, the point of going to the Moon was not to discover
what the Earth and Moon have in common, but to see their differences, so
we could better understand the Earth. That is why doctors need to learn
from managers: to be better doctors.
1. Smith, R. What doctors and managers can learn from each other.
http://bmj.com/cgi/content/full/326/7390/610
2. McLellan, A. “Rock and Role; the hsj interview with Sir Liam
Donaldson”, HSJ, 27/03/03
3. Beecham L. BMA Chairman criticises erosion of clinical autonomy.
http://bmj.com/cgi/content/full/327/7405/8-a
4. NHS target obsession “cost patients their sight". The Times Online.
22/07/03
5. Fiddian-Green.R.G. Red tape: a double-edged sword.
http://bmj.com/cgi/eletters/325/7376/S191a
6. McGucken, B. Doctors and Managers. The other end of the telescope.
http://bmj.com/cgi/eletters/326/7390/652/a#30870
Competing interests:
I organise management courses for doctors
Competing interests: No competing interests
Richard Smith mentions that NHS managers often lack access to high
quality information. The National electronic Library for Health (NeLH) is
doing something about this: it has set up a specialist library for health
management which aims to provide timely and efficient access to high
quality information resources for health managers, clinical managers and
leaders and those involved in commissioning health services. It is freely
available to all at www.nelh.nhs.uk/management . This project has been
running as a pilot and has as of today (1.4.03) been given 3-year funding
by the NHS Information Authority; we very much welcome feedback as we look
to develop our site.
Quality criteria for assessing Web resources, produced by OMNI/BIOME
[www.biome.ac.uk], have been used as a quality threshold for resources
included in our database of appraised resources. In addition the team has
piloted quality criteria for use specifically with management resources
(loosely based on the DISCERN appraisal tool for consumer information
[www.discern.org.uk]) which continue to be evaluated for usefulness within
the project.
Competing interests:
Project Manager, National electronic Library for Health Management
Competing interests: No competing interests
IT WAS INTERESTING TO SEE THE 2 LEADING ARTICLES IN THE BMJ ON THIS
TOPIC, SINCE IT WAS HARD TO IDENTIFY ANY PRACTISING DOCTORS AMONG THE
WRITERS (APART FROM ONE). HOW CAN SMITH PONTIFICATE ABOUT THE MOTIVES OF
CURRENTLY PRACTISING CLINICIANS IN THE MODERN NHS WHEN HE FAILS TO MENTION
THE GROSS UNDERFUNDING, LACK OF BEDS ,CANCELLED SESSIONS ,ARTIFICIAL
TARGETS ETC AS THOUGH THESE ARE ACCIDENTAL RATHER THAN GOVERNMENT POLICY
FAITHFULLY IMPLEMENTED BY MANAGERS. ALSO WHERE IS HIS EVIDENCE IN PARA 2
THAT MANAGERS WORK EXTREMELY HARD- WHERE DOES ONE FIND A MANAGER IN A
HOSPITAL AT 8PM ON A FRIDAY NIGHT?. I HAVE NEVER SEEN ONE IN 32 YEARS IN
THE NHS.
IF SMITH IS SO PERCEPTIVE HOW DID HE FAIL TO PREDICT THE COMPLETE LACK OF
ACCEPTABILITY OF THE (MANAGEMENT LED) CONSULTANT CONTRACT IN THE NHS. THIS
SURELY IS A BETTER MEASURE OF THE CURRENT MANAGER/DOCTOR DIVIDE.
I ALSO NOTE HIS ARROGANCE IN REFERENCING HIMSELF OR HIS PUBLICATION
EXCLUSIVELY.
Competing interests:
PATIENT CARE AS FIRST PRIORITY
Competing interests: No competing interests
Re: Re: WHAT DOCTORS CAN LEARN FROM MANAGERS
I agree with Cox, that all doctors and dentists would benefit from
management training, particularly general practitioners and dentists
working in practices who are really running a business. Even, or possibly
especially, dentists and doctors working in PCTs need management
training.
Some medical schools (Manchester included) have management as an
option in the undergraduate curriculum, but it is very difficult to get
management into the undergraduate curriculum, there are so many demands on
the students’ time. Also studying management is a bit like reading a
travel guide, it is not until you get there that you really start to
appreciate what it is all about.
But I think all Undergraduates could benefit from some training in
personal management skills, like Time management and team development,
which would actually help them during their studies. Other management
skills, such as leadership and management of change, become more relevant
when they start working in the NHS, then management is all around.
Some fellowship exams do have a least a token management component,
but I agree with Cox all (especially Dentistry) should have some component
of Management.
Competing interests:
I teach a management course in a medical school
Competing interests: No competing interests