Competing Clusters and the Physician Leader

The way healthcare is provided in the future may be markedly different from how it is provided today, as information infrastructure and resource constraints move healthcare out of facilities and into peoples’ homes and workplaces.

The enormous investment in capital resources in large hospital systems cannot continue to accelerate at its current pace; the boundaries of the healthcare delivery system must be redefined radically and rapidly. For physicians and those in leadership positions throughout the industry, the expansion of these boundaries calls for greater cognizance of morally ethical conduct to avoid conflicts of interest.

Physicians are expected to navigate through many issues amid external and internal forces that influence critical decisions. The diverse environments in which physicians practice must be understood within definable professional identities that transcend industry boundaries and traditional medical disciplines such that their professional role remains true to its traditional roots as healer/shaman from a sociological, ethical, and fiduciary perspective.

Due to their difficulty in accepting the efforts within organized medicine to re-establish an ethnic of professionalism over the last 20 years, Hafferty and Castellani developed a model defining a seven-cluster system of medical professionalism based on their work in complexity science.(1)

In their study of the medical profession from a sociological perspective and through the lens of complexity science, they delineated the ways physicians seek to establish their own identity in their profession and society. They argued that these seven clusters of medical professionalism emerged as a direct response to the historical forces of decentralization in which organized medicine has been situated for the past 30 years.

Hafferty and Castellani viewed the historical forces of decentralization within the medical profession and within the complex system’s distinction between organization and dynamics such that the values, orientations, beliefs, specific skills, and ways of controlling the position within the larger bureaucratic structure are dynamically at play with one another in 10 key aspects of medical work that create competing clusters of professionalism. They identified 10 key aspects of medical work as autonomy, commercialism, social justice, social contract, altruism, professional dominance, technical competence, interpersonal competence, lifestyle ethic, and personal morality.

Organizing Medical Work

Castellani and Hafferty use the complexity science agent-based processes such as emergence, evolution, adaptation, feedback, autopoiesis, perturbation, self-organization, and operating far from equilibrium as terminology to understand medical professionalism as a complex system. They identified the seven clusters as different ways of organizing medical work that uniquely combine and practice the 10 aspects of medical work in the complex system.

The element of complexity Hafferty and Castellani apply is network analysis. Each cluster is impacted by both internal and external forces that affect physicians as they grow into leaders or delve deeper into their clinical practice/research and the peer group with which they are engaged over time.

External forces such as managed care, consumerism, and health policy reform, and internal forces including health information technology, evidence-based medicine approaches to care processes, and challenges to authority and autonomy within complex organizations, impact the development of professional identity.

Lifestyle. Physicians who identify with this cluster place strong values on family life and achieving balance between their time at work and devotion to family, spiritual needs, and other interests. There is also a greater tendency to seek part-time or employed physician salaried positions.

Entrepreneurial. Physicians in this cluster focus their efforts on improving the business model for healthcare service delivery. Innovations that lead to reductions in the cost of care and the waste of resources, improvement in quality, or expansion of services or products offered are of high importance to these physicians.

While autonomy is important to this group, they recognize the transformation under way in healthcare, the need for greater collaboration and shared authority in organizations. They also will identify more closely with clinically integrated care delivery models and those that affiliate with the corporatization of medicine.

Unreflective Cluster. The focus of this cluster is on the day-to-day work that typifies episodic patient care. The individuals here may be somewhat disengaged from reform efforts, business model transformations, or research. The unreflective segment of the physician community tends to make no distinction between their personal and professional identity and may be particularly vulnerable during times of change. Salaried employment models such as those offered by hospitals may be attractive to those who simply want to hunker down and see patients.

Academic Cluster. The academic cluster attracts physicians who are the majority in the medical teaching ranks. Within this cluster are challenges to be reconciled. The presumed value placed on teaching by the academics is not reciprocated in financial compensation or tenure.

The need to generate revenue from research competes with responsibilities of clinical practice within the academic environment, especially as the regulation in resident work hours and overall shortage in general surgery and general internal medicine squeeze the time to teach even further.

In the field of general surgery, the industry experienced a 4.2% reduction in the general surgeon workforce between 1981 and 2005.(2) External forces or stressors (e.g., financial pressures, changes in status) may increase the likelihood of verbal abuse of subordinates.

Activist Cluster. This group is clearly focused on advancing the ideological needs of healthcare on local, national, and global scales. The physician activist embraces the challenges of motivating peers and other stakeholders to support grassroots movements that can improve public health or the health of a population in general. These altruistic efforts may detract from time in the practice of clinical medicine, which may in turn create a conflict between financial stability and leadership development.

Empirical Cluster. Physicians attracted to the empirical cluster typically are academic physicians who are research orientated in contradistinction to those in academia who have a teaching focus. This group values the creation of new medical knowledge. The pressure to bring in research revenues to establish tenure may lead to a focus on safe, incremental approaches to science that lag in advancing evidence-based medicine practices, innovation of new medical technologies or therapies, or innovation in patient and population health models.

This group may have little concern with idealistic movements in society but may still be marked by a strong sense of benevolence that must be balanced by their realistic need for grant-based revenues that often restrict radical approaches to scientific inquiry.

Nostalgic Cluster. Hafferty and Castellani consider the nostalgic cluster to be the most dominant of the seven. This cluster tends to serve as a locus for those physicians operating at leadership levels across the industry in academic medical institutions, in medical societies, and in the production of medical publications.

As a collective, this group is focused on maintaining levels of autonomy and, while historically seen as fighting the commercialization of medicine, may have championed national movements such as the call for a transition away from the problematic fee-for-service model of reimbursement for care in exchange for a culture more driven by value-based purchasing initiatives, shared savings programs, and pay-for-performance incentive programs. Although they perceive that there may be problems or unintended consequences to work through in this transition,(3) as a whole the aristocracy of medicine recognizes the need for change.

Implications for Physician Leadership

Professional ethics should keep the interests of patients at the forefront of decision making by physicians working in each of these seven clusters. The aspects of medical work that are most emphasized within an individual cluster are distinctive and therefore varying in leadership development implications.

Hafferty and Castellani identify key values in each of the seven clusters that define the professional behavior of physicians operating within the constructs of that cluster. The clusters can therefore be used to identify implications of leadership for physicians operating in each of the clusters.

For the nostalgic cluster, viewed as the ruling aristocracy of medicine, self-reflection regarding their idealized notions of the profession’s past versus the dynamic changes of the contemporary professional will be revealing.

For the entrepreneurial physician, self-reflection on the impact of disruptive innovation on complex adaptive systems as it pertains to their ideal of improving care will be useful.

Those in the academic cluster must parse their role in training future physicians with curriculum and culture change that prepares physicians for the changing healthcare system.

Physicians in the lifestyle cluster must reflect upon the potential limitations to their personal leadership growth and development as they pursue the work/life-balancing act that is increasingly complicated in contemporary American medicine.

The empirical physician cluster offers the opportunity for physicians to lead by helping to define what, how, and why resources are used for research. Pertinence of effort becomes the guiding principle for leading in this group, such that research in system redesign and comparative effectiveness are emphasized.

The potential for strong engagement in health reform campaigns/public health grass roots movements for activist physicians is paramount, as long as physicians in this cluster understand the importance of bringing other physicians along in their efforts. Leadership development for activists involves skills in influencing others rather than simply fighting for pet causes.

Finally, the leadership for the so-called unreflective physician may involve engagement in those aspects of healthcare delivery that most influence their day-to-day work, such as care coordination, patient safety efforts, and workflow redesign. These physicians should not be overlooked as leaders, for their willingness to work on system improvement at the micro level will improve the likelihood of success in clinical integration efforts and population health management strategies.

The seven clusters described by Hafferty and Castellani have interesting implications for physician leadership development. The obligations of physicians, not only to their patients, but also in their wider professional roles to peers, clinical teams, students and others in the industry, necessitate self-reflection as to the pitfalls and potential opportunities implicit in the values embedded in each of the seven clusters.

References

1. Hafferty FW, Castellani B. The Increasing Complexities of Professionalism. Academic Medicine. 2010;85(2):288–301.

2. Kavic M. Professionalism, Passion, and Surgical Education. JSLS. 2010 Jul-Sep;14(3):321–24.

3. Mehrotra A. Sorbero, ME, Dumberg CL. Using the Lessons of Behavioral Economics to Design More Effective Pay-for-Performance Programs. Am J Manag Care. 2010 Jul;16(7):497–503.

4. Excerpted from MD 2.0: Physician Leadership for the Information Age by Grace E. Terrell, MD, MMM, FACP, CPE, FRCPE