Clinical advocate or serving another master? (The lot of the public hospital Chief Medical Officer)
BY DR RODERICK MCRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS
Before you read on, I want to be clear that I am not seeking to have an easy free kick, and I note not one size fits all: it’s a big country. All of us employed to practice medicine in public hospitals understand the organisational complexity and the essentially guaranteed inadequacy of government funding support. In this context, I respect the truth that the Chief Medical Officer (CMO) community participate in those decisions which influence the deemed appropriate distribution of resources, improving general hospital performance and with the rest of us, striving for the delivery of the highest quality care for our patients.
But, and now the but, I do not want to experience a trend where CMOs cease to practice proper leadership of medical staff by no longer working collaboratively with other doctors about solutions and deciding direction. One becomes increasingly concerned if CMOs direct junior medical staff at orientation sessions not to apply for employment entitlements of overtime payments as compensation for such work in direct contravention of employment entitlements.
Academic literature has regularly published findings that the best performing hospitals have leaders who are doctors. I acknowledge here that to be successful, a CMO needs to build credibility on the administrative side to have sufficient influence for the benefit of patients and doctors. It is less clear that an administrative qualification per se is necessary or required for a CMO, as opposed to a CEO. When a doctor (with the right competencies and skill) is on the hospital’s senior management team we all benefit from having a professional who ‘gets’ both sides of the equation and operates as an effective liaison between the two.
However, there are studies that show CMOs are now spending most of their time on the managerial aspects of their job, which greatly limits their time spent on clinical practice, teaching and/or research. While the CMO generally has some extent of a clinical background, offering opportunity for them to build trust and support among their medical colleagues, the role itself has a tendency to push the CMOs orientation away from being a clinical advocate to instead being a supporter or even agent of the hospital’s ‘party line’.
In my view, there is a degree of incompatibility between the CMO’s need to maintain trust with medical staff and their (at least perceived) need to be a persuasive backer of managerial ‘bean-counter’ decisions. I don’t suggest our CMOs have lost sight of the responsibility to patients and community. It just must be challenging to, on the one hand, be charged with implementation of public hospital priorities decided, often unilaterally, by our administrative masters and on the other, act as clinically independent public health and doctor advocate (however they learn of the hospital medical staff’s view). I fear this tension is often resolved through the prism that we cannot expect optimum outcomes because we are in resource-poor public health. That is wrong; we always must press for the optimum!
So, rather than hospital executive teams requiring a CMO to show loyalty by choosing their (wrong?) side, I think we need to instead encourage CEOs to embrace their CMO’s unique positioning and allow their CMO to properly balance their duties. This encouragement comes from how the CMO’s freedoms and expectations are set by their employing hospital.
I recommend a good start is for a CMO’s KPIs to centralise having both the express freedom to fearlessly advise their executive on medical workforce planning, clinical innovation and service development, and the clear expectation that they will always bring the voice of and fiercely advocate for their clinical colleagues at the table.
Preventing the CMO from becoming isolated and embracing their engagement with us will not only break down resistance to implementing necessary and useful change, but will contribute to not only improved performance (budget and patient related), and most importantly staff morale. Whatever we do, CMOs cannot be allowed to slip into apologists for managerial obstructionism.
Published: 11 Oct 2019