Issue 46 / 2 December 2013

THE relationship between administrators and clinicians in health care has much in common with the biblical quote underpinning the separation of church and state: Render therefore unto Caesar the things that are Caesar’s; and unto God the things that are God’s.

In the case of health care, doctors most likely consider themselves as God and administrators as the more fallible Roman emperor.

There is a common belief among corporate and hospital hierarchies that doctors make substandard bureaucrats or executives. Having trained for a decade and a half in a highly technical, clinical environment that is short on business, budget and management experience, doctors are seen as ill equipped for the entirely different skill set of management.

This is further entrenched by the negative attitudes many doctors have towards administrators, with doctors who do move into management roles seen as “going over to the dark side”.

But there is growing evidence from management firms, especially in American health care organisations, that the best run facilities with regards to cost management and clinical excellence have doctor–managers.

A recent joint London School of Economics and McKinsey report titled “When clinicians lead” found that hospitals with the greatest levels of clinician participation in management scored about 50% higher on important measures of performance, such as safety, cost and patient satisfaction, than those with the lowest levels.

Importantly, the authors found that doctors incorporated a sense of efficiency and accountability into their daily work.

Doctors are trained to focus squarely on treating disease. I was taught from day one of university to do everything in my power to cure, heal or advocate for the patient in front of me. But what about the patient who is not in front of me?

British health economist Roger Taylor  discusses this topic in his recent book God bless the NHS. He holds that doctors must better incorporate the “patient in the waiting room”, by which he means being mindful of the limited resources available to treat both the patient in front of you, as well as all other potential patients.

Much like the McKinsey report, Taylor notes that when doctors are more engaged with the financial management of the system, there can be a range of insights and improvements in incentives that may not be apparent to non-medical administrative staff.

While health policy took a back seat in the lead-up to the recent federal election, reining in the ballooning costs of health care in the face of ageing populations, costly new medical technologies and a demanding public will remain one of the greatest challenges for Western governments.

I spoke to Dr Emma McCahon, a Sydney paediatrician leading the way in bridging the gap between administrators and clinicians, about the doctor’s role in management. She is in charge of patient flow at Sydney Children’s Hospital and runs a leadership and management program for junior doctors through the NSW Department of Health.

“Doctors tend to hide behind patient care and not take too much interest in the management side”, she told me. “You just can’t implement programs in quality or safety without having people who can really negotiate with doctors on the ground — all the evidence overseas points to involving clinicians in the management side.”

However, Dr McCahon says most doctors “simply don’t see the whole range of players involved in the delivery of health care, from the nurse to the person folding out the linen. They also know nothing about cost”.

Mary Ditton, a senior academic in health management at the University of New England, told me administrators “are too undermined and poorly respected in the health care chain”. Sending a clear warning to the medical profession, she says the “industrial dominance of doctors in Australia is increasingly becoming an anomaly in the Western world”.

Dr McCahon says the essential cultural shift to more doctor involvement in management will take decades and believes it will happen from the bottom up. But she warns that doctors risk further whittling away of their authority if they, as a professional group, do not lead the community to rein in health costs.

This needs to occur in our discussions with patients and their treatment decisions as well as in our interactions with administrators.


Dr Tanveer Ahmed is a Sydney psychiatrist, author and local government councillor.

Dr Ahmed has given an assurance to MJA InSight that this is his original work.


6 thoughts on “Tanveer Ahmed: Born to rule

  1. Ian Haywood says:

    I note the comments above talking about RACMA, In psychiatry we often suffer because for historical reasons we have separate medical-administrative hierachy, (who are psychiatrists but usually aren’t FRACMAs, and so, although well meaning often are “outmanned and outgunned” by the rest of the hospital system), I think we would be better off if we let ourselves be managed by the medically-trained, albeit non-psychiatrist general hospital administrators.

  2. Tony Sara says:

    Dr Ahmed might conceivably gain a deeper understanding of the divide between doctors and administrators from a perusal of the Garling report which went into this topic in some depth.

  3. tom gavranic says:

    Growing up in far North Queensland in the 1940s, I remember the matron and visiting doctor doing inpatient rounds together and then having a meeting with the hospital secretary over a cup of tea, before I was seen in the outpatient clinic. I daresay they would also report regularly to the hospital board, with its public representatives. So why has it proven so difficult to upscale this style to cope with the modern era? Perhaps we should be listening more to Schumacher’s “Small is Beautiful” than to our megacorporations with their economic rationalism? 







  4. Sally Tideman says:

    RACMA offers a wide range  of options to doctors wanting to gain insight and credentials in the area of medical leadership/management and administration.

    The Fellowship  trains for a career in  professional medical administration. The Associate FRACMA enables clinicains who have an interest, or find themselves leading a Department etc – to gain skills and competency whilst continuing their clinical committments.

    The article by O Sullivan and McKimm( British Journal of Hospital Medicine Nov 2011 Vol 72 No 11 Medical Leadership:an international perspective) speaks to the inter-relatedness of medical engagement-medical leadership and successful implementation of health service improvements. Numerous UK articles and in particular the  work of Chris Ham and team supports the crtitical naure of the  medical leadership-medical engagement link.

    A Workshop delived by RACMA to Emergency Physicians in Adelaide 24th Nov- and the feedback from participants speaks to the unmet need – medical staff wanting to get involved and be engaged and making a difference in manageing health,leading their teams and and providing excellent care in a system they understand.


  5. Department of Health Victoria Clinicians Health Channel says:

    The fact that Doctors are not trained for management or even to conduct their own practices as businesses is a failing in our medical education.
    Most practitioners learn “along the way”, which is risky or purchase that knowledge from others, which is expensive.
    Managing larger more complex organizations such as hospitals and health systems requires specialised and broad training and study in areas foreign to most doctors. The basic underpinning is a medical background and clinical experience on which to draw.
    Involvement of doctors in local and system wide decision making is essential if the care provided to patients, communities and nations is to improve.
    All medical colleges now conduct leadership and management training often using RACMA as a specialist resource.
    The “them and us” view of management by clinicians is changing with the contribution of exceptional medical managers and medical leaders – in m y view it will continue to develop as a healthy and positive collaboration for the benefit of us all.

  6. Gavin Frost says:

    For over 40 years now  the Royal Australasian College of Medical Administrators as a recognised specialist College had been providing just this leadership training for medical practitioners who see just this benefit to the health system from medical leadership 

    For further information check out

Leave a Reply

Your email address will not be published. Required fields are marked *