Leading beyond the bottom line, Part 4. The questions it has raised.

The Leading Beyond the Bottom Line article series has received an overwhelming response from ACPE members, mostly in enthusiastic support of this new leadership concept. Some of the important questions raised by members are presented with answers from the authors. This article also explores the moral challenge of leadership and why health care is more than a business. In recent years, there's been confusion about the role of the health care enterprise, its leadership and its management. We have lost our way about the "moral" thing, the "right" thing, because we have no philosophy to guide us. To manage or lead in this "business" of health care, a philosophy is required that recognizes the multiple elements to which the leader has responsibility and obligations: the customers, community, employees, and, certainly, the financial assets.

Leading beyond the bottom line.

Do physician executives approach managing and leading health care organizations like a CEO of a Fortune 100 company? Or does their training as physicians first give them a unique perspective, leading them to view organizational issues differently? The authors suggest that to be a physician executive is to be the practitioner, teacher, coach, and mentor for a new philosophy of leadership and management called Leading Beyond the Bottom Line. While the financial health of an organization is critical to its survival and its ability to fulfill its purpose, the trap is to focus on maximizing the bottom line. This new philosophy leads an organization to attend in equal measure to the (1) welfare of its patients, (2) its financial health, (3) the well-being of its employees, and (4) the building of its community. "The Optimal Organization" is one in which these four objectives are seen not only as related, but interconnected, and the goal is to maximize all of them. The legitimate role of the physician executive is to manage in search of Pareto Optimum, or the maximum benefit for all four organizational objectives. Clearly, this is a tougher job than maximizing profits or just optimizing profits and patient care.

Leading beyond the bottom line: organizational assets for the new economy. 2.

Organizations are created to aggregate resources to accomplish some purpose, be it to provide health care, raise a family, or build cars. These resources are assets. A manager has a fiduciary responsibility, by practice, and, in many cases, by law, to make the best use of those assets. Traditionally, we've evaluated the use of assets through financial statements. The troublesome aspect of these financial statements is that they were designed to measure only those things that can be counted simply--financial and physical assets. But our world has moved from an industrial, manufacturing age to an information, service economy and we are learning that intangible assets are as powerful--potentially more powerful--in creating value as are tangible assets. Recognizing the intangible asset value of employees, customers, and the community is the challenge in this new service economy. Effective health care leaders need to leverage and manage all of an organization's assets.

Innovative leadership: generating ideas.

One of the most challenging functions a physician executive performs is being an innovator--coming up with new ideas to keep ahead of the pack and to solve problems that need fresh solutions. Robert Hodge, MD, CPE, FACPE, and Barbara Linney interviewed Roger Schenke, Executive Vice President of the American College of Physician Executives, and gleaned seven pointers that you might consider to help generate a flow of new ideas or when you get "stuck." They are: (1) read voraciously and link unlike things together; (2) talk to people whose circle is bigger than yours; (3) stop thinking about the problem and focus on something else; (4) care enough to keep wrestling with a problem and not give up; (5) stay open to new ideas even if they are uncomfortable; (6) be willing to risk and take chances; and (7) find a place to carry out the ideas.

Sexual function of women taking antihypertensive agents: a comparative study.

OBJECTIVE: To develop a method to evaluate the effects of clonidine and prazosin on sexual function in hypertensive women. DESIGN: Crossover, active-drug controlled pilot study. SETTING: Community recruitment to a university-based teaching hospital. PATIENTS: Ten premenopausal and eight postmenopausal women with mild hypertension and unimpaired sexual function. INTERVENTION: Periodic, self-administered daily diaries assessed the sexual arousal and desire and orgasmic function of women receiving placebo, clonidine, and prazosin. MEASUREMENTS AND MAIN RESULTS: Using analysis of variance for orgasmic characteristics and comparison of the percentages of yes responses to the sexual function questions, no significant difference in the levels of sexual function of women receiving placebo, clonidine, and prazosin was found. However, there was a suggestion that clonidine and prazosin affected some aspects of sexual function. Of the women who received clonidine first, fewer were receptive to partner approach during medication therapy (49%) than during placebo (61%). Fewer women wished for their partners to approach them (WISH) during therapy (41% and 53% for clonidine and prazosin, respectively) than during placebo (60%). In the group that received prazosin first, WISH was affected (32% for prazosin, 31% for clonidine, 45% for placebo). Orgasmic strength increased from 2.1 on placebo to 2.7 on clonidine (second medication), measured on a four-point Likert scale. CONCLUSIONS: This pilot study developed a method using self-administered daily diaries for evaluating the effects of antihypertensive agents on sexual function in hypertensive women. These potential effects need to be evaluated in larger studies.

Improving preventive care at a medical clinic: how can the patient help?

We developed a comprehensive individualized preventive care reminder system and then tested the hypothesis that directly involving patients in the reminder process would lead to greater use of preventive services than involving physicians only. There were three experimental groups of 350 patients each: in group 1 physicians and patients received the reminder; in group 2 physicians only received the reminder; in group 3 neither physicians nor patients received the reminder. Nine preventive care services were studied: blood pressure measurement; dental exam; ocular pressure measurement; stool exam for occult blood; influenza, pneumococcal, and tetanus vaccinations; mammography; and Papanicolaou smears. Need for these services was determined by telephone interview and chart review. To determine whether services were obtained, charts were reviewed after four to eight months of follow-up. For overall compliance with preventive recommendations and for several individual services (stool exam for occult blood, tetanus vaccination, mammography), group 1 patients received significantly more preventive care than group 2. Likewise, group 2 patients received more preventive care than group 3. These data show that involving patients in reminder efforts is an effective means of raising the level of preventive services.

Premium will continue to be on performance. Interview by Wesley Curry.

With a new name for its professional organization (the American College of Physician Executives) and a new certifying organization (the American Board of Medical Management), the profession of medical management is in the throes of significant and far-reaching change. At the College's National Conference in Washington, D.C. in May, we talked to two leaders of the profession, Michael B. Guthrie, MD, MBA, FACPE, and Robert H. Hodge, Jr., MD, FACPE about what the future holds for physician executives and what physician executives can do to position themselves for success. Dr. Guthrie, the Immediate Past President of the College is Vice President for Business Development, Penrose/St. Francis Healthcare System, Colorado Springs, Colo. Dr. Hodge, the new President of the College, is a Program Director, W.K. Kellogg Foundation, Battle Creek, Mich.

Double-blind crossover comparison of piroxicam and naproxen in the treatment of active osteoarthritis.

Since the initial marketing in the early 1970s of the nonsteroidal anti-inflammatory agents of the propionic acid type, there has been a gradual escalation of the dosage recommendation for each of these drugs. In contrast, the dosage recommendation for piroxicam has remained constant. In this 12-week, double-blind crossover study, the standard dose of piroxicam 20 mg/d has been compared with the newly recommended dosage of naproxen 500 mg twice a day in 19 patients with active osteoarthritis. In the piroxicam treatment interval, there was statistically significant improvement in six of nine clinical parameters as compared with five of nine clinical parameters for the naproxen treatment interval. Adverse experiences with both drugs were mild to moderate. Both piroxicam and naproxen resulted in statistically significant improvement in right grip strength, the time to walk 50 feet, daily activity assessment, and in the total joint pain. In addition, piroxicam resulted in statistically significant improvement in both the physician and patient assessment of disease activity. Naproxen treatment was associated with a statistically significant decrease in total joint swelling.

Incidence of 24-hour faculty coverage in teaching EDs.

There is growing concern in academic emergency medicine as to the appropriateness of 24-hour faculty coverage in the teaching emergency department. We surveyed 170 teaching emergency departments, 49 of which had approved emergency medicine residencies, asking for information regarding 24-hour faculty coverage. We were able to separate each department into one of 15 profiles based on the two variables of average ED yearly census and hospital type. Seventy-three percent of university teaching hospital EDs and 65% of those with emergency medicine residencies have 24-hour faculty coverage; 83% of private teaching hospital EDs and 100% of those with emergency medicine residencies have 24-hour faculty coverage; and 79% of city/county teaching hospital EDs and 80% of those with emergency medicine residencies have 24-hour faculty coverage.

Pulmonary function testing in a general medical practice.

This study examined the feasibility and yield of spirometric screening in a general medicine clinic. Each of 354 randomly selected patients answered a questionnaire on respiratory symptoms and performed pulmonary function tests. Pulmonary testing required approximately two minutes and cost 95 cents per patient. Former smokers who stopped smoking because of symptoms displayed a higher prevalence of abnormalities than expected, and life-long smokers a lower prevalence (P less than 0.001). Fifty-three percent of current smokers had an abnormal pulmonary function test, and forty-two percent of these had no severe pulmonary symptoms. Pulmonary function tests performed in an outpatient clinic are rapid and expensive. Such tests demonstrate a large number of abnormalities which can be used to encourage smoking cessation.

Diabetic care: an integrated subspecialty and primary care approach.

The University of Virginia Department of Medicine has reorganized its adult diabetic ambulatory care program to provide optimal primary care and subspecialty services. This new program, the Diabetes Consult Service of the University Medical Associates, is organized to provide primary care by a single physician in addition to subspecialized medical, podiatric, educational, and nutritional services for each patient. The system avoids many of the common problems encountered in providing care to adult diabetics in a university hospital setting ahd has been well accepted by both patients and providers.

Resistance among fecal flora of patients taking sulfamethoxazole-trimethoprim or trimethoprim alone.

Because of the widespread occurrence of resistance to sulfonamides among Enterobacteriaceae, some researchers have suggested using trimethoprim (TMP) alone instead of the combination sulfamethoxazole-trimethoprim (SMX-TMP) in treating infections with TMP-susceptible organisms. To answer whether SMX-TMP suppresses the emergence of resistant organisms compared with TMP alone, quantitative fecal cultures were made for total and TMP-resistant organisms before, during, and after SMX-TMP (800/160 mg twice a day) or TMP (200 or 100 mg twice a day) was given to 48 patients for 4 weeks in a prospective, randomized study. All three regimens left anaerobes intact and reduced the total aerobic coliform fecal flora by approximately 4 logs throughout the 4-week treatment period. In 11 of 19 (58%) patients taking TMP 200 mg twice daily, TMP-resistant organisms emerged or increased during therapy (P less than 0.01, compared with none of the 12 controls), whereas in only 4 of 18 (22%) patients on SMX-TMP did TMP-resistant organisms increase. These TMP-resistant organisms increased by less than 1 log and were predominantly Pseudomonas and Acinetobacter species. In only one instance did an SMX-TMP-resistant Escherichia coli strain emerge after 4 weeks of SMX-TMP therapy. The slight increase in Pseudomonas and Acinetobacter species seen with TMP alone in this study raises a potential risk of giving TMP alone in settings where these organisms may cause serious infections, as in immunosuppressed patients.

Multiple use of disposable insulin syringe-needle units.

Fourteen insulin-dependent diabetics were asked to use their insulin syringe-needle units three times in succession to determine the efficacy and safety of this practice. The mean duration of time each patient participated in the study was 20.4 weeks, and a total of 2,000 injections were taken. No signs of infections at the injection site were observed. Multiple use of disposable insulin syringe-needle units appears to be safe and cost beneficial.

Estimating compliance with diuretic therapy: urinary hydrochlorothiazide-creatinine ratios in normal subjects.

We gave 21 healthy young men 100 mg of hydrochlorothiazide daily to determine whether or not urinary detection of the drug was feasible as a measure of compliance on a standard antihypertensive regimen. All subjects took the drug daily for 6 days, after which they were divided into four groups with differing patterns of medication administration. Urine hydrochlorothiazide and creatinine measurements were obtained to validate the urinary hydrochlorothiazide-creatinine ratio (UHCR) as an accurate quantitative index of compliance. The subjects achieved a constant level of UHCR of 13 +/- 3.0 within 48 hours of hydrochlorothiazide administration. The UHCR levels decreased to 5.0 +/- 0.8 48 hours after discontinuation of the drug (p less than 0.001). UHCR values in the range of 13 +/- 6 indicate that the subject has ingested hydrochlorothiazide 24 hours previously. The UHCR is a potentially useful means of assessing compliance in hypertensive patients taking hydrochlorothiazide.

Reducing ward-clinic conflicts by rotational scheduling of house staff.

Many internal medicine residency training programs are being modified to permit each resident to gain more outpatient experience, including providing continuous care to a defined panel of patients for three years. Increasing emphasis on these outpatient responsibilities and education, however, places demands on the resident that conflict with his responsibilities on the inpatient wards. In this paper the authors describe the development and implementation of a rotational scheduling system aimed at substantially alleviating the conflict between inpatient and outpatient responsibilities. During the first year of operation 84 percent of house staff members indicated their preference for continuing the system in future years.

Electrocardiographic changes associated with multiple yellow jacket stings.

A previously healthy 38-year-old man was stung multiple times by yellow jackets without any signs of anaphylaxis being observed. An electrocardiogram taken 16 hours later revealed episodes of wandering atrial pacemaker, junctional rhythm, and intermittent premature ventricular contractions. These arrhythmias disappeared spontaneously.

Equestrian injuries. Results of a prospective study.

In a prospective study involving 110 injured equestrians, there were no noteworthy correlations between age, sex, or experience of the amateur riders and injury occurrence. Tack failure caused several injuries. Among fox hunters the incidence was related only to frequency of hunts. The most common severe injury was to the head, associated with lack of headgear. Fewer than 20% of the 110 riders used a protective helmet. There were four renal contusions and one bladder laceration. The most frequent injuries were fractures of the upper extremities. Wearing a good-quality protective helmet and checking tack are important for injury prevention.