Examples of recent posts about the risks posed by domain neutral biomedical leadership are:
"NY Times Proclaims Anyone Can Run a Health Care Organization with a Little Studying Up" (Poses)
"Health Care Leaders: Don't Know Much About Health Care" (Poses)
"On Optimal Expertise for Leadership in Biomedicine" (me)
"Informatics, or Infomagic? Health IT Cannot Flourish When Everybody is an Expert" (me)
and "Pfizer/Wyeth Merger And Sacrificing The Future: Laying Off Scientific Staff All Over The Place" (me).
I have also written of a cross-occupational invasion of healthcare by the IT profession, in the form of power and territorial grabs over clinicians with regard to the tools clinicians increasingly need in order to provide patient care.
These leadership inversions, where domain neutral personnel are viewed as best able to lead any endeavor as if the world consists of interchangeable, faceless resources following equally interchangeable processes, are due to attitudinal laxity and permissiveness on the part of medical leadership, a takeover of healthcare by those with primary pecuniary interests, and perhaps a lack of appreciation for the value of domain expertise as sign of a waning western culture.
In a recent hospital CIO interview, in this case of CIO Avery Cloud at New Hanover Regional Medical Center in Wilmington, NC, we see both of these elements - supportive views towards healthcare leadership by domain amateurs, and towards a cross-occupational invasion of healthcare by IT personnel - combined:
Q: Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?I'm sure CIO's would like to think that they could "run any of the departments in a hospital."
A: That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.
I’d like to think that I could run any of the departments in this hospital [wow - ed.] A good example is that nobody is surprised when the CFO runs the pharmacy department [i.e., nobody in this CIO's limited circles - ed.], or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same [In fact, it likely would be a big surprise to many -ed.] A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division [this is, in fact, stunning and should be a cause of great concern to healthcare regulators if true - ed.]
(How about: Legal? Risk management? Health Information Management a.k.a. Medical Records? Biomedical engineering? Nursing? Trauma? Diagnostic Imaging? Neurosurgery?)
The question is this: is this a realistic view? Or, is it an extreme form of hubris and the Dunning Kruger effect? Can they run complex departments far outside their core competencies optimally? Or will they more likely be running an area they know little about by the seat of their pants?
Further, do leadership roles in organizations such as NIH or the Centers for Disease Control call merely for an MBA and domain neutral backgrounds? If not, why not?
Why are hospitals exempt from a requirement for domain specific expertise in their leadership?
As to CIO's (and, for that matter, CFO's) running hospital pharmacies, let's show the knowledge gaps graphically by first exploring the prerequisite training of a typical Pharm.D. pharmacist:
Professional Degree (Pharm.D. Degree) Curriculum
Class of 2011, 2012, & 2013
(Admitted Fall 2007, 2008 & 2009)
First Year, Fall Semester
NBAN 301 Principles of Human Anatomy 3 credit hours PSIO 743 Fundamentals of Physiology 5 credit hours PHAR 700 Pharmacy as a Profession 1 credit hour PHAR 701 Pharmaceutical Care Lab 1 2 credit hours PHAR 702 Physical Pharmacy 3 credit hours PHAR 703 Intro Pharmacy Practice Experiences 1 1 credit hour PHAR 720 Patient Health Education 2 credit hours Total hours 17 hours
First Year, Spring Semester
BIOC 531 General Biochemistry 4 credit hours PHAR 708 Pharmaceutics 3 credit hours PHAR 709 Immunology and Biotechnology 2 credit hours PHAR 710 Intro Pharmacy Practice Experiences 2 1 credit hour PHAR 711 Chemical Properties of Drugs 2 credit hours PHAR 712 Pharmaceutical Care Lab 2 2 credit hours PHAR 737 Disease Prevention and Health Promotion 2 credit hours Elective 2-3 credit hours Total hours 18-19 hours
First Year, Late Spring – after spring term concludes
PHAR 714 Introductory Community Rotation (2 weeks) 2 credit hours
Second Year, Fall Semester
PCOL 743 Pharmacology 1 3 credit hours PHAR 715 Pathophysiology & Therapeutics 1 4 credit hours PHAR 716 Chemistry of Drug Action 1 3 credit hours PHAR 717 Intro Pharmacy Practice Experiences 3 1 credit hour PHAR 723 Pharmaceutical Care Lab 3 1 credit hour PHAR 727 Medical Literature Evaluation 2 credit hours Elective 2-3 credit hours Total hours 16-17 hours
Second Year, Spring Semester
PCOL 744 Pharmacology 2 3 credit hours PHAR 719 Intro Pharmacy Practice Experience 4 1 credit hour PHAR 724 Pharmaceutical Care Lab 4 2 credit hours PHAR 725 Pathophysiology & Therapeutics 4 credit hours PHAR 726 Chemistry of Drug Action 2 2 credit hours PHAR 728 Pharmacy Management 2 credit hours Elective 2-3 credit hours Total hours 16-17 hours
Second Year, Late Spring – after spring term concludes
PHAR 729 Introductory Institutional Rotation (2 weeks) 2 credit hours
Third Year, Fall Semester
PHAR 730 Pathophysiology & Therapeutics 3 4 credit hours PHAR 731 Biopharmaceutics & Pharmacokinetics 3 credit hours PHAR 732 Non-Prescription Drugs 3 credit hours PHAR 733 Pharmacy Systems 2 credit hours PHAR 735 Pharmaceutical Care Lab 5 1 credit hour PHAR 742 Intro Pharmacy Practice Experiences 5 1 credit hour Elective 2-3 hours Total hours 16-17 hours
Third Year, Spring Semester
PHAR 734 Pharmacy Law and Ethics 3 credit hours PHAR 736 Pharmaceutical Care Lab 6 1 credit hour PHAR 738 Outcomes Assessment/Quality Improvement 2 credit hours PHAR 739 Therapeutic Patient Monitoring 3 credit hours PHAR 740 Pathophysiology & Therapeutics 4 4 credit hours PHAR 741 Clinical Pharmacokinetics 3 credit hours PHAR 746 Intro Pharmacy Practice Experiences 6 1 credit hour Elective 0-2 credit hours Total hours 17-19 hours
Students complete eight five-week experiences beginning in the summer preceding their fourth year. Students will have required experiences, such as ambulatory care and acute care, and elective experiences.
Students are required to complete at least 10 professional elective hours selected from an approved course list during their first, second, or third professional year and prior to fourth year experiential rotations. With the exception of Fall semester in the first professional year, one elective can be taken each semester of the didactic program. Electives are intended to complement the required curriculum and allow students to select courses based on professional interests. Students wishing to take electives during summer terms may do so after their first professional year on any of the campuses in the WVU system (Morgantown, Parkersburg, Potomac State, West Virginia Tech) provided the courses are selected from the list of professional electives or are deemed equivalent by the University. Students wishing to receive course credit for courses taken outside of the WVU system must have pre-approval by the Curriculum Committee.
Of course, even assuming no requirement for a Dissertation defense (which is a typical Ph.D. requirement), the candidate needs to take state and/or federal exams for licensure:
Licensure. A license to practice pharmacy is required in all States, the District of Columbia, and all U.S. territories. To obtain a license, a prospective pharmacist must graduate from a college of pharmacy that is accredited by the ACPE and pass a series of examinations. All States, U.S. territories, and the District of Columbia require the North American Pharmacist Licensure Exam (NAPLEX), which tests pharmacy skills and knowledge. Forty-four States and the District of Columbia also require the Multistate Pharmacy Jurisprudence Exam (MPJE), which tests pharmacy law. Both exams are administered by the National Association of Boards of Pharmacy (NABP). Each of the eight States and territories that do not require the MJPE has its own pharmacy law exam. In addition to the NAPLEX and MPJE, some States and territories require additional exams that are unique to their jurisdiction.
(I can add that the typical M.D. curriculum, such as at the medical school I attended, is even more rigorous. That is prior to the medical internship, residency, and postdoctoral fellowship(s) most physicians also must perform, where they become intimately familiar with the services of many hospital departments).
Now, let's explore the comparable pharmacy science/biomedical training of the typical hospital CIO or CFO (or CEO for that matter):
(This, of course, is the mathematical symbol for the null set.)
... So what is missing? There seem to be two obvious areas that are not taught.The first is health care. There are only two courses in this curriculum on "healthcare policy" and "healthcare management." ... The second area missing is ethics, particularly the business ethics of health care. There are simply no courses even remotely related.
In the first of my posts linked above I wrote:
... Those in charge [and who lack domain credentials -ed.] cannot see that which the domain specialist sees.
They cannot see because they lack the training, experience, and what is described as 'meta-competence' (in this brilliant article on competence [the Dunning-Kruger effect - ed.]) essential to seeing that which is obvious. Obvious, that is, to those who do not lack these characteristics. In addition, I've also observed that some lack the fundamental analytical abilities essential to understanding and managing the complexities of biomedical R&D.
Why those without domain expertise are in charge of organizations whose long term viability depends entirely on the most advanced and creative pursuit of biomedical 'miracles' [i.e., pharma - ed.] is another matter. I won't address this here, other than saying it reflects the adverse consequences of a bias that has evolved in management "science."
That bias is the belief that all the world consists of faceless labor resources performing easily definable processes upon interchangeable widgets, and that management can therefore be done by generic managers, exclusively. Some of the world is like that [i.e., fast food chains - ed.], but some isn't, such as biomedical R&D. [And clinical medicine as well - ed.]Management in the absence of domain expertise in this industry is, in fact, mismanagement.
There is nothing here to spin, there is nothing to debate. There is nothing to discuss. This is a first principle.
Failure to accept this reality results in corporate failure.
These views apply to hospitals perhaps even more critically than to biomedical R&D. In hospitals, mistakes in judgment can result in great patient harm, and far more rapidly than in an R&D organization.
Finally, in the same CIO interview there's this:
Q: If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?
A: I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one ... So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.
The fact that this "customer is king" advice seems to merit constant repetition among healthcare IT leadership circles, especially when the “customers” are clinicians with patient care obligations and responsibilities, should be a cause of deep reflection and introspection among those in HIT. At the very least, they need to ask themselves - and healthcare professionals need to ask them - "who are you, and what are your motives for stepping foot in our hospital?"
It is also such a fundamental first principal that its frequent repetition suggests typical hospital CIO's are not truly fit in 2009 to lead anything in healthcare where domain expertise and viewpoints are essential, healthcare IT included. Its need for frequent repitition - dating to many HIT publication I've seen since I entered the Medical Informatics field professionally in the early 1990's - suggests they don't truly recognize that the business of hospitals is taking care of patients, the clinicians being the enablers of that business, everyone else being facilitators. The known problems and failure rates of heath IT in hospitals is corroborative of that view.
Healthcare reform will certainly require healthcare leadership reform, and the first task of that reform should be a re-evaluation of expertise required to tamper with people's lives and well being in a hospital setting.