There has been a dramatic transformation in American healthcare during the 1990s. The number of physicians in single-person or small-group practices is dwindling. Both healthcare providers and patients are adjusting to larger organizations, and this transition has been difficult for both parties.

As doctors join larger healthcare organizations, there is a need for the organizations to engage their physicians as active players in addressing issues related to the delivery of outstanding healthcare in mid- to large-sized organizations.

Many physicians who are accustomed to a high degree of autonomy in their practice have found it particularly difficult to adapt to the role of "organizational player" when it comes to their involvement in the management of healthcare organizations.

A better understanding of how to engage physicians as full-fledged organizational players is important because:

* Managed care has made it necessary for doctors to understand both the medical and financial implications of their decisions.

* Healthcare organizations are highly politicized systems. Without the support of followers, leaders and operating systems fail.

* Change is so dramatic, uncertain and complex that leaders must have broad involvement and understanding from their physician colleagues.

* The trend to larger healthcare organizations is resulting in greater numbers of physicians to manage.

* Healthcare management is struggling to figure out how to engage physicians on organizational issues.

* The overall job satisfaction of doctors is decreasing.

The future success of healthcare organizations will increasingly depend upon the creativity of their members, and effective leaders of these organizations will be those who find ways to retain their talented staff and support them to do their best, most imaginative work. Five clear patterns emerged in Meridian's exploration of the circumstances and attitudes that diminish physicians' likelihood to work on organizational issues. These include:

1) Working in an organization is necessary, but not desirable for many physicians, especially if it interferes with the quality of patient care.

2) Physicians have a low need for affiliation and thus a low allegiance to their organizations.

3) The nature of physicians' work emphasizes individualism and control and works against effective team play.

4) Non-leader physicians are rated low as followers.

5) Healthcare organizations are managing through an unsettling transition period with inexperienced leadership. Many physician leaders are unprepared for the magnitude of this change.

The practical implications of these patterns reflect these preliminary conclusions:

* Clear and appropriate corporate direction will be paramount for healthcare organizations to survive. Each healthcare organization needs to build a clear vision or "brand identity" and then align everything to that corporate direction. Three of the four healthcare organizations with which we spoke did not have full agreement at the top on their corporate direction.

* If senior managers are unclear about their organization's direction, they will be unclear as to the role of their non-leader colleagues. In many cases, physicians are working on matters that they shouldn't. Physicians should only work on the most complex, strategic issues.

* You get what you reward. Pay is a powerful tool for shaping behaviors and establishing expectations for the kind of involvement organizations want.

* Physician leaders must have the capability to develop followers/organizational players as well as the capability to sell frontline doctors on policy matters. One-on-one relationships offer the best way to persuade physicians to support issues. Many physician leaders have not had adequate experience to deal with the dramatic change occuring in their organizations.

* Many leaders interviewed are operating with commonly-held, traditional assumptions about physicians' role as organizational players. These assumptions -- many of which are drawn from an industrial/business model -- may not be appropriate for healthcare today. For instance, it might be wise to accept that only a fraction of the physicians in an organization are going to be active players. Work on the critical few. Invest in the physicians who can and will make the biggest impact.

* Much more effort and investment needs to be put into developing the roles and skills of leaders and non-leader physicians. A well-articulated roadmap and set of expectations for non-leader physicians is essential.

* Healthcare organizations need to have structures and systems in place that allow physicians to deliver outstanding care to their patients. Physicians spend too much of their time on extraneous matters or are burdened with administrative overload. Patient care suffers.

Healthcare organizations face a daunting task -- to balance new demands in the marketplace with ever increasing and changing regulations while delivering excellent patient care. Success during these times of dramatic change will require extraordinary efforts by all within organizations.