While discussing cholesterol levels and appropriate body mass indexes at my annual physical exam, which really only happens every three or four years, my good-natured primary care physician addressed me with some bristling sarcasm. “You’re just a PINO,” he said to me. “A Physician In Name Only. You’re not a real doctor anymore.” Although we had known each other for years, to him, I was no longer a fellow MD. I was a suit; closer to “them” than to him. He laughed and meant it to be just a good jab at an old friend, but the terminology stuck with me.
There has been a staggering increase in recent years of physicians taking on non-clinical roles, not to mention the increase in physicians pursuing business and management degrees. In the late 1990s, there were only five or six joint MD/MBA programs; a scant collection producing doctors with business degrees. It was a novelty, an expertise that was not much in demand. The current trend of employing “leadership doctors” is evident in the fact that the Association for MD/MBA Programs now lists 54 MD/MBA programs across the United States with an estimated 500 dual degree graduates per year. Business savvy clinicians are inundating our ranks.
More and more organizations are realizing the value of placing a physician in a non-clinical leadership role. To start, physicians are recruited to act as “physician champions,” to gather support from the medical staff for the organization leadership. Second, and more obviously, non-clinical physicians can gather working knowledge of the clinical and physician operations to better the organization.
An important fact to remember when looking at these objectives is that although physician leaders are trained clinically, they genuinely need to get their feet wet and actively work in the clinical setting for some time before having the privilege to speak on behalf of their clinical colleagues, who still practice 100 percent of the time.
A true PINO is inadequately equipped for both physician leadership goals. Either the PINO skipped working in the clinical field and is too green, having gone straight to administrative work, or the PINO has lost touch with fellow clinicians over the years. The PINO will neither hold nor merit support from those working the front lines of clinical care. Moreover, when a physician is not actively working in the clinical setting, his advice is rarely beneficial. The PINO will not have real-world experience, and will not understand the workflow and operations they are asked to advise on. Another possibility is that even if they did work actively in the field at one time, their experience is now dated (“Back in my day...”) Finally, the PINO will never feel the pain that comes from uninformed decisions. The initiation of processes and documentation without a true understanding of its effect on physician workflow is a recipe for disaster.
Avoiding a PINO label is not easy, but safeguards are readily available. A physician leader should maintain his hands-on clinical work. Always. Even if you hold just one clinic, four hours a week, always continue to work as a doctor. There is no better way to earn the respect of your colleagues than to do what they do on a regular basis. This also will instill in you a knowledge of clinic workings and difficulties, making you a more informed physician leader. Understandably, administrative and clinical schedules can be challenging to balance. If you cannot keep a regular clinic, volunteer for coverage, consultations, second opinions, mentoring, or supervising opportunities — anything that will keep you clinically connected. It’s also important to keep on top of the paperwork surrounding the profession. You need to remain on a standing level with your clinical colleagues. Do not drop your board certification. Do not relinquish your medical staff privileges. Do not drop your medical association memberships. All of these items are important to keep you grounded firmly in the clinical setting.
That said, even if you stay active, you should know your limits and surround yourself with good physician advisors. If asked to implement a new process, don’t take advice from other physician leaders, sitting in their own offices with spreadsheets and quality charts. Speak to those who it will affect, those who can provide the greatest insight.
The biggest barrier to breaking out of (or avoiding) the PINO label is fear. Physician leaders are chosen because of stellar performance but what if, when they return to their clinical roots, they are found to be just average? It is difficult to think one is a Senior Physician and yet only an adequate clinician. It is important to remember that the goal of keeping an active clinical base is to accurately represent the physician group. Turn to those who are “better clinicians” and use their knowledge, combined with your leadership and business qualities, to have real influence at any organization.
Most importantly, do not become more comfortable with the suits than with the white coats; if you do, then don’t call yourself a physician.
Kenneth C. Nash, MD, MMM, is a professor of Psychiatry and Vice Chair for Clinical Affairs in the Department of Psychiatry at UPMC. He also serves as Chief of Clinical Services at UPMC Western Psychiatric Hospital. The author would like his readers to know (even if his PCP doesn’t) that he sees patients weekly, takes weeknight calls, and provides vacation coverage for the inpatient units at UPMC Western Psychiatric Hospital. Dr. Nash also teaches a rookie success class for the National Football League.
