Letters to the Editors

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Physician leader should create knowledge-sharing organizational culture TO THE EDITORS: I wish to comment on the article by Chervenak et al.1 dealing with ethics and power relationship of physician leaders in obstetrics and gynecology. The authors drew on three famous historic figures to elucidate the dimensions of authority and power, as well as of leadership systems within institutions, a project surely of interest to scientific readers. However, the authors did not address the following: 1) are ethics actually neglected in this professional society or its associated hierarchical system?; 2) what are the requirements and elements of professional ethics befitting such a professional society?; and 3) how did they construct the system of ethics? Organizational culture could be one influencing factor, but a series of stepwise processes, such as organization policy, mission, vision, and value, and strategic planning, as well as leadership type and management way of doing things, could be the real factors that get things done. I was wondering which type of physician leader could survive in academic medical center now. Under the era of cost containment and the escalation of medical expenditure in health care, would research pressure discourage the inspiration of a moral ideal of teaching or self-sacrifice devotion in clinical practice? Gregorian leadership pays heed to the virtue of integrity and moral excellence— but it should be based on self-discipline and mutual trust and a knowledge-sharing organizational culture. For a Gregorian leader, it is difficult to resolve the “accurate” resource allocation,2 gain-sharing, increasing physician fee, and add up physicians’ beneficiary and compensations. For the next step to transform organizational culture for physician leaders, I suggest the Five-Step Model of Skinner3: 1)

develop motivation for change; 2) strengthen organizational capacity for improvement; 3) identify strategic directions in prevention and behavioral health care; 4) conduct a critical functions analysis; and 5) improve performance using rapid cycle change and tools. To transform organizational culture can seem an endless effort for physician leaders in an uncertain and competitive health care institution. It may be that the ethics of profession and corporate culture are not neglected by physician leaders, but rather are simply seen as a view or perspective, norm, or life style incorporated into the way of academic thought and doing. f Ching-Ming Liu, MD, MPH Department of Obstetrics and Gynecology Chang Gung Memorial Hospital, Linkou Medical Center Chang Gung University College of Medicine No 5, Fu-Hsin St., Kweishan Taoyuan 333, Taiwan [email protected] REFERENCES 1. Chervenak FA, McCullough LB, Baril TE. Ethics, a neglected dimension of power relationship of physician leaders. Am J Obstet Gynecol 2006;195:651-6. 2. Longest BB, Rakish JS, Darr K. Managing health services organizations and systems. 4th ed. Baltimore, MD: Health Professional Press; 2000;469 – 89. 3. Skinner HA. Promoting health through organizational change. San Francisco, CA: Benjamin Cummings (Pearson Education); 2001;149 –58. © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.11.014

REPLY We thank Dr Liu for responding to our article. It was beyond the scope of our article to provide a history of medical ethics. Suffice it to say that ethics has been part of the history of medicine from the earliest times in cultures around the world.1 We drew on Hobbes, Hoffmann, and Gregory because of their pertinence to the ethical challenges of physician leaders today. The history of medical ethics is not only of scholarly interest; it also provides powerful concepts that physician leaders can use to responsibly shape organizational culture. Dr Liu asks a very timely question: which type of physician leader could survive in an academic medical center now? This is a judgment, we believe, best left to each reader—and the answer will provide an ethical diagnosis of the state of his or her center’s organizational culture. Whether the reader should be pleased (Gregorian culture), concerned (Hoffmannian culture), or dismayed (Hobbesian culture) is likewise a judgment that we entrust to the reader. Finally, Dr Liu invokes the Five-Step Model for transformational change. This is a useful tool for physician leaders to use, but only if they can make a reliable account to their colleagues of the changes that should be made in their academic medical center. e12

American Journal of Obstetrics & Gynecology APRIL 2007

Ethics is essential for making such an account. It is more important to know what changes physician leaders should be pursuing—at least Hoffmannian and better Gregorian, in our judgment—than to know processes for change. Put another way, the questions of “who decides” is very important, but “what should be decided” is in all cases the more fundamental question confrontf ing physician leaders. Frank A. Chervenak, MD Weill Medical College of Cornell University 525 E. 68th St., Box 122 New York, NY 10021 Contact Dr Chervenak at [email protected] Laurence B. McCullough, PhD Baylor College of Medicine Houston, TX REFERENCES 1. Jonsen AR. A short history of medical ethics. New York: Oxford University Press; 2000. © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.11.015