xx AACP Newsletter, Volume 13, Number 1, Winter 1999
President's Column: The Role of the Medical Director in Mental Health Systems
In King County, where I am part of our county mental health system medical directorship, we are having a discussion regarding the role of the medical director as a loyal member of agency administration vs. a professional devoted primarily to our patients and the utmost in quality care. The following letter to Dr. Mark Avery (Medical Director at Valley Cities Community Mental Health) is part of this dialogue:
Dear Mark,
I wanted to go back to a point you made in our brief interchange about sharing openly with our agency executive directors. You had shared how well you work with your CEO at your CMHC and how much support you each give each other. We have all seen your relationship with your CEO as nearly ideal and one that should be modelled throughout the system. Ideally the administrative prerogatives and the clinical prerogatives can come together and differences in perspective will not be conflictual but complimentary. We all want to bring our executives along into deeper understandings of clinical issues and each of us wants to get ever more sophisticated about administrative realities. I don't ever want to be understood to think that there is invariably conflict between the two perspectives. A dialectical tension is not conflict. It can be a source of creativity. It should foster a stimulating discussion which challenges all members of the administrative team making all our jobs enriched.
My point is that the program administrator and the clinical administrator must represent perspectives which are in a natural tension. It is the responsibility and ethic of a program administrator to manage a budget that is always resource poor and to deploy resourses an a way that brings the most good to the most people. Ideal, or even adequate care, for some individuals must, at times, be compromised. A clinician participating in administration has a different responsibility and a different ethic. A clinician comes from the perspective of looking at cases one by one. A clinician must be an advocate for the individual and push the point that each individual deserves respect and optimal care. A clinician is responsible for assuring that scientifically driven clinical wisdom is the basis for quality principles in delivering care. Science, as it applies to clinical care, doesn't easily lend itself to compromise. It is inevitable and healthy that discussions between program and clinically oriented members of an administrative team will embrace the natural tension between the individual and group perspective. Programmatic and clinical perspectives both deserve a voice. I believe it is the responsibility of the medical director to articulate the clinical perspective at the administrative table.
If we as medical directors take the opportunity to articulate clinical idealism on the administrative team, then what can we do to assure that the tension in the clinical/programmatic dialectic does not lead to conflict in our relationships with our directors? First, we should be in constant formal and informal discussions with our executives. We should be respectful of their burdens and be sensitive to what constraints they are under in the frequently harsh realities of our systems. We should become connoiseurs of administration, admiring and respectful of clever ways of running programs with tight budgets. We need to recognize our CEO's for making skillful moves in their difficult management dance. We should offer thoughtful suggestions when they seem to be failing to ballance program survival with the needs of the clientele. It is our job to create a climate where we can speak to the ideals of respect for individual patient needs and state of the art clinical quality. Yet it is our job to handle sometimes harsh realities and support necessary tough decisions while keeping the ideals alive. It is sometimes our duty to assure that our CEO's keep in mind that reality based decisions are not going to enhance quality clinically. Such a recognition may often demand that some energy from the administration be expended advocating for improved funding or rule changes in our sponsoring entities so as to restore quality. We may at times not be appreciated for these reminders. We are vulnerable for being discounted as hopeless idealists. But there isn't a one of the CEO's I know in our system who doesn't have the idealist embedded deep within them. If we skillfully draw that out of our executives, and enable them to feel better about their work role, we will be admired. Good clinical imput into administrative decision making should assure that the utmost is done to manage resourses so as to create for our patients the most humane, client centered, family oriented, culturally competent and quality oriented service feasable.
I hope this clarifies my position which I assume is not that different than yours. As we have encountered some confusion and faltering in the discussion of medical direction in our system I would like to propose that these understandings and principles form the basis of our suggestions regarding our roles with our executive directors. Clearly our system needs to clarify and enhance the role of medical direction in our system. This will be good for everyone; the psychiatrists, our program administrators at all levels and, most important, our patients.
Charles Huffine, MD
President