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A Generational Thing

by Emily Friedman

First published in Hospitals & Health Networks OnLine, June 5, 2007

As is happening throughout society, a generational shift is occurring in health care. Significant numbers of nurse leaders, physicians, CEOs and board members are retiring or nearing the end of their careers. What impact will this change have, and will health care win or lose as a result?

Certainly anyone could have seen it coming: When 76 million people are born in one 18-year period (in this case, 1946 to 1964), they are going to be a formidable force in society. Much has been written about the baby boomers and their impact over the years.

A Change in the Profile

My focus is on one particular dynamic that involves not only the boomers, but also the generation that preceded them, the one often referred to as the Greatest Generation--those who lived through the Depression and World War II. Most members of that generation who served as health care leaders have retired, but their profile is pretty consistent: The vast majority of them were white men; some had master's of health administration (MHA) degrees. (This was a change from 50 years earlier, when many hospital administrators were women who were either members of religious orders or laboratory technicians or nurses.)

Those who came after were also largely white men (the major exemptions were executives in the public sector and Catholic hospitals and systems). They were even more likely to have MHAs, but where they studied had changed; many MHA programs, once largely based in schools of public health, had moved into business schools. Indeed, the joint MHA-MBA was very much in vogue, and with it came an increasingly commercial view of health care.

Gone were the administrators who had worked their way up the ranks by serving in lower-level jobs in small hospitals; now hospital and health system leadership was a formal profession, and those who were not properly educationally prepared were, for the most part, shut out. Their replacements were part of the MHA-prepared future.

Meanwhile, other changes were afoot. It had once been common for a person to achieve the rank of CEO at a hospital or health system or hospital association and serve in that capacity for decades. Those folks are few and far between these days; whether it is because of board unrest, acquisition of a hospital by a system, scandal or ambition on the part of others, these CEO-for-a-lifetime people are a rare breed, and, in my opinion, headed for extinction.

What Does the Future Look Like?

So what will the new generation of health care leaders look like?

Demographically speaking, there are more women in high places. The director of research of the American College of Healthcare Executives (ACHE), Peter Weil, conducts a study every five years of the career attainments of ACHE affiliates. His 2006 survey found that more women were achieving CEO status compared with previous studies. Indeed, women head more hospital associations, major health systems and hospitals than was true five years ago.

Members of minority groups have also made inroads; two of our largest non-public health care systems are headed by African-Americans, and there has been progress elsewhere as well.

Benefits and Risks

So what are the benefits and risks of this generational shift?

On the plus side, any organization can benefit from the perspective of new eyes, and in health care, where leaders traditionally were in place for a very long time, a fresh look at things is almost always beneficial. In addition, those whose experience is more contemporary and more in tune with the times are likely to be able to react to challenges in a more appropriate fashion, which is a nice way of saying that those of us who are older do tend to get stuck in the mud.

On the negative side, leadership turnover means a lessening of stability in health care organizations, and, given the volatility of health policy and politics these days, instability may not be the optimal situation. Furthermore, just as happened with the wave of term limits in legislatures, we are losing both organizational and professional memory. I noted with sadness the passing last month of Taylor McKenzie, M.D., the first Navajo person ever to become a medical doctor. He served his community faithfully for generations, and was an icon and inspiration to young Native Americans who aspired to the profession of medicine. What did he know that we will not learn from him? How much more will we lose as our other icons pass on? It is not enough to create oral histories, which I do as volunteer work; we need to get the lessons of our pioneers out to those who pursue the same professions. Their lessons must be part of active teaching and learning, not just dusty volumes on a shelf somewhere.

And on the I-don't-know side, a key question remains unanswered: Will the new generation of leaders view health care as a social service, as a special sector, as a societal good? Or will health care be seen as an investment opportunity, a business like any other, a commodity? The public still sees it as the former, but many of the new leaders of health care view it as the latter. Congress, Wall Street, the Internal Revenue Service, unions, political operatives and others are involved in this debate. The future of health care will rest on what is decided.

Three Scenarios

I offer three possible scenarios as this generational swing in leadership takes place.

Scenario one: Business as usual. A colleague of mine who ran a large hospital used to boast that his entire leadership team, save himself, was composed of women; he took great pride in the fact that the next generation would reflect that. When he retired, his board recruited a white man from another hospital as his replacement.

It is entirely possible that, despite the fact that there is now an extensive cadre of women and minorities who are experienced and capable of leadership, the historical pattern will prevail: Traditionally trained white men, who are buddies with the retiring CEO and with his board, will gain the top spot. No matter that more than half of all MHA students are women; no matter that more than half of all medical students are women; no matter that the future of the United States will be a diverse racial and ethnic tapestry. The traditional power relationships will go on, as members of the generation still holding power reward each other as before.

Scenario two: Demographics change, but behavior does not. It is also entirely possible--probable, in fact--that more women and members of minority groups will achieve high positions of leadership; unless we want to obtain our future leaders from temporary staffing agencies, this is almost inevitable. However, it is likely that they will have been largely educated by teachers of the Old School, or else by teachers who have never worked in a hospital or system or association and whose lessons are rife with partisan bias, whether from the left or the right, and short on practical experience.

As a result, the gender or race or ethnicity may change, but the behavior, the philosophy and the "mission" may not. It may be that professional aspirations will be far more about the bottom line and personal income and less about the obligations of health care leaders to be protectors of the vulnerable and agents of social change. The former philosophy was characteristic of the Greatest Generation; the latter is often true of those who came after.

Scenario three: Back to the future and back to the past. The third possibility is that the generation of health care leaders now coming into their own will truly be different, that they will look at our sector with really new eyes, that their entire perspective will be revolutionary.

The question, of course, is whether that will be a good or a bad thing. In terms of its being a good thing, we might hope for a reinforcement of the general belief in this society that health care is a social good that should be available to everyone, and the consequent social mandate that health care, seen as different from the commercial sectors, should behave accordingly. That would include its leaders.

In terms of the generational change being a bad thing, we might face a future in which it's perfectly OK to view health care as a commodity, a place to make money and please shareholders, a place where the gang at the top make a great deal of money while the folks in housekeeping can't feed their families, a place where if you don't have the money or the insurance, you can die on the street because that's how the market arranges things.

Our health care system is under enormous public pressure and scrutiny these days. To what degree it retains its autonomy will lie in the hands of this new generation of leaders. What they do will tell the tale. I hope it is a story that future generations will want to read.

First published in Hospitals & Health Networks OnLine, June 5, 2007

Emily Friedman 2007

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