CMO Experiences: A Rudimentary Case Report

The chief medical officer position, a unique role in U.S. healthcare systems, calls for leadership practices that foster a balance between the physician and administrator work processes, knitting together several interprofessional groups without favoring or denying any. The CMO must “balance the New England Journal of Medicine with the Wall Street Journal”(1) and speak the language of the executive boardroom and the medical staff lounge.

Current studies specific to CMOs generally are informative, but practical, empirical literature is ambiguous and untested, lacking sufficient insight regarding definition and practices common to the position.

The ever-evolving U.S. healthcare paradigm demands so much more of the CMO than simply a voice for physicians who must contend with medicine as a business. Instead, CMOs are leaders of dynamic relations that contribute to the mutual success of physicians, staff, and hospital administrators.(2,3) This shift has the CMO standing “precariously with one foot firmly planted on each side of the fence. The delicate nature of this position can lead to splinters in some sensitive areas.”(4) Accordingly, the social and interpersonal processes of the position require further exploration to better inform CMO leadership practice.

Specific guidance regarding definitions and challenges of the CMO position are discussed in physician leadership and healthcare management literature.(3) A scarce offering of empirical and theoretical papers, as well as in roles and responsibilities from practicing CMOs, first-hand interviews and trade journal positions are available.(1-3,5-7) As such, there is a void in physician leadership research regarding lines of inquiry, including study processes, specific to how and why CMOs exist within, relate to, and lead U.S. healthcare systems. This void leaves a significant view of CMOs open to unfounded and rhetorical interpretations and guidance for the position. As such, a ground-level exploration of the practical work and issues confronting CMOs in the United States today is called for.

Literature Overview

A comprehensive literature search was undertaken with an eye toward papers focused on CMO practice, first as physician leaders then focused on CMO practice in the United States. Initial key search terms included chief medical officers, physician leaders, leadership, healthcare, United States, and health systems. These were entered into several databases including Google Scholar, PsycINFO, EBSCOhost, Sage Complete, Medline/PubMed, and Web of Science. Several scholarly journal articles, non-peer-reviewed trade journal articles, and commentaries were found. The search was then focused on more contemporary CMO-specific literature in order to tighten the findings. International articles regarding CMOs specifically were initially uncovered and revealed information about physician leadership/CMO practice, theoretical foundations, and additional historical background globally.(8-14) Finally, the CMO-specific articles were further filtered for U.S.-only studies.

Unfortunately, empirical literature regarding the CMO position specific to the United States is limited for guidance regarding challenges of the role and development of the position. The only empirical and/or qualitative-based studies discovered within the United States at the time of the participant interviews were a CMO-centric dissertation from 2003 and role/responsibilities based on an author’s experience from 2015.(3,5) After 2016, the search found, specific to CMOs in the United States, the impact of the CMO in a Washington-based health system (2017), a discussion of CMO roles/responsibilities in a dialysis provider organization (2018), and a recent article surveying CMOs along with CEOs and other healthcare leaders.(15-17) Besides that, the literature search revealed only theoretical papers and gray literature such as firsthand accounts, interviews, and trade journal papers; little else was available.

The following clusters the articles specific to CMOs in the United States into three categories:

• Theoretical perspective offering a comprehensive view from the perspective of traditional leadership.(5,18-20)

• Firsthand, self-reporting, and implicit knowledge as a CMO and interviews of CMOs offering information applicable to practice.(2,4,6)

• A comprehensive list of must-have leadership skills and the right leadership skills to include as part of the CMO position.(1,3,15,17)

Overall, the literature search, which used several key words across multiple databases, revealed little to help understand the experiences of CMOs and the elements of practice and position development. In other words, this contemporary collection merely attempts to provide guidance regarding the role of this unique physician leader. This realization calls for an exploration, at a ground level, of the real-world experiences through the voices of CMOs in practice.

Study Method

An exploratory case design was incorporated in order to discover the fundamental experiences of CMOs in their role as unique leaders regardless of being employed by one of the several hospitals within one healthcare system. Specifically, participants were all physician leaders with the title of chief medical officer within a group of hospitals of one regional division of a larger U.S. healthcare system at the time. This particular regional division includes more than five hospitals within multiple counties, large and small cities, and rural areas. The CMO position comes with assumed homogeneity, but job descriptions vary within the regional division, suggesting the CMO role may differ from hospital to hospital. As such, the following inclusion and exclusion criteria were used.

Inclusion criteria. The sample CMO participants’ experience in the position ranged from novice CMOs to veteran CMOs. The study also included CMOs who had left the position but had experience in the position within the past 12 months. In addition to the CMO title, a former CMO who was working in a similar capacity within the healthcare system was included as a participant.

Exclusion criteria. Physician leadership positions within the healthcare system including chief of staff, chief patient experience officer, and chief executive officer. Because the study was interested in the experience of CMOs specifically, there was neither inclusion nor exclusion for demographic data of the participants, e.g., age or gender. The demographic data were collected, but as information for potential future studies.

Interview Process

Interview and Participants. Nine participants were selected as CMOs in a group of hospitals in one division of the national healthcare system. One participant was selected from a competitor hospital as a peer reviewer of the responses and additional data to support transferability of the findings. Each participant underwent an initial interview lasting one hour and a follow-up interview lasting 30–40 minutes. Participant interviews were done via face-to-face, Skype, and conference call. All interviews were recorded, and consent was obtained prior to the initial interview. Each interview, both initial and follow-up, generated an average of 10–15 single-spaced pages of transcription for analysis.

The interview questions below were provided to the participants before the initial interview and used as a guide:

• What are/were your experiences of CMOs as healthcare system hospital employees?

  • How do/did you define the role?

  • How do/did you succeed in the role?

  • How do/did you learn to perform the role?

• What are/were the primary issues faced by CMOs and how do these issues affect their ability to perform the CMO job?

Table 1 provides the list of participants. The list reflects pseudonym, time as CMO, position, clinical background, and age group at the time of the interview. The participants reflect a variety of medical areas and age groups, as well as a wide range of time as CMOs. Purposive sampling was used to identify the participants as current and past CMOs. Of note, the regional division of the health system at the time of the study had newly acquired most of the hospitals, reflected in the lower “years as CMO” noted in the table.

Analysis

The raw interview data and documents were collated into workable and sensible partitions. NVivo for Mac, a computer-assisted qualitative data analysis software (CAQDAS) package aided in analyzing the interview transcriptions. The use of NVivo for qualitative analysis in exploratory case studies specific to healthcare is well demonstrated across a multitude of thesis and dissertation work. This particular CAQDAS works well in the robust collation of multiple interview-centric media.

The initial review of all the CMO interview data was categorized to identify central ideas, similarities, and differences. The constant comparative method by Glaser & Strauss (21) was used, through NVivo for Mac, to develop themes from the data. As the data were recurrently reviewed, new categories and themes emerged.

A review and reflection of the themes grew with each new or follow-up interview. This developed further assertions about each participant case and provided explanation and meaning regarding each new insight or issue.(22) The continual thematic review provided what had been gained by learning about and performing this work.(23) Saturation of response data was achieved when additional interviews failed to contribute to the new or existing thematic analysis.

Findings

“As far as our job goes, I still think it is nebulous to some extent. I would love it defined a little better.” This simple statement by Dr. F speaks volumes regarding the lack of guidance concerning the CMO role and saliently encapsulates the frustrations expressed by the participants. Accordingly, the CMOs either self-defined the role in general terms or based the definition on what they thought the administration/system expected them to do. The response analysis discovered three prominent themes: role ambiguity, role credibility, and role development (Table 2).

Role Ambiguity. All the participants had at least one opinion, but more commonly several, regarding the definition of their role, not only as part of the system but as a CMO in general. First was the challenge of role definition and ambiguity. Both had a significant impact on taking the position and accepting the realities associated with the job. Many felt their place was between physician colleagues and administrative employers as advocates with the ability to speak to both sides. As such, taking the job and confronting the realities of the work were nestled within this theme, providing further substance regarding why the physician participants took the CMO position although conflicts arose from them being both a physician and an administrator.

As noted, the CMOs saw themselves as physicians first and administrators second. Knowing this, why would the participants take a job that would drastically affect their interaction with patients?

“I think, ultimately, the part that was most interesting was the quality and safety component. I just felt like we [the hospital] did not have a very good grasp of what our quality and safety issues were. We did not have a process in place. That was my first task.” (Dr. G)

The findings reflected that their concern for patients in terms of care and safety within the system trumped their need to continue practicing medicine on a full-time basis.

The reasons for taking the job, although multifaceted, were strong enough to make these successful clinicians drastically change their work life. The responses revealed that the participants entered the job with a vision of what it would be like and how they would perform, yet many of them experienced unanticipated challenges.

“You are kind of stuck between two factions that do not always agree. The docs need more of this; they need more of that; they want this done, and their primary goal is to take care of patients in the right way and make their lives easier. The administration’s job is to make sure patients are taken care of and make sure that financially the hospital is performing well. As such, the CMO has to be the guy in between that sort of has to play the fence a little bit.” (Dr. B)

However, the reality of getting to the point of alignment where groups are working in tandem is a challenge. It required the participants to be diligent in their role as facilitators and translators of a common vision.

“There is always common ground, though. I found that out, that if I cannot get them exactly what they want, maybe I can get them to at least, what I call, a happy place where they feel that they are somewhat validated in where they want to go and what they want to do.” (Dr. A)

Another reality of the position experienced by participants was how they were viewed by their physician colleagues. Each participant had an experience or two when they were confronted with the perception that they went over to the “dark side, sell out, and had become a suit.”

“I knew it was going to happen, ...that my relationship[s] with many of my colleagues, and my friends for that matter, were going to change 180 degrees. I was going to immediately be looked at as the enemy. I understood that, and I accepted it.” (Dr. F)

The participants confronted role conflict daily. For example, one participant who always had to balance the needs of the system and the needs of the medical staff was confronted by the limitations found in budgets and resources as well as the expensive advancements in patient care technology. For him, this was like being pulled in opposite directions.

“Then, you have guys who want more money for call, so that is a budgetary item. How do you stay neutral? You are cutting these doctors because they are a contract group, but then you have employed docs who want to make two thousand dollars a night to be on-call. How do you balance that?” (Dr. B).

Overall, the participants continued to work through both the ambiguity of the position and the conflicting responsibilities. What is impressive is how they can work through the challenge of performing essentially two roles in one — by recognizing the most important thread woven throughout the hospital and healthcare system, which is, of course, the patient. The CMO participants, thus, keep the focus on the patient, not only for themselves as healers but also for their colleagues and administrative counterparts as participants in that goal.

“All these years I have been a physician, but like I said, sometimes it is a little hard to juggle. I see the value as well in the administrative role because I always try to keep in my mind that my administrated mission is to improve safety and quality of patient care, so I stay focused on that.” (Dr. E)

Role Credibility. The second theme that surfaced early in the interviews was credibility. This was defined by the participants as a feeling of respect from physician colleagues that allowed the CMOs to move the medical staff through changes experienced by the healthcare system. Maintaining credibility among their peers helped prevent hospital and system administrators, with no clinical expertise, from making patient care decisions without medical staff support.

“I would say that most CMOs understand that their organization has to be successful financially, but they want to be viewed as physicians. They wake up in the morning, and when they shave, they see a physician. They do not see an administrator. That is why they were hired.” (Dr. J)

One challenge was maintaining a clinical practice in the face of growing administrative demands. As stated, the participants were seen as credible when they maintained some semblance of being a physician. But being both a doctor and administrator was more than a full-time job, and most accomplished this by splitting their time. Although taxing on time and energy, most of the participants understood that clinical practice must be part of the job in order to maintain their skills and the respect of their peers.

“Many CMOs do not work as physicians any more. They are not taken seriously as they have no idea about the intricacies of EMRs or being on call. I feel that’s why many feel the need to continue some portion of their practice.” (Dr. G)

As such, the findings suggested maintaining a clinical practice, or a clinical presence, was vital to the credibility of CMOs among their medical staff peers. Although a few of them have given up practicing medicine, the rest were adamant that continuing to use their skills gave them a feeling of still being a doctor and the social and political leverage to affect medical staff behavior. The continuance of a medical practice alongside administrative demands was not without challenges though.

“I think clinicians feel like someone that is in the administrative side will lose the clinical perspective, and I can see how that could happen because I am in meetings all day long. I am only clinical now because I am choosing to do so after hours. So, I want to do a half day a week in my clinic, they [administration] said no. So, I am doing call one week a month, but I have to go outside of my 9 to 5.” (Dr. D)

The challenge for the participants relative to credibility was authority. In an organizational sense, leader authority is what Burke(14) called “right to.” For example, the authority to make the medical staff align with practice protocols or transition to a paperless charting system was met with cynicism and resistance. The CMOs felt they had no real power to make their physician colleagues change. Instead, the responses supported an influential power.

“It is a very soft type of power and authority. It is not a direct veto-power or something like that. One way was to work with influential physicians, to have them express the same desires that I had for going forward.” (Dr. C)

“There is really no way to say, ‘You have to do this.’ It is just trying to speak to each one of those physicians that is in opposition to it to convince them of the importance of doing it.” (Dr. E)

The theme of role credibility exposed the importance of CMOs as physicians who are still part of the fold, the physician culture. The reasons for continuing to be part of the physician in-group included being trusted as an advocate for their colleagues and patients. To establish credibility among their peers, participants had to maintain a semblance of medical practice.

The fact that the CMOs continued to practice their art made it easier for them to influence the medical staff of their hospitals. In the findings, influence was power, or authority, although not in a traditional, authoritative way. Instead, the participants used influence, leveraged by their anchor to continued medical practice, to move the medical staff through appropriate healthcare policy and protect the medical staff from novel or poorly thought-out healthcare system practices.

Role Development. The final theme that emerged from participant responses addressed how they learned to do the job of CMO. The participants were asked about all types of training for the CMO position as well as continuing medical education, or CME. One of the most profound responses from the participants was the lack of formal training models specific to the practicality of the job. The participants depended primarily on informal learning over formal learning paradigms.

“I have not had any formal training for this position. I have attended a few leadership-type conferences or seminars just in general. Specifically, to be a CMO, I have not really had any formal training.” (Dr. E)

Formal executive and leadership curricula, including MBAs and MHAs, provide business and leadership development but, according to the participants, were incomplete for guiding the specific needs of CMOs as leaders working with very distinct and strong groups. Thus, the findings disclose a dominance of mentorship and informal learning.

“I was very fortunate because I had three staff chiefs that were very good. One of them was a physician, and that was probably my best mentoring because he and I could think together, and he wore the other hat as Chief Administrator.” (Dr. H)

The role development theme encompassed the very heart of how the participants learned to do a good job. Because many of them felt lost when starting in their role as CMO, avenues to gain more knowledge were available but unstructured, at least initially, to help them grow in the position. As such, informal and incidental learning models are the primary pathways to getting good at the job. Since all of the participants experienced new and challenging issues, they were not meek when it came to seeking help. There were situations they encountered that, during reflection, motivated them to look for guidance.

“I was responding to things. It was always responding. If I was doing nothing but that, I could say, ‘Hey. Look, here is a problem. Let’s take this on. Let’s do a process, and we can make this better.’ Instead, I was so far behind because of all my other work that a problem would come up, and I would have to put the fire out. So, I could not be as proactive about those sorts of things.” (Dr. B)

As noted above, the participants spent so much time reacting to immediate hospital issues, it left little time for learning. Thus, some of the participants had to create time in their day to learn; otherwise, they would rarely have the chance to grow outside of the situation.

“There are no books. I will be honest with you, sometimes I wonder if the organization is not spending the money wisely on this position. It is not about me; it is just about if they are really getting their money’s worth out of it. I think that is a legitimate thing, especially as dollars tighten in healthcare.” (Dr. F)

Overall, the experiences of the participants fit with the descriptions found within informal and incidental learning structures. The heavy dependency on mentors, self-directed learning, and on-the-job training gave some of them the feeling that more could be done. Table 2 provides the essence of each theme as reflected in the response.

Implications

The CMO position historically has been guided by limited research regarding assistance toward practice. The participants’ responses supported several propositions for CMO practice and are outlined in Table 3, which provides a succinct list revealing implications affecting leadership, organizational change, and learning. Each focus represents a larger umbrella under which CMO practice resides. The implications, drawn from the findings, are associated toward the focus and its impact on the CMO position.

How CMOs affect more than one practice area in U.S. healthcare is of great importance. For example, working with resistance, which was found to be an essential component of CMO practice, is in the focus of organizational change. Since the actions taken (which underlie the results experienced) by the participants appear to encompass change resistance, the organizational change focus was the area most commonly affected.

Limitations

Chief medical officers were interviewed in multiple hospitals within a relatively new single division of a larger national healthcare system. Since the year of this work, the national healthcare system has grown exponentially to include a much larger footprint across the United States. As such, the findings are limited in quantity of participants fitting the inclusion criteria but should be considered a first step toward understanding the depth and breadth of the experiences. The nature of this limitation finds perhaps not enough responses or participants to grasp what is being experienced in a larger scale. At the time of this work, although limited, the quantity of participants still allowed for impactful theme development and future discussions and research around such themes.

This work also appears one-sided as it was concerned with the experiences of CMOs as they performed the role of a unique physician leader. Specifically, using this group allowed for first-hand descriptions of the position, culminating in findings supportive of the project purpose. From one perspective, the focus on CMOs was instrumental toward getting the data needed to understand the context. On the other hand, obtaining responses just from CMOs may not have provided a complete picture of the role.

In the future, research should be expanded to include outside views. It would be especially important to understand the uniqueness of the CMO position by capturing views for the role from other members of the executive health system team. This could lend not only to the depth to the finding, but also add greater trustworthiness and appeal to a larger audience.

The next step is to push forward with a larger, perhaps more diverse group of CMOs, which would expand the premise of current work beyond a single healthcare system in a single regional division. It is important to note, though, that the findings, as discussed, were not bound solely to the context of a healthcare system, division, or its hospitals. Building on the context of the CMO role calls for more diversity in participants, methodologies, and methods, as this is simply a starting point for future work.

Conclusion

The chief medical officer position has proven to be instrumental in the progress of the U.S. healthcare system in the 21st century. The findings proposed that although the position is indispensable toward healthcare vitality, the experiences of CMOs are incompletely understood in literature and there are limitations to practical-level experiences and guidance. Thus, the work of the CMO needs a more complete understanding of the role to limit practice variability and inefficiencies within the role.

Twenty-first century healthcare is much more integrated, inter-professional, and technology-savvy than ever before. The CMO responses provided endeavor to dig deeper into the day-to-day meanings of the CMO position through the eyes of the participants, in a practical manner. What was discovered through thematic analysis, however, is how incredibly challenging this very important position has become for physicians who take on the role of chief medical officer.

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