Annals of Long Term Care

What brings physicians to choose to accept a position as a medical director in long-term care? It is less likely a lifelong passion specifically trained for, and more likely a position of circumstance—perhaps a plea from a desperate administrator, an opportunity to make a little more money, a passion for caring for the frail, or natural inclinations toward leadership and management. I most certainly never imagined myself in long-term care when I took a job at a county-run nursing home in 2000. It looked interesting, I needed work, I itched to lead, and they needed me.

When I joined what is now Edgemoor Distinct Part Skilled Nursing Facility, the county of San Diego was at a crossroads. Our facility was ancient, morale was skidding, there were concerns about the care and management, and our quality indicators were less than stellar. The question at that time was: Should Edgemoor rebuild (both literally and figuratively) or close? Fast-forward to 2009, and enter a beautiful, newly-built facility with a strong referral base, quality indicator scores to be proud of, and a cultural transformation that has given me an opportunity to reflect on how we have changed and what factors were instrumental in our success.

Being an excellent physician and being an excellent medical director require different skill sets and approaches. A physician often works alone and independently in a series of one-on-one brief interactions that involve a few minutes of listening and examining, cognitive skills to make a diagnosis and assessment, followed by the development of a plan (orders), which the physician expects to be implemented/followed. In contrast, medical directors work as a somewhat peripheral, mostly absent part of a team that is dominated by nursing culture, nursing perspective, and numerous regulations. The problems presented to medical directors are often too complex for short pronouncements. One thing that is common for both is that the physician may be treated deferentially face-to-face, but compliance with their excellent recommendations is often low. Physicians are often hurried and impatient; medical directors have to be extremely patient because things move slowly.

Through my experience, it appears that there are three components that are necessary in order to effect lasting change in an organization: leadership, partnership, and culture change. The medical director is one component of the leadership of the facility. Ideally, there is a triad of power with the director of nursing, the administrator, and the medical director. However, this triad can be complicated in systems with “corporate offices” or when there are other individuals who wield strong formal and informal power. In reality, the medical director may have little real power to implement an agenda. Much more power lies with nursing (it is a nursing home, after all) or administration. Medical directors are sort of like the Judicial branch of the U.S. government: They issue decisions but have no actual power to implement them (the role of the Executive branch) or to fund them (the power held by the Legislative branch). The Judicial branch can put a halt to things that are terrible or occasionally surprise everyone with a new perspective.

Medical directors cannot be effective without forging effective, mutually beneficial relationships with the other leaders and using their influence to get others’ buy-in for change and improvement. Buy-in is allocation of resources, which may be financial, time, or energy. And buy-in is responsiveness—attention and support to the change initiative. When a medical director is planning a new initiative (for example, our initiative to go “smoke-free” or “restraint-free” or to reduce in-house pressure ulcers), it is best to plant the seed of an idea early, well before one plans a change initiative. Speak off-handedly about the idea and back away: “Did you know some facilities use no restraints at all?