Medical Informatics: Non-Clinical career options for physicians This
Transcription
Medical Informatics: Non-Clinical career options for physicians This
Medical Informatics: Non-Clinical career options for physicians This presentation was created for use at the SEAK conference on Sunday, September 13, 2009. Conference Brochure: http://www.seak.com/Sem_NCC09.htm 1 The agenda is laid out in order to paint a clear picture. Where are the jobs, especially those informatics jobs appropriate for career changers of all levels of experience? The major categories are provider organizations and those who serve them most directly, that is healthcare consultants and application vendors. Included are payers and healthcare cost management organizations like MCOs, PBMs, disease management firms, etc. And finally, government and academic organizations, where vital research, policy, and public health initiatives are conceived, led, and evaluated. What is the work of medical or health informatics? It’s not my goal this morning to attempt to provide an overview of informatics. The dictionary’s definition of informatics doesn’t provide much help: “the science of processing data for storage and retrieval; information science.” A serviceable definition is, however, necessary to ground this talk. So, let’s say that health informatics work is the management art and science of assuring that everyone knows what the best of us know when it comes to getting the best possible healthcare to people. That may be drug interaction information to physicians, self-care information to patients, workflow support for bar code medication administration to nurses, cost, utilization and process data to senior and midlevel executives, and support for all aspects of health sciences. There are two dimensions to this “what” perspective: 1) How do executives and managers help knowledge workers? And, 2) The MBA perspective. How does this map into business terms like sales, implementation services, marketing, product management, etc., and what are the relevant, clearly described roles and expectations? Why consider a health informatics career? This may seem obvious, since you’ve chosen to attend or read this presentation. That said, it’s worth a few moments of specific attention if the goal is to understand the options most relevant to you. Basically, there are two driving factors. The world has changed since you choose to pursue a clinical career, and you have changed. Lastly, the How do you prepare for and pursue a health informatics career? 2 Where are the jobs, especially those informatics jobs appropriate for career changers of all levels of experience? The major categories are provider organizations and those who serve them most directly, that is healthcare consultants and application vendors. Included are payers and healthcare cost management organizations like MCOs, PBMs, disease management firms, etc. And finally, government and academic organizations, where vital research, policy, and public health initiatives are conceived, led, and evaluated. There are health informatics career options in a wide variety of organizations. The first type of organization is the consultancy. They serve the other organizations on the list in that vendors, providers, payers and government hire consultants to get nonrecurring jobs done. There are different kinds of consultancies, from large, multinational organizations including IBM, CSC or Accenture to smaller boutique consultancies that focus on a specific type of service, and small to individual contractors. The good part about consultancy as a career step is that they typically offer the greatest learning potential, especially early in your career in a specific industry. The biggest downside is that there is often a heavy travel burden. Vendor jobs and careers are another consideration. Vendors who hire physicians range from application software providers, to device manufacturers, to vendors of content such as publishers. Note that vendors frequently offer consulting services such as implementation support. We’ll get into the kinds of work done by each of these organizations shortly. Many provider organizations have physicians in health informatics roles. Currently, the CMIO role is one of the most common. There are also physicians serving in CIO and COO roles with health informatics-related responsibilities. There are also physicians in staff roles, that is, subordinate to line managers. Many of the larger health care provider organizations do a fair bit of self-development, so many of the job functions found in vendor organizations can be found in these provider organizations. All of the larger health care payers and insurers have a CMO (Chief Medical Officer). Increasingly, these physicians have components of health informatics in their roles. These organizations often have physicians internal to the company working on development projects like PHRs, care profiling, disease management, and other areas where clinical sensibilities are required. There are a lot of physicians working in government agencies doing health informatics related work and this number increases every year. Some of the more exciting work is taking place at AHRQ and the other organizations under HHS, including the CDC, CMS, FDA, and NIH. See http://www.hhs.gov/ . Finally, the most exciting, cutting edge health informatics research comes from grants to academia. Increasingly, there is a recognition that much more health informatics training will be required. The extent to which that will be fulfilled by traditional academic professionals is unclear to me. 3 What is the work of medical or health informatics? It’s not my goal this morning to attempt to provide an overview of informatics. The dictionary’s definition of informatics doesn’t provide much help: “the science of processing data for storage and retrieval; information science.” A serviceable definition is, however, necessary to ground this talk. So, let’s say that health informatics work is the management art and science of assuring that everyone knows what the best of us know when it comes to getting the best possible healthcare to people. That may be drug interaction information to physicians, self-care information to patients, workflow support for bar code medication administration to nurses, cost, utilization and process data to senior and mid-level executives, and support for all aspects of health sciences. There are two dimensions to this “what” perspective: 1) How do executives and managers help knowledge workers? And, 2) The MBA perspective. How does this map into business terms, like sales, implementation services, marketing, product management, etc., and what are the relevant, clearly described roles and expectations? 4 So this brings us back to what health informaticists actually do. One area I'll call general management (done by managers), and the second I’ve named improving knowledge work. A renowned writer and management consultant, Peter Drucker, was once asked to describe the difference between executives and managers. He said, “Executives do the right things, and managers do things right.” I'm going to skip past the "do the right things" function of executives in today's talk, i.e. the broad issues of quality improvement, performance improvement, patient safety, and improving healthcare value, except to mention that they define and guide the work of physicians doing healthcare informatics work. Instead, on this slide I'm addressing the responsibility of physician health informaticists to provide management services to their companies and their clients . . . to do things right. When I was in medical training I heard an often repeated quote from Dr. Peabody, “The secret to caring for the patient is caring for the patient." The exact same principle applies outside of doctoring. Great professional managers truly care about their peers, superiors, and subordinates in exactly the same manner. That is evidenced by empathetic listening. It's evident in translating and restating what has been heard. It's evident in follow-up observation work to validate what one has heard or seen in numbers to ensure that it’s meaningful. And it takes the form of action, including one-on-one communication, coaching, providing feedback, and other management functions I’ll address later in this talk. 5 In his 2005 book entitled, Thinking For A Living: How To Get Better Performance And Results From Knowledge Workers,Thomas Davenport elaborated this list of 10 ways to improve knowledge work. I think it does a great job at a high level of describing the range of services that Health Informatics professionals provide. Physicians in health informatics often serve a critical role in clarifying current processes, as well as the desired future processes that organizations seek to create. This often requires the perspective of a physician to fully appreciate the clinical dimensions relevant to a clinical transformation initiative, and is captured in item one, “Adopt a process orientation.” For example, many care delivery organizations will review several service lines, looking to improve things like how can we improve care delivery for community acquired pneumonia? In response to that, a health informaticist might create an activity diagram that maps out exactly what happens between the time a patient walks through the hospital doors with pneumonia, and when they walked out 4.2 days later having been successfully treated for that pneumonia. There are physicians working on implementations in consulting organizations, at vendors, in healthcare providers, and for payers who deal exactly with those kinds of issues. Now that we get process orientation, it's probably self-evident that scripting the work, item three, embedding knowledge into the work, number four, and automating decisions, item five, could each be areas needing specific work. 6 In addressing what to healthcare interactions do, another way to get at this is through what departments they work in and what those departments are broader sense do. Shown here is what I'm calling the classic MBA classification. All organizations which have products or services to sell have a sales organization internally. Vendors and consultants who sell into the healthcare industry, especially those sales that touch physician executives were end-users in the sales prospects, employee physicians to support those sales efforts. A clinical credibility that an experienced physician can bring to the sales process is extremely valuable. Physicians doing that kind of work are often involved in needs assessments product demonstration processes, scoping out new work more new products, and a variety of related functions. Similarly, there is a large and growing need for physicians, both in the consulting and vendor organizations, to help with clinical implementations. Physicians serve businesses marketing needs in a variety of ways, including writing white papers, presenting at meetings, maintaining blogs, and other marketing functions. There are a wide variety of roles related to product management, product development, and other functions being served by physicians in a wide range of companies today. In my career, I have met many physicians who have founded companies, who have developed and launched business units within existing companies, and more commonly, had careers blending these and the other roles including sales, marketing, product management, etc, spanning decades after successful patientfacing clinical careers. Why consider a health informatics career? This may seem obvious, since you’ve chosen to attend or read this presentation. That said, it’s worth a few moments of specific attention if the goal is to understand the options most relevant to you. Basically, there are two driving factors. The world has changed since you choose to pursue a clinical career, and you have changed. So, understanding yourself is critical in selecting the best next career step for you. 8 Here we are at 7:30 AM on a Sunday morning at an airport hotel in Chicago. I think it’s entirely appropriate to ask ourselves explicitly why are we here? The two-fold answer is both obvious and subtle: The world has changed since we chose a traditional medical career. When I did my undergraduate and graduate medical training in the 1970s and 1980s, there were reasons that contributed to why students were attracted to medicine: The appeal of autonomy and independence, of science, income, and societal recognition. Even in the mid- to late 1970s, it was clear that things were changing. And this wasn’t confined just to medicine. The independently owned and operated corner pharmacy disappeared, along with many other autonomous, smart, lucrative and respectable ways to earn a living. These, combined with the changing revenue and costs associated with practicing medicine, would cause any intelligent professional to evaluate their options. The other reason we’re here, is that we have changed. In addition to having decades more experience than we did when we chose a traditional medical career, we are also that many years older. For many physicians, our brain’s ability to handle complexity and challenges has increased. 9 In the space of world changes, how has the old deal changed? Or more importantly, how has it been changing and is likely to continue to change? There are a lot of positives, including lifestyle improvements, more powerful diagnostic and therapeutic options, educational resources and practice opportunities. My expectation is that you who chose to here today are interested in health informatics career opportunities that currently exist. That is the primary thrust of this presentation. The roles and career options that I’m walking through are largely established ones. There are roles and career options that leverage health informatics to transcend traditional provider, payer, consulting, government, Pharma, and academic traditions. Increasingly, businesses are looking at new and innovative ways to think about health and health services. The move on the part of Google and Microsoft in recent years to support personal health records for consumers is one such example. There is a wide range of startup companies (many of you have been starting up for years now), as well as new ventures and existing companies to address this new world. The names given to the New World? Health 2.0. Consumer centric care. And many, many other variations. 10 In addition to the world changing, we are changing personally. Most of us have been collecting insights as a result of working through marriage, child raising, caring for dependent parents and siblings, and other forms of social growth. At the same time, many of us have experienced both professional growth as well as, at times, professional stagnation. That, combined with a personal vision of continued growth, development, and achievement can leave all of us, at times, disappointed. As illustrated by the article on the next slide, this midlife crisis can actually be an extremely good thing. 11 “In a paper published in 1965, Elliott Jaques, then 48 and a relatively unknown Canadian psychoanalyst and organizational consultant, coined the term “midlife crisis.” Jaques wrote that during this period, we come face-to-face with our limitations, our restricted possibilities, and our mortality. In his own midlife and beyond, however, Jaques did not seem to live with a sense of limitations. In the 38 years between the publication of that paper and his death in 2003, at age 86, he wrote 12 books; he consulted to the U.S. Army, the Church of England, and a wide variety of companies; he married Kathryn Cason, who was his wife and collaborator for more than 30 years; and, with Cason, he founded a consulting company devoted to the dissemination of their ideas.” What do I like about this article? It starts off with “Debunking the Myth of Midlife Decline,” proceeds through “Debunking the Myth of Magical Transformations,” and deals directly with the reality of career change – the advantages and opportunities, and understandable concurrent fear. The writer also points out how incapacitating it can be to deny the issue of reality and not step up to it. 12 This slide illustrates graphically the point of balance brain function growth. On the left-hand side, labeled "CDC growth charts: the United States," there is a pediatric growth chart for girls ages two to 20 showing growth in height where the normal population is stratified by percentiles. On the right is a growth chart of a different sort. On the x-axis, in contrast to the pediatric growth chart that goes from age two to age 20, this chart goes from age 20 to age 70. The y-axis on the right shows cognitive stratum which takes into account the increasing abilities for abstract thinking that we all have as we grow older, more complex thinking involving parallel lines of logic, etc., tasks that span longer periods of time. The orange circle shows the range of cognitive stratum that most of us were at about the time we finished our medical training between ages 25 up to 35. The purple oval shows the range of cognitive power in the positive stratum typical between ages 45 and 55. This right chart was taken from a book entitled, “Human Capability: A Study Of Individual Potential And Its Application,” written by Elliott Jaques and Kathryn Cason. Most of us are sufficiently self-aware to appreciate the increasing ability to manage complexity that comes with aging. 13 Extremely important question – you need to think this through and re-think it through for each opportunity if you’re currently practicing medicine. Highly personal and emotional question – don’t underestimate that. But don’t project values (yours or anyone else's) on the practice issues. People who evolve their careers are not simply good or bad if they choose one route over another. It will be harder to maintain clinical skills while developing other skills. However, it may be possible to work in a niche area where this is less of an issue. Social acceptance within a provider organization may require continuing practice a half-day a week. The mechanics of being present at multiple facilities, meetings, and getting your work done adequately outside of meeting work may require giving up practice. In the short term, the decision can be reversible. Over the longer term, it may not be practical to return to practice. Also, over the longer term, you may not have the time and energy to be effective if you continue practice. A commitment of a half-day a week is often actually a larger time and energy commitment. YES - Absolutely continue practice for some roles in some organizations, especially change agent roles in provider organizations (not necessarily change sponsor roles like VPMA, CMO, etc.) NO – Absolutely appropriate and necessary to advance your career in some roles in some organizations. Practicing physicians can appear to not be committed to their executive role when they decline an important meeting, show up late, don’t show up, or are not prepared for meetings they’ve committed to. When they say, sorry, I ran late in clinic, the non-clinicians and non-practicing clinicians who showed up on time and prepared lose critical confidence and trust in that physician’s commitment to the organization. This is a very hard situation with an obvious, important soft side. Real issues and constraints refers to practice opportunities, travel/schedule pressure, malpractice coverage, and maintaining adequate skills for practice style. If your clinical skills are not in demand (due to a local oversupply), you may have challenges establishing and maintaining a clinical practice. The reverse is true as well. If you’re the only guy in town who can do cardiac valve replacement surgery in patients who have failed previous attempts, working a half-day a week in surgery would be an exceptionally great fit. Consultancy and vendor roles often have between a 20 and 80 percent travel burden and it’s often seasonal. I personally average about one night per week sleeping in a hotel room, with air travel on either side of that and six to eight hours face-to-face with an out-of-town client. During trade show seasons and during the fourth quarter of the year, that can be two to four nights a week, and typically three or four weekend days. I have two children and a working spouse. Imagine that kind of travel and maintaining a clinical practice. And by the way, business travel is scheduled eight days or less (half the time) from the travel date. So rescheduling patients or arranging cross coverage is a consideration. Malpractice coverage varies with role and organization, but can present challenges. Maintaining skills, CME credits, professional society accreditation, and referral patterns need to be thought through. There are a lot of physicians with health informatics careers who practice and a lot who don’t. Adequate prior clinical experience and confidence are generally required and the most important things to consider. I think it’s also important to have thought out for yourself a strong opinion. Hold that opinion loosely! You’ll be working with clinicians hold their opinions strongly to their professional detriment. 14 How do you prepare for and pursue a health informatics career? A quick digression here… Mostly from Wikipedia: The Tower of Babel, according to chapter 11 of the Book of Genesis, was an enormous tower built at the city of Babel, the Hebrew name for Babylon. According to the biblical account, a united humanity, speaking a single language and migrating from the east, took part in the building after the Great Flood. The people decided their city should have a tower so immense that it would have "its top in the heavens.” However, the Tower of Babel was not built for the worship and praise of God, but was dedicated to the glory of man, with a motive of making a “name” for the builders. God, seeing what the people were doing, came down and confounded their languages and scattered the people throughout the earth. It had been God's original purpose for mankind to grow and fill the Earth. In modern life, there is an information explosion, brought to you by Google, your email and snail-mail inboxes, and other inescapable broadcasts. When it comes to learning anything new, we face the: Tower of Babel problem – (being a professional, I’ve turned this into an acronym) Blogs, Articles (Web pages), Books, often Extremely Long Blather and Bias, Elegant but Lame 15 In addition to coming to conferences like this one, HOW can you and should you learn, efficiently, to make this transition? At this point, we’ve covered the broad dimensions of career options in terms of roles, types organizations, and what is entailed if you choose a role that involves managing people and projects. My goal now is to pass on a little bit of the best advice regarding ways to learn, efficiently, quickly, at a low cost, and in a manner that can potentially fit into your current lifestyle. Highly efficient sources for critical and efficient learning - Mini-mentors - Social Networks - Addressing the BABEL - Podcasts, blogs and non-RSS syndicated content - Commercial and free audio-visual resources I will wrap up by pulling it altogether in the form of a case study. 16 Selection of potent, accurate, time-efficient input on diagnostic or therapeutic options is not a new problem for anyone in this audience. Time management is also a closely related competency for successful clinicians. In this information age, the ability to satisfy your information needs quickly, at the appropriate depth, is extremely important for anyone contemplating changing their career. You need to gain and maintain an awareness of : 1) the industry issues that are attracting attention, have revenue potential, and/or will be driven by inexorable policy (e.g. you must address medication reconciliation and reducing Medicare re-admissions, even though they won’t generate new revenue) 2) who is doing what, including who is looking for clinicians interested in a non-clinical career move 3) specific opportunities and the relevant specific issues (e.g. understand in reasonable depth the problem or solutions that a potential employer has indicated are important, e.g. Scrum.) 17 “Today’s professional service firms are so busy making money that they’ve lost the art of making talent.” This is the opening line of the article “Why Mentoring Matters in a Hypercompetitive World” by DeLong, et al. The concept of formal, planned traditional mentoring, over a period of months or more, was a standard practice when I worked for Hewlett-Packard 25 years ago. As professional workloads have increased and an employee turnover rate of from three to five years has often become the norm, there isn’t much traditional mentoring in common practice. As in medicine, true professionals have a teachable point of view and are eager to share it. In contrast to traditional mentoring programs, “Mini Mentors” has taken off. Easily 10 percent of my professional colleagues are willing and eager to spend 30 to 60 minutes with people interested in pursuing a career path they’re familiar with, or helping others simply thinking through how to handle a management challenge. In my personal experience as a mentee, I’ve found that more than half of the extremely intelligent and experienced executives I’ve met will schedule time to listen and coach. Same is true if there’s a referral through a friend. Also in my experience, and not paradoxically, those who have something of value to share are much more available than those who are stumblebumbling their way through life. The principles on this slide are highly relevant. I would strongly recommend the Pod cast from: Manager-Tools: The Basics of Mentoring http://www.manager-tools.com/2006/06/basics-of-mentoring-part-1-of-2 It offers guidelines on: Whom Should I Ask? How Long Should It Last? You May Ask How Does It Work? And the Role of Feedback. Harvard Business Review: January 2008 Why Mentoring Matters in a Hypercompetitive World, by Thomas J. DeLong, John J. Gabarro, and Robert J. Lees 18 Stay in touch with people you’ve met who you would do a favor for if asked. Building and maintaining a social network takes work. A lot of people don’t do it for that reason. Don’t be one of those people. You should aim to maintain a social network of no fewer than 50 people, exclusive of family and co-workers. Ideally, your network should be about 150. One simple way to start is to buy yourself a new tool. I highly recommend purchasing a Neat Receipts scanner and software. With this you can take the business cards you collect at a conference and effortlessly scan them into your computer and contacts list. With just a little bit more work, you can add to this information what you discussed with the person. It then becomes very straightforward to follow up after the conference by e-mail. Tools: LinkedIn; your address book; local and regional professional societies References: Manager-tools “How To Build A Network” available at http://www.managertools.com/podcasts/Rutgers_Women_in_Business_Presentation.ppt Audio at: http://www.manager-tools.com/2009/06/rule-50 19 The topic of social networks is a problem. In addition to the informal social networks we reviewed on the previous slide, there are natural networks that form within organizations. I found the graphic on this slide in the article titled, “Competent Jerks, Multiple Pools, and the Formation of Social Networks,” by Tiziana Casciaro and Miguel Sousa Lobo , again in HBR. If you were faced with the need to accomplish a task at work, what sort of person would you pick to help you—someone able to get the job done or someone enjoyable to be around? Studies done in four very different organizations consistently showed that most people would choose a “lovable fool” (someone who, to varying degrees, is more likable than competent) over a competent jerk. I’m including this to highlight the importance of diversity. We tend to like people who are similar to us. It’s harder to reach out to, develop and maintain relationships with those who are different from ourselves. These relationships are, however, often the most beneficial. 20 In slide 17, I introduced the topic that in modern life there is an information explosion, brought to you by Google, your e-mail and snail-mail inboxes, and other inescapable broadcasts. There are also a pile of books on most of our bedside tables, in our offices, and honor bookshelves that we’d love to read. When it comes to learning anything new, what we face is a problem that I’m playfully referring to as the Tower of Babel – an acronym for Blogs, Articles (Web pages), Books, often Extremely Long, or “Blather And Biased, Elegant but Lame” The bottom line for career changers is that we need to learn very quickly and efficiently. Thanks to the content on the Internet, it’s possible to find work in and fashion a course for essentially any endeavor. The course can start at any time we wish. It may include selected reading, books on tape, audio podcasts, video podcasts, a book downloaded to Amazon’s Kindle, a Webinar, or some other delivery vehicle. The common elements, however, are that this takes some self-awareness, discipline, and coordination to work learning into our modern lifestyle. For some, it’s reading or listening on the commute to work. For others, it’s worked into a daily exercise routine, such as virtually attending conferences while exercising on a treadmill. It also requires some willingness to experiment with new technologies and content. For example, I’ll bet there’s more than one person in this audience who has an iPhone and has never listened to a podcast on it. BABEL Podcasts, blogs, and non-RSS syndicated content Commercial and free audio-visual resources Blogs, Articles (web pages), Books, often Extremely Long 21 Podcasts are like little radio shows. They are published on the Internet and are freely available to download to music players like the iPod. They can be easily played on any computer, can be a great way to attend what ends up being mini-lectures on virtually any topic you can think of. And you can attend these lectures whenever and wherever you want. As I mentioned earlier, many people find listening to them while commuting to be very useful, whether you’re driving or riding on public transportation. One podcast series that I recommend to better understand health informatics is the HIMSS/AMDIS Physician Community Podcast. I would also highly recommend the Manager–Tools podcast. There is a lot of material in that series related to career changing, interviewing, basic management skills, and other topics that would be relevant to this audience. Blogs is a term derived from weblog, and most closely resemble a newspaper column on a specific theme from a specific person. There are any number of interesting blogs out there. Many would be highly relevant, largely to scan for a flavor of what people are doing in health informatics. To get you started, I would recommend looking at the healthcare–informatics.com/blogs site. There you will find my blog, as well as those of more than a dozen other professionals who work in various areas of health informatics. Another blog worth taking a look at is called “Life as a Healthcare CIO.” 22 Aside from the audio podcasts we discussed on the previous slide, there many other audio and video materials available to learn more about health informatics. Surprisingly, there are several years worth of lectures from highly credible sources. Often, book authors provide a one-hour lecture reviewing the elements of their book. This can be a highly effective way to get a review of a new topic very quickly and inexpensively. Several years ago, I was approached by a leading competitor looking to hire someone where the work would require a technique I was not familiar with. I listened carefully as the recruiter described this role and the technique as best he could. When I got off the phone, I did a Google search and found that the author who invented the technique had done a presentation recently which was available in video form. In essence, I got a personal briefing from the world expert, exactly when I needed it, and for free on the Internet. In addition to various free sources of audio and video educational materials, there are important commercial sources to be aware of as well. Most of the national healthcare conferences are recorded and available for purchase. In recent years, many have been made available for download from the Internet. So whether I’m able to attend the conference or not, I can enjoy the presentation slides as well as at least the audio of the speaker presenting the slides, and save the best for future reference. Again, this is an unparallel opportunity to connect with the leading experts, specifically when and where you’re interested in their topics. 23 This 16-minute video from Morrie Shechtman is definitely worth the time to watch. He covers the issue of the old deal and the new deal we discussed earlier with terrific clarity. 24 Several times in this presentation, I made reference to Manager-Tools. My general advice is go to the Website, manager–tools.com, and listen to any podcast on a topic that looks interesting. There is a set of podcasts on the site identified as “the basics,” which would be a great place to start. There’s also plenty of information on interviewing, resumes, dealing with recruiters, and other related topics. If you find that it’s your style to listen to podcasts, I’m sure you’ll find these very interesting and valuable. You’ll also find a set of podcasts that focus on what are called “career tools.” I’ve listened to several of these and found them quite good. The Basics of management: http://manager-tools.com/podcasts/all-podcasts?sort=asc&order=Date&filter0=108 25 Earlier in this presentation I made reference to the ability to get just-in-time tutoring from the world’s experts on many contemporary topics. This slide simply shows how I went from the word ”scrum” to identifying the author of the preeminent text book on the topic, as well as an hour long video tutorial summarizing the technique in the book. These are very powerful tools for rapid learning. 26 When I was putting these slides together, I felt like something was missing. I realized that there was an intrinsic quality to working for a corporation that might be important to call out in the process of discussing non-clinical careers for physicians. The first issue is where does the professional's power and influence come from? In many ways the four items listed under this bullet highlight the issues we discussed earlier in this presentation. That is with the exception of the last item, "core group structure.“ For more on that topic, I strongly encourage those of you who are interested to read the review on Amazon.com of Art Kleiner's book, “Who Really Matters." The second list, Interpersonal Effectiveness, addresses some of the key structure and process issues found in every organization, corporate or otherwise, that may lead to either healthy functioning or what's called a passive aggressive organizational dysfunction. If you’re interested search for the article, "The Passive -- Aggressive Organization," by Gary L. Neilson, Bruce A. Pasternack, and Karen E. Van Nuys, in the 2005 Harvard Business Review. It’s freely available on the Internet. The Passive-Aggressive Organization: “It’s a place where more energy is put into thwarting things than starting them, but in the nicest way. A startling percentage of companies, especially large, established ones, display the symptoms.” 27 28 29 30