So what should a Chief Medical Officer do, anyway?
Unraveling the knot at the center of health tech org charts
Let’s say you’ve started a “digital health” company as a non-clinician. At some point along the way you will inevitably need to bring some clinicians on board. Usually this is when you realize you cannot go direct-to-consumer, that healthcare has rules, and/or because while you wanted to start a “tech” company, you’ve actually started a services company. Ouch. Fear not faithful readers, we are going to dive into what makes managing clinicians, especially physicians, just so unique, with some guidance on how to best bring them into your organization, starting with the top executive, the Chief Medical Officer.
What is a Chief Medical Officer (CMO)? What do they do, exactly? The CMO role is a big job, and like any other executive requires a team supporting them to function well. As we will cover in Part 2, clinicians, specifically physicians, are both primed and prone to do a larger share of individual contributor work than their colleagues. Some of this is due to professional upbringing and some is due the intersection of unique knowledge, high labor cost and regulatory/licensing requirements. Nevertheless, here are the (as of yet discovered), 5 pillars of a CMO role beyond strategic responsibilities of all executives. Spoiler alert: no one does them all well.
The five pillars of a CMO:
Sales Support
Clinical Administration or “Office of the CMO”
Clinical Development & Training
Clinical Operations/Management
Direct Clinical Care Delivery
Sales Support aka “A doctor we know”
Every new health care company, especially those with non-clinician founders and/or CEOs, will need to trot out some physician for credibility at some point during their sales process, the dog in the dog and pony show. The CMO-as-individual-contributor takes on several roles here – sitting in meetings, answering questions, even (gasp!) doing some of the sales presentations. Often they are positioned in front of opposing clinicians to neutralize their critical gaze.
Outside of direct pitches and sales meetings, clinical leaders give talks, write think pieces and are generally placed in the “thought leadership” category if they have the charisma (and support) to pull it off. Great work if you can get it, except the travel can be rough.
An aside about travel, most clinicians live down the street from where they work, so work travel is an insane concept. The not sleeping in your bed part, not so much, that we (and our spouses, to a lesser extent our children) have learned to deal with. We also don’t understand expense accounts.
The challenge with sales work is that it is individual contributor work, at the whim of other internal executives and (potential) customer desires. This is not unique to clinicians executives, but remember this “always pulled away” phenomenon when we get into the deep work of development and operations. The unique challenge for clinician leaders is when we ALSO have patient care responsibilities, generally considered a good idea for morale and service development. The double-ended unavoidable interruption phenomenon is brutal AND poorly understood at worst and meekly tolerated at best by everyone else.
CMOs who are good at sales will end up doing mostly sales, so you will need to hire support for the other roles. Again, normal for any other executive, but inexplicably problematic for clinician leaders, either because we cost so much, are too proud to ask for help, are really smart and capable so we seduce others (and ourselves) into thinking we can do it all, or all of the above.
If you are in this role, do not draw arbitrary distinctions about “the business stuff” and the “clinical stuff.” You run a clinical business and you are more capable of learning the “business” parts you don’t understand than the other executives are in learning the nuances of clinical medicine that took you a decade to master. Embrace your tremendous learning ability, crack the books, be willing to look foolish asking questions and get good.
Clinical Administration, the Office of the CMO
This is the boring, yet crucial element of running a clinical business, especially when licensed prescribers are involved. We are talking about licensure, credentialing, competency certifications, malpractice insurance, peer review protections, quality and safety reporting, incident management, privacy elements of HIPAA, owning the Professional Corporations in each state, etc. Think of these as the procedural enablers and protectors of clinical care, with the substantive elements covered in a different pillar. For clinician executives this is often the most “executive” thing they do in terms of leading others in running a function. Hurray?
This is a place to invest in administrative support and technology. Think of this function like your legal and compliance functions and resource accordingly with the right skills. Clinicians tend to accrue on the extremes of risk tolerance, with start-up clinicians being some of the most wacky, optimistic risk-seeking people out there. Don’t let them be in charge alone! Not only are these processes prescribed, detailed and nuanced, they come with documentation requirements and regular renewal cycles. There is no “one and done.”
Complexity grows rapidly as you add different clinicians, cross state lines and into government insurance programs. The rules will be confusing and arcane, the legal spend unsettling and clarity will always escape you. Welcome to healthcare!
Pro-tip: There are a few clinicians somewhere in your organization who LOVE this stuff. Deputize them under the CMO, hire an admin and let the CMO restrain them from going too crazy. You will be thankful when you have your first complaint/violation/DOJ letter/malpractice suit/clinician stealing drugs event.
Clinical Development and Training
My favorite, not going to lie. Sometimes called product, service, clinical or just development, this is the part of the business where you define what you actually do. This part of the business changes as your organization matures. The least interesting version is “clinical protocols” or “software requirements” but the basic idea is that a clinical service needs clinical input. Because I could (and will) write about this topic forever, for now, like the office of the CMO, staff this one with multidisciplinary professionals. In the beginning, while your clinician(s) may have clinical knowledge, converting that into usable operational guidance that can be experienced as a delightful service is far beyond them. Lower your expectations of what one clinician can do alone, even less what a few can do together (bicker endlessly about minutiae). Elevate this into a function, rather than an individual contributor role as soon as possible.
Pro-tip: Nurses (or those with a nursing background) are MUCH better at insisting upon and therefore creating step by step protocols than any other clinicians. Internal medicine physicians, those edge case-finding special snowflakes, are the worst.
We will cover staffing this function in Part 3: Career Paths for Clinicians, but in brief, choose your best clinicians for training, and your most averagest clinicians for development. The reason being, your best clinicians work in weird ways, and will design unusable things if you let them build for themselves. But, given what it takes to make a great clinician, they are generally the most empathetic communicators you have, which makes them dynamite in a training environment.
Clinical Operations & Management
If this previous pillar is “what is supposed to happen” then this is the “what actually happens” portion of your organization. It should be the largest by headcount and therefore chaos, and encompasses everything from “the vaccine fridge broke and we lost $50K” to “Doctor T. keeps making everyone cry” to “we don’t have a nurse available to work tomorrow.” Logistics, equipment, personnel management, service recovery, you name it. This pillar draws on the output of the administrative and development pillars to deliver your actual value to patient customers.
This pillar requires the greatest depth of executive skills from your clinician leadership, so it is the area where we start to see gaps in clinician leadership capability, bandwidth (or both). In an attempt to remedy this shortfall, most organizations experiment with dyadic leadership with a clinical and an operator leader working together. We continually put two in the box or attempt to matrix our way out of the basic fact that most clinicians were too busy learning and being clinicians, acting as individual contributors, to learn and apprentice in the skills of management. Pairing a clinical and ops person together inevitably results in power struggles and chaos. The individual contributor responsibilities pulling on clinicians (seeing patients and/or selling) means they always lose out to a full time, more experienced manager and get sidelined. The clinical spirit gets crushed, people leave, and your business falls apart. Sorry, but it keeps happening. Instead, find, develop and support the right clinical leaders and give them operational support.
For those of you still attempting to divide “clinical” and “operational,” the only definition that I’ve ever found is: “If clinicians find it boring, it is operational. If non-clinicians find it intimidating, it is clinical.” In other words, there is no clean divide, so stop looking for one! For those of you wondering where “quality” should live, the administrative pillar should be the scorekeepers, and the operating teams should be the players. Best to have them separated for optimal continuous improvements in performance.
Of note, it is the management of clinicians that is the most detestable part of the CMO role, and so a series of titles get spawned such as Chief Clinical Officer, Nursing Officer, Medical Director, etc. We will get into why this is so in Part 2, but needless to say, if all the clinicians do not ultimately roll up to your CMO, then they will become a disenfranchised executive.
Clinical Care
This one is self-explanatory and if you are exhausted just getting to this point in the list, think about how your clinicians feel! The usual pattern is that the CMO starts by providing care out of necessity of being the only clinician. From there they stay in the game more for inputs for developing the service over time. At some point, when many other clinicians come on board, they keep seeing patients for a combination of personal reasons (not wanting to let go) and to keep morale with the troops. A word to the wise – you will have to let go at some point. Caring for patients is a competitive athletic endeavor. When you are out of shape, you risk your patients and embarrassing yourself, so know when you should step back because of the crushing weight of your other responsibilities.
As you can see, being a CMO can/should be a very challenging job. In the best case scenario, you have a CMO/COO/CP(roduct)O hybrid who grows as an executive leader, who should be called the COO, with other corporate functions like HR and Legal placed with another executive. Most companies seem to have one person in each position, reporting to the CEO, who is then forced, while busy selling and fundraising, to resolve disputes between the triumvirate without the benefit of technical skills, specific details or time to do so. This results in an organizational logjam with confused priorities that befuddles your people and carries over into your customer experience. The worst case is that your underpowered CMO starts shedding responsibilities they don’t like, stunting their executive growth and marginalizing themselves within the organization, ultimately leaving to be replaced and/or having the role questioned entirely. Not great.
In Part 2, we will dig into the unique quirks that can contribute to clinicians being a challenge to manage, while emphasizing their absolutely unique value contribution. In Part 3, we will address what to do about it. More soon!