So You Want to be a Medical Director?

The ad seems straightforward: “Wanted: Medical director for a 120-bed, three-star facility in suburban area. Eight hours a month.” The idea of padding your income sounds appealing; how difficult could a job be that requires only one day a month? The answer is, more difficult than you might think. A nursing home is a highly regulated environment, with rules guiding every drug prescribed and everypolicy decision made; each employee is under close scrutiny at all times, including the medical director and everyone he or she oversees. A position as medical director of a nursing home does offer many rewarding opportunities to improve care for the nation’s elderly and most vulnerable patients. It also comes with a myriad of challenges, which any prospective applicant must carefully consider before knocking on the door of opportunity.

What Does a Medical Director Do?

The medical director serves an important role at the nursing home, and federal regulations defining that role at first glance appear straightforward. The Code of Federal Regulations (42CFR483.1-483.75), which originated in 1975 and are often called OBRA or F-tags, outlines the medical director’s roll in F501 (42CFR§483.75(i):

(1) The facility must designate a physician to serve as medical director. (2) The medical director is responsible for (i) Implementation of resident care policies; and (ii) The coordination of medical care in the facility.¹

While this job description is direct and to the point, the proverbial devil resides in the details, also known as the Interpretive Guidelines. The Centers for Medicare & Medicaid Services (CMS) issues these guidelines, which were last updated in 2006. Over time, the Interpretive Guidelines have clarified the role of the nursing home medical director, seeking to bring more professionalism to the position and emphasizing the importance of the medical director’s leadership within the facility.^1-5

The guidelines delineate the necessary qualifications for a medical director, which include knowledge of practice standards in medicine and long-term care; the many hats the medical director wears (eg, clinical leader, conflict-resolver, advocate); and his or her duties at the facility, consisting primarily of implementing policy and serving as a member of quality committees. Each state has its own guidelines for long-term care facilities that may further shape the role of medical director. A medical director might serve as an employee of a single facility or a nursing home “chain” or may be contracted to execute certain duties for a specified sum or an hourly rate.

Eight hours (1 day) per month is the minimum time commitment required for a 100- to 200-bed facility,⁶ and the medical director must cram a great deal of oversight, meetings, and reviews into this short window. Standard responsibilities include attending committee meetings (eg, quality improvement committee, infection control committee), evaluating policies and procedures, and reviewing difficult cases or incident reports.

Immersed in Policies and Procedures

The medical director’s time is not meant to be spent on clinical visits or resolving individual problems. The medical director is expected to take a systems approach to care. For example, whereas an attending who learns that Mr. Smith’s advance directive was left behind when he was transferred to the hospital might telephone the hospital and arrange to send the advance directive over, the medical director must take a wider view of the situation. Why did Mr. Smith go to the hospital when his wishes were for “comfort care?” What assessment did the nurse perform? What was the physician told? Where were the documents and why did they not accompany Mr. Smith to the hospital?

The medical director identifies the multiple systems that came into play during the incident and tries to determine which ones succeeded and which ones failed. Then he or she considers ways the organization might modify policies or procedures to prevent the error from recurring. The exact role of medical directors in policy and procedure development and implementation varies, but the expectation is that it involves more than just signing the front cover sheet of the “P and P” binder. The intent of the F501 regulation is to ensure that the medical director has a key role in helping the facility incorporate current standards of practice into resident care policies and procedures.

Medical directors are not asked to supervise staff members’ daily performance, but they are expected to develop, review, approve, and help oversee implementation of the policies and procedures covering everything from admission, to infection control, nursing practices, resident rights, end-of-life care, and management of 24-hour physician coverage.¹ These responsibilities are accompanied by enhanced liability—medical directors are sometimes more likely to be named in lawsuits involving care at the nursing homes where they work.⁷

At the Front of the Herd

Perhaps the biggest challenge a medical director faces is in providing oversight and quality assurance of the other physicians employed at the nursing home. Although this rarely involves direct supervision (eg, hiring, paying, or dispensing raises), the medical director is responsible for developing mechanisms to monitor and improve the physicians’ behavior. A medical director may have to recruit physicians or assist them in separating from service. The medical director might also be tasked with setting expectations for the other physicians, as well as counseling, educating, or motivating them on how to improve their care practices. Carrying out these types of actions generally requires tact, excellent communication skills, and an ability to help others see “What’s in it for me?”

Physicians are notoriously difficult to manage—some have said it’s like herding cats—and are accustomed to practicing alone with little oversight. Physicians have established routines they consider efficient and comfortable and are reluctant to alter them. One physician may not believe that another with a similar specialty, even with the title of medical director, has any particular expertise to justify giving unsolicited advice. Some physicians chafe under regulatory requirements (eg, prescribing restrictions) and oversight that they feel infringes on their autonomy. Regulated pharmacist reviews of records are potentially another source of tension. Managing physicians effectively necessitates working alongside them and facing the same challenges, listening to their perspectives, finding a nonintrusive way to “help,” and convincing them that the proposed changes are in their best interest.

Building a Foundation for Success

Being a successful medical director requires a solid understanding of long-term care issues and practices and leadership skills. Nationally accepted statements concerning the roles, responsibilities, and functions of a medical director expand upon the Interpretive Guidelines and can be found at the American Medical Directors Association (AMDA) Website (www.amda.com). AMDA aims to professionalize the job of medical director and identifies four domains critical to medical director success: physician leadership; patient care/clinical leadership; quality of care; and education, information, and communication. For those interested in serving as a medical director, AMDA offers training to become a Certified Medical Director (CMD) and provides recertification opportunities.

Educational instruction includes clinical coursework in geriatric medicine and conditions commonly encountered in the long-term care setting (eg, falls management, pressure ulcer diagnosis, prevention and treatment, polypharmacy, psychotropic medication and behavior management, dementia, diabetes) and offers courses in leadership, management, regulations, and quality improvement techniques. AMDA’s training in leadership and management—a subject rarely taught in medical school—is particularly helpful. Physicians attracted to medical directorships may have inherent leadership traits, but developing leadership and management competencies requires time and effort. Any expectations a prospective medical director might have that, as a natural leader, he or she will simply be able to step in, tell others what is wrong, and then write an order and have it followed will be quickly dashed.

Leadership is about setting the standard and convincing others to strive for the same level of excellence, and it requires lowering barriers and providing proper incentives. Clinical acumen is essential for a CMD. The medical director is the know-it-all, go-to person and must have an up-to-date understanding of the issues in geriatric medicine, long-term care, and risk management. Medical directors are experts called upon to set policy, decide on best practices, and deal with highly complex clinical and ethical challenges, such as the large pressure ulcer in a patient refusing all care and the irate family that plans to sue, or the end-of-life ethical dilemma in Room 56.

Medical directors apply their knowledge to advancing the quality of care, reviewing processes and developing systems designed to assure and improve quality. In addition, as members of the Quality Improvement Committee, medical directors are expected to know current terminology on quality management (eg, continuous quality improvement, quality control, person-centered care, root cause analysis, Plan-Do-Check-Act, Lean). The education, information, and communication component of CMD training focuses on the need for medical directors to be excellent communicators and educators and to model up-to-date clinical practice.

Cultural and Political Savvy Needed

On a day-to-day basis, being a medical director requires one to be passionate about excellence, good at meddling, and unafraid to be “under the microscope” and to be political, patient, and persistent. Too often, an excellent physician asked to become a medical director fails because the needed skill set is different.⁸ Physicians often work independently, having a series of brief one-on-one interactions. In contrast, medical directors operate as a somewhat peripheral (mostly absent) member of a team dominated by nursing culture, nursing perspectives, and numerous regulations.

Long-term care facilities are primarily run by and staffed by nurses, and successful medical directors must be savvy to this culture. Whereas hospital nurses are predominantly registered nurses, long-term care facilities may have only one registered nurse for 30, 60, or 90 patients. Most nursing staff are certified nursing assistants and licensed vocational nurses, who have far less education than registered nurses and are not permitted to assess patients. Long-term care nursing has its own vocabulary—a language of abbreviations and acronyms, of state and federal regulations.

Physicians rarely have an understanding of nursing culture, and nurses rarely volunteer to teach it to them, much to the detriment of both professions. Success as a medical director depends on learning to understand nurses’ culture and speaking their language, thereby gaining their trust. Influencing an organization involves aligning your objectives with the existing nursing culture. A medical director must understand the facility’s political nature and avoid becoming a “pawn” used to advance the agenda of one person over another.

A physician in this position must also remain watchful for the “Yes, doctor” response, where he or she is treated deferentially face-to-face and given assurances that “It will be done,” yet nothing changes and business proceeds as usual. Present only 8 hours a month, keeping to the office signing policy and procedure manuals and listening to reports in the Quality Committee meeting, the medical director might be treated respectfully, yet fail to get a true picture of how the facility is functioning. To be successful in improving care, the medical director needs to investigate the organization more closely to gain an understanding of its strengths and challenges.

Is This Job for You?

Considering what the job is really asking, perhaps the advertisement should have been written thusly: Wanted: Medical director for 120-bed, three-star facility in suburban area. Eight hours a month paid, although the job will consume more of your energy and time than this. Must be comfortable assuming responsibility for high-risk situations not directly under your control, handling conflicts, writing, speaking, attending meetings, navigating inter-office politics, confronting other physicians, and signing your name. Must be able to convince other physicians to change their practices, be politically savvy, and bilingual, with fluency in “nursing.” Understanding of geriatrics a plus. Must not be bothered by nurses, pharmacists, and regulations constantly telling you how to improve your practice. Despite the regulations, meetings, and the seemingly endless policies, conflicts, and politics, the medical director position can be immensely satisfying. Medical directors get to take care of patients “where they live,” alongside caregivers eager to learn, in a dynamic and growing field of medicine. The training and mentorship offered through AMDA equips one with the skills needed to succeed and a valuable network of resources and colleagues. Working as part of an interdisciplinary team greatly enhances medical care and produces real-world solutions to almost every problem faced. As medical director, your influence extends beyond the care of a single patient. Initiatives to reduce the use of restraints and unnecessary medications, to improve the care of those with dementia, and to reduce falls have an impact on not just one patient, but on all those who come afterward. What you accomplish as medical director is dictated more by your initiative and perseverance than by any mandate. If, after reading this, you are still interested in the position, go for it! Dr. Ferrini has served as a full-time medical director in a 192-bed, five-star, distinct-part long-term care facility in Santee, California, for 11 years and was honored in 2009-2010 as the AMDA Medical Director of the Year for her role in transforming her facility.

References

1. State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities. www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed March 11, 2011.

2. AMDA-Dedicated to Long Term Care Medicine. www.amda.com. Accessed March 11, 2011.

3. Institute of Medicine. Improving The Quality Of Long-Term Care. Washington, DC: National Academy Press; 2001. Accessed March 11, 2011.

4. Levenson SA. Medical Direction in Long-Term Care. A Guidebook for the Future. 2nd ed. Durham, NC: Carolina Academic Press; 1993. 5. Levenson SA. Medical Director and Attending Physicians Policy and Procedure Manual for Long-Term Care. Dayton, Ohio: MEDPASS; 2005.

6. Brubacker MK, Ferrini RL. Maximizing physician services in aging services. Presented at: American Association of Homes and Services for the Aging (AAHSA) Annual Meeting; Chicago, IL; November 10, 2009.

7. Kapp M. Is there a doctor in the house? Physician liability concerns and quality of care in nursing homes. California Healthcare Foundation; 2008. Accessed March 11, 2011.

8. Ferrini R. Perspectives. Making the successful transition from physician to medical director. Annals of Long Term Care: Clinical Care and Aging. 2009;17(12):25-26.