Many ASA members have interacted with members of the “C-suite” at various health care facilities. These interactions, discussions, and negotiations can range from the pleasant, to the unpleasant, to the occasionally absurd. But, as a predominantly hospital-based specialty, anesthesiology has no choice but to cultivate some sort of effective working relationship with administrators in order to remain robust and viable on the local level.
Let’s flip the script and imagine what goes through the minds of health care executives when they face us and other physicians across the conference table. Our guide in this exercise, and our Expert this month, is Mr. Russ Armistead, a very recently retired hospital executive with many decades of experience. Mr. Armistead is noted for his pleasant, unflappable demeanor and his desire to lead from the front lines and be visible to all hospital personnel.
Can you give a brief biographical blurb – early life, education, professional trajectory?
I grew up in a small town in Virginia and worked with my father’s oil business while in high school. I went to Virginia Tech and majored in business and accounting, with the idea of becoming a CPA with a national accounting firm. After graduation, I worked as a CPA for Ernst & Young in Winston-Salem, North Carolina, for six years. Two years after starting that job, my wife and I had a special needs child (spina bifida and hydrocephalus), and I knew I would need limited travel and access to specialty care. Fortunately, one of my audit clients was Wake Forest University (WFU) Clinics (i.e., physician practice plan), which added an accounting position for me at the WFU College of Medicine. Six months later, I was asked to work for the dean of the College of Medicine and spent 24 years in various staff and executive leadership positions. While working, I went to graduate school at WFU and earned an MBA. I learned health care from the perspective of representing physicians. I was responsible for the finances of the college and practice plan while reporting to the dean.
What got you interested in becoming a hospital executive?
Luck and confidence in my ability to succeed! I left WFU after 24 great years. I was still relatively young, so I set up my own consulting firm to keep busy and earn some money. I was hired by the interim president, dean, and board of a medical college and hospital in Toledo, Ohio, as a financial consultant, paid by the day! It was a public institution, so my contract was front page news for the Toledo Blade. Shortly after I arrived, I realized they were planning to hire a physician to lead the hospital. I went to the interim president and dean and told her I could be both the CFO and CEO, since their immediate issue was improving finances. I said, “If you hire someone else, you will never be sure who is succeeding or failing. Let me do both, and if I’m not successful, it would be easy to fire me! Besides, I will be cheaper than another new person.” Well, she agreed, and I was successful in improving the hospital finances over the next 10-12 months.
What about the job did you find most rewarding?
I first needed to figure out my duties as the CEO, since this was the first time I was working for a hospital. So, I called a friend who was a hospital CEO and literally asked, “What do I need to do?” Sounds crazy, but it worked. The most rewarding part of the job is the ability to help staff and physicians provide the best patient care possible. The constant interaction with staff and physicians and the feedback that you are helping them make a difference in patients’ lives was also rewarding.
What were the least pleasant aspects of the job?
The least pleasant aspect is dealing with personnel issues like terminating an employee or forcing corrective action. These are necessary and I always remind individuals that while the current job is not right for them, there is a job they can do well. They just need to find it. Also, working in a “sunshine state” (where all communications are public) is difficult. You must always be honest but be very thoughtful about how you say things.
As a nonphysician, how have you been able to establish common ground and optimal communication with physicians?
This is easy now that I have over 40 years of experience. Always remember you are not a physician and will not be effective if you try to be an equal! Physicians will respect you if you are honest and truthful with them, but that is about as close as you will get. I learned my lesson early on in a faculty practice plan committee meeting with all the department chairs while I was serving as director of the practice plan business functions (i.e., billing/collecting physician fees). The committee chair was asked a question about the business operations and asked me to respond. I did, and there was a follow-up question that I started to answer but was interrupted by a department chair who told me they did not ask me the question. Then the committee chair asked me to answer the follow-up question. I learned it was important to remember my place as a guest and not a member.
I also learned from my WFU days that I could be an equal in discussions with one physician, but if there was more than one physician present, I would have no chance of convincing them about anything! I have seen physicians, who I knew disliked each other, join together to destroy my idea(s). The only way to convince physicians to change or agree with an idea developed by a nonphysician is to identify a trusted physician leader (especially an informal leader) and convince that physician that the idea or process was appropriate. If the physician agreed, he or she would introduce or support the idea, and it would have a chance of success. Otherwise, a waste of time!
Most important for me is that I like working with physicians and respect their skills and knowledge. My guess is this comes from my early need for medical specialist care for our son, or maybe just not growing up in hospital administration. There is a natural tension for resources between physicians and hospital leaders, which is healthy. Both have their responsibilities. Just remember, only doctors can admit patients into hospitals!
Hospital margins have never been very strong, and financial issues seem especially pressing these days. How do you see this affecting health care facilities?
Hospitals need to be financially strong to provide the best technology and equipment for physicians. These capital needs are significant and critical for physicians and staff to provide the best possible patient care. COVID changed the hospital world. The increased personnel costs across the hospital and the increased need to support physicians have dramatically reduced financial margins and, in some cases, caused financial losses. Meanwhile, the insurance industry has been unusually profitable because reimbursement rates have not caught up with increased hospital costs. I expect it will be another three to five years before reimbursement rates catch up. Hospitals will need to reduce capital spending to maintain financial stability, and smaller hospitals may not survive.
Aside from finances, what do you see as the biggest challenges for hospitals and hospital systems?
Hiring and maintaining staff at all levels is critical. Both the shortage of properly trained staff and high stress levels cause burnout and resignations. The same issues exist for physicians. Burnout is real, and the hard work ethic of senior physicians does not always exist in younger physicians. Younger physicians demand more work/life balance, which will cause a shortage of physicians in the next 10 years or so. Physicians and hospitals will need to determine how artificial intelligence will affect patient care. Safety within the hospital has become a critical issue – assaults on staff and physicians have become more commonplace. Additional security and safety measures are now required.
A big question, but one you are highly qualified to answer: How might the American health care system be improved and made more sustainable?
America has the best health care system in the world, but access is limited unless you have resources. The burden of caring for the uninsured and underinsured is a significant problem. We need to direct resources to preventative care to keep people healthy rather than devoting all our resources to treating illnesses and discharging patients who will often return. This is a societal issue that health care faces. Better living and eating, and managing alcohol and tobacco usage would do a lot to make our health care system more sustainable.
Now that you are retired, what are your plans?
We will alternate between North Carolina and Florida – wintering in Florida, with the summers in North Carolina. We plan to spend time enjoying family and grandchildren as they develop into adults. We will travel in the U.S. and internationally. I have a goal of paying more attention to my health and learning a new language.
Any parting words for our readers?
My most treasured honor was being made an “honorary member” of our hospital’s medical staff when I first retired in 2017. Each of you, as physicians, are in a place of privilege in our society, and you have a significant responsibility to maintain that privilege. Work/life balance is important, but you still retain a special responsibility to do what is best for your patients.
Remember, most hospital staff care equally about patients, too – learn to work with them as a team. You, your staff, and your patients will be better off if you do.