An Exploratory Case Study: Effects of a Physician Organizational Socialization (Enculturation) Program
By Richard Pitts, DO, DABEM, DABPM
Abstract
This article presents compelling data supporting a comprehensive enculturation program for physicians entering a medical group practice and fills a void in the literature about improving the process whereby physicians can more effectively enter a medical group. As far back as 1999, a study noted that physicians joining the Mayo Clinic physician group took five years to be fully integrated into the medical group. Further research was called for, yet no studies on enculturation of physicians into a medical group have been reported. Unlike medical science, in which double-blind studies are the gold standard for proving a hypothesis of care, double-blind studies are essentially impossible to conduct in the social sciences. However, what can sometimes be identified are patterns of behavior that although they fail the test of a double-blind study can be helpful in decision making when it comes to individual and group behavior. It is in that spirit that I conducted a social science exploratory case study. In the midst of a challenging year of conversion to an electronic medical record, the survey had a 40% response rate with compelling comments on the effects of the program. The study suggests that the enculturation program provided those queried a clearer understanding of the complexities of a large integrated medical group, with much earlier integration into a large medical group in contradistinction to the Mayo Clinic study. This study is important because of the lack of research in the area of enculturation of physicians into large medical groups.
Introduction
Why should an organization care about what happens when a newcomer joins the organization? It seems obvious that companies invest time, energy, and money in recruiting and trying to retain workers that a company values. However, do organizations try to discern the newcomer’s perspective on what happens when a newcomer joins a company? Some newcomers set personal work goals, and these frequently are centered around job satisfaction.1 Yet what if these goals are not achieved or are deemed unachievable by the newcomer? The newcomer’s commitment to the organization may either falter or simply not develop at all.2
Schein3 shook up the management world with his thoughtful article on what happens when someone joins an organization. For better or worse, a newcomer receives an informal or a formal introduction to the organization in which the newcomer learns what it means to belong to the organization. Schein3 coined the term organizational socialization to describe the process whereby newcomers learn how to get things done in an organization in an acceptable manner while remaining welcome there. It seems that achieving mutual expectations is what organizational socialization is all about. Yet organizational socialization that is too formal risks making the newcomer a conformist to such an extent that creativity and fresh ideas are smothered. Conversely, too little of a socialization process in an organization may result in the newcomer being disruptive. Perhaps even worse, if no formal organizational socialization occurs, informal socialization may occur, resulting in a default culture. Companies may be reluctant to invest time and money in an organization socialization program. Yet can the dollar value of a loyal and committed organization member be calculated?
“In effect, we must teach our students to become change-agents, whatever their disciplinary specialty turns out to be. We must teach them how to influence their organizations from low positions of power without sacrificing their professional values in the process. We must teach them how to remain creative individuals in the face of strong organizational pressures.”3p10
Of all professions, medical groups may have the most difficult time socializing newcomers.4 After US medical students complete college, they must complete an additional 7 to 11 years of technical education (specialty dependent) to become licensed and achieve board certification. Although the technical training is intense and comprehensive, physicians in general do not receive training in group dynamics or learn how to become an effective member of a medical group. In this study, I investigated the effects of formal organizational socialization on a six-year cohort of new physicians entering a medical group.
Bender et al5 found that it could take up to five years for a physician to reach the highest level of group function at the Mayo Clinic. They posited that it is common sense that whatever must be done to integrate new physicians as quickly as possible into a health care organization should be done. As a result of their findings, Bender and et al called for research in the area of physician socialization into health care organizations.5
Besides trying to make medical groups function more effectively, what about reducing physician attrition from medical groups? Cooper-Thomas and Anderson1 established that newcomer acquisition of information improves job satisfaction and commitment to the organization and decreases intention to leave an organization. Also, patient satisfaction relates directly to physician satisfaction, which in turn relates to being tightly bonded to the medical group. Hence, satisfaction for all three—medical group, physician, and patient—is highly interdependent.6,7
Purpose
This study was conducted as a preliminary attempt to understand the effects of a formal organizational socialization program for physicians who enter a large medical group practice.
Significance
Effective organizational socialization assists with at least three facets of an organization member’s life: improved job satisfaction, improved commitment to the organization, and decreased likelihood of leaving the organization.8 At the time that I conducted my study, the most recent data on health care costs in the US were from 2004. According to the Centers for Medicare and Medicaid Services, 2004 US health care costs approached $1.9 trillion. Estimates were that these costs would rise an average of 7.2% per year, resulting in an estimated cost for health care of $4.0 trillion by 2015.9 In an attempt to decrease overhead costs, physicians tend to practice in groups instead of alone.10 Yet little has been written about how to integrate physicians into a group environment. The knowledge generated by this research may have wide applicability to the medical profession as it transitions to more of a group-practice environment from solo entrepreneurial practices. Also, those medical groups that continue to add new physicians may also benefit from understanding the importance of rapid organizational socialization of newcomers. This research may help to establish recognition that rapid organizational socialization may help stem the loss of physicians from a medical group as well as help physicians reach their full potential within the group earlier than the five years suggested in the study by Bender et al.5
Background
I conducted my study at Kaiser Permanente (KP) Orange County, which had approximately 340,000 patient members at the time. The county is a mixed urban and suburban community. KP is a partnership between two entities, an insurance plan—the Kaiser Foundation Health Plan—and the Permanente Medical Groups. The KP program provides comprehensive care to almost nine million individuals and has an annual budget of more than $25 billion. One of KP’s core values is to spend as much of the premium dollar on health care as possible and as little as possible on nondirect patient care11 (Kenneth Bell, MD, personal communication,December 2003).a
The Colorado Permanente Medical Group (CPMG)determined that the loss of a single physician from [the] CPMG resulted in approximately $300,000 in expenses not related to direct health care as well as unnecessary utilization of medical resources (Kenneth Bell, MD, personal communication, December 2003).a
Corroborating the CPMG study, Buchbinder et al12 reported similar results. Included in the costs were the expense of recruiting a new physician to replace the one who left, training costs of integrating the new physician into the culture of the organization, increased Emergency Department visits because of lack of familiarity by the patient with substitute physicians, and an increase in the use of laboratory and radiology studies.
Literature Review
What are the dimensions of organizational socialization? In a seminal article, Chao et al13 identified a lack of precision in terms of the dimensions of organizational socialization. In 1994, literature on the topic was focused on either the process of socialization or its content. However, Chao et al noted that there was little if any actual research to verify the content of organizational socialization. They designed and completed a five-year longitudinal study that set out to confirm six content dimensions of organizational socialization through the use of a self-reporting questionnaire that used a Likert scale for reporting. Their research supports the idea that organizational socialization is a dynamic state depending on what is going on in an individual’s life at the time a survey is completed. The results of their study support the idea that job performance, proficiency, company politics, language unique to the organization, organization goals and values, and organization history are six conceptual dimensions of organizational socialization.
The beginnings of organizational socialization as a science can be traced to the mid-1900s. At that time, anthropologists started to explore the commonalities found in groups of people and, more specifically, how these groups of people or collectives behaved.14 What evidence is there of the significance of the first year in a new organization? Chatman15 found that the socialization process of new members of an accounting firm was especially active during the first year of employment.
What about rapidity of organizational socialization? Cooper-Thomas and Anderson1 identified a gap in the literature with respect to how quickly organizational socialization takes place. They constructed a longitudinal study over eight weeks in a group of British army recruits. Although this study was admittedly in a very intense military environment, significant adjustment was found in the newcomers at the end of two months of training.
How is the idea of success measured in organizational socialization programs? Typically, researchers have adopted three items to measure that correlate with success: job satisfaction, organizational commitment, and intention to quit.16
Research Design Methodology
Unlike medical science, for which double-blind studies are the gold standard for proving a hypothesis of care, double-blind studies are essentially impossible to conduct in the social sciences. However, what can sometimes be identified are patterns of behavior that despite failing the test of a double-blind study can be helpful in decision making when it comes to individuals’ and groups’ behavior.
Currently KP offers a health care program in eight regions: Mid-Atlantic (Washington DC, Virginia, and Maryland), Ohio, Georgia, Colorado, Southern California, Northern California, Northwest (Oregon and Southwest Washington), and Hawaii. At the time that I carried out my research, these eight regions combined served approximately nine million members. In each region, a regional Permanente Medical Group (PMG) is partnered with the Health Plan to provide integrated health care. The PMGs are discrete corporations with physician shareholders. In Southern California, the PMG is organized as a partnership of approximately 4500 physicians called the Southern California Permanente Medical Group (SCPMG). There are many subdivisions of the Southern California Region of KP, one of which is KP Orange County, CA. KP Orange County has approximately 400 physician partners serving approximately 340,000 Health Plan members and is one of the fastest-growing medical service areas in the KP program.11
The population for this study was physicians new to SCPMG Orange County. These new physicians completed a formal nine-month organizational socialization program. The program was designed in accordance with the work of Chao et al.13 The program met approximately every two weeks for nine months. Each meeting was approximately 90 minutes long. Teaching methods stressed small-group interactions followed by reports to the larger groups from the small groups.
Study Subject Selection
Permission was sought and granted by the Walden University institutional review board and by the medical director of the KP Orange County Medical Service Area to conduct the proposed case study research.
Great care was taken to avoid selection bias of study subjects. Six years of physician-participant archival logs were used to determine data for physician participants, including what year each one participated in the program. A random-number generator was used in the selection of names to take part in the study. Three candidate participants were randomly identified from each of the six-year cohorts of participants, yielding a total of 18 possible participants.
A letter of invitation approved by the institutional review board, was e-mailed to the 18 potential participants, along with the initial study questions. Seven of the 18 invitees were willing to participate in the study, and 11 formally declined, citing current intense work conditions because of the implementation of an electronic health record. Originally, the study was envisioned as using face-to-face interviews. However, with workplace conditions changing because of the implementation of an electronic health record, virtually all of the candidates preferred to answer the questions in writing at their convenience.
Data Collection
Participants were asked to fax the completed questionnaire to a secure fax. On arrival, the faxes were photocopied and separated into two batches, which were securely stored at two separate physical locations. As each fax arrived, the participant list was updated to reflect completion of the questionnaire.
Data Analysis
The purpose of this exploratory case study was to gain an initial understanding to serve as a platform for a more comprehensive case study of the effects on participants of a formal organizational socialization program. The initial analysis of the data began with data loaded into an Excel (Microsoft, Redmond, WA, USA) spreadsheet. Color-coded data cells were used to identify patterns of responses. Usefulness of the questions was also evaluated.
Limitations
The purpose of an exploratory study before a more in-depth study is in essence to see whether the researcher is on the right track in planning a more detailed study. Hence, inherent in an exploratory study is incompleteness. However, important information may still be obtained, as is presented here. An additional limitation is that because data collection was done through self-reporting, the data have the potential for reporting bias and/or recall bias.
Results
Of the 14 questions in this exploratory study, six questions were simply gathered data. Eight of the questions were substantive and generated a total of 84 potential response cells on the data spreadsheet. Seventy of the 84 cells could be populated with data, yielding an 83% cell-completion rate.
Color-coding of the 70 data cells suggested four major areas of confluence or themes with respect to answers. (Table 1) Sample responses in support of these themes are:
1. Developed a strong sense of belonging: “Having the history/philosophy of KP gave me a sense of belonging and understanding. I feel like I belong rather than just [show] up for a job.”
2. Gained improved communication skills: “It was a great venue [in which] to meet my fellow colleagues, and my interaction with them was enhanced by the program. We now usually page each other first for advice because we have such a great relationship.”
3. Gained multiple resources for success at home as well as at work: “I am more patient with others. I also see that my husband is more patient with me, and we try to understand each other’s point of view on a personal and a professional level.”
4. Gained information in the program that will produce better function within the organization: “I feel that doing the enculturation program allows me to appreciate how complex yet organized our system is and how I can work best within this system and what is expected of me.”
Questions and Sample Responses
The following key questions were used in the survey; I have included some of the compelling responses from the cohorts sampled:
• Engaged in workplace? (All responded yes.)
• Can you cite examples in your work at KP where you used principles that you learned in the enculturation program to help you solve your problems?
- “Daily dealings with patients, staff, colleagues.”
- “Learning about the process of change in a large organization. We have successfully acquired more psychiatric space at Euclid after reviewing the data, working collaboratively and problem-solving instead of making hasty decisions.”
- “Be ‘proactive, not reactive.’ With angry patients, I try to hear what they are saying and listen to them, and they are very appreciative.”
- “Doing group and team activities in the enculturation program has assisted me tremendously in [understanding] how our other specialties operate, and to develop friendships.”
- “There was a situation in which a patient was belligerent to the staff and support staff. Instead of directly confronting the patient, I recruited the ombudsman (KP ombudsman presented during the enculturation program) to serve as a liaison, and everyone was happy.”
- “With the enculturation program, I have become more open-minded, appreciative, creative, patient, efficient, and knowledgeable about our organization—which has resulted in better patient care.”
- “The four (clinical) habits program showed me how to better interact and respond to my patients. It has definitely helped me in situations when I had to deliver bad news to my patients, [such as a] diagnosis of colon cancer.”
• Have you seen behavior in either yourself or others as a result of the enculturation program? If yes, what behavior?
- “Being leaders/role models in the workplace.”
- “From the way my colleagues operate, it appears that they have also completed the enculturation program, so I have not noticed that they don’t demonstrate these principles.”
• Are you happy with your position at KP Orange County? (All responded yes.)
- “I feel much satisfaction in my work.”
- “I feel like I belong and can do what is best for my patients without worrying about the cost. Generally, there are very few egos to deal with.”
- “I like helping my patients. I enjoy being with my coworkers …. I don’t enjoy the stress of too much indirect work.”
- “Wonderful partnered and associate physicians willing to work together for the needs of our members. Good working relationships with ancillary staff.”
- “Indirect work difficult at times.”
- “I have been very satisfied and happy with my position [here]. I enjoy my job, my peers, my work environment, and the way patients are receiving good quality care.”
- “I enjoy working with my patient population. It is gratifying. I also enjoy working with my colleagues.”
- “Happy, strong group of colleagues.”
• What aspects of the enculturation program contributed to either your job satisfaction or dissatisfaction?
- “Helpful to understand culture of organization. Helpful to know that change can be accomplished. Specific physician examples discussed at sessions.”
- “Understanding the culture of SCPMG. Enabling me to have the tools necessary to make change if change was needed. Created a sense of community with peers in different specialties. Seven Habits course in retrospect [was] invaluable [for] interacting with patients and peers.”
- “I think the most important factor was the friendships that I developed. This goes a long way each day in making my job fun and challenging.”
Discussion
This preliminary study prepares for a more comprehensive study, as is often the case in both the medical sciences and social sciences. It can save valuable time and resources later by fleshing out unforeseen issues in designing a comprehensive study or by confirming preliminary assumptions regarding the more comprehensive planned study. On occasion, an exploratory case study may uncover compelling information of interest to the larger community, as in this study.
Overwhelmingly, the respondents agreed that the enculturation program provided them with valuable information and tools to better do their jobs at KP and to a certain extent in their private lives as well. Their clearer understanding of the complexities of the organization resulted in earlier integration into a large medical group, in contradistinction to the Mayo Clinic study. Substantial effort was undertaken to avoid selection bias, which suggests that the broader group may provide similar results.
As already mentioned, the four major areas of confluence or themes from physicians’ responses were as follows: 1) developed a strong sense of belonging; 2) gained improved communication skills; 3) gained multiple resources for success at home as well as at work; 4) gained information about the program that will produce better function within the organization.
An unsolicited comment from John Davenport, MD, JD, Chief of Family Medicine for KP Orange County, supports the positive effects of the enculturation program as reported here. Dr Davenport noted that when asking for physician volunteers for projects or committees, he received a higher percentage of positive responses to his call for help from the physicians who had completed the enculturation program than from those who had not. This observation is consistent with information on citizenship, ownership, and partnership responsibilities presented during the new-physician enculturation program.
One final observation with respect to the enculturation program at KP Orange County: The physicians who complete the program are frequently heard to say that they have formed lifelong friendships that cross geographic and specialty boundaries. Many physicians comment that when they need advice on how to manage a case, instead of using a call list to get help, they will simply call one of their friends in that particular specialty—a friend made during their participation in the enculturation program. Does this confirm the idea that first comes a relationship, then comes ease of communication? What value can be placed on ease of communication when asking for help in a large organization?
Improved understanding of the complexities of the KP organization, along with improved understanding of expectations in the areas of citizenship, ownership, and partnership, plus earlier engagement in the group role as physicians in a multidisciplinary medical group, are compelling reasons for a robust and competently administrated enculturation program early in a physician’s entry in to a medical group.
a Former Medical Director, Kaiser Permanente Orange County.
Disclosure Statement
The author(s) have no conflicts of interest to disclose.
Acknowledgments
I would like to acknowledge the following individuals as sources of encouragement for this work: Jeff Weisz, MD, Medical Director SCPMG; Mark Klau, MD, Physician Director-Leadership Development SCPMG; Nancy Spiegel, Manager-Leadership & Organization Leadership SCPMG; Lucia Soh, Director-Physician Leadership and Performance SCPMG; Karen Olson-Coordinator Physician and Graduate Education KP Orange County; Edward Ellison, MD, current Associate Area Medical Director for KP Orange County; and Kenneth Bell, MD, former and long-time Associate Area Medical Director for KP Orange County. And, a very special thank you and acknowledgment to Ruth Maurer, PhD, my faculty chair and mentor at Walden University. Dr Maurer’s help and guidance were key in successfully completing this exploratory study.
Katharine O’Moore-Klopf, ELS, of KOK Edit provided editorial assistance.
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