The middle and top management of hospitals in Slovakia is predominantly represented by physicians. This situation is well defined and justified when it comes to department heads, who represent middle management. However, even at the level of hospital directors, where more complex managerial knowledge and skills are required, physicians are most commonly found, with other professions being the exception. It is implicitly assumed that a physician represents the optimal candidate for this managerial position, since they have detailed knowledge of the hospital environment and the healthcare system, as well as patient needs, and this knowledge will have a positive effect on organizational efficiency and the quality of services provided. The necessary management knowledge can be supplemented through management training courses. This situation is not unique to Slovakia — it predominates abroad as well. However, abroad it receives considerable attention (e.g., Simpson 1994, Thorne 1997, Davies 2003, Davies et al. 2003, Harrison and Lim 2003), including regarding possible sources of conflict arising from the dual physician-manager role, as pointed out by, for example, Kippist and Fitzgerald (2009). In Slovakia, this problem has not yet received systematic attention, despite the fact that a non-physician hospital director is rare. This article presents some international experiences evaluating the impact of physicians in hospital management positions on the organization.

The Dual/Hybrid Role: Manager and Physician

A physician in a top hospital management position needs to balance two roles: the physician role, which focuses on addressing individual patient needs primarily in terms of diagnosis, therapy, prognosis, and prevention, and the top management role, which focuses on the entire organizational system, ensuring its smooth operation, resource management, processes, strategic management, change management, and quality management.

The proportion of time that a physician in a managerial position devotes to each role depends primarily on their position in the management hierarchy (Fig. 1). While at lower levels of management the majority of their working time is spent with patients, in a top management position managerial tasks clearly predominate.

Figure 1: The proportion of time that a physician in a managerial position devotes to individual roles — clinical work and management — depending on their position in the organizational hierarchy. (According to Boulton 2002).

However, the preparation of physicians for managerial positions has significant shortcomings. Management, as well as other disciplines key to organizational management such as law or economics, are minimally represented in undergraduate medical education. However, even in postgraduate education and lifelong learning, management is represented only to a limited extent. Management courses are part of postgraduate education and are required for middle and top management positions in healthcare facilities.

However, as Harding and Ford point out (Harding and Ford 2001), short-term courses without deeper management knowledge may paradoxically reinforce previously inappropriate habits, and some courses are more suitable for profit-oriented organizations. Moreover, the dual role of a physician in a higher management position can be a source of professional conflict as well as conflict with the surrounding environment in both horizontal and vertical directions.

Professional Conflict

Professional conflict generally arises when there is a misalignment between professional values and organizational tasks. The result is typically low employee satisfaction, demotivation, reduced performance and its quality, as well as increased employee turnover (Hoff 1999).

The hybrid clinical manager is originally a clinical work expert, and their role is to some extent paradoxical. A professional originally focused on working with individual patients finds themselves in a different situation. In a managerial position, their activity should focus on change management, decision-making and problem-solving, human resource development, and fulfilling organizational goals. However, it appears that hybrid managers devote relatively little time to working with data, quality and process management, strategic planning, and the organization's relationship with its environment. It seems that the hybrid clinical manager in a healthcare organization may not always be the optimal solution (Braithwaite 2004).

On the other hand, it is important to emphasize that the hybrid clinical manager and the healthcare organization share fundamental primary values. These are a focus on the patient and providing the best possible care. However, it appears that performing the dual role (physician and manager) can be problematic not only for the hybrid clinical manager themselves, but also affects organizational performance.

The role of the hybrid clinical manager in the complex healthcare environment is complicated and requires consideration of both managerial and medical issues in decision-making. Since physicians are primarily specifically trained to address medical problems, they generally consider their managerial duties a burden that actually diverts them from their "real" work (Iedema et al. 2003, Fitzgerald and Dufour 1998), and despite functioning in top management, they professionally identify primarily as physicians. A preference for the clinical component of their work may lead to postponing decisions, neglecting the fulfillment of managerial tasks, and a "vacuum" in management.

In the case of a preference for managerial work, original clinical experts experience frustration from neglecting clinical work, leading to reduced job satisfaction, demotivation, reduced performance, burnout syndrome, and turnover. These factors have a significant psychological impact with potential health risks (Selko et al. 2007). Moreover, the current trend, not only in Slovakia, is focused on reducing costs and increasing the efficiency of healthcare facilities, so the limited preparedness and knowledge of hybrid clinical managers in financial management and strategic planning increases their sense of frustration and affects organizational performance and the quality of services provided.

The hybrid clinical manager's role is also paradoxically perceived by their environment, and conflicts may arise in both horizontal and vertical directions that stem from complicated expectations.

Colleagues at the horizontal level, on one hand, expect that the hybrid clinical manager will continue to perform their share of clinical work. Since this expectation is unrealistic, they negatively perceive their increased clinical workload as "covering" for their superior. On the other hand, they expect the hybrid manager to solve all their management problems, which, given the organization's human, technological, and financial resources, as well as its external relationships, is very complicated. Considering limited financial resources and continuous legislative changes, these expectations are often difficult to fulfill.

Vertically, the hybrid clinical manager is exposed to expectations primarily from higher levels of management and stakeholders, and again paradoxically, the expectation is to ensure high quality and organizational performance on one hand, while maintaining and developing a high professional medical level in the case of the specific hybrid manager.

Works focused on the roles of hybrid clinical managers have identified several barriers that prevent the possible balancing of the dual role (Kippist and Fitzgerald 2009). These are primarily the time demands required by clinical and managerial duties. Hybrid clinical managers primarily see their career in the development of the clinical profession and have little interest in focusing preferentially on managerial work. An objective cause is often the formal lack of clarity of the hybrid manager's position, manifested, for example, in the absence of clearly defined tasks in the job description for dual managerial positions.

Published international experiences show that the hybrid clinical manager may not always be the optimal manager for a healthcare facility. However, another problem may be presented by the model of professionals with management education (executive MBA for healthcare) in top hospital management. This trend is significant abroad, particularly in the USA and the UK, and is related to finding the optimal model for financing healthcare and efforts to improve its efficiency.

However, this model also contains possible sources of tension. According to Edwards et al. (2003), one source of tension between physicians and managers is their different education, different cultures, and different ways of viewing the world. International experiences show that the solution lies in recognizing and naming the fundamental paradox: identifying shared values and the need to recognize that physicians and managers think — and should think — differently.

If managers suddenly began to focus primarily on individual patient needs, regardless of consequences for others and the budget, then the healthcare system would collapse. If physicians decided that their primary problem was ensuring the smooth operation of the system and implementing healthcare policy, regardless of the individual patient sitting before them, then the quality of care and the patient relationship would collapse. Defining and recognizing this paradox is an appropriate starting point for addressing this problem.

There are many reasons why this problem must be discussed: disillusionment, demoralization, loss of trust, lack of cooperation and communication are certainly not tools for ensuring high-quality healthcare. However, on the other hand, the fact that physicians and managers have different cultures creates space not only for conflict, but also for mutual enrichment (Smith 2003).

A very important fact is that between these cultures there are not only differences, but they also have much in common. In both professions, people work who are passionate and willing to work with high commitment, often to the point of neglecting their own health or family. In both cases, education is long, demanding, and never ends. Despite what is often said, management does consider the ethical dimension, and ethics is taught in management faculties as long as in medical faculties. Managers and physicians are both people of action. They are also accustomed to taking responsibility for decisions. Both professions have specialists: managers can specialize in finance, marketing, or human resources, just as physicians can specialize in neurology or pediatrics. To be successful in their profession, both professions need communication skills, although both have a poor reputation as communicators. Both professions excessively use professional jargon. Physicians and managers are often bearers of bad news and guide people toward change — however, many in both professions have weak interpersonal skills. And finally, both professions mature with age.

One advantage of medicine is that physicians even in higher positions work directly with patients (customers). Managers in higher positions who lead large organizations focus more on strategy — as they are expected to — but thereby distance themselves from the customer. Some time spent with the customer is invaluable, and many managers in higher positions incorporate this into their programs. However, this different orientation is fundamental and important — physicians focus on their individual patients, managers focus on the organization. Every hospital, and every primary care practice, will need both approaches to thinking if they want to be successful.

On the other hand, physicians need to learn to think strategically, work in teams, and within large organizational complexes. Neither physicians nor the organizations they work in are known for good future planning. Physicians tend to react retrospectively to situations that have already arisen. Physicians are generally poor at leadership, often creating organizations that cannot be effectively managed and then selecting a leader by compromise (Smith 1993). However, leaders must define the direction and path of the organization and then motivate people to want to follow them.

Managers are better informed about quality issues than physicians. They also know that complex decisions are best made in effective teams — that is, teams in which people understand and utilize differences in opinions and attitudes and work with the positive use of conflict. However, many physicians tend toward dominance in teams. Managers are generally better prepared for conflict and negotiation, knowing that the best negotiation strategy is a "win-win" outcome rather than a "win-lose" one. Managers have greater knowledge of economics and finance than physicians. Economics is fundamentally linked to the distribution of limited financial resources — a problem we face daily in healthcare. Limited or no knowledge, particularly in microeconomics, is therefore a significant disadvantage for physicians.

The doctor-manager relationship receives considerable attention abroad, is intensively studied, and solutions are sought and discussed (Nash et al. 2003). Despite differences in healthcare systems across countries, a considerable degree of consensus is achieved in recommendations.

Above all, the need for interdisciplinary education for both managers and physicians is emphasized, at the earliest possible stage of their professional education. The need for management research is also highlighted, which would analyze and evaluate both the management and processes of healthcare delivery and the clinical performance of healthcare facilities. It is also recommended that evaluation reports of healthcare facilities include both components: the medical/clinical and the managerial (Nash 2003, Carpenter et al. 1998). A serious task is to reduce the gaps between clinical culture and organizational management/managerial culture (Malcolm et al. 2003).

In Slovakia, there are still shortcomings in management education and training for healthcare facility managers. The preparation of specialized managers for healthcare (executive MBA programs for healthcare) is not yet being considered, nor is such a specialization available in Slovakia's higher education or university offerings, despite the preparation of specialized healthcare managers being one of the recommendations of the World Bank project (Boulton 2002). An exception was the PHARE project, within which 18 Slovak healthcare managers received education in healthcare and social services management at the Business School of the University of Leeds, United Kingdom (Harding and Ford 2001). Moreover, research focused on healthcare facility management, particularly in the context of continuous reform interventions in Slovakia's healthcare system, is absent.

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This paper was presented at the 5th annual conference titled "Health Psychology 2010", held on May 19, 2010 in Bratislava. The conference was organized by the Section of Health Psychology of the Slovak Psychological Society at the Slovak Academy of Sciences in cooperation with the Health Section of the Ministry of Health of the Slovak Republic. The event was further prepared by: the National Heart and Vascular Diseases Institute in Bratislava, the Faculty of Health Sciences of St. Elizabeth University in Bratislava, the WHO Office in Slovakia, KISH Košice, the Department of Psychology at the Faculty of Arts of the Catholic University in Ružomberok, and the Department of Psychology at the Faculty of Arts of the University of Trnava.

The proceedings of the 5th Conference on Health Psychology, Bratislava, 2010, were published in electronic form only. Availability: http://www.prohuman.sk/psychologia/zbornik-prispevkov-z-konferencie-psychologia-zdravia-2010