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Dr. Paul Swiercz

Dr. Paul Swiercz

Professor, Department of Management
The George Washington University
School of Business

Evolving Change: Healthcare Workforce Structure

Transcript

Dr. El Tarabishy: Hi everyone. I’m going to have fun here, now, because he’s a very good friend of mine and a colleague of mine in the Department of Management. Dr. Paul Swierz is here. So, I asked him continuously to come to this session because he’s going to instigate some very interesting thoughts and some challenging thoughts as well. So, Dr. Paul Swierz, thank you for coming.

Dr. Swierz: Welcome.

Dr. El Tarabishy: You kind of are in both domains in the business world, but also you came from the health care or the health industry, here. So, tell us explicitly kind of your two halves that you play throughout your history, or your time, your experiences.

Dr. Swierz: Well, early in my career I had aspirations to be a member of the health care industry, and it turned out that I ended up being a medical technologist and was certified by the American Society of Clinical Pathology. So I did that job for a while, and then I liked health care and I ended up moving over to public health.

I went to the University of Michigan for a degree in Public Health, became involved in environmental health. And then after that, I thought I wanted to know something more about organisations and business, so I took my health care interest and worked on another Master’s and PhD and did early, significant research in the health care industry, particularly around questions about who’s working there, okay. [laughs] And how is it structured, how is it changing?

Dr. El Tarabishy: So, you looked at the workforce, or you looked at the professionals in the health care industry, but other industries as well. So let’s get to the discussion here. Explain to us the workforce, how do you see the workforce in the health care industry?

What’s — it’s changing, it’s definitely changing here. Everything is changing in how we define them, how we compensate them, how we evaluate them. What’s your take on all this evolving change or disruptive change that’s happening?

Dr. Swierz: Well, of course, you know, there’s disruptions occurring everywhere, [laughs] okay. So, health care isn’t unique in that regard. But I guess I would argue that the disruptions in health care are closer related to the uniqueness of health care, and one of the things I think makes it particularly unique is the structure of the workforce and how it has emerged over time. Particularly the professionalization and occupational categorization of the health care delivery system.

Dr. El Tarabishy: Explain a little bit more how do we evaluate them in a system where, in the business world, if you don’t perform, you’re out. [laughs] But in the health care, it doesn’t follow that system clearly. It’s kind of an intricate or complicated system.

Dr. Swierz: Well, I think performance is consistent across all organisations. The health care system standards of performance or maybe consequences of poor performance can certainly be more significant for the patient, but I think that is a particular challenge in part because of the health care industry social responsibility is unique. People look to the health care industry unlike, you know, hospitality.

You can’t run a hospital as though it’s a hotel, but certainly there are aspects to the hospital that are related to the hospitality and how the patient receives care. That’s part of the performance appraisal.

But the expertise required to deal with infection control in the hospital has meant that there are people who are professionals in cleaning a room, cleaning a surgical suite, making sure that the hospital doesn’t become a vector of disease rather than a place one goes to recover from disease. So, those are some of the unique challenges that are associated with health care.

Dr. El Tarabishy: Can we argue that health care is neither private or public, it’s a combination of both?

Dr. Swierz: Well, I –

Dr. El Tarabishy: Or is it one or the other?

Dr. Swierz: Well, I mean, it’s historically up in through the 1970s, most of health care was either non-profit, charitable, Sisters of Mercy, other, you know, religious groups. Lutherans would have their hospitals, Presbyterians would have their hospitals. Catholics would have their hospitals. And then of course, you had community hospitals where the community really supported it. And then of course you had more governmental hospitals, particularly the VA system.

The idea of private health care is a relatively recent phenomenon, particularly on the scale that we have it on now. And I think the industry is still very much trying to figure out how to deal with this different mix of players in terms of to whom the hospital is accountable, okay. Particularly when we’re talking about the for-profit hospitals and how one judges a fair pricing system and a fair reward system in that context.

Dr. El Tarabishy: We talked about business models for hospitals or for the health industry here. Is it fair to apply a business model to a health care industry, or is it something that we should take caution of? I’m kind of, I come from the business world. For me, a business model is a way of operations, right, to figure out what is the inputs and the outputs and how to measure them and how to compensate them.

But a business model also takes into account the human capital that’s involved in it. You’re an expert on human capital, right, the definition of what a worker is. Explain it from that aspect. What is your definition of human capital in the health care and the private sector? Do they relate, or are they somewhat in contradictions?
Dr. Swierz: Well, I think there’s actually two questions in there. One is the notion of the business model, and so I’m part of a group of people who rejects the idea that conventional business models in terms of the for-profit sector model of business, the kind of model that’s made the great private sector enterprises that we have in the United States. I think that’s not well suited to health care.

And I think we have been trying to force fit it to health care for some many decades and haven’t been successful, and I would really like us to do a better job at confronting those differences and finding better approaches to dealing with those differences. The second part of your question has to do with the human capital, and I think one of the very unique things about health care is what I call its intensive credentialism.

The degree to which people need assurance of competency, and one of the ways that we have crafted over time to provide assurance of competencies is to create mechanisms for giving people certificates of accomplishment that say yes, I can do this. I can do x-rays, I can do nuclear medicine, I can do physical therapy, you know, almost anything you — you know, I remember when phlebotomy, drawing blood, became a vehicle for certification.

So there aren’t very many jobs in health care where people aren’t either by regulation or by expectation to seek some kind of certification. And then trying to manage these various interest groups within health care and who’s domain, where’s the responsibility reside, you know, under which of these various certification programs, is challenging.

Dr. El Tarabishy: On the topic of human capitals, and we had long conversations about this and you’re doing a lot of research, and actually you teach a very popular class at GW. We talked about the employee, the model employee and how it has for many years, you know, The Organisational Man, I think it was Whyte that wrote the book. And yet we now move into something called the knowledge worker.

You have some new compelling ideas that you’re putting forward, and saying let’s re-examine this. Talk about your, what you teach in the class when it comes to this definition of what is an employee, and try to relate it to this new health care domain that we live in.

Dr. Swierz: The health care, in terms of the employment domain, probably the single biggest challenge for health care has been the relationship between the, well, the players like the insurance companies and most specifically the physicians. The physicians in the US model, beginning around the turn of the 20th century following the Flexner Report really positioned themselves as independent professionals, and so they culturally and historically have never thought of themselves as preparing to be employees.

They have prepared themselves first and foremost to be professionals, but then secondarily, to create and manage a practice and you know, manage their own careers through the practice. And then of course they do practice groups and things like that, and have relationships with — using the hospital as an example — their workshop, that is the hospital. That’s still unresolved.

Now, in probably the last 20 years, you’ve had a group of physicians appear that are called hospitalists and now these are physicians who actually are residents in the hospital and depending on how it’s arranged, are oftentimes employees of the hospital. So, they’re not really managing an independent practice anymore. But many other arrangements are such that the physicians are really a form of contractors, and you have a web of contracts and so different parties are merging together at different places.

In terms of the hospital, that’s a place where you have a pretty stable workforce, but you also have people, these contractors, kind of flowing in and out of that work space. So that’s a real challenge. The other thing with regard to some of my course in research, I’m very intrigued by — you referred to it as a knowledge worker. I think that’s a classic and important term.

It was first introduced in 1959 by, as you know, by Peter Drucker, and I think it’s showing its age a little bit in the sense that the knowledge worker was valued primarily because they had this base of knowledge and it couldn’t’ be kind of accessed unless the individual gave it. That’s still true, but I think there’s a new more emergent challenge or group of workers, and I’m calling these the cognitive workers.

And the cognitive workers are differentiated from the knowledge workers in the sense that it’s just not a question of kind of recalling and applying knowledge that they have, but the cognitive workers are those who are part of the knowledge creation part of the enterprise. And so, to kind of try to fit it into this discussion as best I can, you know, we just had this situation where the Google machine beat the Go player.

Dr. El Tarabishy: Yeah.

Dr. Swierz: Okay.

Dr. El Tarabishy: The Korean . . .

Dr. Swierz: The Korean, yeah.

Dr. El Tarabishy: Go specialist.

Dr. Swierz: Go player. And Go is like, ten times more complicated than chess, so it’s like this, you know, significant leap in demonstrating the capacity of machines. Well, when I’m listening to that, I’m thinking about well, medical diagnosis, okay? And how a classic physician’s key skill was the knowledge and then the capacity to take kind of obscure signals from a patient and craft them into a diagnosis.

I think there will be people who will soon be arguing, like Google argues with regard to driving or flying an airplane, that most diagnoses are going to be better made by machines than they are by physicians. And I think that’s a kind of disruption that’s going on.

Dr. El Tarabishy: So you’re — that’s why I said to people, I said watch out, he’s going to be some radical ideas coming out here. So, let’s talk about this cognitive, what do you call them, cognitive worker?

Dr. Swierz: Yeah.

Dr. El Tarabishy: Is the right word, worker, for it? Or cognitive individual?

Dr. Swierz: Well, I mean, you know, if you’re kind of selling your labour for money I call you [laughs] a worker.

Dr. El Tarabishy: [laughs]

Dr. Swierz: Okay, I call that, I call that, I call that work, when people are delivering in pursuit of compensation, I call that work.

Dr. El Tarabishy: So, let’s do the adjacent universe here.

Dr. Swierz: Uh huh.

Dr. El Tarabishy: And we have MBA students coming here, right, and let’s move them away from being knowledge acquisitioners. Let’s call them cognitive students. How do you see them play out in this new MBA domain and this new education system, because everything’s available on Google?

What we’re talking about here, they can download some digital books, quickly watch some YouTube videos. What’s differentiating us, and how does that fit into these new challenges that are coming out where innovation is changing the rules of the game as we speak, but it’s always been there?

Dr. Swierz: Well, I’ll try to approach that kind of in a health care setting, and what’s happened to health care over the last 50 years, anyway, and probably longer than that. But, in kind of classic health care when we had the physician as the brain, let me call it that for lack of a better way.

And then, you know, I was part, when I was part of medical technology, I was part of something that was then called the allied health professions. And these people were also often referred to as physician extenders. These were occupational groups in health care that were intended to be like the implementers of the knowledge and skills of the physician, to extend them, to make their systems more accessible.

Well, what’s happened is that the. . . there’s been a realignment of responsibilities. And it’s not to say that the role of the physician has in any way been diminished, but what we now know is that good health care requires a much broader distribution of responsibilities and authority, and a much, much higher level of collaboration across all of the various people who are part of the health care delivery system.

To the extent now, I’m particularly intrigued by the degree to which contemporary medicine is embracing alternative healers. You know, the massage therapy, and dieticians, you know, health care people in exercise, experts in exercise and things like that.

So we’ve got a much broader universe of players and the skills, going back to your question, I think much of our educational system in health care in particular has been focused on acquisition of the individual level of a set of professional skills, with less emphasis on the skills required for the integration across these various categories or skill groups.

So, we’re going to, going forward with the cognitive workers, we’re going to need people who have what we might call more advanced integrative skills, where they can see connections between all of these different options and all of these different needs, to craft the personalized health care experience that people need.

Dr. El Tarabishy: And, let’s go back to you, right? You advocate for a whole new model of learning, and you, usually in business schools or in other schools, you give students a case, a business case to analyze. Right? And you tell them, here’s the case, here’s the challenges, go solve the problem.

Yet, you’ve turned the tables a little bit on the students and you said I don’t want you to provide me with any, solve me the solution for the case, I want you to actually write me a case. Talk a little bit about your model here and why this is important from a cognitive perspective.

Dr. Swierz: Well, you know, I think there’s two components to the learning in the university, in the business school, and one is the skills acquisition. So, you know, if we’re talking about finance, you got to know how to do the mathematics of finance. If you’re an accountant, you got to know the rules, if you’re an HR person, you’ve got to know compensation, selection, and there’s lots of techniques. So, that’s really hard knowledge.

But, and it’s very important, but especially when we get in the MBA programs, in the MBA programs in particular, we’re trying to educate people — it’s a terminal degree — and we’re trying to educate people for work that’s going to express itself over the next two to three decades, because they’re not going to come back for the MBA after they’ve got the MBA.

So we’re trying to prepare them with a very long range perspective, and a set of skills that prepares them for that. Many universities have found that the case method, and case learning is a tool, is a powerful tool for doing that. And I agree with that. Where I begin to have my own, develop my own point of view on it, however, was that when I was teaching these cases, my students were constantly looking for the solution, you know?

It’s a classic scientific management perspective. There’s one best way, there’s one best answer, there’s, you know, it’s accounting or chemistry, whatever, what is the answer to this problem? [laughs] Let me write it down. Well –

Dr. El Tarabishy: Let’s Google it. [laughs]

Dr. Swierz: Yeah, yeah, in reality, you know, I’m really a fan of systems theory, and the systems theory notion of equifinality, which really means is that actually, there’s probably multiple right answers, okay? And the more complex the system the more difficult it is to find a right answer. So a cognitive worker, a successful leader, has to have that capacity to create answers that are unique the complex situations that they’re facing.

So, what I did is I began challenging students to write case studies, and so I call it SWIFT learning. Student Written Instructor Facilitated case writing. SWIFT case writing, okay. The idea was, is that having the students write their own cases makes it real for them because they draw on something that they value, some kind of event or challenge that they value. But more importantly, it causes them to understand the limitations that are associated with learning from other people’s cases.
We in our school, in our management department, we’re very much into lifelong learning, we’re very much into experiential learning. And that really means learning from the experiences you’re in, okay. [laughs] As your career unfolds.

And just to kind of go one step further, and that brought me to the most recent course that I’ve been working on, and that’s called Critical Thinking Skills for Executive Leadership, where I’m trying in particular to enhance the ability of leaders to critically — not cynically — but critically, critically analyze their work environments and become part of the solution, and then communicate that to the people that they’re working with in a successful way.

Dr. El Tarabishy: Thank you. One last question.

Dr. Swierz: Okay.

Dr. El Tarabishy: Your history at GW, you know. Why GW? Why come learn at GW? You know, what’s so unique about it?

Dr. Swierz: Well, let’s kind of acknowledge that most of our lives are controlled by serendipity, okay? [laughs] So, there’s a big serendipity component to coming to GW. I happened to be in the labour market when GW needed somebody. And when I saw the opportunity, I said why [laughs] wouldn’t I want to go to GW?! Okay?

So, you know, it was one of those experiences that it would be kind of silly for me not to take an opportunity to be part of a great university in one of the great cities of the century, and so you know, that’s what I’ve been doing for almost — well, for a long time now. Okay? [laughs]

Dr. El Tarabishy: Great. Thank you for your time.

Dr. Swierz: Okay.

Dr. El Tarabishy: Alright, and I appreciate it, and there will be more to come.

Dr. Swierz: Alright, great. Thanks for, thanks for being meeting with, sharing this –

Dr. El Tarabishy: Thank you.

Dr. Swierz: Thank you.

Dr. El Tarabishy: Okay, so, the debrief on Paul Swierz. I told you he was going to be controversial, but good controversial because he raised a lot of good points for us to reflect on here. He challenged my notion of the knowledge worker, right? He introduced this whole concept of a cognitive worker, some who co-creates knowledge, right? That looks at knowledge as more of a resource. But at the same time, how do we co-create it?

He coupled this with his whole SWIFT manual, which is don’t give me the solution. There’s many solutions to the problem, right? Help me write the case to look at it from different angles here. That’s a very interesting take as you move forward with your MBA program, and with this course, right?

Especially the introduction course, especially this intro course. Looking at it from a perspective saying there’s many solutions, many angles to look at. Bring your cognition, bring your thinking skills here, and start critically analyzing the different challenges that there are, and looking at it from an opportunity perspective. Kind of rethinking this whole concept of what is employment? What is the employer-employee relationship here?

You know, what’s the doctor’s roles? What are the health care professionals’ roles? What’s the role of the CEOs? What’s the role of hospitals in this whole spectrum, right? And I don’t have the answers to this, and I don’t think anybody does have the answers to this, but just reflecting on it is maybe starting the process of critically thinking about things. And that’s, I think, why we’re all in here, is to start critically thinking about the challenges that we face today.

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