The career path to becoming Chief Information Officer is as diverse as the individuals who occupy the role. Some have come up through the information technology (IT) ranks, installing networks, coding software, backup up data warehouses, designing and implementing applications. Others cross over from the business side of the house - marketing, customer service, finance, operations - once the individual realizes that all business processes have software as an essential part of their operation.

The Medical Doctor (MD) as CIO adds a new wrinkle to the mix. It also extends the black humor that says "CIO" really means "career is over." It becomes an end point, albeit one with privileges and (some) power. By the way, "CIO" has yet another meaning that we will explore shortly.

If we take a step back and look at the methods and practices that inform each role - MD and CIO - there are some engaging fits and misfits. At a high level and when the training is at its best, the MD is trained to

• handle symptoms in relation to underlying causes, making difficult differential diagnoses,

• thinking organically about systems as a complex interacting whole

• communicate with the customer [patient] as an end in her- or himself, deserving respect

This seems like a good fit for the role of CIO. It includes the necessary skepticism that the presenting error message thrown up by the application has anything to do with the underlying cause. The network is slow so the application times out and "thinks" the connection is down without saying anything about the network. Things are not what they seem.

Organic metaphors are increasingly common in an information technology context. Computer viruses are pervasive on the Internet, and virus detection software embraces the metaphor of inoculation, though it is inevitably a step behind the pathogen. Human engineering factors are critical path, and best practices indicate caution about the vector with whom one exchanges bodily fluids - or email attachments. The goal of "self healing" IT systems is on the horizon, and ongoing monitoring of "heart beat" in high availability systems is implemented by mechanisms that are still primitive but increasingly powerful.

In comparison with the "human biocomputer," our IT systems are primitive at best, using kludgey mechanical and serial processes where the wetware is able to perform complex protein synthesis. This makes our most sophisticated business intelligence systems seem like child's play. So the metaphors and analogies are likely to remain limited, conditioned, and qualified for the foreseeable future.

The "people skills" of the CIO - whether MD or information techology (IT-trained) - are as diverse as the individuals who occupy the role. Given the pressure of primary care medicine, clinical practice does not always promote listening, empathy, and education to good health to the extent we all might wish. The myth (and misfit) of the physician as member of a "sovereign profession," whose word is law, has been explored and (to an extent) debunked in the wake of the HMO revolution of the 1980s. This is not new news (and for those for whom it is, Paul Starr's The Social Transformation of American Medicine is as timely today as ever.) It is not that the role of CIO is intrinsically more humbling than that of the MD; but both require mastery of the distinctions between knowing what you know and knowing what you don't know - and knowing there is a third area - you don't know what you don't know - the area of "blind spots," out of which most system disasters and malpractice actions arise. Of course, there is no easy answer for the latter - since by definition one does not know what it is that one does not know - but the prophylaxis, if not the antidote, is to be resolutely open to inquiry into one's own limitations and those of the systems on top of which one is riding. In short, CIO also means "chief inquiry officer" - always inquiring, always asking "what if," and creating possibilities for the future.