Summary: For the clinician leaders healthcare desperately needs, training has to begin in medical school and continue throughout a career.
The connection between great leaders and successful organisations that effectively innovate to remain competitive and provide shareholder value has been well demonstrated in business. To that end, many industries have, for decades, offered leadership development and training programmes as a strategy to cultivate a pipeline of leaders; leadership development as an industry is valued at over $15 billion annually.
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Healthcare has lagged behind other industries in terms of leadership training, even though some have suggested that it is an essential competency for physicians to provide accessible, high quality healthcare and navigate a continually changing system (Rotenstein et al. 2018; Lerman and Jameson 2018). Since 2012, peer-reviewed literature shows a marked increase in papers discussing physician leaders. Studies have also demonstrated that training physician leaders improves physician satisfaction (Shanafelt et al. 2015). Along with an increasing demand for physician leaders, there has been a significant expansion in the number of courses to train physicians in this area. However, there are no current guidelines or requirements to mandate leadership curricula within medical education.
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A former medical student and I conducted a landscape analysis that demonstrated that leadership training in medical schools falls into three categories: 1) dual degree programmes (MD/MBA); 2) longitudinal tracks with a leadership focus; and 3) classes that ranged from a one-off session to multiple, months-long components. At the same time, we also conducted a national survey of medical students and found that many believed they had insufficient experience in critical leadership skills, and particularly lacked experience and skills in managing teams. However, they expressed a desire to gain these skills and increase their competence in being able to lead at a variety of levels: team, clinic, or health system.* At the medical residency level of training, some residency programmes have offered leadership curricula or “tracks.” Post-residency, there are a few specialised leadership fellowships for physicians, and a growing number of continuing education leadership training opportunities for physicians at varied career stages.
In most of these examples, trainees opt-in to the leadership development track or course, which increases the likelihood that participants are actively seeking a management or leadership-oriented career. It does not account for those who might become “accidental” or “volunTOLD” leaders at some point in their lifetime. Currently, medicine selects leaders based on demonstrated clinical excellence or scientific innovation, but those forms of success do not automatically mean that a clinician is well equipped for the role of a leader. Within the literature on physician leadership there is no universal agreement on core skills and competencies physicians need to lead, and the possibilities range from problem-solving skills and communication skills to high degrees of emotional intelligence and a deep understanding of topics like quality improvement, payment, or health systems (Frich et al. 2015).
The barriers to adding leadership development to medical training are numerous and include the following (Cadieux et al. 2017; Grunberg et al. 2018):
- Disagreement on the importance of teaching leadership
- Lack of available space and time within an already packed curricula
- No predefined curricula to ease adoption of new coursework
- Minimal resources, such as faculty and funds, to implement training
- No consensus on the best time within training for leadership development
Essentially these barriers translate to the key questions of: Is teaching leadership important? Who do you teach? What do you teach? Where does it fit? How do we pay for it?
Over the last five years I’ve spent an increasing amount of my time thinking about, and designing programmes, that aim to educate physicians to be leaders. I do not have the solutions to all of the barriers listed above, but have felt the reality of these challenges as I’ve worked on programmes from design to delivery. I’ve taught a range of learners, from fourth-year medical students to executive leaders. The programmes have varied in terms of format: 100% virtual, blended (online and in-person), and 100% in-person. They have also been varied in length, from once per month for ten months to a three-day in-person intensive to four weeks of a block elective at the medical school. From these different experiences, I’ve come to four conclusions about training physicians to be leaders.
We Need to Build a Pipeline of Future Leaders
I believe it is worth investing in—and exposing medical students to—a portfolio of leadership skills and concepts despite the barriers to adding them to a medical school curriculum. This was affirmed through my experience in teaching a fourth-year elective course for medical students titled “The Physician as Leader.” The course I co-direct is an intensive, month-long elective that focuses on providing students with skills to lead themselves, lead others, and better understand the organisations and systems they are about to transition into as medical residents. We use modalities such as case studies and guest lectures provide students with a glimpse into the realities of managing and leading within healthcare organisations, and convey that leaders will be needed at every level—not just in the C-suite. While the course is positioned near the end of the students’ medical education, the feedback we hear from students is that the interpersonal leadership skills the course teaches and reinforces (communication, feedback, collaboration, conflict and team dynamics) are most useful to them, and would have been highly relevant and valuable had they been taught earlier in their time at medical school. Regardless, they are grateful to have more skills to use heading into residency where they will be leading medical students and working on clinical teams.
Learning to Lead Takes Practice
Leadership programmes often emphasise increasing one’s knowledge. But, having knowledge does not necessarily mean that people know how to translate it into action. Learners need to have an opportunity to assimilate what they are learning, try new ways of behaving, and reflect on those actions or experiments. In the Physician as Leader course, we do this through a required team project. The final deliverable or outcome of the project is less important than the process of the student team working together over the course of the month. Longitudinal programmes with an in-person component enable participants to practice leading over a longer period of time and afford them the opportunity to reflect and discuss challenges with peers. Our ten-month programmes typically ask learners to take on a personal leadership or improvement project for the duration of the programme. We ask that participants select projects that will impact their ability to lead within their current setting and build time into the programme for project-related reflections and feedback. This ensures participants are finding time to practice what they are learning.
Training Options Benefit Learners
The physician leadership training market is increasingly crowded, especially in terms of continuing medical education. But, I think choices in terms of programme content, timing, and format are advantageous for different learning styles as well as potential resource constraints (available time and money). I directed a 100% virtual leadership academy over a 10-month period that covered the fundamental concepts and skills for leading within a clinical practice. The audience for this programme was mainly community health centres across the U.S.; we had over 250 participants and 71% of the participants were attending alongside their clinical teams. It is unlikely that these health centres would be able to send an entire team to an in-person programme elsewhere in the U.S., but they do have the resources to attend a 90-minute webinar once per month. Contrasting with the virtual approach, I am part of the faculty team for a Medical Director Leadership Institute, which is an intensive three-day in-person programme held in Boston. The programme aims to build skills and address the challenges that medical directors face in their roles. The participants who choose this programme value the focused, time-limited nature of the programme and the ability to connect with other attendees during and after the programme.
Measuring the Impact of Training Needs to Improve
The current literature and available data demonstrates that programme evaluations of physician leadership training programmes tend to focus on participants’ self-perceived changes in knowledge, skills, and attitudes (Frich et al. 2015; Miranda and Voce 2018). These changes are typically assessed at one or two specific points in time, usually before the programme begins and at the conclusion of the training. Additionally, programmes report participant satisfaction scores and, occasionally, career promotion metrics. These measures do not demonstrate the impact of training on the clinic, health system, or patients. While measuring impact beyond the individual level is ambitious, it is critical to understanding if the time and resources spent on training is a good investment.
Healthcare needs the clinical leadership that physicians provide, both on the frontlines, but also in the C-suite. However, physicians need training to lead, and leadership skills are not currently a core part of physician training. By starting physician leadership training early, focusing on giving students and residents opportunities to practice leading, and measuring the impact of leadership curricula beyond individual learners, we can improve healthcare delivery for many stakeholders: patients, physicians, clinical teams and health systems.
- The demand for physician leaders is increasing
- By starting physician leadership training early, eg in medical school, we can improve delivery of patient care
- Longitudinal programmes allow more time for participants to practice the skills they are learning in their current environment
- Different training options will appeal to different audiences, allowing more participants to engage with training
- Measuring the impact of a programme beyond the individual learner is critical if we are to understand whether leadership training is a good investment