This transcript of the discussion has been edited for clarity and length.
Mike Sacopulos: The Healthcare Administration, Leadership, and Management (HALM) certification is a relatively new accreditation for physicians. My guest today stepped forward not only to embrace HALM certification but also to assist fellow physicians through the process by creating a book to help them.
My guest today is Dan Handel. Dr. Handel is the Vice President and Chief Medical Officer for the central area of Atrium Health in Charlotte, North Carolina. He is the program director for Healthcare Administration, Leadership and Management at Atrium Carolinas Medical Center. Dan Handel, welcome to SoundPractice.
Daniel A. Handel: Thanks Mike. Glad to be here.
Sacopulos: Could you describe your path to becoming a physician leader?
Handel: Absolutely. The interesting thing is my dad was a hospital administrator, not clinical by background, and I never understood what he did for a living, so I said, “I’m going to do something different. I’m going to make an impact on the world.” I said, “I’m going to go to med school.” So, I went to med school. I chose the path of emergency medicine because I frankly didn’t have the attention span to do the long rounds of an internist or long procedures in the OR of a surgeon. I did residency in emergency medicine in Cincinnati. Then I decided, I had gotten an MPH during med school and really wanted to pursue health services research, so I went out to the West Coast. About six months into my research fellowship, my chair at the time said, “Hey, we’re going live with this thing called EPIC. Do you want to help me?” That pretty much was the end of my research fellowship, which was kind of serendipitous because I realized very early on I didn’t want to chase research grants for the rest of my career.
Did an EPIC go live? I’ve done two since then. But that quickly led from informatics into being an ED medical director. About eight years into doing that, I was really focused on how do we improve patient throughput, patient logistics. ED boarding was and continues to be an issue, and I decided I wanted to go upstream and really lead it at a hospital level. I was fortunate to have and start my first CMO role in South Carolina in 2014, and I’ve done a couple different roles since then.
The irony is, I’ve come full circle, and do work very similar to what my dad did in his career. It’s really funny — when my oldest son was 12 years old, he looked at my card and he said, “Chief Medical Officer. Officer. Dad, do you arrest doctors?” And I said, “Well, it’s probably as good an explanation as any.” I think it’s really funny because it’s hard to explain to people outside of our world what CMOs do or what other physician leaders do. Some of it’s other physicians, but there’s all sorts of things that are involved, and it’s always the other duties as assigned.
Sacopulos: Well, let’s talk a little bit more about that because that’s fascinating. Your son’s position is absolutely tremendous. What are some of the unexpected duties that come with being a chief medical officer?
Handel: Well, I think sometimes it’s the translation of speaking physician, doctor-ese, if you will, administrative speak. Sometimes it’s trying to constantly connect the dots between what frontline clinicians are doing and how does their work impact the larger goals of a hospital, of a health system. Constantly trying to go from the front lines to the 300-foot level to the 3,000-foot level and really trying to do that crosswalk all the time. Honestly, the most enjoyable part of my job is not necessarily the regular blocking and tackling of being a CMO, but the other larger strategic things that you get to be involved in from time to time. Because you really feel like over time you’re able to impact and make a larger impact in terms of how you deliver healthcare to the entire community. It’s not just the patient in front of you.
Sacopulos: When I gave the briefest, briefest of bios for you, I mentioned the Healthcare Administration Leadership and Management program. Could you give me a 30,000-foot view of HALM?
Handel: Absolutely. A lot of academic departments around the country, a lot of emergency medicine departments, anesthesia, we’ve seen them in, have had these homegrown administrative fellowships that people would do right out of residency. They would basically serve as a de facto assistant medical director for the operations leader in that department. I ran one when I was at OHSU Health & Science University back in around 2010, 2011. We had great success in terms of graduates of that program. One’s a CMO, one’s a chair, there’s a lot of great work they did, but it was very focused on a particular specialty. I’ve talked to colleagues in anesthesia, a similar thing, and there’s probably numerous other specialties.
To the Accreditation Council for Graduate Medical Education (ACGME)’s credit a few years back they decided, okay, we need to put some academic rigor around what is the content and the mastery of knowledge that a future physician leader needs. So they created an accreditation pathway for Healthcare Administration, Leadership and Management — sometimes you’ll hear HALM, H-A-L-M Fellowship Program. When you read through the guidelines, you can either do it right out of a residency, which is what we did at Atrium Health, or you could do it mid-career. I have yet to see a program that has done it as a mid-career fellowship.
The nice thing is it creates that rigor so that when we applied for accreditation in our program, (and our first fellow actually starts next month in August), and we are the third program, there are about nine programs nationally now. There are milestones that keep us making sure that by the end of those two years the fellow has been exposed to all of the core content that the ACGME is set for. It’s really exciting. It’s really early on for these fellowships, and my hope as an advocate and a champion for physician leadership development is that these programs only continue to grow over time.
Sacopulos: Yeah. It’s absolutely a great program. During the two-year fellowship, how much time on average do you believe a fellow spends on this area?
Handel: The way that the ACGME structures it is, the standard is that 50% of their time is spent in administrative work and 50% clinical. We’ve structured ours similarly. The way the ACGME is set it out is that if the fellow does not come in with either a healthcare MBA or an MHA, they need to do a two-year program. Most of the fellowships around the country have set it up where they’ve married their fellowship to the completion of an MHA or healthcare MBA, because that’s really what you need to make sure you cover all of the core content of the ACGME in a rigorous fashion. They do that for two years. If people have a master’s degree, the ACGME says you can do the fellowship in one year, because they assume you’ve got the base core content mastery, and then it’s really focused on that experiential side of things.
The intent is to have the fellow get a parallel of the content mastery through their master’s program and then also the experiential exposure over those one to two years to really see how the knowledge is applied in the real world.
Sacopulos: Excellent. And what’s the application process for someone wishing to be a fellow?
Handel: It depends on the fellowship. Most of the programs, ours included, started with internal candidates. I think as people feel more comfortable with how their fellowship is designed, most of them will open it up to external applicants as well. But when I’ve talked to other program directors, they tend to start internally as they get the program up and running and then they expand it out. It does not go through the match, which is the algorithm that a lot of residency and fellowship programs use. You’re interested, you apply, you interview. The way we do our cycle, at least, is we interview over the summer with the selection of a fellow by the fall of the last year of the residency, which is typically when most residents are either looking to do other clinical fellowships or to apply for an attending job somewhere either locally or somewhere around the country, so that we have them locked in that fall period for the following summer. We did it last year and that’s the similar process we’re going through for this fall.
Sacopulos: Excellent. I omitted the fact of your work on a textbook .
Handel: Oh, yes.
Sacopulos: And maybe we could talk a little bit about the impetus behind creating a textbook and a little bit about the textbook.
Handel: As I learned that the ACGME had created this accreditation pathway, I said, “I want to be a part of this.” I found out that there was a cohort of people writing the test questions for the board certification exam. They had the first board certification exam in November of 2024, last fall. But as I was writing the questions, it’s not like, I’m an emergency physician by background, it’s not like there’s a textbook for this exam. I was going to all these different resources. It was very labor intensive to do it, and I had the thought, okay, we need to develop a textbook for this. As we continue to try to get more rigorous about the science and the knowledge behind becoming a physician leader, how do we create that one source of truth for people, whether they’re taking the exam or they’re a physician leader and they just want to go to a reference? That was the genesis of the creation of the textbook.
The American Association of Physician Leaders (AAPL) was a perfect partner. Obviously, I’d been an AAPL member, I’m a certified physician executive, so I was very familiar with their education curriculum. And when I talked to Peter Angood and Nancy Collins, they had already been thinking about how do we parallel our educational content with the HALM fellowship, and as more and more people do it? It’s interesting now we’ve had one wave of people take the exam, they’ve all gone through the practice pathway. So if you go to the American Board of Emergency Medicine website or you just do an internet search in terms of practice pathway, it’ll say, based on these criteria, here are the typical titles of people who are eligible. So people who took it last fall — and the interesting thing is the book came out in April and the people who have read it who already took the exam — the common theme I hear from them is, I wish I had this book when I was studying for the exam.
People say, well, they had a list of the core content, but they didn’t have one study guide to do it. The way we set up the book is, at the beginning of each chapter, there’s a note that says this is the core content from the ACGME that this chapter covers. We didn’t go straight through. We bucketed different aspects of the core content that made sense. Then we had 44 other phenomenal authors from around the country, from different areas of content expertise. We have lawyers talking about the compliance, the policy side of things. We have finance people talking about that. We have HR experts talking about the HR parts of it. Things that as physician leaders, we don’t come to naturally from being a content expert.
We’re really proud of the book. It’s grouped by the nine sections of the core content, and it flows really well. We’re hoping as more and more people step up to take the exam to become board certified in this area of specialty, that they find the book useful and value added, and it really helps streamline their time in terms of how they study for the exam.
Sacopulos: What surprised you in the preparation and drafting of the book and working with these 44 individuals?
Handel: I think the hardest thing, honestly, is how do you wrap your hands around it? It’s one thing to have the core content and realize, this is a very broad content area of knowledge. How do you get that into something that’s digestible? We were very intentional in titling the book, The First Edition. We do not think this is a “one and done” publication. We want to get feedback from people who’ve already taken the exam, people who are taking the exam this November who’ve read the book and said, “Yes. You were spot on. This was really helpful in this section. You probably need a little more content in this section.” We want to keep trying to get that continuous feedback, so we can continue to evolve the book so that it better meets the needs of people who are going to take the exam in the future.
The ACGME will very likely change their core content over time. As they revise the core content, we feel it’s very important for the book to reflect that and stay up to date on that. My goal is that this is going to be like any clinical specialty textbook. It’s going to have multiple editions that are constantly updated every few years to make sure that it has the most up-to-date information and that it has the most relevant and the most precise data that meets the needs of the people who are studying for the exam.
Sacopulos: How do you go about getting feedback?
Handel: Podcasts like this are a great example. My email address is in the textbook. If you let me know what you think, email me, what works, what doesn’t work. And they can reach out through AAPL as well. We want to hear from people because the more feedback we get, the better we can make the book in subsequent editions.
Sacopulos: Well, it’s certainly a dynamic area, and I could see why you would not want to have a static textbook for a dynamic area. What plans are there for the second edition? Do you have projections on how many years out that is?
Handel: It’s interesting. I think obviously we’re going to give it a few years, probably three years, two to three years or so. I think it depends on the feedback we get on how well we are supporting people and taking the exam and also, really taking direction from the ACGME. If they do change the core content in any significant fashion, we want to make sure that we respond to that as quickly as possible. We’re going to constantly review the content and make sure that it stays in sync with where the exam is going. If we do see those significant shifts, we will update accordingly in a timely fashion to make sure that we stay on top of it and that we stay in sync with where the exam is going so that people feel prepared every time they use the book as a study guide.
Sacopulos: Are there ongoing educational requirements for those who have gone through a HALM fellowship program?
Handel: I think it’s too soon to tell. It’s an excellent question. Before we got on our call today, I was researching that. I don’t see that yet. The first round just got board certified from the exam last November. Something to keep in mind, they weren’t originally planning to do the exam every year; they were planning on doing it every other year. But one of the encouraging things is there was such a demand from people and interest in the exam, they decided, we can’t wait and do it every other year, so we’re going to do it yearly. I think it was a great move on their part. I think it also helps, depending on the timing, as more and more people do the fellowship, you don’t want someone to finish the fellowship in July or August and then have to wait for more than a year before they can take the exam. You want it when it’s fresh in their minds. It would be no different from any of us completing a clinical residency and saying, “Okay. You can’t take your board certification exam for at least a year, probably more.”
You want it when they’re at their peak of their content knowledge. They’re coming right off the fellowship. They’ve been staying on top of the literature, not only through our textbook, but in terms of other sources. I’m encouraged that they’ve moved it from an every other year to an every-year exam. It’s exciting to see how people learn from this. I’m also really curious to see who’s going to go through the practice pathway. Between now and 2030, people are eligible to do the practice pathway to take the exam, who meet certain criteria in terms of their job titles, their job scopes or responsibility to take it. Obviously, the first wave of people hadn’t completed the fellowship yet, they’re going through this practice pathway. It will be really interesting to see how people step up and find value in doing the board certification process.
Sacopulos: Do you anticipate unusual uses of the knowledge in the board certification by individuals? I think we could all understand that there would be certain administrative positions that this would be perfect for. Are there other areas that maybe folks out there haven’t thought about that this process, fellowship and ultimate board certification, could be beneficial for?
Handel: It’s an interesting question. If you think about it, historically, people in CMO-like roles, they were just the oldest physician on the medical staff and they said, “Okay. You’re the most senior person. You’re going to be our VPMA or CMO.” But to the credit of physician leaders over the years, they’ve gotten much more intentional in becoming a physician leader. It wasn’t just something to do to get out of clinical practice. People like myself, I started very early in my career saying I wanted to do physician leadership because I think it’s very important to improve the quality of care that we deliver at scale. As you’ve seen that evolution over the years and the decades, you’re seeing more and more physicians get a healthcare MBA and MHA. The AAPL is an excellent vehicle for doing that through their different pathways. You see more and more physicians getting that certified physician executive credential.
You’re seeing people getting much more intentional in terms of their formalized learning in terms of degrees. Now the question is, does becoming board certified in HALM become the next evolution of that? As more and more people are applying to CMO jobs, to chief physician executive jobs, chief clinical officer jobs, who are physicians, the expectation now is that you have a master’s degree, whether an MBA or an MHA. When I got my first CMO job, one of the things my boss, at the time, said that set me apart from other applicants was, he said, “Well, you’re finishing up your healthcare MBA.” The question is, does the fellowship, the board certification, become that next tier that will differentiate candidates for these physician leader roles in the future? It’s obviously too soon because there are so few people who are actually board certified at this point, but does that become the next level of certification, of education that is the expectation for all physician leaders moving forward?
Sacopulos: In thinking about our time talking today, it occurred to me that we’re at a time in the practice of medicine that physicians frankly have taken a hit from the general public. How does the fellowship and board certification process, if at all, help with interaction with the general public and with patients, and trust of physicians in the medical profession in general?
Handel: I think the benefit you have of clinical leaders, whether you’re a nursing leader or physician leaders, is that we are able to connect that patient experience at the front lines to larger ways of how we deliver care. It is not healthcare leadership decisions being made in a vacuum. So you can say, well, we’re making this decision at a larger level, but I can actually, either from past experience or talking to some of my physician colleagues, translate how that is going to impact that particular patient in that particular moment. Once again, as we talked about before, it’s doing that ascent and descent from the front lines to the 300- to 3,000-foot view of saying not only is this decision the right thing in terms of improving our ability to deliver care to a community at large, but it also, when you boil down to that individual patient, it makes the best sense for them as well. And constantly being able to translate at those different levels, I think will go far to instill trust.
I continue to practice clinically. It’s very important for me to do so. Because there are things that I discover on my shifts as an emergency physician, saying, “Why didn’t someone tell me about this before?” This is really important. This is something that we need to address at a larger level. Constantly having that sounding board, whether you’re practicing directly or you’re still tied very closely to your physician colleagues on the front lines, really helps getting that constant feedback loop to make sure that we are continuously focused on how do we improve how we deliver care better at scale.
Sacopulos: That’s very interesting because I think what you’re saying, and correct me if I’m wrong, is that to some degree, you have an active medical practice which informs how you perform your administrative roles. Is that fair?
Handel: Absolutely. I think it’s also — obviously I only practice in an emergency department — it’s important for physicians to be very intentional in terms of going out to round in areas, especially outside of their area of clinical expertise. I meet regularly with surgeons, I go to the OR see what they’re doing, what are their processes in OR, rounding with other physician leaders in an inpatient setting. You have to go to the [inaudible 00:23:22], to use the Toyota lean terminology, to really understand firsthand and then be able to connect with the frontline physician, saying, if I understand this correctly, since I am not a surgeon, I don’t understand this, what you’re doing, this is how it works, this is how we look at system issues to make sure that the path of least resistance do the right thing, is always at top of mind so that we continue to set up systems so that you have the support, you have the infrastructure to deliver the best care possible.
If people are having to do workarounds to do the right thing, we don’t have the right systems in place. We need to constantly get that feedback loop of, this is how we continuously improve our systems so that people can easily do the right thing moving forward.
Sacopulos: How do you think the AAPL can support those who wish to become home certified?
Handel: Obviously, the textbook we put out is a prime example of that. I think as we get more and more feedback, we’re looking at creating a board prep course for people. We’ll have people who will give a synopsis of the textbook, they can review that in a relatively short fashion. We’re talking about how do we create more content for people as a board prep course, if you will. Those are some of the things we have in the docket for the future. But also as people go through the study and the board review process, they’re going to say, “Oh yeah. I’m really strong in this area, or I may need a little deeper dive or a little more content expertise in this area,” say, finance, for example. The AAPL has finance courses you can take or HR courses.
So, things that they may feel a little weaker on. The nice thing is the AAPL set-up where you can do a focused course, whether in person or online, to really help hone your skills in that particular area, if you do have a knowledge deficit. It is going to evolve. I think the book was just the foundation of the work we’re doing, but we’re really looking at how do we continue to develop this as a way to not only prepare people for the exam, but also set them up to have that continuous learning journey over the course of their careers.
Sacopulos: It must be exciting to be in at the beginning or ground floor of this. I think that’s a sign of true leadership, both on your part and on the part of the AAPL to envision where this is going and help prepare physicians to move forward as leaders. We certainly need that. As our time together comes to an end, give me your thoughts on the challenges physician leaders face today.
Handel: I think the biggest thing is really sticking to your why, your purpose of doing this work. As we all know, there are all sorts of challenges to continuing to deliver care to our communities, whether it’s reimbursement challenges, whether it’s preventive health, population health things, and really trying to continue to have that focus on the North Star of not only why we got into medicine, but why we decided to become a physician leader. And trying to maintain that focus, and when you get mired in the details or the crisis of the moment, taking a step back and saying, “Okay. Why did we get into this in the first place?”
I think as long as all of us as physician leaders continue to focus on that purpose, that why, that really helps rejuvenate and keep people thinking, today was not the best of days. There were a lot of crises. It was emotionally exhausting, but it helps fuel the soul, the fuel the spirit of what gives me energy, what’s gives me joy to continue to do this day after day, week after week, year after year, decade after decade. I think we’ll continue to do that, but also serve as a role model for other healthcare leaders to say, this is why this is important. Some of the best nonclinical leaders I’ve worked with have that sense of appreciative inquiry of, “Dan, explain to me this issue in layman’s terms of why this is important.” Because I think sometimes as physicians, we get sucked into the technical aspects, the medical aspects of something. But having someone who really forces you to stop and pause and say, explain this to me as if I was a layperson or a patient, why is this important?
Constantly connecting back to the purpose of why we do this is exciting. The reason, when I get back to why I started doing this work, of my journey as a physician leader is, I realized if I was doing purely clinical work, even if I was a full-time emergency physician, I may touch a couple thousand patients in a year. You work 10 to 14 shifts a month over 12 months, but then going to a higher level, you start adding zeros to that impact. Instead of thousands, it’s tens of thousands, hundreds of thousands of patients. The thing that’s exciting to me about the textbook is hopefully being able to have that positive impact on other physician leaders, so you start adding even more zeros to that impact, the better you’re able to help develop other physician leaders, the better they’re able to help their communities. You really start creating that multiplier effect. From my perspective, that’s what gives me energy, that’s what gives me joy and makes me really excited about this book, not only now, but how it’s going to evolve over time.
Sacopulos: One more time for our audience, tell us the title of the textbook and where it may be found.
Handel: Sure. It’s Healthcare Administration, Leadership and Management, HALM, the Essentials, first edition . You can find it on the AAPL website or through Amazon or any other places where books are sold.
Sacopulos: Excellent. My guest has been Dan Handel. He is Chief Medical Officer, but without arrest powers, at Atrium Health in Charlotte, North Carolina. Dr. Handel, thank you so much for your time and thank you for your leadership on this so important issue.