What the HALM Is This?

Peter Angood: What the HALM is this? It’s Healthcare Administration, Leadership, and Management (HALM), and it’s new. Today in Chicago, at the AAPL Annual Leadership Conference, we have the experts to help us understand what HALM is about. We will also discuss where AAPL fits into all of this.

I’m privileged to have three people joining me here today: Dr. Kevin Weiss, Dr. Suzanne White, and Dr. Richard Hawkins. All three of our panelists have exceptional experience within the realm of credentialing, certification, and medical education.

Kevin B. Weiss, MD, MPH, is chief sponsoring institutions and clinical learning environment officer at the Accreditation Council for Graduate Medical Education (ACGME). Weiss oversees Sponsoring Institutions and the Clinical Learning Environment Review (CLER) program.

Suzanne R. White, MD, MBA, is director for the American Board of Emergency Medicine (ABEM) and chair of ABEM’s initiative for HALM. White has chaired the American Board of Medical Specialties Medical Toxicology Sub-board and served as educational programming chair for the American College of Medical Toxicology.

Richard E. Hawkins, MD, is president and chief executive officer of the American Board of Medical Specialties (ABMS). Hawkins is responsible for creating, planning, and implementing the strategic direction of ABMS, which establishes the standards that its 24 member boards use to develop and implement educational and professional evaluation, assessment, and certification of physician specialists.

But what does HALM mean for each of you?

I will start with Kevin, then Suzanne, then Rich, to give us a short overview of their institutions and HALM. Then I’ll lead us into a series of questions. Kevin, what is HALM?

Kevin Weiss: About seven or eight years ago, we started a discussion at ACGME around the question, “Are there gaps in needs in American healthcare?” We did a full year of canvassing the country, literally going from city to city, looking to understand what the different types of stakeholders were saying. What the additional needs for graduate medical education looked like.

The ACGME developed a document, “Sponsoring Institutions 2025,” that considers what the healthcare landscape would look like in 2025. As part of that process, we found a big gap developing in how we prepare physicians to be leaders in this new kind of healthcare environment in the United States. For example, the Chief Medical Officer role is changing. You’re either going into a system role or you’re going from president to CEO.

It’s all very complex. Systems are going from single-hospital to multi-hospital, multi-hospital to billion-dollar health systems, to multi-billion-dollar health systems. What we’ve seen is the consistently missing piece of strong track leadership development.

The way that physician leadership happens, probably in your own experience, is that you recognize that in addition to being a physician, you saw the need to be part of the solution at the system level. Part of being a good caregiver meant that you weren’t just taking good care of your patient, but there were ways you could collaborate with others to build bigger solutions that would help lots of patients. That is a natural leadership trajectory for physicians. But the healthcare environment, at least a medical education environment, doesn’t have a track for that.

That got us started on the conversations for what eventually became HALM. Fast forward, HALM was approved officially by our board. And we just had our first set of applications come through. A few weeks ago, we announced our first two institutions that have our first HALM fellowship: Mount Sinai Health System in New York City and Cleveland Clinic. Those are the first two fellowships that have established themselves, and we’re starting to get some more coming in.

Angood: Suzanne, why would the emergency medicine board respond and rally up on this one?

Suzanne White: We did! Emergency medicine has a long history of supporting administrative education. We’ve had administrative rotations as part of our residency programs for 35 years plus and have about 40 unaccredited administrative fellowships in emergency medicine across the U.S. So, we were very interested in this.

There’s a societal need to have highly trained, highly skilled executives who are physicians, and we see better health outcomes in that environment.

Kevin, I think you said it best: There’s a societal need to have highly trained, highly skilled executives who are physicians, and we see better health outcomes in that environment. Whether we’re talking about the care of patients or we’re talking about population management and health service lines, patient safety, and quality, it is imperative that we have more physicians who are highly trained in those positions. We have seen many emergency physicians rise up into those roles across health systems, naturally, because we tend to be action-oriented.

Emergency physicians interact with all the specialties in the hospital. So, it was important to us that we take this on; make sure that we had a role. HALM brings standardization to the training programs. It allows us to have high quality and to be able to verify that the individuals coming out of the programs have met certain standards, certain competencies. That’s important to the public. The trust from the public that we are turning physicians out of programs who meet certain standards is very important to us.

Angood: Thank you. Rich, the main board of ABMS has 24 other boards within it. In your role, you interact with all the boards, with other types of credentials. Why would you pay attention to this one and the emergency medicine representatives at this time?

Richard Hawkins: I always pay attention to what they are doing in emergency medicine. I want to acknowledge the heavy lift that ACGME did in building the accreditation process for the programs and what ABEM did in leading our conversations with the task force that led to an approved certificate.

During the process, we heard from several of our boards, and we all agree that it’s important to have physicians in leadership positions in our healthcare systems. What Dr. Weiss alluded to is another way to help create a cadre of qualified individuals.

For board certification, we require training in an ACGME-accredited program with a structured program of learning and assessment. We require that our diplomates, those who achieve our certificate, demonstrate their competence, that they meet standards for knowledge and skills in their specialty, and that they commit to professionalism, maintaining the knowledge and skills and improving the care they provide.

For every medical or surgical specialty that has conducted the research, board certification has correlated with better healthcare and better health outcomes. So, we believed that we brought something to the table here, helping to be an avenue for preparing qualified positions to serve in these positions.

Angood: What types of institutions do you think should be doing these HALM fellowships?

Weiss: We designed the fellowship to be very flexible. I’d encourage those interested to go to the ACGME website and enter the search word HALM. You will see all the information needed, including a list of the FAQs.

We started by talking with CEOs of a number of organizations. They can look across a health system and direct the training of individuals. The intent of the design is to be shaped by those health systems that say, “We want to have leaders.” But it’s not for a particular type of health system; it’s for different health systems in different environments.

Then we talked with CMOs and chief nursing officers in addition to the CEOs, and they said, “For our most senior officers, when we recruit, we have our methods of getting them trained. Sometimes we send them to specific training. Sometimes we want them to go through a specific set of coursework.”

Many of you have gone through your organization’s specific leadership training. For early-career folks who are just learning how to get into leadership, there isn’t a consistent way of training.

So, we wanted the design to be flexible so that the system can decide how they want to situate their fellowship. It’s probably going to be for early- to mid-career in general, though that’s not specified in the requirements.

The training could be for organizations as small as a federally qualified health center that wants to do this for their own federally qualified health center or perhaps a network of ambulatory care centers. Flexibility is the key.

As far as the components in terms of time, there are two. One is a 24-month fellowship, the other a 12-month fellowship. The fellowship also accommodates people who’ve completed master’s degrees in related fields so they can get credit for that.

It’s a very flexible field, but what is not flexible is the experiential learning. You need to be able to be seated in the executive leadership world, to step away from your clinical responsibilities and be part of the leadership responsibilities. You need to move around in the leadership functions of an institution to understand strategy, to understand finance, to understand risk management, to understand things that aren’t specialty-specific.

So HALM is not meant for a particular type of health system, it’s meant for any health system that is interested in developing leadership and doing it in a community that has a consistent type of learning that is standardized. And now we’re fortunate that it’s not only going to be standardized in terms of the training, but there’ll be a standardized assessment that will be helpful for the individuals who complete the training.

Angood: Suzanne, that was a good description of the organizational benefit. What are some of the individual benefits for getting certified and are other boards becoming involved now?

White: Yes, emergency medicine is the administrative board. I must thank ABMS for thinking about this as a multispecialty certificate, that it wouldn’t be owned by one board. So we offered co-sponsorship to any other boards that wanted to step up and be co-sponsors. The American Board of Anesthesiology, American Board of Family Medicine, and American Board of Preventive Medicine have been truly instrumental to the approval of the specialty by ABMS. They’ve done a tremendous amount of work.

I have to thank AAPL too. Peter Angood has been with us through this entire process, from the very beginning. He helped us develop and review the core content. He helped us look at the structure. Peter was one of the key voices when we went before the ABMS Committee on Certification (COCERT). Peter was there to weigh in and support the need for this type of initiative. Thanks for being an amazing partner.

Angood: Thank you.

Weiss: I would echo that, too, from ACGME. We’ve leaned heavily on the knowledge and wisdom from Peter, as an important stakeholder, from the start. So, thanks again.

Hawkins: Dr. White mentioned co-sponsored boards. You’re aware of our more traditional boards, like internal medicine or surgery, and the subspecialties, such as infectious disease or vascular surgery. Co-sponsored boards are a way that we’re able to embrace emerging disciplines like pain medicine or sleep medicine that span multiple specialties. For example, in sleep medicine, there are six co-sponsored boards: internal medicine, family medicine, pediatrics, anesthesiology, neurology, and otolaryngology. And they work together.

With a co-sponsoring board structure, there’s one administrative board, and for HALM, it is emergency medicine. They then develop and administer the knowledge assessment for all the boards. The individual co-sponsoring boards then manage the other aspects of their programming, overseeing the code of conduct, identifying partners to provide educational activities, and perhaps supporting improvement activities.

There’s also another category of boards called “qualifying boards.” Those certified physicians would be eligible, but once they become certified, they would become a diplomate of ABEM, and they would work with their primary board.

Angood: Thank you, that’s very helpful. Suzanne, could you provide detail on how you qualify to sit for the exam? As oftentimes comes with a new board or board credential, there’s the discussion of grandfathering. There’s also the discussion about what prior experience is recognizable within HALM. I know all of this is detailed on the website, but maybe you can give this audience some insights.

White: The most important thing is flexibility. There are multiple pathways to eligibility to sit for the examination. One is a practice pathway, another is training plus practice, and another one is a full training pathway for someone coming directly from a fellowship.

I’m happy to say that the certification AAPL offers does qualify as a component of those pathways that involve practice. I believe it’s 12 months credit for two of the three pathways, depending on the path.

Angood: Thank you! Yes, at AAPL we are very appreciative. The grandfathering period to apply is seven years, correct? So for those who are interested, it’s worth having a look at the website to get the details. The program’s open now, correct?

White: Yes, that’s correct.

Hawkins: Peter, it is typical for us to offer a practice pathway for any new subspecialty that allows the leaders in the field, those who created the discipline, the educators, the opportunity to become certified. They have seven years to do so for this one. And I think the requirement is three years in a position of leadership. So it’s very typical for us to do that.

Angood: Maintenance of any credential these days is important. There are variable approaches, and I doubt that we at AAPL will have this all figured out yet for HALM per se, but this organization has 50 years of experience. We have great information resources, education, along with a loyal and wonderful community. What do you think is the potential of AAPL’s participation in not only sending folks to get certified, but in the maintenance side of it?

Hawkins: I think it is very high. In our standards for continuing certification, there are requirements for the board to provide aggregate assessment data to the professional societies and others who create educational programs. There isn’t another society that would align with HALM better than AAPL.

Likewise, there’s a requirement that the boards collaborate with their society partner to identify important gaps in each specialty and to fill those gaps, emphasizing disparities. There’s an opportunity here in terms of improvement projects or anything else that AAPL may want to engage in.

Angood: That’s great. We have the CPE credential, the Certified Physician Executive. It is similar to other fellowships. What is your view on how this CPE credential fits in with fellowship training? Does it separate from the credentialing side of an institution? Where do you think it fits?

Weiss: It’s important to think about that. Probably the most significant piece will be what programming will look like in your fellowship. And much of what would be in the credential is the same educational content that by domain has been specified in the fellowship regarding competency in leadership and administration. Probably the most noticeable would be choosing between a 12- or 24-month pathway to get to the training.

And, may I add, if you come in with what’s master’s level training, you’re able to reduce 24 months training down to 12 months. There is a place for the discretion of program directors. The question will go to our institutional review committee to decide whether this type of credential is equivalent to what would be a master’s level training in terms of educational content. I’m sure that the IRC would be more than happy to take a look at that in their deliberations and then adapt as we need to. I think there’s a nice opportunity there.

Angood: That’s good. For AAPL, the CPE credential is 170 hours of coursework and a three-and-a-half-day capstone event. As part of their own qualification to do all of that, candidates need to show and demonstrate their experiences. So we should certainly have more conversations around that. I’m sure there’ll be a fair amount of interest among our constituency on how this will work. Rich, Suzanne, Kevin, you have spent a lot of time thinking about physician leadership. Where do you think the physician leadership future lies and why?

Hawkins: Well, I hope it resides in a very good place. We are here because we all think physician leadership is critically important, and there’s evidence to support that.

I worry about the priorities of many of our health systems in terms of focusing on productivity and revenues. And it would be good to think that physician leaders might weigh patient care and population health over revenues and productivity, or at least equal to that in terms of the hospital priorities.

I want to be optimistic about it. I think there’s a role for us here and there’s a role for us to rethink the priorities for healthcare delivery.

Angood: Even as the care delivery patterns change and the places where delivery is undertaken change and as we all shift to social determinants of health, and population health, there’s a strong role for physician leadership all across the industry. Suzanne, what’s your opinion on that one?

White: I’m super optimistic, and the reason for that is we see so many leadership positions available now that were not there previously. And, this is an accelerator to allow physicians to get into those positions and to be able to prove their value as leaders. I think that is a positive thing for us. I’m extremely optimistic about that. Who better than a doctor to be in a role that’s vacant?

There has been so much movement. It used to be that the CEO never changed; there wasn’t as much movement, and now we have opportunities opening up everywhere. So, I think it’s great to have that combination of openings plus acceleration so that our physicians can more rapidly get into those roles.

Weiss: It is pretty straightforward, and I join in the optimism because I think that this is a really hopeful, good place to be. I think what we see when we go around the country and when we do our CLER visits and talk to individuals like you in the C-suites and talk to the CEOs of our great institutions, large and small, is that the role of the physician leader really has an opportunity to emerge.

We are increasingly entering into a complex environment, including private equity. How many of you were involved in conversations around private equity in your roles? How many of you were involved in corporate merger and acquisition conversations five, six, seven years ago in terms of standardization across complex systems of quality and safety?

These things didn’t really exist in our lexicon or in our toolkit. And without physicians stepping into them, other people will professionally move into that spot.

The biggest thing we see in our senior leadership, but particularly our CEO leadership, is that when [a system] is run by an individual who’s extremely competent in business but without a clinical background, it separates from the mission a bit. The role gets further and further away from that clinical background.

I’m very respectful of the nurses and even the pharmacists who end up in CEO roles; however, I’m very partial to the physician community when they step into that role. Physicians bring a dimension that keeps the mission of patient care in almost every decision in a way that’s quite different than someone who doesn’t have that training.

That’s the beauty of having the physicians step into leadership roles, but it’s not a given that we as a community of physicians will do that unless we make opportunities. Up until now, it’s been really bootstrapping on individuals who decide they want to do it. But individuals have had to find the way through pathways, such as you have here. We need to broaden that conduit.

That’s why I’m optimistic. There are many physicians who are early in their careers who would love to do this. It takes a little bit of help to get them into a pathway to help them move into these different roles, taking leadership roles and moving forward.

Audience Question: I would like to say this is a wonderful opportunity. I have completed the CPE here, but based on the keynote speeches, the presentations we’ve had today, tell me how this is going to incorporate DEIJ [diversity, equity, inclusion, and justice] principles so that this is not just one more barrier to people like me and my Black and Brown colleagues.

Angood: Underserved populations, gender equity, et cetera, are hugely important. For those of you who didn’t catch it recently, in The Washington Post was another op-ed piece about all of the adverse influences that female physicians have in their work environment. It’s not the first piece that we’ve seen on that. We all know that about 50% of the medical school population is female, but the workforce of females is just 31% still. And that doesn’t even get us close to the Black or Brown or other underserved populations. I think all of us would agree that we really need to keep on working to get that equity in our workforce overall.

Hawkins: Obviously, in our organization, like many of you, we are focusing on our own diversity and inclusion issues in our staffs and in our governance. But we’re also looking at our programs. We want to make sure our programs don’t have an adverse impact on workforce diversity. And we’re also looking at our programs to address inequities and disparities in healthcare as well.

We recently had a symposium with the National Board of Medical Examiners (NBME), American Board of Internal Medicine (ABIM), and Association of American Medical Colleges (AAMC) on equity and assessment to make sure that we’re addressing anything in assessment that could be having an adverse impact on diversity—from knowledge assessment to oral examinations to assessment in the workplace—because there’s potential bias there. So we’re very conscious of that and are being very attentive to it. We saw the symposium as just the start of our work here.

Weiss: If I might add to that, by ACGME formerly stepping into this space, it turns a very different corner for those who choose this route because it’s now a transparent route. There are rules about meritorious selection. There are rules about expectations.

We have common ACGME program requirements that allow us to look inside these programs and see what’s going on inside there, particularly around diversity, equity, and inclusion like 6.b).(6) comes to mind as our common program requirement and 1.b).(4). We have these things built in, and until now, physician leadership development has been done without that formal structure. We have great leaders, but we can now have a process that’s much more meritocratic.

That’s probably a good thing here, much more transparent and rule-based, which allows for access for individuals who may not have felt comfortable trying to find their way into a more informal ladder.

Now that doesn’t mean there can’t still be informal ladders, nor are we at ACGME saying there shouldn’t be. What we’re saying is this: Let’s create a very straightforward pathway to leadership that everyone understands, that everyone when they go into it knows how it’s going to transpire, that they have a reasonable shake to get into the process. And when they leave, executive suites across the country will know what people have had as their experience. I hope that helps as well.

Angood: Great, thank you both. Did you want to add to that, Suzanne?

White: Yes, I would add that ABEM certainly has looked at HALM as an opportunity to emphasize the development of leadership skills that help achieve equity and also address social determinants of health. That can become a standardized approach to making sure that we are developing leaders with those in mind. So, I think that’s our perspective on that as well.

Personally, I would also add that I think having the opportunity to be trained as a Fellow earlier in your career will address some issues. It’s very hard for individuals, for women in particular, to go back later and pick up those skill sets. And oftentimes, there’s that gap, the age gap, in terms of when they actually enter into a leadership position. I think this earlier introduction and support that they will get in the clinical environment, learning in that environment, will be helpful as well.

Angood: Diversity, equity, inclusion. It’s on everybody’s minds these days. At AAPL we have an incredibly diverse staff; we have a wonderfully diverse board. Look at the diversity here in this room, our audience today.

As an organization, we have been committed to diversity and inclusion all the way along. We’ve had women in leadership initiatives since I started. We have a couple of great books out there about physician women leaders and STEM women leaders. We need to do more still on the underserved populations, but we’re clearly on that path. So thank you for bringing that up because it’s really important.

Audience Question: I’m a residency director in emergency medicine, so I’m familiar with all these organizations and hearing this new certification and hearing from everyone here that they’re very supportive of having physicians in these managerial roles that are very, very important. Is the next step to say really that these organizations should promote physicians as being CEOs of hospitals or health systems or things like that? And if that’s the case, then when CLER visits come along, are you going to look at the leadership of those institutions?

Angood: At our own organization, we have a quarter million physicians in our database. We’re doing a review of the literature, doing a meta-analysis on the impact and outcomes related to physician leadership, not only as an individual but as an organization as well.

And we’re also doing a look-back on the impact of our credential, as well as the master’s degree programs that we sponsor. Our plan is to bring that forward in our ongoing commitment to thought leadership and influence around the benefits of physician leadership.

I will also say, we remain committed to the career of novice, intermediate, and advanced trajectory. How do we help you get there? How do we help you maintain it? And I think, as Rich described, there’s a community that we’re committed to helping support.

Weiss: I want to thank you for bringing CLER into the picture. I hope that CLER provides value as we go forward. What it does say to me is that there’s a gap in our ability to help society have physicians who can, in addition to their clinical acumen, their skills, their compassion, all the things that the physicians bring to the table, that there’s a business side to healthcare that is an imperative. If we don’t bring a significant portion of physicians along to own that, it will still need to get done, but it’ll get done without that component.

And we see this on the CLER visits each week in the field. I’ve been on a couple of visits recently just to observe, and I can see how the chief medical officer roles are changing.

We have to get ahead of that. As a profession, we want to be able to bring our skills to the table. Our skills are deep and wide in terms of the ability to help in our health system. Without that, it’s just going to be a different health system, and physicians are going to be further removed from mission. That’s why it’s so important to us.

Angood: Rich, do you want to jump in?

Hawkins: We are contemplating more of an advocacy role. Right now, we’re moving more into advocacy around legislation that interferes with evidence-based care and self-regulation. And would we want to have a role where, based on our concerns about the priorities of healthcare systems, we advocate for more engagement of physician leaders who focus more on patient care and population health?

Audience Question: First of all, I’ll say thank you. I’m really glad to hear that we are encouraging physicians to grow as leaders during their training. Also glad to hear about the comment that came up with respect to diversity, inclusion, and equity and how ACGME in this realm can ensure that that is maintained through these training programs.

One aspect that we don’t talk about is diversity, inclusion, and equity from the international medical graduate perspective. International medical graduates continue to fill a big vacuum in physician and leadership shortages in our country, and they continue to serve in areas where nobody else does. Yet, we don’t talk about equity when it comes to international medical graduates.

As we explore these programs, I would also encourage that we explore leadership for international medical graduates in that domain so there can be representation for international medical graduates alongside.

Angood: Thank you very much for that. You’re absolutely right. About 26% of the workforce these days is international or foreign medical grads. Our own organization works closely with the Educational Commission for Foreign Medical Graduates (ECFMG) and their subsidiary foundation, the Foundation for Advancement of International Medical Education and Research (FAIMER), which is all about trying to improve the quality of the folks entering into the country. But I think there’s a challenge to all of us here to keep responding to what you just described. So thank you so much for bringing that forward.

Hawkins: Just a comment that across the self-regulatory organizations in medical education and practice, there’s a lot of discussion right now about how we can track our impact on diversity and inclusion across the continuum. One thing that we’ve realized is it’s hard to track it because we all have different data and we lack data, particularly on international graduates. That’s one of the things we’re talking about: How can we get a better handle on the data and share it across the continuum? We just developed the data sharing with AAMC. We’re in conversations with ACGME and AMA about looking at the common sets of data across the continuum to know where we are.

Weiss: ACGME is deeply committed to the international medical graduate. We had for, well, longer than I’ve been there, policies that prevent discrimination of any sort. Most recently, in the past seven, eight years, we’ve had ACGME International, which has helped broaden our understanding of what it is to not just look at our accreditation system domestically, but we’ve learned how it looks in other parts of the world.

In the past year, we’ve set up a new program with ECFMG called the Non-standard Training Program (the NST program), which allows for individuals on J-1 visas to come in for short-term training so that we can actually increase the number of individuals coming in.

And in the past year, we went from zero to 100 NST sponsoring institutions, and we’re very excited about that as a new opportunity. So, this HALM is a way to level the playing field a bit because it’s the standards of ACGME that will allow people to have an equal shot at being part of it. And there are standards that have to be met and will be monitored by the review process to make sure that there are concerns raised. If complaints come in, we go out and we try and find out the nature of them and if it’s a complaint about discrimination, we are on top of it. It’s a good thing that we’re able to do that.

Angood: That’s great. What a terrific panel discussion and set of insights and opinions! Suzanne, Rich, Kevin, thank you very much.