In pursuit of high-quality healthcare through physician–hospital alignment, physicians are increasingly called on to lead and influence a diverse and often disparate set of constituents (e.g., patients, staff, senior management).(1,2) Growing evidence indicates that healthcare systems led by physicians not only have better quality of care ratings and outcomes, but also achieve organizational financial scores equal to nonphysician managers.(3) This has led to calls for increasing leadership training efforts for practicing physicians and residents.
Several options are available to physicians wishing to obtain training in leadership skills. One option is enrolling in full-time, part-time, or executive MBA programs that often market a physician leadership track. Other options include those offered by the American College of Healthcare Executives, which is primarily for healthcare administrators, although it does offer a “boot camp” for physicians.
The certified physician executive or CPE program offered by the American Association for Physician Leadership (AAPL) provides a wide array of live, facilitated, and self-study modules to develop key leadership skills and core competencies. Completing the CPE curriculum or a qualifying graduate management degree program such as an MBA, MHA, or MPH qualifies a member to sit for the CPE certification exam.
The CPE allows the holder to pursue AAPL fellowship designation, which requires demonstration of actual achievement in a leadership capacity. Besides many one- to two-week courses, specialty professional societies also provide leadership training to members.(4)
More homegrown or intramural physician leadership programs have also functioned successfully over two decades.(5) Indeed, some group practices and academic medical centers have preferred intramural programs to develop physician leaders.(6) However, developing and cultivating physician leaders internally involves strategic buy-in from many stakeholders, a champion physician leader, and resources to start a program.
Under favorable circumstances, the advantages of developing such physician leaders outweigh the few disadvantages. Disadvantages can include variable organizational support, a steeper initial learning curve, lack of a formal certificate, and little or no compensation for teaching faculty.
Although intramural leadership programs have improved subject matter knowledge, there is a paucity of useful information regarding lessons learned and challenges faced in implementation.(7,8) Thus, we describe our leadership course at an academic medical center, emphasizing lessons learned and changes to the program over seven years. The goal is to help others who are considering starting or attempting to improve an existing program.
Program Description 2011 to 2018
The Faculty Leadership Institute (FLI) is a 12-month program that is a part of the Ohio State University (OSU) College of Medicine’s Center for Faculty Advancement, Mentoring, and Engagement (FAME).(9) FLI invites applications from all full-time faculty and selects 30 participants to join FLI, which includes a rigorous educational component associated with 12 monthly sessions.
The program included classes facilitated by local experts, homework, self-study, and a group Capstone Project (see Table 1). Sessions focused on five core areas: character, interpersonal skills, business acumen, healthcare leadership, and change management (see Figure 1).
Figure 1. Faculty leadership institute curriculum
From 2011 to 2018, 167 faculty members from diverse areas within medicine completed the leadership program (see Figure 2). The original leadership program for surgeons, which formed the basis for FLI, was described in 2013.(10) The original program was expanded in 2013 to include “high-potential” faculty from other departments, including a few researchers and non-clinicians.
Figure 2. Specialty area of the FLI participants
Application Process
Announcements soliciting applications for the program were distributed through departmentwide emails and communication with College of Medicine leadership. The initial application required a curriculum vitae and a statement of interest; however, it became clear that participant motivation and a career plan allowing them to use or apply the FLI education was more important.
The application was modified to include questions about applicants’ motivation for participation, previous leadership experience, professional successes and failures, and goals for participation in the program. Additionally, a signed statement certifying commitment and motivation to participate in all coursework and program dates was required.
We also initially required applicants to be at the medical center for three to five years. Because new faculty members were being recruited for specific leadership roles, this requirement was dropped in 2014 at the request of department chairs.
Sessions
Participant evaluations were gathered after each session and at the end of each program year. Our team looked for common themes such as participant comfort, material, presentation, speaker effectiveness, and suggestions for improving the session. Core areas and a high-level syllabus covered in the FLI curriculum are shown in Figure 1 and Table 1, respectively.
Because feedback consistently noted problems with the length of the program, the number of sessions was pruned from 15 to 12, and an introductory session was held a week in advance (rather than the evening before) to afford participants time to read a brief book on leadership and other relevant articles.
Survey responses also led to business planning being rolled into the financial management session, which was then expanded by 30 minutes. Instead of small case studies prepared by participant teams, facilitators were urged to use brief case studies in their sessions. Audio recordings of each presentation were available for participants.
Facilitators were changed based on their effectiveness, appropriateness of content, audience participation, and ability to engage participants in skills being coached. Improvement in post-session knowledge surveys were also used to select facilitators from year to year.
Attendance
When nominating faculty for participation, department chairs and division chiefs agreed to relieve physicians for sessions. In addition, participants committed to missing no more than two sessions. However, some faculty were tardy or left for emergencies. In addition, certain sessions were difficult for participants to make up by simply reading materials or listening to audio recordings. As shown in Figure 3, several faculty members did not finish the program because of attendance requirements.
Figure 3. Number of applicants and program completers
Potential solutions could include requiring names of alternative clinicians for coverage in their signed agreement or allowing some participation by videoconferencing (e.g., Zoom™ or Microsoft Teams™). Although group discussion and networking are best optimized in person, this could be an effective compromise.
Teams
Each cohort of 30 participants was divided into five teams of six members at the introductory session, and a team Capstone Project was presented at the final session. Teams were balanced by specialty, gender, race/ethnicity, and rank as much as possible. We guided each team in choosing their project, which was then refined by providing previous FLI graduates, senior administration, and physicians as advisors. Team projects were judged by experienced faculty and session facilitators based on the written report and presentation.
We are unable to determine if the teams created synergy, because the project is selected by the team with instructions to make it as “real life” as possible. However, it would have been more relevant to embed each team within an existing or new project in the hospital.
Another option would have been to engage teams in small sessions throughout the year and describe their personal growth and learning as part of the Capstone. Participants commented that projects sometimes did not seem authentic as there was no assurance that any of the plans would be utilized.
Most teams reported difficulty having face-to-face meetings for their Capstone Project. Some teams used Skype, conference calls, Google Calendars, and Google documents to work on their projects remotely. The best solution seemed to be a meeting just before or after the monthly sessions. The introduction of video meetings during the COVID-19 crisis using Zoom or Microsoft Teams may be the best solution.
The director of the program also emailed brief (<10 minutes) readings, including classic articles, about session topics every 10–14 days throughout the year to current and previous program graduates.
A WhatsApp group chat may be an effective way to share knowledge between participants. An annual conference with presentations and guest speakers on leadership may also encourage continued networking.
Emotional Intelligence Assessment
We incorporated standardized assessments of emotional intelligence to increase self-awareness of strengths and areas for growth. Five cohorts participated in the Hayes Emotional Intelligence 360 instrument.(11) The recent switch to the Leadership Circle Profile©, which measures two primary leadership domains — Creative Leadership Competencies and Reactive Tendencies — was prompted in 2019 due to poor responses from the vendor for further information on scoring issues.(12)
As part of our ongoing research effort to identify optimal participants for FLI, our last cohort also participated in the Hogan assessment at program entry given the impact of personality on business success.(13,14)
Although we provided free 360° evaluations and two or more free sessions with a certified coach, a few participants skipped their 360° evaluations, and few took advantage of coaching sessions. Presumably, this was due to a lack of time, inconvenience of the coaching location across campus, or a lack of understanding of how to best utilize this service.
This finding should be discussed with department chairs in the post-program meeting for graduates of FLI. They should be encouraged to regularly question and support their participating faculty in following through on the commitment, particularly coaching sessions.
Participant Feedback
At the conclusion of each year, our team reviewed participants’ comments, including their evaluation of each facilitator as described. This, along with the degree of post-FLI improvement on self-reported subject matter knowledge, enabled us to evaluate each facilitator.
For instance, low talent management, communication, and business acumen scores resulted in modifications the following year, such as a change in talent management facilitators. There also was a shift to less didactic material about legalities and regulations with more focus on the practical functioning of human resources related to challenges encountered when leading peers and employees.
The communication session required a change from an academic content facilitator to a consulting firm, which resulted in a more interactive, relevant, and “real-world” session. The financial management session was expanded by 30 minutes, and significantly more pre-reading was provided to give participants time to acquire basic knowledge before the session.
Post-Program Participant Development
The original goal was that department chairs and senior leaders would use these faculty members in their divisions, departments, or administrative units. When this was not the case for many faculty members, we initiated meetings with the “manager” of each participant (the leader responsible for their annual evaluation) before and after starting FLI to learn about the progress of their nominees. Part of the reasoning was to also remind managers of their commitment to advance the careers of their nominees.
Then, a brief seven-minute “Shark Tank” presentation to senior administration by teams in the 2018 cohort made executives aware of useful ideas generated and the potential opportunities where graduates could assist. A formal certificate from the university was not possible primarily because of lack of classroom hours.
The biggest challenge, therefore, has been placing program “graduates” into meaningful experiences throughout the medical center. Possibly because of multiple graduate level programs, such as the MHA or MBA programs associated with the university, our FLI program graduates have not had the expected traction to become more involved in priorities of the medical center.
One solution may be to assign and embed individuals with leaders throughout the medical center before starting coursework. Other solutions include inviting groups of FLI participants to attend hospital retreats and board meetings and represent the leadership program at department or division meetings to share their knowledge. This is also an opportunity to assign influential sponsors to each participant.
Discussion
Healthcare system executives need physician “champions” to lead and help hospital administration drive change and reach institutional goals. While physicians gradually move into leadership positions by virtue of experience and longevity, most may not be prepared to lead with the skills necessary to meet the challenges and attain the trust of senior executives. Chief executive officers often remark that they actively encourage budding physician executives to go through formal leadership education of some kind.(15)
While “leadership” is frequently espoused as a core organizational competency, many hospitals fail to implement adequate leadership training at any point during the continuum of a physician’s career pathway — from medical school to senior level appointments.(16) Furthermore, the current culture rewards “high-potential” physician leaders chosen without utilization of valid selection methods. Potential may be based on skill at their current position or relationship with an established leader but may not necessarily translate into skills or success as a leader.
To avoid this, hospitals need a talent management function for physicians that is initiated as a part of the on-boarding process for our newest or youngest colleagues. Motivation to pursue leadership and develop new skills, as well as emotional intelligence, are important criteria for candidates. While meta-analytic findings on the efficacy of such leadership programs are promising, more research is needed to understand the effects of certain training program characteristics (e.g., training content and trainee characteristics) on leader effectiveness.(8)
Compared to the cost of attending intramural leadership programs, attending external leadership programs may be more expensive because of travel and housing expenses, in addition to lost income. Our annual estimated cost paid by the division or departments was $2,500 per participant, although one-third of that and the dean’s match were used by the umbrella organization (FAME), which had a larger mission.
However, the curriculum of some external programs such as the Certified Physician Executive program offer more extensive syllabi in addition to leadership training.(17) Our program expenses were minimized by using our own meeting rooms, negotiating external facilitator fees, and sharing administrative resources.
Measuring a return on investment is problematic in leadership programs. A systematic review of leadership training programs for academic faculty suggests that they have modest effects on outcomes important to academic medical centers.(18) The authors reported that these training programs did positively affect the careers of participants in terms of such factors as advancement in academic rank, hospital leadership positions, and publication success.
Sixteen percent (2.6% annualized) of FLI graduates left the institution, which was slower than annual attrition rate of between 6% and 9% at the medical center. Without a matched control group, the difference may or may not be significant. Perhaps other rewards or financial incentives, such as a bonus or raise for completing the program, would improve retention of aspiring leaders.
We continue to maintain a longitudinal database of all participants and record achievements such as academic advancement and hospital leadership roles. Because participants are selected from a larger pool of applicants, only a control group may be able to answer whether the program is beneficial in the long run.
Several tools may evaluate faculty development programs. The Context, Input, Process and Product (CIPP) model utilizes evaluation of context, input, process, and product in judging a program’s value.(19) Patton’s developmental model is cyclical, process-oriented, and uses real-time data to allow enhancement of the program to succeed in complex situations.(20)
Kirkpatrick’s four levels of evaluating training programs have been widely utilized to understand its impact on similar programs in the academic, business, and government sectors.(21) In retrospect, our participant surveys did conform with Level 1 (reacting or ratings of each session) and Level 2 (learning or pre- and post-program surveys of knowledge in each content area), yet we would have learned more by eliciting information on Level 3 (participant plans for behavioral change after the program).
Although four “judges” evaluated each team’s Capstone Project, we did not provide an independent assessment of the impact (Level 4). Rice(22) notes that very few programs conduct evaluations, and even fewer complete all four levels.
Some of the lessons learned related to participant selection, content, sessions, and teams are valuable.
First, the challenges related to engaging “graduates” into a much broader leadership framework within the institution are serious. A formal plan to place them in existing or new hospital projects is critical. Hospital leaders can be recruited to screen team projects and determine if they fit with existing projects. Failure to address this will result in disappointment and cynicism among aspiring leaders.
Second, the program must also be in step with the medical center’s goals and strategic plan. Third, there was not a charted pathway post-leadership training for faculty to enter a formal mentee role.
Our medical center recently did start a formal mentorship program. Program graduates should be given priority over other faculty. A few departments have now used FLI training to appoint faculty to important committees, but a salary bump would also be an appropriate incentive.
Finally, institutional leadership has to commit to have a formal “leadership track” for FLI graduates who wish to advance in academic rank.
Limitations
Our findings reflect our experience at a single academic medical center and may differ from experiences at other programs. Second, although our observations are based on several cohorts, we do not have long-term surveys to validate our observations. There may be a substantial lag-time between completion of the program and achieving a desirable leadership position.
Part of the challenge in developing a physician leadership program is also the level of education required of physicians with varying levels of knowledge in a rapidly shifting healthcare arena. Before addressing value-based care or population health, emphasis must be first placed on basic knowledge such as strategy, managing change, communication skills, working within teams, and managing oneself.
Conclusions
We continue to accumulate a longitudinal database of faculty FLI graduates to demonstrate empirical value to the institution. Feedback from chairs, division chiefs, deans, and administration suggests that the leadership program is providing the medical center with faculty members who can function at a much higher level, which is helpful in succession planning. However, ongoing success of such leadership programs requires flexibility and continual refinement to meet the needs of participants and the healthcare system.
All extramural and intramural physician leadership programs should continue to share their experiences, allowing meaningful improvements in training physicians to lead our healthcare systems into the future.
Acknowledgments
Special thanks to Deborah Pond, Elizabeth English, Heather Brod, and Phillip Binkley for their involvement and contributions to the success of the FLI program.
References
Rotenstein LS, Sadun R, Jena AB. Why Doctors Need Leadership Training. Harvard Business Review. October 17, 2018. https://hbr.org/2018/10/why-doctors-need-leadership-training .
Xirasagar S, Samuels ME, Stoskopf CH. Physician Leadership Styles and Effectiveness: An Empirical Study. Med Care Res Rev. 2005;62(6):720–740.
Berger DH, Goodall A, Tsai AY. The Importance of Increasing Surgeon Participation in Hospital Leadership. JAMA Surgery. 2019;154(4):281–282.
Day CS, Tabrizi S, Kramer J, Yule AC, Ahn BS. Effectiveness of the AAOS Leadership Fellows Program for Orthopaedic Surgeons. J Bone Joint Surg Am. 2010; 92:2700–2708.
Scott, HM, Tangalos EG, Blomberg RA, Bender CE. Survey of Physician Leadership and Management Education. Mayo Clinic Proceedings. 2017;72(7):659–662.
Stoller JK. Developing Physician-leaders: Key Competencies and Available Programs. J Health Adm Educ. 2008;25:307–328.
Lacerenza CN, Reyes, DL, Marlow SL, Joseph DL, Salas E. Leadership Training Design, Delivery, and Implementation: A Meta-analysis. J Appl Psych. 2017;102(12):1686–1718.
Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership Development Programs for Physicians: A Systematic Review. J Gen Intern Med. 2015;30(5):656–674.
Faculty Leadership Institute. https://medicine.osu.edu/faculty/fame/our-programs/fli .
Satiani B, Sena J, Ruberg R, Ellison EC. Talent Management and Physician Leadership Training Is Essential for Preparing Tomorrow’s Physician Leaders. Practice Management 2014;59(2):542–546.
The Hayes Group International. 360-Degree Leadership Development Survey. www.thehayesgroupintl.com/services/surveys-and-assessments .
Leadership Circle Profile. https://leadershipcircle.com/en/products .
Hogan Assessments: Predict Workplace Performance. www.hoganassessments.com .
Fletcher KA, Garcia S, Satiani B, Binkley P, Friedman A. Personality Predicts the Efficacy of a Physician Leadership Development Program. Am J Med Qual. 2021 May 27.
Lyons, MF, Ford, D, and Singer, GR. Physician Leadership. How Do Physician Executives View Themselves? Physician Executive. 1996;22(9): 23–26.
Perry J, Mobley F, Brubaker M. Most Doctors Have Little or No Management Training, and That’s a Problem. Harvard Business Review. December 15, 2017. https://hbr.org/2017/12/most-doctors-have-little-or-no-management-training-and-thats-a-problem .
Certified Physician Executive. www.physicianleaders.org/education/certified-physician-executive.
Straus SE, Soobiah C, Levinson W. The Impact of Leadership Training Programs on Physicians in Academic Medical Centers: A Systematic Review. Acad Med. 2013; 88:710–723.
Stufflebeam DL. CIPP Evaluation Model Checklist. https://wmich.edu/sites/default/files/attachments/u350/2014/cippchecklist_mar07.pdf .
Patton MQ. Developmental Evaluation. Evaluation Practice. 1994:15(3):311–319.
Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs. 3rd ed. San Francisco: Berrett-Koehler Publishers, Inc; 2006.
Rice AA. Evaluation of the Impact of a Large Corporate Leadership Development Course. Dissertation. Western Michigan University, Kalamazoo, MI. https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=1458&context=dissertations&httpsredir=1&referer= .