Time to Rethink Physician Leadership Training?

Physicians have long occupied an important place in healthcare leadership, but historically they have been most prominent in guiding the clinical practice of medicine rather than the business and management side of the clinical enterprise.

Medical schools, residencies, and clinical departments most often have been led by physicians chosen for their clinical expertise and, especially in academia, for their research and publishing prominence. Non-physicians typically manage the business duties such as formulating and managing budgets, hiring personnel, supervising and firing support staff, and meeting regulatory demands. This healthcare organizational model has prevailed for more than a century.

Beginning in the 1990s, calls for physicians to take senior health system leadership positions grew louder. Early voices advocated for the installation of those intimately familiar with clinical medicine demands — physicians, mostly — as though a medical degree coupled with clinical experience would adequately equip a physician to lead all facets of a healthcare enterprise. At the time, the challenge seemed to be finding physicians interested in the job. In 1999, Michael B. Guthrie wrote:

Many of the issues confronting healthcare organizations require physician involvement and understanding, and the physician executive is a tool to achieving physician participation. Physician leaders can become the mediators between physicians and organizational management, minimizing miscommunication and maximizing agreement and understanding. Yet few doctors seem willing to stand up and speak positively for the plans and proposals that will move the institution forward, and healthcare executives are often frustrated by physician leadership that fails to articulate and implement the vision and objectives of the organization.

Understanding physician leadership and exploring the challenges in managing and leading physicians require an understanding of the physician-mindset — a completely different mindset than that of the typical healthcare executive.(1)

A year later, Richard W. Schwartz, MD, MBA, termed physician leadership “essential to the very survival of teaching hospitals.” Schwartz observed, however, that physicians will need additional training to “acquire competencies” to meet burgeoning business demands of academic medical centers:

Academic medical centers (AMCs) face severe financial constraints because they must now compete directly with private providers that focus exclusively on cost-effective healthcare delivery. Educational and research capacities developed at AMCs have been supported by government and third party payers, but government support is diminishing. Physicians are ill-equipped to respond to market pressures.(2)

Despite the perceived need, educational institutions moved slowly to address the different education and training new physician leaders would need to competently command a clinical enterprise. In 2009, James K. Stoller, MD, criticized the traditional factors used to select physicians as organizational leaders. He also raised a related concern: that a physician’s experience as a member of a specialty might be counterproductive to a C-suite role. Characterizing the background as a “call to action,” he reflected:

The many challenges in health care today create a special need for great leadership. However, traditional criteria for physicians’ advancement to leadership positions often regard academic and/or clinical accomplishments rather than the distinctive competencies needed to lead. Furthermore, physicians’ training can handicap their developing leadership skills. In this context, an emerging trend is for health-care institutions to offer physician-leadership programs.(3)

Stoller complained that, “Though developing great leaders and embracing change are well-established characteristics of frontrunner organizations in many industry sectors, health-care institutions have generally lagged behind and are just recently awakening to the importance of developing physician-leaders.”

He worried that aspects of physicians’ training and clinical experience could actually stand as potential barriers to effective leadership, and though he offered few concrete answers, he explained the rationale for intentionally developing better physician leadership against the background of significant changes emerging in the business of medicine. He forcefully asserted, “These challenges call for and, in fact, demand great leadership from within health care” (emphasis added).

By 2014, progress was accelerating. Physician Executive, the publication of the American College of Physician Executives, published a special white paper entitled The Value of Physician Leadership.(4) Estimating that only 5 percent of healthcare enterprise leaders were physicians, authors Peter Angood, MD, and Susan Birk predicted, “The health care industry has entered an era marked by seismic change and disruption of the status quo, and one area that is experiencing high demand and explosive growth is physician leadership” (emphasis added).

In the intervening years, demand for physicians to fill roles in the C-suite has only increased. Doctors are steadily filling chief executive officer, chief operating officer, and chief business strategist roles in large and small healthcare organizations. The difference since Stoller’s 2009 call to action is striking.

In his 2019 article, Amol K. Gupta, MD, traced the growth of physician CEOs and studied their impact on healthcare organizations as measured by his own analysis of the 2019 U.S. News and World Report rankings and other data,(5) yet he questioned whether a medical degree and clinical experience were the distinguishing factors. He concluded:

Current evidence suggests that hospitals with physician executives outperform those without. In what may be considered recognition of the positive impact that physician CEOs have on the quality of hospital care and management, there is an increasing effort to cultivate leadership in medical students and qualified physicians through university and non-university business and administration programs. Nevertheless, there is a need to further assess what professional characteristics define the CEOs who manage the leading hospitals and how those characteristics impact hospital quality. Such research will help indicate whether a physician’s background is the major mediating factor of improved hospital management and health care. It will also help define what characteristics physician and non-physician CEOs need to develop to ensure that they can guide positive change within their hospital, refocusing health care back to its original intention: patient care.(6)

Physicians’ clinical experience may familiarize them with some of the administrative and business realities of clinical medicine delivery, but as Gupta points out, it remains unclear what differentiates successful physician CEOs from ineffective ones. It is entirely possible the differentiating factor may be preexisting attributes of health systems willing to entertain the prospect of a physician-CEO, or the innate abilities and personality of the physician leader.

Exploring Leadership Training Programs

Another consideration may be the complaint that Guthrie voiced in 1999: the combination of statistical chance coupled with a chronically inadequate candidate pool. We share Gupta’s observation and raise related concerns: Are the defining skills and qualities even being taught? And once taught, is the learning secured by the equally urgent need to maintain, refresh, and revisit performance through mentoring, self-reflection, and other means?

Rather than answering the question, physician leadership training programs responded instead with daunting lists of course offerings hoping to hit the mark. Clearly, medical education and clinical experience alone do not prepare physicians to meet the myriad leadership demands of a complex healthcare organization and per Gupta’s analysis as recently as 2019, neither have leadership training programs.

Stoller raised a worrisome question when he pointed out that medical school and clinical practice actually might be counterproductive to the leadership demands of a complex health system. For example, to be more effective, do aspiring physician leaders need to un-learn their tendency toward diagnosis and treatment on a micro basis? Or because in the clinical arena their patients’ health and welfare hang in the balance, is a clinician’s compelling need for diagnostic certainty before moving forward with decisions a helpful quality when leading a complex business in an ever-changing business environment?

Is a “healer-leader” a combination that predisposes toward ineffectiveness as a business leader? Do the vaunted professional and personal bonds, conceived in medical school and strengthened to tribal intensity in residency, create a limiting myopia for a CEO? Stoller’s misgivings clearly warrant increased consideration.

Nevertheless, a consensus has emerged that physicians who seek leadership positions should pursue knowledge, skills, and qualities through additional training and mentoring. Many medical and business educational institutions now offer healthcare leadership training ranging from certificate programs to advanced academic degrees.

Associations also have emerged for the education and support of physicians who aspire to the highest organizational leadership level. Formed in 1997, the American College of Physician Executives, now the American Association for Physician Leadership (AAPL), is according to its website, “[C]ommitted to educating, training, and supporting physicians of all types, encouraging them to assume leadership and management opportunities within the global health care industry.”(7) AAPL says it trains thousands of physicians yearly in certificate programs and master’s-level programs as well as offering individualized leadership training.

Review of leading programs’ classes paints a graphic picture of the wide array of issues modern healthcare executives may face, impliedly suggesting what their sponsors believe is important for training physician leaders. Northwestern University’s highly rated Kellogg School of Management’s Physician CEO program lists more than 30 subjects in its curriculum.

Rethinking Physician Leadership Training

What qualities, knowledge, skills, and experiences should an aspiring physician-CEO pursue? Long lists of classes, although impressive, may unintentionally deter one from beginning a pursuit or encourage another to become a “jack of all trades, master of none.” Even worse, exhaustive curricula may obscure or omit entirely the distinguishing characteristics of a truly effective leader.

We must rethink physician leadership training. Selectivity matters; every hour spent mastering one subject represents an hour lost mastering others. Expansive curricula may allow an institution to boast varied content, but such programs demand significant time commitments that come at the expense of family and revenue-producing clinical time with little assurance that successful completion results in effective leaders.

Programs with curricula focused more clearly on those skills and knowledge common to effective leadership, concluding with training in methods and resources to refresh and revisit leadership performance through ongoing mentoring, self-reflection, and other means (to “sharpen the saw” as Stephen Covey graphically put it(8)) will be readily adopted and more likely to yield impactful physician leaders.

With nearly 80 combined years spent observing executive healthcare leadership intimately, we believe effective education and training at its core must prioritize four key skills: communication, talent selection and management, crisis management, and finance (in perspective), coupled with four foundational leadership attributes: humility, courage, focus, and intellectual curiosity.

We urge anyone considering a physician leadership program to scrutinize the curriculum to determine if these areas are listed and accorded the time and creativity each deserves.

1. Communication. A leader’s most fundamental function is to lead, and to lead she or he must effectively communicate to a wide audience that includes board members, donors, and local and national political leaders, as well as environmental service workers, all levels of clinical staff, myriad nonclinical staff, and of course, to patients and their families in all forms of communication from written to spoken, in large groups and small teams.

Achieving an organization’s potential; advancing its clinical mission; building resilience and reliability; and providing safe, quality, and compassionate care with attention to financial stability requires effective communication. Inspiring a varied audience originates with a clear statement of values, ethics, and mission. However, effective communication is complex; words have special significance in an organization, but the impact is easily affected by hundreds of factors such as tone, attitude, body language, and facial expression.

Inconsistency within the leadership team can readily undo the most carefully crafted message. A leader’s actions, decisions, and personal behavior can be powerfully inspirational or devastatingly self-defeating, as can those of other executive team members who function visibly as proxies for the leader.

Leadership is communication played out on the big screen. Few current curricula accord communication training in all its facets the priority it deserves and the creativity it requires considering how fundamental the skill is to success.(9)

2. Talent selection, development, and management. Learning the skills necessary to assemble a strong team is indispensable to leadership preparation. Training in the operational mechanics and legal framework around hiring, evaluating, and firing is not nearly enough; learning to select, train, and motivate key personnel is more useful to top leadership.

Leaders must be taught to approach human resource opportunities strategically. They must learn to prize diversity in all its forms, reflecting the workforce and community served by the organization, not for political correctness but for the richness and insight that can be obtained only by imbuing the team with a variety of perspectives and life experiences.

Insightful identification of need and formulation of job descriptions cannot be left to human resources personnel using time-worn market titles, descriptions, and pay scales. Leaders must be incisive about talent needs, creative about options for filling them, and selective for the range of qualities beyond the core specialty for which recruits are being considered. An excellent finance mind for example, will be limited without effective communication skills or a capacity to work collegially across disciplines within the enterprise.

Perhaps even more basic, instilling effective team building skills must include recognition of and ability to screen for intrinsic qualities of integrity, professional accountability,(10) sincerity and honesty, and a commitment to inclusion. Leaders assembling teams must be equipped to assess candidates’ personal and professional motivation and their abilities to adhere to core values, ethics, and the corporate mission. Once this is assured, leaders can then be schooled in team and talent management. Focusing on an impressive curriculum vitae without regard to those personal attributes may work against a leader’s own message, sometimes with devastating effects.

The leader exists at the organization’s epicenter, answerable for their team. Training aspiring leaders in strategic, mindful selection of talent, continued development, and real-time feedback promotes accountability to the mission’s values and goals. Failure to do so exposes leaders to a serious vulnerability that is limiting always, potentially derailing at the worst.

3. Crisis management. Crisis is an ever-present risk in medicine. The very best corporate executives can be undone by mismanagement of a single incident. The most carefully engineered health system is still a high-stakes and inherently dangerous endeavor.

Any large workforce will include troubled souls compelled to violate boundaries. Clinicians can engage in harmful, even scandalous behavior. Large-scale infections break out. An accidental overdose of a celebrity’s child exposes a health system to national scorn.(11) Deficiencies in endoscope cleansing(12) can affect large numbers of patients over time. Workplace violence is an everyday threat.(13)

In any sector, the list of potential crises is varied and diverse, but within healthcare, a crisis can be paralyzing in the moment with long-term crippling consequences for the future. In a world with a continual news cycle, leadership training must prepare aspiring leaders in crisis management, including how to establish a culture in which potential disasters are likely to be identified quickly because trusted team members feel safe to report bad news, how to prioritize messages and establish a crisis management team to assess the threat and mobilize resources and talent needed to stem ongoing harm, and the value of embracing the concept of trauma-informed leadership(14) to improve the enterprise, all the while consistently demonstrating adherence to the organization’s core values.

4. Finance (in perspective). Too often, finance trumps most everything else. Leaders are challenged every day by issues powerful enough to divert them from their organization’s raison d’être. Regulatory obligations, public relations worries, research faux pas, staff retention issues all can stymie organizational core missions.

Finance can dominate the C-suite’s attention in nearly all organizations, not just healthcare. Healthcare organizations, however, most frequently lose their way by succumbing to the siren song of financial margins at the expense of quality, safety, and other patient priorities.

Studies have shown that investments in new technology often lead to expensive overuse, including providing medically unnecessary treatment and billing for the unnecessary services.(15,16) Clinicians have landed in prison and organizations have suffered severe financial penalties for that reason.(17) When money is the goal, caregivers who are productive financially may be protected no matter how toxic and damaging their behavior.

Examples of healthcare organizations motivated by financial interests at the expense of their core mission are sadly commonplace. Leadership training programs must produce aspirants who are conversant in finance but are sensitized to the tension that always exists between finance and corporate values and well-equipped to properly balance finance’s relative importance to the organization’s healthcare mission.

There are, of course, many other nearly essential and nonessential skills a leader would do well to acquire. However, mastering these skills — communication, talent recruitment and management, crisis management, and finance balancing — is critical, but underemphasized in most physician leadership curricula.

Intrinsic Qualities That Set Leaders Apart

Leadership entails more than mastering the four key skills outlined above. Training programs must consider how extraordinary leaders use the tools in which they are trained, and that is determined in great part by the leaders’ qualities and values. Training programs determined to graduate impactful leaders should routinely attend to their trainees’ personal development in four key categories.

Not everyone who wants to be a leader can or should be a leader. Effective healthcare leaders have personal qualities that are not often addressed in leadership training programs or get passing reference at best and are almost never accorded the creative and unique educational approaches these topics warrant. These four intrinsic qualities— humility, courage, focus, and intellectual curiosity — make a real difference and set leaders apart from competent managers.

1. Humility. Humility may be the most important personal quality in a leader. So many important attributes flow from humility or require humility as a necessary substrate like personal integrity, self-awareness, natural inclusiveness, eagerness to seek out others’ points of view, an openness to understand the impact a leader has on others and their performance, kindness, respect and constructive help for those who fail, and selflessness.

Humility is necessary for those in leadership positions to view the corporate mission with clarity. With the mission in clear view, effective leaders instinctively set aside personal interests or better balance financial goals for the benefit of the corporate mission.

Humble leaders can risk failure because they accept that they are working for organizational, not personal outcomes. Humble leaders are better listeners because they embrace the possibility that the most important idea may not be their own. And it is humility that reminds successful executives of the need to constantly refresh and revise their leadership style and content. Humility is the antithesis of weakness; it is the rare strength that allows leaders to acknowledge their own vulnerability to see and serve a mission beyond their own.

2. Courage. Courage is the other side of the humility coin. Humble leaders have a clear line of sight; courageous leaders are able to pursue a vision. Humility tempers courage and minimizes recklessness; courage empowers leaders to make hard decisions. Courage distinguishes a leader from a manager.

Too often, aspiring leaders enter programs as honor students unfamiliar and uncomfortable with failure. Effective leadership training must use real-world case studies to creatively highlight the vital role courage plays.

3. Focus. The core healthcare mission should place patients’ and caregivers’ well-being(18) at the center of all they do. Successful leaders must unfailingly keep that mission in focus despite the vicissitudes of operational challenges and insidious-but-omnipresent temptations to serve their own or others’ personal or individual values — decisions driven by compensation or profit, for instance. True leaders must filter daily demands and existential crises through the sieve of their foundational principles to keep the ship relentlessly, seamlessly on course.

Executives who elevate finances over quality or safety have lost their focus. Defensive or evasive reactions to a crisis at the expense of transparency and honesty place the organization’s mission at risk. Whether paralyzed by fear of failure, discomfort, or any other reason, leaders cannot ignore or avoid difficult human management decisions. Acting to preserve the leader’s own position or reputation over the organization’s future risks failure or diminishing both.

Almost all other healthcare enterprise concerns such as finances, staff joy and sense of meaning, safety and retention, marketing, patient satisfaction, and regulatory demands fall into line when leaders demonstrate a capacity to make the hard decisions to keep the mission central. Creative and insightful training approaches that counter natural tendencies to short-term and self-centered perspectives are overdue.

4. Intellectual curiosity. Just as humility and courage are two sides to the same coin, the drive to explore new frontiers is the counterpart to a steadfast commitment to organizational mission. Intrinsic to the very concept of leadership is a restlessness with the status quo. Author David Foster Wallace observed:

“A real leader is somebody who, because of his own particular power and charisma and example, is able to inspire people, with ‘inspire’ being used here in a serious and non-cliché way. A real leader can somehow get us to do certain things that deep down we think are good and want to be able to do but usually can’t get ourselves to do on our own.”(19)

Healthcare is dynamic and the stakes are high. Leaders with proven longevity who consistently make measurable differences to advance the healthcare organizations they lead question the status quo. They are willing to explore new paths while inspiring others to follow.

Impactful leaders embrace innovation, experimentation, with an openness to novel solutions as a means of serving and improving on their clinical mission. To be otherwise is the antithesis of what it means to lead. Leadership training programs must impress upon their trainees the importance of this and equip them with strategies for constantly refreshing and revising organizational goals.

Focusing On Leadership

Many self-labeled “leadership programs” are really management programs. They dwell in minutiae and fail to adequately focus on the core qualities that define the very concept of leadership.

If leadership education hopes to produce new physician leaders who will guide healthcare in a dramatically changing world, programs must do a better job of focusing on skills and attributes that predictably set the best apart, then secure the fruits of that training by furnishing them with thoughtful and novel approaches to ongoing mentoring and reinvention essential to help leaders sustain their edge long-term.

Where to start? Maybe program leaders themselves should emulate the four essential qualities of leadership: humility, courage, focus, and a determination to explore new frontiers. Only then will they have the clarity to see what will produce transcendent leaders, the fortitude to act on that new vision with creativity and radical departures from the status quo, the recognition of the critical importance of diversity, and the commitment to deliberate, conscious programmatic reinvention that will effectively serve healthcare’s rapidly and ever-changing landscape.

References

1. Guthrie MB. Challenges in Developing Physician Leadership and Management. Frontiers of Health Services Management. 1999;15(4):3–26.

2. Schwartz RW. Physician Leadership Is Essential to the Survival of Teaching Hospitals. Am J Surg. 2000;179(6):462–8.

3. Stoller JK. Developing Physician-Leaders: A Call to Action. J Gen Intern Med. 2009;24:876–878. https://doi.org/10.1007/s11606-009-1007-8

4. Angood P, Birk S. The Value of Physician Leadership. Physician Exec. 2014;40(3):6–20.

5. Goodall AH. Physician-Leaders and Hospital Performance: Is There an Association? Soc Sci Med. 2011;73(4): 535-39. PMid: 21802184. https://doi.org/10.1016/j.socscimed.2011.06.025 .

6. Gupta, AK. Physician versus non-physician CEOs: The effect of a leader’s professional background on the quality of hospital management and health care. J Hosp Admin. 2019:8(5)47–51.

7. American Association for Physician Leadership. www.physicianleaders.org

8. Covey S. Habit 7: Sharpen the Saw. The Seven Habits of Highly Effective People. FranklinCovey. www.franklincovey.com/the-7-habits/habit-7 .

9. Hickson GB, Moore IN, Pichert JW, Benegas, M. Balancing Systems and Individual Accountability in a Safety Culture. In From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd ed., published by The Joint Commission; 2012; 1–36.

10. Hickson G, Pichert J, Webb L, Gabbe S. A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors. Acad Med. 2007;82:1040–48.

11. Ornstein C. Dennis Quaid Files Suit Over Drug Mishap. Los Angeles Times, Sept. 16, 2014. www.latimes.com/entertainment/gossip/la-me-quaid5dec05-story.html

12. Eisler P. Deadly Bacteria on Medical Scopes Trigger Infections. USA TODAY, Jan. 21, 2015. www.usatoday.com/story/news/2015/01/21/bacteria-deadly-endoscope-contamination/22119329/ .

13. Sanchez R, del Valle, L. Man Accused of Killing Boston Doctors Told Police He Had Affair with One and Killed the Other in Self-defense. CNN December 6, 2019. www.cnn.com/2019/12/05/us/boston-doctors-murder-trial-thursday/index.html .

14. Lockert L. Building a Trauma-Informed Mindset: Lessons from CareOregon’s Health Resilience Program. Center for Health Care Strategies. June 2015. www.chcs.org/building-trauma-informed-mindset-lessons-careoregons-health-resilience-program .

15. U.S. Department of Justice. Tenet Healthcare and Affiliated California Hospital to Pay $1.41 Million to Settle False Claims Act Allegations for Implanting Unnecessary Cardiac Monitors. U.S. Department of Justice website. www.justice.gov/opa/pr/tenet-healthcare-and-affiliated-california-hospital-pay-141-million-settle-false-claims-act .

16. Herndon JH, Hwang R, Bozic KJ. Healthcare Technology and Technology Assessment. Eur Spine J. 2007; Aug;16(8):1303. doi:10.1007/s00586-007-0369-z.

17. Cardiologists Charged with Fraud by the US Justice Department for Overuse of Stenting. www.justice.gov/usao-edmi/pr/united-states-intervenes-health-care-fraud-action-and-obtains-4-million-settlement . Cancer Doc Fata’s Sentence Stands, Federal Judge Rules. The Detroit News, Feb. 7, 2020. www.detroitnews.com/story/news/local/oakland-county/2020/02/07/cancer-doc-farid-fata-conviction-upheld/4692724002/ . Some Farid Fata Cancer Patients to Share in $8M Malpractice Settlement. Detroit Free Press, July 20, 2016. www.freep.com/story/news/local/michigan/oakland/2016/07/20/fata-cancer-patients-share-8m-settlement/87336964/

18. Mathias D. Improving Patient Safety by Easing Caregiver Burden. Nursing. 2019;49(1): 62–4. doi: 10.1097/01.NURSE.0000549740.50378.94. Lucian Leape Institute. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, MA: National Patient Safety Foundation; 2013. Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826-32. doi:10.1001/jamainternmed 2017.4340.

19. Wallace DF. The Weasel, Twelve Monkeys And The Shrub: Seven Days In The Life Of The Late, Great John McCain. Rolling Stone, April 13, 2000.