Special Article

Survey of Physician Leadership and Management Education

H EATHER M. SCOTI, M.B.A., E RIC G. T A GAtOs, M.D., R OBERT A . BLOMB ERG, M.A.I.R.,

AND C LAIRE E. B ENDER, M.D.

Health-care organizations ha ve recognized the need toprepare ph ysicians for va r ious leadership and man­agement positions within their own institutions. In thepa st , those who d esired further education had tosearch beyond the boundaries of th eir practice to ful­fill thi s need. The demands of a dynamic and chang­ing health-care environment have created increasedpressure on organizations to develop a larger cadre ofphysician leaders and managers among their sta ff andto accomplish thi s outcome in a cost-effective, efficientmanner. This article examines the resul ts from asurvey of leading medical institutions on the existenceof in-house leadership and management educational

Increasingly, health -care organ izations are recognizing theneed to prepare their physicians for various leadership posi­tions within their institutions. Kusy and associa tes ' ob ervedthat, with critical reforms emerging during the 1990s, health­care organizations are changing at " lightning speed ." Theynoted that, although historically, health-care leaders werepredominantly from nonclini cal backgrounds, today thepresence of physicians as leaders of reform is increasinglystrong. The need to educate physician-scholars for leader­ship in the health-care system has also been an identifiedpriority for "stakeholders" in traditiona l med ical educat ion.!Merry] attributed this shift toward physician leadership tofour developments in health-care delivery during the late20th century- the increase in institutions that deliver com­plex health care, a fundamental restructuring of health-carefinances, a progressive cha nge from inpatient to ambulatorycare, and the introduction of a series of leadership and man­agement practices know n collectively as total qua lity man­agement. Aluise and colleagues" asserted that, because phy-

From Management and Employee Education (H. 1.5.). Division of Com­munity Internal Medicine (E.G.T .). Human Resource Strategies (R.A.B.).and Departme nt of Diagnostic Rad iology (C.E .B.). Mayo Clinic Roches ter,Rochester. Minnesota,

Address reprint requests 10 Dr. E. G. Tangalos, Division of CommunityInternal Medicine. Mayo Clinic Rochester, 200 First Street SW. Rochester,MN 55905.

programming. It also documents th e approaches usedby the responding organizations and the content oftheir course work. Numerous institutions are accept­ing the challenge for increased physician exper t ise inleadership and management by de veloping their ownin-house programs. Future directions for Mayo initia­tives in succession planning will be obtained from thi sbenchmark sur vey.

(Mayo Clin Proc 1997;72:659-662)

AHA = American Hospital Association; CEOs =chief executiveofficers

sicians have a central role in plannin g and allocating med icalcare services and other health-care resources, they must beprepared to serve as interface professionals between thedelivery of medica l service s and the management of hea lthcare. For whatever the reasons identified , health-care insti­tutions must now make the critical decision of who should betrained in health-care leadership and how this training shouldbe provided.

Some institutions respond to the need for physician lead­ership by providing opportunities for their staff to attendadministrative programs that are offered off campus. Manyinstitutions, however, are fulfilling this need by offeringtheir own in-house leadership programs. At least one man­aged-care organization has established its own "university"for the education of its physician staff.' Dur ing the late1980s, only 32% of respondin g hospital chief executiveofficers (CEOs) informed the American Hospital Associa­tion (AHA) that they were prov iding leadership training forelec ted and appo inted medical staff leaders or heads of de­partments." Trai ning models and defined compete ncies wereproposed;" The 1991 AHA survey" indicated an increasingtrend toward orga nized physician leadership programs forelected and appointed medica l staff leaders in communityhospitals (35.5% in 1991). Unfortu nately, only minimalinformation is ava ilable on the nature of these in-houseprograms, espec ially in rega rd 10 integrated group practicesand academic health centers.

Mayo C/in Proc 1997;72 :659-662 659 © /997 Mayo Foundation / or Medical Education and Research

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660 PHYSICIA LEADERSHIP AND MANAGEME T EDUCATION

MAYO FOUNDATION SURVEYIn 1995, Mayo Foundation in Rochester, Minnesota, under­took a survey of 122 of the leadin g medi cal institut ions in thenation . The purposes of the survey were to asce rtain theexis tence of physician leadership and management educa­tional programs among these institutions and to benchmarkthe efforts of Mayo concerning organized physician educa­tion. The survey was conducted under the auspices of theLeadersh ip Education Subcommittee, a group of seven phy­sicians and administrators charged by the Mayo PersonnelComm ittee to establish and implement physician leadershipeducation and development programs. At both the institu­tional and the individual level. there was a "readiness fordevelopment?' ? and an "o penness to experience" !' new ideasand explore unfam iliar issues . Th e findin gs of that surveyare subsequently described.

METHODSIn May 1995. a survey developed by the subcommittee wasmailed to CEOs of the 112 best hospitals (as identified in theJuly 1994 issue of U.S. News and World Report) and the topIO health maintenance organiza tions (HMOs) (as identifiedin the December 1994 issue of Business Insurance).

The survey was acco mpanied by a cover letter to the CEOthat explained the purpose of the survey and was signed byone of the authors (C.E.B.), who is chair of the subcommitteeand a member of the Board of Governors. We chose toundertake our own survey rather than use a sponsoring orga­nization such as the AHA . ames and addresses of theCEOs were obtained from the 1994 AHA guide.

Respondents were asked to answer 33 questions relatingto demographic s, program exis tence, history, des ign, andeva luation. They were asked to respond within 3 weeks.Data from these surveys were compiled and arc reportedherein by major descr iptive category .

RESULTSProgram History and Background.-Ofthe 122 institut ionssurveye d, 26 responded; thus, the respon se rate was 21.3%.(Responses were kept anonymous beca use we believed thatthis approach would increase the likelihood of response.)This response rate is comparable to that reponed by Collinsand Porras? (23.5%) in their recent eva luation of visionarycompanies from service and industry nat ionwide. In oursurvey, 15 of the 26 institutions tracked the exte rna l pro­grams attended by their physician leaders. The program thatwas attended the most often was the one offered for divisionchiefs by the Harvard School of Public Health (53.3 %). Theprogram offered by the American College of Physici an Ex­ecutives was also well attended (33.3 %).

Eight institution s (3 1%) provided some type of in-housephysician leadersh ip educational programm ing, whereas 18

Mayo Clin Proc , J uly 1997, voln

(69%) did not. The ensuing discussion focuses only on thoseeigh t institutions.

Of the eight respondents with in-house programs, fiveinstitutions had had program s for 5 or more yea rs, whereastwo had had programs for 2 to 4 yea rs. Most respondents(86%) with in-house programs used focus groups to identifytheir physicians ' educational needs, although some (43%)were al 0 influenced by legal or regulatory mandates and bythe recom mendations of external consultants. Most of theseinsti tutions surveyed a mean of three gro ups to assess educa ­tional needs . Representatives from the phys ician exec utiveleadership of the institution (department chai rs, chiefs. andpresidents) were surveyed by 63% of respondents. Boardmembers, administrators, and attend ing physicians wereeach surveye d by 50% of respondents.

Program Design and lmplementation.-Of the respon­den ts with organized in-house programs. 88% preferredseminars for program delivery. Most of these institutions(88%) directed their leadership program s to their exec utivetier, although many (63%) also targeted attending phys iciansand administrators .

Programs were generally offered on wee kdays. durin g theday, or on work time. and they were usually well attende d.Most institutions (88%) did not charge for program atten ­dance. Of the eight responding institutions, four alwaysprov ided continuing medical education credi ts to physiciansfor program attendance. whereas four had never providedcontinuing medical educa tion credits .

Speakers for intramural programs were usually identi fiedthro ugh institutional networks. through recommendat ions ofothers, and by institu tional representatives visiting universi­ties. colleges, confere nces. or workshops. Of the sevenrespondents who answe red this question , four indicated that26 to 49% of their speakers were from their own organiza­tion . two had intramural speakers at least 75% of the time.and one had intramural speakers 50 to 74% of the time. Formost institutions, the typical I-d ay fee for an outside consul­tant was between $ 1,000 and $5.000. Overall program costsfor 1994 varied by institution and ranged from $25 ,000 to$250,000.

The topics most likely to be addressed in leadership pro­grams included quality manage ment. issues in health care.leadership principles, strategic plann ing, management prin­ciples, economics of health care. finance and acco unting,and gove rnment and policy issues (Fig . 1). Each one of thesetopics was addressed in organ izational leadership programsby more than 60% of respo nding inst itutions. Courses thatdea lt with communica tion and interpersonal skills were ofless importa nce.

An equal percentage of institutions (29%) indica ted thatparticipants usually attended between 8 and 16, 17 and 24, ormore than 30 hours of in-house leadership and man agement

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Mayo Clio Proc, July 1997,Vol 72 PHYSICIAN LEADERSHIP AND MANAGEMENT EDUCATION 661

20

Mutual respect 111ll~gMotivation -I

DiversitySexual harrassment

Personnel/employment issuesCommunicat ions

Conflict resolutionInterpersonal skills

Legal issuesEthical challenges

Government/policy issuesFinance/accounting

Economics of healthcareManagement principles

Strategic planningLeadership principles

Issues in healthcareQuality management

o 40

%

60 80 100

Fig. I. Topics addressed in institutional leadership and management programs for physicians.

educational programs annually. Participants generally at­tended these programs during work ing hours . In addition toleadership educationa l programs, mos t institutions offeredother developmental act ivities for physicians, such as tui­tion reimbursement, planned mentoring, or on-site M.B.A.program s.

Program Evaluation.-Of the eight institutions with or­ganized leadership programs, two had no formal mecha­nisms for obtai ning participant feedback. The other sixindicated that participants generally rated their programs asgood or very good. Orga nizational perspective on programeffectiveness was similar. More than 70% of the institutionsbelieved that their leadersh ip programs were effective inachieving their stated objec tives.

DISCUSSIONThe rapidly changing health-care environment and the ne­cessity to prepare physicians for future role in managed careand in-system governance were some of the factors cited forthe deve lopme nt of in-ho use physic ian leadership programs.The belief was that organized institutional prog rammingcould be tailored to specific knowledge deficiencies in phy­sician staff while providing the key business and manage­ment skills needed for them to become collaborative partnersin the delivery of cost-effective, quali ty health care.

Benefits of In-House Programs.-ln addition to build­ing gene ral management and leadership skills, organizationsthat participated in the survey wanted their in-ho use pro -

grams to be vehicles for communicating internal activi ties,finances, and plans to physician staff. Programs were de­signed to accomplish manifold objectives, including assist­ing physicians in the transition from clinician to manager,deve loping leadership potential in young physicians, andpreparing physicians to understand and manage the changesresulting from the evolving healt h-care environment.

Not surpri singly, participating institutions with organizedin-house programs believed that the custornization of pro­gram s to fulfill organi zat ional needs was one of their greateststreng ths. They also identified facu lty expertise and a teamenvi ronment as other important program strengths. Someorganizations were able to identify tangib le achievementsfrom their programs, citing improved Joint Commission onthe Accreditation of Health Care Organizations scores ormeasurable gains in specific leadership skills . In addition ,institutions ascribed the building of collegial relations withintheir organizations as an important indirec t benefit of theseprograms.

Several suggestions were also volunteered by the respon­dents. The se included securing the involvement of forma land informal physician leaders hip, developing an advisoryboard primarily composed of phy sicians, foc using oncus tomization of the program to fulfi ll the need s of theorganiza tion, maintaining small class size to foster interac­tive learning, establishing some means to measure learning,and considering the provision of academic credits toward anM.B.A.

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662 PHYSICIAN LEADERSHIP AND MANAGEMENT EDUCATIO

Limitations of tile Study.-The responses to our surveysugges t that several leading medical ins titutions have o rga­nized in-house ph ysician leadership pro grams and that so meare also ex tend ing this service to administrators. Becau seou r survey was mailed anonymously with a return envelope,we do not kno w if the responses ac tually reflected the posi­tion of the CEO, an educa tional coordina tor, or a person inhuman resources.

In light of our res ponse rat e, the margin of erro r for oursample is ±20 %. Thus, it is difficult for us to ex tra po late theresults of o ur survey and to apply them to the entire popula­tion of medical inst itutions that pro vide in-h ou se ph ysic ianleadership programs. The main purposes of th is report are torelate the find ings fro m the survey and to communica tecommo n characteristics among responding insti tutions.

We could have used a differenl approach to producehigher respon se ra tes . A prem ailing te lephone ca ll may haveiden tified the appropriate person to whom we sho uld haveaddressed the survey if that person was not the CEO. Elimi ­nat ing deadlines on responses and using a spo nsoring organ i­zation suc h as the AHA might also ha ve resulted in high er

response rates,

SUMMARYOur survey should provide insight into the process used bysome med ical organi zati on s to dev elop and implement in­hou se pro grams for ph ysician leadersh ip. Among organi za­tion s, no uniform approa ch has yet eme rge d for the develop­ment of ph ysician leadership and management sk ills. Insti­tutions that part icipated in the study ee m to be broade ningtheir ba<;e o f physician leadersh ip ta len t by targeting not onlyph ysician executives for organize d in-ho use program s butalso other attending physicians who might be interested inongoing lead ership opportunities wi thin the organization.

Th e pro grams in these insti tut ions are apprec iated an dvalu ed by parti cipat ing ph ysician s and often res ult in thebu ilding of a colleg ial cl imate withi n the organization. Inaddition, in-hou se prog rams are primaril y designed to ta ilo rlead ersh ip and management educati on ; thu s, they are co nsi s­tent with orga niza tional culture and need . O ften , the topi cs

MayoClin Prot, .July 1997, voln

selected arc those that help ph ysician s meet the ch all enges ofexternal env iro nme ntal forces.

Becau se of the dem ands of a high ly co mpeti tive andrapid ly changin g health-care env iro nme nt, the trend towardmore in-hou se leade rship programs in medi cal inst ituti on swill co ntinue. Good universit y-based programming ex istsfor those who seek leadership train ing . Organi zat ions willcontinue 10 identify ways to prepare their ph ysicians to as­sume various leadership positi on s wh ile medi cine continu esits evolution ary pat h into the busin ess envi ronment.

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