Introducing residents to a career in management: the Physician Management Pathway

Leadership Development in Postgraduate Medical Education: A Systematic Review of the Literature

PURPOSE

To evaluate and interpret evidence relevant to leadership curricula in postgraduate medical education (PGME) to better understand leadership development in residency training.

METHOD

The authors conducted a systematic review of peer-reviewed, English-language articles from four databases published between 1980 and May 2, 2017 that describe specific interventions aimed at leadership development. They characterized the educational setting, curricular format, learner level, instructor type, pedagogical methods, conceptual leadership framework (including intervention domain), and evaluation outcomes. They used Kirkpatrick effectiveness scores and Best Evidence in Medical Education (BEME) Quality of Evidence scores to assess the quality of the interventions.

RESULTS

Twenty-one articles met inclusion criteria. The classroom setting was the most common educational setting (described in 17 articles). Most curricula (described in 13 articles) were isolated, with all curricula ranging from three hours to five years. The most common instructor type was clinical faculty (13 articles). The most commonly used pedagogical method was small group/discussion, followed by didactic teaching (described in, respectively, 15 and 14 articles). Study authors evaluated both pre/post surveys of participant perceptions (n = 7) and just postintervention surveys (n = 10). The average Kirkpatrick Effectiveness score was 1.0. The average BEME Quality of Evidence score was 2.

CONCLUSIONS

The results revealed that interventions for developing leadership during PGME lack grounding conceptual leadership frameworks, provide poor evaluation outcomes, and focus primarily on cognitive leadership domains. Medical educators should design future leadership interventions grounded in established conceptual frameworks and pursue a comprehensive approach that includes character development and emotional intelligence.

The Affordable Care Act and Its Effects on Physician Leadership: A Qualitative Systematic Review

OBJECTIVES

The Affordable Care Act (ACA) shifted the focus in medical care from quantity to quality. This qualitative systematic review aimed to determine the key skills necessary for effective physician leaders after the implementation of the ACA, and to compare them with key skills identified prior to its implementation.

METHODS

A qualitative systematic review was conducted. A systematic literature search on leadership skills for physicians returned 26 articles published between 2009 and 2016. Thematic analysis was used to categorize the data presented in each article. The results from the thematic analysis were then compared with a similar article published before the implementation of the ACA.

RESULTS

Teamwork and team-building, communication, and self-awareness skills were mentioned most often. The percentage of articles mentioning teamwork and team-building skills (61.5%) was significantly greater than the percentage (25%) reported before the implementation of the ACA (P ≤ .04).

CONCLUSION

With the shift toward quality of patient care, health care workers at all levels should strive to work as a team to provide the best quality of care at all stages of patient care.

Leadership Training in Graduate Medical Education: A Systematic Review

BACKGROUND

Leadership is a critical component of physician competence, yet the best approaches for developing leadership skills for physicians in training remain undefined.

OBJECTIVE

We systematically reviewed the literature on existing leadership curricula in graduate medical education (GME) to inform leadership program development.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we searched MEDLINE, ERIC, EMBASE, and MedEdPORTAL through October 2015 using search terms to capture GME leadership curricula. Abstracts were reviewed for relevance, and included studies were retrieved for full-text analysis. Article quality was assessed using the Best Evidence in Medical Education (BEME) index.

RESULTS

A total of 3413 articles met the search criteria, and 52 were included in the analysis. Article quality was low, with 21% (11 of 52) having a BEME score of 4 or 5. Primary care specialties were the most represented (58%, 30 of 52). The majority of programs were open to all residents (81%, 42 of 52). Projects and use of mentors or coaches were components of 46% and 48% of curricula, respectively. Only 40% (21 of 52) were longitudinal throughout training. The most frequent pedagogic methods were lectures, small group activities, and cases. Common topics included teamwork, leadership models, and change management. Evaluation focused on learner satisfaction and self-assessed knowledge. Longitudinal programs were more likely to be successful.

CONCLUSIONS

GME leadership curricula are heterogeneous and limited in effectiveness. Small group teaching, project-based learning, mentoring, and coaching were more frequently used in higher-quality studies.

Medical student healthcare consulting groups: A novel way to train the next generation of physician-executives

Meeting the challenges of the evolving healthcare environment requires leadership of physicians well-trained in clinical medicine and healthcare management. However, many physicians lack training in business and leadership. While some residency programs have management tracks, training at the medical school level is currently lacking. We developed the Hopkins Health Management Advisory Group, an extracurricular program at Johns Hopkins University School of Medicine that exposes medical students to healthcare management and fosters development of leadership skills. Teams of students work directly with health system executives on 3-6 month-long projects using management consulting principles to address problems spanning health system domains, including strategy, operations, and quality improvement. Since the program's inception, 23 students have completed seven projects, with 13 additional students currently working on three more projects. Sponsors leading six out of seven completed projects have implemented recommendations. Qualitative survey respondents have found the program beneficial, with students frequently describing how the program has helped to develop professional skills and foster knowledge about healthcare management. These early assessments show positive impact for both students and the institution, and suggest that such programs can train students in management early and concurrently in their medication education by immersing them in team-based health system projects.

Business Education for Plastic Surgeons: A Systematic Review, Development, and Implementation of a Business Principles Curriculum in a Residency Program

BACKGROUND

Rising health care costs, decreasing reimbursement rates, and changes in American health care are forcing physicians to become increasingly business-minded. Both academic and private plastic surgeons can benefit from being educated in business principles. The authors conducted a systematic review to identify existing business curricula and integrated a business principles curriculum into residency training.

METHODS

The authors anonymously surveyed their department regarding perceived importance of business principles and performed a systematic literature review from 1993 to 2013 using PubMed and Embase to identify residency training programs that had designed/implemented business curricula. Subsequently, the authors implemented a formal, quarterly business curriculum.

RESULTS

Thirty-two of 36 physicians (88.9 percent; 76.6 percent response rate) stated business principles are either "pretty important" or "very important" to being a doctor. Only 36 percent of faculty and 41 percent of trainees had previous business instruction. The authors identified 434 articles in the systematic review: 29 documented formal business curricula. Twelve topics were addressed, with practice management/administration (n = 22) and systems-based practice (n = 6) being the most common. Four articles were from surgical specialties: otolaryngology (n = 1), general surgery (n = 2), and combined general surgery/plastic surgery (n = 1). Teaching formats included lectures and self-directed learning modules; outcomes and participant satisfaction were reported inconsistently. From August of 2013 to June of 2015, the authors held eight business principles sessions. Postsession surveys demonstrated moderately to extremely satisfied responses in 75 percent or more of resident/fellow respondents (n = 13; response rate, 48.1 percent) and faculty (n = 9; response rate, 45.0 percent).

CONCLUSIONS

Business principles can be integrated into residency training programs. Having speakers familiar with the physician audience and a session coordinator is vital to program success.

Simulating the physician as healthcare manager: An innovative course to train for the manager role

INTRODUCTION

During their formal studies medical students acquire extensive medical expertise. However, the medical profession demands additional competencies, such as those involved in efficient resource allocation, business administration, development, organization, and process management in the healthcare system. At present students are not sufficiently prepared for the physician's role as manager. In response, we designed the seminar course, MeCuM-SiGma, to impart basic knowledge about healthcare policy and management to students of medicine. This project report describes our teaching strategies and the initial evaluation of this educational project.

PROJECT DESCRIPTION

In this semester-long, seminar course introduced in 2010, medical students gather experience with the competencies mentioned above as well as learn basic management skills. The course is offered each winter semester, and students sign up to attend voluntarily; course coordination and organization is done on a voluntary basis by physicians and employees of the Mentoring Office (MeCuM-Mentor) at the Medical School of the Ludwig Maximilian University (LMU) in Munich, Germany. The course is open to all students enrolled at the two medical schools in Munich. During the first part of this elective, students learn about the basic principles of the German political and healthcare systems in case-based, problem-based tutorials led by trained tutors and in lectures held by experts. In the second part of the course students take on the roles of the University Hospital's executive board of directors and supervisory board to work on an existing hospital project as a group within the scope of a simulation. This phase of the course is accompanied by workshops conducted in cooperation with university-based and off-campus partners that address the procedural learning objectives (teamwork, project management, negotiation strategies, etc.). A suitable, authentic issue currently facing the hospital is selected in advance by the course organizers in coordination with the hospital's executive board. Students then work on this issue in the third and final phase of the course under the supervision of tutors and with assistance from hospital employees. At the end of the course the students formally present the results of their work to the hospital's executive and supervisory boards.

RESULTS

The course undergoes written student evaluation, a round of oral feedback, evaluation of the final projects, and feedback from the hospital's executive and supervisory boards. All attendees to date have reported a substantial gain in general knowledge and increased knowledge about the healthcare system, and rate the relevance of the course as being high. The majority felt the content was important for their future practice of medicine. Overall, students evaluated the course very positively [overall rating on a six-point grading scale (1=excellent; 6=unsatisfactory): 1.28 (mean)±0.45 (standard deviation)].

DISCUSSION

The importance of the physician's role as manager in medical organizations and as a guiding force in the healthcare system is neglected in medical degree programs. Our seminar course attempts to address this shortcoming, is the object of great interest and receives positive evaluations from seminar participants, our cooperative partners and the executive and supervisory boards of the University Hospital in Munich.

Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned

BACKGROUND

Effective clinical leadership is associated with better patient care. We implemented and evaluated a pilot clinical leadership course for second year internal medicine residents at a large United States Academic Medical Center that is part of a multi-hospital health system.

METHODS

The course met weekly for two to three hours during July, 2013. Sessions included large group discussions and small group reflection meetings. Topics included leadership styles, emotional intelligence, and leading clinical teams. Course materials were designed internally and featured "business school style" case studies about everyday clinical medicine which explore how leadership skills impact care delivery. Participants evaluated the course's impact and quality using a post-course survey. Questions were structured in five point likert scale and free text format. Likert scale responses were converted to a 1-5 scale (1 = strongly disagree; 3 = neither agree nor disagree; 5 = strongly agree), and means were compared to the value 3 using one-way T-tests. Responses to free text questions were analyzed using the constant comparative method.

RESULTS

All sixteen pilot course participants completed the survey. Participants overwhelmingly agreed that the course provided content and skills relevant to their clinical responsibilities and leadership roles. Most participants also acknowledged that taking the course improved their understanding of their strengths and weaknesses as leaders, different leadership styles, and how to manage interpersonal conflict on clinical teams. 88% also reported that the course increased their interest in pursuing additional leadership training.

CONCLUSIONS

A clinical leadership course for internal medicine residents designed by colleagues, and utilizing case studies about clinical medicine, resulted in significant self-reported improvements in clinical leadership competencies.

Physicians as managers of health care delivery and the implications for postgraduate medical training: a literature review

BACKGROUND

As increasing demands on health care services are posing new challenges to practicing physicians worldwide, physicians have to extend existing and develop new competencies in various domains of their profession. Management and leadership is one of these domains, and relevant competencies have been incorporated in many new competency-based (postgraduate) training programs. Among trainee physicians and clinical educators, however, good understanding remains scant in relation to the definition and content of the physician's competency as manager.

SUMMARY

One objective of this article is to identify the specific knowledge, skills, and attitudes required for the development of managerial competencies in physicians. The article also establishes both the extent to which competency-based curricula are successful in equipping medical trainees with managerial competencies and the availability of programs specifically designed to develop these competencies. We reviewed publications retrieved through a PubMed search using relevant keywords, combined with the "related articles" function and a manual search of the references of the retrieved articles. Forty relevant articles were selected. They addressed residents' needs for management education and described the design, implementation, and evaluation of management education curricula. Most of the studies were conducted in North America and within the family medicine specialty. The most commonly taught topics were financial and management concepts and quality assurance. In all studies, training resulted in improved knowledge about management issues. All curricula were evaluated positively despite the use of different educational methods.

CONCLUSIONS

Management education in health care appears to be generally considered essential and necessary. There is, however, no clear consensus as to when in the medical education continuum, how, and for how long management education should be provided.

An innovative residency program designed to develop leaders to improve the health of children

Physician-leaders are needed to address the widening gap in health disparities in an increasingly complex health care system. To be effective leaders, physicians need specific training; yet despite its importance, leadership training is rarely addressed during graduate medical education. As a result, most physician leadership training occurs after residency training. To address this gap in medical education, in 2004 the authors developed the Pediatric Leadership for the Underserved (PLUS) program at the University of California, San Francisco. The PLUS program incorporates leadership development into the framework of standard clinical training by providing specific sessions in personal leadership development and in related skills such as team building, negotiation, and conflict management. Leadership training is explicitly tied to clinical experiences to maximize relevance and opportunities for "real-time" application of new skills and knowledge. In addition, the curriculum includes sessions to develop and implement a three-year longitudinal child health project. Trainees are organized into advising groups to provide structured faculty and peer-peer advising. Key lessons learned in the implementation include the importance of having a skill-based, rather than a topic-based curriculum, and of exposing trainees to concrete examples of the many career paths of physician-leaders. Early outcomes from 2004 to 2009 include program evaluation data, trainee accomplishments, and postgraduate careers. This paper aims to inform other training programs about the development and feasibility of a residency program that incorporates leadership and underserved medicine curricula into the framework of standard clinical training.

Canadian residents' perceived manager training needs

BACKGROUND

Despite widespread endorsement for administrative training during residency, teaching and learning in this area remains intermittent and limited in most programmes.

AIM

To inform the development of a Manager Train-the-Trainer program for faculty, the Royal College of Physicians and Surgeons of Canada undertook a survey of perceived Manager training needs among postgraduate trainees.

METHODS

A representative sample of Canadian specialty residents received a web-based questionnaire in 2009 assessing their perceived deficiencies in 13 Manager knowledge and 11 Manager skill domains, as determined by gap scores (GSs). GSs were defined as the difference between residents' perceived current and desired level of knowledge or skill in selected Manager domains. Residents' educational preferences for furthering their Manager knowledge and skills were also elicited.

RESULTS

Among the 549 residents who were emailed the survey, 199 (36.2%) responded. Residents reported significant gaps in most knowledge and skills domains examined. Residents' preferred educational methods for learning Manager knowledge and skills included workshops, web-based formats and interactive small groups.

CONCLUSION

The results of this national survey, highlighting significant perceived gaps in multiple Manager knowledge and skills domains, may inform the development of Manager curricula and faculty development activities to address deficiencies in training in this important area.

Teaching and learning the physician manager role: psychiatry residents' perspectives

BACKGROUND

Despite widespread consensus that additional training in administration is needed to prepare physicians for practice, little is known about how best to teach managerial competencies and how to integrate teaching into existing postgraduate curricula.

AIM

This study aimed to elicit resident perspectives on administrative curriculum development following exposure to a pilot physician manager curriculum at the University of Toronto.

METHODS

The authors held five focus groups of psychiatry residents at the University of Toronto during 2008, engaging 40 trainees. Resident perspectives on barriers to teaching and learning administrative skills, preferred curriculum content and format and suggestions for integration of administrative training into the residency programme were elicited.

RESULTS

Identified barriers to learning include lack of physician manager role clarity, dearth of learning opportunities and multiple competing demands on residents' time. Residents value a formal administrative curriculum and propose additional opportunities for experiential learning such as elective rotations and mentorship opportunities. Suggested strategies for integrating administrative teaching into residency include faculty development, rotation-specific administrative objectives and end of rotation resident evaluations.

CONCLUSION

Our findings provide valuable learner input into an emerging educational framework aiming to address barriers to teaching administrative skills during residency and facilitate longitudinal reinforcement of learning.

The business of emergency medicine: a nonclinical curriculum proposal for emergency medicine residency programs

Over the course of their postgraduate medical education, physicians are expected not only to acquire an extensive knowledge of clinical medicine and sound procedural skills, but also to develop competence in their other professional roles as communicator, collaborator, mediator, manager, teacher, and patient advocate. Although the need for physicians to develop stronger service delivery skills is well recognized, residency programs may underemphasize formal training in nonclinical proficiencies. As a result, graduates can begin their professional careers with an incomplete understanding of the operation of health care systems and how to utilize system resources in the manner best suited to their patients' needs. This article proposes the content, educational strategy, and needs assessment for an academic program entitled The Business of Emergency Medicine (BOEM). Developed as an adjunct to the (predominantly) clinical content of traditional emergency medicine (EM) training programs, BOEM is designed to enhance the existing academic curricula with additional learning opportunities by which EM residents can acquire a fundamental understanding of the nonclinical skills of their specialty.

Work profiles identified from the 2007 Pharmacist and Pharmaceutical Scientist Career Pathway Profile Survey

OBJECTIVES

To investigate the underlying factor structure of respondents' work profiles that were created using the 48 items in the Career Pathway Evaluation Program, 2007 Pharmacist and Pharmaceutical Scientist Profile Survey, and use the resulting factors to describe the 26 different work categories listed in the survey.

METHODS

Exploratory factor analysis was used to describe the underlying structures (factors) that best represented respondents' work profiles. Descriptive statistics and analysis of variance were used to describe the 26 different work categories listed in the survey.

RESULTS

Ten underlying factors were identified for the respondents' work profiles. A description of these factors among the 26 different respondent categories revealed variation among the categories that can be useful for describing the career categories in the American Pharmacists Association Career Pathway Evaluation Program.

CONCLUSIONS

Variations in work settings among various pharmacy careers were identified. The profiles constructed in this study could be helpful to individuals as they consider various career paths and choose elective coursework or experiential sites during their pharmacy education.

Training experiences of U.S. combined internal medicine and pediatrics residents

PURPOSE

To investigate the demographics and training experiences of internal medicine and pediatrics (med-peds) physicians.

METHOD

A cross-sectional survey addressing demographics, training experiences, and career plans of fourth-year residents graduating from combined internal medicine and pediatrics programs that were identified in the American Academy of Pediatrics database was initiated in May 2003. Questionnaires were mailed up to four times to nonresponders through August 2003.

RESULTS

Valid responses were received from 212 of the 340 graduating residents (62% response rate). The majority (186/208 [89%]) reported that they would choose med-peds training again. Career planning (135/210 [64%]), office management (173/212 [82%]), and outpatient procedures (155/211 [73%]) were the only areas where the majority desired more training. Neonatal intensive care training was the only topic area that the majority of residents (142/212 [67%]) reported could have been carried out in less time. Nearly all residents (183/196 [93%]) planned to care for children and adults. Residents' self-assessment of their preparation was good to excellent for evidence-based medicine (192/210 [91%]), caring for patients with special health care needs (179/209 [86%]), and use of information technology (169/208 [81%]). Residents felt equally well prepared for postgraduate activities in internal medicine and pediatrics primary care (170/212 [80%] versus 163/211 [77%], p = .305, NS) and internal medicine and pediatric fellowships (186/207 [90%] versus 181/208 [87%], p = .058, NS). Only 112 of 209 residents (54%) felt their preparation for research was good to excellent.

CONCLUSIONS

The study findings suggest that med-peds residents are satisfied with their decision to train in med-peds and with their level of preparation. They feel equally well prepared to care for adults and children, and well prepared to care for patients that may transition to adulthood with complex needs, to assess evidence, and to use information technology.

The impact of a novel resident leadership training curriculum

BACKGROUND

Today's complex health care environment coupled with the 80-hour workweek mandate has required that surgical resident team interactions evolve from a military command-and-control style to a collaborative leadership style.

METHODS

A novel educational curriculum was implemented with objectives of training the residents to have the capacity/ability to create and manage powerful teams through alignment, communication, and integrity integral tools to practicing a collaborative leadership style while working 80 hours per week. Specific strategies were as follows: (1) to focus on quality of patient care and service while receiving a high education-to-service ratio, and (2) to maximize efficiency through time management.

RESULTS

This article shows that leadership training as part of a resident curriculum can significantly increase a resident's view of leadership in the areas of alignment, communication, and integrity; tools previously shown in business models to be vital for effective and efficient teams.

CONCLUSION

This curriculum, over the course of the surgical residency, can provide residents with the necessary tools to deliver efficient quality of care while working within the 80-hour workweek mandate in a more collaborative style environment.

A preliminary report of an educational intervention in practice management

BACKGROUND

Practice management education continues to evolve, and little information exists regarding its curriculum design and effectiveness for resident education. We report the results of an exploratory study of a practice management curriculum for primary care residents.

METHODS

After performing a needs assessment with a group of primary care residents at Wright State University, we designed a monthly seminar series covering twelve practice management topics. The curriculum consisted of interactive lectures and practice-based application, whenever possible. We descriptively evaluated two cognitive components (practice management knowledge and skills) and the residents' evaluation of the curriculum.

RESULTS

The mean correct on the knowledge test for this group of residents was 74% (n = 12) and 91% (n = 12) before and after the curriculum, respectively. The mean scores for the practice management skill assessments were 2.62 before (n = 12), and 3.65 after (n = 12) the curriculum (modified Likert, 1 = strongly disagree, 5 = strongly agree). The residents rated the curriculum consistently high.

CONCLUSIONS

This exploratory study suggests that this curriculum may be useful in developing knowledge and skills in practice management for primary care residents. This study suggests further research into evaluation of this curriculum may be informative for practice-based education.

Physician leadership: enhancing the career development of academic physician administrators and leaders

As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician-administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician-educator and clinician-researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.