Uncovering physicians’ leadership needs in Nova Scotia: a case study
Marina S. Kwak, Sarah Tahir, Alison MacPherson, Lauren Murray, Matthew Madill and Scott Comber, PhD
In response to an identified need for an advanced leadership course for experienced physician leaders, we sought to better understand the specific needs of such physicians in Nova Scotia. In 2017, 51 applications for Doctors Nova Scotia’s Physician Leadership Development Program (PLDP) were subjected to thematic content analysis to determine the top physician leadership skills that experienced physicians desired to develop or enhance. To complement this information, we consulted three content experts from PLDP partner organizations and carried out a systematic literature review of five academic databases.
Five themes were identified: effective communication, conflict resolution, project management, understanding organizational dynamics, and relationship management. We recommend that the development of these skills be prioritized for physician leaders in Nova Scotia.
KEY WORDS: physician leadership development, LEADS framework, conflict resolution, project management, health care, communications, organizational dynamics, relationship management
Identifying experienced vs. developing physician leaders
A review conducted by the Rotman School of Business for the Canadian Medical Association (CMA) identified the need for an advanced leadership course for experienced physician leaders.1 In 2015, Doctors Nova Scotia (DNS) began working with Joule Inc., a CMA subsidiary, to develop a program aimed at improving the skills of such physicians. A core focus of this program is on systems thinking and the skills needed for solving complex problems. This work culminated in the Physician Leadership Development Program (PLDP),1 which began accepting applicants for 25 seats in 2017. When 61 applications were received, DNS interpreted that as indicating a substantial need for leadership training Top.
This study defines experienced leaders as: those in senior leadership roles, e.g., zone chief, site leader, department head, or those who demonstrate leadership competencies found in senior roles, such as applying approaches to innovation and design thinking and having coaching skills and/or knowledge to effectively influence and navigate complex systems. Developing leaders are those who are new to, or early in, their career and have no experience in senior leadership and no demonstrated leadership competencies associated with senior leadership roles.
Among the 61 PLDP applications in 2017, 51 captured the leadership development needs identified by experienced leaders. The other 10 were excluded because they did not meet our criteria.
Health care in Nova Scotia
The health profile of Nova Scotia and its shifting population demographics demonstrate a need for physician leadership in health care delivery and economics. An estimated 61% of the population is classified as overweight, with rates of diabetes, high blood pressure, arthritis, heart disease, and respiratory disease 9% above national averages.2 Concurrently, the province’s demographics are shifting because of an aging baby boomer population, which is increasing health costs3 and is projected to increase the burden on the health care system.4
Physician retention is an ongoing issue, with burnout a significant contributing factor.4 Physician burnout has a cascading effect on the health care system, as it is shown to decrease quality of patient care and physician retention, and increase physician migration.5 Decreased retention, coupled with an increasingly strained health care system, may make Nova Scotia a less desirable place to work, which directly relates to and threatens the province’s ability to recruit and retain physicians.6
In 2014, the provincial government released a report discussing the challenges and strategies to overcome them.4 Leadership may be one such strategy, as research conducted by the Mayo Clinic shows that leadership styles can mitigate physician burnout and positively affect quality of life.7 A partnership agreement emerged, and the province’s PLDP was developed in partnership with Joule and CMA, in consultation with the Nova Scotia Health Authority (NSHA), IWK Health Centre, and Dalhousie Medical School (personal communication, B. Johnson, senior communications advisor, DNS, 9 Jan. 2019). Top
To understand the leadership needs of experienced physician leaders, qualitative data were collected: from PLDP application forms received from DNS; through consultations with content experts; and via a systematic literature review of essential leadership skills recommended for physician leaders. Data from the three sources were then aggregated and analyzed using thematic content analysis8 to identify relevant themes and patterns.
For this study, answers to the first three of the four questions on the PLDP application form (Appendix A) were analyzed as they were most relevant to discovering leadership skill needs identified by experienced physician leaders. Each question was analyzed separately, and the responses were coded into themes. Themes were sorted to form three groups based on frequency of in-text mentions: major, unique, and leftover. Passages and abbreviated topics were coded, and codes were adjusted as new data emerged, which resulted in a codebook. Codes were transformed into categories using descriptive wording and then the number was reduced by attempting to group topics and establish interrelationships.
The data were assembled and preliminary analysis was performed through detailed discussion of themes and sub-themes. Questions one and three (Appendix A) provided insight into the motivating factors that lead physicians to improve their leadership skills. Question two was used to identify the leadership skills physicians desired to enhance, based on frequency of mentions (Table 1).
Applications to the Physician Leadership Development Program
Via its newsletters and websites, DNS invited experienced leaders to apply to the 2017 PLDP. DNS listed program components, selection criteria, and key outcomes for the program. A total of 61 applications were received and were reviewed by a selection committee composed of representatives of DNS, Dalhousie University, NSHA, IWK, and Joule (B. Johnson, 9 Jan 2019, personal communication).
Of the 61 PLDP applications, 51 were analyzed for the purpose of this study because they met the definition of experienced leaders. The selection process was done by scoring each candidate based on the questions asked in PLDP applications (Appendix A). Top
Consultations with content experts
Three experts were consulted for their various perspectives in the fields of leadership, leadership education, and development, more specifically, physician leadership content expertise.
On 9 Nov 2017, Ms. Andaleep Ali, then associate director at Joule, was interviewed because of her expertise in physician leadership curriculum and program development across Canada. On the same date, Ms. Lorie Campbell, executive coach and leadership development professional with NSHA, was interviewed because of the knowledge she has gained from coaching interactions and experience with NS physicians. On 14 Nov. 2017, Dr. Lara Hazelton, director of faculty development for Dalhousie University’s Faculty of Medicine, was interviewed. Dr. Hazelton is an expert in the field of medical education, specifically in leadership development for physicians both internal and external to Dalhousie University.
Each leadership content expert was asked the same semi-structured questions, for example, which skills they considered most relevant for developing physicians (Appendix B). Shorthand notes were taken and thematic content analysis8 was applied to extract themes and patterns.
Systematic literature review
A third source of information on physician leadership needs was a systematic review of five databases. ProQuest, PubMed, Canadian Electronic Library, Web of Science Citation Review and Scopus were searched using the following keywords:
To ensure relevance, only data from the last five years (2012–2017) were included. Concurrently, a scan of the grey literature with the same time restrictions was conducted. All searches began at a global level to ensure extensive results, and papers referring to new or developing physician leadership were highlighted. LEADS was used as a search term to generate results relevant to the Canadian healthcare system.9 In all, 87 articles were reviewed. Top
Table 1 lists the top skills experienced Nova Scotia physician leaders desired to enhance. These are the skills chosen by at least five of the 51 physicians applying to the PLDP in 2017.
Content expert consultation
During consultations with content experts, we identified various areas as integral to developing physician leaders. These are (in no particular order):
The literature review revealed four broad themes as important to physician leadership as well as a number of sub-themes (Table 2).10-23 Top
Overall findings and comparison
Based on thematic content analysis of PLDP applications, consultations with content experts, and the literature review, we uncovered four broad themes and seven associated sub-themes that were mentioned in at least two of the three data sources (Table 3). If a theme was mentioned in two of the three methods, it was considered by the researchers to be significant to physician leadership.
Five sub-themes were mentioned in all three data sources: effective communication, conflict resolution (a component of effective communication), project management, understanding organizational dynamics, and relationship management. Top
Effective communication was clearly an important broad theme. In the PLDP application responses, 12 of 51 physicians expressed a desire to enhance their communication skills with stakeholders to effect change (Table 1). Harris et al.24 showed that early and mid-career physicians appear to underappreciate the value and importance of communication skills and relationship building.
Conflict resolution, a sub-theme of effective communication, was also mentioned by 12 PLDP applicants (Table 1). The ability to manage and resolve conflict may only be present when a physician can communicate her/his ideas effectively. In expert consultations, conflict resolution was noted as crucial for developing physician leaders and essential for effective leadership.25 This ability is necessary for building effective relationships and can assist physicians in dealing with high-conflict personalities (L. Campbell, personal communication, 2017). Thus, teaching skills in conflict resolution is integral to developing comprehensive and innovative health care leadership. Top
Project management, a sub-theme under change management, was mentioned by 11 PLDP applicants (Table 1). The literature review supported the importance of project management and highlighted how project-based teamwork contributes to organizational cohesiveness, synergy, and innovation.12 The expert consultations supported the importance of project management and raised the need to improve financial and business skills of physicians for them to successfully manage projects.
Understanding organizational dynamics is a sub-theme under systems thinking and was mentioned by 8 PLDP applicants (Table 1). Experts stated that improved knowledge of roles and expectations could be used to address inefficiencies in the Nova Scotia health care system (L. Hazelton, personal communication, 2017). It is also noted by Clausen et al. 25 as crucial to achieving health care transformation, as it helps physicians understand which actors in the system could be targeted to effectively implement change. Top
In this study, relationship management pertains to the management of conflicting personalities. It was cited by 7 PLDP applicants (Table 1), who revealed a desire to improve their ability to manage difficult, high-conflict, or apathetic people in team settings. Skill in relationship management also enhances team building and interdisciplinary collaboration. We classified relationship management as a sub-theme of emotional intelligence, which was a common theme in PLDP applications and the literature review. However, content experts did not mention emotional intelligence explicitly, but emphasized the development of sub-themes, particularly awareness of one’s current leadership style.
Improving physician leadership skills can have significant benefits, including collaboration and the effective use of limited health care resources.22 Further, strong physician leadership has been linked to improved patient care and system outcomes as well as physician retention. Hence, finding ways for physicians to improve the five main skills identified here would be highly beneficial.
The five skill sets we identified are areas of focus for improving physician leadership in Nova Scotia. This is the first time that both experienced physicians’ self-identified needs and experts’ identified needs for developing physicians have been captured in a Nova Scotia context. Addressing these leadership needs would create stronger physician leaders in the province.
Physician leadership has been directly related to the improvement of both health systems and outcomes.7 Further, having organizational support for physician leadership is an important factor in leadership advancement.26 Therefore, we recommend the continued development of physician leadership programs by DNS with content delivery methods to address the five theme sets identified in this study. Top
Appendix A. Relevant questions from the Physician Leadership Development Program application form
Appendix B. Questions posed to content experts
We thank Doctors Nova Scotia, in particular Barb Johnson, Katie Mallam, and Karen Pyra, for the opportunity to explore this issue and for their ongoing support. We are grateful to Andaleep Ali, Lorie Campbell, and Lara Hazelton, MD, for providing important insights.
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2.Nova Scotia Health Profile 2015. Halifax: Government of Nova Scotia; 2015. https://tinyurl.com/y4x6avbb
3.Physician recruitment and retention action team report. Halifax: Doctors Nova Scotia; 2014. https://tinyurl.com/y2d3owla
4.Younglai R. Canada’s health-care system braces for hike in costs with influx of seniors. Globe and Mail 2015;8 Nov. https://tinyurl.com/yy5595xg (accessed 12 Nov 2017).
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Marina S. Kwak is the lead author and contributed substantially to the research and article preparation. She sought research ethics board approval and was liaison between the supervisor, stakeholders, and other researchers. Sarah Tahir, Alison MacPherson, Lauren Murray, and Matthew Madill participated in the research and preparation of the final article. Dr. Scott Comber supervised the research. All authors approved the final version of the article.
The authors have no conflict of interest. Fully informed, voluntary, and written consent was obtained from all persons mentioned in this article.
Marina S. Kwak was a master of public administration student at Dalhousie University when this article was written. She is now a Canadian public servant, working as a policy and business analyst.
Sarah Tahir was a master of public administration student at Dalhousie University when this article was written.
Alison MacPherson was a master of business administration student at Dalhousie University when this article was written. She now holds a global marketing position in an international pharmaceutical company.
Lauren Murray was a master of business administration student at Dalhousie University when this article was written. She is now a management consultant.
Matthew Madill was a master of business administration student at Dalhousie University when this article was written. He is now a financial analyst.
Scott Comber, PhD, supervised this research. He is an expert in physician leadership development and a researcher, scholar, and a professor at Dalhousie University.
This article has been peer reviewed.