Volume 7 no 2

Developing physician leaders: why, whether, and how good?

James K. Stoller, MD, MS

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Developing physician leaders: why, whether, and how good?

James K. Stoller, MD, MS

 

https//doi.org/10.37964/cr24734

 

 

The challenges of providing high-quality, seamless access, and value in health care require great leadership; these needs are compounded by crises like the coronavirus pandemic. In the context that physicians often lead both in titled and informal leadership roles and that evidence associates effective hospital performance with physician leadership, leadership skills are widely needed by doctors. Yet, leadership competencies are not traditionally taught in medical school or during graduate medical training. Furthermore, some aspects of clinical training may conspire against physicians’ developing optimal leadership traits. The tension between need and preparation highlights the imperative to develop physicians’ leadership competencies. Increasingly, physician leadership development programs are being offered, e.g., by some health care organizations, professional societies, business schools, and consulting firms. Still, many unanswered questions beyond the “why” surround such programs: what is the best way to develop physician leaders and are such programs effective? This article considers the rationale for developing physician leaders as well as some leadership handicaps that physicians face by virtue of their clinical training. Attention then turns to considering the evidence regarding the effectiveness of such programs and framing remaining questions for further study.

 

KEY WORDS: leadership development, rationale, effectiveness

 

CITATION: Stoller JK. Developing physician leaders: why, whether, and how good? Can J Physician Leadersh 2020;7(2):85–88.

 

Great leadership is clearly needed in health care today. Daunting challenges of optimizing access, lowering costs, and assuring the highest quality care (i.e., enhancing value), all while maintaining caregiver well-being — the so-called Quadruple Aim1 — surely require skillful leadership. Navigating decisions in resource-constrained environments, such as health care, and communicating these decisions to stakeholders are quintessential leadership competencies. Furthermore, crises, like the coronavirus pandemic, magnify the need. And leadership competencies matter. They are different from the clinical and scientific skills that physicians cultivate during training. Top

 

Physicians lead in a wide variety of contexts, e.g., on the wards, leading clinical and research departments, and sometimes in the executive suite. They are both “small l” leaders (who lack formal titles but lead change efforts to optimize care) and “big L” leaders (who have formal titles, such as department chair, dean, CEO, etc.). Top

 

Several lines of reasoning support the advantages of engaging physicians in formal leadership roles in health care organizations. At the highest levels of leadership, observational data2,3 show a significant association between the highest rating of health care organizations and having a physician as the CEO. An association between enhanced efficiency and financial performance when the CEO of the health care organization is a physician has also been shown.3 As current supportive examples of this association, all five hospitals rated highest in 2019–2020 by U.S. News and World Report — Mayo Clinic, Massachusetts General Hospital, Johns Hopkins Hospital, Cleveland Clinic, and New York Presbyterian — are led by physician CEOs. Attribution of top hospital rating to having a physician CEO is clearly not possible from available studies (because correlation is not causality, of course), and there are many superb hospitals whose CEOs represent other disciplines. However, potential explanations for the benefit of physician leadership include physicians’ enhanced core understanding of the health care environment, their enhanced interaction and relationships with other physicians based on the common experience of doctoring, and the clinical credibility that they uniquely enjoy, which enhances followership.4 Beyond the executive suite, leadership by physicians without formal titles is critical in all clinical “microsystems” in health care organizations, e.g., in optimizing clinical care on the wards, contributing to review and search committees, etc.5 Top

 

Further support for the importance of physician leadership in health care organizations comes from parallel observations in other sectors.3,4 For example, universities that are led by presidents who have higher levels of career scholarship enjoy higher global rankings in research and scholarship. Similarly, in Formula 1 racing, the most successful racing teams are led by individuals who have been Formula 1 drivers, as opposed to non-driver mechanics, engineers, or managers. Synthesizing these observations from disparate sectors — higher education, sports, and health care — Goodall4 has framed the “theory of expert leadership,” which holds that “organizations perform most effectively when they are led by individuals who have inherent knowledge of the core business activity.” Top

 

Just as physicians bring advantageous traits to leadership, so too do they bring unique challenges and potential handicaps as leaders. For example, although learning environments are evolving favourably in many academic medical centres, traditional medical training has selected for and cultivated “gladiator” or “Viking” behaviours, which have caused physicians to be described as “heroic lone healers.”6,7 To the extent that such “command and control” conduct conspires against optimal leadership and can undermine a collaborative spirit, emerging physician leaders must “unfreeze” these behaviours as part of their developing leadership competencies. Physicians must recognize that there are multiple leadership styles, e.g., democratic, affinitive, visionary, etc.,8 and be able to adopt the right style for the right circumstances. Top

 

In a similar vein, physicians are trained clinically to be “deficit-based thinkers,” i.e., clinical reasoning sees symptoms as problems to be solved by generating a list of potential causes in service of a solution.9 Indeed, deficit-based thinking is core to the time-honoured practice of differential diagnosis, which is essential in clinical reasoning. Yet, organizational thinkers espouse the antithesis of deficit-based thinking — so-called “appreciative inquiry”10 — as a better way to think about and lead organizations. The notion is that “words create worlds” and that the way an organizational question is framed informs the answer. Issues framed through a strengths-based lens are likely to generate more informed, stickier solutions that unleash discretionary effort in an organization. Physicians who create cultures based on classic virtues — trust, compassion, hope, courage, temperance, wisdom, justice — instead of “carrot and stick” compliance-based cultures are more likely to engage caregivers and unleash discretionary effort, leading to enhanced organizational performance.11 Thus, to both function as clinicians and to lead optimally, physicians must be situationally mindful and nimble to invoke differential diagnostic reasoning when they are practising medicine but to embrace appreciative inquiry when they are leading. Top

 

Finally, physicians are also trained to be “dichotomous thinkers.”9 The practice of medicine routinely calls on doctors to translate continuous biologic variables (blood pressure measurements, electrolytes, etc.) into yes/no decisions. For example, we might treat with an antihypertensive medication if the diastolic blood pressure is 91 mm Hg but might not if it is 89 mm Hg. This penchant to dichotomize the world can predispose physicians to what Collins11 has called “the tyranny of the or” rather than the “genius of the and,” the latter deemed an important leadership competency. As such, as physicians learn to lead, they must learn and be intentional about embracing the “and.” As F. Scott Fitzgerald said, “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function.” Although dichotomously minded in their clinical practice, physician leaders must learn to embrace seemingly conflicting realities (e.g., we can provide optimal care and anchor on value) and still function.

 

Taken together, the impetus for physicians to lead — whether from the executive suite or on the wards5 — and the need to develop leadership competencies among physicians begs two questions: are we developing physician leaders today, and what is the evidence that such leadership development is effective? Top

 

Outside health care, leadership development programs have been signature and longstanding features of successful multinational corporations. Corporate universities are offered by IBM, Toyota, Motorola, and many others. Health care organizations have generally been slower to embrace leadership programs for physicians and, although such programs are increasing in recent years on the strength of supportive observational data, their adoption remains incomplete. In 2012, Davidson et al.13 reported that 57% of surveyed health care institutions offered no such leadership development programs; a 2015 survey of members of the Association of American Medical Colleges14 found that, although 65% reported offering faculty development programs of some type, 88% sent faculty away to other organizations for training. To the extent that leadership training in an academic medical centre is perhaps best taught locally with attention to organizational culture and by faculty who enjoy local “street credibility,” organizations are encouraged to develop intramural leadership programs. Examples include programs at Emory, Harvard, Stanford, McLeod Health, Hartford Healthcare, Cleveland Clinic, and Mayo Clinic. Still, health care organizations with well-developed intramural leader development programs are currently in the minority. Top

 

Notwithstanding a growing volume of supportive observational data, the other burning issue is whether leadership development programs work, i.e., has institutional performance been rigorously shown to be enhanced because physician leaders have received leadership training? High-quality evidence here is woefully thin. Meta-analyses regarding the impact of physician leadership development have consistently identified few controlled studies or observational studies that assess, no less show, that participants in such programs exert a favourable organizational impact.15 Furthermore, to my knowledge, despite the expense of organizing such programs (e.g., faculty costs, food and facility costs, and most notably, the opportunity costs associated with taking physicians off-line for such training), no study has formally addressed the cost-effectiveness or return-on-investment of such programs.

 

All in all, the need for effective leadership in the current challenging health care environment remains indisputable. To the extent that physicians bring distinctive benefits to health care leadership; that leadership competencies matter; but that leadership training is not part of traditional medical curricula, either in medical school or during graduate medical education, greater attention to developing physician leaders is needed. At the same time, while designing and offering such programs, a keen focus on assessing optimal training strategies, determining when such training is most needed in a physician’s career,16 and rigorously assessing the objective impact of such programs, including their cost-effectiveness, is urgently needed. Top

 

References

1.Sikka R, Morath JM, Leape L. The quadruple aim: care, health, cost, and meaning in work (editorial). BMJ Qual Saf 2015;24(10):608-10. https://doi.org/10.1136/bmjqs-2015-004160

2.Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73(4):535-9. https://doi.org/10.1016/j.socscimed.2011.06.025

3.Tasi MC, Keswani A, Bozic KJ. Does physician leadership affect hospital quality, operational efficiency, and financial performance? Health Care Manage Rev 2019;44(3):256-62. https://doi.org/10.1097/HMR.0000000000000173

4.Goodall AH. A theory of expert leadership (TEL) in psychiatry. Australas Psychiatry 2016;24:231-4. https://doi.org/10.1177/1039856215609760

5.Bohmer R. Leadership with a small “l”. BMJ 2010;340:c483. https://doi.org/10.1136/bmj.c483

6.Lee TH. Turning doctors into leaders. Harv Bus Rev 2010;88:50-8.

7.Stoller JK. Can physicians collaborate? A review of organizational development in healthcare. OD Practitioner 2004;36:19-24.

8.Goleman D, Boyatzis RE, McKee A. Primal leadership: learning to lead with emotional intelligence. Boston: Harvard Business School Press; 2004.

9.Stoller JK. On the paradox of ‘dichotomous and ‘deficit-based’ thinking in medicine. BMJ Leader 2018;2(3):115-7. https://doi.org/10.1136/leader-2018-000085

10.May N, Becker DM, Frankel RM. Appreciative inquiry in healthcare: positive questions bring out the best. Brunswick, Ohio: Crown Custom Publishing; 2011.

11.Rea PJ, Stoller JK, Kolp A. Exception to the rule: the surprising science of character-based culture, engagement, and performance. New York: McGraw-Hill Education; 2018.

12.Collins J. Genius of the AND. Built to last. New York: Harper Business; 1994.

13.Davidson PL, Azziz R, Morrison J, Rocha J, Braun J. Identifying and developing leadership competencies in health research organizations: a pilot study. J Health Adm Educ 2012;29(2):135-54.

14.Lucas R, Goldman EF, Scott AR, Dandar V. Leadership development programs at academic health centers: results of a national survey. Acad Med 2018;93(2):229-36.

15.Stoller JK. Developing physician leaders: does it work? BMJ Leader 2020;4:1-5. http://dx.doi.org/10.1136/leader-2018-000116

16.Taylor C, Farver C, Hess CA, Stoller JK. Perspective: can emotional intelligence training serve as an alternative approach to teaching professionalism to residents? Acad Med 2011;86(12):1551-4. https://doi.org/10.1097/ACM.0b013e318235aa76

 

Author

James K. Stoller, MD, MS, is professor and chair of the Education Institute, Cleveland Clinic, and on staff at the Respiratory Institute. He is also Jean Wall Bennett Professor of Medicine and Samson Global Leadership Endowed Chair at the Cleveland Clinic Lerner College of Medicine.

 

Author attestation: The author received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. There are no competing interests. The author is solely responsible for the entire content of this manuscript.

 

Correspondence to:

stollej@ccf.org

 

This article has been peer reviewed.

 

Top

Developing physician leaders: why, whether, and how good?

James K. Stoller, MD, MS

 

https//doi.org/10.37964/cr24734

 

 

The challenges of providing high-quality, seamless access, and value in health care require great leadership; these needs are compounded by crises like the coronavirus pandemic. In the context that physicians often lead both in titled and informal leadership roles and that evidence associates effective hospital performance with physician leadership, leadership skills are widely needed by doctors. Yet, leadership competencies are not traditionally taught in medical school or during graduate medical training. Furthermore, some aspects of clinical training may conspire against physicians’ developing optimal leadership traits. The tension between need and preparation highlights the imperative to develop physicians’ leadership competencies. Increasingly, physician leadership development programs are being offered, e.g., by some health care organizations, professional societies, business schools, and consulting firms. Still, many unanswered questions beyond the “why” surround such programs: what is the best way to develop physician leaders and are such programs effective? This article considers the rationale for developing physician leaders as well as some leadership handicaps that physicians face by virtue of their clinical training. Attention then turns to considering the evidence regarding the effectiveness of such programs and framing remaining questions for further study.

 

KEY WORDS: leadership development, rationale, effectiveness

 

CITATION: Stoller JK. Developing physician leaders: why, whether, and how good? Can J Physician Leadersh 2020;7(2):85–88.

 

Great leadership is clearly needed in health care today. Daunting challenges of optimizing access, lowering costs, and assuring the highest quality care (i.e., enhancing value), all while maintaining caregiver well-being — the so-called Quadruple Aim1 — surely require skillful leadership. Navigating decisions in resource-constrained environments, such as health care, and communicating these decisions to stakeholders are quintessential leadership competencies. Furthermore, crises, like the coronavirus pandemic, magnify the need. And leadership competencies matter. They are different from the clinical and scientific skills that physicians cultivate during training. Top

 

Physicians lead in a wide variety of contexts, e.g., on the wards, leading clinical and research departments, and sometimes in the executive suite. They are both “small l” leaders (who lack formal titles but lead change efforts to optimize care) and “big L” leaders (who have formal titles, such as department chair, dean, CEO, etc.). Top

 

Several lines of reasoning support the advantages of engaging physicians in formal leadership roles in health care organizations. At the highest levels of leadership, observational data2,3 show a significant association between the highest rating of health care organizations and having a physician as the CEO. An association between enhanced efficiency and financial performance when the CEO of the health care organization is a physician has also been shown.3 As current supportive examples of this association, all five hospitals rated highest in 2019–2020 by U.S. News and World Report — Mayo Clinic, Massachusetts General Hospital, Johns Hopkins Hospital, Cleveland Clinic, and New York Presbyterian — are led by physician CEOs. Attribution of top hospital rating to having a physician CEO is clearly not possible from available studies (because correlation is not causality, of course), and there are many superb hospitals whose CEOs represent other disciplines. However, potential explanations for the benefit of physician leadership include physicians’ enhanced core understanding of the health care environment, their enhanced interaction and relationships with other physicians based on the common experience of doctoring, and the clinical credibility that they uniquely enjoy, which enhances followership.4 Beyond the executive suite, leadership by physicians without formal titles is critical in all clinical “microsystems” in health care organizations, e.g., in optimizing clinical care on the wards, contributing to review and search committees, etc.5 Top

 

Further support for the importance of physician leadership in health care organizations comes from parallel observations in other sectors.3,4 For example, universities that are led by presidents who have higher levels of career scholarship enjoy higher global rankings in research and scholarship. Similarly, in Formula 1 racing, the most successful racing teams are led by individuals who have been Formula 1 drivers, as opposed to non-driver mechanics, engineers, or managers. Synthesizing these observations from disparate sectors — higher education, sports, and health care — Goodall4 has framed the “theory of expert leadership,” which holds that “organizations perform most effectively when they are led by individuals who have inherent knowledge of the core business activity.” Top

 

Just as physicians bring advantageous traits to leadership, so too do they bring unique challenges and potential handicaps as leaders. For example, although learning environments are evolving favourably in many academic medical centres, traditional medical training has selected for and cultivated “gladiator” or “Viking” behaviours, which have caused physicians to be described as “heroic lone healers.”6,7 To the extent that such “command and control” conduct conspires against optimal leadership and can undermine a collaborative spirit, emerging physician leaders must “unfreeze” these behaviours as part of their developing leadership competencies. Physicians must recognize that there are multiple leadership styles, e.g., democratic, affinitive, visionary, etc.,8 and be able to adopt the right style for the right circumstances. Top

 

In a similar vein, physicians are trained clinically to be “deficit-based thinkers,” i.e., clinical reasoning sees symptoms as problems to be solved by generating a list of potential causes in service of a solution.9 Indeed, deficit-based thinking is core to the time-honoured practice of differential diagnosis, which is essential in clinical reasoning. Yet, organizational thinkers espouse the antithesis of deficit-based thinking — so-called “appreciative inquiry”10 — as a better way to think about and lead organizations. The notion is that “words create worlds” and that the way an organizational question is framed informs the answer. Issues framed through a strengths-based lens are likely to generate more informed, stickier solutions that unleash discretionary effort in an organization. Physicians who create cultures based on classic virtues — trust, compassion, hope, courage, temperance, wisdom, justice — instead of “carrot and stick” compliance-based cultures are more likely to engage caregivers and unleash discretionary effort, leading to enhanced organizational performance.11 Thus, to both function as clinicians and to lead optimally, physicians must be situationally mindful and nimble to invoke differential diagnostic reasoning when they are practising medicine but to embrace appreciative inquiry when they are leading. Top

 

Finally, physicians are also trained to be “dichotomous thinkers.”9 The practice of medicine routinely calls on doctors to translate continuous biologic variables (blood pressure measurements, electrolytes, etc.) into yes/no decisions. For example, we might treat with an antihypertensive medication if the diastolic blood pressure is 91 mm Hg but might not if it is 89 mm Hg. This penchant to dichotomize the world can predispose physicians to what Collins11 has called “the tyranny of the or” rather than the “genius of the and,” the latter deemed an important leadership competency. As such, as physicians learn to lead, they must learn and be intentional about embracing the “and.” As F. Scott Fitzgerald said, “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function.” Although dichotomously minded in their clinical practice, physician leaders must learn to embrace seemingly conflicting realities (e.g., we can provide optimal care and anchor on value) and still function.

 

Taken together, the impetus for physicians to lead — whether from the executive suite or on the wards5 — and the need to develop leadership competencies among physicians begs two questions: are we developing physician leaders today, and what is the evidence that such leadership development is effective? Top

 

Outside health care, leadership development programs have been signature and longstanding features of successful multinational corporations. Corporate universities are offered by IBM, Toyota, Motorola, and many others. Health care organizations have generally been slower to embrace leadership programs for physicians and, although such programs are increasing in recent years on the strength of supportive observational data, their adoption remains incomplete. In 2012, Davidson et al.13 reported that 57% of surveyed health care institutions offered no such leadership development programs; a 2015 survey of members of the Association of American Medical Colleges14 found that, although 65% reported offering faculty development programs of some type, 88% sent faculty away to other organizations for training. To the extent that leadership training in an academic medical centre is perhaps best taught locally with attention to organizational culture and by faculty who enjoy local “street credibility,” organizations are encouraged to develop intramural leadership programs. Examples include programs at Emory, Harvard, Stanford, McLeod Health, Hartford Healthcare, Cleveland Clinic, and Mayo Clinic. Still, health care organizations with well-developed intramural leader development programs are currently in the minority. Top

 

Notwithstanding a growing volume of supportive observational data, the other burning issue is whether leadership development programs work, i.e., has institutional performance been rigorously shown to be enhanced because physician leaders have received leadership training? High-quality evidence here is woefully thin. Meta-analyses regarding the impact of physician leadership development have consistently identified few controlled studies or observational studies that assess, no less show, that participants in such programs exert a favourable organizational impact.15 Furthermore, to my knowledge, despite the expense of organizing such programs (e.g., faculty costs, food and facility costs, and most notably, the opportunity costs associated with taking physicians off-line for such training), no study has formally addressed the cost-effectiveness or return-on-investment of such programs.

 

All in all, the need for effective leadership in the current challenging health care environment remains indisputable. To the extent that physicians bring distinctive benefits to health care leadership; that leadership competencies matter; but that leadership training is not part of traditional medical curricula, either in medical school or during graduate medical education, greater attention to developing physician leaders is needed. At the same time, while designing and offering such programs, a keen focus on assessing optimal training strategies, determining when such training is most needed in a physician’s career,16 and rigorously assessing the objective impact of such programs, including their cost-effectiveness, is urgently needed. Top

 

References

1.Sikka R, Morath JM, Leape L. The quadruple aim: care, health, cost, and meaning in work (editorial). BMJ Qual Saf 2015;24(10):608-10. https://doi.org/10.1136/bmjqs-2015-004160

2.Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73(4):535-9. https://doi.org/10.1016/j.socscimed.2011.06.025

3.Tasi MC, Keswani A, Bozic KJ. Does physician leadership affect hospital quality, operational efficiency, and financial performance? Health Care Manage Rev 2019;44(3):256-62. https://doi.org/10.1097/HMR.0000000000000173

4.Goodall AH. A theory of expert leadership (TEL) in psychiatry. Australas Psychiatry 2016;24:231-4. https://doi.org/10.1177/1039856215609760

5.Bohmer R. Leadership with a small “l”. BMJ 2010;340:c483. https://doi.org/10.1136/bmj.c483

6.Lee TH. Turning doctors into leaders. Harv Bus Rev 2010;88:50-8.

7.Stoller JK. Can physicians collaborate? A review of organizational development in healthcare. OD Practitioner 2004;36:19-24.

8.Goleman D, Boyatzis RE, McKee A. Primal leadership: learning to lead with emotional intelligence. Boston: Harvard Business School Press; 2004.

9.Stoller JK. On the paradox of ‘dichotomous and ‘deficit-based’ thinking in medicine. BMJ Leader 2018;2(3):115-7. https://doi.org/10.1136/leader-2018-000085

10.May N, Becker DM, Frankel RM. Appreciative inquiry in healthcare: positive questions bring out the best. Brunswick, Ohio: Crown Custom Publishing; 2011.

11.Rea PJ, Stoller JK, Kolp A. Exception to the rule: the surprising science of character-based culture, engagement, and performance. New York: McGraw-Hill Education; 2018.

12.Collins J. Genius of the AND. Built to last. New York: Harper Business; 1994.

13.Davidson PL, Azziz R, Morrison J, Rocha J, Braun J. Identifying and developing leadership competencies in health research organizations: a pilot study. J Health Adm Educ 2012;29(2):135-54.

14.Lucas R, Goldman EF, Scott AR, Dandar V. Leadership development programs at academic health centers: results of a national survey. Acad Med 2018;93(2):229-36.

15.Stoller JK. Developing physician leaders: does it work? BMJ Leader 2020;4:1-5. http://dx.doi.org/10.1136/leader-2018-000116

16.Taylor C, Farver C, Hess CA, Stoller JK. Perspective: can emotional intelligence training serve as an alternative approach to teaching professionalism to residents? Acad Med 2011;86(12):1551-4. https://doi.org/10.1097/ACM.0b013e318235aa76

 

Author

James K. Stoller, MD, MS, is professor and chair of the Education Institute, Cleveland Clinic, and on staff at the Respiratory Institute. He is also Jean Wall Bennett Professor of Medicine and Samson Global Leadership Endowed Chair at the Cleveland Clinic Lerner College of Medicine.

 

Author attestation: The author received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. There are no competing interests. The author is solely responsible for the entire content of this manuscript.

 

Correspondence to:

stollej@ccf.org

 

This article has been peer reviewed.

 

Top

Outside health care, leadership development programs have been signature and longstanding features of successful multinational corporations. Corporate universities are offered by IBM, Toyota, Motorola, and many others. Health care organizations have generally been slower to embrace leadership programs for physicians and, although such programs are increasing in recent years on the strength of supportive observational data, their adoption remains incomplete. In 2012, Davidson et al.13 reported that 57% of surveyed health care institutions offered no such leadership development programs; a 2015 survey of members of the Association of American Medical Colleges14 found that, although 65% reported offering faculty development programs of some type, 88% sent faculty away to other organizations for training. To the extent that leadership training in an academic medical centre is perhaps best taught locally with attention to organizational culture and by faculty who enjoy local “street credibility,” organizations are encouraged to develop intramural leadership programs. Examples include programs at Emory, Harvard, Stanford, McLeod Health, Hartford Healthcare, Cleveland Clinic, and Mayo Clinic. Still, health care organizations with well-developed intramural leader development programs are currently in the minority. Top