White Paper on Physician Leadership

Preface
As one might expect, you could spend years of research and still not digest everything that is out there discussing a) executive leadership in general and b) what makes an effective health care leader. This document summarizes some of the literature in both of those categories. The document also includes observations on health care leadership from two local authorities on the matter.


Introduction
Merriam-Webster defines a leader as “a person who has commanding authority or influence.”

The concept of leadership development, however, is not so clear cut. This suggests that any organization embarking on a leadership-development initiative must first define its goals and its expected outcomes.

One study (Kincaid & Gordick, 2003) found programs focused on developing leaders have aimed at outcomes as diverse as increased organizational productivity, increased sales, and decreased turnover.

The Center for Creative Leadership (CCL) (Martineau & Hannum, 2004) has listed common goals for leadership development programs that include:

  • Participants will share a common language of leadership (for example, they will learn and be able to put into practice specific leadership terms, models, and styles)
  • That the businesses will find it easier to retain talented employees because developmental opportunities exist
  • Delivering products and/or services to market and to clients more quickly
  • Increasing revenue in the case of for-profit companies or broadening and deepening impact in the case of not-for-profit organizations

In health care, physicians have traditionally exercised authority simply by virtue of their credentials and their abilities. Many physicians, as well, have operated essentially as the CEO of a private practice, or at least as a managing partner within a group.

Those models are becoming increasingly scarce, of course.

The cost and complexity of running a private practice is driving many physicians to join health systems as employees. The American Medical Association says that nearly a third (29 percent) of private-practice doctors either work directly for a hospital or for a practice that is at least partially owned by a hospital (American Medical Association, 2013). That percentage is up from 16.3 percent reported in a 2007-08 AMA survey.

As top executives within their own organizations, physicians have also tended to work in silos, which payment reform aims to stop.

“As the need increases to improve clinical outcomes and lower the cost of care delivery, so does the necessity for administrators and physicians to create alliances and share resources,” concluded the author of an article on physician leaders (Avakian, 2011).

All this means that physicians must become different types of leaders than they have been in the past. Mostly that means developing a more collaborative work style.

Though health care reform has placed a renewed focus on a more collaborative, integrated system of care in the United States, the concepts are not new.

Nearly a decade ago, in fact, the Accreditation Council for Graduate Medical Education (ACGME) embedded this notion of “physician leadership” in the competencies it said all residency programs should teach. (American Council for Graduate Medical Education, 2007)

Among the skills outlined is an understanding of “systems-based practice,” which means that residents should “demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”

Some scholars (Martin & Quinn, 2007) have also noted worries about the lack of management skills among physicians dating back two decades, citing a 1994 article that concluded a “lack of academic preparation for management is a clear shortcoming of most physician executive candidates. With a medical education alone, physicians do not have adequate backgrounds or formal training in management disciplines.” (Ottensmeyer & Key, 1994)


Research
Every organization needs good chiefs. It follows, then, that efforts to nurture high-fliers should be beneficial as well.

But what’s the payoff? What is the return on investment (ROI) for developing good leaders?

Researchers have studied this from both inside and outside the health care arena.

Kincaid & Gordick were psychologists who endeavored to quantify the impact that consulting psychologists bring through human resources consulting. They noted the need for health care professionals to speak the language of business.

“If the desired result from both the perspective of the client and the consulting psychologist is evidence of value, and our clients define value in economic terms,” they concluded, “then the utility of our scientific approach should be evaluated by whether we are focused on the basic metric of business, the bottom line.”

They cited research indicating leadership can influence bottom-line profit margins by as much as 47 percent (Lieberson & O’Connor, 1972), and that companies reporting strong leadership development programs were 1.5 times more likely to appear within Fortune Magazine’s “Most Admired Companies” list (Csoka, 1997).

More generally, but in research that still speaks to the importance of a culture than can produce strong leaders, Kincaid & Gordick noted findings that “competency-based selection programs,” which focus on the emotional intelligence of recruits, have documented productivity increases of up to 33 percent and turnover decreases ranging up to 99 percent (Spencer, 2001).

In what they called, “the strongest study of the economic value of placing the right person in the right job,” they said (Hunter, Schmidt, & Judiesch, 1990) demonstrated that individuals capable of performing at least one standard deviation above the norm can translate to a 19 percent increase in productivity for low complexity jobs and a 48 percent increase in productivity for high-complexity jobs.

Martineau & Hannum of CCL also said, “True measures of ROI include data such as the costs of facilities, trainers, materials, and the time participants spend in training and away from their jobs. ROI formulas also include the financial benefits of training, such as cost savings, new revenue, and calculations of the value of perceived job improvement.”

They said measurements should include workplace statistics, such as absenteeism and grievances, as well analysis of records, such as expenditure records, expense account vouchers and performance records.

The authors also stressed the importance of evaluating the results of the initiative and communicating them down through the organization.

In the health care arena, the Cleveland Clinic Foundation (CCF) has offered its lessons learned from several years of leadership development it spearheaded at the Cleveland Clinic (Stoller, Berkowitz, & Bailin, January/February 2007).

As the course evolved over time, the foundation identified a number of ideal features of a physician leadership curriculum:

  • High throughput (i.e., being able to offer the program to as many high-potential physician leaders as possible)
  • Development of a multidisciplinary group of colleagues that learns to work together and develop synergies to advantage the institution
  • Offering a curriculum spread over time (i.e., offering the course as spaced sessions over a prolonged period of time to allow pre-work before consecutive sessions and time for attendees to “ingest” the course learning and to form mature, working groups)
  • Manageable institutional cost for offering the course
  • Institution-specific training (i.e., experience over time has suggested that offering information and context specific to the CCF has had special value)
  • Formation of project-dedicated teams within the course (e.g., around developing business plans) to provide a forum for practicing the teamwork and leadership lessons presented in the curriculum
  • Encouragement of innovative ideas to address institutional challenges

Over the course of the program, according to the authors, participants submitted 49 business plans. Of those plans, 30 (61 percent) had either been implemented or had directly affected program implementation at the CCF.

Examples of adopted plans, the authors said, included: a “short stay” unit as an extension of the emergency room; a geographic and service expansion of the sports medicine program to secondary school athletic programs and to athletically active individuals; a multidisciplinary Inflammatory Bowel Disease Center; a dedicated Women’s Health Program; and a national/international telemedicine consultation program.

The report said the business plan portion of the curriculum, which involved groups working together for nine months, was a key part of the course because it:

  • provided an ongoing real-world context in which to apply the didactic concepts presented in the classroom
  • bound the small working groups together as equals to frame and solve a relevant problem in which the group was interested
  • allowed participants to directly impact and change the organization in a manner different from what they could normally do.

The authors said that despite its costs, which included taking physicians off the job during work days, hospital leaders had staunchly supported the Leading in Health Care course “based on the impression that training future leaders and cultivating impactful ideas through the business plan activity has value for the organization.”

One of the most concrete claims of ROI from leadership development programs comes from the Physician Leadership Institute (PLI), which is a division of the Center for Transformation and Innovation based in Tampa, Florida. The center started as an initiative of USF Health, a partnership of medical programs at the University of South Florida.

On its website (Measurable Outcomes, 2013), the institute says it has helped clients to improve:

  • Cardiology Service Line volume – resulting in $284,000 annual revenue
  • OB/GYN scheduling – resulting in increased patient volume by 15 percent at a rate of $345,000 annually
  • ER wait times – resulting in a 14 percent reduction, reduced elopement by 40 percent, equating to $1.4 million annually
  • Orthopedics scheduling – resulting in increased number of available appointments by 10 percent, estimated to be a financial impact of $112,000 annually.

Remarks
The comments by [hidden content] came during a speech she gave April 22 to the Overland Park Chamber of Commerce as part of its Executive Leadership Series. [hidden content] observations came as part of a question-and-answer feature for the Metro Med.

Both physicians noted the importance of committees in providing leadership opportunities for emerging leaders.

[hidden content] mentioned committees in two contexts: suggesting that aspiring leaders within health care organizations serve on committees to rise up through the ranks, and recommending that Metro Med perhaps provide committee opportunities to help develop leaders for the society.

[hidden content] said her participation in committees relatively early in her career at the Cleveland Clinic was invaluable in learning effective leadership styles.

As a woman in a male dominated world – she was a neuropathologist – [hidden content] said her initial committee assignments were in stereotypical areas, such as the library, daycare, redecorating the offices of the foundation, and women’s health.

Even then, though, she said she learned by watching committee chairmen. She went on to become the first woman elected to the Cleveland Clinic’s board of governors.

[hidden content] spent 25 years in the Army Reserve, and he said civilian organizations could do worse than emulating the military. Taking on greater responsibility is the only way to have a full career, in the Army, he said, and the brass ingrains this concept throughout the organization.

“They do a great deal to foster leadership, and they require leadership in people all the way down to the squad of 8 soldiers – where you have a squad leader and an assistant squad leader,” he said.

Here are some other points [hidden content] made in her talk:

  • Keys to good leadership are listening, praising (she strives to give five compliments for every one piece of constructive criticism), mentoring (potential leaders must seek out role models), stamina (she is a competitive race walker – and she noted that marathoners typically doing the second half of the race faster than the first half), and optimism.
  • Kansas City has a competitive health care market, but in reality, “the only competition an organization has is itself.”
  • Get to know the people in your organization so you can identify the “folks of the future.”
  • Resist the temptation to go back to the same busy people who you know will get the job done. Take a risk on someone who is unproven – “99 times out of 100 that really works very well.”

Prior to assuming her role at [hidden content]. One of the lessons she learned there, she said, was that effective health care workers are now coming in all shapes and sizes.

For instance, she said, the system reduced its readmission rate among hip replacement patients by 19 percent simply by sending someone who was compassionate and a good communicator into the patient’s home to suggest ways to avoid trips, falls, and strains.

“Talent in health care,” she said, “is going to come from all walks of life.”


Bibliography
American Council for Graduate Medical Education. (2007, February 11). Common Program Requirements. Retrieved April 19, 2014, from http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf

American Medical Society. (2013, September 17). AMA News Room. Retrieved April 20, 2014, from American Medical Association: http://www.ama-assn.org/ama/pub/news/news/2013/2013-09-17-new-study-physician-practice-arrangements.page

Avakian, L. (2011, July 07). On the Hospital Agenda: Developing Physician Leaders. Hospitals & Health Networks Daily.

Csoka, L. (1997). Bridging the Leadership Gap (Report No. 1190-97-ES). New York: The Conference Board.

Daiy, C., & Johnson, J. (1997). Sources of CEO power and firm financial performance: A longitudinal assessment. Journal of Management, 23, pp. 97-117.

Deleray, J., & Doty, H. (1996). Modes of theorizing in strategic human resources managment: Tests of universalistic, contingency, and configurational performance predictions. Academy of Management Journal, 39, 802-835.

Hunter, J., Schmidt, F., & Judiesch, M. (1990). Individual differences in output variability as a function of job complexity. Journal of Applied Psychology, 75, 28-42.

Kincaid, S. B., & Gordick, D. (2003, Winter). The Return on Investment of Leadership Development. Consulting Psychology Journal: Practice and Research, pp. 47-57.

Lieberson, S., & O’Connor, J. (1972). Leadership and Organizational Performance. American Sociological Review, 37, pp. 117-130.

Martin, W. M., & Quinn, S. M. (2007). Developing the Physician Executive: From the Surgical Suite to the Executive. Journal of Executive Education, 21-32.

Martineau, J., & Hannum, K. (2004). Evaluating The Impact of Leadership Development: A Professional Guide. Greensboro, N.C.: Center for Creative Leadership.

Measurable Outcomes. (2013). Retrieved April 19, 2104, from Physician Leadership Institute: http://www.physicianleadership.org/roi.shtml

Ottensmeyer, D., & Key, M. (1994). The unique contribution of the physician executive. The Physician Executive.

Spencer, L. (2001). The Economic Value of Emotional Intelligence Competencies and EIC-based HR Programs. In C. Cherniss, & D. Goleman, The Emotionally Intelligent Workplace: How to Select for, measure, and improve emotional intelligence in individuals, groups, and organizations (pp. 45-82). San Francisco: Jossey-Bass.

Stoller, J. K., Berkowitz, E., & Bailin, P. (January/February 2007). Physician Management and Leadership Education at the Cleveland Clinic Foundation: Program Impact and Experience Over 14 Years. Medical Practice Management, 1-6.


APPENDIX
VAN WAY Q & A

As physicians increasingly become employees of hospitals and health systems, how can they become medical advocates within these organizations?

The first requirement of leadership is to take responsibility. If you are an orthopedic surgeon and you do orthopedic surgery, then at that level you are exerting leadership. I think this is why so few physicians go any further than that. They are already doing it. The problem is, in order to take leadership within a health care organization – this true whether it’s a volunteer organization like the medical society or an employment organization or even an organization like the U.S. Army Medical Corp – the first thing you have to do is step up and say, “I’m going to do this. You know, here is something that needs to be done, I’m going to do it.” So you start with responsibility, and if you take responsibility, then leadership comes.

How do you step up and go beyond being an orthopedic surgeon who just does surgery?

I think you have to be conscious that this is what you are doing. Certainly in academics nobody is going to be a department chair without working at it. I knew before I finished residency that I was going into academics, and I knew that one of my goals was eventually to become a department chair. It was not my only goal, nor even my most major goal, but it was nonetheless in the back of my mind all along. Unfortunately, if you ask the average person or the average physician, do you really care what happens in your organization? Well, yeah, who doesn’t? But then you get to the question of what is wrong with your organization and what can you personally do to improve it? Well now, that is where things get touchy. Because a lot of people will say, “Oh, I think this, and this, and this, and this. Well, why don’t you … get on a committee to do something, set up a task force to address the question, and they will say, “I’m too busy for that. I’m too busy in my practice, my kids are small, my wife doesn’t like me travelling that much.” So, I think the first thing is the desire – leaders are discontented people. They are people that want to change things. If you are very happy with the way things are and with your role in an organization, you are not going to be a leader. You are going to be a leader only if you see opportunities to change things in what you consider to be a better direction, and you have enough motivation to devote time to that activity.”

How do you balance the demand of an everyday practice with climbing that ladder?

Well, you work hard, for openers. And I mean that – you work harder than you have to work. If you are a private doc in a private hospital, maybe you don’t care about academic stuff, but you want to work your way up into the hospital staff leadership. You don’t just sort of come up and say, “Hey guys, I want to be the medical staff president.” You say, “Well, I’ll serve on this committee, or that committee,” and then you eventually chair this, or that, or the other committee, and then eventually you work your way into the leadership. You’ve got to be willing to take time away from your practice and away from your family to do that or just away from the other things you’d rather be doing. You know, I think people are leaders less because they suddenly decide, Well, I’m going to be a leader, than they are because, I see something that needs to be done, and I don’t see anybody else around doing it.

You mentioned that, initially at least, you got involved with Metro Med to sort of pay back a debt from not being involved in a medical society at a previous position out of state, where participation among physicians was not encouraged. What has prompted you to stay so involved?

Once I got involved with the medical society, they asked me to be a candidate for president, and I was new in town – it was sort of the idea I’d get my name out in front a lot of people whether I won or not – which I probably wouldn’t – people would know who I was. So I said that sounds like a reasonable thing, so I did that, and I lost, but I had written a couple of things during the candidacy. In those days – we don’t do this anymore – but in those days there had to be two candidates for president and the problem was, the guy who was going to win, was pretty well set, but they had to get someone else to run against him or her. We had to write some stuff, and I wrote a couple things for the bulletin, and they said, we need an editor for the bulletin, how would like to do that, and I said, sure, and I have been doing that ever since [about 25 years].
To the point that a few years later, when I actually did run for president and get to be president, they made me promise that I would take the editorship back after I finished my year as president. I certainly had a lot of encouragement along the way. You know, they could’ve said, oh well, you lost the election, have a good life, that sort of thing. So, some of this I think is very much dependent on encouragement by the people who are in a position to encourage or discourage I think organizations can do a lot to foster leadership, identify people who will take responsibility, and giving them roles in which they can do that.

Physicians tend to operate in silos, leaving the potential for patients to fall through the cracks. Health reform is attempting to force more coordination. How can Metro Med help physicians become more collaborative and what will it take for established practices to learn how to be more collaborative?

I agree with you about the silos. It’s a major problem in medical education, it’s a major problem in medical practice, to the point that the ACGME (Accreditation Council for Graduate Medical Education) adopted some years ago, about 10 or 15 years ago, core competencies that were expected of all physicians, so every residency in whatever specialty should be focused on things like systems-oriented care, and quality improvement, and professionalism, and things that bring the medical profession together rather than emphasizing training in whatever narrow specialty that particular program was engaged in.
One of the reasons that medical societies have been losing membership progressively and losing influence is precisely that physicians pay more attention to their identities as specialists than that as physicians. And it is 10 years into the ACGME initiative, so I think we probably have to conclude that the early results are that some of these initiatives have not been particularly successful. I think the way that medical society can help this is to work with more local physician groups, hospital staffs, the MSMA (Missouri State Medical Association) to focus on things that are important to everybody.

One other way to say it is: How can we ensure that “warm handoff” between providers?

The membership organizations can provide the tools. The problem is that the tools need to be so closely integrated with patient record systems, the hospitals, and the individual practices that it becomes difficult for Metro Med to do that. It is a technical issue as much than anything else, but it’s also an issue that people don’t want to talk to each other. I have seen more and more of a tendency for people to not even communicate well within hospitals, where they are sharing record systems. And you would think it would make it easier, but in fact, the attitude seems to be, well they can always pull up the chart and see what I did, which is true, but it sort of misses the point, doesn’t it?

What role, if any, can physicians take in improving community health by serving on governmental boards or commissions (e.g. a city planning commission with jurisdiction over sidewalks and bike lanes)?

It’s a good question. Too few physicians are willing and/or able to take on leadership in the community at large. I was on a Planning and Zoning Board for three or four years in Colorado, and found it a great opportunity. I haven’t done as much here in Kansas City, largely because I had leadership positions in the Army Reserve for many years. I have a friend who’s a Missouri state Senator, and who has had a significant influence in health legislation in Missouri over the last 10-12 years.
Physicians can become active on boards and/or run for elective office. One caveat is that not every physician is particularly good at this sort of thing. The give and take of politics may be off-putting to physicians who are used to being influential in their hospitals because of their skills and knowledge. When you participate as a citizen, the “MD” or “DO” doesn’t take you very far. A second caveat is that time commitments for citizen involvement are very heavy.
However you choose to do it, the primary investment you make is time. That may be difficult for those physicians in time-demanding areas of practice, but it’s the only way to become active in the community. You have to be willing to budget some number of hours each week to the activity. It can be frustrating, but it’s also very rewarding.

What can Metro Med do internally to foster leadership?

That’s a good question, and I’m not sure I have all the answers on this. As I look around among the organizations that I’m in, a majority of them do a really poor job at fostering leadership, and most of them have leadership groups that are pretty much self-perpetuating. That is not all bad. It’s possible to have a completely open organization with democratic elections and all that, it’s just too cumbersome, so pretty much people use a mixed model. And somewhat paradoxically, the model by which leadership perpetuates itself seems to have less to do with the opportunities it provides its members for leadership than other characteristics of the organization.
The example I might give you is the U.S. Army – I spent 25 years in the Army Reserve – well most of it on reserve duty, not active duty – and that is an organization where if you show even the slightest trace of interest in leadership, you get pushed to attend schools to help you, you get pushed to be in a leadership position. In fact, you can’t have a full career, say a 20-year career, without moving up in a leadership role, whether you are enlisted or an officer. So when you start looking at that, you start realizing, here is an authoritarian organization, there is no hint of a democratic organization, their leadership is totally self-selected by other leaders, and yet, from an individual standpoint, they do a great deal to foster leadership, and they require leadership in people all the way down to the squad of 8 soldiers – where you have a squad leader and an assistant squad leader – and the reason has a lot to do with what the military does and the way they are organized. But the point is, it is one of the best organizations for fostering leadership skills that I have been a part of.

Metro Med does only a modest job. There are no starter jobs. The starter job is on the board – that’s a wrong level for a starter job. There is no feeder system. You are on the board, and you stay on the board for a while. There are some ways that you can move up, but not very many of them. Essentially you stay on the board and then you become an officer, and then president, or you just stay on the board for a while and then go do something else. Metro Med, in turn, acts as a feeder organization for the Missouri State Medical Association, which itself is better than Metro Med, but it lacks a lot of the regional feeder organizations.

What you really want is an organization where someone can stay 20 years and have an experience that gives them progressive responsibility, and is fulfilling without having to become the head guy in the organization. If the only upward pathway is to get to be president, you are not doing very well, you are not engaging your membership very well. Metro Med has a few things – they’ve got legislative affairs, they’ve got a Finance Committee, some other stuff, some other activities that are open to people who can then take their area of responsibility as part of that. My advice to Angela would be to expand that.