Medicine involves leadership. Nearly all physicians take on significant leadership responsibilities over the course of their career, but unlike any other occupation where management skills are important, physicians are neither taught how to lead nor are they typically rewarded for good leadership. Even though medical institutions have designated “leadership” as a core medical competency, leadership skills are rarely taught and reinforced across the continuum of medical training. As more evidence shows that leadership skills and management practices positively influence both patient and healthcare organization outcomes, it’s becoming clear that leadership training should be formally integrated into medical and residency training curricula.
In most professions, the people who demonstrate strong leadership skills are the ones who take on greater leadership responsibilities at progressive stages of their careers. In medicine, physicians not only begin managing and directing teams early in their careers, but they rise through the ranks uniformly.
Within the first years of graduate medical training, or residency, resident physicians in all specialties lead teams of more junior residents, as well as other care personnel, without undergoing any formal training or experience in how to manage teams. It is rare for first-year resident physicians (interns) to not become second-year residents, for second-year residents to not become third-year residents, and for senior residents to not become fellows or attending physicians, although each step involves more management. And the span of leadership and responsibility grows once physicians enter independent practice.
Although medical trainees spend years learning about physiology, anatomy, and biochemistry, there are few formal avenues through which trainees learn fundamental leadership skills, such as how to lead a team, how to confront problem employees, how to coach and develop others, and how to resolve conflict. Some residency programs across the country are developing career tracks specifically for those interested in management and leadership careers, but these paths are often targeted towards individuals explicitly seeking management positions or healthcare management projects in their training, missing the fact that to be a physician is to lead. The set of individuals who would benefit from leadership skills in daily practice is much wider than those with specific career interests in management.
Despite this lack of focused attention toward development of leadership capabilities in trainees, evidence suggests that leadership quality affects patients, healthcare system outcomes, and finances alike. For example, hospitals with higher rated management practices and more highly rated boards of directors have been shown to deliver higher quality care and have better clinical outcomes, including lower mortality. Enhanced management practices have also been associated with higher patient satisfaction and better financial performance. Effective leadership additionally affects physician well-being, with stronger leadership associated with less physician burnout and higher satisfaction.
These benefits are crucial in a healthcare landscape that is increasingly focused on measuring and achieving high care quality, that is characterized by high rates of burnout across clinical personnel, and that is asking physicians to lead larger, multidisciplinary teams of nurses, social workers, physician assistants, and other health professionals.
Medical schools and residency programs should modify curricula to include leadership skill development at all levels of training — and this should be as rigorous as development of clinical reasoning or procedural skills. Leadership curricula should focus on two key sets of skills. First, interpersonal literacy is crucial for effective leadership in modern healthcare. This includes abilities related to effectively coordinating teams, coaching and giving feedback, interprofessional communication, and displaying emotional intelligence. The centrality of these skills has been recognized by healthcare institutions globally, including the American Medical Association, the National Health Service, and the Canadian College of Health Leaders.
A second, separate set of necessary skills deals with systems literacy. In today’s healthcare landscape, physicians need to understand the business of healthcare organization, including concepts such as insurance structure and costs that patients encounter. Physicians are also increasingly responsible for understanding and acting on quality and safety principles to correct and enhance the systems they work in. Finally, given the sensitive nature of their work, physicians must be comfortable with recognizing, disclosing, and addressing errors, and helping their teams do so as well.
Formal education on these topics could take the form of dedicated didactics during medical school and residency training, orientation sessions, and skill-building retreats, which are common in other occupations that require managerial development. At least some teaching should be delivered longitudinally over multiple years. This is important, because as trainees rise in the medical ranks and gain more responsibility (i.e. supervising medical students for the first time as interns, overseeing teams for the first time as junior residents), their ability to engage with leadership content changes.
Trainee performance evaluations should explicitly assess for adequate progression of leadership capabilities, with targeted remediation available for those not demonstrating competency. Residents should not be allowed to progress in training without achieving pre-specified proficiency in these areas. Assessment systems should also be developed to mitigate biases that downplay or disregard women’s and minorities’ leadership capabilities. And importantly, longitudinal studies will be needed to rigorously assess effectiveness of programs for teaching and measuring leadership skills. A 2015 systematic review of physician leadership development programs found that few reported negative outcomes or system level effects (i.e. impact of training on quality metrics) of their interventions.
While these changes may seem daunting given the vast amount of information trainees are already responsible for and the time-constrained nature of training, studies have found that trainees want to formally develop leadership skills. And several programs stand out as examples of how this can be done.
As first described in a 2013 Harvard Business Review article, Vanderbilt’s Otolaryngology program developed a 4-year program for residents consisting of Naval ROTC topics, public speaking training, a micro-MBA course, and a capstone leadership project. This program, which is delivered over morning conferences or dinner sessions (when residents are excused from the operating room), exposes trainees to health care policy, finance, conflict resolution, checklist and debriefing programs, public speaking, and one-on-one communication simulation sessions. Trainees ultimately use the skills they gain for collaborating with Vanderbilt undergraduates, primary care physicians, and others on a population health project during one of their four training years. The program’s founder and Vanderbilt Otolaryngology’s Chair, Dr. Roland Eavey notes that delivering similar content to faculty is key for gaining buy-in regarding the educational importance of leadership and to ensure appropriate modeling of effective leadership.
Meanwhile, at the Uniformed Services University, medical students undergo a 4-year curriculum focused on leadership attribute development. The Military Medical Practice and Leadership didactic curriculum is delivered in preclinical years and focuses on self-awareness, communication skills, and team dynamics. Subsequently, students take part in four multi-day “medical field practicum” experiences, during which they are introduced to their responsibilities as military officers and undergo both lecture and simulation modules focused on patient care, operations, and crisis management. Fourth-year medical students are ultimately evaluated on medical knowledge and leadership abilities in a simulated tactical field setting. Although centered in undergraduate medical education, this program is notable for its longitudinal mix of didactic and practical experiences and its evaluative nature, and could with reductions in time intensity be tailored to the graduate medical education setting.
Undoubtedly, enhancing leadership training in medicine will increase the costs of training and assessment. Yet, as we seek to optimize the therapeutics and procedures we perform to reduce mortality and enhance care quality, we should also seek to optimize the skills of the physicians leading all corners of healthcare system. For as the evidence shows, it can make an important difference for healthcare outcomes, experiences, and financial sustainability alike.
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