August 2007 | Back to Table of Contents
Clinical and Health Affairs
Preparing Physicians to Lead
By John Conbere, Ed.D., Brian Campion, M.D., M.P.A., Tom Gilliam, R.N., M.B.A., and Alla Heorhiadi, Ph.D., Ed.D.
Abstract
The University of St. Thomas’ Physician Leadership College is an 18-month program that trains physicians in leadership and management. It was started in 1999 in response to calls from within the health care industry for more training of physician leaders to guide reform efforts. This article makes the case that physicians need to not only participate in but also to lead change in health care. It also describes the program and reports findings from participants’ evaluations.
The health care industry is evolving rapidly. In such a time, leaders are needed to bring about changes that benefit the common good. This requires leadership from all stakeholders—employers, insurers, government officials, educators, patients, and providers, especially physicians. Because of their training and their role in patient care, physicians have a unique understanding of medicine. For that reason, they should be involved in decisions that could affect their role and practice. If not, they may have to live with policies and decisions that hinder, rather than help, their ability to treat patients. Taking part in such discussions and decisions isn’t usually part of a physician’s job. For that reason, few are prepared to lead such initiatives.
Whether they’re spearheading an electronic health record purchase or implementation, phasing in quality improvement guidelines, or rolling out a pay-for-performance initiative, physician leaders need to get people to accept change and master new ways of working. Change produces anxiety. It involves giving up the comfort of doing work the way it has always been done. It means learning new systems, new ways of thinking. It means being open to the possibility that such changes will indeed make a clinic run more efficiently, keep costs in check, and better serve patients. For many physicians, change may be associated with perceived loss of autonomy and/or income. That is why, when physician leaders urge change, they may be perceived by their peers as having gone over to the dark side. A leader must have the courage to persist when facing such criticism. And having courage is an outgrowth of knowing one’s self, understanding one’s fears and desires, and being able to choose how and when to endure criticism.
The Elements of Leadership
Leadership is both strategic, that is, being able to create a vision and get people to go along with it, and tactical, having the management skills (in finance, marketing, law, and human resources) needed to run an organization. Our experience has shown that it is more. One graduate of the Physician Leadership College (PLC) at the University of St. Thomas put it this way: “It [leadership] takes self-awareness, it takes passion, it takes willingness to state the obvious, and it takes willingness to go where everybody else does not want to go.”
We call this “leading from within.” Leading from within involves having knowledge of one’s self—that is, having a firmly established set of values, being fully aware of one’s feelings, and being cognizant of the dark side of one’s personality.
Having such knowledge gives one a foundation from which to make decisions. Leading from within happens when a person says what he or she thinks, and thinks what he or she deeply believes. In other words, the outer layer of words and behaviors must be in harmony with the inner layer of conscious and unconscious assumptions and beliefs. The harmony of words, actions, and beliefs resonates with people and inspires them to follow.
Failure to lead from within demoralizes employees. For example, in order to pull the company out of bankruptcy, Northwest Airlines executives asked pilots, mechanics, flight attendants, and other workers to sacrifice salaries and benefits. They did, and Northwest emerged from bankruptcy. However, on the heels of that announcement, leaders gave themselves, or accepted, multi-million dollar bonuses. The workers who had sacrificed felt they had been cheated while the leaders cashed in. The damage to the employees’ trust was incalculable. What was missing at Northwest? We suspect the leaders did not listen to their conscience and took the payout without anticipating the consequences of their actions.
Unfortunately, listening to one’s self is not taught in medical school nor does it fit with the scientific method of forming hypotheses and gathering data to prove or disprove them. A study of a cohort of physicians entering the University of St. Thomas’ Physician Leadership College (PLC) showed that while they were intellectually bright, socially adept, and altruistic, they were often unaware of their own feelings and insights.
Physicians can learn how to tap these feelings and be more introspective. One way they can develop such skills in class is by working in groups to wrestle with dilemmas or solve hypothetical problems such as how to improve health care quality while lowering the cost and that not everyone agrees with their ideas for solving problems and that there are problems that don’t have a single solution. Exposing physicians to others’ points of view helps to undo the “I know what is right” syndrome. When respected peers disagree, they have to reassess their own beliefs. The outcome of this process is the development of much more profound sense of self-awareness.
The St. Thomas Leadership College
The University of St. Thomas’ PLC was designed to give physicians the opportunity to explore their own leadership capabilities through reading, discussion, and reflection. It was started in 1999 in response to calls for more training of physician leaders to guide changes in health care. Unlike most executive education programs for physicians, which typically focus on management training, the PLC offers experienced physicians, many of whom already hold management positions, curriculum in leadership and management that is delivered cohort-style in 10 modules over 18 months (Table 1).
The PLC’s curriculum is modeled after traditional business school executive programs and was modified to address concerns unique to health care. Particular attention is given to balancing the science or measurable aspects of health care leadership with the art of medical leadership. Extensive use is made of 3 leadership models: Ronald Heifetz’s theory of adaptive leadership, servant leadership adapted from the work of Robert Greenleaf, and change management as taught by Peter Vaill. Students on average spend 4 to 6 hours a week preparing for on-campus sessions and spend approximately 31 days on campus. The curriculum is offered in 3- to 4-day modules that are scheduled every other month over the 18 months. Class sessions are primarily interactive, and the experiences of the participants are central to discussions. Participants are encouraged to focus on their current leadership responsibilities and to translate classroom learning into gains for their organizations. Students are assigned faculty mentors and are encouraged to identify a mentor at their workplace who can help guide their development.
At the beginning of the program, students are assessed by an industrial psychologist regarding their leadership strengths and weaknesses. The students then set goals for themselves as they go through the program. The psychologist coach and the student meet regularly to assess progress and modify goals. Students are expected to understand and articulate ways in which their behavior changes over the course of the program. Periodic self-assessment and feedback from employers, peers, and faculty contribute to the students’ understanding of their progress.
Participants
Seventy-one students from the first 6 cohorts have completed the program; 5 have withdrawn. Three of the 5 who withdrew enrolled in the St. Thomas MBA program, and the other two withdrew for personal or work-related reasons. The mean age of the students was 46 years, with a range of 35 to 57 years. Eighty-four percent of the students were men. Forty-six percent came from large integrated-delivery systems. Forty- three percent worked for large group practices, and 9% were employed by hospitals or hospital health systems.
Twenty-seven percent of matriculating students held senior management titles such as CEO or vice president. Fifty-one percent were mid-level managers with titles such as director or department chair. Seventeen percent had no institutional title but carried substantial influence within their organizations. A number from this group were Bush Fellows who were high achievers in their practice and community. Less than 1% had only a governance role in their organization (Table 2).
Program Effectiveness
According to information gleaned from course evaluations from participants in the first 6 cohorts, participants are highly satisfied with the quality of the curriculum and instruction. They consistently rate individual course offerings 4 or higher on a scale of 1 through 5. Student rankings of the first 9 modules ranged from 4.3 to 4.6. Consistency of ratings between and among cohorts was evidenced by a low standard deviation. Module 10, in which students’ learnings are integrated, was not ranked numerically. However, students have told us it is highly valued. Similarly, faculty rankings were consistently high. Scores for the first 9 modules ranged between 4.4 and 4.6.
Student comments on their evaluations are generally positive and echo 3 themes:
1. About course content and pedagogy, they say that learning was enhanced by the participation of and behavior modeled by experienced physician participants and faculty. In addition, the cohort model and the liberal use of case studies were noted as crucial course features. The cohort model also fostered a high degree of trust among participants, which encouraged them to experiment with new behaviors and ideas.
2. About skill building and practical application, they indicate that they learned not only how to lead change but also gained a better understanding of finance, strategic thinking and planning, governance, negotiation skills, conflict resolution, and effectively engaging in dialogue.
3. About personal change, most reported making changes in the way they understood themselves, their roles as leaders, and their relationships with others, although they did not anticipate making such changes when they enrolled. Many felt they better understood the relationship between personal awareness and their style of leadership.
Developing Leaders
Most of the participants in the PLC report that they are better able to communicate and collaborate with their administrative colleagues. For example, Denny Denarvis, a former CEO of Abbott Northwestern Hospital in Minneapolis, described at a national meeting how a group of PLC graduates and medical staff leaders worked with administrators to establish a clinical council to bring together physician leaders and hospital administrators to improve medical care. Another large health system is using physicians who have gone through leadership training to train at least 75 of their peers to help create a culture in which physicians and health care administrators share in decision-making.
We have found that along with improving leadership and management skills, one of the most significant outcomes of participation in the PLC is personal change. Participants report that by the end of their 18 months in the program, they’ve grown in their self-knowledge and become more reflective. One graduate said, “When I’m going to make a decision or when I’m in a meeting and I become frustrated or angry, I am more careful about thinking about why this is the case, what previous experience has made me feel this way, how should I best handle it.” Most graduates report that they are much more comfortable and confident in their role as a physician leader. They report that they are better listeners, both to others and to their inner voice.
Participants also report that the PLC has given them the courage to lead change. As Heifetz points out in his book Leadership Without Easy Answers, exercising leadership is about tolerating losses and moving in a more productive and self-fulfilling direction. Effective leadership requires courage and resolve. One PLC cohort volunteered to undergo in-depth interviews before, immediately following, and 6 months after the PLC experience. One individual noted a number of personal changes including having greater personal awareness, new ideas about his work, and a diminution of fear about being a physician leader. Other students also said that they have increased confidence in their skills and abilities as a result of their coursework in the PLC.
In conclusion, significant and immediate changes are needed in order to improve the quality of medical care and to make it more affordable. We are convinced that physicians must not only actively participate in making such changes but also must lead the effort. Change is arduous, complex, and risky, and it is essential that we prepare physicians to take on the challenge. A key quality of effective leadership is self-knowledge. Listening to one’s self, however, is not taught in medical school nor does it fit with scientific thinking. Consequently, physicians are often unaware of their own feelings and insights. In addition to building the skills of leadership and management, one of the unique facets of the PLC at the University of St. Thomas is that it offers physicians the opportunity for extensive reflection and introspection. We believe such an approach is a key strategy for helping physicians become the leaders needed to redesign health care for the future. MM
John Conbere and Alla Heorhiadi are in oganizational learning and development; Brian Campion is senior fellow in health care leadership and was the first lead faculty for the PLC; Tom Gilliam was the first PLC administrator and is director of the Opus College of Business Center for Health and Medical Affairs; all are at the University of St. Thomas.