Abstract:
Physicians are entering a dynamic and complex healthcare environment with an increasing expectation to lead interdisciplinary teams. Physicians, however, are not provided formal training in leadership, management, or business during medical school. To address this gap, the authors created a four-week medical school elective to teach key managerial, organizational, leadership, and business topics related to health systems. The course material was well-received, particularly the technical skills such as finance and accounting. Future iterations of the course will focus on scaling the course to allow additional students to participate, adding content, improving the integration of the leadership development curriculum with management curriculum, and quantifying the effectiveness of the content for medical students generally.
The demands placed on physicians today are more complex than ever. Beyond providing quality medical care, physicians are often expected to optimize service delivery, oversee budgets, and organize their interdisciplinary staff into highly functional teams.(1) These burgeoning requirements have created a challenge for the modern-day physician who is faced with expectations to meet those demands without the formal training.
Exacerbating this dilemma is the notion that physicians are selected for leadership and administrative roles because of their success in research, clinical skills, and career achievements, but not necessarily due to their managerial or leadership experience.(2) Ultimately, we must move away from the “accidental physician leader” and begin to actively cultivate the skills necessary for physicians to successfully lead and manage teams and healthcare organizations.(3)
Recognizing this gap in training, medical schools are increasingly incorporating management and leadership into their curricula in a wide array of formats. Examples of these efforts include extracurricular leadership speakers series,(4) project-based consulting groups,(5) summer scholars programs,(6) longitudinal elective educational programs (i.e., distinction tracks),(7) or training embedded into the required four-year curriculum.(8)
Alternatively, some institutions have initiated dual Master of Business Administration (MBA)/Medical Doctorate (MD) programs, which have increased in number by 10-fold since the mid-1990s(9) and whose graduates report improved leadership skills, financial acumen, organizational management, and team building.(10) These recent trends exploring innovative ways to deliver this much-needed education is a step forward; however, the best approach for delivering this material remains unclear.(11)
The University of Michigan Medical School (UMMS) established a longitudinal leadership development program with the mission to enhance and develop medical student leadership skills and their ability to positively influence healthcare.(12) Within the program, multiple methods are used to teach leadership skills and concepts, and to facilitate students’ experiential leadership development in all phases of the curriculum.
Currently, methods include small-group workshops, expert panels, newsletters, practical assignments, and deeper-dive electives in the third and fourth years. The program seeks to be collaborative with other curricular components where possible, as well to encourage the implementation of student-driven initiatives.
At the University of Michigan Medical School (UMMS), we implemented a student-driven initiative, combining our established longitudinal leadership program with curriculum developed by faculty from the Stephen M. Ross School of Business at the University of Michigan to create a four-week elective course offered to third- and fourth-year medical students: Strategic Management for Physicians.
The goal of the course is to prepare medical students for the complexities of the modern healthcare system. Herein we describe the course structure, evaluation of its first year of inception, and the generalizable lessons. We anticipate that this pilot study will serve to generate hypotheses that may be tested in a larger study surrounding incorporation of leadership and management training into undergraduate medical education and explore logistical challenges involved in designing and implementing such an intervention.
Methods
In collaboration with the Ross School of Business, the Medical School Leadership Development Program, and UMMS administrators, we developed Strategic Management for Physicians as a four-week elective for third- and fourth-year medical students.
Design and Program Structure
The course was designed to introduce medical students from a wide range of backgrounds to key managerial, organizational, leadership, and business topics related to health systems. The elective was led by cross-appointed university faculty from the Ross School of Business (Butz), directors of the Leadership Development Program within UMMS (Kirst, Zink), and the chief operational officer of UMMS (Comstock).
The course learning objectives (see Table 1) were developed among the course directors and student leaders (Butz, Comstock, Kirst, Zink, VonAchen, Carey). These objectives were consistent with Bloom’s taxonomy of educational objectives(13) and were mapped to the UMMS competencies (see Figure 1).
Figure 1. University of Michigan Medical School core competencies 2019
Overall, the material predominantly focused on the healthcare system in the United States, as most medical students in the United States enter residency programs domestically.(14) However, global markets were also addressed throughout the course. The course was based on business pedagogy including a combination of didactic sessions, simulation and case-based learning, guest speakers, and online modules. (See Appendix A for a copy of the course syllabus).
During the first two weeks, material was organized around core management disciplines typically covered in a core MBA curriculum. Topics were reinforced through “application” sessions focused on Michigan’s academic medical center and health system. Throughout the second two weeks, material shifted toward physician leadership development, specific applications via guest speakers, and increased self-directed learning time (see Figure 2).
Figure 2. Strategic management for physicians course schedule
Course Evaluation
We administered pre- and post-surveys using both Likert-scale and open-ended questions (see Appendix B). We also conducted a focus group using a pre-reviewed facilitator guide to ensure that the questions stimulated discussions relevant to this study.
The purpose of the Likert-scale questions in the pre- and post-surveys was to assess students’ views on the importance of the topics taught in the course (“Importance”) as well as their own self-assessment of their knowledge and abilities in areas of leadership and business (“Proficiency”). Additional Likert-scale questions regarding students’ overall course impressions were included in the post-survey. Open-ended questions were used in the pre-survey to understand students’ goals for the course, and in the post-survey to provide open-ended feedback.
Data Analysis
Responses to Likert-scale questions were quantitatively tabulated and presented as descriptive summary statistics. The results from the open-ended questions and focus group were analyzed via thematic analysis.
Two researchers (VonAchen, Carey) reviewed the surveys and separately performed open coding to build two codebooks. The researchers then discussed and combined the two codebooks into a single codebook. Using this codebook, the researchers coded the surveys and focus group transcript individually. Discrepancies were reconciled via consensus. Researchers also reviewed surveys for representative quotations. Quotations that were independently selected were included. All statistical analysis was completed using Microsoft Excel (2019).(15) The study was deemed exempt by the University of Michigan Institutional Review Board (HUM00175757).
Study Results
Eight medical students registered and participated in the course: four fourth-year and four third-year students. Four students completed the pre-survey, seven completed the post-survey, and seven participated in the focus group. Every student’s feedback was accounted for in either the post-survey or the focus group. Characteristics of the students enrolled in the course are described in Table 2. Students’ views on the importance of the topics taught in the course and their self-assessments of their leadership abilities and business knowledge are described in Table 3. Students’ overall course impressions are described in Table 4.
In the post-survey (n = 7), on a 5-point Likert scale, students scored the course as “valuable to their future practice” at 5.0 (SD 0.0) and scored the course to be a “good use of time” at 5.0 (SD 0.0). On a scale of 1 to 10 (where 1 is “not at all likely” and 10 is “extremely likely”), students reported the likelihood of recommending the course at an average of 9.4 with a standard deviation of 0.9. Students’ overall course impressions (n = 7) are described in Table 5.
Qualitative analysis of the open-ended questions in the post-survey and focus group revealed six major themes described below. Representative excerpts from each theme can be found in Table 5:
Theme 1: Filling a curriculum gap. Although UMMS implemented a mandatory longitudinal leadership curriculum, little in the curriculum addresses management and business topics. Students appreciated the new content and found it valuable.
Theme 2: Technical skills. Content on finance and accounting were covered through a combination of didactic lectures, case-based learning, and UMMS applications, which students found to be particularly helpful and felt more proficient in as a result of the course.
Theme 3: Learning the vocabulary. Students were exposed to core business, finance, and accounting terminology throughout the course, better preparing them to understand and contribute to administrative and leadership conversations.
Theme 4: Leadership stories. Six non-physician guest speakers delivered individual guest lectures, two of which took place at the business school in conjunction with a group of multidisciplinary students. Eight physician guest speakers joined for the Physician Leadership Symposium. Overall, speakers came from leadership roles in a variety of organizations including medical technology companies, physician groups, hospital administrators, consulting firms, venture capital groups, policy and advocacy organizations, and academia. Students found value in the leaders’ stories and the interdisciplinary interaction among speakers and diverse audience members.
Theme 5: Preparing for future roles and to enact change. Students reported feeling better prepared to make changes in the future organizations in which they choose to work. Additionally, they found the exposure to different types of roles — beyond the familiar clinician-researcher students typically interact with in medical school — to be informative as they plan their future careers.
Theme 6: Challenges and areas for improvement in future years. Students suggested approaches to improving content delivery, including increased repetition of content and specific take-aways from each lecture as well as book club-style sessions; encouraged maintaining a small class size; recommended adding specific content related to law and medicine, personal finance, and insurance models; and offered specific guest speaker recommendations.
Discussion
Our study proposes a novel approach to curriculum implementation and adds to the growing sense of the importance of expanding medical curriculum to include leadership and management skills. Our course is differentiated from previous efforts to meld business and leadership training to medical students because of the breadth of curricula covered, the focus on clinical students, and use of multiple validated modalities shown to increase engagement and content retention, including simulation-based learning,(16,17) problem-based learning,(18,19) and small-group learning.(20) Our results provide informative lessons related to the content, structure, and implementation of future leadership courses.
Value of the Content
Medical students valued learning technical skills (e.g., finance and accounting), business vocabulary, the exposure to a variety of leadership roles and stories, and the application-based curricula modality. They specifically found these valuable in relation to their own future career planning as well as their ability and desire to create impact in the future institutions in which they work.
The value students placed on the content is in line with previous studies and interventions; however, the reported improvements in the specific skills were greater than those achieved by prior curricula implemented at the institution level.(11,21) While it is difficult to compare interventions without a standardized assessment tool, our results show promise for future leadership and management curricula. Additionally, while quantitively students reported improvements in various skill domains and an overall positive response to the course, the qualitative focus group participants offered several areas for improvement and iteration of coursework.
Improving Integration of Material
In future iterations of the course, several changes based on student feedback may improve the material delivery. To integrate the leadership development and management topics, we may include additional guest speakers who provide both applications of the management topics and reflections on their leadership style in the context of their role in healthcare. Other options may include case studies of leadership and book clubs to increase engagement in this component of the curriculum.
On top of streamlining content, students reported a desire for exposure to additional topics that may be relevant to their careers, including insurance, medical technology, pharmaceuticals, medical malpractice, and negotiations. Considering that each student has individual career goals, it may not be possible to address each of these individual needs when implementing such a curriculum. However, it is important to provide additional material that is likely relevant to most students. Educators considering implementing a similar course may consider doing a needs assessment to understand the specific goals of their students.
Lastly, the elective may impact the UMMS longitudinal leadership curriculum in several ways. First, our leadership curriculum may serve as a recruitment tool to elicit student interest in and understanding of the importance of the content, with the elective subsequently enabling students to take a deeper dive into content areas. Conversely, several aspects of our elective investigated leadership-related topics that are not currently in the scope of our leadership curriculum yet are important in leadership development. Examples of these topics include negotiations, leadership stories, and management topics, all of which may serve to strengthen the content of our overall leadership curriculum in the future.
Student feedback from the elective course may encourage including some or all of these additional topic areas into the mandatory longitudinal curriculum. Thus, the elective course and longitudinal leadership curriculum impact each other bidirectionally and allow the curricula to improve and build off each other.
Scheduling and Scaling the Course
Medical students at different stages of training have varying priorities and schedules. Thus, elective courses offered once a year are difficult to optimize for student enrollment. Surveys indicated there are more students interested in our course than could enroll in any single four-week period due to scheduling constraints. Expanding the course to meet students’ varying schedules in a resource-conscious manner while maintaining a small-group, discussion-oriented approach will be an ongoing challenge.
Additionally, as medicine continues to emphasize the importance of interdisciplinary care, we may consider expanding course enrollment or specific relevant topics to other healthcare professional trainees (i.e., pharmacy, nursing and physician extender training). Establishing an interdisciplinary reach may inspire other healthcare professional education programs to integrate leadership and management training into their various curricula.
Limitations
There are several limitations to our study. First, Strategic Management for Physicians was developed and administered within a single medical school, with a small group of students who opted to enroll in the course. The small sample size and context may limit our ability to generalize the results. Additionally, given that the course was optional, there is likely selection bias, which may have influenced our results.
Two members of the research team were involved in the implementation of the course and one of the co-authors was a student enrolled in the course, which could have introduced bias. This potential source of bias was mitigated by not involving the research team in specific course content and independently coding the data. The student enrolled in the course was not involved in the design of the course, the research proposal, or the data analysis.
Additionally, there was a low response rate for the pre-course survey. Thus, the results assessing the changes in students’ views on the importance and proficiency of the topics taught in the course should be interpreted with caution. The calculated effect sizes were large, however a larger scale study with a control group would be needed to definitively conclude the impact of the curriculum on students’ proficiency in the topics covered. Lastly, students were surveyed about perceived skills gained as opposed to more objective measures.
Conclusions
This study highlights the potential success and perceived importance of a pilot leadership and management elective course in undergraduate medical education. Future studies should focus on the scalability of leadership and management curricula to larger groups of students. With growing interest and support for interdisciplinary curricula in medical training, further evaluation and expansion of such coursework throughout medical education is critical.
The promising results of this pilot study indicate that it would be worthwhile to examine incorporating medical curriculum to include leadership and management training in a larger, more rigorous fashion.
Acknowledgments
The authors would like to thank Tomás Mauricio for his assistance organizing logistics for the “Strategic Management for Physicians” course.
Funding
Funding from the Alpha Omega Alpha Medical Student Service Leadership Project Grant and the University of Michigan Medical School helped make the development of the course possible. No funding organization was involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Appendix A: Course Syllabus. Strategic Management and Problem Solving
Course Description:
This course introduces medical students coming from a wide range of backgrounds to key managerial, organizational, leadership, and business topics related to health systems. It begins with the core physician-patient relationship (i.e., “patient-centric”) and from this foundation builds models of care delivery. Students participate in a combination of didactic sessions, simulation and case-based learning, and online modules. Lecturers include faculty from the Ross School of Business, Michigan Medicine, and UMMS. Early on subject matter is organized around core management disciplines:
Students also receive technical training in Excel data analysis, financial modeling, PowerPoint, and sharing and presenting information. By mid-course, our focus turns to cases, specific applications, and physician leadership as a key component of program- and systems-building, including global settings. Finally, students become facile by the end of this course in leveraging key data sources that will help them throughout their careers.
The course aims to prepare students for the complexities of the modern health care system and to take leadership roles in health systems to effect change that improves the quality of care, work environment, and financial sustainability of the organizations in which they choose to work.
Students learn approaches to framing a business problem and developing a structured approach to solving it. Students have the opportunity to develop a framework for their own impact project and receive ongoing support to select, scope, and execute their desired project. Alternatively, students may choose to participate in an ongoing project with Med ECG.
Course Requrements:
Attendance at all sessions is required
Preparation prior to the course sessions
Final project presentation
Completion of course surveys and evaluations
Accommodations:
The University of Michigan is committed to providing equal opportunity for participation in all programs, services and activities. Students wishing to receive accommodations must register with the Services for Students with Disabilities (SSD) office as soon as possible.
Course Outline:
We organize early subject matter and class sessions around management functional disciplines, much like a first-year core MBA curriculum. These early classes are hectic, because we lay out so much core material. The US gets the most attention, but throughout the course global markets are integrated fully.
Please see the grid at the bottom of the next page for the layout of the functionally focused material early in the course. We proceed row-by-row. Each class begins by isolating one central or fundamental issue. We proceed from this issue to an imperative. Once the issue is laid out and the imperative articulated, we set forth the management and institutional foundations. Each topic has teaching tools and brings in related material (referred to in the last column as “reference points”) and lay out additional resources.
This course is often provocative, but always within the mainstream and backed up/linked to peer-reviewed publications and other authoritative sources. Nothing is unorthodox, partisan, or at odds with basic economics or management principles. (Up to a point students are encouraged to put forward unorthodox, novel, and even partisan views.) Indeed, one key aim of this class is to take industry conventional wisdom — which is not especially rigorous — and to cast it within a principled and evidence-driven management framework. This exercise yields big payoffs.
There are no prerequisites for taking this class, but we rely on a handful of core concepts, first and foremost the U-shaped average cost curve. We pause throughout the course to lay out other key concepts, including just for example, opportunity cost and annuities. We repeatedly reinforce these core concepts.
Reading materials, assignments, and other details are made available to students on the first day of class.
Learning Objectives:
To master general management skills around core principles in economics, cost accounting, operations, financial accounting, corporate finance, organizational behavior, strategy, and marketing.
To apply these skills and principles directly and routinely to health care delivery and to systems of care, and to demonstrate these competencies.
To understand the historical context in which health care stands, including the broad forces that have created this context and the clinical, operational, and economic drivers going forward.
To foster a broader health system culture in which clinicians and administrators system-wide make ready and competent use of proven management principles.
To exceed ACGME standards with regard to the systems-based practice competency, which requires that residents “demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to call on system resources to provide care that is of optimal value.”
To provide the managerial foundations for leadership, and for the ongoing professional development of health care leaders.
To understand personal strengths and working styles, and display keen self-awareness and communication skills while navigating professional and group relationships.
To recognize the attributes and behaviors of transformational and servant leadership, and to deepen the connectivity of sense of purpose at the individual and organizational level.
Data Sources and References
This is a data- and evidence-driven course. Though we leverage many different sources, a few recurring references are worth highlighting, both because we will rely disproportionately on them and because they can serve the students in this course well for many years to come:
Medicare Reports to Congress (Every March and June)
The March report in particular marches comprehensively through all care domains.
Medicare Payment Basics
This site provides a short pdf on how CMS reimburses each care domain. Most other payers follow suit.
Healthcare Cost and Utilization Project and HCUPNet
https://www.hcup-us.ahrq.gov/ and https://hcupnet.ahrq.gov/#setup
This is the gold standard for all-payer claims data, as well as impressive master data.
World Health Organization’s Global Health Observatory
Indispensible data for those interested in global health and health care outside the US.
American Hospital Directory (Subscription Only)
Data regarding > 7,000 hospitals nationwide. Includes Medicare claims data and hospital cost reports.
Advisory Board
Munios.com
A data base of bond offerings – with invaluable health systems summaries
Freida
The American Medical Association’s Database of Residencies/Fellowships
CB Insights on Digital Health
Appendix B: Strategic Management For Physicians – Pre-Course Survey
The purpose of this pre-course survey is to assess students’ views on the importance of the topics taught in this course as well as their own self-assessment of their knowledge and abilities in the areas of leadership and business. All responses to this survey will be anonymous, though students will use a unique identifier so that responses to the pre- and post-surveys can be linked.
Importance
On a scale of 1 to 5, with 1 indicating “not at all important,” 3 indicating “neither important nor unimportant,” and 5 indicating “extremely important,” how important do you think it is for physicians to be able to perform the following tasks?
Understand and explain the administrative, strategic, and operational challenges facing health care organizations.
Build a conceptual framework to address complex problems.
Apply analytical skills needed to identify important trends within large datasets.
Communicate findings and recommendations in a clear, concise fashion using written and oral presentation formats.
Develop and employ techniques to effectively interact with individuals from all levels of an organization and negotiate with different parties to achieve a common objective.
Develop and employ teamwork skills to effectively delegate and coordinate tasks among team members to reach a common objective.
Proficiency
On a scale of 1 to 5, with 1 indicating “not at all proficient,” 3 indicating “somewhat proficient,” and 5 indicating “extremely proficient,” how proficient do you feel performing the following tasks?
Understand and explain the administrative, strategic, and operational challenges facing health care organizations.
Build a conceptual framework to address complex problems.
Apply analytical skills needed to identify important trends within large datasets.
Communicate findings and recommendations in a clear, concise fashion using written and oral presentation formats.
Develop and employ techniques to effectively interact with individuals from all levels of an organization and negotiate with different parties to achieve a common objective.
Develop and employ teamwork skills to effectively delegate and coordinate tasks among team members to reach a common objective.
On a scale of 1 to 5, with 1 indicating “not at all proficient,” 3 indicating “somewhat proficient,” and 5 indicating “extremely proficient,” how proficient do you feel in the following business skill sets?
Economics
Cost accounting
Financial accounting
Corporate finance
Organizational behavior
Health care operations
Marketing
Information systems
Team development and leadership
Quality improvement
Business strategy
Unique identifier
Please enter your unique identifier that you used at the beginning of the course. Please use the last 2 digits of your phone number, first two letters of your best friend’s name, and first two digits of your home address.
Student Characteristics
What year are you in medical school?
M3
M4
What gender do you identify as?
Male
Female
Other
What race/ethnicity do you identify with?
Non-Hispanic white
Non-Hispanic black
Hispanic
Asian
Other
Are you less than 25 years old?
Yes
No
Do you plan to pursue an MBA or do you already have an MBA?
Yes
No
What specialty do you plan to go into? (free response)
Strategic Management for Physicians – Post-Course Survey
The purpose of this post-course survey is to assess students’ views on the importance of the topics taught in this course as well as their own self-assessment of their knowledge and abilities in the areas of leadership and business. The survey will also assess how valuable the students found the course. Students also have the option to provide comments and specific feedback regarding the course. All responses to this survey will be anonymous though students will use a unique identifier so that responses to the pre- and post-surveys can be linked.
Importance
On a scale of 1 to 5, with 1 indicating “not at all important,” 3 indicating “neither important nor unimportant,” and 5 indicating “extremely important,” how important do you think it is for physicians to be able to perform the following tasks?
Understand and explain the administrative, strategic, and operational challenges facing health care organizations.
Build a conceptual framework to address complex problems.
Apply analytical skills needed to identify important trends within large datasets.
Communicate findings and recommendations in a clear, concise fashion using written and oral presentation formats.
Develop and employ techniques to effectively interact with individuals from all levels of an organization and negotiate with different parties to achieve a common objective.
Develop and employ teamwork skills to effectively delegate and coordinate tasks among team members to reach a common objective.
Proficiency
On a scale of 1 to 5, with 1 indicating “not at all proficient,” 3 indicating “somewhat proficient,” and 5 indicating “extremely proficient,” how proficient do you feel performing the following tasks?
Understand and explain the administrative, strategic, and operational challenges facing health care organizations.
Build a conceptual framework to address complex problems.
Apply analytical skills needed to identify important trends within large datasets.
Communicate findings and recommendations in a clear, concise fashion using written and oral presentation formats.
Develop and employ techniques to effectively interact with individuals from all levels of an organization and negotiate with different parties to achieve a common objective.
Develop and employ teamwork skills to effectively delegate and coordinate tasks among team members to reach a common objective.
On a scale of 1 to 5, with 1 indicating “not at all proficient,” 3 indicating “somewhat proficient,” and 5 indicating “extremely proficient,” how proficient do you feel in the following business skill sets?
Economics
Cost accounting
Financial accounting
Corporate finance
Organizational behavior
Health care operations
Marketing
Information systems
Team development and leadership
Quality improvement
Business strategy
Overall course impressions
On a scale of 1 to 5, where 1 is “strongly disagree” and 5 is “strongly agree,” please reply to the following statements:
I found the course to be valuable to my future practice.
The course was a good use of my time.
The course fulfilled the stated learning objectives.
The course fulfilled my personal expectations.
On a scale of 0 to 10, where 1 is “not at all likely” and 10 is “extremely likely,” how likely are you to recommend the course Strategic Management for Physicians to other medical students?
What did you like about this course?
What would you like to see changed about this course?
Are there any topics that were not covered that you think should be? If so, what?
Any other comments or questions:
Unique identifier
Please enter your unique identifier that you used at the beginning of the course. Please use the last 2 digits of your phone number, first two letters of your best friend’s name, and first two digits of your home address.