The importance of effective physician leadership has become ever more apparent as our healthcare system grapples with the worsening workforce attrition associated with the COVID-19 pandemic. Studies show that the phenomenon of physician burnout is a contributing factor to workforce shortages.
One prospective longitudinal study at Stanford University found that the two-year turnover rate of physicians with burnout was twice that of physicians who were not burned out.(1) Survey results show that 63% of physicians in the United States reported at least one burnout symptom by the beginning of 2022.(2) A 2021 national survey of more than 2,000 physicians revealed that almost 50% of the respondents reported feeling overworked and planned to either retire early, look for another career, or look for another employer.(3)
Because of healthcare trends associated with an aging population, increasing chronic disease burden, and decreasing number of people entering the medical profession, a physician workforce deficit of up to 45,000 primary care and 87,000 specialty care physicians by 2025 has been projected. This shortage is expected to worsen because of the COVID-19 pandemic. Lack of opportunities for professional growth and development, unprofessional behavior exhibited by organizational leadership, and mistrust between administrative leadership and physicians have been cited as key contributors to physician burnout in healthcare organizations.(4)
The cost of physician workforce shortages and burnout is striking. In addition to the negative impact on organizational culture and patient and staff experience, the cost to replace a physician has been estimated to be two to three times their annual salary or about $1 million per 1.0 full-time equivalent.(1) The cost of burnout among healthcare managers has been estimated to be $300 billion per year.(5)
There is growing evidence that effective physician leadership has a positive impact on efforts to reduce burnout and address workforce attrition. A Mayo Clinic Health System study of 3,896 physicians showed statistically significant relationships between the leadership qualities of supervisors and improvements in work satisfaction and burnout scores. For every 1-point increase in a composite leadership score, there was an associated 3.3% decrease in burnout and a 9% increase in satisfaction.(6)
National physician staffing companies, such as Sound Physicians and TeamHealth, have improved physician engagement and decreased turnover rates by expanding leadership opportunities and supporting physician leaders through training aimed at skill development in areas with frequent deficits, such as managing others, building relationships, and implementing strategic decision-making.(7)
Although physicians are assumed to be healthcare leaders because of their clinical education and experience, these factors alone may not result in effective leadership skills. Few formal leadership development programs are integrated into medical school and residency curricula. Additional training is needed to develop interpersonal literacy (e.g., managing teams, managing conflict, coaching others) and systems literacy (e.g., understanding the business of healthcare, strategic planning, and navigating the organizational landscape), which are critical components of successful physician leadership.(8)
Understanding physician leaders’ preparedness levels and needs can inform organizations and institutions on how to support physician leadership development.
Methods
A study was conducted to explore physician leaders’ perspectives about their preparation for administrative leadership roles. Participants with historical and/or current administrative physician leadership roles in clinical settings (e.g., medical, clinical, and/or site directors) were recruited by a snowballing technique in which study participants provided referrals to other study participants. One interviewer conducted one-on-one semi-structured interviews via videoconference, phone, or in person. Notes taken during and after the interviews were analyzed to determine overarching themes related to physician leadership preparedness.
Interviewees were asked questions about their current and/or past administrative physician leadership positions: how they defined their roles; what knowledge, skill, and experience gaps they experienced when starting their roles; what were their biggest challenges; and what leadership development opportunities were or would have been helpful in supporting their roles (Figure 1).
Figure 1. Interview Script and Questions
Interviewee responses to questions about role definition and gaps were categorized based on terminology for different physician leadership responsibilities that Perry and Mobley defined in their 2017 Harvard Business Review article: clinical, relational, business, and strategic (Table 1).(7) Clinical skills included those used to provide direct patient care. Relational skills encompassed interpersonal engagement. Business skills involved the application of technical knowledge. Strategic skills were associated with tactical methods for supporting the overall vision and mission.
Responses to how interviewees filled gaps were categorized by opportunity type. Responses to leadership challenges were categorized by the source of engagement: self, others, and the environment. Responses to desired leadership development were categorized into skills and opportunities.
Results
From January 2022 through March 2022, 27 physicians were interviewed. Interviews lasted between 30 and 90 minutes (Table 2). Of the interviewees, 13 (48.1%) identified as white, 11 (40.7%) identified as Asian, 2 (7.4%) identified as black, and 1 (3.7%) identified as Latinx. There were 15 (55.6%) physicians who identified as female and 12 (44.4%) who identified as male.
Physician experience ranged from 7 to 45 years, with a majority (10, 37.0%) within the 21- to 30-year range. Primary care physicians made up 23 (85.2%) of the total interviewees. Twelve (44.4%) interviewees possessed additional post-baccalaureate degrees beyond their doctor in osteopathic (DO) or allopathic (MD) medicine degree. They included master’s degrees in public health (MPH), science (MS), business administration (MBA), public policy (MPP), theological studies (MTS), and/or social science (MSS).
At the time of the interviews, 12 (44.4%) interviewees worked in a public safety net setting, eight (29.6%) in an academic safety net setting, four (14.8%) in an academic non-safety net setting, and three (11.1%) in the private sector. Of the 20 (74.1%) interviewees who worked within a safety net institution, 12 (60%) were in a public health setting and eight (40%) were in an academic setting. Of the seven (25.9%) interviewees not in a safety net health center, four (57.1%) were in an academic setting and three (42.9%) were in the private sector.
Perry and Mobley define physician career states based on skill requirements for increasing leadership responsibility: individual practitioner, physician leader, market physician leader, group physician leader, and enterprise physician leader. Individual practitioners require relational and clinical skills; physician leaders additionally require business skills; and market, group, and enterprise physician leaders additionally require strategic skills.
In reference to this career stage classification, all 27 interviewees (100%) had past or current experience as individual practitioners, 26 interviewees (96.3%) as physician leaders, and 17 interviewees (63.0%) as a market, group, and/or enterprise physician leaders.(7)
Categorizing Leadership Role Definition and Gaps
Of the specific skills identified as defining the administrative physician leadership role (Figure 2), the three most frequently mentioned skills were relational: role and self-awareness (15.8%), workforce development (15.1%), and teambuilding and engagement (13.0%). Role and self-awareness accounted for most responses (22.5%), noting leadership skill gaps (Figure 3). Each of the remaining skills accounted for no more than 10.8% of the total responses.
Figure 2. Skills Defining Administrative Physician Leadership Roles
Figure 3. Skill Gaps in Administrative Physician Leadership Roles
Most responses describing administrative physician leadership roles and gaps were associated with relational skills: 50.7% and 47.1%, respectively (Table 3). Business skills comprised 32.2% and 46.1%, clinical skills comprised 8.9% and 2.9%, and strategic skills comprised 8.2% and 3.9%, respectively.
In describing how skill gaps were filled (Figure 4), most responses included learning from others (31.6%) or training programs (29.8%). Interviewees reported they learn from others by having role models, reaching out to experts, participating in peer groups and networking, and collecting feedback from colleagues and patients. Interviewees referenced participating in national, state, and regional training programs as ways to fill their skill gaps. The remaining responses included degree programs; coaching, mentoring, and sponsorship; research; on-the-job training; continuing medical education (CME); college courses; residency training; improvisational comedy; and conference attendance.
Figure 4. How Administrative Physician Leaders Filled Skill Gaps
Of the biggest challenges interviewees faced in their administrative physician leadership roles, 44.2% of responses were associated with self-awareness, 40.4% with managing others, and 15.4% with managing the environment. Self-awareness challenges included self-management and reflection, understanding expectations, stress management, and understanding their career pathway. Challenges in managing others included workforce engagement and establishing trust, handling personnel issues, supervising staff with a longer tenure than themselves, managing conflict, and addressing staff shortages. Challenges in managing the environment included understanding the landscape, integrating systems, managing through the COVID-19 pandemic, and advancing diversity, equity, and inclusion.
When asked what type of leadership development would have been helpful, interviewees provided responses that were categorized as either skills or opportunities. Of the skills identified (Figure 5), most responses involved role and self-awareness (53.6%). Other responses included teambuilding and engagement (14.3%), communication (14.3%), financial management (7.1%), system engagement and networking (3.6%), health policy and law (3.6%), and conflict management (3.6%).
Figure 5. Desired Skills for Administrative Physician Leadership Development
Responses for desired opportunities for leadership development (Figure 6) included training programs (40.2%); opportunities to learn from others (23.2%); coaching, mentoring, and sponsorship (17.1%); degree programs (7.3%); research (3.7%); residency training (2.4%); on-the-job learning (2.4%); continuing medical education (2.4%); and conference attendance (1.2%).
Figure 6. Desired Opportunities for Administrative Physician Leadership Development
This evaluation did not identify a common structured path or pipeline for physicians to pursue an administrative leadership career, and many physicians used a piecemeal approach in preparation for their leadership roles. Although many physicians participated in formal training programs, there was no keystone opportunity that satisfied most of their leadership development needs. Many sought leadership development opportunities reactively rather than proactively when confronted with a knowledge or skill gap. One physician mentioned “waiting outside of a director’s house on the weekend” to learn more about clinical operations for their leadership position.
Surprisingly few interviewees proactively pursued administrative physician leadership positions such as clinical or medical directorships. Many were encouraged by their supervisors or mentors to take on these roles with little to no knowledge of what the roles entailed. Three interviewees expressed a desire to leave their current administrative leadership roles after understanding and performing the associated duties and responsibilities. One interviewee decided not to pursue additional training for their current position because they decided it was not part of their desired career path. However, this interviewee also felt uncertain as to what career direction to take.
The authors speculate about whether having a structured career pipeline could support awareness of expectations for administrative physician leadership positions and reduce the risk of physicians taking on roles that ultimately do not support their professional interests and career goals.
Another notable finding was that one interviewee, who held a group physician leader position at the time of the interview, transitioned to that role without experience as a physician leader. The interviewee took on the position initially as an interim role and felt “thrown into the role.” The interviewee took on the permanent position one year later and admitted that it was a “steep learning curve” but felt they possessed leadership qualities and potential for this role. At the time of this writing, it was discovered that the interviewee held the position for less than two years. The authors question whether a lack of preparedness contributed to this interviewee’s transition out of the group physician leader position.
Discussion
The benefit of effective physician leadership in health systems is widely recognized. Not only has effective healthcare leadership been associated with improved quality of care, patient and workforce satisfaction, financial performance, and clinical outcomes,(4,9,10,11) but also it could contribute to a reduction in workforce attrition.
It is essential to understand the specific needs of physicians so that leadership development opportunities can be developed and tailored to support today’s healthcare workforce. This study reveals overarching themes related to administrative physician leadership preparedness and development.
There was consensus among interviewees that education and training beyond traditional medical school and residency education were needed to prepare physicians for healthcare leadership roles. Although interviewees recognized the need to develop both relational and business skills, priority was placed on relational skills related to awareness of self and one’s own role, workforce development, and team building and engagement. Interpersonal and communication skills, influencing others, and emotional intelligence have also been identified in the literature as highly valued relational skill competencies for effective physician leadership.(12,13)
The COVID-19 pandemic exposed an underlying and increasing need for connecting with others and building relational skills. People felt socially isolated because of government stay-at-home orders, masking requirements, and physical and social distancing requirements. Healthcare workers experienced community stigma related to their occupation.(14) Several physicians in this study identified the “loneliness” associated with their leadership roles and a need to learn and network with others who shared similar roles and responsibilities.
This study pointed to the need for more leadership development opportunities. To inform the design of a leadership development course, a landscape analysis of 38 leadership training programs across the country was completed. Aside from three self-paced programs, the program duration ranged from 1 to 24 months. Costs ranged from $0 (institutional support for internal programs) to $50,000 and did not necessarily include travel expenses, required organizational membership, or conference attendance fees.
The duration and costs of leadership development programs can make it difficult for physicians to participate. Physicians in healthcare organizations generally require approval from their supervisors to carve time out from their clinical responsibilities, which can negatively impact earnings under relative value unit (RVU) compensation models. Continuing medical education allocations, if available, generally cover only a fraction of program costs and eliminate additional financial support for licensure and other professional costs.
The authors believe that internal institutional physician leadership programs may provide a solution to the extensive time and financial commitments required by external programs. Internal programs promote strategic priorities by building a pipeline and pool of potential leaders, developing talent within the organization, and reducing the time and resources used for recruitment and retention.(15) They can also increase leadership competencies, build leadership culture, and provide additional support for physicians engaging in quality improvement initiatives that directly benefit the institution.(16,17) Internal leadership programs have also shown reductions in physician attrition.(18,19)
Limitations
Several considerations should be addressed when interpreting the findings of this study. Recruitment and interviews followed a qualitative study design, and a less rigorous approach was taken for the analysis, which was appropriate for this study. The assessment took place at one large, multisite academic health system, which might not represent all regions or organizational cultures.
This assessment may be missing insights and perspectives of physicians working in other environments such as private practice, not-for-profit, for-profit, and military environments. Perspectives from healthcare professionals who work in dyad relationships with physicians could have provided deeper insight into the need for physician leadership development. Also, physicians’ perspectives on leadership preparedness may not be consistent with their institutional priorities.
Conclusion
Physicians need training to prepare for administrative leadership roles and responsibilities as they and healthcare institutions navigate the post-COVID-19 landscape. Physician leadership development should include and prioritize relational skill development so that physicians can achieve effective leadership competencies.
Providing opportunities for physicians to participate in leadership development programs can have a positive impact on the individual and institution in addressing workforce shortages, improving clinical outcomes, fostering a leadership culture, and creating pipelines and pools of talent for future physician leaders.
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