The Need for Physician Leadership Education

Healthcare is the largest industry in the United States, accounting for 17.9 percent of the gross domestic product, translating to $10,348 per capita expenditure.(1) National healthcare expenditure (NHE) has grown faster than the economy since 1970 except for a brief period after implementation of the Affordable Care Act in 2010.(2) The industry is realizing the need to engage physicians in business decisions, especially since physician and clinical services contribute to 20 percent of the $3.3 trillion NHE.(1)

It has been acknowledged that education programs must embrace changes in physician training so that physicians are prepared to engage in organizational decisions that inevitably involve their careers.(3) There are multiple opportunities to embrace business and leadership training at both the undergraduate and graduate medical education levels.

At the 2015 American Medical Association’s (AMA) Accelerating Change in Medical Education meeting, addressing this shortcoming in training was recognized as integral to enhancing the medical curriculum. In 2015, a national survey of medical students chronicled the intense desire for business education, as well as the need to integrate such training into the medical school curriculum.(4)

Because physician involvement in organizational management increasingly is being recognized as important to improve quality outcomes, management and leadership training for physicians should be encouraged.(5) The number of MD/MBA programs in America has grown to 70 in the past 20 years; more than half of these started after the year 2000.(6) According to data from the Association of American Medical Colleges, about 150 students were enrolled in dual MD/MBA programs during 2016, representing fewer than 1 percent of the medical graduates.(7)

Improving residents’ leadership skills is not a novel idea.(8) In 1999, the Accreditation Council of Graduate Medical Education (ACGME) established practice-based learning, interpersonal and communication skills, professionalism, and systems-based learning as four of the six major competencies. Teamwork and leadership are recognized as sub-competencies to be attained for successful completion of clinical training.(9)

Residents also support these innovative learning opportunities. Two surveys of orthopedic and internal medicine residents at two separate programs have confirmed residents’ desire to learn more about business and leadership, respectively, during residency.(10,11) In another survey of surgery program directors (PDs) across the United States, 87 percent strongly agreed or agreed that residents should be trained in business and practice management, and 70 percent believed that their current residents were inadequately trained in these areas.(12) A survey of chief residents and PDs in dermatology revealed that 78 percent of respondents felt training in leadership skills was important and that a formalized leadership curriculum would help residents become better supervisors and physicians.(13)

Barring these isolated surveys conducted by specific programs, to our knowledge, no survey has been conducted eliciting responses from residents and PDs from multiple specialties across the nation regarding perceived needs for business, management, and leadership education during residency and fellowship. We conducted this survey to accomplish the following objectives:

1. To understand the perceived needs of residents and fellows (hereinafter referred to collectively as residents unless necessary to distinguish) and their PDs regarding this type of training;

2. To analyze if the perceptions of residents and PDs were consistent across variables such as gender, ethnicity, state, institution, specialty, prior business/economics course work, years of work experience, type of practice the residents were contemplating post-training, and involvement with the management of clinical practice; and

3. To determine what type of schedule residents and PDs would prefer to facilitate attendance if such a program was created.

Materials and Methods

Two separate questionnaires for residents and PDs (Appendices 1, 2) gathered demographic information and perceived needs for business/management/leadership education from residents and fellows. Designed as an online survey using Qualtrics, containing 14 and 11 items, either multiple-choice or 5-point Likert-scale questions, were presented to residents and PDs, respectively. The Institutional Review Board at Rice University per State of Texas Master IRB Reciprocity Agreement granted an exemption for the study.

An email with the survey link was sent to 760 designated institution officials (DIOs) at institutions sponsoring residency programs (ACGME report, 2016). The DIOs were requested to forward the survey to the residents and PDs at their respective institutions. Informed consent was collected through an online information sheet that provided details of the survey, participants’ rights, and the right to exit at any time. Follow-up emails were sent three weeks later to non-responding institutions.

After six months, a second round of emails was sent only to institutions in the Houston area, as we wanted higher participation from local institutions and it was convenient for the DIOs on this project to disseminate to their teams. To encourage participation, all respondents’ email addresses, collected delinked from the survey, were entered in a drawing for 10 $50 Amazon gift cards. The survey was kept open from mid-June 2016 until the end of January 2017.

Analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were calculated using Microsoft Excel 2013 (Microsoft Corp.). Responses were collapsed to binary categories: “Notable/Great extent” and “Somewhat or less.” Binomial tests of proportions were used to test the probability of selecting “Notable/Great extent.” The null hypothesis for the binomial test was that the proportion of responses was 50 percent (proportion = 0.5) versus the alternative that the proportion was not equal to 50 percent.

Fisher’s exact tests were used to test the contingency tables comparing the responses from PDs versus residents for each question of interest and to test if the Likert-like responses varied in each category. Statistical significance was defined as p< 0.05. For all statistical hypothesis tests, missing values were removed from the analysis.

Results

Of the survey emails received by 753 DIOs, 195 links were opened and presumably forwarded to residents and PDs, yielding a rate of 26 percent (Table 1). There were 489 responses (405 residents and 84 PDs) from 4,027 secondary recipients who accessed the email containing the survey link (12 percent response rate). Responses were received from 26 states across all four regions of the United States. Combined responses from PDs and residents were recorded from 67 (9 percent of recipients) unique institutions — 363 (2 percent of recipients) from 57 institutions for residents and 68 (8 percent of recipients) from 29 institutions for PDs (Table 2). Only 22 institutions had at least one resident and one PD respond to the questionnaire; because of the anonymity of the data we cannot ascertain if the residents and PDs were from the same program. Of the 405 physicians-in-training who responded, 284 (70 percent) were residents, 100 (25 percent) fellows, and 21 (5 percent) did not report their level of training (Table 3).

When considering their residents, 19 PDs (23 percent) thought that more than 40 percent of their residents were pursuing an additional degree, which is similar to what the residents responded. Of the additional degrees, the MBA degree was least-frequently noted by the PDs as being offered (n = 18, 21 percent).

Residents and Fellows Responses

Regarding the importance of future physicians having a background in business and management, 82 percent of the residents believed that it will be important to a “Notable/Great extent” (Figure 1). The need was felt more strongly by non-white male residents (92 percent) and was significantly different from white male residents (73 percent). In all cases, significantly more residents indicated that it was important to understand the business of medicine to a “Notable/Great extent.”

The perceived importance of management education was higher for those who took more than three business courses (94 percent) versus others (80 percent). Type of practice contemplated after training was also related to resident response; however, irrespective of the practice contemplated, more residents indicated such training to be important to a “Notable/Great extent”: 77 percent for academic practice, 74 percent for community-based practice, 79 percent employed by hospital, 92 percent for group practice and 100 percent for solo practice (only six responses).

There were 273 (73 percent) residents who indicated that they were interested to a “Notable/Great extent” in learning about the business of medicine. Significantly more male than female (78 percent vs. 68 percent) and non-white than white residents (86 percent of non-white respondents vs. 64 percent of white respondents) indicated interest to a “Notable/Great extent.”

Similar to the question on importance of understanding business, responses were related to the number of courses taken, and more than half of the residents indicated “Notable/Great extent” for each group. Again, those who had taken more than three business/economics courses were more likely to respond “Notable/Great extent” compared to others. Interest was also statistically significant for all types of practice considered except community-based practice and for all specialty groups except for those in family medicine and pediatrics.

When considering the value of a 14-day management program in their curriculum vitae, 65 percent indicated important to a “Notable/Great extent.” Response pattern did not significantly vary by gender, white vs. non-white, number of business courses taken, or specialty. However, the value of such a training was found to be related to the type of practice considered, specifically those thinking of academic (60 percent), group (76 percent), and solo practice (100 percent of six responses), while community-based (59 percent) and employed by hospital (59 percent) were not.

The residents preferred a schedule of every Saturday for 14 weeks (35 percent), followed closely by Friday/Saturday alternate weeks for 14 weeks (26 percent) and Monday to Friday over four consecutive weeks (24 percent).

Program Directors Compared to Residents

Regarding the importance of future physicians having an understanding or background in business and management, only 61 percent of the PDs responded “Notable/Great extent.” This was significantly fewer than the 82 percent of the residents who responded as such (Figure 1). In considering the residents’ interest in learning about the business side of medicine, only 38 percent of the PDs responded “Notable/Great extent” — significantly fewer than the number of residents who responded that way.

In terms of the value of a 14-day management program on the residents’ resume, only 50 percent of the PDs thought this would be important to a “Notable/Great extent” — a value significantly less than the response given by the residents. The PDs believed that the residents would be “Somewhat or less” involved in the managerial aspects of practice irrespective of the type of practice they thought their residents would embark upon. Furthermore, the response patterns for the PDs did not vary significantly by gender, ethnicity, or institution.

Consistent with the preferred scheduling choice of the residents, the PDs also most frequently indicated that every Saturday for 14 weeks (40 percent) would be the preferred scheduling of a program; however, their next frequent choice was a Monday through Friday four-week schedule (25 percent), which was not congruent with the residents’ reported preferences.

Discussion

Our national survey study demonstrated with statistical significance that more than 50 percent of the residents favored overall business education irrespective of gender, ethnicity, and specialty, except in certain areas where male residents showed more interest; the PDs were ambivalent in supporting this type of education.

These results are consistent with prior studies that reveal that current residents, across all specialties, perceived the need for more training in business, management, and leadership beyond what educational leadership felt they needed. Program directors did not perceive receiving such training as important as the residents did, nor did they realize the importance their residents placed on this need. This disconnect between educational leadership and residents is significant.

There also were differences in residents’ perception based on gender and ethnicity. It is recognized that fewer women and fewer underrepresented minorities pursue MBA degrees.(14,15) In our survey, more male residents and more non-white residents responded positively in favor of specialized management training. We also noticed that more residents who planned to work in group or solo practice indicated a need for management education.

Perhaps the differences in perception stem from the possibility that PDs are already overwhelmed with existing clinical education requirements (sheer volume of the knowledge and skill acquisition necessary to become a competent physician), work-hour restrictions, need to integrate research time, and a host of changing evaluation metrics such that sufficient attention to this new area might appear onerous. The PDs also may not recognize that many systems integration and quality requirements might be satisfied with management and leadership education. Alternatively, residents may be more familiar with the practical requirements in the practice of medicine than the PDs are.

As training programs in leadership become more common because of increased demand,(16) there is an obvious need to reform the graduate medical education system at a national level, thereby addressing residents’ evolving needs in the dynamic field of healthcare.

While many medical schools have undergone some form of curricular reform in recent years, graduate medical education training has not undergone the same degree of curricular reform on a national level.(17) In general, no additional time is specifically allocated to development of management and leadership skills during medical education in the vast majority of GME programs. However, there are some exceptions to the traditional GME curriculum. Dell Medical School in Austin, Texas, offers a Distinction Program to physicians in training. The Foundation Curriculum offers coursework in a variety of nontraditional domains including leadership, value-based care, and design thinking. Residents are also given the opportunity to develop Distinction Projects based on their area of interest.(18)

The ACGME has incorporated requirements for interprofessional education in its most recent revision of the Common Program Requirements.(19) As advances in medical knowledge reinforce the benefits of management and leadership education, the need to engage PDs in providing leadership training and the integration of these programs into the ACGME becomes critical.

Limitations

Although the response rate of our study was low (but still within the typical range of online survey response rates), the sample sizes for both the binomial tests and the Fisher’s exact test were reasonable. Post-hoc power analyses showed that for our sample sizes, the binomial test had sufficient power (at least 80 percent) to detect a difference of 16 percent, while the Fisher’s exact test had sufficient power (at least 80 percent) to detect a difference of 18 percent when comparing the PDs to the residents. Thus, our study has sufficient statistical power to be of significant value.

The Fisher’s exact test can handle limited data; however, it can be sensitive to specific patterns in the data and not be a robust estimate of the relationship at the population level.(20,21) To check robustness, we used a generalized linear mixed effect model (using binary responses as an outcome) to test for clustering across institutions.(22) In all cases, clustering was not significant. Additionally, we used Fisher’s exact tests to examine if the reminder sent to the regional area institutions (institutions in Houston) caused a bias in the response patterns. No significant relationship was found between the institutions (or the timing of the final reminder) and the responses. Furthermore, due to the anonymous nature of the survey, specific association between the participants and existence of MD/MBA program in their institutions could not be ascertained.

Conclusion

Our national survey of graduate medical education residents demonstrates that many current residents and fellows favor the addition of business, management, and leadership education to their curricula. Additional studies surveying residents who have recently graduated or who are currently in practice would also be helpful to ascertain their thoughts regarding the need for leadership education during their training. Further research in this area is warranted to determine how to best provide appropriate education to enhance these residents’ successful careers.

Acknowledgement

The authors declare no sources of funding for this study.

Megan Gossett (logistics and editing); Dr. Sherilynn Gordon Burroughs (the authors dedicate this report in memory of Dr. Burroughs, Department of Surgery, DIO at Houston Methodist Hospital, Houston, Texas who was involved in preparing and implementing this research. She is missed dearly).

References

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2. Centers for Disease Control and Prevention. Trend Tables. National Center for Health Statistics; https://www.cdc.gov/nchs/data/hus/2015/093.pdf . Accessed August 1, 2017.

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4. Wanke TR, McDevitt JL, Jung MJ, Meyer M, Puri L, Gonzalez CM, Saucedo JM. Integrating Business Education in Medical Schools: A Multicenter Survey. Physician Leadership J. 2015;2(6):54-9.

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6. Viswnathan V. The Rise of the MD/MBA Degree. The Atlantic. 2014; Sept. 29.

7. Wynn P. Having Business Know-How Opens Up New Career Opportunities for Physicians. Association of American Medical Colleges News. 2017; Feb. 6. https://news.aamc.org/medical-education/article/business-know-how-new-career-opportunities/?utm_source=newsletter&amp;utm_medium=email&amp;utm_campaign=AAMCNews020817 . Accessed August 1, 2017.

8. Jardine D, Correa R, Schultz H, et al. The Need for a Leadership Curriculum for Residents. J Grad Ned Educ. 2015;7(2):307-09. doi:10.4300/JGME-07-02-31.

9. ACGME Common Program Requirements, ACGME approved focused revision: September 29, 2013. Effective July 1, 2016.

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12. Lusco VC, Martinez SA, Polk HC. Program Directors in Surgery Agree That Residents Should Be Formally Trained in Business and Practice Management. Am J Surg. 2005 Jan;189(1):11-3.

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15. Wirz M. Opting for an MBA Education: A Gender Analysis. A Review of Evidence from GMAC Reports. Cambridge, UK: Cambridge University Judge School of Business; 2014.

16. Jain SH, Goodman EB, Powers BW, Katz JT. The Residency-MBA program: A Novel Approach to Training Physician Leaders. Healthc (Amst). 2016;4(3):142-4.

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18. University of Texas at Austin Dell Medical School Distinction Program for Care Transformation: https://dellmed.utexas.edu/education/academics/graduate-medical-education/distinction-program-for-care-transformation . Accessed May 7, 2019.

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Appendix 1. Resident Questionnaire

• Please specify your gender and ethnicity.

• Please choose the Institution you are affiliated with (state and institution).

• Which program are you in (specialty and subspecialty)?

• Which of the following best describes your current level of training (resident, fellow, year of training)?

• How many undergraduate or graduate business and/or economics courses have you taken (0 to 3+)?

• How many years of professional work experience did you have prior to medical school (0 to 3+)?

• Have you completed or are you pursuing any additional degrees/special training (Yes, No)?

• Which of the following have you completed/currently completing/plan to complete (MBA, MPH, PhD, MS, Certificate (Teaching, Research, Global Health, Quality and Safety, Other), other)?

• Please rate the following (Not at all, A little, Somewhat, Notable extent, Great extent).

  • How important do you think it will be for future physicians to have an understanding of and/or background in business and management?

  • How would you rate your interest in learning about the business of medicine?

  • How valuable do you think a 14-day management certificate program on topics such as Strategy, Finance, Negotiation and Process Improvement would be if included on your resume?

• If a 14-day certificate course were to be offered, what type of schedule would be best for you? (Monday to Friday full day spread over 4 consecutive weeks, Fridays/Saturdays full day every week for 7 weeks, Fridays/Saturdays full day alternate weeks for 14 weeks, Every Saturday full day for 14 weeks)

• What type of practice are you considering after your training (residency/fellowship)? (Solo, Group, Employed by hospital, Community-based, Academic)

• If solo/group practice, who would you prefer to handle the business matters related to your clinical practice? (Yourself, Employ a Business Manager, External Consultants, One of my partners, Indifferent)

• Please rate the following (Not at all, A little, Somewhat, Notable extent, Great extent)

  • In terms of the managerial aspects of practice, how much of a role do you expect to play, regardless of type of practice?

Appendix 2. Program Director Questionnaire

• Please specify your gender and ethnicity.

• Please choose the Institution you are affiliated with (state and institution).

• According to your records, approximately what percentage of residents/fellows pursues additional degree/training? (<10 percent, >10 percent but less than 40 percent, 40 percent-60 percent, >60 percent but less than 80 percent, >80 percent)

• Does your institution offer additional degrees/training? (Yes, No)

• Which of the following does your institution offer? (MBA, MPH, PhD, MS, Certificate (Teaching, Research, Global Health, Quality and Safety, Other), Other)

• Thinking of your trainees, please rate the following (Not at all, A little, Somewhat, Notable extent, Great extent).

  • Importance for future physicians to have an understanding of and/or background in business and management.

  • Residents’/fellows’ interest in learning about the business of medicine.

  • Value of a 14-day management certificate program on topics such as Strategy, Finance, Negotiation, and Process Improvement on a resident’s or fellow’s resume.

• If a 14-day certificate course were to be offered, what type of schedule would be best for your specialty? (Monday to Friday full day spread over 4 consecutive weeks, Fridays/Saturdays full day every week for 7 weeks, Fridays/Saturdays full day alternate weeks for 14 weeks, Every Saturday full day for 14 weeks)

• What type of practice do you think the majority of your residents/fellows are likely to consider after their training (residency/fellowship)? (Solo, Group, Employed by hospital, Community-based, Academic)

• Who do you think will handle all business matters related to the clinical practice? (Physicians themselves, Employ a Business Manager, External Consultants, Indifferent)

• Regardless of the type of practice, please rate the following (Not at all, A little, Somewhat, Notable extent, Great extent)

  • Your trainees’ role in the managerial aspects of practice?