Transitioning from Physician to Hospital Leader: A Competency-Based Model

In the era of healthcare reform from volume-based to value-based care, the role of physician leaders within healthcare organizations is growing throughout the United States. In the past decade, the number of all acute care hospitals and Accountable Care Organizations (ACOs) with physician leaders has increased markedly, and better quality has been linked to better leadership.(1,2)

As the trend of transitioning physicians into organizational leaders grows and organizations continue to expand the roles and scope of physician leaders, the need to better prepare physicians for the demands of managerial leadership grows as well. Although leadership has been added as a core medical competency, it is often taught informally and is a small part of the physician’s extensive clinical education.(1)

Leadership development programs (LDPs) guide organizations in cultivating their leadership talent. Though healthcare organizations are not unique in their need for quality LDPs, their goals and leadership candidates are different because physicians often lack direct experience with fundamental business processes and management that career hospital administrators have learned over the years as they advanced through leadership positions.(3)

What physicians know as they transition to a leadership position is both a barrier and a benefit. Although their clinical knowledge may emphasize patient care, they also must understand the organization. Building a true foundation of physician leaders within an organization is not accomplished with crash courses in management, finance, and human resources.

Over many years, physicians under the watch of an attending physician develop clinical expertise; however, with no practical work experience and very little formal training, they often are expected to perform as expert administrators. Certificate programs have their place, certainly, but long-term growth and development of physicians who are identified as future leaders can serve an organization in the long-term.(3)

The Path To Leadership

Conventional medical education is structured to build knowledge and skills from broad and generalized foundations into more specific areas of focus in a conical form. Over time, importance shifts from general studies to a selected emphasis, with some competencies losing relevance along the way as the physicians-in-training hone their expertise in a specific area of medicine (cardiology, family medicine, gastroenterology, etc.). This inevitably leads to the narrowing of the less-relevant aspects of their medical education. The refinement of expertise results in a conical knowledge structure with the broad, general knowledge forming the base and the specialized skills comprising the capstone.

Administrative professionals frequently begin their careers in specific roles within a department or functional area and later expand into more global capacities. Administrators become generalists as they gain experience and responsibility, managing projects or a group of individuals. At the height of their careers, administrative leaders manage multiple competencies at a variety of levels, including strategy, finance, operations, and human resources (see Figure 1).

Figure 1: Inverted transition from physician to organizational leader

The period during which physicians become organizational leaders begins an inversion of roles from clinical specialists to administrative generalists. Organizational well-being relies heavily on effective leadership, so from the vertex of the inverted cone, physicians must rapidly expand their knowledge base to reach “break-even” as Michael Watkins writes in The First 90 Days (2013). They must transcend from their specialty background to break down silos and assume skills of meta-leadership, essentially beginning the transition from specialist back to generalist, as shown in Figure 1.(4)

Although some physician leaders participate in graduate education or independent certification programs to learn and develop leadership skills and knowledge, in-house LDPs can be tailored to an organization’s needs, leverage existing staff, and instill a sense of camaraderie and teamwork among participants.(4) Traditional LDPs often operate as certificate programs, in which participants attend seminars or training sessions, sometimes with a capstone project to culminate the leadership training.(1,4,5) Despite the popularity of LDPs at healthcare organizations, mentorship and on-the-job experience (both central elements of Graduate Medical Education [GME]) have been identified as the most effective means of developing leadership skills, with LDPs themselves ranked somewhat lower.(6)

An LDP specifically geared toward physicians can account for the gaps found in typical LDPs and might be much more beneficial for both the organization and physicians than a one-size-fits-all approach. Structuring an LDP to be effective for physician leaders means structuring it to include elements already found in a GME, including mentorship, demonstrated competency, and gradual learning through experience.

Continuing Leadership Education

GME provides a tiered educational hierarchy that helps resident physicians develop personal, clinical, and professional expertise under the guidance and supervision of more experienced faculty and staff. Oversight ensures the safety and appropriate care of patients by the residents, who gradually assume more responsibility as they demonstrate their clinical competence. To impart the core competencies needed to become a highly effective physician leader, an LDP curriculum that follows the same tiered approach enforces demonstrated capability and personal investment.

A continuing leadership education (CLE) model, designed after the same general structure as a typical GME and following a core of competencies tailored to an organization’s needs, allows physician leaders to develop skills in a progressive and formalized process that is impactful and transferrable. The tiered structure of a CLE includes Leader Internship, Leader Residency, and Leader Fellowship (see Figure 2). The individual physician’s investment in matriculating through the program to gain the skills required of “practicing physician leaders” enforces personal responsibility and adds value to the organization. A CLE should begin when a potential physician leader is first identified.

Figure 2: Continuing leadership education

Just as important as selecting potential physician leaders is identifying those who express an interest in leadership roles but who are not well suited for leadership roles at that time. In the way physicians are continuously assessed on their clinical skills with candid yet constructive feedback, unsuitable leader candidates should be informed why they are not a good fit for the role. At the same time, the physicians’ qualities and skills that are beneficial to the organization should be recognized to minimize the risk of disengagement.

If it is unclear whether a physician will be successful in a new leadership position, requiring him or her to serve in an interim capacity may be one option, depending on the potential needs of the organization. Whether it is an interim or more permanent appointment, setting the role expectations up front, along with identifying criteria to be used for evaluating performance in the role, are important. With that basis, if the leader must be removed, the removal can be balanced and objective.

The selection process can be based on a variety of factors but should ensure that mutual interest is established between the physicians and the organization in participating in the CLE. After being selected, the physicians continue to serve in their primary role as clinicians while beginning to participate in supervised projects with administrative preceptors. Initially, small roles like facilitating meetings, gathering data, working in teams, etc., introduce the physician leaders to basic aspects of management and leadership in the Leader Internship level.

Leader Internship

The CLE begins within the physician leader’s medical specialty or current department. Assuming leadership roles within a department provides introductory opportunities for physicians to gain leadership skills while still practicing in a familiar field. As Leader Interns, physicians are given opportunities to develop early on many of the fundamental skills that administrators have developed throughout their careers — including communication, decision-making, and business etiquette — through positions that might include smaller medical directorships. Administrative staff tools for strategic decision-making, presentations, and organization are introduced under the guidance of an administrative or physician leader mentor.

The Leader Interns continue to act in their primary role as physicians while undertaking minimally demanding roles on administrative projects. The goal of the CLE is to gradually introduce active physicians to a future in hospital administration; therefore, their time and effort should prioritize their clinical duties with a small percent devoted to the Leader Intern role. As the physicians demonstrate competency in fundamental skills and knowledge, the leadership role gradually expands to account for more and more of their time. Mentors guide the physician leaders in defining career goals and future needs as they achieve leadership milestones and prepare for the next level of the CLE: Leader Residency.

Physician and non-physician mentors offer benefits: Physician mentors who have already risen through the leadership ranks can help future physician leaders navigate the balance between their clinical workload and increasing administrative responsibility. Physician mentors can ask mentees to reflect on the commonalities and differences in skill sets required to be effective in both worlds and bridge the gap between the two.

In contrast, non-physician mentors typically provide a distinctly different perspective in leadership development for physician leaders and help them understand how the business side of healthcare approaches the process. In addition, non-physician mentors with their stronger financial and operational backgrounds assist the mentees in rounding out their leadership skillset. It is recommended that physician leaders find a combination of both in their mentor network to ensure a composite of perspectives.

Leader Residency

The Leader Residency builds on the skills learned during the Leader Internship with an emphasis on personal development. In a Leader Residency, physicians begin to understand their role within the organization along with their personal strengths, weaknesses, and strategies for progression or improvement. Within the first 90 days of Leader Residency, mentors should guide physician leaders in taking an active role in the organization and identifying where their qualities would be used most effectively while helping them to develop relationships and establish trust among peers.

As the physician leaders integrate further into the operations of the organization, their goal should shift to serving the needs of the organization. Their diagnostic skills previously used to treat patients must evolve to guide the institution as administrators. Because physician leaders in this stage are directly involved in steering healthcare organizations through ever-changing markets and policy reform, strategic planning will be a major component in Leader Residency. Understanding not only how to develop strategy, but also how to drive strategy through execution is essential as the scope of responsibility grows for the physician leader.

Leader Fellowship

The final stage of CLE involves physician leaders who have demonstrated their effectiveness and understanding of the fundamental traits of business and leadership in the Leader Internship and higher level strategic decision-making and personal growth of the Leader Residency. At the Leader Fellowship stage, physician leaders might have assumed a senior leadership role within the organization, using the skills and experience of the CLE to influence system-level decisions and outcomes in quality, operations, etc.

As Leader Fellows, physician leaders should begin to focus on developing the next generation of leaders within the organization, physicians and others. Becoming a mentor emphasizes the sense of personal responsibility to the organization and can galvanize organizational leadership into a cohesive unit.

In addition to mentorship, succession planning should begin to develop a successor in the role. New participants in the CLE can form cadres in future leader tracks representing the various functional areas of the organization. Those following the Quality track, for example, form the pool of candidates to succeed the chief quality officer. Through mentorship, the CLE can strengthen the sense of purpose throughout the chain of leadership and instill a strong sense of the organization’s mission, vision, and values.

Conclusion

The increase in physician-led healthcare organizations represents a unique opportunity to benefit from the experiences of physicians while growing their administrative abilities. Although physicians have proven to be efficient and effective, they often lack the business experience to adapt easily to administrative careers. They are unlike career administrators in that, until they are brought into leadership roles, they have had very little practical experience with management of people and projects.

Conventional leadership seminars and courses are typically geared toward a general audience and lack the long-term growth focus of a program dedicated to providing actual experience in areas of need. A CLE provides physicians alternative options in their career path that might be as equally rewarding as practicing within their clinical expertise. The home-grown approach of a CLE can provide organizations with a physician leadership team that is well prepared for each step as their duties transition from clinical to administrative in focus. A CLE can transform physician leaders in ways that satisfy organization goals, while imparting skills to serve them throughout their careers.

References

1. Rotenstein LS, Sadun R, Jena AB. Why Doctors Need Leadership Training. Harvard Business Review, October 17, 2018. https://hbr.org/2018/10/why-doctors-need-leadership-training .

2. Colla CH, Lewis VA, Shortell SM, Fisher ET. First National Survey of ACOs Finds That Physicians Are Playing Strong Leadership and Ownership Roles. Health Aff. 2014;33(6):964–71.

3. Throgmorton C, Mitchell T, Morley T, Snyder M. Evaluating a Physician Leadership Development Program – A Mixed Methods Approach. J Health Organ Manag. 2016;30(3):390–407.

4. Scott HM, Tangalos EG, Blomberg RA, Bender CE. Survey of Physician Leadership and Management Education. Mayo Clin Proc. 1997;72(7):659–62.

5. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership Development Programs for Physicians: A Systematic Review. J Gen Intern Med. 2015;30(5):656–74.

6. McKenna MK Gartland MP, Pugno PA. Development of Physician Leadership Competencies: Perceptions of Physician Leaders, Physician Educators and Medical Students. J Health Adm Educ. 2004;21(3):343–54.