Fairchild, David G. MD, MPH; Benjamin, Evan M. MD; Gifford, David R. MD, MPH; Huot, Stephen J. MD, PhD
Dr. Fairchild is currently chief, Division of General Medicine at Tufts-New England Medical Center, Boston, Massachusetts. At the time of writing this paper, Dr. Fairchild was director, Primary Care Services, Brigham & Women’s Hospital, and assistant professor of medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts. Dr. Benjamin is vice president, Healthcare Quality, Baystate Medical Center, and assistant professor of medicine, Tufts University School of Medicine, Springfield, Massachusetts. Dr. Gifford is assistant professor of Medicine and Community Health, Brown University School of Medicine, and chief medical officer, Rhode Island Quality Partners Inc., Providence, Rhode Island. Dr. Huot is director, Primary Care Internal Medicine Residency, and associate professor of medicine, Yale University School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
Correspondence and requests for reprints should be addressed to Dr. Fairchild, Tufts-New England Medical Center, Box 212-General Medicine, 750 Washington Street, Boston, MA 02111; telephone: (617) 636-1083; e-mail: 〈DFairchild@tufts-nemc.org〉.
For articles on related topics, see pp. 205–213, 250–257, and 258–264.
Strong physician leadership is an important element in successful health care systems.1–3 As the health care environment has grown more complex, the need for physician leaders to participate in administrative and management decisions has increased.4–6
However, physicians in general7 and academic physicians in particular8 have historically prized their autonomy and viewed management as outside the purview of medicine. In the academic environment, junior faculty were to avoid administrative duties so they would not be distracted from teaching and research.9 Administrative responsibilities were generally considered “a necessary evil” of advancement to senior academic rank.
It is within this traditionally anti-management academic environment that the increased need for physician administrative leadership is creating new career opportunities for academic physicians who are capable of working at the interface of clinical medicine, health care finance, and management. Although existing within academic medical institutions, these positions often have a significant “service” or administrative component and thus would be considered nonacademic positions to be avoided in the traditional academic paradigm.
We will argue, however, that there is academic opportunity for physicians in these administrative leadership positions. While similar in many ways to traditional clinician–educators and clinician–researchers, these physicians, hereafter referred to as academic physician administrators and leaders (APALs), require different training and make unique academic contributions that differentiate them from their traditional academic physician colleagues.
In this article, we offer a definition of APALs, discuss the obstacles APALs face as they attempt to integrate into academic medical centers, and outline the challenges academic medical centers face in mentoring and supporting these unique faculty. Further, we suggest modifications to both traditional academic structures and the role of specialty societies that would support better the career development of academic internists in leadership and administrative roles.
Who Are Academic Physician Administrators and Leaders?
APALs are academic physicians who spend the majority of their effort in an administrative role that is vital to an academic medical institution or to academic medicine in general. An APAL's primary contribution is administrative leadership that supports programs or functions integral to academic medicine. Just as teaching and research are central to the careers of clinician–educators and clinician–researchers, respectively, the administrative role is central to the APAL's career and the context for academic and scholarly activity.
Expanding the concept of an academic physician beyond clinician–educator and clinician–researcher, APALs could be characterized as clinician–administrators. It is self-evident, however, that simply having an administrative job within an academic medical institution does not per se qualify a physician as an academic physician. Physician–executives, for example, often eschew traditional academic medicine pursuits to focus their efforts on the administrative tasks associated with operations. In contrast, the academic component is central to APALs who may blend their administrative and leadership jobs with patient care, teaching, or research—the traditional elements of academic medicine.
By participating in clinical activity, teaching, and research, APALs appear similar to their clinician–educator and clinician–researcher colleagues; however, the role of an APAL differs from the clinician–educator or clinician–researcher role at most academic medical centers. As a result of their administrative experiences, APALs are in a unique position to contribute to the advancement of the practice of medicine by making scholarly contributions in the fields of health care finance, management, and leadership. In addition to written scholarship, APALs may use their experiences to educate students and residents. In summary, academic activity distinguishes APALs from nonacademic physician–executives.
Evolution of the Academic Physician Administrator and Leader Role
Although we have observed an increasing number of junior faculty in APAL positions, we are aware of no data quantifying an increase in the administrative and leadership opportunities for academic physicians. However, there are several reasons why an expansion of these positions makes sense: physicians respond well to physician leaders, especially on issues of medical management; health care reimbursement is shrinking, and the expanding interface of finance and medicine invites physician leadership10; APAL positions, offering operational challenges and the opportunity to develop and evaluate health care delivery systems, represent exciting career opportunities for faculty members; and “hard money” support for management positions makes it possible to cross-subsidize other academic pursuits.
With growing frequency, students and residents interested in APAL positions ask us for career advice. As the APAL positions have developed a higher profile within our academic institutions, they have become increasingly attractive to medical students and residents. Yet training and mentoring young physicians interested in APAL careers is a challenge for academic medical institutions.
Skills And Training Requirements
Being a successful APAL requires additional expertise beyond the typical skills of an academic internist.11–13 Strategic planning, finance, leadership, negotiation, and other management skills are often necessary in these positions,14 but represent skills not taught at most medical schools or postgraduate residency programs. While job experience is one of the best educational tools and provides the life experience so helpful in management, a well-rounded management portfolio may take years to develop. To facilitate career development and to obtain necessary skills, some APALs obtain MPHs, MBAs, or other similar degrees. This is a very time-consuming educational strategy, however, that is not easily generalizable to most physicians. Alternatives to formal degree programs include some general internal medicine fellowships and Robert Wood Johnson Clinical Scholar Programs that provide training opportunities in business and leadership. The American College of Physician Executives, although not specifically oriented toward academic physicians, has a broad offering of educational programs for physician–executives including degree-granting programs in medical management. The Association of American Medical Colleges leadership-training seminars and the Executive Leadership in Academic Medicine program are both oriented to leadership development in the academic environment. Other programs such as the Certified Medical Director for nursing homes can also provide helpful skills.
Academic institutions must recognize that to the extent junior faculty APALs do not have broad management or leadership experience, career development training will be of proportionately greater importance. Whether by developing internal programs or relying on external offerings, academic medical institutions should make administrative leadership career development programs available to physicians interested in APAL positions. To be successful, APALs must obtain these additional skills, blend them with their clinical, teaching, and research skills, and achieve benchmarks of academic productivity that will be recognized and valued by their institution's appointments and promotions committee.
Faculty Development and Promotion
Although many administrative leadership positions may not be inherently academic in focus, by blending service to the institution with the elements of academia, these positions can become fulfilling for academically oriented internists (see List 1). However, traditional academic support structures and promotion criteria15 are not well suited to APALs, making academic advancement potentially difficult.
The APAL's sources of external research funding and venues for publishing scholarly work may differ from those of their more traditional faculty colleagues. An APAL's research topics may include management, quality improvement, finance, and leadership—areas that may stretch beyond the bounds recognized by medical school promotion committees. Peer-review publications may appear in management or finance journals that are unfamiliar to promotions committee members. In addition, funding may come from nontraditional sources such as industry or foundations. In some instances, salary support may come from the parent institution as “hard money” for administrative duties. Given their institutional responsibilities, most APALs are not likely to receive research grants from sources such as the National Institutes of Health, one of the metrics by which research faculty are judged. Similarly, as teaching is not their primary focus, APALs will not develop large teaching portfolios.
Because of these differences, academic promotion as an APAL could be challenging. Although the same general standard of assessing local, regional, and national impact still applies, the academically significant administrative service component of APALs’ work should be viewed as complementing, not detracting from, their academic worth. While APALs cannot expect to be promoted solely based on operational management, promotion criteria in some medical schools may need to be modified to explicitly recognize excellence in the administration and leadership of significant academic programs.
For example, the University of Pennsylvania School of Medicine has developed clinician–administrator promotion criteria16 (see List 2) within the clinician–educator track to recognize program leadership and other significant administrative contributions. Other medical schools should consider developing similar clinician–administrator promotion criteria as a means of encouraging the academic advancement of APALs. There is precedent for elaborating unique promotion criteria in response to changes in academic medicine. Just as the clinician–educator track in medicine17 was developed to recognize the importance of clinical teaching within the medical faculty, a clinician–administrator promotion pathway would validate the academic value of leadership and administrative contributions.
Mentoring, one of the most important factors associated with successful faculty development,18 is another area that is currently not well developed for APALs. Since APAL positions are relatively new, fewer well-established mentors are available. Lacking a single suitable mentor, we have developed relationships with mentors in specific content areas (e.g., quality improvement, finance, health service research, information systems, leadership). For some, mentors may not be available at their parent institution. Creating regional and national mentoring and networking opportunities is an area where medical societies could have a particularly important impact on the professional advancement of APALs.
Medical Society Support
Medical societies are another mechanism for supporting APAL career development. In addition to being educational opportunities, society meetings provide valuable networking and mentoring opportunities for physicians with common backgrounds and mutual interests. Further, specialty societies are in a position to generate policy discussions such as the need for clinician–administrator promotion criteria. Medical societies should assess the APAL career development needs of their membership and develop programmatic offerings to facilitate networking, continuing education, mentoring, and career advancement activities for APALs.
Academic Physician Administrators and Leaders and Medical Education
To foster the development of APALs, medical schools and residency programs should consider developing administrative and leadership electives. Typically focused on a well-circumscribed project, these electives would provide students and residents the opportunity to work closely with an APAL within their institution. Informal clinician–administrator electives have been developed at some of our institutions (EB, DF). Other institutions such as the University of Minnesota have developed a formal management-training program for residents.19 Leadership skills, necessary in many aspects of medicine but essential for APALs, should be offered during physician training.
Postresidency programs, including some general medicine fellowships, offer training in skill areas helpful to APALs (statistics, epidemiology, quality improvement, and study design), but additional training in finance, management, and leadership is also required for many APAL positions. The development of an administrative and leadership track in general medicine fellowships could provide focused training and programmatic support to help launch junior APALs in their careers.
An increasingly complex health care environment is accentuating the opportunity for physician leadership in administrative and management decision making.10 However, the traditional academic medicine notion that only senior physicians should assume administrative roles, and that junior faculty should eschew service jobs to concentrate on clinical care, teaching, and research, no longer fits well with the current academic environment. The expanding interface of the clinical and administrative aspects of medicine is creating management and leadership career opportunities for junior faculty physicians in academic medical centers. The challenge for APALs is to create an academic career within the management and leadership arenas of medicine—areas traditionally shunned by academics in medicine, but consequently ripe for scholarly inquiry.
Not surprisingly, existing academic structures are heavily oriented toward the support of traditional academic physicians: clinician–researchers and clinician–educators. Career-development infrastructure such as promotion criteria and mentoring capabilities must evolve if they are to support the growth of APALs. It is noteworthy that recognition of administrative duties and leadership has been successful for administrative psychiatry, a branch of the specialty oriented to the study of leadership, management, and other areas of interest to psychiatrist clinician–executives.20
Enhancing the academic element of administrative and leadership positions in academic medicine will attract the best and the brightest academic physicians to these important roles. Academic medical institutions and medical societies should assess the degree to which their career development infrastructure advances the careers of physicians currently in APAL positions and how well their educational programs train future administrative physician leaders.
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