Crites, Gerald E. MD, MEd; Ebert, James R. MD, MBA; Schuster, Richard J. MD, MMM
The nature and causes of today’s health care crisis are complex. Some policy makers believe that educating and developing physicians as leaders could play a role to help resolve the crisis because physicians have unique, experience-based perspectives regarding the health delivery system.1,2 Growth of the American College of Physician Executives membership from 1,747 to 12,266 between 1985 and 2000 suggests an increased need for physician executive education.3 Two popular education solutions for physician executives are grounded in business management (master of business administration [MBA] or master of medical management [MMM]) or public health (master of public health [MPH]). Many programs offering these degrees are designed for success in learning management and business skills, but it is unclear whether they are successful in developing leadership skills.4,5
Executive education is also offered to physicians earlier in their careers. As of 2005, there were 125 allopathic medical schools in the United States, with approximately 46 offering a combined MD–MBA, at least 75 offering an MD–MPH, and 2 offering an MD–master of heath administration program.6 These undergraduate dual-degree programs are becoming more popular because some medical students are recognizing a need for education in business management or public health earlier in their careers. Although a few of these programs provide leadership training (personal communication, R. Maeshiro, Association of American Medical Colleges (AAMC) Division of Medical Education, December, 2005), we know of no one that has an explicit focus on leadership education as an identifiable program component. Indeed, course offerings beyond typical management skills—including personal, health systems, and organizational approaches to leadership—seem nominal.7 Integration between MD degree programs and MBA/MPH programs can be difficult, and most only offer program components in series (where medical students in effect leave medical school, enter graduate school, then either return to medical school or enter postgraduate training) rather than concurrently (personal communication, R. Maeshiro, AAMC Division of Medical Education, December, 2005).7
In 2004, the BPLDP program leaders proposed to the Wright State University Boonshoft School of Medicine (BSOM) leadership a program theory on early physician leadership education. Specifically, our theory is that if a separate leadership curriculum is integrated with business management or public health education at an early stage of clinical education, such as during undergraduate medical education, then graduates, organizations, and communities may benefit sooner and experience a more positive impact from the effort. Because we know of no leadership curricula existing to adapt to the context of dual-degree undergraduate education, the first step for educators would be to construct a model leadership curriculum. Also, because suitable models to guide integration of the three program components (MD degree, leadership curriculum, and MBA/MPH degree) are lacking, the second step for educators would be to study and implement program integration. In this article, we describe our qualitative inquiry to create an early physician leadership curriculum and how we analyzed and implemented program integration.
The Boonshoft Physician Leadership Development Program (BPLDP) was developed at the Center for Global Health Systems, Management, and Policy (referred to hereafter as the Center) at BSOM. Founded in 1973, BSOM is a community-based medical school that focuses on generalist education. The Center, founded in 2000 with a gift from a local philanthropist, Oscar Boonshoft, provides education and research to address health system problems.
Two early BSOM educational offerings were Health Systems Management and Strategic Leadership in Health Care. These two courses are part of a health care concentration for midcareer professionals and linked either to a graduate certificate in health care management or an MBA offered through the Wright State University Raj Soin College of Business. Both courses are scheduled as evening seminars once weekly. In 2003, the BPLDP leadership proposed extending these two courses and offering them to medical undergraduates. The proposal envisioned using these two core courses as the foundation for a future leadership development curriculum and linking them to the existing MBA degree program or the MPH degree program, newly created in 2004. The original plan was to integrate three program components: education in clinical medicine (MD), strategic health care leadership (Leadership Curriculum), and a focus in either business management or public health (MBA or MPH). The resulting programs would be five-year MD/MPH or MD/MBA dual-degree programs, and students from both degree programs would participate in the Leadership Curriculum together. The MBA, MPH, Health Systems Management, and Strategic Leadership in Health Care courses were vetted and approved through BSOM and the School of Graduate Studies (the MBA program underwent an additional review at the Raj Soin College of Business).
In 2004, Mr. Boonshoft provided another gift of $3 million, this time to build the program described in the proposal. This gift formally established BPLDP program, and, soon thereafter, a program director (J.R.E.) and an educational consultant (G.E.C.) were hired to design, operationalize, and manage the program components. The latter gift also established a scholarship for MBA or MPH student tuition and other educational expenses. The center director (R.J.S.), the BPLDP program director, and the educational consultant comprised the program leadership (hereafter referred to as we or us) and made all strategic decisions for the Leadership Curriculum and program integration. The curricula for the MD, MBA, and MPH are determined by other university committees.
In 2004 the first cohort of students matriculated. MD candidates are contacted and encouraged to apply to the BPLDP program, and students who contact the BPLDP first are encouraged to apply to the MD program (the latter program accepts approximately 100 students per year). Selection to the BPLDP program is an ongoing, coordinated process involving leadership and staff at the BPLDP program, BSOM, MPH, and MBA programs. Since 2004, we have attempted to target 10 students each year for selection into the BPLDP program (with the goal of five in the MD/MPH and five in the MBA/MD program), but we have accepted more or fewer students depending on the candidate pool and attrition. By January 2007, the BPLDP program consisted of four cohorts that totaled 25 students.
Early Program Development
To assess the general need in our program, one author (R.J.S.) sponsored a survey of a sample of 24 first- through third-year students. The responses indicated interest in either an MD/MPH or MD/MBA dual-degree program at BSOM (mean responses >2.8 on a four point ordinal response scale, with 4 being strongly affirmative). The students also indicated that leadership skills are an important component of either dual-degree program (mean responses >2.8 on the same scale).
Early in the program design process, we were committed to a program sequencing method that would maximize opportunities for integration within and between program elements (MD, Leadership Curriculum, and MBA or MPH). Depending on the academic quarter, students would study in MD or MPH/MBA courses in daytime contact hours. In the evenings of every quarter, the students would study in the Leadership Curriculum. Charts 1 and 2 provide examples of how this sequencing later became manifest once the design process was completed (in this model, MD and Leadership Curriculum are constructed on a five-year plan along with either the MBA or MPH program).
Despite having the delivery sequencing decision identified, we still had questions regarding three design issues that still needed resolution:
▪ What educational model or theory would be most appropriate for the Leadership Curriculum? What literature supports this model or theory? What adaptations would be necessary for our program to accommodate this curriculum?
▪ What leadership educational content already exists in the program components (MD, leadership core courses, and MBA/MPH)? How could omissions and redundancies, as well as integration opportunities, be identified?
▪ On the basis of the answers to the two questions above, what should be the goals of the Leadership Curriculum? How would these goals and answers from the questions above inform Leadership course design, including objectives, instructional strategies, and assessment methods?
Below we describe the results of a one-year systematic inquiry to answer these questions.
Leadership Competency Development
Early in the program design, we committed to helping students develop the knowledge, attitudes, and skills that physician leaders actually need in their work. This emphasis led us to choose a competency-based educational model as the framework for our Leadership Curriculum design. Because no competency models already existed specific to leadership education of physicians, we began an inquiry to identify and adapt other leadership competencies for our setting. We identified 39 leadership competencies from a literature search in three databases (medicine, education, and business)8–16 and added an additional 11 we believed were also important but not represented in the literature.8–16 The primary guides we used to combine these competencies were the National Center of Health care Leadership Core Leadership Competencies and the book Primal Leadership.13,14 These sources, although not appropriate for unmodified adaptation for physician leadership, did suggest that competencies could be organized around major themes (or major competencies) such as awareness and relationship building. During several meetings, we used these guides to organize the 50 competencies around seven major competencies and 28 subcompetencies. At each point in the process, we vetted each combination option and made decisions via consensus. We were also explicit in building the model that would provide the best opportunity to measure minimum leadership competency attainment for undergraduates later in the course of study.
We validated this process by engaging three major stakeholder groups, represented by BPLDP faculty, current BPLDP students, and community partners, to evaluate our initial model. We presented the preliminary competency model during separate focus groups held with 20 local physician leaders and with the first two BPLDP students. After we clarified the model with feedback from these two groups, we mailed a survey to 14 program faculty seeking their assessment of the competency model. Using a modified Likert scale (1 = strongly disagree and 5 = strongly agree), faculty were asked to assess the clarity of each competency or subcompetency and its impact on leadership education. All seven of the competencies had mean impact and clarity scores of greater than 4.0 and all but one had SD <1.0. The qualitative responses were consistent with the quantitative data. See List 1 for the final BPLDP Leadership Competency model, with its definitions and subcompetencies.
After identifying the Leadership Competencies, we reviewed the program components (MD, MPH, MBA, Health Systems Management, and Strategic Leadership in Health Care courses) to identify where existing leadership principles and skill education were already being taught, how current teaching related to the new competency model, and opportunities for integration and the need for additional program content.
We reviewed all course syllabi from the MBA, MD, and MPH programs and the Health Systems Management and Strategic Leadership in Health Care courses, and contacted course faculty when clarification was needed. To help analyze data, we used a matrix composed of subcompetencies and courses. Additionally, we called on others to scrutinize the matrix for errors and inconsistencies and to assure thematic precision. We were able to identify the skill sets that aligned with the leadership subcompetencies and that were already represented in the MD, MBA, or MPH programs and the Health Systems Management and Strategic Leadership in Health Care courses. We identified no overlaps between these program components. The review identified that existing MBA and MPH program components focused mainly on context-specific skill sets for each degree, namely awareness, analytical thinking, and planning. The Health Systems Management and Strategic Leadership in Health Care courses also addressed subcompetencies in awareness and forward thinking. The MD program only addressed interpersonal communication. None of the competencies was fully addressed in the matrix, and the existing programs were not designed to provide students opportunities to integrate knowledge across competencies in real or simulated educational transactions.
Program Mission and Curriculum Development
The results of the literature review, competency model development, and program review enabled us to clarify the BPLDP program mission:
▪ To provide an integrated educational solution for medical students in clinical care, health care leadership, and education grounded in either public health or business management.
▪ To provide a comprehensive leadership educational solution through personal, organizational-based, and systems-based approaches to leadership education (i.e., a strategic leadership focus).
▪ To develop students who will learn knowledge, attitudes, and skills that physician leaders need and use successfully in their careers (i.e., a competency-based focus).
▪ To increase the supply of well-educated physician leaders to the health care system.
With this mission and the detailed information gained from the activities described previously, we performed a needs analysis to address the educational gaps in the current program, and we redesigned the curriculum. Our redesign process consisted of four steps: brainstorming design possibilities, testing these possibilities against the competency model and program restrictions (i.e., feasibility), reorganizing thematic course components to maximize integration, and final curriculum design. We continued to use the leadership competency model as a template for basing the design decisions. When we originally designed the Health Systems Management and Strategic Leadership in Health Care courses for midcareer physicians, we made assumptions that they had a contextual experience for interpreting the course material. When we made modifications to these courses and designed additional courses for the medical undergraduates, we realized that course instructors would have to modify their teaching methods and examples to adjust for the undergraduates’ lack of experience. We made these judgments on the basis of three years of experience with teaching this course material to fourth-year students.
As a result of our analysis, we redesigned two courses, created three new courses, and modified the existing mentorship program. First, we expanded the Health Systems Management and Strategic Leadership in Health Care courses to address more subcompetencies in ethos and awareness. We created the Health Systems Communications and Health Advocacy and Change courses to address two competencies: communications, and initiative and change. We created the Field Experience in Health Advocacy and Leadership course to provide students opportunities to demonstrate use of multiple competencies in an authentic health care advocacy project. Finally, we modified the five-year mentorship program to align it better with the building relationships competency.
Our program development activities confirmed our assumption that leadership education should not be specific to either a business or public health model. This conclusion affirmed our earlier decision to offer the leadership courses simultaneously to both MPH and MBA students.
List 2 presents the final Leadership Curriculum with course names, course goals, and examples of classes/modules. Below, we provide a brief description of each course and how it integrates with other program components:
Health systems management.
This course, modified to fit BPLDP content and currently offered as monthly evening seminars during the first two years of medical school, provides foundational knowledge in health systems management principles and concepts. In particular, it focuses on developing multiple perspectives of health systems problems within the context of economics, finance, and population-based care, using health care scenarios as learning tools. Further, it introduces students to self-analysis of their leadership skills. It serves as one of the health care concentration courses for the MBA and MPH programs, and is the foundational knowledge course for the Leadership Curriculum.
Strategic leadership in health care.
Offered as monthly evening seminars during years three and four, this course, also modified to fit BPLDP content, builds upon Health Systems Management and also integrates many of the analytical principles and practices learned in the MPH and MBA courses. Specifically, students learn the process of strategic analysis, strategic planning, strategic management, and organizational principles within a health care context and examples. Additionally, students build upon the leadership practices learned in Health Systems Management via seminars and exercises that develop interpersonal skills and self-management. Strategic Leadership in Health Care is a required course in the health care concentration for the MBA and MPH programs.
Health systems communication.
This course, designed specifically for the BPLDP and offered in flexible format during clinical electives or breaks in clinical schedules, helps students learn the communication skills need by health care leaders and managers. The course goal is for students to learn the principles of communicating in a health systems and health care organizational setting. The course offers a laboratory experience where specific skill sets can be learned in simulated settings, and it builds on the interpersonal skills learned in the first three years of the MD program and the Organizational Dynamics and Leading Teams course, which is required of all BPLDP students. This course has been successfully piloted.
Health advocacy and change.
This course, offered in flexible format during clinical electives or breaks in clinical schedules, provides students an opportunity to learn leadership skills of changing individual, group, and organizational thinking in the health care context. This course builds upon knowledge gained in MBA and Health Systems Communications courses by offering further emphasis on persuasion and advocacy training. Currently in its final stages of development, this course was also designed specifically for the BPLDP and emphasizes acquisition of knowledge through readings and discussion and application of knowledge through simulated exercises.
Field experience in health advocacy and leadership.
This course will be offered in the fifth year as a field project. After placement in a health care delivery or policy organization, students will select an area or issue to advocate. Students will be required to act in roles consistent for advocacy and change, such as a process improvement consultant, legislative issue advocate, or community organizer. We will require the students, individually or in teams, to plan, implement, and evaluate an advocacy project to change policy or practice. This project will require students to utilize skills from multiple competencies. This field experience will occur during the culminating experience for the MPH students; the MBA students will be placed through a partner health care organization. The students will be evaluated by an on-site advisor and a course director, using competency-based assessment tools, on the quality of the project and their appropriate use of various leadership competencies during the project. This course is in final stages of development and was also designed specifically for the BPLDP.
Although this program requirement does not include formal instruction, it provides students an opportunity to develop a mentoring relationship with a physician leader in the community. During program matriculation, students are assigned to a local physician leader. The student and mentor are encouraged to meet two or three times a year. Mentoring is intended to provide students with a model with whom they can explore intangible aspects of physician leadership, including benefiting from experiences and exposure related to the mentor’s leadership role. We encourage the mentors to offer a relationship beyond coach and advisor, and many mentees do seek guidance on issues, such as personal and professional balance, that go beyond these more limited roles. By participating as a mentee during five years with a strong role model, students should learn how to select future mentors, effectively utilize these relationships, and build their own mentoring skills. We solicit feedback from students concerning the mentor program throughout the year, including sharing their mentoring experiences. Once assigned to a mentor, students remain with the same mentor as long as they find the mentor–mentee relationship productive. A mentee can be reassigned to another mentor if needed. This program was specifically designed for the BPLDP.
Student assessments for both the Health Systems Management and Strategic Leadership in Health Care courses consist of trait-based instruments that assess three individual or team study questions that address ongoing knowledge, and a final project (paper) that requires demonstration of knowledge attained during course experiences. The assessments for the later courses, Health Systems Communication Health Advocacy and Change, and Field Experience, are currently in development, but will incorporate competency-based approaches such as primary trait analysis and performance evaluations.
Current physician executive education is designed for midcareer physicians and many programs focus on education in management principles and practices.4,5 Although management is closely related to leadership, some authors suggest that leadership education requires students to learn different skill sets such as interpersonal communication, relationship building, strategic thinking, and change advocacy.4,16,17
We have described the systematic, qualitative inquiry at our institution, which resulted in a program that integrates undergraduate medical education, leadership education, and an education in business administration or public health. The results of the inquiry yielded program theory development, program delivery design, a competency-based curriculum model design, and a review of existing programs as the basis for a new leadership curriculum. Although detailed descriptions of courses and skills were found, the literature provided limited guidance for the development of a comprehensive leadership curriculum for medical students. Wherever possible, we engaged stakeholders and incorporated relevant literature resources to assure that the decisions we reached were valid.
The BPDLP and related curricula may have limitations. First, there are no external credentialing bodies with the qualifications to help guide and review such a program. Second, growth in the number of leadership programs such as this may be inhibited by the significant personnel and monetary resources required. Third, student assessment policies and procedures have not yet been finalized for all courses in our curriculum. We, and likely other programs, have not constructed and implemented psychometrically sound competency-based measurement tools in such areas as communication and advocacy. Finally, regarding program evaluation, linking teaching and learning to important and sustainable outcomes for students and demonstrating the impact of these outcomes on communities and organizations are daunting tasks, and may require several years of study.
We anticipate addressing several strategic issues about this program in the next few years. First, we plan on developing competency-based assessment tools and devising research to establish the psychometric properties of these tools. Second, we intend to implement a program evaluation plan; this plan will be an interval study of program success and will include short-term and long-term outcome assessments. We are currently conducting a study to identify these outcomes, and we anticipate presenting this as part of the program evaluation plan in 2008. Third, we plan to collaborate with similar programs and representative organizations in order to share experience, knowledge, and resources to improve program quality.
Our program may be the first to offer an integrated, comprehensive curriculum on leadership education for medical undergraduates. The program is based on the theory that, by offering a separate leadership curriculum integrated with business management or public health education at an early stage of clinical education, graduates, organizations, and communities may benefit sooner or experience a more positive impact from the effort. If the theory is found to have validity, the impact on physician leadership education could be significant; the implication would be that leadership education could be effectively offered earlier to physicians and a reconsideration of medical undergraduate education policy and offerings might be in order. Also, analyses of short- and long-term program evaluations of this program may inform the development of standards for physician leadership education.
The authors would like to thank Mr. Oscar Boonshoft for his conceptual and financial support. They also express appreciation to Barbara Schuster, MD, MACP, for her conceptual and programmatic contribution.