Gunderman, Richard MD, PhD; Kanter, Steven L. MD
In some institutions the best students are carefully schooled to avoid leadership responsibilities…. The plain fact is that all over this country today trouble is brewing and social evils accumulating while our patterns of social and professional organization keep able and gifted potential leaders on the sidelines.1 - —The late John W. Gardner, faculty member and trustee at Stanford University, president of the Carnegie Corporation, U.S. Secretary of Health, Education and Welfare, and founder of Common Cause and Independent Sector (1968).
Today fewer than 4% (i.e., only 235) of our nearly 6,500 U.S. hospitals are headed by physicians (personal communication, Sara Beazley, American Hospital Association, March 15, 2008). By contrast, in 1935 physicians were in charge of 35% of hospitals.2 This represents a 90% decrease in the number of hospitals with physician chief executive officers (CEOs). We maintain that this is an undesirable state of affairs, and it would not be surprising to learn that many medical educators, practicing physicians, health policy makers, patients, and community leaders hold a similar view. Training and practice in medicine provide important leadership advantages that hospitals and health care organizations urgently need. For this reason, we argue that medical schools should be making a greater effort to prepare physicians for leadership. In this article, we explore the reasons that physicians do not tend to become hospital CEOs, make the case that they should, and explore the implications of this argument for our system of medical education. While we have focused on preparing medical students and residents to lead hospitals, many of our arguments for leadership education also apply to other opportunities for physician leadership, such as chairing a department or presiding over a professional organization.
Ample evidence indicates that the U.S. health care system is ailing. The United States spends far more per capita on health care than any other nation on earth, yet approximately 50 million Americans lack health insurance.3,4 Moreover, the United States ranks last among 19 industrialized nations in the rate of preventable death.5 Of course, simply diagnosing the poor state of the U.S. health care system does nothing to support a recommendation that physicians should assume leadership of more hospitals. Perhaps physicians are one of the problems in U.S. health care, not the solution. Might entrusting more physicians with hospital leadership responsibility merely make a bad situation worse?6 We think not, especially if we reexamine our vision of a well-educated physician.
Causes and Results of the Dearth of Physician Leadership
Why have hospitals moved away from—rather than toward—leadership by patient-care professionals, especially physicians? In part, the answer lies in education. Many medical schools and residency programs make relatively little effort to prepare physicians to assume such responsibilities. Perhaps those medical educators suppose that future physicians need to learn so much about diagnosing and treating disease that no time remains to prepare them to lead. Another issue may be intellectual elitism. Some physicians might regard running a hospital as an administrative task, not a serious scholarly or intellectual endeavor.
Some may argue that hospital leadership is simply not part of a physician’s job description. “I went to medical school to learn to care for the sick,” a physician may say, “not to read financial statements, study organization charts, lobby community leaders, and develop strategic plans.” Many physicians see health care organizations and the health care system as black boxes. They expect hospitals to provide the resources they need to care for patients, but grasp little of the effort and skill required to meet those demands or to balance them against other institutional challenges and opportunities. Some physicians may even regard hospital leadership with disdain; they have little patience for hospital politics and no desire to play such a political role themselves.
Physicians may also fear that assuming greater leadership responsibility would threaten their clinical commitment. Nonphysician hospital CEOs do not care for patients. How could physicians possibly compete as leaders unless they relinquish their clinical responsibilities and devote their full attention to administration? Other physicians may judge that if they do not continue to care for patients, many years of hard work in medical school and residency will have been for naught. Some physicians may feel unqualified for leadership. What kind of education and work experience are necessary to lead a hospital? If hospital leadership requires a postbaccalaureate degree in business or health care administration, they may deem the price simply too high.
Yet physicians pay a high price for remaining on the sidelines of hospital leadership. Career satisfaction in the medical profession is deteriorating. In 1973, only 15% of physicians expressed any doubts about their choice of career.7 By contrast, a 2002 survey of physicians over the age of 50 showed that over half would not choose to pursue medicine as a career again, and nearly half would advise their children against doing so.8 At least six of the top seven sources of physician dissatisfaction are influenced by the leadership of health care organizations. These include cost cutting by hospitals, scant opportunities for teaching and research, hospital utilization review, declining autonomy for making both medical and nonmedical decisions, and the sometimes counterproductive organizational culture of hospitals.9
This level of discontent is highly problematic because work satisfaction is an important element in leading a happy and fulfilled life. Dissatisfied physicians are two to three times more likely than their satisfied colleagues to leave the practice of medicine.10 They are more likely to change jobs, and such turnover spawns discontinuous, substandard medical care.11 Physician dissatisfaction breeds poor clinical management,12 negatively impacts patient safety,11 lowers compliance rates,13 leads to an increased rate of medical errors,14 and contributes to higher health care costs.9 Moreover, hospital policies affect physicians’ relationships with patients and colleagues, their personal growth, their freedom to provide quality care, the availability of hospital resources, and the hospital’s prestige.9 We believe that physicians could redress growing professional dissatisfaction by assuming a greater role in hospital leadership. Our health care systems have a substantial interest in promoting the organizational engagement and professional fulfillment of physicians, and one of the best ways to promote this interest is to get physicians more involved in leading hospitals, especially when they are still in training, through physician education. To provide high-quality medical care for a patient is fulfilling, but to improve the quality of care for many patients can prove equally fulfilling.
Reasons for Physician Leadership
Physicians bear a moral responsibility to respond to the call to health care leadership. When physicians take the Hippocratic Oath, they pledge to put the interests of patients first. This means mastering aspects of health care that lie beyond the traditional ambit of the doctor-patient relationship. The prerogatives to admit patients to hospitals, keep patients in house, prescribe medications, perform diagnostic and therapeutic procedures, refer patients to colleagues, and even take on new patients are each powerfully influenced by decisions made in hospital boardrooms and executive suites. If patient-care professionals do not answer the call to leadership, those who do are likely to be people with little or no direct patient-care experience.
There are important parallels between caring for patients and running a hospital. To ensure effective collaboration, both physicians and hospital CEOs need to function like symphony conductors. In both cases, physicians are dealing with an extremely complex entity (the human body, a hospital) composed of different systems that must work in harmony to secure the welfare of the whole. Optimal care requires the contributions of a variety of disciplines and services.
Many participants in the contemporary health care system, both patients and health professionals, feel that the United States has great medicine but a broken health care system. One key to remedying this situation is to inject more scholarly inquiry and clinical wisdom into health care organizations. Like practicing medicine, running a hospital is both an art and a science, but the quality of investigation and hypothesis testing in hospital administration lags far behind that of patient care.15
Moreover, caring for patients is an inherently ethical endeavor. Hospital leaders can easily forget that their organizations are not businesses whose product happens to be health care. To the contrary, most hospitals are fundamentally benevolent organizations which need to observe sound business practices. Significant clinical experience, as well as education and training in the ethical dimensions of medicine, can help decision makers strike the appropriate balance between economics and ethics.
Physicians could contribute more effectively to health policy dialogues if they better understood institutional perspectives on health care. To complain that patients are suffering from lack of resources is somewhat disingenuous. Physicians need to understand where those resources come from, what they cost, and what sacrifices are necessary to supply them. For physicians to decry the errors and inefficiencies of the health care system is not enough. They need to understand the roots of those errors and inefficiencies and help to formulate institutional and system-wide proposals that redress them. Physicians—not hospital administrators—already bear the medicolegal liability for adverse outcomes. Further, no one understands the importance of trust better than physicians. More than anyone else in the hospital, physicians are oriented to protect patients and patients’ rights and are capable of promoting physician engagement. Physicians must roll up their sleeves and help at the organizational administrative level to build a health care system that merits the trust of patients and communities.
Just as the health of each patient is embedded in the community, so the health of each doctor-patient relationship is embedded in the health care system. To understand health and disease solely at the molecular, cellular, or even organismal levels is insufficient. If academic medicine confines medical research and education to these levels, it will shortchange the next generation of physicians and do patients and communities a disservice. To uphold public trust, medical educators need to foster expertise and commitment at the interpersonal, institutional, and societal levels of health care. To make impressive inroads against communicable diseases in the 20th century, physicians needed to think epidemiologically. In the 21st century, physicians will be unable to make inroads against the ailments of the U.S. health care system unless they educate their successors to think organizationally.16 This is what Rudolf Virchow,17 arguably the greatest pathologist in the history of medicine, had in mind when he said that medicine is less a biological science than a social science.
What will happen when physicians take a more active interest in the leadership of hospitals? Young people who enter the medical profession because they want to help people and make a difference will discover that holding a position of leadership in health care organizations provides an important opportunity to do so. It enables them to take patient advocacy to a higher level, transforming moral arguments and professional responsibilities into institutional policies that promote the welfare of patients and those who care for them. This can be immensely fulfilling work, and some evidence suggests that physician CEOs actually find their careers more fulfilling than physicians who devote their full attention to clinical practice.18
Preparing Future Physicians for Leadership
Medical school deans and residency program directors need to reexamine the ways they educate physicians and provide better preparation for leadership. The first crucial decision concerns who receives admittance into medical school. Demonstrated leadership interest, aptitude, and experience should become a more important admission criterion. Such leadership potential could manifest itself in many different ways including, among other possibilities, service in student government, editorship of a student newspaper or journal, founding or operating a business, and service through civic and religious organizations. Once students matriculate into medical school, medical educators need to treat them as future leaders, in part by providing them with opportunities to gain real leadership experience through such venues as student government, community service, and medical school and hospital committees. Four years of medical school followed by three to six years of residency training may be insufficient to produce a hospital CEO, but the curricula of most programs could certainly become more conducive to the cultivation of leadership. One way to highlight the importance of leadership would be to include it more explicitly in student assessment, ensuring that students who develop in this domain receive credit for their efforts.
All medical students and residents should enjoy opportunities to learn why leadership is important, study its costs and rewards, and test their level of interest in pursuing careers as leaders. Of course, all future physicians cannot become hospital CEOs; nor should they. It is both necessary and desirable that most physicians focus most of their energies on clinical work, education, and/or research. Yet for physicians to understand the organizational side of health care, on which the health of every patient and community depends, is more important than ever.19 Like the stethoscope and the scalpel, hospitals are essential tools of contemporary medicine, and physicians must thoroughly understand them and how they work in order to wield them effectively. Moreover, a physician who is well prepared to lead a hospital is likely to make a better section chief, department chair, dean, or officer in a professional organization—as well as a better community leader and patient advocate.
The prospects for cultivating the leadership potential of the next generation of physicians are bright. Medical students and residents are as capable as they have ever been. Many premedical students have gained valuable leadership experience through experiences in student government, campus organizations, athletics, and community service. We need to cease overloading medical students and residents with so many academic and clinical responsibilities that their desire to continue to practice leadership through these activities gets overwhelmed.20,21 Students who enter medical school asking, “What can we do to make a difference for our patients and communities?” should not shift their attention entirely to, “How am I going to memorize all this material in time for Friday’s exam?” The change in voice from “we” to “I” is as worrisome as it is important, and medical education should foster a more team-oriented mindset. Business schools and health administration programs have been focusing on teamwork and organizational thinking for many years, and 21st-century medical schools can ill afford to neglect such perspectives.
Medical educators can better prepare medical students and residents to become leaders by introducing them to certain questions that lead to a richer understanding of the “anatomy and physiology” of hospitals and the health care system. How does the U.S. health care system compare to the systems of other nations? What are the roles of federal, state, and local governments, private corporations, and patients in financing health care? What are hospitals and what do they do? How do they assess their performance, and what differentiates successful hospitals from the unsuccessful ones?22 What role do physicians play in hospital policy making and operations? How do policy and operations impact health care quality and costs? What role can physicians play in improving health care at the local, state, and national levels? In health care today, who are some of the exemplary physician-leaders, how did they assume leadership responsibility, how do they manage to function effectively as members of multidisciplinary teams, and what advice would they give to future leaders?
Medical students or residents might be organized into teams, each charged with answering an organizational or system-wide question and presenting their findings to their colleagues. Discussion and even debate could play an important role in ensuring that students gain experience as opinion leaders. Debate topics might include the pros and cons of a single-payer health care system and the use of quality measures as a basis for physician compensation. Students and residents could interact regularly with health care leaders in existing venues such as committee meetings and through new programs such as “leadership rounds.” Those with strong interests in the organizational side of medicine would benefit from enrichment opportunities, such as clerkships and elective courses23 that include a service-learning component. More medical schools could offer joint degree programs combining medicine with such disciplines as business, health administration, and public health, as well as ethics, history, and economics. We are not suggesting that one third or even one tenth of the general medical school curriculum be devoted to leadership. Rather, we are suggesting that leadership education become an integral part of all medical student and resident education, and that medical schools and residency programs designate leadership as a field of scholarly concentration so that highly motivated and capable learners have opportunities to pursue further studies.
Viewing U.S. medical education over the past few decades, an impartial observer might conclude that the medical profession has abrogated its responsibility to prepare physicians to play leadership roles in promoting the interests of patients and communities. The time is ripe for a reexamination of the role of leadership in medical education.24 Medical educators need to redouble their efforts to help medical students and residents understand the health care challenges before them, show them that they are capable of contributing important solutions, and let them discover for themselves the rewards of leading. Many hospitals will not enjoy optimal leadership until we persuade those with the deepest understanding of the science and art of patient care—the physicians—to assume greater responsibility for what hospitals do. Medical educators need to help tomorrow’s physicians discover that hospital leadership is both a moral responsibility and a personal and professional privilege.
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