Ackerly, D. Clay MD, MSc; Sangvai, Devdutta G. MD, MBA; Udayakumar, Krishna MD, MBA; Shah, Bimal R. MD, MBA; Kalman, Noah S.; Cho, Alex H. MD, MBA; Schulman, Kevin A. MD; Fulkerson, William J. Jr MD; Dzau, Victor J. MD
Dr. Ackerly is research fellow, Duke Clinical Research Institute at Duke University, Durham, North Carolina, clinical fellow, Harvard Medical School, Boston, Massachusetts, and a resident in internal medicine, Massachusetts General Hospital, Boston, Massachusetts.
Dr. Sangvai is assistant professor in community and family medicine, pediatrics, and psychiatry and behavioral sciences, Duke University, Durham, North Carolina.
Dr. Udayakumar is assistant professor of medicine and global health, Duke University, Durham, North Carolina, and assistant professor, Duke-National University of Singapore Graduate Medical School, Singapore.
Dr. Shah is assistant professor of medicine, Duke University, Durham, North Carolina.
Mr. Kalman is an MD/MBA student, Duke University, Durham, North Carolina.
Dr. Cho is assistant professor of medicine, Duke University, Durham, North Carolina.
Dr. Schulman is professor of medicine, Gregory Mario and Jeremy Mario Professor of Business Administration, and associate director, Duke Clinical Research Institute, Duke University, Durham, North Carolina.
Dr. Fulkerson is professor of medicine, Duke University, and executive vice president, Duke University Health System, Durham, North Carolina.
Dr. Dzau is James B. Duke Professor of Medicine and chancellor for health affairs, Duke University, and president and chief executive officer, Duke University Health System, Durham, North Carolina.
Please see the end of this article for information about the authors.
Correspondence should be addressed to Dr. Dzau, Office of the Chancellor, Box 3701 Medical Center, Duke University, Durham, NC 27710; telephone: (919) 684-2255; e-mail: email@example.com.
First published online March 23, 2011.
Over 20 years ago, an editorial in JAMA asserted that “physician–executives may be the only ones capable of coping with the rapid and profound changes as well as the medical, financial, and ethical complexity that now beset the practice of medicine.”1 Despite this call, the current supply of physician–executives is far outstripped by the need,2 with a dearth of individuals who excel in both clinical medicine and management. For example, the number of physicians directing hospitals has been on the decline rather than on the rise, with fewer than 4% of U.S. hospitals headed by physicians (compared with 35% of hospitals in 1935).3 In response, there are continued calls for leadership from physician–executives, individuals who not only understand the challenges of delivering medical care but can also navigate the broader health care system with astute business strategy and management skills.4–6
While the health care system is presently faced with a shortfall of physician–executives in roles such as hospital chief executive officers (CEOs), even more worrisome is the lack of an established pipeline of potential physician–leaders. This predicament is particularly compelling in academic medicine, where the traditional, and oftentimes competing, missions (education, research, and clinical care) present unique leadership challenges that require a broader administrative skill set beyond those required to manage a delivery system alone. For example, in education, the workforce demands of the health care system are changing at the same time that technology (e.g., information systems and simulation technologies) is enabling new models of training. In research, new challenges have arisen due to a rapidly expanding knowledge base coupled with new legal and regulatory challenges and increased pressures for immediate results, both scientific and financial. The clinical care enterprise in academic medicine may be faced with the largest immediate challenges as shrinking margins from clinical care make it more difficult to improve the quality of patient care while also supporting the other elements of academia. These trends require leaders with experience in the trenches of care delivery as well as strategy, policy, and operations.
The larger part of the current generation of physician–leaders has achieved their current roles in a fashion that can be described as “accidental administrators.” Starting from the medical school admissions process (based largely on science aptitude) through early- to midcareer promotion practices (based largely on research output or clinical volume), physicians are often identified and promoted to leadership positions based on their career achievements and distinction, with less emphasis on their management skills and experience.
In the specific example of academic department chair searches, it has been noted that the process often places emphasis on research success over managerial experience.7 Department chairs represent a critical core in academic medicine (there currently are approximately 3,000 department chairs nationwide), and their positions demand as much understanding of the running of a business unit as of research and clinical operations. Unfortunately, much of academic medicine's leadership has assumed this kind of management position without any formal training or skills in finance, marketing, procurement, human resources, accounting, or strategy.8
This career trajectory has often left physicians initially ill equipped for the requirements of management roles. Thus, many ultimately successful leaders have been somewhat “accidental,” required to “learn on the job” the skills to be effective managers and executives.9 However, this system of placing physicians in leadership roles without the appropriate tools can lead to a loss in confidence in those physician–managers, limit the career development of those unsuccessful in their roles, or, worse, result in mismanagement of systems. Although few hard data exist, some scholars have also argued that the reliance on the accidental administrator model can create a succession vacuum, ultimately resulting in poor leadership transitions. As a result, we believe that a career trajectory that includes a balance of clinical practice with early and continuous experience as a leader and manager should define the new model of physician–executive development.
From Accidental to Cultivated Leadership
Meeting the call for more capable physician–executives will require improving leadership and management education across the continuum of medical training, including premedical education, undergraduate and graduate medical education, and midcareer support. Along this continuum, we believe that targeting graduates of joint doctor of medicine (MD) and master of business administration (MBA) programs as they enter residency training provides the most opportunity to identify potential leaders early and cultivate the careers of future physician–executives.
Another 1980s JAMA editorial proclaimed, “If medicine is to survive as an independent profession, we need MD-MBA administrators to lead us.”10 If such is to be the case, the increased interest in formal business training among medical students, reflected in the growth in the number of joint MD-MBA programs nationwide, is a fortunate development, albeit 20 years later. According to information available from the Association of American Medical Colleges (http://services.aamc.org/currdir), there were only 6 formal MD-MBA programs nationwide in 1993, which expanded quickly to 33 in 2001 and 51 in 2009. Although this trend is generally positive, potential leaders are often lost even before residency begins. The end of medical school is a critical branch point for students to decide to invest in clinical training or to forgo clinical care for the myriad other opportunities available to them. As more students acquire concurrent graduate management training and the number of MD-MBA graduates increases, these individuals have two distinct career choices on graduation from medical school: enter clinical residency training and set aside management experiences for three or more years; or begin management careers, often leaving behind clinical medicine.
In recent years, firms have aggressively recruited MD-MBA candidates without postgraduate training for traditional business careers in the finance, consulting, biotechnology, medical device, and pharmaceutical industries. Although national data on postgraduate career paths are not readily available, anecdotally, a significant number of trainees completing MD-MBA programs do not pursue clinical roles. In our own institutional experience over the past 20 years at Duke University, only 24 out of 32 MD-MBA graduates entered the National Residency Match Program and matriculated at a residency program. Of those who choose not to enter residency programs, few will likely return to the practice of clinical medicine.
The reasons for this attrition are likely many, but contributing factors are apt to include a lack of established career pathways after graduation, suitable mentors with a similar background, opportunities within clinical medicine to further develop and showcase management skills, or recognition among many health care organizations, especially in academic medicine, of the leadership potential of physicians with formal management training.
Furthermore, for those MD-MBA graduates who pursue residency training, there is concern that the skills acquired in business school will grow “stale” during residency training, making the transition to management roles after residency more difficult. This loss of continuity caused by the lack of continued managerial development may lead to a regression of skills (real or perceived), making the postresidency job search a particularly challenging one.11 Articulated another way, “the options [for MD-MBAs to contribute to an organization] are endless, but even today the pathways remain poorly defined.”11 Thus, presenting MD-MBA graduates with a pathway by which to pursue and develop their dual interests should be quite appealing to students and health care organizations alike.
Residency training and physician–executive development
Residency training represents a critical weak link and opportunity for intervention. Not only have studies revealed that management training in residency is desired yet inadequate,2,12 many believe, as we do, that residents are far enough in their training to provide both clinical support and critical managerial energy and productivity that can be tapped in a structured program.9 Developing both clinical and management skill sets during graduate medical education holds the promise of engaging future leaders of health care at an early career stage, keeping more MD-MBA graduates within health care, and creating a bench of talented future physician–executives.
The Duke Medicine Management and Leadership Pathway for Residents
In an effort to provide physician–trainees with the knowledge and skills essential to bridge clinical practice and management to become effective physician–executives, the Duke University School of Medicine and the Duke University Health System (known collectively, with the School of Nursing, as “Duke Medicine”) launched the Management and Leadership Pathway for Residents (MLPR) in 2009. Approved by the American Board of Internal Medicine (ABIM) and the Internal Medicine Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME), the MLPR enrolled its first two trainees in July 2010.
The MLPR is targeted toward residents in training who have already obtained graduate management training (e.g., MBA, master of health administration) or who have several years of prior management experience. Trainees within any of the clinical residency programs at Duke are potentially eligible for the MLPR. As such, the program seeks to attract the best of the MD-MBAs being produced across the United States who have already displayed strong clinical skills as well as deep leadership potential and a passion for driving health care innovation.
For these candidates, the MLPR offers an unprecedented opportunity to interact with senior institutional leadership to develop management and leadership skills while obtaining world-class clinical residency training. This program provides MD-MBA graduates who are contemplating traditional MBA career choices (e.g., finance, consulting, industry) with an alternative opportunity to remain active in clinical medicine while also pursuing management experiences. The MLPR provides an avenue for the skills gained in business school to be put to use during clinical training to help avoid potential “atrophy” while taking advantage of what enrollees have to offer to health care early in their careers. Simply stated, the MLPR gives the dual-degree holder an opportunity to view her or his career not as a binary choice between business or medicine but, rather, as a path that combines both.
To achieve its goals, the program incorporates four components beyond the trainee's existing clinical responsibilities: (1) a focused didactic curriculum, (2) practical management rotations, (3) a longitudinal project, and (4) committed mentorship. Although trainees will enter the program having previously obtained an advanced management degree (or equivalent experience), the program provides additional, targeted didactic sessions and structured learning programs. The option to take courses at Duke's Fuqua School of Business or other Duke schools is offered to MLPR trainees to allow them to acquire more advanced understanding of specific subjects they feel are relevant to their career goals. Additionally, a newly created certificate in health care management and leadership will be jointly offered by the health system and the business school for trainees who successfully complete all components of the MLPR.
As with clinical graduate medical education, the core curriculum of the management training within the MLPR will be experiential rotations during which trainees apply and develop their skill sets under the guidance and mentorship of senior managers. These rotations will provide trainees with the opportunities to hone their developing management and leadership skills under expert supervision. The management rotation concept, already employed by many health care organizations to train early career administrators, also will expose physician–trainees to diverse research, education, and clinical care settings, providing the breadth and depth of exposure that is often otherwise unavailable to physician–managers.
After admission to the program and completion of their intern year, trainees will spend approximately 6 months on clinical rotations and 6 months in structured management experiences (modules) each year for 2 to 3 years, leading to a minimum of 15 months of management experience over the course of the program (Chart 1). These management rotations will be project based, with a clear work product that can be produced in 3 to 6 months. To accommodate these rotations, MLPR trainees add a fourth year to a traditional 3-year residency program (e.g., categorical internal medicine residency) or repurpose built-in elective or research time within longer programs. The 15 to 18 months of structured management experiences (modules) can be intermingled with traditional clinical rotations in 6-month blocks as preferred by the trainee or clinical residency program.
Potential modules include, but are not limited to, health system management and operations, financial management and planning, quality improvement and safety, information technology/informatics, technology transfer, global strategy and program development, research enterprise management, clinical service enterprise management, and supply chain management. To facilitate synergy across training, clinical rotations and management modules will be aligned to the extent possible. For example, a trainee may participate in a clinical rotation or have an interest in nephrology and then complete a management rotation aimed at improving outpatient dialysis services in surrounding counties.
To provide a unifying experience throughout the program, MLPR trainees will undertake a longitudinal project working directly with one senior executive. This experience will provide consistent mentorship as well as the opportunity to contribute to a high-priority initiative over a period of years rather than months. The longitudinal project is designed to encourage the trainee to feel ownership over specific management issues beyond smaller, experiential projects, and will foster the ability to comanage administrative and clinical duties, which will be critically important to future physician–executives.
We anticipate that the focus of the longitudinal project will highlight the sector within health care that the trainee envisions joining on completing the training program. The trainee's mentor will help shape the scope and goals of this longitudinal project.
Many physicians who have leadership aspirations struggle to receive consistent managerial mentorship. The design of the MLPR prioritizes this critical component of early career development and formalizes the mentorship process, recognizing the contributions of expert mentors by funding protected time for mentoring.
On admission, trainees will be paired with a mentor from the senior management team who is aligned with the trainee's specific career interests. Each trainee will meet with his or her MLPR mentor monthly and will also meet quarterly with the MLPR program directors. By working closely with a senior leader, MLPR trainees will have the opportunity to experience the inner workings of an academic health sciences system, including participation in board meetings and the like.
The MLPR has been established with the full support of Duke Medicine's senior leadership, as reflected in the leadership of the program. The program's executive director is Duke's chancellor for health affairs and president and CEO of the health system, and the executive vice president of the health system serves as the program director. The program has two associate program directors, both of whom are Duke faculty with MD-MBA training, and the program is provided overall guidance by a senior-level curriculum/advisory committee.
The MLPR relies on a shared investment model, reflecting the broad support for the program across the institution. Funding support is provided by Duke's Graduate Medical Education Endowment Innovation Fund, participating clinical departments, the administrative units through which trainees will rotate, and the office of the chancellor for health affairs. Trainees will receive their regular salary stipend during their enrollment in the MLPR. The program will seek to obtain additional funding to enable future expansion and sustainability from multiple other sources such as grants, private–public partnerships, and philanthropy.
Measuring Success and Early Outcomes
After meeting the requirements of ABIM and ACGME approval, two residents were first enrolled in July 2010. As these trainees progress and more begin the program, assessment of the value of the program will be critical to ensure its sustainability. In measuring the ultimate success of the program, both quantitative and qualitative metrics will be employed, as well as more short-term versus long-term metrics. Short-term measures include the value created for the clinical or academic departments during the rotational and longitudinal projects. These assessments will be based on a combination of actual financial metrics, operational metrics, and survey data regarding the specific project results. Qualitative reviews by key stakeholders or partners involved in the trainees' management rotation or project will also be important, as well as measurement of trainee satisfaction. The program has already begun to meet some of these short-term metrics, including the conclusion of a “test run” of the management rotation concept by an MD-MBA-trained attending physician. One-to-one mentorship relationships are already established for the first class of trainees and are working well to date. Furthermore, a dedicated seminar series has already attracted a handful of “blue-chip” external speakers in addition to internal faculty.
Long-term metrics will focus on trying to quantify the program's ability to create and foster a pipeline of physician–executives who are successful in leading health care organizations in the future. An alumni database will be created to track the career progression of trainees. Periodic assessments will be reported on the number of MLPR graduates who are in senior management positions. Further assessments may be conducted with the potential employers of graduates to gain an understanding of the perceptions of the training program, its graduates, and the influence of the program on health care management and innovation.
Career Development for MLPR Graduates
One of the critical factors for the long-term success of the MLPR will be the continued career development of graduates after they leave the program; and, without a deliberate attempt at development, there is a risk for career inertia among the graduates. For the graduates themselves, one of the most important factors in evaluating the program will be the job opportunities available to them on completion, as well as continued career development opportunities.
Our aspiration is that graduates of the MLPR program will be seen over time as the skilled and experienced individuals needed to fill leadership positions in health care delivery (e.g., medical directors, practice leaders, clinical service line leaders) as well as academic medicine (e.g., department vice chairs, associate deans supervising research and/or education). Graduates of the MLPR are also well poised to develop a scholarly career that includes exploring new models of care delivery, new models of payment, and other disciplines aimed at improving health care.
The leadership of Duke Medicine is committed to continue to support the career development of MLPR graduates, including providing management and clinical opportunities after completion of training. We believe that nurturing a community of physician–managers who hold promise to develop into institutional leaders is a worthwhile investment for the institution and will, in fact, create a competitive advantage for Duke Medicine.
Expanding the Reach
The need for physician–executives goes far beyond the reach of Duke Medicine alone. We understand that other academic institutions as well as nonacademic providers could benefit from a cultivated pipeline of physician–executives. We hope that in a subsequent publication we can provide an update on the progress and metrics of early trainees' success in this innovative training program. Furthermore, we hope that other models will take shape elsewhere and that best practices can be developed and shared over time.
The rapidly evolving field of health care demands that future leaders excel not only in clinical medicine but also in the management of complex financial, regulatory, operational, and other challenges that dominate health care research, education, and delivery. Physicians have traditionally been viewed as the potential leaders of health care organizations. However, many physicians have become leaders “by accident,” and active cultivation of future leaders is needed. The MLPR is a first-of-its-kind program which seeks to catalyze the emergence of a new generation of leaders by providing residents with rigorous clinical training along with mentorship and extended rotational management opportunities to gain project-based operational experience across the clinical, research, and educational activities of an academic health sciences system.
Damon M. Seils, MA, assisted with manuscript preparation.