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Leadership in Academic Medicine: Purpose, People, and Programs

Sklar, David, P., MD

doi: 10.1097/ACM.0000000000002048
From the Editor
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Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

One of my first experiences with leadership occurred 35 years ago. I was at a dinner meeting of my state emergency medicine specialty society, and we were bemoaning the disorganized state of our local trauma system, the poor participation of our members in meetings, and the lack of funding to support our organization. After we had all finished our meal, the president of our chapter reminded us that his term was ending soon. We needed a new president to start in two months. “Who’s interested?” he asked. There were no responses. We went around the room and each person explained what personal challenges made it impossible for him or her to take on the presidency. When they reached me, I mentioned that my wife was pregnant and I was far too junior and inexperienced to become president. A few minutes later I was elected president by acclamation.

Unlike some states, where the presidency of the state chapter was a much-coveted position, in my rural state it was considered a necessary burden, like food shopping or taking out the trash. Something we would all need to do eventually. As mail from the national organization began arriving at my home over the next month with a variety of requests for decisions and signatures, I soon realized how little I knew about health policy, organizational finance, or political advocacy—all topics where my opinions and participation were being solicited. I began to seek advice from former presidents, institutional leaders, and the literature about how to be a good president. I was curious about what advice I would get. “Be discreet and decisive,” offered one of them. “Showing up is 90% of the job. When you don’t show up is when the others in the room criticize you,” said another. “Don’t put your hand in the cookie jar,” advised a third. I knew the advice grew out of personal experiences and problems each one had faced, but it did not seem particularly relevant to my situation. I heard about various leadership development programs where I could learn the skills that would help me become a competent leader. I attended one of them, and it soon became clear that the future leaders who were my classmates were all more or less like me: clinicians who had been chosen or elected to take on a role for which they had no expertise or training. The course provided a generic introduction to health care finance, negotiation, political advocacy, and strategic planning as well as an introduction to the vocabulary of management. But I had no idea how to apply what I had learned. And so I made mistakes, learned some lessons from them, and handed over my presidential responsibilities after a year.

Since that time I have served as president of two national organizations in my specialty and chair of the board of directors of a third. At my own institution I’ve been a program director of a residency, a departmental chair, a dean of graduate medical education, and a designated institutional officer. As editor-in-chief of this journal I interact with national leaders on a regular basis; coordinate the efforts of our reviewers, the deputy and associate editors, and professional staff; and with them set the direction for the journal. On the basis of these experiences, it would seem that I should be well qualified to provide a useful perspective about leadership, but I find myself increasingly skeptical about whether my past experiences could serve as useful guidance for others facing the leadership challenges ahead in health care. My hesitancy is partly based on the uniqueness of each leadership role and the fact that problems arise requiring skills that resist general advice. I am also concerned about the lack of adequate evidence to support our past leadership training programs, the lack of diversity of our leaders, and the failures of organizational leadership in spite of well-qualified leaders. I also believe the current landscape of health care will require new models of health care delivery and different types of leaders. Can we move from the ad hoc type of leadership training I experienced to a more organized and aligned approach that will produce a diverse cadre of leaders prepared for the new challenges of health care delivery? Some basic definitions will help as we begin the search for answers to this question.

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What Is Leadership?

Stogdill1 provided a definition of leadership 69 years ago that still is useful:

Leadership may be considered as the process (act) of influencing the activities of an organized group in its efforts toward goal setting and goal achievement.

Using that definition with more recent modifications, Hartley et al2 provided a framework for understanding leadership in health care. The framework includes the meaning of leadership (concepts), the skills and abilities needed by individuals (capabilities), the context that influences leaders, challenges that define the goals and aims of leaders, the roles and resources needed for leadership (characteristics), and the evaluation of leadership (consequences).

Judge and Piccolo3 discuss two popular theories of leadership: transformational and transactional leadership, noting that transformational leaders offer a purpose that transcends short-term goals, while transactional leaders focus on equitable and efficient solutions to current problems. They suggest that both types of leadership can be beneficial and complementary depending on the situation.

Blumenthal et al4 encapsulate this idea in health care, describing effective leaders as those who

articulate a vision or goal, communicate this vision to others, build willing support for this vision, and empower others through passion and teamwork to be leaders in return.

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What Is the Purpose of Leadership?

Blumenthal et al suggest that

improving leadership skills of practicing clinicians yields superior outcomes for patients and health care organizations … by encouraging teamwork, facilitating the design and close monitoring of care processes, promoting a clinical culture that supports safe practices, and enabling innovation and continuous development of skills and outcomes.

The evidence for how leadership contributes to better patient care outcomes has generally been connected to the effects of teams and the influence of leaders on team function. While not specifically addressing leadership but, instead, the related phenomenon of team function, Salas et al5 performed a meta-analysis of the effects of team training upon the performance of teams. They found that team training was effective and that “team training can explain 12% to 19% of the variance of a team’s performance.” This finding suggests that a major purpose of leadership in health care is linked to augmenting the functioning of teams, which in turn augments their effects on the quality of health and health care for patients and communities.

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What Do We Know About Programs to Educate Clinicians for Leadership?

Educational programs that address health care leadership have generally focused on skill- and knowledge-building or on experiences aimed at interpersonal dynamics and team management. Programs have included medical students, residents, and practicing clinicians from a variety of specialties. Frich et al6 performed a systematic review of leadership development programs for physicians and identified 45 relevant studies, of which 42% were single-residency or fellowship programs. The educational content of the programs included leadership, teamwork, financial management, self management, conflict management, quality improvement, communication, and health policy. They noted that most programs targeted resident physicians with no formal leadership roles or physicians in midlevel management positions. They found no programs for physicians in top-level leadership positions and found that the programs in their review targeted physicians exclusively with no participation of other health professionals.

Their article raises questions about whether leadership training in health care is properly designed to teach the specific skills that medical students and residents need in their current roles. Since these trainees work and learn within a hierarchy, leadership skills would include helping them learn to recognize the effects of that hierarchy and their situation’s power relationships upon their ability to make use of leadership skills. In acknowledgment of the power differential between residents and faculty, Clapp et al7 in this issue of the journal suggest engaging residents in authentic problem-solving discussions with faculty and using these discussions to improve communications within the department. In this way, the residents would be able to consider and address contextual issues related to leadership, especially those of hierarchy and power.

Implementation of leadership skills can be particularly challenging for learners, who are in vulnerable positions within the medical education hierarchy. Li et al8 describe the tension between participation of novice learners in communities of practice and the effects of hierarchies and power upon their participation. And Hafferty9 discusses how the hidden curriculum of unwritten behavioral expectations has an influence on how successfully students navigate the learning environment. The education of students about leadership can run up against contradictory messages about expected student behavior when clinical teams stress passivity and compliance with authoritarian rules.

The leadership challenges for faculty are somewhat different from those of students. In this issue, Lucas et al,10 in a survey of leadership programs at academic health centers (AHCs), note that much of the emphasis of education for leadership has focused on preparing faculty for future leadership roles by giving them information on the types of leadership styles and culture, how to lead change, a description of organizational structure, and improving interpersonal effectiveness and communications skills. Some of the programs identify leadership competencies, but evaluation of leadership programs has mostly been limited to assessing the satisfaction of participants with the program. Lucas et al suggest that a more rigorous evaluation process for leadership programs is needed and could be a useful topic for a consensus conference.

Both Frich et al and Lucas et al note that most leadership programs in health care have been lecture based and have emphasized transmission of knowledge. They suggest that other educational alternatives should be considered. Education that occurs as part of authentic or simulated experience could provide context for leadership concepts. Cooper et al11 describe a patient-safety-related simulation experience for teams of administrative and clinical leaders. The scenarios were meant to encourage interactions between participants that would prepare them for actual leadership challenges. Edmonstone12 endorses this view of leadership training, which departs from the building of individual competencies and instead

focuses on the development of leadership as a process which includes interpersonal relationships, the social influence process, and team dynamics all situated within the all-important context. It also assumes that leadership is not about individuals but about collectives.

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Diversity and Leadership

The nature of leadership and whether it is fundamentally about individual qualities of the leaders or about relationships, organizational culture, and context could have important implications for the diversity of leadership at AHCs. Efforts to increase underrepresented minorities and women in leadership positions such as medical school deans might emphasize more teamwork and relationship skills and less individual achievement. Schor13 in this issue highlights the differences between the numbers of women and men in dean positions in the United States, noting that in 2016, women constituted between 12% and 18% of medical school deans and that “women have made little progress in their quest to gain entrée into the leadership suite in academic medical institutions.” Schor recommends “educational interventions, supportive infrastructure for women-predominant life events, and enhanced mentoring opportunities.” Helitzer et al14 report that most women faculty who participated in three long-standing career development programs gave the programs high ratings, particularly because they enhanced the attendees’ interpersonal skills, leadership, negotiation, and networking.

More leadership enhancement programs are also needed for underrepresented minorities in academic medicine to achieve the goals of diversity in academic medicine described by Nivet.15 Unfortunately, inadequate progress has been made in increasing leadership diversity for women and underrepresented minorities, but recently educational interventions about implicit bias have shown promise in reducing gender bias16 and may also be applicable to addressing racial and ethnic bias in leadership selection.

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The Way Forward

So what is to be done to improve the training, selection, and support of leaders?

First of all, we need to make a better case for leadership development so that the investment of health care resources in leadership can be justified. Sarto and Veronesi17 in a literature review note that “fundamentally, clinical leadership has been found to enhance efficiency and effectiveness of hospitals along a number of performance indicators.”

They suggest that this occurs because effective clinician leaders have critical knowledge for decision making, higher credibility, a reputation for improving the organization, commitment to cost containment, and greater attention to patient needs due to their ethical beliefs and adherence to professional norms. More research is needed to better demonstrate that well-designed leadership training in health care yields better patient care outcomes as well as improvements in other areas of health such as public health, disaster management, health promotion, and disease prevention. Such research findings could encourage more widespread support for leadership training and the inclusion of leadership education in student and resident curricula.

Second, leadership training should be aligned with the specific context and level of the student or faculty member. This would likely mean that leadership training would be progressive and move along in a stepwise manner as the needs of learners changed. It would also be important to improve the learning environment so that students would not encounter behavioral expectations that contradict their leadership training when they became novice members of clinical teams. Leadership training could then be perceived as part of ongoing professional development linked with clinical responsibilities. Specific training for individuals who take on organizational or institutional responsibilities would correspond to the new expectations and roles they assumed. For some individuals with career aspirations in health care leadership, a master’s degree in health administration or business may offer an excellent opportunity to develop formal knowledge and leadership skills to complement their experience in clinical leadership.

Third, we need to develop the field of leadership scholarship in health care. Like professionalism, leadership becomes most acutely recognizable when it is absent or deficient. What are the important questions that scholars should consider to help provide the basis for better leadership educational programs? How will the changes in our health care system affect the types of leadership models that would be most effective? How do questions about health equity, power, class, and race relate to leadership? I encourage you, the readers of Academic Medicine, to suggest possible ways that our community of health professions scholars can contribute to this agenda, through letters to the editor or other types of submissions to the journal and through participation in meetings and symposia focused on the scholarship of leadership.

Finally, diversity of gender, race, and ethnicity in leadership at all levels should be recognized as important contributors to organizational success in health care. The effects of implicit bias and other types of biases in selection of leaders should be studied, and interventions should be developed to improve selection processes. But awareness of implicit bias is really only part of the solution. Racial, ethnic, and gender bias in leadership selection and retention is likely connected to disparities in health and health care. Since health and health care needs differ greatly based on class, wealth, race, and ethnicity, the selection and support of diverse leaders with strong commitment to addressing disparities and providing equity in health care should be integrated into leadership development programs in health care.

Retention of a diverse group of leaders is also important, and unfortunately sexual harassment can affect the workforce. In this issue, Bates et al18 remind us of the serious effects of sexual harassment at academic health centers. They highlight organizations taking proactive approaches to prevent harassment, especially at conferences, and they provide recommendations for addressing harassment when it occurs and preventing it in the future.

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Final Thoughts

While I continue to be somewhat skeptical of current leadership training programs in health care, I am convinced of the importance of effective health professions leadership in bringing about the kind of health system we will need for the future. That system will need to address the racial, class, and ethnic disparities in health, the growing costs of health care in an aging society, the role of technology in health care, and the roles of patients and families in health care decision making. These changes in the health care system will require diverse leaders who are able to bridge the intergenerational gaps in health care spending, values, and allocation of public resources. We will need leaders who understand the biosciences, social sciences, and health humanities and also have skills in business and administration.

I am encouraged by the enthusiasm and creativity of many who have chosen to work in the leadership field. Wiley Souba is a longtime advocate for physician leadership. In this issue he and his coauthor19 provide a hopeful view about the importance of having a vision for the future and how leadership can bring about needed change. “The best way to get people on board,” they maintain, “is to articulate a future that is alluring enough, worth going after enough, that they will think and act differently.” I believe that if we can develop a shared vision for the future goals and purposes of our health care system and the roles of health professions leaders in making that vision a reality, leadership training for health professionals will become a critical part of the integration of education and health care delivery and an essential component of achieving better health for our population.

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References

1. Stogdill RLeadership, membership and organization. Psychol Bull. 1950;47:1–14.
2. Hartley J, Martin J, Benington JLeadership in Healthcare: A Review of the Literature for Healthcare Professionals, Managers and Researchers. 2008. Coventry, UK: Warwick Business School, Institute of Governance and Public Management; http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1601-148_V01.pdf. Accessed September 12, 2017.
3. Judge TA, Piccolo RFTransformational and transactional leadership: A meta-analytic test of their relative validity. J Appl Psychol. 2004;89:755–768.
4. Blumenthal DM, Bernard K, Bohnen J, Bohmer RAddressing the leadership gap in medicine: Residents’ need for systematic leadership development training. Acad Med. 2012;87:513–522.
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© 2018 by the Association of American Medical Colleges