INTRODUCTION
The environment in which hospitals and health systems function has evolved in the past decade. Clinical leaders are now at the center of addressing new challenges related to this shift, which includes the movement toward value-based payment models (Hafner, 2016), increased interest in community and equity in healthcare (Castellucci, 2017), and a global pandemic (Jacobs, 2021). In addition, in an environment where hospital and health system revenues are increasingly linked to clinical outcome metrics, the importance of clinical leadership has continued to grow (Jahn, 2018). Chief medical officers (CMOs) and similar clinical roles are responsible for addressing the value proposition for payers, patients, and the community (Castellucci, 2017). Clinical leaders working in teaching hospitals and health systems face an additional layer of complexity due to the quadripartite mission of academic medical centers (AMCs)—clinical care, medical education, research, and community collaborations (Smitherman et al., 2019).
As the role of CMO and related positions expands, it becomes more important to understand the influences—and the barriers to—the successful execution of the role. To date, the only large-scale published survey of clinical leadership at teaching hospitals was conducted in 2005 (Longnecker et al., 2007) when the CMO position had been newly created at most institutions to bring a new, unique, and diverse role in the academic enterprise. With the dramatic developments in AMCs since the previous large-scale surveys, there is a gap in the understanding of the current needs, challenges, and responsibilities of today's clinical leadership.
The current study surveyed clinical leadership at teaching hospitals and health systems again, updating a version of the original 2005 survey with important dimensions relevant to the current environment. The results detail how the role and responsibilities have evolved and capture challenges and job satisfaction. These findings shed light on the breadth of the role across academic medicine and opportunities for addressing potential future challenges in the role.
METHODS
The primary data source for this study was a survey of clinical leadership among the Association of American Medical Colleges (AAMC) hospital and health system membership.1 The survey, conducted July 2020 to September 2020, included 391 eligible individuals across 290 institutions. Surveys less than two-thirds complete were excluded from the analysis to ensure that the results would be comprehensive. To provide context for the primary data source and to draw conclusions about the expansion and evolution of the CMO role, 2020 data were trended with data from two previous iterations of the survey from the same membership source: one conducted from April 2005 to July 2005 among 340 eligible individuals across 280 institutions (Longnecker et al., 2007) and another from May 2016 to June 2016 among 383 eligible individuals across 312 institutions with results (the 2016 results have not been published).
All surveys consisted of multiple-choice, free response, and rating questions. The analysis drew from frequency counts of survey responses, sometimes disaggregated by the seniority of the respondent. Senior clinical leaders were defined as those respondents reporting the title of CMO and tenure in the position for 5 years or longer. We used SAS statistical software (Version 9.4) and Microsoft Excel 2019 for analysis.
All surveys in this study were approved by the American Institutes for Research Institutional Review Board (IRB), which provides IRB review services to the AAMC.
RESULTS
In the 2020 survey, 30% (117 out of the 391) of eligible clinical leaders responded. We retained 106 responses, representing 79 member institutions, after excluding 11 of the respondents who failed to meet our inclusion criteria. Our 2016 survey included 165 (43%) responses out of 383 recipients, whereas the 2005 survey had 154 (45%) responses out of 340 recipients (Longnecker et al., 2007). The following sections specify the number of respondents by item, which varies across the survey, with proportions presented as rounded percentages.
Demographics
In 2020, 32% (8 out of 25) of senior clinical leaders identified as female. The share of respondents who identified as male was higher the longer a respondent had occupied their position. All the clinical leaders who indicated that they had occupied their positions for 15 years or longer identified as male (see Figure 1). Overall, in 2020, 26% (27 out of 105) of clinical leaders identified as female, compared with only 16% reported in 2016 (23 out of 143; see Figure 1).
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FIGURE 1: Years of Experience for Association of American Medical Colleges Clinical Leaders in Current Position by Gender, 2020 Note. In the 2020 survey, the participants were given a range of possible gender identity responses including male, female, trans male/trans man, trans female/trans woman, gender queer/gender nonconforming, and different identity (please state). All respondents reported either male (74%) or female (26%).Source. The authors' analysis of data from a survey of clinical leadership among Association of American Medical Colleges membership in 2020.
Compensation
Compared with 2016, clinical leaders reported higher compensation in 2020 (see Table 1). There are differences in the distribution of compensation across regions, especially in 2016 when Midwest leaders were compensated at a lower rate compared with other regions. However, trends through 2020 show that these differences have narrowed particularly within the highest income tier (see Figure 2).
TABLE 1 -
Selected Characteristics of Association of American Medical Colleges (AAMC) Clinical Leadership Survey Respondents, 2005, 2016, and 2020
|
2020 |
2016 |
2005 |
|
Senior Clinical Leaders |
Non–Senior Clinical Leaders |
All Clinical Leaders |
All Clinical Leaders |
All Clinical Leaders |
| Total sample |
26 |
80 |
106 |
165 |
188 |
| Gendera
|
| Male |
68% |
76% |
74% |
84% |
Not asked |
| Female |
32% |
24% |
26% |
16% |
Not asked |
| Total compensation |
| ≤$300,000 |
4% |
6% |
6% |
20% |
Not asked |
| $300,001–$400,000 |
17% |
19% |
18% |
21% |
Not asked |
| $400,001–$500,000 |
13% |
15% |
14% |
20% |
Not asked |
| $500,001–$600,000 |
8% |
26% |
22% |
20% |
Not asked |
| >$600,000 |
58% |
34% |
39% |
20% |
Not asked |
| Have more than one administrative title |
31% |
20% |
23% |
28% |
34% |
| Duration of position in respondent's organization |
| <5 years |
0% |
24% |
18% |
12% |
16% |
| 5–9 years |
23% |
13% |
15% |
21% |
20% |
| ≥10 years |
73% |
60% |
63% |
60% |
62% |
| Do not know |
4% |
4% |
4% |
6% |
3% |
| Has an administrative partner |
| Yes |
65% |
56% |
58% |
Not asked |
Not asked |
| Is a member of the senior management team of the hospital/health system or medical school |
100% |
88% |
91% |
93% |
82% |
| Is a member of the hospital/health system governing board |
38% |
39% |
39% |
37% |
49% |
| Mean number of hospitals respondent is responsible for |
11.3 |
2.9 |
5.0 |
3.7 |
1.9 |
| Number of physicians the respondent is responsible for |
| 0–100 |
4% |
14% |
12% |
37% |
11% |
| 101–500 |
12% |
24% |
21% |
22% |
32% |
| >500 |
84% |
62% |
67% |
41% |
57% |
| Satisfied with current position |
| Strongly agree |
48% |
33% |
37% |
43% |
40% |
| Agree |
40% |
43% |
42% |
41% |
53% |
| Neutral |
12% |
13% |
13% |
9% |
0% |
| Disagree/Strongly disagree |
0% |
11% |
9% |
7% |
7% |
aIn the 2020 survey, the participants were given a range of possible gender identity responses including male, female, trans male/trans man, trans female/trans woman, gender queer/gender nonconforming, and different identity. In the 2016 survey, the participants were given two gender identity response options: male or female.
Note. Percentages may not add to 100 due to rounding.
Source. The authors' analysis of data from surveys of clinical leadership among AAMC membership in 2005, 2016, and 2020.
FIGURE 2: Total Compensation for Association of American Medical Colleges (AAMC) Clinical Leaders by Census Region, 2016 and 2020Source. The authors' analysis of data from surveys of clinical leadership among AAMC membership in 2016 and 2020.
Administrative Titles and Duration
Twenty-three percent (24 out of 106) of respondents reported having more than one administrative title, which was lower than previously reported (see Table 1). The three most common administrative titles reported by order of frequency were CMO, 62% (66 out of 106), vice/associate dean for clinical affairs or similar, 20% (21 out of 106), and associate CMO, 9% (9 out of 106).
Thirty-three percent of clinical leaders (35 out of 106) reported that their current position had existed in their organization for less than 10 years. The majority, 63% (67 out of 106), reported that their current position had existed in their organization for 10 years or more (see Table 1). Seventy-three percent of senior clinical leaders (19 out of 26) compared with 60% (48 out of 80) of non–senior clinical leaders indicated that their positions had existed in their organization for 10 years or more.
Qualification for the Position
The most common qualifications identified by clinical leaders as to what led to their selection for their current positions were previous practice leadership positions, 65% (69 out of 106), prior medical staff leadership positions, 61% (65 out of 106), and recognition as a “master clinician” in their hospitals and practices, 44% (47 out of 106).
Reporting Relationships and Scope of Role
On average, senior clinical leaders reported being responsible for approximately four times more hospitals (11.3) than non–senior clinical leaders (2.9). Similarly, 84% (21 out of 25) of senior clinical leaders reported having responsibility for more than 500 physicians compared with only 62% (49 out of 79) of non–senior clinical leaders (see Table 1).
In 2020, 50% of CMOs (53 out of 106) indicated that they reported directly to the hospital or health system CEO. This is lower than the proportion of clinical leaders who had indicated that they reported directly to the hospital or health system CEO in 2005, 63% (97 out of 154; see Figure 3).
FIGURE 3: Percentage of Association of American Medical Colleges (AAMC) Clinical Leaders Reporting Directly to Each Role, 2005 and 2020Note. CMO of the health system was not one of the options provided to respondents in the 2005 survey. Source. The authors' analysis of data from surveys of clinical leadership among AAMC membership in 2005 and 2020.
Senior clinical leaders indicated that the most common administrative positions reporting to them were associate or assistant CMOs, 65% (17 out of 26), physician advisers (utilization review), 65% (17 out of 26), and chief quality officers, 42% (11 out of 26). For non–senior clinical leaders, the most common positions reporting to them were associate or assistant CMOs, 40% (32 out of 80), service line director, 35% (28 out of 80), and physician advisers (utilization review), 34% (27 out of 80; see Figure 4).
FIGURE 4: Percentage of Titled Positions that Report to Association of American Medical Colleges (AAMC) Clinical Leaders, 2020Source. The authors' analysis of data from a survey of clinical leadership among AAMC hospital and health system membership in 2020.
Governance Activities
All senior respondents (26 out of 26) reported that they were a member of the senior management team of their hospital, health system, or medical school. By comparison, 88% (70 out of 80) of non–senior clinical leaders indicated that they were a member of the senior management team at their hospital, health system, or medical school. Thirty-nine percent (39 out of 100) of the clinical leaders whose hospital or health system had a governing board indicated that they were members of the governing board. Sixty-five percent (17 out of 26) of senior CMOs compared with 56% (45 out of 80) of non–senior CMOs indicated that they had an administrative partner (see Table 1).
Work Effort
Clinical leaders provided their allocation of total work time across different CMO and non-CMO activities in a typical calendar week. Among senior clinical leaders, overall work effort was distributed across CMO activities (83%), clinical practice (10%), other administrative activities (3%), or one of several other activities (5%). By comparison, non–senior clinical leaders spent less of their work week on CMO activities, about 63%, and had more time in clinical practice (15%) and other administrative activities (15%).
In the 2005 survey, the five duties for which the highest percentage of respondents reported responsibility were clinical quality (91%), patient safety (84%), graduate medical education (GME; 70%), inpatient services (67%), and outpatient services (65%). Three of the five top CMO duties in 2005 continued to top the list of common CMO duties in the 2020 survey, albeit with diminished frequency. In 2020, CMOs' top five most common duties were clinical quality, cited by 93 clinicians, patient safety, cited by 87 clinicians, compliance and risk management, cited by 68 clinicians, medical staff office, cited by 63 clinicians, and inpatient services, cited by 60 clinicians. In 2020, CMOs spent 55% (54 out of 99) of their time on GME. In addition, 2020 CMO duties included options that were not reported in the 2005 survey such as patient experience, 60% (59 out of 99), population health, 48% (48 out of 99), telehealth, 32% (32 out of 99), diversity and inclusion, 37% (37 out of 99), and community physicians, 23% (23 out of 99).
Job Satisfaction
When asked to evaluate job satisfaction in their role on a 4-point scale, senior clinical leaders were 12 percentage points more satisfied with their current position than non–senior CMOs (see Table 1). Compared with 2016, reported institutional support declined by 11%–60% in 2020. In 2020, 61% of clinical leaders (63 out of 103) indicated that they agreed or strongly agreed with the statement that their position was clearly defined within their organization, which was similar to the 62% (79 out of 127) reported in 2016.
Factors That Influence Effectiveness
To improve their effectiveness, 74% (67 out of 90) of clinical leaders indicated that they would like to be offered seminars on hospital and healthcare finance for clinicians, 61% (55 out of 90) wanted more seminars on patient safety and clinical excellence strategies for clinicians, and 58% (52 out of 90) wanted seminars on management and leadership for clinical leaders.
DISCUSSION
These findings enhance the understanding of the CMO position in medical schools and teaching hospitals and health systems that are members of the AAMC. The CMO role has gained prominence in AAMC-member institutions, reflecting the trend toward reliance on the CMO's role as a strategic leader, as seen in other healthcare organizations such as insurance and pharmaceutical companies and in nonhealthcare companies such as Google, BP, and Ford (Jacobs, 2021).
CMOs have become vital members of their institutions' senior management teams. Their responsibilities are no longer limited to traditional hospital-based clinical leadership activities and present new challenges and opportunities. Although their most-reported duties are still centered on clinical quality, the breadth of their work allocation has expanded, and that finding is consistent with prior research (Jahn, 2018). These added duties often reflect the needs of value-based care, with new emphases on population health, diversity and inclusion, patient experience, and telehealth. A growing proportion of the CMO's role is also devoted to risk management. These areas of expanded scope are supported by a dyad leadership model where CMOs collaborate with administrative partners such as chief nursing officers or chief operations officers to determine and operationalize the institutional vision.
The shifting healthcare governance structure has also had an impact on the direct reporting relationships associated with the CMO role, which adds complexity to the organizational bureaucracy that CMOs must navigate. In 2020, a smaller proportion of CMOs reported directly to the CEO of the health system or hospital compared with 2005 (49% in 2020 compared with 63% in 2005). However, a significant proportion of hospital CMOs now report to a system CMO, a role that was virtually nonexistent in 2005. Hospitals that historically operated independently even under joint ownership are now working more collectively as systems, and the clinical leadership structure is evolving as well (Jahn, 2018).
The decline in the proportion of CMOs reporting satisfaction with their position and the decline in the proportion reporting satisfaction with the organizational support to accomplish their goals is a barrier to CMO success. CMOs also communicated that they would like additional training in finance, patient safety, clinical excellence strategies, and management and leadership tailored to meet their needs as clinical leaders and the growing demands on their positions. Competency development in these areas is consistent with the elevated importance of quality and safety in healthcare (Harolds, 2021).
As the the CMO role continues to expand and evolve, so has compensation. The average CMO compensation package has grown larger over time and across geographical regions, especially for the clinical leaders who receive more than $600,000 in overall compensation.
The demographic composition of the people who occupy the CMO role has also evolved. The role has become more diverse as a result of the increase in the proportion of clinical leaders who identify as female. However, the increase in diversity has been limited to lower levels of seniority. Like the results reported in a national survey of more than 1,000 CMOs in 2001 (Gill & Kirschman, 2002), most senior clinical leaders today still identify as male.
Study Limitations
The results may be subject to nonresponse bias, which may have been affected by the timing of the survey during the COVID-19 pandemic. Furthermore, the survey draws from AAMC hospital and health system membership only, which may limit the generalizability of the results. In addition, the survey did not collect clinical leaders' physician specialty data, therefore, limiting any analysis by physician specialty. Future research should include analysis by specialty type—a comparison of surgical versus nonsurgical clinical leaders, for example.
CONCLUSION
The CMO role continues to evolve amid an unpredictable healthcare landscape. Given AMCs' quadripartite mission of clinical care, medical education, research, and community collaborations, CMOs now have responsibilities for all four areas. Compared with 15 years prior, the CMO role now oversees more hospitals on average, has greater system-level visibility, and has greater female representation. These findings also highlight that the CMO position is integral within AMCs. The roles and responsibilities have continued to grow in complexity and have become more diverse over time.
