Leadership Development in Medicine

Article · June 4, 2018

Health care in the United States suffers from a persistent and worsening disconnect between the capacity of the physician-leadership workforce and the needs of our expanding and increasingly complex health systems. Closing this gap will require leadership skills that are not acquired during traditional medical training.

The practice of medicine is evolving rapidly.1 New health care technologies and precision therapies are shaping medical decision making and patient care. A diverse group of commercial and government payers are continuously changing approaches to the approval of clinical services, quality oversight, and payment. Health systems are implementing electronic health records, quality-improvement programs, multispecialty clinical service lines, and programs to improve population health. In light of the rising costs of care and shrinking margins, payer and provider systems are consolidating to improve efficiency. Adding to this complexity, academic medical centers in particular have several interdependent but distinct missions that require different types of financial planning and business models.2

The expanding scale and complexity of health care delivery create challenges for communication, mission alignment, and system-level planning and oversight. This transformation has occurred within a short period, and the pace of change is unlikely to slow. Our profession has been somewhat complacent in the face of these disruptive forces and hasn’t prioritized cultivation of leadership skills such as communication, team building, collaboration, and deliberative decision making that will position the next generation of physician leaders to succeed in this rapidly changing environment.

We believe it is time for a critical assessment of the ways in which health systems develop, select, and support emerging physician leaders. In any high-performing organization, leaders have a disproportionate influence on organizational culture and performance. In academic medicine, the stakes are particularly high, since our missions of clinical care, research, and professional training affect the health of entire populations directly or indirectly. Health care represents 18% of the U.S. economy, and there are nearly 6000 hospitals and more than 1 million physicians in the United States. Depending on their roles, physician leaders of departments, quality-improvement programs, clinical service lines, practice groups, information technology teams, and other units may manage budgets similar to those of medium-sized businesses and work in organizations that are often among the largest employers in their community. Although training in finance, business planning, and personnel management is central to the professional development of health system executives, these topics are not generally emphasized in the training of physician leaders.

Physician leaders were traditionally selected on the basis of their national prominence and excellence as master clinicians, star researchers, and revered educators. These credentials remain important, but they aren’t sufficient in the current health care climate. Given the high rate of turnover among physician leaders such as department chairs and deans,3,4 we can no longer afford to neglect the skills that are essential for leaders to succeed. We believe there is a need for a new generation of leaders who can promote strategic and cultural alignment in the face of rapid change. Supporting the growth of such leaders takes time and commitment. Leadership development should begin during medical school, and potential leaders can be nurtured at each stage of professional advancement. We suggest that health systems focus on three key strategies for promoting the effective development of physician leaders.

First, such systems could build a diverse pipeline of future physician leaders from within the organization. This approach would expand the pool of potential leaders, allow emerging leaders to take on progressively increasing responsibility, and ensure that leadership strategies are aligned with the organization’s culture and priorities. Health systems could start by identifying potential leaders and engaging them in task forces, committees, retreats, and formal training programs. Each of these activities requires dedicated time and institutional support for leadership development.

Providing frequent, structured feedback to emerging leaders offers opportunities for ongoing assessment of leadership potential, mentoring, and succession planning. Whenever possible, goals, metrics, and incentives should be transparent and quantitative. Developing talent from within — a foundational approach in other industries — can reduce the time required for recruitment, transition, and integration. Even with an enhanced focus on leadership development, however, external recruitment will remain a well-validated strategy for diversifying input and experience.

Second, health systems could implement a deliberate process for rigorously mining talent pools, whether internal or external. The most promising leaders are those who not only have experience and a compelling vision but also exemplify the core values of the institution and can engage and inspire others to rally around a shared vision. Physicians are understandably passionate about their own clinical specialties and research areas, but leaders need to understand, respect, and support the diverse interests of their teams and the institution in a balanced way. Physician leaders also need to partner effectively with nonphysician colleagues, including business leaders, administrators, and nurses.

The search and selection process should therefore evolve beyond reviewing curricula vitae and performing casual interviews, which are all too often focused on selling the role rather than rigorously evaluating the skills and experience of the candidate. For example, behavior-based interviewing can be used to solicit concrete examples of leadership traits, allowing candidates to describe their prior leadership experiences, decisions they have made, their approach to change management, and instances when they engaged stakeholders in challenging circumstances.

Third, health systems could implement structured processes for “onboarding” and methods for gathering feedback. For example, listening tours that allow newly appointed leaders to solicit viewpoints from current leaders, faculty, and staff are invaluable for learning cultural norms and strategic priorities for the new role. This process also serves to establish new collaborative partnerships and build credibility for the new leader.

Lack of alignment on important issues with one’s board, president, dean, CEO, or department chair is a common reason for failure and turnover in leadership positions. New leaders should have a realistic understanding of what’s expected of them and be given the chance to develop relationships that support effective planning and allow them to earn a few quick wins. With formal training in organizational learning, new leaders can master core proficiencies such as team building, consensus building, strategic planning, and change management. Ongoing support from executive coaches and mentoring from other leaders can increase emotional intelligence, facilitate decision-making processes, and enhance communication and collaboration skills.

Once a leader is settled in, term appointments and formal reviews provide important opportunities for feedback and the development of action plans. Formal self-assessments, coupled with internal or external reviews, also provide opportunities for stakeholders to share candid feedback and promote continuous organizational improvement.

Objective evaluation of each of these approaches will be critical in order for health systems to develop an evidence base for leadership development in medicine. Few studies use objective performance measures such as quality metrics, faculty and staff engagement and retention, or research impact to assess the effect of leadership training on institutional performance.5 Controlled comparisons among various leadership development programs would be valuable for determining best practices and disseminating those findings.

To meet the challenges of an increasingly complex landscape, we believe health systems should make leadership development an organizational priority. Identifying and supporting emerging leaders, carefully matching leaders with roles, and proactively supporting new leaders during deliberate onboarding and mentoring processes could help close the leadership gap in health care. Health systems that use these strategies may be best positioned to achieve organizational efficiency and effectiveness — which should be reflected in increased patient and physician satisfaction and improved clinical outcomes.


From the Perelman School of Medicine, University of Pennsylvania, Philadelphia.

1. Dzau VJ, Cho A, ElLaissi W, et al. Transforming academic health centers for an uncertain future. N Engl J Med 2013;369:991-993. Full Text | Web of Science | Medline
2. Ramsey PG, Miller ED. A single mission for academic medicine: improving health. JAMA 2009;301:1475-1476. CrossRef | Medline
3. Groves KS. Examining the impact of succession management practices on organizational performance: a national study of U.S. hospitals. Health Care Manage Rev 2017 August 3 (Epub ahead of print). CrossRef | Medline
4. Rayburn W, Grigsby K, Brubaker L. The strategic value of succession planning for department chairs. Acad Med 2016;91:465-468. CrossRef | Medline
5. Lucas R, Goldman EF, Scott AR, Dandar V. Leadership development programs at academic health centers: results of a national survey. Acad Med 2018;93:229-236. CrossRef | Medline

This Perspective article originally appeared in The New England Journal of Medicine.

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