“Business of medicine” issues are now forefront in the minds of most physicians.
The economic pressures to reduce cost while increasing quality are intensifying across practice environments. The complexity of managing patients with chronic disease and the need for collaboration among multiple physicians is becoming the new normal, as is focus on patient and staff satisfaction. In short, the role of the physician is changing rapidly.
Most medical schools in the United States have adapted their curricula to include team-based approaches. However, graduating students still lack the fundamental business and leadership training needed to effect the changes required and simultaneously maximize quality and reduce cost in clinical practice.
Regardless of whether future physicians decide to work in a large health care system or solo practice, they will need fundamental knowledge and skills in three key business disciplines: leadership, teamwork, and data analytics.
Luckily, most medical schools have a nearby source for evidence-based teaching on these topics: the adjacent business schools on their campuses that have been studying and teaching these concepts for decades. Recognizing the importance of these skills for physicians, a growing number of medical and business schools already have become more integrated: nearly half of all U.S. allopathic medical schools now offer joint MD/MBA degree programs. Our experiences, as a professor (R.P.) and student (A.F.) at both the Stanford School of Medicine and the Stanford Graduate School of Business, have given us insight into the relevance and growing importance that this particular blend of interdisciplinary studies could have for physician education.
With the introduction of the Medicare Access and CHIP Reauthorization Act (MACRA), all physicians will be pushed to participate in new models of care. For this reason, we believe the time is right to provide this education and expertise more broadly.
We propose that medical schools, in conjunction with business school faculty, develop an interdisciplinary four-week clinical rotation during the fourth year of medical school. In our view, the best learning experiences would be project-based, combining components of didactic teaching sessions and hands-on experience. The goal of the four-week course would be for the student to identify and solve real problems facing the school’s hospitals and clinics.
By the end, students would have developed the business skills needed to lead multi-disciplinary teams, serve as contributing team members, and apply data analytics to improve clinical practice.
Leading Large, Diverse Care Teams
Health care delivery in the United States is rapidly shifting away from traditional solo practice. Even physicians in small office settings are increasingly leading teams of mid-level providers. Today, nearly half of adults in the United States suffer from one or more chronic diseases, necessitating coordination of care by multiple providers for optimal outcomes.
Leading medical teams is as complex as performing a surgical procedure. Intelligence and medical expertise are required, but not sufficient. While training in evidence-based leadership skills is notably lacking in most U.S. medical schools, business schools offer these courses as part of their core curricula.
The current shift from fee-for-service to value-based payments will alter physician practice and payment going forward. Addressing contentious issues such as salary, incentives, relative performance, metrics, and contract negotiations — skills taught to all business students — will be essential.
Through business school courses that emphasize both intrapersonal and interpersonal leadership, fourth-year medical students would learn to evaluate their own unique strengths and weaknesses as leaders and set goals for improvement. And they would discover approaches to creating environments where innovation and diversity are likely to flourish. As team-based care grows, and as physicians navigate the complex and risky shift from fee-for-service to bundled and capitated payments, so, too, will the need for effective physician leaders increase.
Being an Effective Team Member
Physicians should not expect to lead all the teams in which they participate. As essential as team leadership skills are, physicians need to understand the importance of being effective team members as well. As much skill is required to support a leader as to be one.
Business schools provide students with an evidence-based understanding of why teams function or fail and how they personally can become more effective team members (see Table). Many business schools use simulated environments to teach team dynamics and help participants learn how to develop team culture, set clear expectations, and communicate effectively. These abilities require emotional intelligence and deep understanding of interpersonal dynamics — concepts and skills that are essential to maximizing quality, increasing patient safety, and improving clinical performance.
Using Data Analytics to Redesign Operational Systems & Gain Clinical Insight
Without major improvements in operational efficiency, our nation will be unable to fund the cost of providing the highest quality medical care to a demographically older and more diverse population. Accomplishing this will involve much more than improving supply chain costs and shortening hospital stays. It will require right-sizing the number of hospitals and specialists, reducing time between procedures, and leveraging information technology in powerful, new ways. Health care is too diverse across geographies and too fragmented in its structure and reimbursement methodology for this to be done exclusively by management consultants or health plan administrators. Physicians will need to own this process to create the effective, organic change that comes from those closest to patient care and is most trusted by fellow doctors. As difficult as it is to change physician behavior, our observation is that when the process is not led by a physician, the results usually fall short of expectations.
As the availability of comprehensive electronic health records increases, knowing how to develop and use data analytics may be as important for the emerging generation of doctors as learning to diagnose cardiac murmurs using a stethoscope has been previously.
Business school students, via their core curriculum, are taught mathematical, computer-driven approaches to applying data analytics to operational problem-solving and are trained to identify opportunities for increased operational efficiency (see Table). Over the past decade, business professors have written a variety of case studies from real-world hospitals and clinics. Including them in the fourth-year curriculum will allow students to learn from the experiences of these different institutions and incorporate the key concepts into their clinical practice.
As reimbursements drop, physicians in the future will need to identify opportunities to improve performance by decreasing bottlenecks in their offices, reducing patient wait-times for the operating room, modeling alternative treatments to determine the most cost-effective option for a particular patient, and performing statistical analysis to identify trends in patient quality outcomes. “Working smarter, not harder” is only a slogan until physicians master the requisite skills to translate the potential into practice. Doing so requires innovation and continuous improvement. Neither happens without leadership and data.
As a growing percentage of medical care is provided using modern technology, including telemedicine and digital health, the importance of this type of expertise will expand.
We Can Teach These Skills without Sacrificing Clinical Training
Given the increasing complexity of medical knowledge, natural questions arise: When can we fit this learning into the four years of medical school? And, what would it look like?
The evolution of medical curricula has allowed for more elective rotations in the final year. Often for students, it is a time of waiting as they focus on completing residency applications and travelling to interviews. This would be the optimal time for an interdisciplinary “business of medicine” elective that would make the fourth year of medical school more valuable to students.
Four weeks would be similar in length to the majority of other rotations, and an adequate amount of time to identify and examine a real-world problem. Students working in groups could conclude how best to increase the rates of screening for cancer or how they might streamline the hospital discharge process. This program would not be a complete business and leadership education. Like other fourth-year elective rotations, it would develop the foundation for lifelong learning in this area.
Return on investment from this training would begin as soon as the participating students enters residency, where they are given substantial influence on clinical processes and the effectiveness of the overall clinical environment. Done well, this educational experience would help participants to contribute more effectively to their residency programs, and after graduation in their clinical practices. Over time, the experience would benefit the health care system as a whole.
To maximize quality and avoid rationing of health care in the United States, we must transform the way medical care is organized, reimbursed, and technologically supported. These changes won’t happen without strong physician leadership at every level. Key skills — leadership expertise, teamwork, and the use of big data to improve operations — are all vital and can be taught effectively and mastered by students from diverse backgrounds, as accomplished today in leading business schools. Introducing these concepts and skills to physicians as a core rotation during their last year of medical school will prove as valuable to them, their patients, and our nation as any other medical student clinical elective they otherwise might take.
This article originally appeared in NEJM Catalyst on November 3, 2016.