There is a growing acceptance of the practice of formally developing physician leaders to help navigate the increasingly turbulent health care landscape. Research points to the important role that clinical leadership can play in improving the performance of health care organizations. Growth in compensation for physician executives, particularly those with postgraduate management degrees, signals higher demand and appreciation of their value.
However, only 5% of hospitals are led by physicians, in part because of a shortage of qualified candidates. This shortage may reflect the fact that physician leaders are all too often accidental leaders lacking formal training, or needing training that is more specialized than that offered in a typical MBA track. Relatively few health organizations offer formal career tracks for clinicians who want to lead, and some actively discourage leadership development for clinicians, particularly for those generating significant service revenue.
Harvard’s Master in Health Care Management (MHCM) program is a 2-year, part-time, executive-style program that graduated its first cohort in 2001 and has operated continuously since. It admits mid-career physicians working full-time who enter with at least some administrative responsibilities.
With the graduation of our 15th cohort, we were interested in better understanding (a) the value of formal physician-specific training, (b) the impact the training had on the leadership trajectory of graduates, and (c) the challenges graduates faced in transitioning from clinical practice to organizational leadership. In 2016, we sent a two-part survey to all 312 alumni who had graduated from the program from 2001 through 2015; the overall response rate was 29%.
Ironically, physicians themselves may be the greatest source of resistance to becoming effective leaders; many view leadership and management as offering little or negative value, some even seeing it as a move to “the dark side,” generating, as one survey respondent described it, “peer suspicion and isolation.” An early graduate of the MHCM degree program noted that “it is still difficult at times being considered a ‘physician on the dark side.’” A former health system Chief Quality and Safety Officer recommended to those who aspire to be physician leaders that they “Maintain your values of what drew you into medicine in the first place. Don’t become ‘one of them’ — be with them but different from them.”
The Value of Formal Training
Ninety percent of respondents rated the Master in Health Care Management program as “very” or “extremely valuable.” The competencies consistently rated as most valuable throughout their careers were financial literacy, strategic thinking, and change leadership. The number of valued competencies increased as the alumni moved into higher-level positions.
Following the lead of Mountford and Webb (2009), we categorized participant positions into three levels: primarily in frontline practice, averaging 75% time in clinical work and representing leadership at the clinical practice level; service line leadership, averaging 50% time in clinical work and representing leadership at the level of the clinical division or department or service line in which the respondent trained; and institutional leadership, averaging 18% time in clinical work and representing the higher levels of leadership at the C-suite level.
On a personal level, the formal leadership training gave graduates confidence to lead, opened their eyes to new possibilities, and enhanced their overall enjoyment and fulfillment in their careers. Newfound courage and conviction to lead is essential because, as one respondent emphasized, “executive leadership isn’t easier than taking care of patients; there are many days it is harder.”
The educational experience provided an expanded sense of what was possible, pushed graduates to try new things, and helped them understand what they enjoyed doing. Greater confidence and broader perspectives contributed to fulfilling professional goals, which spilled over into personal fulfillment and, for many, rejuvenated the joy and fulfillment of their medical careers beyond what they could have imagined.
Insights from Program Participants
“Graduating from MHCM opens so many doors. I still feel like I have so many career options and never feel stuck in a defined path.” —Chief Medical Director, Large Specialty Practice
“Allowed me to move into ACO arena with confidence and I was trusted to innovate based on the superior knowledge of health care reform I received and the skills I honed in the program. Being innovative is directly correlated to my satisfaction — I want to build and transform.” —System Vice President, Health System
Career Path After Graduation
Upon admission to the MHCM program, most participants could be characterized as early-stage service line leaders: 72% were in roles such as directors of clinical sub-specialties, chiefs of service, or chairs of academic departments, overseeing clinical areas in which the participants had trained. The others were in frontline practice (11%) and institutional (17%) leadership roles. Institutional positions took them outside their areas of clinical expertise, and into broader roles such as Chief Medical Officer, Chief Information Officer, and Chief Executive Officer.
By the time of the survey (an average of 7 years post-graduation), 84% of graduates reported increases in leadership responsibilities since graduation. For those graduating 6 or more years earlier, more than 60% reported being in institutional leadership roles, and only 27% were at the service line level. A few were frontline practitioners from application through time of survey, while others transitioned into and out of that category over time.
We asked graduates to describe their greatest accomplishments since graduation. For the few who remained primarily in frontline practice, they reported using their managerial skills to improve the management teams and profits of their medical practices, strengthen partnerships with hospitals, and build strong clinical programs.
For those leading service lines, graduates reported fundamentally improving the operations of their organizations. Notable accomplishments included moving core measures from the 20th percentile to the top quartile; improving patient, physician, and employee satisfaction metrics by more than 100%; engineering and implementing surgical quality initiatives that received national recognition; and developing measures of outcomes and costs in multiple disease spaces.
Those at the institutional level spoke of making their organizations work by developing trust; providing guidance and a great deal of political and moral support for the people who were actually doing the work; tackling strategic challenges; and mentoring others. They also influenced national practice by leading professional associations and organizations.
Program Alumni Describe Accomplishments
“I led an ACO from scratch, and am designing the next-generation products in analytics and performance improvement.” —Former Health System VPMA
“I merged three medical groups into one group, set up a new governance model, and overhauled the compensation system to a new salary-based model.” —CEO, Large Physician Group
“I led a financial and quality turnaround at one of our hospitals. Other people did the overwhelming majority of the work. I controlled the purse strings, starved problems, fed opportunities, and provided political and personal support to the people doing the work.” —CEO, Health System
Challenges in Transitioning to Organizational Leadership
Even within this self-selected group of physicians who proactively sought out leadership training to facilitate their transitions, our survey illustrates that moving away from clinical work and into physician leadership presents real challenges. Many of the barriers graduates encountered were consistent with those surfaced in previous research. Specifically, graduates noted resistance, skepticism, and outright suspicion not only from their peer clinicians, but also deep hostility from other professional staff.
Despite formal courses in organizational behavior and transitioning to leadership roles, they cited surprise at the rough-and-tumble of organizational politics and dynamics — one respondent described hospital management as “toxic,” and another noted that he quickly learned the limitations of advisory roles without teeth and the importance of executive sponsors to get established in substantive leadership roles.
However, sometimes the resistance comes not from peers, but from organizational superiors. One respondent was Chief of Surgery at a hospital within an academic health system when beginning the MHCM program. “As I expanded my administrative responsibilities, I started having issues with my Chair; he perceived me as a threat, as I was getting involved in central leadership.” Because of this, the respondent left that position and took a job at another health system. “I am very busy clinically . . . [but] I am actually discouraged to [expand administrative responsibilities] as my employer see me as a strong clinician who has beaten all the odds to develop a very strong and busy clinical program.”
Despite a shortage of effective physician leaders, the financial value of the high-performing clinician can be an impediment to the transition for physicians with formal management education. A “lack of roles for physician leaders” exists at the health system of one program participant, a former Chief Medical Officer who describes “a deep hostility to physician leaders from other professional groups, and deep suspicion from physician colleagues.”
Dealing with Image and Identity
Beyond the challenge of how they are seen by others when undertaking leadership roles, respondents cited difficulty seeing themselves as leaders. Many cited loss of personal identity as clinicians and found giving up clinical practice difficult.
After having devoted their professional careers to developing expertise and technical skills, they found that unlearning ways of thinking taught in medical school to instead think like leaders was very challenging.
Interestingly, while approximately 25% of graduates referred to loss of clinical identity in some way, more recent graduates (those less than 5 years out) expressed the sentiment most acutely. Graduates of earlier cohorts noted that “big positions” don’t come without giving up clinical practice; yet some high-level executive physicians continued to see patients on a regular but limited basis.
Additional Insights from Program Graduates
“I had to come to terms with my new identity as an administrative leader who had a clinical background, rather than a clinician who had some administrative responsibilities. It was not an easy transition and took me about 5 years to traverse.” —Health Network President and CEO
“The only way to reach the highest levels of leadership is to severely limit or eliminate your clinical practice. However, this puts you at greatest risk of disconnecting from the realities of what you manage.” —Institute Director, Academic Medical Center
Consistent with the growing evidence of the positive impact that physician leaders can have on patient quality and safety, clinician engagement and well-being, and health system performance, our survey suggests that, when well-prepared physicians do go into health care management and leadership roles, they find it personally fulfilling and have tremendous impact on patients at every level — on the front lines and on the services and throughout the organizations they lead. Formal training is perceived as transformative, yet resistance from powerful institutional players remain. We must celebrate their accomplishments, spread the word, and inspire others to follow in their footsteps.