Primary research

Leadership in academic health centers in the US: A review of the role and some recommendations

Health Services Management Research 2014, Vol. 27(1–2) 22–32 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0951484814546958 hsm.sagepub.com

Thomas P Weil

Abstract The leadership of the US’s most complex academic health centers (AHCs)/medical centers requires individuals who possess a high level of clinical, organizational, managerial, and interpersonal skills. This paper first outlines the major attributes desired in a dean/vice president of health affairs before then summarizing the educational opportunities now generally available to train for such leadership and management roles. For the most part, the masters in health administration (MHA), the traditional MBA, and the numerous alternatives primarily available at universities are considered far too general and too lacking in emotional intelligence tutoring to be particularly relevant for those who aspire to these most senior leadership positions. More appropriate educational options for these roles are discussed: (a) the in-house leadership and management programs now underway at some AHCs for those selected early on in their career for future executive-type roles as well as for those who are appointed later on to a chair, directorship or similar position; and (b) a more controversial approach of potentially establishing at one or a few universities, a mid-career, professional program (a maximum of 12 months and therefore, being completed in less time than an MBA) leading to a masters degree in academic health center administration (MHCA) for those who aspire to fill a senior AHC leadership position. The proposed curriculum as outlined herein might be along the lines of some carefully designed masters level on-line, self-teaching modules for the more technical subjects, yet vigorously emphasizing integrate-type courses focused on enhancing personal and professional team building and leadership skills.

Keywords Academic health center administrators, leadership training for physicians, medical center administration

Introduction Academic health centers (AHCs), often referred herein also as medical centers, rank high among our nation’s more complex health organizations to manage.1 Historically, their origin was closely linked to providing high-quality undergraduate and graduate medical education. Later on, as an integral part of enhancing their teaching programs, the nation’s leading medical schools significantly expanded their basic and clinical research efforts, so these endeavors are now by themselves huge enterprises at some AHCs. Today, almost all AHCs simply encounter more complex operational and fiscal encumbrances that are far more demanding of their leadership than those usually experienced by the average multi-hospital, integrated health system with only modest teaching and research endeavors.

A few examples of this complicated role now experienced by medical centers with significant teaching and research activities follow: (a) The AHC ‘‘family’’ reaching some consensus on a short- and long-term strategic plan for the medical center that balances the often conflicting roles of teaching, research, and the delivery of healthcare services. This undertaking was never considered an easy task, and now far more difficult in the current

Bedford Health Associates, Inc, Management Consultants for Health and Hospital Services, Katonah, NY, and Asheville, NC, USA Corresponding author: Thomas P Weil, Retired President, 1400 Town Mountain Rd., Asheville, NC 28804, USA. Email: [email protected]

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23 environment of more limited resources and increasing political pressures. Almost always ongoing are heated deliberations, often complicated by governance issues, between the medical school faculty and hospital officials at the primary and affiliated teaching institutions relating to their joint responsibilities and their fiscal support of medical student, resident, and fellowship training. Considerable emotional strain is experienced at various levels of the AHC when seeking compromises on operational-fiscal issues when delivering ambulatory and inpatient services, particularly as many health institutions are experiencing decreasing revenues, increasing expenses, attempting to enhance quality of care, encountering far more regulatory control, and witnessing the reduction of NIH support. This decision-making process is far more complicated when the AHC is positioned in a highly competitive market where there are nearby many well-trained specialists and other tertiary-oriented hospitals endowed with significant fiscal resources. Under such circumstances, the AHC properly evaluating various investment alternatives becomes so critical; Assuming that the faculty practice plan is under the medical center’s aegis (although this is not always the case), agreements are often difficult to consummate that lead to an equitable distribution of these funds among the clinicians whose professional services provide a majority of the income, the basic science faculty who are often subsidized by the plan, and between the university’s central office and the medical school dean’s office when it comes to sharing the administrative overhead funds; Residents of the geographically adjacent communities to the medical center, in some metropolitan areas to include more than several hundred thousand persons, should receive accessible, cost effective, high-quality healthcare from the AHC’s various ambulatory and inpatient services whenever the clinical faculty is responsible for the direct delivery of care. It is far more manageable for the medical center to finance these services when most of its patients are privately insured, something that is rarely the case.

Being able to sustain the tripartite AHC mission of teaching, research, and delivery of healthcare in an effective and efficient manner requires masterful organization and management skills. In addition, to then successfully coordinate and integrate these frequently interrelated and many times overlapping efforts requires leadership expertise that is the ultimate

responsibility of the AHC’s senior executives. In fact, in the most recent decades the nation’s major medical centers have not only sustained themselves, but for the most part prospered in an enormously competitive healthcare environment. Before the formation of these enormously large and complicated networks, directing such efforts were medical school deans, who almost always were wellrespected physicians not only having an outstanding reputation in his/her clinical specialty and from publishing cutting-edge research, but also had the ability to attract other preeminent clinicians/researchers. Often recruited were also those with a high degree of leadership, management, and interpersonal skills. Although these attributes are still critical today, the sheer size and complexity of most medical centers suggest that the promotion, as consummated often in the past, of a key departmental chair to become a vice president of health affairs or similar role, should occur less frequently today without that individual acquiring some additional training and related experiences.2 This paper focuses on how to prepare those who are to be appointed to these most senior AHC leadership positions.

Purposes and introduction The purposes of this paper are four fold: (a) to outline the attributes traditionally thought to be appropriate for a medical school dean/vice president of health affairs; (b) to summarize the approaches that are currently being used to train many of our nation’s physicians for leadership and management roles; (c) to suggest that the inhouse leadership and management programs available at a relatively few AHCs should be more widely implemented; and (d) to recommend that one university establish a masters degree program in academic health center administration (MHCA) for those who aspire and who would be adept in a senior AHC leadership role. Establishing such a curriculum could be supported by the argument that there is an additional set of knowledge and skills required to be engaged in AHC administration than being trained as a top clinician and researcher. In fact, this MHCA program should also be open to highly qualified DDSs, DVMs, RNs, PhDs, and non-clinicians with exceptional skills to enhance the leadership and management of these immense complex environments called AHCs/medical centers. AHC administrators are defined herein as the AHC’s chief executive officer (CEO) most often called a dean or a vice president of health affairs (dependent of the university’s organizational structure) and his/her most senior staff. In larger medical centers, this might consist of the five or seven deputy and associate vice presidents/deans. So there is no confusion, the role of the AHC’s CEO and his/her staff’s responsibilities is

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assumed to encompass the entire organization, management, and financing of the medical center’s education programs, its basic and clinical research endeavors, most often one or more of its teaching hospitals, and its ambulatory and inpatient healthcare delivery systems. Some might argue that the leadership training needed for a vice president of health affairs position at a private, highly sophisticated research-oriented AHC should be different than the dean of a small state supported school of medicine. Among the nation’s top law and business schools, the same core curriculum is almost always required irrespective of background and future aspirations, with the student in the secondyear selecting electives and research papers that provide the opportunity to explore particular areas of interest. The same pattern is envisioned here in the training of AHC leaders, since in a 20þ year career, one academic medical center leader could potentially be on the staff of two or three institutions with combinations such as: small or large, private or public, or, research-oriented or focusing on providing the state with primary care physicians.

Requirements of leadership in AHCs The more specific attributes desired in an effective medical school dean or in more recent decades a Vice President of Health Affairs has been a recurring theme in the academic medical literature.3–6 The most frequent and obvious qualities mentioned to be an effective dean include: a top-notch clinician and researcher, who can attract others to enhance the medical center; has some natural leadership capabilities and inherent management skills; can visualize the medical center in the context of appropriately balancing medical education, quality medical research, and community healthcare delivery serving a broad population base; and has the ability to persuade colleagues to ‘‘see the bigger picture’’ and thereby, they become genuinely team players. Naylor,7 when Vice Provost/Dean at Toronto, added other dimensions when he cited: ‘‘mentorship, learning and teaching competencies, and so called emotional intelligence.’’ (Emotional intelligence is defined herein as: the ability to identify, access, and control the emotions of oneself, of others, and of groups.) Some key content knowledge cited for a medical school deanship includes such qualities as being well versed about academic medical center governance, expectations of clinicians and scientists, and the process of medical education; and certain attitudes such as commitment to the success of others and the appreciation of institutional culture.8 Possibly the most straight forward statement came from two medical

school leaders in Hong Kong: ‘‘The most important thing is to possess the managerial skills to tackle the three-way tension between management, academic leadership, and professional leadership.’’9 Early on most of these leadership attributes were not thought to be ‘‘teachable’’ in the classroom, although they could be significantly enhanced by preceptorship/ mentoring and by skillful coaching. Interestingly, some recent research suggests that becoming a leader in one’s field has less to do with innate talent, but more to do with: (a) the availability of meaningful opportunities early in one’s career and (b) the cumulative effects of experiencing much greater than average experiences and seasoning.10 Conversely, there is some evidence11,12 that many of the AHCs leaders who ‘‘fail’’ (e.g. a tenure of say less than four years) display limited knowledge and understanding of the personal and professional interrelationships inherent in these complex organizations they manage; demonstrate insufficient understanding of the institution’s historical culture; do not appropriately handle within their organization those with disruptive behavior;13 and lastly, particularly in medical center complexes with more limited resources, the AHC’s CEO fails to recognize that he/she for all practical purposes is serving at the behest of several powerful departmental chairs, who control most of the organization’s fiscal resources. Knowing some of the attributes of being a leader, some of the more obvious questions are: what type of training and experiences should physicians obtain, who are interested in preparing himself/herself to be a member of an AHC senior leadership team? Are there now some in-house educational approaches being utilized that other medical centers might emulate to enhance their physicians’ leadership and management capabilities?

Leadership development for AHC leaders A significant number of paths are now available in the US to train AHC administrators, most of them unfortunately for reasons discussed below are not particularly well designed for honing in on the content areas needed to assume the roles and responsibilities of the most senior AHC leaders. This is in spite of the fact that formalized training in health management for physicians and others started a half century ago by graduating from one of 18 programs in hospital administration. Nine months of didactic education on campus was followed with 12 months of an administrative residency, resulting in approximately 200 masters level graduates per annum. Since then, there has been a vast increase in the number of available alternatives established in the US where it is possible to obtain

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such training as well as there has been a huge surge in the number of individuals pursuing a management role in the health field. These options are now discussed in the context of training those who seek senior leadership roles in our nation’s AHCs: (a) Preceptorship/mentorship. Preceptorship has been practiced in the US for centuries whereby there is a relationship on a one on one basis between a ‘‘student’’ and an experienced staff person, who provides individual attention to the neophytes’ learning needs, offering feedback regarding performance, making wise decisions, setting priorities, and managing time. Mentorship is somewhat different as it assumes a personal developmental relationship whereby a more experienced or a more knowledgeable person helps to guide someone less experienced or knowledgeable through an ongoing relationship of learning, with constant dialogue and with continuing to provide more professional challenges. As in the past, preceptorship and mentorship will continue to be a frequent mode to train AHC administrators having previously been proposed to be an effective approach.14 In an increasing number of cases, AHCs are retaining executive coaches to enhance their physicians’ capabilities and to refine their skills as another way for senior managers to learn about himself/herself and, thereby, potentially become a more accomplished leader. Unfortunately, there is no solid empirical evidence that these approaches achieve much, nor that they are effective in training future senior leaders. It could be argued that they now occur so frequently and almost always are spoken highly of that they must deliver significant value. (b) Association of American Medical Colleges (AAMC). Founded in 1876, the AAMC, representing 141 US accredited medical schools and nearly 400 major teaching hospitals, has been at the forefront through their journal, ‘‘Academic Medicine,’’ (as evidenced by the references contained in this paper), and their various reports and seminars to encourage improved medical center organization and management. In recent years, a topic of considerable interest has been focused on how to potentially enhance the search processes for departmental chairs.15–17 They are often most difficult to fill since they currently require increasing administrative responsibilities and therefore, offer less time of personally being involved in clinical and research activities and their departmental budgets are so dependent on

their faculty colleagues being reimbursed for patient care services.18 AAMC may be experiencing a significant programmatic shift as its president during its 2012 annual meeting called for ‘‘a new vision of leadership of the nation’s medical schools and teaching hospitals that multiplies ‘the intelligence, creativity, and commitment of our faculty, students . . . ’’’19 This is to be achieved by more online options, bringing AAMC in-house capabilities to individual medical schools, and by making these leadership efforts to be more inclusive by integrating interests from students through senior executives. Critical to this plan are the AAMC seminars for two to five days for executive development, for interim and aspiring leaders, for enhancing graduate medical education, and for early career women faculty development. Some possible shortcomings of such endeavors as well as other similar short-courses described later on might be: (a) the course content does not address the issues and opportunities specific to the participant’s institution; (b) physicians usually would be attending these courses separately so the opportunity to build teamwork is not easily achieved; (c) significant expenses are incurred compared to in-house training endeavors; and lastly (d) it is unlikely that a few days of such seminars will produce more than wetting of the appetite for more training by the aspiring medical center leader. (c) Association of the University Programs in Health Administration (AUPHA). Currently the US has over 300 masters level programs in health services administration (HSA), graduating over 3000/ annum, offering MHAs, MBAs, MPHs, and other degrees, to an increasing number of them through executive-type programs and/or online.20 The full-time student most often has a bachelors degree and has had limited work experience, the average age of those entering these programs is 24.7 years of age. Less than 1% of them have previously received an American/Canadian medical qualification. These two-year academic programs, with a summer externship, primarily attract those interested in the management of health systems, medical group practice administration, consulting, healthcare planning, and similar roles. The curriculum content in most of these programs is informative for physicians and frequently too general for aspiring senior AHC leaders;21 these masters level graduates are exposed to limited information concerning AHCs; and probably more important, they receive virtually no dialogue in applying theory into practice because only 10% of the full-time faculty of the nation’s most highly ranked programs have a

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masters or doctoral degree in the field.22 These HSA graduates represent a huge pool of potential management talent as evidenced by over 40,000 being members of the American College of Healthcare Executives. Only a relatively few are physicians, who have the potential to lead medical centers with major teaching and research programs.

Whether medical students without significant prior work and hands on clinical experience, and lacking a background in the administrative-social sciences can fully reap the benefit from an MBA program so early in their career is an obvious question?24 Virtually all MD/MBA graduates go on for a year’s internship in order to be licensed, but some of these graduates have shun residency training in a well-recognized clinical discipline. Without also being board certified in a patientcentered specialty, MDs/MBAs can experience a lack of professional standing among their colleagues. In any case, most of these MD/MBA graduates are now at least a decade away from being considered as serious candidates for senior AHC leadership positions.

majority of these clinical scholars are interested in health policy not in medical center management roles. It is estimated that less than 10% of its graduates now hold senior management positions within an AHC. (f) American College of Physician Executives (ACPE). ACPE offers in conjunction with the Carnegie Mellon University, the Thomas Jefferson University, the University of Massachusetts, and the University of Southern California, a master in medical management (MMM) degree that is open only to MDs/DOs.26 This program’s first 105 classroom hours are provided by the ACPE faculty; and then, the physician has the option to complete the remaining academic requirements with one of the four above named universities. These programs infrequently discuss the management issues specifically related to AHCs. Almost all those enrolled in MMM programs (started in 1998) are considering ‘‘medical administration’’ as a second career and aspire to a position such as a hospital vice president of medical affairs, a chief medical officer, director of quality assurance, the CEO of a large multi-specialty clinic, or a similar role. There were 485 MMM graduates at the end of 2012 with an additional estimated 2000 doctors now in the pipeline for the degree. This ACPE program should not be considered as a significant training ground for the senior leadership of major medical centers. (g) Other related academic activities. Several of US’s most prestigious universities (e.g. Harvard, Michigan, Yale) offer an executive MBA for physicians and other senior healthcare executives. Somewhat less scholarly and pricy, are executive MBA programs for MDs and others with experience in the health field, provided by a large number of universities, including from some institutions where instruction is almost solely on-line.

(e) The Robert Wood Johnson Foundation’s Clinical Scholars Program. For more than three decades, this two-year, masters level scholars program, with four participating institutions (Michigan, Penn, UCLA, and Yale) that was recently disbanded, has enhanced the research skills of physicians, who are committed to a career in academic medicine, public health, and health policy.25 This program, with an annual entry class of 20, has already trained over 1200 physicians, most frequently from the primary care specialties; and, a vast majority having already completed their residency training before becoming a clinical scholar. This program has attracted ‘‘some of the best,’’ but a

There are other leadership training opportunities such as: Executive Leadership in American Medicine (ELAM) that promotes the advancement of women in academic medicine for associate and full-professors selected competitively, the program consisting of three one-week sessions of intensive training; and, Harvard and other universities provide several weeks of intense training on campus to enhance physician leadership development in AHCs and for chiefs of clinical services. With more physicians assuming leadership and management positions in the health field, the demand and the number of such programs will continue to increase. These endeavors undoubtedly will enhance the abilities of those who are or aspire to be chairs or directors of

(d) MD/MBA. Almost half of the nation’s medical schools now offer a combined five- or six-year MD/MBA curriculum for an estimated 500 medical students, who early on are interested in ‘‘medical administration.’’23 This dual degree effort appears to be fueled by medical students, who want to utilize their future MD qualification for something other than direct patient care and by those who want to impact the practice of medicine through an improved healthcare delivery system. The MBA course requirements are often completed as medical school electives. In most of these programs, a significant problem is the lack of integration by the relevant faculty of some of the medical, business, and healthcare issues as they emerge by the virtue of the different course content in this dual degree program.

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major centers/divisions/programs, but are not perceived as being sufficiently broad enough in scope and in depth, to offer for most desired emotional intelligence training to prepare the neophyte for more than a mid-level position within a complex AHC.

a ‘‘new hire’’ orientation for primarily junior faculty. Of the approximately 25 AHCs in the US that offer extensive leadership and executive training, 10 are summarized below to illustrate the huge diversity of these endeavors:

(h) AHC sponsored leadership programs. Developing a pipeline for effective leaders has to be a top priority for well-functioning AHCs and major steps are being achieved in implementing this objective. As the challenge of managing these large complexes becomes even more complicated, major medical centers throughout the US are increasingly developing and implementing customized, in-house educational programs that focus on leadership and management primarily for physicians, but in an increasing number of cases, including senior administrators.

– The Brigham and Women’s Hospital Leadership Program for mid-career physicians, other clinical staff, and administrators is cited as a rigorous leadership development program in collaboration with the Harvard Business School and delivered over eight months, four 2.5 day modules and six interim sessions. The curriculum includes personal leadership styles and effectiveness, leading teams and projects, decision-making, and other related topics. – Cleveland Clinic Foundation revised its Leading in Health Care in 2002 program to add new topics related to leadership and organizational development (e.g. emotional intelligence, situational leadership) and now focuses more on small groups developing business plans, presenting them to the total group, and later on evaluating their practical efficacy.35–37 – Duke Chancellor’s Clinical Leadership in Academic Medicine, for senior clinical faculty with significant administrative responsibilities, is a six-day program held over a four-month period. The first purpose of this program was cited as: ‘‘to increase the successes of program participants and strengthen the pipeline for Duke Medicine’s next round of senior leaders.’’ – Emory’s Woodruff Leadership Academy’s participants are nominated and competitively selected among senior faculty and administrators; and, ‘‘features classroom sessions in such areas such as organizational structure, strategic planning, finance, and leadership skills coupled with off-site team projects and weekend retreats.’’ – Harvard’s Macy Institute Program for Leading Innovations in Health Care and Education encourages faculty from various healthcare disciples to apply for a program jointly offered with the Harvard Business School that uses classic management studies and case studies with small and relatively large group discussions. – Johns Hopkins’ Office of Faculty Development for junior, mid-career, and senior faculty maintains an on-line library of web-based resources for leadership development; and, provides mentoring leadership and succession planning programs. Hopkins also has a year-long Leadership Development Program for established and emerging senior faculty and administrative leaders, and

Leadership development initiatives from AHCs Some of the more innovative activities in AHC leadership education for new faculty, division chiefs, and chairs are now underway by the AHCs themselves. Several of the larger, more prestigious medical centers started around 1997 establishing their own leadership academies with dedicated programs for enhancing physician leadership and management capabilities within and for their own organization. Only a few of these endeavors are specifically focused on enhancing a pipeline for their most senior AHC positions. There is significant variation among these efforts in terms of their use of didactic sessions, hands-on learning experiences, and the amount of individual coaching and mentorship provided. There is also significant divergence in terms of the type and number of participants, the curriculum, the length of the program, and what is expected as the outcomes. Examples of where AHCs have started in-house physician leadership and management training programs, and have published papers about their experiences include: the Mayo Clinic,27 the M.D. Anderson Center,28 the Cleveland Clinic Foundation,29 the University of Washington,30 McGill University,31 Duke University,32 and the University of Michigan.33 A useful source of such information is the AAMC’s ‘‘Medical School Based Career and Leadership Development Programs’’34 that outlines the career development and executive education programs of 50 medical schools and 2 teaching hospitals. Based on the information provided by each institution, 20 were judged to provide more comprehensive leadership and management training than just providing for a few days

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Health Services Management Research 27(1–2) among its goals is to ‘‘advance leaders in its organization.’’ – Stanford’s Development Leadership program, open for faculty of all ranks in leadership positions, is a nine-month program with some required reading and case study preparation prior to sessions to ‘‘develop the leaders needed to implement institutional strategies and meet future challenges in academic medicine.’’ – University of California, Davis, Mid-Career Program for associate professors, is a year-long program focused on learning core competencies necessary for effective departmental and/or section/division leadership. Each participant must develop and implement a leadership project under an experienced mentor. – University of California, San Diego’s National Center of Leadership in Academic Medicine has a two-part program for junior faculty that begins with 16 half-day workshops focused on leadership development and skill building. During the second part, each class member selects an individual professional development project and works with an appropriately-matched senior faculty member.

Possibly the most comprehensive, although very small, of the available in-house efforts for such physician initiates is the Duke University’s Internal Medicine Management and Leadership Pathway (MLPR), an 18-month rotational experience established in 2009 for Duke Medical Center residents or fellows,38 who have a prior MBA or MHA or two years of work experience. Two MLPR students are selected each year to ‘‘study across multiple disciplines, including health-system management and operations, financial management and planning, quality improvement and safety . . . .’’ With a prior MBA or MHA, completing a medical residency and/or fellowship program at Duke, and being tutored by their senior faculty and administrators on ‘‘medical management,’’ these graduates with some seasoning are prime candidates for top AHC positions. Their first class graduated in June 2013, with one remaining at Duke and the other completing his oncology fellowship. This summary of the current approaches to train health managers suggests that by far the largest number of graduates are the non-physicians who receive a MHA or equivalent. A few of these are appointed later on to the inner circle of a AHC staff being responsible for the management of one or more of its primary and affiliated teaching hospitals or one of its key healthcare delivery systems. The vast majority of the physicians who graduate the ACPE, MD/MBA, MBA, and other masters level programs most frequently seek medical administrative roles in community

hospitals or similar less complicated environments than large AHCs. For the most part, the contents of these masters-level programs are far too general, although they do orient the physician to the broad principles of organization, management, marketing, finance, and other similar topics. These master level endeavors are not targeted to the specific needs of those seeking AHCs senior leadership positions. An increasing number of the more prestigious and well-endowed AHCs are providing in-house ‘‘leadership and management education’’ some of them in rather sophisticated ways. But, compared to the overall need there is still a relatively modest number of institutions offering such programs and in enrolling participants, who might be considered to be ‘‘in training.’’ Those AHCs with significant resources such as Duke, Emory, Johns Hopkins, Harvard, and Stanford, just to mention a few, expend some notable efforts to enhance their overall leadership-management capabilities particularly at the chair/department/division/director level. Virtually none of the current inhouse leadership and management training efforts are specifically focused on those to fill the most senior medical center positions.

Recommendations for the future development for AHC leaders The two key recommendations that follow focus on: virtually all AHCs either expanding existing or establishing new in-house physician-administrator leadership and management programs as those employed in the health field are experiencing increasing difficulty in providing high quality medical education opportunities and delivering more direct care with fewer resources; and, starting a new experimental 12-month masters degree, professional program(s) to train medical center administrators. On the basis of a highly competitive process, it should be possible to carefully select at the start 25 students per year (mid-career individuals with clearly recognized leadership potential and a few of whom who had previously taken a leave of absence and enrolled full-time in a MBA program). The rationale for starting such a degree program follows: a curriculum can evolve that is targeted more specifically to the educational and professional needs of those who aspire to fill these complicated AHC leadership positions (e.g. can focus on the issues outlined early on in this paper); there are a significant number of physicians already seeking leadership and management education as evidenced by their completing a MBA or similar program, and this proposed MHCA program should provide more knowledge and leadership skills in a shorter period of time than other existing

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masters level efforts. For these reasons, the MHCA degree is proposed and outlined in some detail below.

Some specific recommendations Several recommendations follow that could well enhance AHCs generally, with the last proposal outlining a possible professional 12-month masters degree program to specifically focus on the training of medical center administrators:

Recommendation A All AHC administrative neophytes should have a preceptor or mentor who they can meet with them at least once a month or preferably on a more frequent basis. How this is to be accomplished, and the specific goals and objectives depends on a number of factors. How to achieve such a melding is often laden with a host of tactical issues (e.g. one of the two has insufficient time or interest, does the mentor need to be a senior executive?). How to implement this approach is not as critical as the concept: offering an environment whereby there is lots of meaningful dialogue, because where there is active discussion, solid learning has a high probability to occur. An AHC or even the AAMC could well serve as the ‘‘clearing house’’ for such a coordinating effort for those willing to be a mentor and for those seeking a mentorship.

Recommendation B Almost all of the technical knowledge (e.g. strategic planning, finance, marketing, accounting) and related skills needed as a senior AHC executive can be learned on-line from didactic presentations, case studies, and finally, exercises to test comprehension of the material presented. Younger physicians, other clinical professionals, and administrators for a host of reasons prefer on-line learning than most didactic sessions. However, leadership training, team building, perfecting emotional intelligence, and similar more interpersonal skills virtually always need to be taught in smaller groups or individually, although experience in delivering more formal presentations should be included in the curriculum. To implement this recommendation, every AHC should provide for its junior, mid-level, and senior faculty and administrators an on-line library of web-based resources for leadership development. The AHC’s faculty development office could potentially orchestrate whereby several physicians who are studying the same on-line content, could meet on a regular, but somewhat informal seminar basis, and challenge each other on their recommended case study solutions, and the

exercises’ findings and conclusions. Significant technical learning could be accomplished in this manner. Less critical is the availability of a ‘‘standard textbook’’ similar to the White-Griffith book, ‘‘The Well Managed Health Care Organization’’,39 or an updated and more extensive version of Wilson et al., ‘‘Pearls to Leaders in Academic Medicine.’’40 There would be some advantages for a several seasoned AHC practitioners to write a new book and provide some integrated case studies that could be used primarily to sensitize masters level MHA students, physician in various graduate degree programs, and others to the problems and issues faced by AHCs. Those in the early stages of considering a medical management career, those participating in medical center based leadership programs, and others that might find sections of such a textbook useful.

Recommendation C Preferably all the 141 US medical schools and their primary teaching hospitals should have ongoing academies with dedicated programs to improve the leadership and management capabilities of their physicians and administrators. A number of common threads in the existing in-house sponsored programs discussed earlier might well be included in designing new or enhancing existing AHC-based endeavors: – Specifically designed programs for junior, midcareer, and senior leaders lasting at least several months and in some situations for over a year; – Competitive selection to be a candidate for the more thorough AHC training efforts; and, the more general, shorter courses available for all interested faculty and administrators; – Technical knowledge related to leadership and management education can be for the most part self-taught on-line; and the AHC’s leadership office should make available resources to facilitate such learning; – -The leadership training focusing on perfecting emotional intelligence, team building, and interpersonal skills to be taught (could be off-site and on weekends) in relatively small groups or individually by experienced faculty often to be recruited from affiliated graduate schools of business or public affairs. Individual coaching and mentoring is also recommended. Not to be underestimated is the importance of teaching team building whereby the new chair/division chief become more cognizant of now having to focus on the needs of and mentoring of his/her colleagues rather than continuing to concentrate on

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Table 1. Proposed curriculum to train health center administrators. Module A. An overview of the environment—the general ‘‘stuff.’’ Governance, trusteeship, culture, vision, need for ‘‘emotional intelligence,’’ social psychology, need to negotiate and avoid conflict, value, history, politics, the regulatory environment, demographics, tradition, corporate reporting, fiscal stability, faculty-community physician relationships, assessment of quality of care, and other similar topics. This should provide a broad framework that would allow a perspective candidate later on to assess whether he/she should accept an AHC appointment/promotion; and if so, this AHC administrator should hopefully feel well prepared to assume responsibilities in his/her ‘‘new’’ environment. Module B. The economic, political, and social aspects of the US healthcare system. Similar to the course on medical care organization taught in every school of public health that provides an overview of the delivery of US healthcare services. This course should be preferably taught by a physician, who could focus more on key clinical-epidemiologic factors. Exempt from enrolling would be a physician with an MPH or equivalent qualification. Module C. The financing of healthcare services commencing historically with the passage of Medicare/Medicaid through the present. This module would need to be so structured that the AHC student would become well conversant with how various healthcare services are financed; and also be able to: effectively articulate his/her major findings, conclusions and recommendations from various revenue and expense, and fund balance statements; perform ‘‘quick and dirty’’ five-year financial projections; analyze capital expenditure alternatives; evaluate the efficacy of an accountable care organization or HMO, etc. in relationship to such entities as the medical school, an affiliated teaching hospital, a research institute, an ambulatory care program, or a combination thereof. The fiscal incentives inherent in a specific health insurance program usually make a significant impact on how healthcare services will be delivered. Having a high level of financial dexterity in an AHC leadership role is a distinct advantage. Module D. An AHC’s organization, management, and financing to include the strategic and operating aspects of its major activities. The purpose of this module would be to familiarize the student with the AHC’s major operational responsibilities and usual areas of friction, including the president’s office, admissions office, a primary or an affiliated hospital’s c-suite, the operation of the clinical areas where faculty provides referral services, the central human resources office, and other frequently sensitive areas in the daily management of a AHC. Those with say 10 years of prior experience in AHC administration might be exempt from this module. Module E. Weekly integrative seminars be held with key faculty and all MHCA candidates present. Some potential formats include a brown bag lunch; faculty preparing topics and students being responsible for presentations; the use of outside speakers; a Friday afternoon or Saturday morning colloquium; student reports that represent the work of a team on a specific issue; or a combination of these or others. This is where the program’s faculty and the students can get together and talk, many times the more pungent the discussion, the better the learning. Module F. Case studies directed by experienced (active and retired) academic health center administrators or senior faculty from schools of business or public affairs or from graduate programs in health services administration should be an integral part of a MHCA curriculum. During the first semester a case study a week; during the second semester two case studies a week. Physicians will learn more by reading and analyzing cases than by didactic lectures. The preparation of these case studies in small informal groups and the final discussion in class under experienced tutelage should make a major impact (e.g. emotional intelligence) on how the AHC student will perform in the future. A physician experiencing being rigorously challenged by his colleagues on a proposed solution to a case study might be a humbling experience, but might have an impact on how he/she acts later on in similar situations as an AHC administrator. Possible Module G. A major paper. Most academics would be inclined to include in the MHCA curriculum some type of major paper that focuses on some problem-solving endeavor. This author is not opposed to including a 20–40 page management report, but believes that this program should focus on ‘‘hands on’’ training of health center administrators, and should be based on highly interactive and problem-solving experiences. Rationale: the top business schools do not require a major paper for an MBA.

his/her own personal clinical practice and research; – Case studies relating to AHCs work well for physicians since it is similar approach to what they experienced through medical school, residency, and fellowship training. Cases that require both the testing of technical skills and also enhance understanding of leadership are preferred learning experiences. – Undertaking practical projects that are meaningful to the aspiring AHC leader and to the

organization, and are mentored by a skillful tutor or by an informed group should be encouraged. It is unlikely that any AHC can implement a leadership and management program that encompasses all the variables outlined above. However, this summary provides numerous ways for the 141 medical schools to implement an in-house leadership and management program for their physicians and administrators. Unfortunately, there is probably no ‘‘perfect’’ way,

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each option having some compromises, but there is some solid evidence that these approaches do work.41 Particularly for those medical center complexes without or with a limited leadership and management program, getting some dialogue underway to plan how to enhance the institution’s leadership pipeline and thereby, to improve the organization’s potential performance is the overall thrust of this recommendation. Hopefully, this proposal will not be ignored.

Recommendation D The current in-house leadership and management programs may be the start, but in the long-run should not be considered the principal vehicle to provide the senior AHC executives of the future. Many of the individuals sought to be the medical center leaders will have received training at AAMC and AHC leadership and management programs. This learning pattern should be encouraged. But, it would appear at this time, that some experimentation should be underway to train mid-career physicians and others for these most complex roles—managing a medical center at a senior level. In this context, this final recommendation is proposed: One or a few universities preferably with distinguished schools of medicine, business administration, and public health on a single campus, to receive appropriate federal and foundation funding to embark on a professional degree program (preferably no longer than 12 months in duration and thereby, roughly half the time spent on a MBA) primarily for those in midcareer (with outstanding academic, professional, and personal qualifications), culminating in a masters degree in Academic Health Center Administration (MHCA). For the most part, the proposed curriculum addresses a set of competencies that are unlike medical school, residency, and fellowship training. For some preliminary discussion purposes, the more didactic portions of this new degree program (in additional to the more hands-on experiences outlined in several of the existing leadership endeavors) that is far broader in scope and is far more specific to the needs of AHC leaders is recommended to be offered along these lines outlined in Table 1.

Concluding remarks To make this proposed MHCA program effective and efficient, it is critical to consider the student’s previous education and experiences, and future career goals. Professionals perform more competently in areas of interest to them and where they are highly knowledgeable. Some flexibility rather than a rigid format might be the most appropriate in the training for those seeking senior positions in major medical centers.

The complexities, and the need for better trained and experienced physicians for AHC leadership will only exacerbate in the future because of: an increasing number of aged becoming dependent on AHCs provided tertiary-type services; many small, free-standing physician practices and underutilized, fiscally fragile hospitals will express possible interest in being acquired by an AHC rather than to be shuttered; there will be considerably less monies available to pay for the healthcare sought by the general public; and, there will be a reluctance by more health professionals to step up and assume the increasing burdens and frustrations related to assuming major leadership responsibilities. For these and other reasons, the enhanced leadership and management training of AHC administrators, as outlined above, seems to be so critical. Declaration of conflicting interests The author declares that there is no conflict of interest.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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