Deciding the Future of Healthcare Leadership: A Call for Undergraduate and Graduate Healthcare Administration Education

Good medical leadership is the cornerstone of quality healthcare. However, leadership education for physicians has traditionally been largely ignored, with a focus instead on technical competence. As a result, physicians in many cases have abdicated their role as medical leaders to others, usually businessmen without medical training or expertise, and often a lack of understanding of the human issues inherent to healthcare. Recently, the Southwest Journal of Pulmonary, Critical Care & Sleep published a manuscript, “Leadership in Action: A Student-Run Designated Emphasis in Healthcare Leadership”, describing a curriculum designed to develop future healthcare leaders (1). Hopefully this and similar curricula will prepare physicians in setting direction, demonstrating personal qualities, working with others, managing services, and improving services (2). 

The US suffers from a crisis in healthcare partially rooted in a lack of physician- and patient-oriented leadership which has led to “hyperfinancialization” in many instances. Beginning in the 1980’s there has been an explosion in administrative costs leading to reduced expenditures on patient care but a dramatic rise in total healthcare costs, the opposite of efficient care (3). The substitution of primarily businessmen for physicians as healthcare leaders has at times led to the bottom line being the “bottom line” for assessing success in healthcare. Although it is true that metrics of “quality of care” are often measured, quality of care is hard to define and implement in a way that functionally addresses the concerns of the healthcare system, patients, and physicians. Furthermore, the concept that business personnel acting alone can improve the quality and efficiency of healthcare is difficult to support. It seems to us that the combination of business acumen, an understanding of financial realities, an appreciation of physician needs and their careers, and a deep understanding of the human side of patient care is what is needed. We believe that educating and empowering physician leaders could begin to address this need.

As can be seen in many instances in the country, new medical schools and many training programs are being created as part of, and “report” to, large health care systems, including for-profit, “not-for-profit”, and non-profit organizations(4-6). We must be very cognizant of the potential conflicts in priorities that may occur in such situations, as well as potential opportunities. While a concern could justifiably be that a system or organization focused primarily on finances might neglect the human or science-based aspect of medical training, there could also be opportunities to create leadership training that takes advantage of leadership qualities and skills from both business and medicine. On the other side of the coin, university-based training programs cannot neglect the realities of today’s healthcare system where a facility with administrative and financial issues is required for successful leadership.

We must begin to train physicians to be administrative leaders early in their careers. Leadership training in medical school such as the program described in the article by Hamidy et al (1), and other programs like a residency dedicated to providing a broad medical experience as well as administrative experience under the supervision of physician administrators would be a great start. We already see many physicians in leadership returning to school to complete MBA programs, but training must start earlier if physician leaders are to be successful. The Institute of Medicine has recommended that academic health centers “develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professions education, patient care, and research” (7).  To this end, a few healthcare organizations such as the Mayo Clinic, the Cleveland Clinic, the University of Nebraska Medical Center, and UT Tyler are all headed by physicians and could provide the necessary education with administrative emphases on care and financial stewardship, rather than pure profit (8-11). These better trained administrators would hopefully earn the cooperation of their providers and business partners in providing high quality care that is focused on the humanity of our patients, while keeping in mind strong financial stewardship. 

Richard A. Robbins MD, Editor, SWJPCCS

Brigham C. Willis, MD, MEd, Founding Dean, University of Texas at Tyler Medical School of Medicine Medical Center, Tyler, TX USA; Associate Editor (Pediatrics), SWJPCCS

References

1. Hamidy M, Patel K, Gupta S, Kaur M, Smith J, Gutierrez H, El-Farra M, Albasha N, Rajan P, Salem S, Maheshwari S, Davis K,  Willis BC. Leadership in Action: A Student-Run Designated Emphasis in Healthcare Leadership. Southwest J Pulm Crit Care Sleep 2022;24(3):46-54. [CrossRef]
2. Nicol ED. Improving clinical leadership and management in the NHS Journal of Healthcare Leadership 2012;4:59-69. Available at: https://pdfs.semanticscholar.org/3cc3/36f891d6a4b47d951b2bd280e46f4687dd5b.pdf (accessed 3/25/22). 
3. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003 Aug 21;349(8):768-75. [CrossRef] . [PubMed]
4. Banner University Medical Center-Phoenix. https://phoenixmed.arizona.edu/banner (accessed 3/28/22)
5. HCA Healthcare. https://hcahealthcare.com/physicians/graduate-medical-education/ (accessed 3/28/22)
6. Kaiser Permanente School of Medicine. https://medschool.kp.org/homepagJCe?kp_shortcut_referrer=kp.org/schoolofmedicine&gclid=CjwKCAjwuYWSBhByEiwAKd_n_kFPWcSP0Mj_VbqHJEsnwSwT_YkIErrb1PhcWQgQnRI_odNs5qbHZRoCaMIQAvD_BwE (accessed 3/28/22)
7. Institute of Medicine (US) Committee on the Roles of Academic Health Centers in the 21st Century. Academic Health Centers: Leading Change in the 21st Century. Kohn LT, editor. Washington (DC): National Academies Press (US); 2004. [PubMed]
8. Mayo Clinic Governance. Available at: https://www.mayoclinic.org/about-mayo-clinic/governance/leadership (accessed 3/25/22). 
9. Executive Leadership Cleveland Clinic. Available at: https://my.clevelandclinic.org/about/overview/leadership/executive(accessed 3/25/22). 
10. University of Nebraska Medical Center. Meet Our Leadership Team. Available at: https://www.nebraskamed.com/about-us/leadership#:~:text=James%20Linder%2C%20MD%2C%20Chief%20Executive,Nebraska%20Medical%20Center%20(UNMC). (accessed 3/25/22). 
11. University of Texas at Tyler. https://www.uttyler.edu/president/about/ (accessed 3/28/22)

Cite as: Robbins RA, Willis BC. Deciding the Future of Healthcare Leadership: A Call for Undergraduate and Graduate Healthcare Administration Education. Southwest J Pulm Crit Care Sleep 2022;24(3):55-57. doi: https://doi.org/10.13175/swjpccs006-22 PDF

Disclosures for All

The August 15 edition of the Annals of Internal Medicine published an article “Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination - Randomized Controlled Trial" (1). The study examined open book vs. closed book testing for the American Board of Internal Medicine (ABIM) examination and found no or minimal changes in the outcomes between the two testing conditions.

All in all, this is not very exciting. However, what is interesting is a blog on the article written by Westby G. Fisher, MD in his Dr. Wes blog (2). He examined the disclosures from the Annals editors of the article who claimed no financial relationships or interests to disclose. However, Fisher points out that on its last available Form 990, the publishers of the Annals of Internal Medicine, the American College of Physicians (ACP), earned over $24.6 million in a single year selling their Medical Knowledge Self-Assessment Program to US physicians to study for their board certification and recertification examinations (3). Furthermore, Fisher notes that an accompanying editorial written by ACP's former senior executive vice president, Steven E. Weinberger, MD, a pulmonologist and an employee of the ACP, also did not disclose any meaningful conflicts. However, with compensation of nearly $800,000 in 2014, Weinberger’s compensation was over 3 times the average compensation of pulmonolgists in the Middle Atlantic states of $226,000 (3,4). It seems unlikely that unless their financial status was healthy that the ACP could have afforded a luxury such as Dr. Weinberger.

Fisher notes that the study was conceived exclusively by the American Board of Internal Medicine and executed by their corporate partners at PearsonVue and Wolters Kluwer. However, PearsonVue had more than a minor role in the research and had access to the study registrants' names, addresses, and probably more (2). Each of the 825 physicians enrolled in the study received $250 from the ABIM Foundation. None of the participants were told about the financial benefits to the ABIM, PearsonVue, Wolters Kluwer, or their content creators for participation in this study.

The financial future of many of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) and the 18 approved medical specialty boards of the American Osteopathic Association (AOA) was in doubt until maintenance of certification (MOC) was conceived back in the 1980’s (2). Since then there have been multiple attempts to show MOC leads to better patient outcomes, but to my knowledge, no meaningful improvements have been shown (5-7). Furthermore, advertising for MOC programs with slogans such as “Is your doctor board-certified?” likely led to an erosion of faith in the medical profession. These MOC programs can largely be lumped with other money-making schemes such as continuing medical education and hospital recertification which are funded on the backs of physicians, are time-consuming and have not been shown to improve care.

According to Fisher (2), “conflicted research” as published in the Annals of Internal Medicine misleads the public and represents little more than a free advertising for the financial agendas of MOC organizations who benefit from the research. Furthermore, “…it sets and incredibly low (and untrustworthy) bar for all of academic publishing.”

Although this is strong language, Fisher is right. Disclosures need to be full and honest from all. Here are ours. The cost of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) is funded by the non-profit Phoenix Pulmonary and Critical Care Research and Education Foundation. None of the foundation board of directors, the editors, associate editors, staff, reviewers or authors receive any compensation. Our operating expenses are less than $5000/year and our income is dependent on donations to our foundation. We hope this reassures our readers that we have no hidden agenda and that what they read in the SWJPCC is honestly reviewed.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Lipner RS, Brossman BG, Samonte KM, Durning SJ. Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial. Ann Intern Med. 2017 Aug 15 [Epub ahead of print]. [CrossRef] [PubMed]
2. Fisher WG. Fake news: Annals of Internal Medicine's disclosures. Dr. Wes. August 16, 2017. Available at: http://drwes.blogspot.com/2017/08/fake-news-annals-of-internal-medicines.html (accessed 8/17/17).
3. CitizenAudit.org. American College of Physicians Form 990. 2014. Available at: http://pdfs.citizenaudit.org/2015_05_EO/23-1520302_990_201406.pdf (accessed 8/17/17).
4. Peckham C. Medscape pulmonologist compensation report 2014. Medscape. April 15, 2014. Available at: http://www.medscape.com/features/slideshow/compensation/2014/pulmonarymedicine (accessed 8/17/17).
5. Buscemi D, Wang H, Phy M, Nugent K. Maintenance of certification in Internal Medicine: participation rates and patient outcomes. J Community Hosp Intern Med Perspect. 2013 Jan 7;2(4). [CrossRef] [PubMed]
6. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA.Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. 2014 Dec 10;312(22):2358-63. [CrossRef] [PubMed] 
7. Gray BM, Vandergrift JL, Johnston MM, Reschovsky JD, Lynn LA, Holmboe ES, McCullough JS, Lipner RS. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014 Dec 10;312(22):2348-57. [CrossRef] [PubMed] 

Cite as: Robbins RA. Disclosures for all. Southwest J Pulm Crit Care. 2017;15(2):87-9. doi: https://doi.org/10.13175/swjpcc105-17 PDF