Epidemiology of physician leader development

In front-running organisations outside of healthcare (eg, Boeing, Toyota, Motorola, Honda, General Electric) and in some healthcare institutions, leader development programmes have been adopted vigorously over the last years. However, in most healthcare organisations, uptake of physician leader development has generally been slow, though recently increasing. For example, Davidson et al 9 interviewed 21 leaders of healthcare research organisations in 2012; 57% reported using no physician leader development programmes. Within a few years thereafter, attention to leader development for physicians has seemingly blossomed. Specifically, in a 2018 survey of 161 AAMC academic medical centres (which 58% responded,10 45% reported having a physician leader development programme, complemented by sending faculty to outside programmes (88% of the respondents). This observation and personal experience suggest that adoption of physician leader development programmes by healthcare institutions is rapidly increasing. As examples, healthcare systems (like the Mayo Clinic, Emory, the Cleveland Clinic, McLeod Health, Hartford Healthcare, Emory and so on) all have well-developed physician leader programmes.

What is the evidence that physician leader development programmes work?

The proliferation and popularisation of physician leader development programmes begs the question: do such programmes work?, that is, is there evidence that training physicians in leadership competencies is associated with organisational impact or benefits? Do such programmes demonstrate value? To my knowledge, four meta-analyses and key studies have addressed this issue, with concordance that the evidence for true organisational and/or clinical benefits of physician leader development programmes is relatively sparse. For example, Frich et al 11 assessed 45 eligible studies unit using a Kirkpatrick scale to assess organisational impact associated with the leader development programmes. The Kirkpatrick scale12 (from 1 to 4) is a training evaluation instrument that considers the impact of the training. Four impact levels are proposed: (1) Reaction—Did the learner regard the training programme as valuable?, (2) Learning—Did the learner gain knowledge from the training?, (3) Behaviour—Did the learner’s behaviour change as a result of the training? and (4) Results/impact—Was there an impact on the learner’s organisation that can be ascribed to the training programme? In keeping with the analytic strategy of Frich et al,11 levels 2 through 4 are further stratified into two categories: ‘A’ in which the impact was subjective or self-reported and ‘B’ in which the impact was objective and verifiable.

In the context of the Kirkpatrick evaluative scheme, few of the available studies (16%) objectively assessed acquired knowledge (Kirkpatrick level 2), fewer (4%) assessed concomitant behaviours (Kirkpatrick level 3) and fewer still (2%) objectively assessed system performance (Kirkpatrick level 4).

A subsequent meta-analysis by Straus et al 13 considered 10 eligible programmes with 636 participants (but did not stratify outcomes by Kirkpatrick levels). Four studies reportedly assessed the impact on participation in a programme on physician knowledge of leadership, with reported enhancement in all programmes. Only 3 of the programmes assessed the leadership promotion of programme attendees. In one of the few controlled studies that were reviewed by Strauss et al,13 Day et al 14 assessed the effectiveness of a leadership development programme for orthopaedic surgeons using eight parameters: knowledge of leadership theory, environmental scanning, financial management, communication skills, conflict management, diversity competence, tolerance for the demands of leadership and leadership positioning. Programme graduates (n=67) were compared with applicants who were not selected to participate (n=73). Graduates were rated higher on all leadership parameters other than financial management, supporting the effectiveness of this leader development programme. As a study that included a control group and assessed leadership progression by review of study participants’ curriculum vitae, this single study is among the methodologically strongest available.

In a more recent study, Lucas et al 11 surveyed 161 Association of American Medical Colleges member institutions with a 58% response rate. A minority of respondents reported assessing postprogramme learning (38% Kirkpatrick level 2 and only 30% assessed postprogramme behaviour change (Kirkpatrick level 3), usually self-reported rather than objectively assessed).

Finally, a narrative meta-analysis of leader development programmes in the UK by West et al 15 concluded: ‘overall, the evidence for the effectiveness of specific leader development programmes within the National Health Service is highly variable and little robust evidence has been accumulated, despite the vast sums spent. The need to ensure effective leadership is clear but evaluating their effectiveness empirically is challenging and demonstrating positive effects on patient outcomes has proved elusive’.

In the context of these meta-analyses, table 1 summarises the findings and specific types of impacts that are reported in six of the level 4 studies of physician leader development cited by Frich et al.11 16–21 These organisational impacts included: enhanced communication skills of intensive care unit (ICU) physicians and nurses and self-reported enhanced ICU outcomes;16 enhanced rankings on leadership indicators compared with a control group;17 impaired clinical performance due to targeted improvement projects;18 promotion to leadership roles of programme participants19 20 and successful implementation of business plan proposals.21

Taken together, across multiple settings and countries, with the exception of a few rigorous studies that demonstrate favourable impact associated with physician leader development programmes from a small number of flagship institutions,16–23 the weight of evidence suggests that the answer to the question—does physician leader development work?—remains largely open and unresolved. Stated differently, there is a paucity of available controlled and well-designed studies that assess objectively measured outcomes effected by physicians after their participation in leader development programmes. This gap invites further study.

Experience with physician leader development at the Cleveland Clinic

In the context that the Cleveland Clinic is a physician-led organisation and has had a long-standing interest both in developing healthcare leaders and in assessing the impact of same, I herein describe key findings from several studies of leader development programmes from the Cleveland Clinic.21–23 The menu of healthcare provider leader development programmes at Cleveland Clinic is broad and addresses multiple audiences, from medical and nursing students, graduate medical trainees, established caregivers—physicians, nurses and administrators within the Cleveland Clinic—as well as visiting healthcare leaders. At the apex of a pyramid of offerings is the Cleveland Clinic-Weatherhead School of Management Executive MBA, which is offered as a collaboratively taught programme attended by >50 Cleveland Clinic caregivers since inception in 2013. Box 1 summarises the available offerings that have been provided since the launch of such programmes in 2003.

The earliest such programme, called Leading in Healthcare (LHC), began in 2003 and recruited high-potential leaders, initially physicians only (because the pipeline of physician leaders was perceived to be thinnest then) and later physicians, nurses and administrators in an interdisciplinary learning environment. Over the 13 years that LHC was offered, >520 Cleveland Clinic caregivers attended the 10-month course (which consisted of once monthly all-day sessions). Two assessments of organisational impact suggest that LHC has been highly effective. First, the capstone experience in the course for all attendees consisted of working in teams to develop a fully-fledged business plan for new organisational programmes to address current unmet, important needs. Teams of programme participants worked together over the course of the 10-month programme to prepare these business plans, which were then presented to organisational leadership at the final course session. Of 45 such business plans assessed as of 2007, 61% were deemed impactful, either by being implemented or by ‘killing a bad idea fast’. Both outcomes are deemed beneficial.21

As a second measure of organisational impact of LHC, to assess the leadership trajectories of course participants, Nowacki et al.23 assessed the history of leadership promotion among 272 participants in the first 3 cohorts of LHC. Over the decade following course completion, 43% of course attendees were promoted to a leadership position within the Cleveland Clinic (eg, department chair, medical executive committee membership and so on) and 18% were promoted to two or more leadership positions since completing the course. Such promotions can be considered a Kirkpatrick level 3B impact and, to the extent that effective leaders likely effect organisational change, likely predict a 4B level impact. Furthermore, analysis of attendees’ baseline Emotional Competency Inventory results showed that three emotional intelligence competencies at baseline were significantly associated (p<0.05) with leadership promotion: self-confidence, achievement orientation and change catalyst.

Attention has also been given to the impact of long-standing programmes directed to Chief Residents (Chief Residents Leadership Workshop) and to visiting emerging leader healthcare leaders (in the Samson Global Leadership Academy (SGLA)). The Chief Residents Leadership Workshop is a 2-day course offered annually in August (since 2008) to all Chief Residents at Cleveland Clinic and to selected Chief Residents from other training programmes throughout Northeast Ohio and from Cleveland Clinic Florida. Farver et al 22 assessed the self-reported knowledge impact of participating among 105 attendees of the first 5 offerings of the Chief Residents Leadership Workshop. Preworkshop familiarity with leadership concepts was generally low, with awareness of teambuilding and cultural competence reported to be the best developed (rated 3.0 and 3.18, respectively on a 1–4 Likert scale, where 4 equals very familiar). Similarly, preworkshop comfort levels with personal leadership skills were low, with mentoring (3.35) and conflict skills (3.04) rated higher than the other competencies. Self-reported postworkshop comfort with leadership skills were markedly enhanced, as were participants’ impressions about the effectiveness of the course. Though the outcomes of this study were self-reported, the study extends available experience with leader development programmes by examining a sparsely studied population—chief residents.

Finally, the Cleveland Clinic has offered the SGLA as an executive education offering to visiting healthcare professionals since 2011. In all, 157 physicians, nurses and administrators from 26 different countries have attended this immersive leader course to date. The SGLA organises its pedagogy around development of self (ie, personal leadership competencies like emotional intelligence and so on) and awareness of systems.

In a survey of 45 SGLA alumni about the impact of the course on their personal leadership behaviour (Kirkpatrick levels 2 and 3) and on their organisation (Kirkpatrick level 4), as shown in tables 2 and 3, the large majority of respondents reported gaining personal and social competencies (eg, participating in the course contributed to my being better at managing my emotions, developing the abilities of others and so on). Similarly, most (93%–96% of participants) reported that developing a 3-year leadership plan in the course was personally impactful. In the context that the interval between participation in the course and survey completion was variable and, in some instances, rather short, some reported the view that SGLA participation translated into clear benefits at their organisation (eg, earlier patient discharge, enhanced team engagement and so on).