A matter of degree: the trend toward physician executives' pursuing master's degrees.

During his first decade in private practice, Lorenzo Childress operated under the belief that hanging out his shingle and seeing patients would ensure success. But with the approach of health care reform, he was gradually struck by the realization that he was unprepared for change and lacked the knowledge to efficiently manage his practice.

"You have to be able to manage people, operate the office efficiently, and interact with insurance companies and suppliers," Childress says. "I felt I needed a better understanding of the standard approach of managing a small business. Even though I had done so for 10 years, I felt I had learned a lot of things the hard way and that I could have been a lot more efficient in the business aspects of my practice had I taken a more organized approach to gaining skills in management."

Childress elected to pursue an MBA degree nights and weekends at the Fogelman College of Business at Memphis State University in 1988. When he earned the degree in two years, he almost immediately enrolled in the Master of Public Health program at the University of Michigan College of Public Health because he believed that his education was top heavy with business, and he wanted to round out his training with health courses.

For the next two years, Childress pumped money into airfare flying to the northern campus weekends. He paid steep out-of-state tuition and was forced to cut back his practice and pay another physician to cover. Pursuing the second master's degree was expensive and time-consuming. But Childress doesn't regret his decision. He believed the training afforded him the knowledge and skills that would not only enable him to more efficiently manage his practice, but also enhance his credentials for a move into the realm of medical management, where he felt his decisions could make a difference. In 1990, he did just that. He closed his practice and joined Metro Medical Group, a 110-physician group practice in Detroit, Mich., as Chief Operating Officer and Medical Director.

Childress is one of a growing number of physician executives who have earned master's degrees and one of only a handful who have earned a double master's. This vignette shows the extremes one physician went to to get the sort of training he believed he needed. The majority of physician executives with master's degrees made sacrifices on a smaller scale and spent precious evenings and weekends for two years attending graduate school near their homes to achieve their educational goals.

Of ACPE's 8,814 members, 9.5 percent have already obtained some type of master's degree. The numbers of those who hold MBAs and MPHs are very close, 395 and 362, respectively. A total of 44 members have earned master of health administration degrees, while 19 have master of public administration degrees. The remainder have earned other types, including master of science in health administration, master of science in administrative medicine, master of health science administration, or master of science in business administration degrees. It is not known how many ACPE members are currently working toward advanced degrees.

According to the annual compensation study conducted by the Physician Executive Management Center (PEMC), Tampa, Fla., the number of physician executives with master's degrees or in the process of pursuing one has not shown any dramatic increase over the past few years, a fact that surprises Jennifer Grebenschikoff, Vice President at PEMC. "Everybody's tripping over themselves thinking about getting a degree, so we expected to see an increase of 25 to 35 percent, but that's not happening," she says. "But I think the numbers are going to rise."

Of the 398 VPMAs surveyed by PEMC last year, 7 percent had an MBA, 5 percent had an MS, and 3 percent had earned an MPH. Two percent were working on an MBA and another 1 percent were after an MHA.

PEMC has been recruiting physician executives for 11 years. Two years ago, Grebenschikoff says, was "the first time a client said to us, |We prefer a candidate with a postgraduate degree.' That was clearly an indication of how executive positions will change. It's no longer good enough to be one of the guys when the strategic planning committee meets. The whole role of the physician executive has changed and so have the requirements."

Although there is new interest in the workplace in physician executives with master's degrees, the interest is not being reflected in compensation, Grebenschikoff says. A master's is now considered "icing on the cake," she adds. "A degree tells employers there is commitment," she says. "If employers are looking at two equal candidates for employment, the person with the master's degree will get the job because there's extra value," Grebenschikoff explains. "But doctors have to understand that going back to school is not a ticket [to the top jobs]."

"I feel very strongly that doctors need to reference a degree program just as if they were hiring someone," she said. "Check out the program director. Get the names and phone numbers of doctors who have graduated in the past five years, and ask them what they think of the program. Why would anyone want to spend $25,000 without asking some questions? I certainly wouldn't commit two years of my life without checking."

Which Master's Should I Get?

There is much confusion about the purpose and content of the various master's programs. What's the difference between an MPH and an MPHA, between an MSPH and an MPA, between an MHS and an MBA? According to Karen Kanesfield, Assistant Director of the Accrediting Commission on Education for Health Services Administration, the accrediting organization for master's degree programs since 1968, the differences between all the health-oriented master's degrees are slight. The core requirements are nearly identical. Differences emerge in the courses students select in their areas of specialization.

"A lot of times, there isn't a difference," she says. "You can even get an MBA with a specialization in health care. We require course work in statistics and finance and epidemiology and human resources in every single program. There are specialized content areas included in every program for every degree. Each program can describe what it wants to be, but we compare all programs to one standard."

But that doesn't mean you shouldn't take the time to look for differences when trying to find the right program. "People think too much about the letters that come behind their names instead of the programs," Kanesfield says. "If you're a physician and you want to learn about medical group management, there would be more benefit to getting an MBA rather than an MPH."

Kanesfield believes there's a trend toward physicians' pursuing master's degrees. "Medical students believe they need an MBA now, especially with the future of health care hanging in the balance," she says. "They're going to be the ones running the HMOs, the provider groups, and medical organizations."

While she naturally stands behind e programs her organization accredits, she points out that just because a program is not accredited doesn't mean it's inferior. Accreditation is voluntary, and not all schools believe it's necessary to obtain accreditation. Kanesfield says the school may rely on its reputation rather than seek accreditation. Further, some programs could be too new (not have graduated enough students or have too few faculty members) to meet eligibility requirements, or they might not be conducting enough research to qualify.

"If you're in doubt, call some alumni of the program, and ask how they feel about their educational experience," she recommends. "The program will supply you with names and phone numbers."

Here's how some ACPE members describe their experience.

Master of Business Administration

Members with master's degrees surveyed for this article had very definite reasons for choosing their degree type. Some went after a master of business administration because they believe medicine has become a business, and they felt they could apply successful business strategies to health care. Others pursued master of public health, master of public administration, master of health administration, and master of health science degrees, and some members were convinced that one master's degree was not enough. But it was clear that the choices differed because the needs of the individual physicians differed.

Howard L. Kirz, MD, MBA, FACPE, Immediate Past President of the College, enrolled in three master's programs before zeroing in on the one that best met his needs. "I started in an MPH program, which was very science-oriented," Kirz says. "I realized it wasn't broad enough, so I went into an MHA program. That, too, had the |lock-step' approach. I wanted a program that would let me do what I wanted. It was finally in business school that they said, |Look, you're a senior manager. We don't want to hassle you by making you take the lower level courses when you're ready for the high.' Business school was flexible enough to allow me to study epidemiology, and study design, and outcomes as electives."

Although Kirz is satisfied with his decision, he points out that it may not be appropriate for everyone. "Doctors have holes in their knowledge. I think master's degrees in general have equal market value, but each physician has different learning deficiencies," he said. "You need to decide what program will best adapt to your learning deficiencies."

From an employer's standpoint, Kirz says, a master's degree is advantageous, "but it is nowhere near as critical as the skill set the employee brings. We want people who have more than medical management. The key question is not what letters are associated with a master's degree, but what course work and competencies out there fit my needs?"

Grebenschikoff believes that an MBA may be more advantageous, simply because it affords physicians an opportunity to network with nonphysicians and learn about business from corporate types who teach skills alien to most doctors.

Toni Mitchell, MD, MBA, FACPE, Medical Director, Adult Emergency Care Center, Tampa General Hospital, Tampa, Fla., could have attended a special MBA program for physicians at the University of South Florida, but went after and earned an executive MBA there in 1991 instead. "I know what doctors think," she says. "I wanted to be in with everybody else. There were people from all lines of business in my classes, the users and purchasers of health care. That's what I needed to know about."

Mitchell says she learned the budget process and the phraseology used to comfortably discuss it. The only drawback she noted was that economics was taught with a business rather than a health care slant, but Mitchell adds that she put that knowledge to use on a project on indigent care that was ultimately published in Annals of Emergency Medicine.

Gail V. Anderson, MD, MBA, Vice President, Medical Affairs, Grady Health System, Atlanta, says he "had no illusions of being president of Xerox" when he enrolled in the MBA program at Emory University, Atlanta. "I was convinced that, as a physician at a public hospital and director of a department, I needed more experience in dealing with administration," he says.

As an example, Anderson says, before he earned his MBA and "learned to talk the language," he tried to communicate to administration the need for 4.5 additional physician assistant slots at his organization. "Administration didn't believe me [about the need] and sent down a consultant who determined we needed 4.6 or 4.7. If I could have talked the language...."

Master of Public Administration

William J. Wenner Jr., MD, MPA, Medical Director, Quality Programs, Children's Hospital of Philadelphia, has always had an interest in the legislative side of medicine. He combined training in quality improvement and utilization review with his master's work at Pennsylvania State and earned an MPA in 1990.

When Wenner was exploring his master's options, he considered an MBA, but then his chief interests caused him to take another path. "I'm in an academic health center, and I was interested in combining my interest in research in regulation and setting health policy and having input into the way health care reform is being shaped," he says. "It taught me how to access the Legislature. I was able to get some of the congressmen and aides who are drafting legislation to listen to my ideas on the utilization review aspects. My degree gave me the knowledge and insight I previously lacked."

Master of Health Administration

Herschel Gordon, MD, MHA, Laboratory Director, Ukiah Valley Medical Center Lab, a 94-bed rural hospital in Northern California, believes that even though his degree has not been reflected in his paycheck, his job security has soared, because he's now a more valuable employee. Gordon got his MHA from St. Mary's College in 1989 after attending classes nights and weekends for two years. His found the course work to be very practical and has applied the knowledge at his current position.

"I sit on a committee that deals with quality assurance at the hospital," Gordon says. "I'm the only physician on it, and I feel comfortable dealing with the problems they have to address. I don't have to read up; I come prepared to contribute." Gordon adds that he's been able to improve the management of his lab and to introduce some valuable changes. "I've been able to be proactive," he says.

Master of Health Science

Marc Feldman, MD, MHS, earned his master's degree from Johns Hopkins School of Hygiene and Public Health in Managing Health Services Organizations last year. He is Chief, Division of Anesthesiology at Johns Hopkins Hospital and Health System, Baltimore, Md., so the classes were convenient to attend and focused on public health, his area of interest. "I looked at the executive MBA program, but the real issue for me was that the MHS gave me the skills I needed. I hope to move more into management in the future," Feldman says. He specialized in health finance and management in the degree program and is now teaching classes at the school and doing management consulting and managed care negotiation on the side.

Master of Science in Administrative Medicine

The University of Wisconsin Madison is the only school to offer this program, which is cosponsored by ACPE. It's aimed at training physicians and other health care providers to become medical executives. Martin Hickey, MD, MS, Executive Director, Managed Care Services at the University of New Mexico School of Medicine, Albuquerque, was in the first graduating class in 1990. "I was motivated to get a master's after taking PIM (Physician in Management) I and II, in which I began to learn about general management principles," he says. "I realized that although these courses gave me a general grounding in some of the issues in medical management, there was a tremendous amount I didn't have a grasp of."

In 1988, when Hickey was shopping for a master's program, he looked at an MHA, an MPH, and an MBA before opting for the MS at the University of Wisconsin. He chose this program because it offered a combination of business and health courses. Hickey says he went into the program thinking finance would be a crucial area of study, but he found that, as a physician executive, he has little to do this area. "Organizational behavior, management of professionals, and medical/legal issues provided me with a great foundation to deal with managed care and physicians. Physician executives are leading change, and they have to understand people to be effective leaders." Hickey says "having a master's gives you a tree with branches on which to attach information."

Although Hickey says his degree isn't putting extra money in his pocket, he believes "it helped me get the job. The lay administration feels that most physicians don't have a clue about business. Having come through a master's, I had laid the foundation. It opened avenues for me."

Master of Science in Health Administration

Richard A. Manch, MD, MSHA, FACPE, Medical Director, Physician Services at Samaritan Health System, Phoenix, Ariz., earned his degree from the University of Colorado in 1990. He maintains, "You can argue till the cows come home about which is better, an MBA or another master's. I think which type is less important; it's just important to have one. It shows a certain commitment beyond what you gain from short courses. It's a credential. I haven't left this organization, but I've had a lot of opportunities to do senior management. My degree showed people that I was serious and committed to this type of career."

Master of Public Health

Many women physicians are returning to school for master's degrees in an attempt to break the fabled "glass ceiling." Marsha Milburn, MD, MPH, Vice President, Medical Affairs, Michigan Affiliated Healthcare System, Lansing, didn't want to spend her career bouncing off it. She entered medical management in the public health sector and was "interested in furthering my career in administrative medicine. I wanted a credential." Shortly after she completed her MPH at the University of Michigan School of Public Health in 1986, Milburn landed her current position. She credits the program for arming her with the knowledge she needed to move up. "I think that, as a woman, if you don't have a master's degree, it's going to be difficult to move into upper management," she says.

Master of Medical Management

Accredited through the Department of Health Systems Management of the School of Public Health and Tropical Medicine of Tulane University, New Orleans, La., the master's degree in medical management is brand new. The first students will begin their studies in fall 1995.

ACPE has formed a partnership with Tulane University to offer members who have earned a certificate in medical management from the College an opportunity to earn the master of medical management degree in a flexible and convenient format by attending three 7-day courses on the Tulane campus, with intervening study assignments at home. The program offers distinctive competencies for physicians who want to become medical managers within a curriculum that includes organizational theory, accounting/ financial reporting, marketing management, epidemiology, managed care proposals/negotiations/bidding/ pricing, and payment systems/insurance basics.

Double Master's Degrees

Only a handful of members have put the extra effort into obtaining two master's degrees. Most who have done so say that they wanted to be "well-rounded" educationally and that, if they had it to do over, they'd make the same decision.

James H. T. Tan, MD, MPH, earned a master's degree through a Kellogg Foundation grant while he was in residency. After practicing for about seven years, he discovered that he "had a knack for administration and that I enjoyed it. I thought I should get more skills and train to be an excellent administrator in medicine, so I thought I should get my MBA."

Tan completed work on his MBA in 1993 and left the Southern California Permanente Group, where he was Chief of Service in the Department of Family Practice, to become Chief Operating Officer and Medical Director of a newly formed medical group that will take care of PruCare patients. "My training will help me understand incorporation; how to structure governance, contract, and benefits packages; strategic planning, stratifying my priorities, and understanding the process. Medical school doesn't teach you this," he says. "If I never had the tools, I would be going around in circles."

Although he says there's not much incentive for a physician to obtain a master's degree in Canada, Eric Fonberg, MD, MPH, MBA, is another of the few who completed two advanced degrees. Fonberg wanted to move from his clinical practice into management. At the time--10 years ago--the concept of a physician going after an MBA was "not accepted." So Fonberg opted for the MPH program at Harvard School of Public Health, where he attended full-time for one year. "I found it rather academic," he recalls. "I wanted to go into consulting, and I found it couldn't qualify me as well an MBA."

After obtaining the MPH in 1985, Fonberg went back to his practice and became a manager in a public health unit that served an area of 600,000 people. But he wasn't satisfied. He still longed to get into consulting but found consulting firms weren't interested in the skills he offered. He enrolled in the MBA program at the University of Toronto. When the two-year program ended, he closed his practice and went to work for Ernst and Young. St. Joseph's Hospital was a client of the consulting firm and was searching for a physician to lead the department. Fonberg was that leader. Now he juggles heading the emergency department and continuing with his consulting job simultaneously. So far, neither employer has complained, he says. "One of the reasons I get to play this game is because I'm not just seen as a physician," he says.

Donna Vavala is Contributing Editor of Physician Executive and Managing Editor of College Digest, the College's bimonthly newsletter, and of PRICE, the Newsletter for Physicians Concerned About Medical Costs.