Administrative knowledge and skills needed by physician executives.

Questions regarding training for physician executives have focused on the appropriateness of physicians' obtaining advanced management degrees.[1-3] While recognizing the need for more management training of physician executives,[4] educators interested in management training have not examined whether courses taught in management degree programs meet the needs of current or future physician executives.

This paper reports on a survey of physicians belonging to the American College of Physician Executives. The survey was designed to ask self-identified physician executives their opinions about managerial topics taught in most management degree programs and often taught in continuing medical education courses designed for physician executives and administrators.

Methods

A survey was mailed to 100 physicians listed in the 1991 directory of the American College of Physician Executives, chosen randomly from six geographically diverse states: Georgia, New Mexico, North Dakota, Pennsylvania, South Dakota, and Washington.

Respondents were asked to rate the value of 17 managerial areas in their current work, their preparation in these areas, and the areas where training would be useful for a physician executive. Respondents were asked how training for physician executives could best be accomplished by choosing from a list of eight alternatives. Respondents could add to the given lists and were asked for their comments.

Results

Surveys were returned by 50 respondents, for a response rate of 50 percent. Some respondents did not answer all questions or gave more than one response. Respondents (table 1, page 4) worked largely in hospitals (36 percent), group practices (18 percent), or academic health centers (18 percent). Over half of those returning the survey were involved with some medical teaching (60 percent), but few were involved with management education (16 percent) Thirteen of the respondents identified themselves as medical directors (26 percent). Five (10 percent) were either vice president or director of medical affairs.

Table 1. Type of institution where employed.
Type of Institution       Percentage Reporting
Hospital                            36%
Academic Health Center              18%
Group Practice                      18%
Government                           8%
Managed Care                         8%
Insurance                            6%
Ambulatory Care Center               6%
Industry                             2%
Military                             2%
Other                                8%

The respondents rated communication skills as the most valued of the areas listed (table 2, below). Forty-seven (94 percent) respondents rated communication skills as very valuable and only one respondent listed communication skills as not valuable. Most of the other areas were rated as of some value or were very valuable, particularly personnel management, strategic planning, negotiations, quality assurance, organizational management, and financial analysis. Labor law, employment law and regulations, and political lobbying were ranked lowest of the areas listed. Other valuable areas added by the respondents included "street smarts"; communication with physicians, staff, and nurses; salary negotiations; how to deal with physicians specifically; listening and interpersonal relationships; group leadership; and risk management.

[TABULAR DATA 2 OMITTED]

The respondents were best prepared in communication skills (table 3, page 5) before becoming physician executives (68 percent), although many survey participants indicate they had inadequate preparation in communications (29 percent). Training in most of the areas listed was judged necessary by the respondents (table 4, page 7). Financial analysis (94 percent), personnel management (92 percent), strategic planning (96 percent), organizational management (94 percent), negotiations (94 percent), and communications (94 percent) were the most frequently listed. Labor law (47 percent), employment law and regulations (54 percent), and political lobbying (64 percent) were listed the least number of times. Areas added by the respondents included continuing clinical skills, how to deal with physicians, listening and interpersonal skills, total quality management, and developing the human side of medicine.

[TABULAR DATA 3 and 4 OMITTED]

A fellowship in administrative medicine was the most popular choice as a method of training (table 5, page 7) by the respondents (28 percent). Obtaining a master's degree in business administration (18 percent), management (6 percent), or public health (8 percent) was frequently cited. Short-term seminars or workshops, such as the ones sponsored by the American College of Physician Executives, were chosen by 12 respondents (17 percent).

[TABULAR DATA 5 OMITTED]

Discussion

The role of physicians as executives or administrators has changed from the traditional medical director job.5 Forces creating this change include: * Growth of U.S. health care into a

multibillion dollar industry. * Increased surveillance by the Joint

Commission on Accreditation of

Health (are Organizations. * Growth of managed care. * Increased involvement by the federal

government through Medicare

and Medicaid programs. * Threat of litigation. * Pressure from other external

forces, such as patient care advocacy

groups and local government.

The medical director can no longer be a semi-retired physician spending small amounts of time conducting committee meetings. The physician administrator's role has evolved to what Kindig describes as one that "contains tasks in general management as well as clinician/physician management activities and validates the concept of the boundary-spanning role."[7] Physician executives now work in CEO-level positions with responsibilities in organizational planning, budgeting, marketing, and program development.[8] These duties are not part of a typical clinician's training.

What knowledge and skills should the physician executive possess? This question is important to answer if one believes physicians are not naturally ready for the management field.[9] More physicians are going into managerial roles. Their qualifications and abilities for this work vary, thus creating a need for training. A number of training programs are available,[10-16] and the course offerings vary. Usually, the curriculum includes course work on economics, health care organization, health care economics, personnel management, strategic planning, and organizational management. Sometimes, the courses are designed for physicians, but usually they are presented to a varied group of students, with only some of the students being physicians. The value of these courses for physicians is not clear.

A review of the literature failed to find any research that identifies the managerial knowledge and skills needed by today's physician executives and how to obtain these skills. The curricula of current offerings tend to follow examples set by MBA programs, MHA programs, or amalgams of the two. One must question whether these courses are germane to the tasks as seen by those performing them, or whether the training reflects only the thinking of the educators.

The survey results reported here suggest that quality assurance, utilization review, communication skills, and personnel management are of greatest importance to the respondents, while only preparation in communication skills was felt to be currently adequate. Inadequate preparation was noted especially in financial analysis, employment law and regulation, marketing, and health care law, despite the relative importance placed on these areas of knowledge by the respondents.

While expressing inadequate preparation and relative value to the job, the respondents listed employment law, political lobbying and health care law as relatively low in need for training. As one respondent commented, a physician manager can consult with experts in these fields. Training for physician executives should perhaps concentrate on "personnel" skills, such as communication and negotiations, and just introduce physician managers to the basics of other managerial topics.

A surprise survey result was the popularity of a fellowship in administrative medicine, perhaps because it is similar to the traditional training physicians get in clinical care: college, then medical school, followed by residency, culminating with a fellowship. I found no mention of fellowship in the literature, including information from the American College of Physician Executives.[14,17-20] Educators should give more thought and research to the development of an administrative fellowship. Academic family practice programs may be interested in developing such fellowships.

This survey is limited by the small number of physicians surveyed. The demographic characteristics of the respondents are different from those in the findings by Kindig,[2] with fewer government respondents and more group practice respondents. However, the results of this study are similar to the findings by Montgomery.[8] The demographics of the nonrespondents are not known. Only six states were used in the study. The topics listed in my study were not exhaustive, and it is possible that vital managerial areas of interest or need were neglected. In particular, the area of decisional analysis was not listed, yet none of the respondents added it to the survey.

Summary

Managerial knowledge and skills are becoming necessary for today's physician executive. Training in management is desirable now and will become mandatory for future physician managers. Ways to obtain this training are varied, with a fellowship in administrative medicine, continued training through seminars and workshops, and a degree in management being the favored choices among those self-identified as physician managers. Leaders in management education need to design programs to help physician executives better prepare for their jobs both now and for the future.

References

[1.] Kindig, D., and Sanborn, A. "Is There a Master's Degree in Your Future?" Physician Executive 16(1):15-8, Jan.-Feb. 1990. [2.] Kindig, D., and Lastiri-Quiros, S. "The Changing Managerial Role of Physician Executives." Journal of Health Administration Education 7(1):33-46, Winter 1989. [3.] Schneller, E. "The Leadership and Executive Potential of Physicians in an Era of Managed Care Systems." Health and Health Services Administration 36(1):43-55, Spring 1991. [4.] Detmer, D., and others. "A Curriculum for Physicians in Management." Hospital Medical Staff 11(5):28-34, May 1982. [5.] Cohen, R. "The Evolution of the Hospital Medical Director: A Historical Perspective." Physician Executive 13(6):11-4, Nov.-Dec. 1987. [6.] McCormick, J. "The Making of a Hospital Physician Executive." Physician Executive, 16(5):27-9, Sept.-Oct. 1990. [7.] Kindig, D. "Background and Issues. Symposium Management Education for the Physician Executive." Journal of Health Administration Education 7(4):677-82, Fall 1989. [8.] Montgomery, K. "Today's Physician Manager: A New Breed." Physician Executive 12(5):14-7, Sept.-Oct. 1986. [9.] Rockey, P. "The Differences Start with Education and Training." Physician Executive 13(4):28-9, July-Aug. 1987. [10.] Wilkinson, R. "Management Skills: Where to Get Them." Hospital Medical Staff 11(5):22-4, May 1982. [11.] Hamilton, T. "The Role of Training in Professional Development." Physician Executive 16(6):38-9, Nov.-Dec. 1990. [12.] Riddick, F. "The Physician Executive: Part 2. The Mature Physician. Retooling for Management Roles. Consultant 28(2):120,125-7, Feb. 1988. [13.] Kissick, W. "Health Care Management According to Ben Franklin." Journal of Health Administration Education 7(4):723-33, Fall 1989. [14.] Neumann, B. "Structure and Advantages of a Distributed Educational Model for Health Care Managers." Journal of Health Administration Education 7(4):711-22, Fall 1989. [15.] Rodwin, V., and Kovner, A. "New York University's Advanced Management Program for Clinicians." Journal of Health Administration Education 7(4):702-10, Fall 1989. [16.] Kindig, D. "Administrative Medicine at the University of Wisconsin-Madison." Journal of Health Administration Education 7(4):734-7, Fall 1989. [17.] Schneller, E. "Role Design for the Physician in Management: The Mandate of Managed Care." Journal of Health Administration Education 7(4):683-93, Fall 1989. [18.] Brown, G. "Physician Executives, or Management Training for Physicians." Journal of Health Administration Education 7(4):694-701, Fall 1989. [19.] Ruelas, E. "A Different Approach to Continuing Education of Physician Executives." Journal of Health Administration Education 7(4):738-42, Fall 1989. [20.] Eubanks, P. "Clinicians: Manage Your Move to Manager." Hospitals 65(5):60, March 5, 1991. [21.] Beyt, B. "A Student's View." Physician Executive 16(1):19-20, Jan.-Feb. 1990. [22.] Grebenschikoff, J., and Kirschman, D. "Getting the Third Degree." Physician Executive 15(2):27-8, March-April 1989.

Carey Vinson, MD, MPM, is Family Health Center Director, Forbes Family Practice Residency Program, and Medical Utilization Director, Forbes Regional Hospital, Pittsburgh, Pa. He is a member of the College's Societies on Hospitals and Academic Health Centers, and its Forums on Cost Management and Quality Health Care.