Is there a master's degree in your future?

Is There a Master's Degree in Your Future?

"Is a management degree important for physician executives?" What are the considerations in choosing the right degree and program?" Those questions are increasingly on the minds of physician executives. In this article, the authors summarize what is known about these questions and share their thinking on some possible answers.

Information about the extent to which physicians in management have graduate training and about current trends is incomplete.[1] Definitional issues add complexity in terms of what group of physicians in management we are reporting on or talking to? The American Medical Association Physician Masterfile listed 14,399 physicians in 1986 whose "primary professional activity" was administration. In a 1986 survey of a sample of this group,[2] 12.7 percent reported having a management master's degree, but 9.8 percent were MPH degrees received an average of 17 years previously. Such degrees are unlikely to have provided management education as we currently understand it. The remaining 2.9 percent reported MBA and MS degrees within 8 and 11 years respectively. These would likely correspond more closely to more current management training. In addition, we have recently reported that, in addition to physicians whose primary activity is administration, there are 168,387 who report administrative activities (not including practice record keeping or office work) as secondary or tertiary activities. They spend an average of 6.5 hours per week in administration. Nothing is known about the nature of their activities and educational needs or achievements.[3] Earlier this year, Grebenschikoff and Kirschman reported on data obtained from 1,200 respondents, a 40 percent sample of the American College of Physician Executives membership, to a salary survey.[4] For the hospital-based physician executives in this sample, 15.7 percent reported advanced degrees, of which 3 percent were MBAs, 3 percent were MPHs, 1.2 percent were MHAs, and 5.2 percent were MSs. An additional 10.4 percent reported working on a degree; 4.8 percent MBA, 1.3 percent MPH, 1.7 percent MHA, and 0.8 percent MS. HMO executives showed a higher proportion working on the MBA, while those in group practices had higher percentages of MHA and MS degrees. No information is presented on physician executives in government and academic medicine, which account for about 50 percent of physician executives whose primary activity is administration.[2] The authors indicate that there are no trend data because this is the first year this question has been asked, but they speculate that the number will grow. In the larger sample from the AMA Masterfile, 22 percent of the respondents indicated that formal graduate course-work or an advanced degree would be required for administrative positions in the future, and 62 percent indicated such management training would be advisable.

How To Decide?

Given this information and these apparent trends, how should a medical manager think about how much and what kind of advanced management education to obtain? We always advise individuals contacting us that degree considerations should not be the first step in the process. The pursuit of a formal graduate degree is an expensive and time-consuming process and should not be undertaken lightly. For those with little or no management experience, we recommend negotiating some part-time administrative activity in their own or another health care organization to get exposure to management and the ways in which managerial activity differs from clinical practice. The ACPE "Physician in Management" seminars are an excellent formal introduction to medical management and should almost certainly precede serious consideration of a graduate degree. Similarly, it may be that workshops or individual courses on managerial topics such as accounting, health law, or quality assurance will satisfy short-run knowledge requirements. After completing these introductory steps, many individuals arrive at the point where they are committed to a career in medical management and are seriously considering a management master's degree. The reason is usually some combination of two factors: the coursework required appears to be nearly as substantial as that for a degree, and a belief that the credential will important for career advancement and recognition. This attitude toward advanced management degrees is supported in general by physicians in management today. Grebenschikoff and Kirschman conclude that at the moment an advanced degree is not critical in the selection process for physician executives and that other factors, such as experience and/or professional certification, may be equally important. They do state that everything else being equal, an advanced degree may make the difference.[4] Several graduates of our program with less than average managerial experience have said that their degrees were very significant in their successful placement in extremely competitive situations. It is our professional opinion that, within 5 to 8 years, some kind of formal management degree will be expected by most organizations when they hire physician executives, particularly those in the young to midcareer age brackets.

Basic Questions

The three most important questions to be answered in looking for a specific academic program are which type of degree, what educational format (i.e., on-campus or executive model), and which specific university. With regard to degree type, there are four basic programs that most physician executives will consider--the master of hospital or health service administration (MHA), the master of business administration (MBA), the master of public health (MPH), and the master of science in administrative medicine, management, or other related titles. MPH programs are located in schools of public health, are oriented generally to public health administration, and can often be completed in a single year. They generally do not cover in great depth management material from a business or private sector orientation and often require some coursework in general public health. Subjects such as epidemiology and biostatistics may be more adequately covered. In addition, some positions in public health administration may still require an MPH degree. MHAs and MBAs programs are the most common management degrees sought by physician executives today. They usually require two full years of study in an on-campus format. Universities do not have fully compatible ways of describing quantity of coursework (a credit hour or a "course" will mean different amounts of class contact or hours of study required), so the two-year generalization will be used in this article. It is important to look into each individual program to find out what two years means in terms of hours of class and whether certain prerequisites are included or not included in that estimate. MHA or other health service administration degrees accredited by the Accrediting Commission on Education for Health Services Administration require an integrated series of courses that cover the following content: determinants of health and illness and the measurement of health status; economic, ethical, legal, political, and psychosociologic perspectives on the organization, financing, and delivery of health services; management of organizations and their environments, including communication, conflict management, leadership, management of change, and negotiation; financial, economic, and quantitative analysis, including accounting, finance, economics, cost/benefit analysis, and statistics; information management; and strategic management and marketing. Field work and an integrating thesis or exam are required. GRE or equivalent examinations are usually required.[5] For the MBA program, the Accreditation Standards and Guidelines for Business Administration Programs are somewhat less specific.[6] They specify that the equivalent of a GPA/GMAT total point score be achieved for admission. Foundation courses in accounting, economics, and statistics are encouraged. One year of instruction is required in the "common body of knowledge in business administration." This includes production and marketing of goods and services and the financing of the business and other types of organizations; economic, legal, and ethical environments pertaining to profit and nonprofit organizations; concepts and applications of accounting, quantitative methods, and management information systems, including computers; organization theory, behavior, and interpersonal communication; and a study of administrative processes under considerations of uncertainty, including integrating analysis and policy determination at the management level. In addition, a second year is required that is split between additional work in the common body of knowledge and additional specialized courses aimed at general competence in management.

Course Variety

Individual universities and programs show considerable variation in the exact number and type of courses and the amount of requirements and elective opportunities. It is hard to generalize, but it is probably accurate to indicate that most MHA programs are half business and half health oriented, while most MBA programs are primarily business-oriented. Within this norm, some MHA programs have a little "MBA-type" management coursework and some MBA programs have faculty who offer sophisticated health management material. Master of science programs vary with the specific nature of the degree. For the Master of Science degree in Administrative Medicine at the University of Wisconsin, we studied the role that most clinician executives are playing in their organizations and concluded that most were occupying "boundary spanning" roles between the practice of medicine and business management of their organizations.[7,8] This knowledge, combined with the decision to limit admission to midcareer clinicians who have a general understanding of the nature of the health care system, led us to create an on-campus program that takes three semesters and includes courses from both the MBA program (organizational theory, managerial accounting, insurance, and marketing) and the MHA program (health economics, quality assurance, managerial problem solving, health law, strategic planning, and epidemiology). Some of the latter courses are taken along with MHA students, and some are designed for the clinician executives alone. Next comes the question of whether the mode of instruction will be on-campus, either full-time or part-time, or "executive." Traditional full-time, on-campus instruction for the two-year periods described above is difficult for most midcareer clinicians to consider. Even our Administrative Medicine program, which can be completed in two semesters and two short summer sessions, is difficult for physicians to take advantage of. Exceptions have been individuals who have received fellowships from foundations and a few who have completed the degree as a part of a postresidency fellowship. There is no question that a year and a half or two on campus is the most stimulating and satisfying way of getting a degree, because faculty and elective offerings and the other benefits of a midcareer academic sabbatical are available. However, time and financial considerations make this an option limited to a few lucky individuals. Part-time instruction in the on-campus mode is possible for more individuals, when an appropriate institution is available within driving range of one's organization or home. Advantages include being able to pursue the degree at your own pace, the availability of elective courses throughout the university, and nonresidential tuition for residents of state universities. Disadvantages include the longer time required for the degree (possibly five years if the minimum of one course is taken each semester and summer session) and the difficulty of fitting regular university course schedules into an executive schedule. Many programs have evening and weekend courses, but there are inevitably some required or desirable courses that are only offered Monday and Wednesday from 9:50 to 11:30 AM. The executive mode describes a program whose offerings are organized to fit the schedules of the adult working student. Many executive MBA and MPH degrees are offered in this format, which traditionally consists of one weekend per month for two years. The basic curriculum is similar to that of the corresponding on-campus degree at the school, but courses may be modified to meet the needs/experience of the midcareer student. Disadvantages of this format can be fragmentation of the academic experience; the travel time and expense for students from long distances; the relative lock-step nature of the program, although some electives can be offered; the limited availability of faculty between classes; and the occasionally higher special fees. A variant of this model has recently been pioneered by the Executive Health Administration Program of the Western Network at the University of Colorado. The weekend per month has been replaced by five or six longer residential periods on campus, with various methods of contact during the longer home study period, such as computer conferencing and telephone classrooms. This mode has been adopted by the Executive Program in Health Administration at the Medical College of Virginia and by the University of Wisconsin/American College of Physician Executives Nonresidential Administrative Medicine Program. The advantage of this method is longer blocks of time on campus, which allows for a less fragmented campus experience, and minimal travel expense and time for those coming from longer distances. The disadvantages lie in adapting to the home study teaching methodology and the feeling of isolation that can develop in the several months away from campus. In addition, considerable tension can develop between work demands, academic load, and family responsibilities.

Costs

Program costs also must be considered. Longer programs cost more, and private universities are more expensive than state schools. In state schools, nonresidents will often pay more than residents. For instance, tuition for one year at the University of California/Berkeley MBA program is $1,476 for residents and $5,766 for nonresidents. In comparison, annual tuition at the prestigious private business or health management programs runs from $12,000 to $15,000. Books and living costs are additional. But for many midcareer executives, the direct costs pale in comparison to the indirect loss of income from full-time or significant part-time on-campus instruction; many students feel that total direct and indirect costs can exceed $150,000 per year. All of this leads to a personalized decision, but some generalizations are possible. Relatively few individuals will be able to afford the time, cost, and career interruption of a one- or two-year academic sabbatical, but those who can will likely have an unusually rewarding experience, with benefits beyond the knowledge acquired in the coursework. For the remainder, the next consideration may likely be whether a suitable program is available within driving distance from home or work locations. If the answer is yes, the possibility of part-time on-campus coursework exists and may be a logical choice. In this situation, the existence of suitable programs may be the determining factor in the type of degree sought rather than other considerations. Obviously the reputation of the university has some marketplace value and must be taken into consideration here. If multiple options exist for part-time on-campus study, a decision about the type of degree and program must be made. This often comes down to choosing between an MHA or MS in Health Management or an MBA degree. The MBA degree has the advantage of more courses in advanced business and analytic skills, but this is often at the expense of applications to medical management. Individuals who are planning careers for senior positions in insurance or health industry jobs may benefit the most from this kind of specialization. For most physician executives in medical organizations, 30-40 percent of the advanced business knowledge may be of limited usefulness. For such individuals, MBA degrees that offer electives in health care finance, law, economics, epidemiology, ethics and values management of health professionals, and health organization management should be sought. Otherwise, knowledge in these areas will have to be obtained outside of the degree program. Most MHA or MS programs offer a balance of business and health management courses, but they should be carefully examined to ensure that adequate business coursework in finance, organization theory, marketing, and insurance concepts are covered by business school faculty. These same considerations apply to choosing an executive program if part-time on-campus programs are not available. A final consideration may be the number of physician colleagues in the program. There are advantages to learning along with a large number of colleagues in similar situations, but there is also an advantage to being exposed to other health care and business executives. Currently, two programs are exclusively for clinicians, those at New York University and the University of Wisconsin. Several executive programs are attracting significant numbers (up to 30 percent) of physicians, most notably the Western Network program at the University of Colorado and the new management program at the Medical College of Virginia.

Summary

The decision to pursue a graduate management degree is a serious one, with significant time and resource dimensions but with substantial career benefits to many physician executives. Once a physician decides that nondegree educational opportunities are not adequate, decisions regarding full-time, part-time, or executive modes and degree type and program location must be made. We believe that the executive mode with a balance of business and health management courses in which a significant number of physicians are enrolled will emerge as the preferred choice for most individuals for the reasons outlined in this article, but there is room for diversity and experimentation. We strongly advise those seeking these educational programs to have personal discussions with program faculty and alumni prior to making a choice between final options.

References

[1]."Symposium on Management Education of the Physician Executive." Journal of Health Management Education, in press, Fall 1989. [2].Kindig, D., and Lastiri, S. "Administrative Medicine: A New Medical Spec ialty?" Health Affairs 5(4):146-56, Winter 1986. [3].Kindig, D., and Dunham, N. "How Much Administration Is Today's Physician Doing?" Submitted for publication, 1989. [4].Grebenschikoff, J., and Kirschman, D. "Getting the Third Degree." Physic ian Executive 15(2):27-28, March-April 1989. [5].Criteria and Policies for Accreditation, 1989 proposed revisions. Arling ton, Va.: Accrediting Commission on Education for Health Services Administration, 1989. [6].Accreditation Standards and Guidelines for Business Administration Progr ams. St. Louis, Mo.: American Assembly of Collegiate Schools of Business, April 1989. [7].Kindig, D., and Lastiri, S. "Changing Managerial Roles of Physician Exec utives." Journal of Health Administration Education 7(1):33-46, Winter 1989. [8].Kindig, D. "The Role of Administrative Medicine." Journal of Hospital an d Health Services Administration 34(1):1, Spring 1989.

David A. Kindig, MD, PhD, is Director and Alice Sanborn, MS, is Assistant Director, Administrative Medicine Program, University of Wisconsin School of Medicine, Madison.