Management knowledge and skills required by U.K. and U.S. medical directors.

There have been clinicians in many countries who have adopted managerial roles as a career. Many programs have been developed to train and enhance management skills for these medical practitioners. The change from the clinical to the administrative role has been studied and experiences in this changed role have been pursued.(2) The appropriateness of training for such a role change from clinician to administrator has been the subject of many surveys.(3)(4) In the rapidly changing world of health care administration, there is a need to ascertain the required body of knowledge and skills for medical directors to ensure that future medical directors will be adequately prepared to take on this important role.

Vinson undertook a survey of 100 members of the American College of Physician Executives. He asked a number of questions relating to:

* The value of various areas of administrative knowledge to the practicing physician executive.

* The adequacy of preparation of the physician executive in these areas of administrative knowledge.

* The value to a future physician executive of training in these areas of administrative knowledge.(1)

In the United Kingdom, recent legislation has deemed that National Health Service (NHS) hospital trusts need to appoint a medical directors.(5) Because of the emerging role of medical directors in the NHS, a survey was undertaken by the South Thames Region of the medical directors of its Trusts. The survey, emulating that undertaken by Vinson, was instituted so that comparisons could be made between responses of United Kingdom medical directors and their U.S. counterparts.

Method

A survey was mailed to 59 medical directors in the South Thames Region, which provides services to 6.4 million people. The survey was returned by 45 percent of the respondents, compared to 50 percent in Vinson's survey. As the surveys were undertaken at different times and with slightly different questions, comparisons cannot be absolute. However, the authors believe that there is enough similarity in the responses to make some tentative cross-country comparisons.

Results

As shown in tables 1-3, pages 27-29, physician executives in both countries agreed on the value of many areas of knowledge and on inadequate preparation of medical directors in that area of knowledge prior to taking up his or her role. The areas included formulation of health care policies, strategic planning, business planning and marketing, quality assurance, communication, and time management.

Table 1. Value of Knowledge in Current Work as a Medical Director

Area of Administrative Practice  How would you rate the value of
                        knowledge in the area for
                       your current work as a medical director?
                       No Value (%)  Some Value (%)  Essential (%)
                       U.K.    U.S.   U.K.  U.S.     U.K.  U.S.
Formulation of health
 care policies          4       4      48    40       48    56
Strategic planning
 for the Trust          4       0       8    30       88    70
Financing of the NHS    0       4      52    38       48    58
Trust accounting and
 financial analysis    16       -      72     -       12     -
Management theory      16       2      80    24        4    74
Business planning and
 marketing              0       4      72    66       28    30
Personnel management    4       4      64    16       32    80
Health service law      8       8      76    40       16    52
Medical ethics          4       -      40     -       56     -
Quality assurance       0       4      64    24       36    72
Negotiation skills      0       6      48    29       52    65
Political lobbying     12      24      48    56       36    20
Communication skills    0       2      16     4       84    94
Statistical analysis
 techniques            44       -      40     -       12     -
Time management         4       4      32    38       64    60

Note: Some respondents made no comment

Table 2. Quality of Preparation before Becoming a Medical Director

Area of Administrative Practice  How world you rate your
                        preparation in the area before
                       becoming a medical director?
                       Inadequate(%)   Adequate(%)   Not Needed(%)
                       U.K.   U.S.     U.K.   U.S.   U.K.   U.S.
Formulation of health
 care policies         56     53       40     37      4     10
Strategic planning
 for the Trust         44     60       52     36      4      4
Financing of the NHS   32     68       68     32      0      0
Trust accounting and
 financial analysis    60      -       28      -     12      -
Management theory      36     50       48     48     12      2
Business planning and
 marketing             60     65       36     25      4     10
Personnel management   40     48       56     50      4      2
Health service law     64     60       32     28      4     12
Medical ethics         20      -       80      -      0      -
Quality assurance      52      7       48     51      0      2
Negotiation skills     40     58       60     38      0      4
Political lobbying     40     53       44     24      8     24
Communication skills   12     29       84     68      0      2
Statistical analysis
 techniques            48      -       28      -     20      -
Time management        44     48       48     48      8      4

Note: Some respondents made no comment

Table 3. Suggested Areas of Training for Potential Medical Directors

Area of Administrative             If advising another physician
                                  who is thinking about becoming a
                                  medical director, in which areas
                                   would you suggest training?
                                            Not Needed(%)
                                            U.K.   U.S.
Formulation of health care
 policies                                    4     17
Strategic planning for the Trust             4      6
Financing of the NHS                         4     14
Trust accounting and financial
 analysis                                   12      -
Management theory                           12      6
Business planning and marketing              4     19
Personnel management                         8      8
Health service law                          12     21
Medical ethics                               8      -
Quality assurance                            8     17
Negotiation skills                           4      6
Political lobbying                          20     36
Communication skills                         0      6
Statistical analysis techniques             32      -
Time management                              4     13

Note: Some respondents made no comment

While the two groups agreed that there was a need for medical directors to have knowledge of personnel management, health services law, negotiation skills, and political lobbying, the U.S. physician executive placed more emphasis on the need to know about personnel management, health services law, and negotiation skills. Their British counterparts placed more emphasis on the need to have knowledge of political lobbying. These differences may well be inherent in the differences in systems of providing health care in the two countries. The United States places more emphasis on the private sector and on enterprise bargaining, which would tend to support the view that personnel management and negotiation skills are of great importance. On the other hand, the centralized public system in the United Kingdom places a higher priority on political lobbying skills. The difference in the perceived importance of health service law may well be explained, again, by differences between the two legal systems. The contingency fee system in the United States, coupled with the high litigation rate, would seem to explain this difference.

U.S. physician executives place a higher emphasis on the need to comprehend management theory. Why this should be is difficult to ascertain, but it may well be because the training of nonmedical managers in the United States has, for many decades, been geared to the attainment of master's degrees in business or health administration. As managed care programs in the United States multiply, more medical practitioners are moving to the role of chief executive (president) of institutions. Hence the need, perceived by them, for holding such a qualification is understandable.

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Both groups believe that they had been inadequately prepared to undertake a number of these administrative tasks. Indeed, both parties agree that they were inadequately prepared for all of the areas canvassed. As before, U.S. physician executives placed more emphasis on their inadequacies in the areas of management theory, negotiation, and communication skills. British medical directors placed more importance on inadequacy in preparation for quality assurance techniques. This is an understandable position, because the American health care system has legislated for quality assurance plans for many decades, compared their recent introduction in the United Kingdom.

All agree that training in the areas under consideration was required for potential physician executives. However, there were some differences in the importance attached to these areas of knowledge. U.S. physician executives did not place as much emphasis as their British counterparts did on the value of knowledge in health care policy, health care finances, and accounting practice. In support of the previous stance, the British medical director did not emphasize the need to undertake study in management theory. The American physician executive, again, did not place as much emphasis on acquiring formal knowledge in the areas of health service law, quality assurance, political lobbying, and time management.

Table 4, page 29, indicates the methods by which both sets of medical administrators believe that training of their confreres should be accomplished. Both groups supported specialist training in medical management, with American physician executives believing that attainment of an MBA or equivalent is important. The Americans did not place a high emphasis on on-the-job training.

Table 4. Training Methods for Future Medical Directors

Education Method                               Percentage Response
                                                 U.K.    U.S.
Specialist training in medical management        56%     28%
CME-type seminars or workshops                    40      17
MBA or equivalent                                  8      17
On-the-job training                               64       9
MSc (public health)                                4      11

Note: Some respondents made no comment

Summary

It is evident from these surveys that there is a need for medical practitioners to undertake the medical administrative role in their nations' health care services seriously. Each nation needs to formulate an approved and appropriate method by which medical practitioners can be seen to be adequately trained as medical administrators.

In the United States, there are many academic programs leading to master's degrees in business or health administration. Many U.S. physician executives have undertaken such a course of study. The American Board of Medical Management provides an examination process with the aim of providing board certification for physician executives. This will provide a professional focus for this specialty.

On the other hand, the newly emerging role of the medical director in the United Kingdom has yet to consolidate a professional focus. The recently established British Association of Medical Managers is grappling with this problem. Currently, the Association is attempting to ascertain the role of medical directors in the NHS Trusts and is providing some courses of instruction in various areas of management practice and theory. One of its objectives should be the creation and consolidation of a professional focus for medical administrators in that country.

In Australia, this professional focus was created when the Royal Australian College of Medical Administrators was founded in 1968. The College has pursued the recognition of medical administration as a specialty and has succeeded in having the College diploma recognized by various government authorities as a medical specialty. Indeed, it is rare for a hospital board/health authority in Australia to appoint a medical director who has not undertaken a course of study and training in medical administration.(6) Providing such a recognized specialty training program enables medical administrators to compete, openly, in the market for positions of chief executive of various health care institutions. The experience in other nations is that the person best fitted to head an organization is one who is appropriately qualified and experienced. It would seem that a person with a medical background who subsequently undertakes a management educational program, all other things being equal, would be best suited to head up a medical institution.

Given the pressure on health care systems throughout the world to become more accountable to the public and more cost-efficient, the role of medical administrators will increase. Possibly, there is need to form a world body whereby knowledge and experience in medical administration can be shared between nations.

References

(1.)Vinson, C. "Administrative Knowledge and Skills Needed by Physician Executives." Physician Executive 20(6):3-6, June 1994.

(2.)Lawson, J. "Difficulties in the Transition from Clinician to Manager." Physician Executive 20(7):19-21, July 1994.

(3.)"First Report of the Organization of Medical Care.": World Health Organization, 1957, p. 122.

(4.)Medical Journal of Australia 1095, 1968.

(5.)National Health Service and Community Care Act, H.M.S.O. House of Commons 1990.

(6.)Wood, T. "Educating the Medical Administrator." Community Medicine 9(3):260-4, 1987.