Learning to Lead

Hospital medicine has evolved past the point where practitioners must justify the profession through cost-effectiveness studies. As hospital medicine assumes greater prominence in the healthcare system, hospitalists will be asked to take on larger leadership roles. Programs like the SHM Leadership Academy will help them acquire the skills necessary to guide the development of successful hospital medicine programs.

“Although such studies may produce interesting insights, their role in shaping the development and growth of hospital medicine has little relevance in 2007,” wrote Laurence McMahon, MD, in the December 20, 2007 issue of the New England Journal of Medicine. The tone of his editorial was one of mild exasperation over the publication of yet another study examining the cost effectiveness of hospitalists.

The study to which he refers is “Outcomes of Care by Hospitalists, General Internists, and Family Physicians,” an analysis of nearly 80,000 patient outcomes at 45 hospitals across the United States that was focused on expanding research on hospitalist care beyond the “small number of single-hospital studies examining the practices of a few physicians” that typify this area of research.

Although the results of the study were generally, if modestly, favorable for hospital medicine—hospitalist care “was associated within patient rates of death and 14-day readmission rates that were similar to the rates for care provided by general internists and family physicians;” the authors observed “small differences” in cost between the care provided by hospitalists and that provided by general internists and family physicians; and patients treated by hospitalists had a length of stay that was “modestly shorter than that of patients treated by general internists or family physicians”—McMahon argued that the study missed the point entirely.

The real question, said McMahon, is not “how much better or worse hospitalists are in caring for inpatients, nor is it how much they ‘save’ the health care system. The real issue is, how do we construct a health care delivery system with hospitalists among its core providers? What are the challenges and opportunities?”

“The hospitalist movement has arrived,” wrote McMahon. The primary focus of hospital medicine research should change from trying to justify the usefulness of the profession by pointing to cost savings to exploring the big issues surrounding hospitalist medicine, including quality improvement, comparative effectiveness, clinical informatics, and patient safety. “It’s time to move on,” McMahon concluded.

Robert M. Wachter, MD, chief, Division of Hospital Medicine; chief, Medical Service at UCSF Medical Center; and author of the blog Wachter’s World, believes that efficiency, long a standard used to justify funding for hospitalist programs, will take on less significance, freeing hospitalists to explore the best ways to improve safety and quality.

From McMahon and Wachter’s observations, it is quite evident that the hospital medicine conversation has changed. The profession has consistently proven itself to be a cost-effective model for providing healthcare and has attracted large numbers of practitioners to the field in little more than a decade. With the need to justify the viability of hospital medicine no longer there, hospitalists must now work to leverage their talents to achieve better patient care.

This refocusing of energy in hospitalist medicine is important, according to Eric Howell, MD, director of the Division of Hospital Medicine, John Hopkins Medical Center, because as the field grows and evolves, the role of the hospitalist is constantly redefined. Redefinition has created a need for guidance and leadership, Howell says, because “a lot of young hospitalists are being asked to manage projects requiring skills beyond what they have just out of residency.”

This need for skills and leadership development extends beyond just young hospitalists, according to Paul Spiegel, MD, medical director of Beth Israel Deaconess Health-Care Hospitalist Services, Needham, MA. Spiegel says that he continually searches for ways to improve group efficiency and hospitalist—primary care physician communication and often seeks guidance on business matters.

In their search for education on such matters, many hospitalists are turning to the Society of Hospital Medicine (SHM), pioneers of the industry’s only hospitalist-specific leadership training practicum, the SHM Leadership Academy.

The SHM Leadership Academy

Russell Holman, MD, COO, Cogent Healthcare, and course director, SHM Leadership Academy, says that when it assessed the profession of hospital medicine, SHM identified a need for leadership and designated it as a priority area for education and professional development. Out of this designation was born the Leadership Academy.

Holman calls the academy a “strategic interest” and “one manifestation of the process of overall leadership development” on the part of SHM. In large part, the academy targets two types of individuals, the first being current and aspiring leaders. The second are those not in positions of formal leadership, but who have an interest in the concepts of management and leadership. “These individuals may not have formal authority over anyone, but are still taking on leadership roles within hospital groups through quality initiatives, committees, medical staff affairs, and other leadership positions,” Holman says. He also indicates that there has been interest in the academy from critical care and emergency care physicians. “The appeal is there for anyone practicing within the hospital environment.”

Although there is broad appeal, Holman and Howell believe that a focused, tailored approach is the reason the academy is able to effectively reach so many. They cite four main areas of curriculum development that have allowed them to build what they feel is a strong educational tool that stands out not only in the young field, but in the overall healthcare leadership and development arena.

Tailoring curriculum to the hospital environment

When devising curricula for the academy, SHM examined other leadership course offerings and found that many were generic, lacking real-world applicability in hospital medicine. Courses would often rely on broad case studies and try to appeal to a health plan director in the same way they would a private practitioner. The onus was on attendees to extrapolate wherever possible and apply that information to their unique situation.

“They weren’t using examples that were relevant to the hospital environment in their course work,” says Holman. “We found that by tailoring courses, we made the translation to individual environments closer to home, and much more relevant.”

The right mix of practice and theory

From the outset, SHM tried to recruit subject matter experts from around the world as academy faculty, but membership demanded that practicing hospitalists take part as well. “This is an important concept in adult learning theory,” says Holman. “The topics and content have to be relevant to daily life.” And who better to provide relevant insights than hospitalists who were on rounds the week of their presentation at the academy?

This speaks directly to Beth Israel’s Spiegel, who is also a nephrologist and finds that conferences in that practice area are heavy on theory. “When I attend other conferences, there’s more theory than clinical experience, and at this point, I’m looking for concrete suggestions to bring back to my group.”

Practice what you preach

The SHM Leadership Academy utilizes a model Of learning built around facilitators who promote the completion of case studies; role playing scenarios; guided problem solving; and situation and other table exercises in groups of 10, giving attendees the opportunity to practice the skill sets on site as they are taught. “The facilitators are an extension of the faculty,” Holman explains. “They are experienced hospital leaders who are there to clarify instructions, and above all, give guidance.”

These practice groups also benefit attendees because of the connections they make while working together. The table exercises lend themselves to creating forums in which questions and ideas are discussed collaboratively. “Before you try to find something out on your own after the academy, you work on skills and connect with colleagues off of whom you can bounce any ideas.”

Course refinement

Course modifications and changes are based directly on attendee feedback. This helps the conference to better reflect both micro and macro changes going on within the industry. “People trained five years ago are now requiring different skill sets,” says Howell, who is also a Leadership Academy faculty member. “SHM continually expands courses to advance leadership and incorporate new challenges, such as the economy, that are currently facing hospitalists.”

Learning by unlearning

These principles have enticed more than 1,000 individuals to attend the Leadership Academy; according to post-event feedback, most graduates agree that it was one of the most useful leadership seminars they’ve attended.

SHM is currently working on an evaluation and assessment process to better quantify this information; however, Holman believes the best measuring stick is the accomplishments of past attendees who he has seen utilize what they’ve learned to produce orientations and full program operating manuals, to create and enact quality improvement initiatives, and to enhance recruitment and physician retention. “The academy lends a certain amount of confidence,” he says. “Attendees are more aware of leadership and management issues that they previously weren’t. I think they gain insights into their own leadership style [and can see traits] that may have been a barrier to effective leadership in the past.”

The fact that other organizations are interested in emulating the academy’s format and content, as well as exploring potential partnerships, shows that SHM is onto something. “One of the big successes has been the interest of other leadership organizations in the academy,” says Howell. “Executives of the American College of Emergency Physicians have taken notice of our program and there have been discussions between both groups [regarding collaboration].”

Howell also says that SHM is exploring how relationships with local hospitalist groups can further hospital medicine, but is quick to add that nothing is formal at this time and all discussions are unofficial.

The content in which these organizations are interested, and with what hospitalists can expect to walk away from the academy, is an introduction into the unlearning process. “Much of leadership development is in many ways unlearning things that we learned in medical school and residency, in addition to learning things that were never touched on,” explains Holman. “A lot of the early work people do is simply opening their eyes to a whole different world.”

Rugged individualism and linear thinking

Healthcare, Holman believes, could learn a thing or two from business schools, which stress the principles of collaboration and partnerships. “Teamwork is not taught well and in fact, in medical school and residency, doctors are taught to be rugged individualists.” Holman says that physicians are taught that decision-making is done by individuals who must then individually take responsibility for the decisions they’ve made. The idea of shared accountability is not present.

This mentality becomes ingrained to the point that teamwork is often viewed as a doctor telling others what to do. “It may be done nicely, cordially, and congenially, but nonetheless, we are at the top of the pyramid with nurses, social workers, pharmacists, etc, underneath. Patient care doesn’t happen that way.”

Hospitalists can also expect to learn the philosophy of delayed gratification by studying management styles that tend toward the proactive. “Physicians are reactive, very linear,” Holman explains. “When a patient develops chest pains, we react to symptoms, order diagnostic studies, and lab tests. We find out that the patient is having a heart attack, so we react with the medications and surgeries needed to get better.”

This mentality, Holman recognizes, is contrary to what a successful hospitalist needs to learn and why conflict resolution and business principles are integral to the academy’s course offerings. “Management leaders try to anticipate problems before they become problems. They look further down the road. Instead of reacting to things as they come up, managers and leaders accept delayed gratification. Physicians are much more accustomed to immediate gratification.”

Living the needs

These specific objectives encompass the goals of the entire academy curricula in a nutshell: to provide physicians with skills beyond what they were taught in traditional medical education settings. These skills, says Howell, are developed further every year.

“Within my organization, I first used the leadership lessons to implement a local QI project. Then I established that project across a few departments. Now I’m managing the inpatient services of the entire hospital across all departments. Every time I learn a skill set for leadership, I’m looking for two to three more to help manage change, to bring stakeholders to the table so that I can build on all of my skills and not throw any away.”

This, says Howell, is why the academy is, and must continue to be, specific and focused on the needs of the hospitalist. “We are living the needs ourselves.”

Bradley Schmidt is a freelance healthcare writer. His article “Where Do We Go from Here? A Health 2.0 Progress Report” appeared in the January 2009 issue of MDNG: Primary Care/Cardiology Edition.

Even if you can’t attend SHM’s Leadership Academy, Russell Holman says you can start building leadership skills now. Here’s how:

“Develop a mentoring relationship With one or more physician leaders in your institution that you respect and admire. I think that there is a lot of power in that kind of informal relationship. I personally have benefited from such relationships.”

“Engage in focused reading. This can be a good entry point into opening your mind to leadership and management concepts. There are a number of articles and books that you can read, a few examples being Good to Great by Jim Collins and ‘Physicians as Leaders in the Improvement of Healthcare Systems’ by James Reinertsen.”

“Another mechanism is to utilize courses offered by other organizations. The American College of Physician Executives offers a number of broad-ranging courses through in-person and remote learning opportunities, as does the American College of Emergency Physicians. There are also some very good courses through the American College of Healthcare Executives.”

“Look at taking on some added responsibility in your programs, whether it be assisting your current medical director in some fashion, taking ownership over a project that needs to be accomplished, or joining or leading a committee at the hospital. There’s no better way to learn than to jump in and do it. You can learn from your successes and mistakes whether you’re assisting the director or doing committee work. You’ll benefit from the fact that you’re in a well-supported environment with backup if you’ve overreached your boundaries.”