Hanna Renaldi's Blog: The Importance of Teaching Management in Medical School [Episode 232]

Johns Hopkins Armstrong Institute For Patient Safety & Quality

Do physicians need leadership skills to be good doctors? Johns Hopkins professors Dr. Peter Pronovost and Dr. Chris Myers make an excellent case that the leadership elements of management should be a mandatory part not only of physician training, but of continuing education.

Here’s how and why management skills can make you a better doc.

What motivated you to research the need for management skills in clinical medicine? [1:46]

Dr. Pronovost: Doctors increasingly are expected to lead teams growing in complexity. These teams are expanding in numbers and geography, but the skills physicians need to do that are not formally taught, and as a result we often see disastrous outcomes. We know that teamwork and communication failures are one of the major causes of preventable harm – 120-160K deaths per year. We’ve seen change management programs stall because people don’t practice basic management skills. Good management matters, and is absent from many healthcare organizations. We need to make sure that medical students are ready when they come onto teams to utilize these skills.

Dr. Myers: Adding this training for medical students is critical. People think management skills are only needed later in their career, but when we think about frontlines it is often junior people making decisions. Medical students who have just graduated and are starting internships will be put in charge of small teams of providers and coordinate increasingly complex care. They need to learn leadership skills early in the process instead of playing catch-up.

What skills do you feel are important for physicians? [5:39]

Dr. M: We focus on leadership and hands-on management skills. While it’s important to understand finance, there are specialized people working in those areas. Every type of practice environment needs to be managing interpersonal dynamics, creating good relationships, motivating team members, coordinating information sharing between groups and units, and being attentive to processes of change and aspects of broader organizational culture.

Dr. P: As we thought about where best to focus efforts and what are the best skills and competencies that physicians need every day – influencing interpersonal relationships, information sharing, sense making came to the fore. We focus on things physicians need to do every day, and if they don’t do them well, organizations and physicians themselves suffer.

Where and how should management education be integrated in medical school curriculum? [10:01]

Dr. P: The training for med students is so chock full and every minute is precious. Getting anything added is a struggle. Part of the challenge is the curriculum hasn’t evolved from facts to theory – schools are cramming facts down students’ throats to remember them. Most facts will be outdated and maybe wrong by the time they graduate. We need to accept we’ve lost the facts race – teach theory and concepts so you can build upon facts and frameworks to learn. That is an opportunity to guide where we train.

The second opportunity is navigating curriculum where gaps will cause the most harm. In areas where doctors are suffering because of a lack of these skills, how can you not fit management in is our argument.

Dr: M: It’s a lot easier to Google the right dosage of a drug, rather than Google “How do I motivate a team?” We have an opportunity as medical education has evolved. Before, you’d have to have a whole career’s worth of experience to understand how to approach a management problem. The rise of high fidelity simulation can be used for clinical scenarios but also for interpersonal management competencies.

Dr. P: Med school scientists are almost all basic and clinical scientists, with preciously few social or management scientists. Most medical schools don’t have social scientists, and they need them.

If you could design the ideal management curriculum for medical school, what would it be? [15:02]

Dr. M: I’ll preface my answer with what we see in traditional management training in business schools – students learn the same concepts in undergrad, learn them again as MBAs, and then again in executive education courses 10 years later. Management curriculum for physicians has to also be a repeated ongoing conversation just like we have repeated ongoing education about disease processes or forms of practice. We would hope opportunities students have in med school provide a solid foundation in fundamental theories and frameworks of organizational sciences, just like for MBAs and Exec Ed for more seasoned business managers. We need to create corresponding opportunities for residents and fellows, and later for attending or community physicians, to reinforce viewpoints from an organizational scientist perspective as opposed to the situation now, which is a hodge-podge of training opportunities.

Dr. P: We hope to instill a framework that will develop as a journey over their life. In residency you reflect, meet with colleagues, and continually refine skills. These types of action learning cycles don’t exist for management practices, and yet failure of management practices are a major cause of harm.

Would you want to make some of these requirements part of medical school and then later on in continuing education? [18:06]

Dr. P: Yes, and here’s a concrete example. We have gone into states and pulled doctors for some of our projects. In every one of the states, participating doctors realized the softer stuff is really important but they have no one on staff to talk to about this. They asked, “Can we get together a learning group or dinner group to talk about this stuff and grow our skills together?” The hopeful piece is they want to learn it, but without proper structures or frameworks their efforts might not be as impactful as they could be.

Linda: That makes sense. You can go to a seminar and it is really powerful and you decide to use the techniques, but if you don’t have reinforcement and practice you tend to fall back into old habits.

Dr. M: Exactly, which is one of the reasons why it’s so important to get these skills into medical education. There is a direct benefit of everyone having more understanding, but an indirect benefit for people who have already individually gone off to learn these skills because they realized the importance. When they return and try to implement them somebody says, “That stuff is really hokey, I don’t understand what you are trying to accomplish here, why did you waste a whole weekend doing a course like that?” They encounter real negativity and cynicism about the ideas and it stops the development in its tracks, which wouldn’t happen with a common foundation of understanding. We need to impress upon the entire organization the importance of this to not quash what progress individuals are making.

With the long track of med student to resident to attending, even if you teach management in medical school, if you don’t have the reinforcement, isn’t there a mismatch between learning the skill and when you are in a leadership role? [21:46]

In your article in Academic Medicine you were critical of the haphazard way in which management skills are acquired or not acquired by physicians. But if physicians in training take management classes when they are at the bottom of the totem pole as medical schools students, will they retain the skills when they are in leadership positions and really need them?

Dr. P: The way I think about this is leadership as more a set of behaviors as opposed to a role. A med student/resident could practice in this way: A nurse comes up and is really worried about Mrs. Jones. She doesn’t look as good as she did before, but your attending said a few hours ago Mrs. Jones is looking good and will go home this afternoon. And you know your attending is very busy and doesn’t want to be bothered, so you need to think about who might be able to get a different picture of Mrs. Jones because you think she doesn’t look good. Do I call the attending or is there information I should get before getting him/her involved? How do I navigate that? Sounds like a simple example, but that is real life/death, getting diagnoses right or identifying deteriorating patients.

We did a study on when sentinel events happen, when lots of harm happens, we looked at how many times somebody knew something was wrong, but didn’t speak up or spoke up and didn’t get any attention or wasn’t listened to. Any guess? Over 90%! This is a classic management tool of how to move a team. So, med students/residents don’t have formal authority, but they need all the skills just discussed multiple times a day.

Dr. M: There are opportunities to influence as well. We talk with our MBA students and they certainly don’t have positions of authority early in their careers, but they do have informal opportunities to influence. While we certainly hope this curriculum gets into medical school, we are waiting for the next generation to disseminate more broadly. We hope to see opportunities for organizational sciences and frameworks to train existing physicians in a condensed fashion.

Dr. P: What we’ve seen is if students don’t see role modeling these skill sets quickly get extinguished. We learn that in a very real way when talking about patient safety and speaking up about mistakes and reporting events. Resident training lagged longer so it was hard for training to stick when not reinforced by superiors.

For current or soon-to-be medical students and physicians whose programs do not yet offer these classes, what can they do to acquire these skills? [27:23]

Dr. P: I make this exact parallel to safety training. A few years ago, despite safety being a major killer, it wasn’t taught in medical school, and even now it tends to be a one-hour lecture as opposed to a real course, but much of that change was brought about by the students participating in seminars or forums. This is essential content you need to be a great doctor, so go to your vice dean or others in charge to get this added. So any students who aren’t getting this should advocate that their school look into it. If a school isn’t doing that, there is a variety of curriculum offered, often from business schools, and get some formal training with a peer or colleague but continue the learning journey together. You then have a forum to reflect on what you are doing well, where you need skill building, and you can give feedback and support as they develop their skills as well.

In your article you point out that large health organizations frequently take excellent clinicians and make them administrators. Would these healthcare organizations do better with professional managers as opposed to clinicians who either have no management or just a small amount of management training? [29:52]

Dr. M: Given the complexities of healthcare, it is always helpful to have that clinical experience or perspective, but it’s not a guarantee of effective leadership or management. Sometimes we don’t go past the initial question of, “Who is our best clinician? Ok, they’re in charge now.” We call this on paper as a double loss. Not only are we taking our best clinician out of their clinical practice, but we’re on a hope and a prayer that those good clinical skills will translate to good management skills. There is a growing body of evidence that demonstrated that hospitals that have stronger management capabilities have better patient outcomes and better performance, so to the extent you can pair good clinical experience with strong management skills you want to do that. Whether that be providing serious time for those clinicians to study and get up to speed on critical skills or collaborative leadership arrangements to represent all the skills necessary, the data is pretty clear at this point. That is a significantly better way forward.

Dr. P: Given the complexity of medicine, organizations are well served to have physicians in a leadership role. People often think of it as a dichotomy – I’m a physician therefore I’m automatically a good manager. I’m a good clinician and would be excellent to run the organization. What’s more important to identify is what are the skills needed in this role and having an understanding of clinical work might help, but certainly being excellent in leadership and management skills is also required. Administrators can do an excellent job without clinical experience if they bring the management piece and are humble enough to partner with and learn from clinicians. Same goes with clinicians.

Dr. M: With the rise of simulations, we have an opportunity to assess these skills. What I hear from clinicians is, “I have great data on their clinical outcomes, but how will I know if they will be a good manager?” There is a recent article in the journal Academic Medicine of a group who used interpersonal skills simulation as criteria for hiring their new department chair. They simulated a difficult conversation with a faculty member acting out in role play. This was revelatory. Suddenly people who looked great on paper could be seen as having no orientation, framework, or logic on how to address these types of conversations, and this method really revealed insight they wouldn’t otherwise have. Using simulations not just in clinical capacity but in day-to-day management skills is a great opportunity that goes underappreciated.

How does Johns Hopkins Medical School incorporate management into its med school curriculum? Or does it? [37:54]

Dr. P: I wouldn’t call it management per se, we have a patient safety course that covers many skills – teamwork and communication, conflict resolutions, and there is a transition to the wards course – which of course includes the clinical exam, how to draw blood, but there is also working as a team, interpersonal and inter-team dynamics, but I would love to see much more and more formal training in this area.

As I read your article I expected you to come from the position of if you teach management, you’ll be much more efficient and have cost savings, but your argument is that you will have better patient outcomes. [38:59]

Dr. P: I think there will be cost savings, because there is a lot of inefficiency and waste in healthcare (another keen interest of mine is negative labor productivity despite investing heavily in technology). So there is enormous opportunity to bring some broader management discipline to bear, but bigger impacts will be on better patient care and outcomes.

Dr. M: They go hand in hand, not having to readmit patients. The goals of reducing costs and improving care are not independent.

Any questions you would have liked me to ask you? [39:56]

Dr. M: I’ll just reiterate the point that students have an opportunity and voice to request and encourage medical schools to make these skills more available. As I speak to senior medical students and residents they are all painfully aware that they don’t feel adequately prepared to deal with the interpersonal and professional challenges they will deal with on a daily basis. Rather than simply accepting the curriculum is going to be what it’s going to be, they are active players in shaping the opportunities they have to hone these skills and building the capacity to be a more effective clinician going forward.

Dr. P: I would love to hear if students or people listening decide to advocate how the movement is going.

Where can listeners learn more about your work? [41:33]

Dr. M: On Johns Hopkins Carey Business School website or you can follow me on Twitter at @chrisgmyers for articles and updates related to this area.

Dr. P: The Armstrong Institute’s website has a lot of training and content and programs that students might be interested in regarding management and improving patient outcomes.