The Journal of Pediatrics
Volume 150, Issue 5 , Pages 451-452.e1, May 2007

Leadership in Academic General Pediatrics

  • Tina L. Cheng, MD, MPH

      Affiliations

    • Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
    • ,
  • Peter G. Szilagyi, MD, MPH

      Affiliations

    • Department of Pediatrics, the University of Rochester School of Medicine, Rochester, New York.

Article Outline

 

As the environment in academic medicine becomes increasingly complex and as new healthcare delivery systems, technologies, and scientific advances stimulate change, the need for effective leaders becomes paramount. Leadership has been defined as “creating the future by initiating and sustaining change in areas where there is no precedent, as well as seizing the opportunities offered in the present.”1 There is emerging interest and movement toward physician leadership.2, 3 Physicians, however, receive little training in administrative, management, and leadership skills. Medical school and residency education changes lag behind clinical practice and system change. Lane and Ross state that “physician leadership is critical for attaining balance among conflicting pressures for quality of care versus cost containment, prevention versus high-technology medical intervention, and application of specialized versus primary care.”4

The changing landscape for children and adolescents highlights unique issues requiring leadership. The growing number of children in poverty,5 threats to health insurance coverage, and the rising burden of chronic physical, mental, and social disorders all directly affect clinical care. Clinical programs increasingly consist of multidisciplinary teams with physicians as leaders but others as experts in specific fields. Similarly, funding of the education and research missions in pediatrics is precarious. Successful research programs have become multi-faceted, requiring leaders who manage people as well as scientific investigation.

More than 15 years ago pediatric leaders highlighted the emerging role of the division chief. Fiser noted that “division leaders in academic medicine today must have many of the preferred requirements for chief executive officers of large corporations …  [they] must have some working knowledge of business administration, must be sensitive to the changing circumstances of the medical marketplace, and must also understand that marketplace pressures cannot be permitted to detract from or interfere with the work of individuals in research, excellence of care, or teaching.”6 Stapleton added: “Division chiefs are expected to develop clinical programs, administer budgets, supervise office personnel, educate medical students and residents, recruit faculty, develop research programs, train subspecialty fellows, and maintain their personal academic productivity.”7

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Need for Leadership Training in AGP 

Academic General Pediatrics (AGP) is a relatively new field, having established its national organization—the Ambulatory Pediatric Association (APA)—in 1960. AGP has progressed through the 1990s when the field was characterized as potentially “endangered,”8, 9, 10 to its current state as an established field facing new challenges of expansion and integration with other fields within healthcare.11 General pediatric divisions play a significant role in clinical care, education, research, and advocacy in their institutions. The generalist orientation, including individual and population health, research translation to practice and policy, and a broad view of health systems, is critical for our nation to achieve Healthy People 2010 goals of improving quality of care and eliminating disparities in health. Generalists bridge disciplines necessary for assessing and addressing future healthcare needs including epidemiology, health policy, community health, and the academic and practicing pediatric community. Academic generalists have developed a major role in the care and study of the child with emergency and inpatient needs, and the child with complex chronic conditions.

The field of AGP faces change. With changing family demographics and needs, technological and scientific advances, expansion in emergency, hospitalist, as well as community-based care, shifting workforce, and calls for reform of well child care,12, 13 there is a need for strategic planning and strong leadership in visioning and preparing for the future.14 In AGP, balancing the missions of clinical care, education, research, and advocacy is a continuing challenge. Workforce concerns include declining resident interest in primary care15, 16, 17 and in academic fellowships,18, 19 reduction in funding of Title VII primary care programs that support many training efforts including fellowships, and concern that many fellowship-trained pediatricians are choosing clinical-oriented careers rather than traditional academic careers.20 As a relatively young field with predominance of junior faculty in AGP divisions, leadership development is of particular importance.

Turnover rates of leaders in pediatrics emphasize the need for leadership development and succession planning. A recent survey of pediatric department chairs found that the mean annual turnover rate was 17%21; a survey of division directors of AGP divisions found a similar rate with many interim directors.11 Not surprisingly, when AGP division directors were asked about training needs, leadership skill development was most frequently mentioned.11 A recent survey of the 1800 APA members asked about new initiatives APA might sponsor to support their professional goals. Leadership skills were frequently mentioned including “training on how to run a division” and “faculty development programs that can be replicated and potentially offered regionally” (C. Minkovitz, MD, MPP, personal communication, November 2006).

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New Skills for Future Leaders 

McKenna and Pugno delineate four types of physician leadership needed in healthcare today including leadership to enhance clinical excellence, promote organizational effectiveness, advance and disseminate evidence-based innovations, and advocate for reform of healthcare policy, laws, and regulation.2 Much literature exists on healthcare leadership but less on competencies specific for physician leaders. Some have delineated physician competencies to include skills in communication, leadership, interpersonal skills, self-motivation/management, organizational knowledge, organizational strategy, administrative skills, and thinking.22 One survey noted that interpersonal and communication skills, professional ethics, and social responsibility were most important for effective physician leadership.23

Leaders of today need to be more knowledgeable and sophisticated to function in an increasingly collaborative and global world and to lead new technological and scientific initiatives. Training needs focused on the changing healthcare environment include quality assurance, clinical benchmarking, decision-making, strategic planning, communication skills, organizational change, effective listening, and systems thinking.24 Medical practice executives identified key future needs including a population and broad perspective on healthcare, strong planning, conflict management, financial management, team building, and communication skills.25, 26

In AGP there are particular leadership skills relevant for future roles. Emerging roles for primary care pediatricians include chronic care coordinators, multidisciplinary team players, genomic interpreters, community collaborators, and hospitalists.14 These roles suggest that team building, and interpersonal and cross-disciplinary communication skills may be particularly important.

Leadership skills have been described as the “process skills that provide the framework for accomplishing all other professional responsibilities.”27 General skills are critical; however, a challenge in leadership training is making it relevant across disciplines and to local circumstances. Training must include specific technical skills, reflection and enhancement of personal leadership characteristics, and must emphasize application across disciplines and institutions.28

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The Leadership Training “GAP” 

Though record numbers of physicians are earning degrees in management, business, health administration, and public health, many in MD dual degree programs, concern remains about a leadership “gap.”2, 29 Management, administration, and leadership training is not a formal part of medical training despite the importance of these skills in practice.30 Some suggest that training of clinicians and managers is culturally different in norms and values.31 For instance, clinicians are trained to be autonomous decision-makers, whereas managers are planners, team players, and delegators.32, 33 Schwartz also notes that private industry focuses on the internal development of leaders, whereas academic medicine fills many leadership positions by outside recruitment, potentially disrupting continuity of institutional goals.33 It is widely recognized that leadership skills can be taught and medicine must transcend cultural differences and develop leaders.

Current leaders are often chosen because of excellence in clinical care, teaching, or research, not necessarily for demonstrated administrative or leadership skill.7 Although leadership programs have been developed at some institutions or through organizations such as the American College of Physicians Executives and the Association of American Medical Colleges, many leaders have not had the benefit of this training and much learning occurs experientially on the job. Many advocate that the undergraduate medical curriculum introduce and reiterate topics of healthcare economics, organizational behavior, financial imperatives, outcome measures, and leadership training.34 Developmental educational opportunities must address the leadership gap and focus on other leadership gaps including women and minorities.35, 36

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Strategic Planning for the Future 

The need for leadership development in AGP has led to the convening of the first National Leadership Conference in Academic General Pediatrics in Spring 2007. The APA has led this effort with involvement of the American Medical School Pediatric Department Chairs, Inc. (AMSPDC) leadership. This conference targets division directors, current and future leaders in AGP, will teach leadership skills and discuss the future of AGP. Department chairs were asked to nominate current and future leaders to participate in the conference, and the response has been overwhelming. In pediatrics, other leadership development efforts have been initiated including the American Academy of Pediatrics’ Pediatric Leadership Alliance.37 These efforts offer models for ongoing planned efforts to develop leaders to influence the future.

Leadership conferences, however, are not enough. Ongoing development that addresses general, discipline, and institution-specific issues are needed. Education on leadership must be developed as a core competency and begun in medical school. Multimodal methods for training beyond degree programs and conferences must be developed and evaluated including Web training, mentoring programs, and community service experiences. Some feel that coaching or mentoring from an experienced leader and on-the-job experience are the most effective means for developing physician leadership.25 Leadership training requires a commitment of resources and release time for individuals to develop expertise. Finally, academic physician leaders often require unique skills and different measures of academic productivity. This role must be valued and recognized in academic promotion.38

Although recent activity in leadership development is promising, research is needed on its effectiveness including the knowledge, skills, and attitudes necessary for change.39 There has been progress in the development of evaluation measures of pediatrics leadership training38; however more work is needed on outcomes. Long-term tracking of individuals and outcomes and developing best practices must be part of this effort. To address the future, continuous strategic planning and quality improvement mechanisms, creation of developmental opportunities for future leaders, and explicit succession planning are crucial. Forward-thinking leaders and their development are of strategic importance for improving the health of children, adolescents, and families.

References available at www.jpeds.com.

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References 

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PII: S0022-3476(07)00032-7

doi:10.1016/j.jpeds.2007.01.014

The Journal of Pediatrics
Volume 150, Issue 5 , Pages 451-452.e1, May 2007

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