Transforming medical competency into medical management capability : developing physician leaders by finding management in medicine

Abstract: Background: Management thinking has made inroads into health care, but the relationship between medicine and management is often described as one of competing logics. Given a recognized need for bridging the two logics, studies have been conducted to better understand the role of clinicians in the leadership and management of health care. Several reviews have concluded that clinically trained leaders have a positive impact on hospital performance. While management and leadership competencies have been incorporated into all levels of medical education and training, research suggests that current medical leadership development practices yield limited success. The ever-changing health care context expects medical leaders to learn how to use and adapt their medical competencies in uncertain environments to address unfamiliar challenges, i.e. develop medical management capabilities. Leadership development programs which engage physicians in addressing complex challenges of health care, are pedagogically sound, and resonate with the professional ethos of the physician role warrant research and development. Aim: The aim of this thesis is to deepen the understanding of how to better develop medical management capabilities of physicians and to apply this understanding in the design and evaluation of a leadership development program that is anchored in medical practice. Methods: This thesis is an action research project conducted in a learning partnership with the Karolinska University Hospital. It resulted in the design, delivery, and evaluation of a medical leadership development program. This thesis is comprised of three sub-studies that combine multiple qualitative methods for data collection and analysis. Study I explored the qualities and capabilities effective physician leaders attribute to their success in leading change and how they developed these. It was based on twenty in-depth semistructured interviews with emerging and senior health care leaders in Sweden and the design was informed by Appreciative Inquiry. Study II systematically explored conditions that can either facilitate or impede the influence of medical leadership on organizational performance. The systematic review included seventythree empirical studies and literature reviews which were analyzed using thematic synthesis. The findings of Study I and II were combined with seven observations (42.5 hours) and interviews with prospective program participants in order to develop a program theory about medical leadership development and articulate Context-Intervention-Mechanism-Outcome (CIMO) configurations. This resulted in a design for a medical leadership development program for Patient Flow Managers. In Study III, a realist evaluation design was used to explore the CIMO configurations and program theory. It utilized prospectively and retrospectively collected data from direct program observations (30 hours), program team participatory observation notes, two post-program focus group interviews (n=12), and participants’ summative evaluation forms in order to unpack the underlying mechanisms of participants’ learning processes. A revised program theory for medical leadership development was formulated. Findings: Study I suggests that medical leaders who make positive contributions to health care organizations and systems are driven by a purpose to improve health care and exhibit qualities of endurance, positive outlook, and authenticity. They ground management in medicine by understanding the medical consequences of managerial decisions and employ a scientific approach to understanding problems and measuring progress. They engage others and act on interdependencies. Such qualities and capabilities are developed as a result of a diversity of work experiences, reflection, and an organizational environment that nurtures learning and ambition. Educational initiatives add value when they are integrated with practice. Characteristic of thematic synthesis, Study II proposes a hypothetical model that comprised of a virtuous cycle of management through medicine and a vicious cycle of medical protectionism. The virtuous cycle illustrates how willing leaders, when supported by leadership development embedded in quality improvement, are likely to foster participatory leadership practices that cultivate medical engagement. The vicious cycle illustrates how incidental leaders, less interested in their own development, tend to adopt and mimic historically dominant management approaches, i.e. management through command and control, which leads to medical disengagement and perpetuates the risk of recruiting incidental leaders. The leadership program for Patient Flow Managers, Leading in Complexity, was delivered as part of an action learning program. Through three iterations, a total of twenty-eight physician managers worked in small groups to address their leadership challenges. The program provided a space to connect around improving everyday operations supported with theory and evidence from medical management research. The revised program theory, presented in Study III, suggests that in the context of a university hospital, medical leadership development needs to be supported as a deliberate practice of grounding management in medicine, permeated by psychological safety, a learning orientation (cultivating a growth mindset, surfacing and challenging mental models, establishing routines for learning, supporting presence, and metacognitive processes), and a scientific mindset. The program should be anchored in participants’ everyday challenges and embedded in the organization’s strategy as new ways of leading operations and improvement are being developed, studied, and assimilated. Conclusions: This thesis looks anew at the relationship between medicine and management. When jointly purposed to improve health care, they have now a clearly established value in what they together can create for health systems, service providers, and patients. Medical competency can be transformed into medical leadership capability by grounding management in medicine through deliberate leadership practice permeated by psychological safety, learning orientation, and a scientific mindset. The research process employed in this thesis implies that action research collaboratives around university hospitals’ leadership and organizational challenges could be created to design responses to complex challenges while contributing to the scientific body of knowledge in medical management.