Physician leadership: enhancing the career development of academic physician administrators and leaders.

As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician-administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician-educator and clinician-researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.     

Selecting physician leaders for clinical service lines: critical success factors.

PURPOSE: Clinical service lines and interdisciplinary centers have emerged as important strategic programs within academic health centers (AHCs). Effective physician leadership is significant to their success, but how these leaders are chosen has not been well studied. The authors conducted a study to identify current models for selecting the physician leaders of clinical service lines, determine critical success factors, and learn how the search process affected service line performance. METHOD: In 2003 and 2004, the authors interviewed clinical and executive personnel involved in 14 programs to establish, or consider establishing, heart or cancer service lines, at 13 AHCs. The responses were coded to identify and analyze trends and themes. RESULTS: The key findings of the survey were (1) the goals and expectations that AHCs set for their service line leaders vary greatly, depending on both the strategic purpose of the service line in the AHC and the service line's stage of development, (2) the matrix organizational structure employed by most AHCs limits the leader's authority over necessary resources, and calls forth a variety of compensating strategies if the service line is to succeed, (3) the AHCs studied used relatively informal processes to identify, evaluate, and select service line leaders, and (4) the leader's job is vitally shaped by the AHC's strategic, structural, and political context, and selection criteria should be determined accordingly. CONCLUSIONS: Institutions should be explicit about the strategic purpose and stage of development of their clinical service lines and be clear about their expectations and requirements in hiring service line leaders.     

A curricular model for the training of physician scientists: the evolution of the Duke University School of Medicine curriculum.

Duke University School of Medicine offers an unusual doctor of medicine educational program. The core basic sciences are taught in year one, core clinical clerkships are completed in the second year, the entire third year is devoted to scholarly investigation, and elective rotations are fulfilled in the fourth year. The creation of this unique structure presented many challenges and is the product of a desire of key faculty 40 years ago to change radically the way medical education was taught. Over the years, improvements have been made, but the underlying principles of these visionary leaders have been retained: inquire not just acquire, flexibility of choice, and in-depth exploration. In the spirit of innovation that was established 40 years ago, leaders and faculty at Duke developed a new curricular model in 2004, called Foundation for Excellence, which is anchored in integrated, interdisciplinary innovation. The authors describe the process of curricular reform and provide a detailed overview of this unique approach to medical education. In keeping with Duke's mission to graduate clinician-researchers and clinician-educators, reducing the basic science curriculum to one year created a year saved, which students are now required to devote to scholarly pursuits. The authors argue that adopting a similar one-year basic science curriculum would make instructional time available for other schools to achieve their own institutional goals.     

Perspective: physician leaders and their bases of power: common and disparate elements

Physicians hold numerous types of leadership positions in academic, executive, and/or clinical environments. To be successful, physician leaders must exert power, or social influence, as power is conceptualized in social psychology. The power of leaders accrues through their positions, expertise, or other factors, such as communication abilities or their ability to influence others to identify with the vision they espouse. This article discusses the types of leadership roles that physicians play and the power types they must apply in these roles. Crossing all leadership roles are a series of necessary personal characteristics and interpersonal competencies that result in what has been called "referent power," a more subtle form of social influence that is crucial for success regardless of position. Leadership training that includes practice in cultivating these personal characteristics and interpersonal competencies should be an essential component of medical and graduate medical education. Studying the types and nature of power also would be a valuable contribution to courses on professionalism in medical practice. Examples are provided of the types and uses of power that may be applied in the various leadership roles that physicians hold.     

Values and ethics: a collection of curricular reforms for a new generation of physicians.

In recent years, medical educators have expressed concern that the reductionist-positivist mode of medical education fails to equip physicians with the skills and attitudes to meet the full range of patients' physical and emotional needs. Indeed, the authors suggest that neither patients nor physicians are satisfied. Among the factors responsible are a pervasive industrialization of clinical practice, a progressive segmentation of patient care, and a deepening shortage of both primary care and specialty physicians. But underlying these system issues is a lack of adequate schooling in the values, ethics, and culture of caring. Today's physicians must simultaneously be analytical, perceptive, and self-reflective. They must have the capacity to see their patients as individuals with differing psychological, social, and historical natures. And they must have insight into their own values and behaviors. All of this contributes to making a competent and humane physician. To aid medical students in achieving these characteristics, the authors contend that medical education must be radically restructured so that knowledge and skills are taught within the context of values and ethics. This commentary explores such reform through the lens of three articles published in the current issue of Academic Medicine, by Litzelman and Cottingham, Kanter and colleagues, and Dobie. These articles are the product of a national call that resulted in more than thirty abstracts, testimony to the fertile thinking already being applied to this problem. It is the authors' hope that this series of papers will stimulate still more thinking and lead to the curricular reform that future generations of physicians deserve.     

Bladder cancers. Their process of development and its modification

Much information on the development of bladder cancers and its modification has accumulated. It is generally considered that the presence of chemicals in the environment including carcinogens and modifiers (promoters, inhibitors, anti-promoters, etc.) is responsible for the geographical variation in human neoplasia including urinary bladder cancer development. A diagrammatic representation of the possible interactions between environmental factors and tumor development in man is shown in Fig. 6. Thus if potent carcinogens or promoters are present, neoplasia results, with tumor death occurring within an individual's normal lifetime. However, lack of such substances or the existence of powerful inhibitory factors is presumed to slow down the process, so that the normal life-span is not affected. It is therefore of prime importance for thorough awareness of the factors involved to be generated.     

Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers

Disorganized/Disoriented (D) attachment has seen widespread interest from policy makers, practitioners, and clinicians in recent years. However, some of this interest seems to have been based on some false assumptions that (1) attachment measures can be used as definitive assessments of the individual in forensic/child protection settings and that disorganized attachment (2) reliably indicates child maltreatment, (3) is a strong predictor of pathology, and (4) represents a fixed or static “trait” of the child, impervious to development or help. This paper summarizes the evidence showing that these four assumptions are false and misleading. The paper reviews what is known about disorganized infant attachment and clarifies the implications of the classification for clinical and welfare practice with children. In particular, the difference between disorganized attachment and attachment disorder is examined, and a strong case is made for the value of attachment theory for supportive work with families and for the development and evaluation of evidence-based caregiving interventions.     

Viewpoint: Developing a physician workforce for America's disadvantaged.

Eliminating health disparities will be difficult as long as many rural and disadvantaged inner-city communities remain medically underserved. The authors argue that the current debate on physician workforce policy has not adequately emphasized medical schools' social mission to educate physicians who will improve health care access and equity; fulfilling that mission means training students who will deliver primary care to underserved people. But fewer medical students are entering primary care specialties and practicing in underserved areas, and students who have the characteristics that make them likely to select such careers are increasingly uncommon among medical school matriculants. Unless there is a dramatic change, the imbalance will only become worse. The authors argue that the epidemiology of medical student career choice is sufficiently understood to permit schools to accept applicants with those characteristics, both demographic and individual, that are known to increase the probability of students caring for populations in need after graduation. Programs that have selected students on the basis of those predictors have been successful in increasing the distribution of doctors to primary care specialties and underserved areas, but these have not been of sufficient scope. The authors present a proposal for prioritizing medical school admissions to favor applicants who, rather than delivering just high grades, will contribute to improving America's health care outcomes.     

Effect of environmental factors on the development of allergic disorders in infancy.

A total of 1167 infants were followed for 1 year in a population-based prospective study to assess the effect of environmental factors on the development of allergic disorders. Some of these environmental factors are interdependent. Mothers who formula fed their infants smoked more often (p less than 0.001) and tended to belong to lower social classes (p less than 0.01). Logistic regression analysis was performed to adjust for these confounding variables. Maternal smoking adversely affected the prevalence of asthma (p = 0.003) defined as three or more separate episodes of wheezing and total allergy (p = 0.02). Infants in lower socioeconomic groups developed asthma significantly more often (p = 0.03) than infants born in higher socioeconomic groups. There was a nonsignificant trend for infants born in summer to develop asthma more than infants born in winter (p = 0.08). No effect of these factors was observed on eczema, food intolerance, or on the subgroup of infants with definite allergy (clinical disorder with positive skin prick test [SPT]). Exposure to animal dander did not influence the prevalence of clinical disorder, but positive SPT reaction to cat dander was more prevalent in infants who were exposed to cats and/or dogs (p = 0.04). Positive SPT to house dust mite occurred significantly more often in infants who were formula fed (p = 0.05). The environmental factors had a profound effect on the prevalence of asthma but not on other allergic disorders.     

The long-term effect of an innovative family physician curricular pathway on the specialty and location of graduates of the University of Washington.

PURPOSE: To report the specialty and rural/urban distribution a mean of 19 years after graduation for a cohort of students from a family physician curricular pathway. METHOD: Specialty and location information for medical students who had entered the University of Washington between 1968 and 1973 was obtained from the 1994 Physician Masterfile of the American Medical Association. RESULTS: Of the 239 family physician pathway graduates, 173 (72%) had intended family practice at graduation, and 136 (57%) were family physicians two decades later. The proportions of all graduates in family practice and of graduates serving rural Washington as family physicians had increased over that of a cohort of students who had entered the University of Washington prior to the introduction of the pathway curriculum. These proportions surpassed the goals set at the time the new curriculum was introduced. CONCLUSION: With early identification and support of students interested in family practice, an increased number entered the specialty and were still family physicians in mid-career.     

Relationship of diet in the development of atopy in infancy

We examined the relationship of diet to the development of atopic manifestations in a group of infants with an immediate family history of atopy, followed prospectively from birth for up to 20 months of age. There was no relationship between the development of atopic dermatitis, rhinitis and wheeze and either 2 or 4 months exclusive breast feeding, or the introduction of cow's milk or solids in the first 4 months of life. In addition there was no relationship between the introduction of milk, egg or wheat into the diet and the development of skin-test positivity to these foods. In fact, five infants developed positive skin tests to the food prior to its introduction into the diet, suggesting exposure via maternal breast milk. Thus we have been unable to show a protective effect of either breast feeding or cow's milk or solid avoidance on the development of atopic disease in infancy.     

Perspective: deconstructing integration: a framework for the rational application of integration as a guiding curricular strategy

In response to historical criticism, evolving accreditation standards, and recent reports on curricula, medical educators and medical schools have been eagerly pursuing integration as a goal of curricular reform. The general education literature broadly considers integration to be the deliberate unification of separate areas of knowledge, and it provides support for the concept that integration better meets the needs of adult learners in professional education. The use of integration as a curricular goal is not without its critics, however, nor is it free of difficulties in implementation. In this perspective, the authors propose that most of these difficulties arise from a failure to recognize that integration is a strategy for curricular development rather than a goal in itself, and they argue that adopting a systematic approach to integration offers many potential benefits. They articulate the conceptual and practical issues that they believe are critical to consider in order to achieve successful curricular integration, and they suggest that integration should be approached as a subset of broader curriculum development decisions. They propose a three-level framework for applying integration as a guiding curricular strategy, in which decisions about integration must follow curricular decisions made at the program level, the course level, and then the individual session level.     

Increasing the pool of educational leaders for UCLA.

The dual goals of the faculty Fellowship in Medical Education (MEF) program at the David Geffen School of Medicine at UCLA, established in 1992, are to prepare excellent teachers to serve as clerkship chairs, course chairs, or residency program directors while strengthening their dossiers for promotion based on a scholarly approach to curriculum development, implementation, and evaluation. Fellows are nominated from their departments and must demonstrate a strong interest in assuming educational leadership in their respective specialties. A total of eight fellows are accommodated each year based on interviews with the MEF faculty. The two-year program consists of two seminars and two projects focused on four objectives: to critique teaching and testing practices in medical education in light of current theories of learning; to develop and implement curricula that reflect these theories; to improve personal teaching skills through reflection and feedback; and to design and conduct an educational research or program evaluation study. An analysis of the curricula vitae of faculty members who have completed the fellowship suggest that this program continues to provide educational leaders for the school as originally intended. Of the 71 medical school faculty members who completed the MEF between 1993 and 2004 and have remained at the university, 43 (61%) have assumed new leadership roles in medical education. The evaluation data strongly suggest that the MEF has had a major role since its inception in creating a pool of faculty members with the confidence to manage the tasks of educational planning and implementation.     

Population medicine in a curricular revision at Case Western Reserve.

Inclusion of population medicine in a medical school curriculum has received growing attention. Recently, the Association of American Medical Colleges has highlighted this issue through support of the Regional Medicine and Public Health Education Centers initiative. The Case Western Reserve University School of Medicine joined this consortium while implementing a new curriculum in which population medicine would be an underlying theme woven with the classic science elements of disease. The organization for the first two years of the new curriculum, which was implemented in 2006, is a six-block structure during which the basic sciences are learned with key concepts of population medicine woven throughout. The focus for this article is Block One, in which population medicine is the major emphasis of the introduction to medicine. The first week, students learn social determinants, impact on communities, and social aspects of diabetes mellitus, even before addressing a patient's clinical presentation. Emphasis on student-centered learning is undertaken as part of the new curriculum, using a series of weekly, case-based, small-group sessions. This type of group learning is used throughout Block One as students encounter key components of population medicine. A thesis requirement was also introduced as a mechanism to emphasize research with opportunities for research in population medicine as well as other medical sciences. A variety of mechanisms are described to measure the outcomes of Block One.