Residency training just isn't what it used to be.
The residents who want to become tomorrow's hospitalists need to learn more than clinical skills to succeed. “Today's hospitalists are part of many different teams. They must lead teams of students and residents and teams that include health providers such as nurse practitioners and pharmacists. But they are also members of management and administrative teams,” said Edgar Pierluissi, MD, professor of medicine at the University of California–San Francisco (UCSF).
The expansion of hospitalists' roles and duties has made old teaching methods obsolete, said Diana Mancini, MD, a hospitalist at the Denver Health Medical Center and associate director of the internal medicine residency at the University of Colorado. “The paradigm of ‘see one, do one, teach one’ is not effective in providing the concentrated training residents need to lead teams,” she said.
Logistical changes in hospital medicine have exacerbated the need for leadership as well, Dr. Mancini said. “As medical centers comply with work-hour restrictions, it becomes more important for hospital medicine residents to learn leadership skills because they will be working with teams that can change as often as every three or four hours,” she said.
To some, these skills come naturally. “There is a certain subset of residents who can come into an environment, ascertain what's there, and…titrate care or alter communications or goals according to the situation,” said Dr. Mancini. But not all can do this. “Others might struggle with team dynamics. That's why we need to provide leadership training,” she said.
Many hospitals, health systems, and academic medical centers have developed such training, focusing on business and management skills that will help internal medicine residents prepare to become leaders.
“Although they can learn leadership skills on the job, leaving that to chance is really not in the best interests of either patients or hospitals. Residents need some other, more targeted way of learning how to lead,” said Dr. Pierluissi.
Hard skills, soft skills
Although no two residents will be alike in terms of their strengths and weaknesses, prior training, and chosen career path, all residents should come out of leadership training with both hard and soft skills.
Hard skills include strategic planning, process management, and technical or administrative procedures. Leadership training should foster understanding of why these skills are necessary, said David Gallagher, MD, ACP Member, chief of hospital medicine at Duke University in Durham, N.C. “For example, residents should be able to see why it's critical that discharge summaries follow a certain template. You can tie procedures like that to the bigger picture of the cost of readmission, both for the patient and the hospital.”
Soft skills include team building, listening, communication, negotiation, and conflict resolution. These come into play when hospitalists seek to apply their hard skills in ways that can affect a hospital's procedures, explained Dr. Gallagher. “Hospitalists are in a unique situation in that they work all over the hospital. They are in the trenches, so they can advise administration on goals that are achievable and strategies that may or may not be good ideas, but they need to be able to communicate to do this effectively,” he said.
Communication and listening are particularly important when working in interdisciplinary teams. “There has to be an understanding of the other parties involved—nurses, pharmacists, social workers, and others actively involved in patient care—and how the forces at play in their profession will affect a team's ability to reach its goals,” said Dr. Gallagher.
Dr. Mancini agreed. “Hospitalists need to be able to step outside a situation and see it as other members of the team see it, and they have to be able to negotiate and navigate the situation to completion,” she said. In addition to the perspectives of other professions, future hospitalists need to understand generational differences, because they may find themselves leading teams that include older clinicians who have already been in practice for 25 or 30 years.
Each hospitalist residency leadership program will differ on the finer points, but the experts agree that experiential learning is critical. At UCSF, residents participate in group projects where they learn time management, handoff, and presentation skills as well as how to build coalitions and communicate their vision to other staff members, said Dr. Pierluissi.
“We want hospitalists to be able to build an environment where everyone feels safe in bringing up concerns and suggestions, and where team members can share mental models,” he said. “But at the same time, we want hospitalists to be able to communicate expectations clearly and present the results of their efforts effectively.”
Local medical leaders, public health officials, and entrepreneurs in health technology speak to the residents at UCSF about leadership, the better to illustrate how leadership skills are essential in different areas of health care, said Dr. Pierluissi. “We invite physician leaders from administrative, business, philanthropic, and academic settings to share what they've learned and discuss how they make decisions in their areas of expertise.”
Dr. Mancini encourages hospital residency leadership programs to tap into the collective knowledge of leaders in a variety of fields. Together with her husband, Samuel Mancini, a former Army officer who trained at West Point and has a background in business, Dr. Mancini created a two-year curriculum on leadership that focuses on business strategies and uses examples from outside the medical sphere.
“We've had politicians speak about conflict resolution, people from the aerospace industry talk about safety, and executives talk about why this or that business failed. Then we ask the residents if they can think of times when similar situations occurred in medicine,” Dr. Mancini said. “Sometimes residents hear the message better from people who are outside medicine, so they don't end up focusing on the clinical aspects of medicine itself.”
Residents in Duke's Management and Leadership Pathway for Residents participate in 18 months of project-based management modules and have the opportunity to take courses at Duke's Fuqua School of Business, School of Law, and Terry Sanford School of Public Policy. According to Adia K. Ross, MD, MHA, ACP Associate Member and a resident in the program, much of the learning is process-oriented, which she says will help her be a more effective leader.
“We learn how to think in terms of patient metrics, who needs to be involved, and who will be affected downstream,” she said. “We learn that if you can demonstrate that you understand where [others in a process] are coming from, you can get more buy-in.”
Other programs, such as the Cleveland Clinic's 10-month Leading in Healthcare course, include a local angle with the goal of enhancing leadership within a health system. One of the course's three content areas focuses specifically on Cleveland Clinic culture and history. The other two content areas cover health care finance and leadership skills such as emotional intelligence, situational leadership, conflict resolution, and team-building.
Although Leading in Healthcare is designed for Cleveland Clinic staff, chief residents are eligible to participate in a two-day summer express version. The information is compressed and focused on specific topics such as organizational development or finance and accounting, according to James K. Stoller, MD, FACP, a professor of medicine at the Cleveland Clinic.
“In the four years we've offered the retreat, 86 chief residents have participated, and the feedback is that they feel it increased their level of comfort in resolving issues,” said Dr. Stoller, noting that the Cleveland Clinic is looking into researching whether the retreats change resident behavior.
Dr. Stoller stressed that retreats or intensive seminars of this nature should have follow-through back at the hospital. “Keep the residents connected with faculty who can help them react to their learning, and who can model the leadership behaviors,” he said. “The learning has to be grounded in the reality of medical training, and embedded in the culture of an organization.”