Advanced degrees for surgeons and their impact on leadership

Good leaders are made not born. If you have the desire and willpower, you can become an effective leader. Good leaders develop through a never ending process of self-study, education, training, and experience.¹
—A.G. Jago

Leadership is defined as “the process of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task.”² In 1935, physicians were in charge of 35 percent of the hospitals in the U.S.³ In contrast, in 2009, physicians headed fewer than 4 percent (235) of nearly 6,500 hospitals.⁴ Inadequate leadership education and preparation in the curricula of most U.S. medical schools and residency programs has contributed to this shift. Success in academic medicine requires scientific and clinical aptitude. However, a hallmark of accomplishment that receives little attention in medical school curricula is aptitude for leadership and organizational skill. In particular, physicians must learn and apply advanced skills in recruitment, retention, communication, conflict resolution, and strategic planning.

In the past, physicians acquired most of these skills through passive observation of peers and mentors, who were sometimes inconsistent in their behavior as role models. With more specialized leadership skills required, pursuit of a second degree might facilitate preparation for leadership positions. Medical schools have taken note of this new interest among students and physicians, which is reflected in the increasing number of dual-degree programs (MD/MBA, MD/PhD, and MD/MPH) available throughout the U.S.

In surgery, a growing number of surgeons in leadership positions have dual degrees. This article explores the motivations behind pursuing dual degrees, as well as the impact they may have on preparation for leadership roles. What is the unique perspective of the traditional physician-scientist, MD/PhD, in helping to guide academic surgery? How does new emphasis and interest in international surgery benefit from more surgeons with MD/MPH dual degrees? How does an improved business perspective achieved through an MD/MBA help inform surgeons who interact as much with hospital administrators and investors as they do with patients? This article addresses these and other pertinent questions for surgeons in this evolving profession.

Physicians pursuing an MBA

The increasing complexity of health care delivery and declining reimbursement have prompted physicians and physicians-in-training to evaluate whether excellent clinical education alone is enough to sustain a successful career. Some senior physicians are taking management and business courses, while others are taking on more extensive training to obtain an MBA. Physicians-in-training are following suit. The number of MD/MBA programs has increased dramatically over the past 30 years, and there are now more than 65 such programs in the U.S.⁵

“When you get an MBA, you learn a new language,” said Robert Udelsman, MD, MBA, William H. Carmalt Professor and chairman of surgery, Yale University, New Haven, CT. “It’s been helpful to me in understanding how funds get channeled through departments and hospitals and how different institutions work. Before getting the MBA, my only financial knowledge came from buying a house, paying a mortgage, managing a section, and funding grants.” (Personal communication with Dr. Zheng, February 3, 2012.)

The MBA curriculum generally consists of a foundation of core classes divided along the traditional business verticals of strategy, operations, finance, marketing, leadership, and human resource management. Elective courses delve into industry or country/region-specific topics—such as health care operations, provider strategy, and medical device commercialization—and develop both analytical and soft skills, such as model and simulation building and negotiation, respectively.

A 2007 survey of MD/MBA degree holders indicates that the most pertinent skills these individuals had acquired were those related to “evaluating systems, operations, and implementing improvements, learning how to be an effective leader, comprehending financial principles, working within a team, and negotiating effectively.”⁶ Though there is high variability, most surgical training programs do not provide formal training on negotiation, health care process improvement, or financial principles.

“We shouldn’t think of academic surgery only as teaching, basic science research and clinical work anymore,” noted Lynt Johnson, MD, MBA, FACS, Robert J. Coffey Professor and chairman of surgery, Georgetown University, Washington DC. “Leadership comes in many flavors. In the next 10 to 20 years, I think there [will be] tremendous opportunities, in both departmental leadership and hospital leadership, for surgeons with a background in business.” (Personal communication with Dr. Zheng, March 20, 2012.)

The decision to pursue an MBA is dependent on individual career aspirations. Those who embark on joint-degree programs often look to broaden their careers outside of clinical work. MD/MBAs are often recruited into management positions at bio-pharma and medical device firms, as strategy consultants for management consulting firms, and as associates for investment banks, sometimes without completing a residency. Physicians with entrepreneurial inclinations also find that an MBA may be helpful in building the professional networks necessary to launch a new device or commercialize a new technology.⁷ Senior physicians with increasing administrative responsibilities often pursue an MBA to communicate more clearly and negotiate more effectively with other hospital administrators and executives.

Two traditional paths currently exist for MD/MBAs. College graduates may apply to one of the 65 MD/MBA joint degree programs currently available, and senior physicians may decide to take evening and/or weekend classes in pursuit of an executive MBA. Though less common, a third pathway exists for residents wishing to pursue an MBA during their “research years,” if their chair and program director see value in formalized leadership and business training. Lastly, new leadership tracks such as those at Duke University, Durham NC, and the Methodist Hospital in Houston, TX, now enable MD/MBA graduates to leverage their MBA skills in administrative rotations while in surgical residency.

Pursuing an MBA requires a significant investment of time and money. A traditional full-time MBA program takes 22 months to complete, and tuition for a top program is approximately $80,000 per year. MD/MBA joint programs condense the dual-training pathway into five years (usually saving one year of tuition). An executive MBA is geared toward physicians with some management experience (usually more than 10 years of work experience) and costs considerably more, averaging approximately $150,000 for a 22-month part-time program. In the 2007 survey of MD/MBA degree holders mentioned earlier in this article, 81 percent of the 87 survey responders believed that their business degree had been “very useful or essential in the advancement of their careers.”⁶ The cost of the degree can be significantly subsidized through scholarships and grants or sponsorship arrangements with employers (hospitals or departments).

Determining whether an MBA is worth pursuing depends on an individual’s goals. What is clear is that knowledge of business practices and how to navigate the complex health care environment is essential for a successful surgical career today. To that end, the surgical societies have created several resources and opportunities for surgeons and surgeons-in-training to develop these skills. For residents, the Surgical Council on Resident Education portal offers a series of online lectures on systems-based practices, which covers basic principles of negotiation, cost accounting, and so on. For residents looking to sharpen their leadership skills, the American College of Surgeons (ACS) Division of Education, in partnership with the Resident and Associate Society (RAS) of the ACS, has created an annual Resident as Teachers and Leaders course that helps residents master critical nonclinical skills related to leading a team and teaching. These tools provide an introduction into the business of medicine and formalized leadership instruction, and they may also help physicians determine whether an additional degree in management is appropriate.

Global surgery and the MPH degree

The MPH degree has become one of the most popular supplementary advanced degrees for physicians to obtain. Although traditional medical education for physicians has focused on identifying and treating illnesses on behalf of an individual patient, public health education is directed at populations, and includes the assessment of risk factors, the development of health education programs, and implementation of appropriate strategies with the goal of not only increasing overall health, but also of reducing infirmary and preventing disease. As such, it would seem a viable transition for health care professionals with medical training to expand individual-based methodologies to population-based programs—to effectively transition from empowering patients to empowering communities.

The MPH degree is a freestanding professional credential that may lead to a career in a variety of areas, including health education and promotion, health policy and management, epidemiology, biostatistics, environmental health, and toxicology, as well as international medicine. In fact, the current political milieu has propelled the topic of health care and health policy into the foreground, essentially compounding the interest in and necessity for national strategies for public health. A dedicated MPH curriculum can motivate and equip surgeons to tackle the salient contemporary considerations of disease prevention, health care provisions, and administrative cost curtailment.

As with other advanced degrees for physicians, acquisition of an MPH can be achieved in two ways: integrating the curriculum along with medical education, culminating in combined MD/MPH programs, or pursuing a supplementary degree at a separate time.⁸ The choice of a particular pathway is dependent on personal career goals and motivation, associated current responsibilities, and the institutional availability of programs. Most MD/MPH programs take five years to complete. However, some institutions allow enrollees to take all the required coursework within the four years of medical training. Alternatively, physicians may complete the stand-alone MPH program over a single year full-time or, for certain programs, over a longer period part-time.

Opinions vary as to the optimal course for pursuing an MPH. Proponents of combining the programs in medical school claim that physicians gain a greater perception of the complementary disciplines of medicine and public health and that they appreciate the seamless integration of the fields. On the other hand, however, some academicians maintain that the MPH should be obtained on its own so that it is not abbreviated in any way to accommodate the work involved in earning a medical degree or fulfilling residency responsibilities. In fact, the rigors of surgical clinical training may disallow a combined approach, but some physicians may consider pursuing it separately during research years.

Increasingly, programs are offering the MPH program to medically trained personnel. Driving this shift is greater awareness of global health concerns as well as the formalization of public health curricula. In some institutions, more than 20 percent of medical students enter an MPH program at some point between entering medical school and leaving for residency.⁹

The addition of international experience to assimilate population-based strategies into practice has also proved valuable.¹⁰ Individuals with an MPH can expect to effectively and efficiently participate in the provision and administration of preventative health services, either domestically or abroad, as well as be involved in health care policy, continuous quality improvement efforts, the delivery of culturally competent care, and international collaboration.

Many health leaders have obtained their MPH. In fact, every director of the U.S. Centers for Disease Control and Prevention since 1956 has had a dual MD/MPH degree, except for one who had an MD/PhD.¹¹ These directors’ contributions to national and global health are indisputable.

Within the surgical leadership, the adoption of dual degrees is somewhat different. Of the 303 surgeons appointed to either the ACS Board of Regents or Board of Governors, 18 have combined MD/PhDs, 11 have MD/MBAs, and 25 have other advanced dual degrees (for example, MD/MSc, MD/JD, and even MD/MA); the MD/MPH contingent only accounts for four individuals.

Colleagues with MPH degrees emphasize that their coursework prepared them to conduct needs assessments and involve priority populations and stakeholders in specific planning processes, design strategies, and interventions. It also helped them to design instruments to collect data, manage fiscal and human resources, and implement action plans and obtain acceptance and support for programs.

These skills have enabled residents to set up makeshift surgical clinics in underserved nations, determine where and how to set up latrines and provide sanitary conditions, and even how to find and preserve necessary fresh water. In addition to formal coursework, relief missions to Haiti, India, Honduras, and Kenya have demonstrated the importance of understanding how to allocate and optimize scarce resources. The increasing burden of global disease and the economics of health care policy is a contemporary international concern. Whether the MD/MPH is worthwhile and cost-effective depends on the individual’s career goals. What is clear, however, is that surgeons are steadfast in their aim to inspire and achieve quality as well as embrace the opportunity to equip themselves with the necessary skills to face future challenges. With the MPH advanced degree, a surgeon can transform into the veritable global physician.

The physician-scientist track

The MD/PhD is the most traditionally pursued dual degree among physicians. Graduates of these programs are typically innovative, comprehensively trained physician-scientists prepared to play a key role in the translation of scientific findings to clinical practice and vice-versa. MD/PhD programs typically attract students with a strong aptitude for the basic sciences and a passion for understanding how things work. More recently, physicians are pursuing less conventional degrees in fields ranging from anthropology to zoology. Currently, the Association of American Medical Colleges recognizes more than 100 MD/PhD programs available nationwide.¹²

Most MD/PhD programs include two years devoted to the basic science courses of the traditional MD curriculum, and to one major graduate course, followed by three to four years of graduate study, including the pursuit of a doctoral thesis in the chosen field, supplemented with an ongoing clinical tutorial during those years. The final 13 to 14 months of clinical rotations are, again, part of the medical school course. It is expected that students will complete both degrees in seven or eight years with some variability inherent in pursuing research. The discipline of study may comprise a wide variety of biomedical sciences, such as biochemistry, cell biology, immunology, microbiology, neuroscience, and so on. If a physician’s passion for scientific research becomes evident during residency, this interest can be translated into a PhD degree, which typically takes three years to complete, during or after residency, in addition to the clinical years of residency.

Most MD/PhD graduates follow career paths consistent with their training as physician-scientists and enter academic medicine with a focus on running research laboratories. Devoting time to a research career is essential for physician-scientists to succeed in obtaining the necessary funding for their research endeavors.

“The PhD degree was very helpful and gave me a strong background that allowed me to address scientific issues critically,” said Kevin Staveley-O’Carroll, MD, PhD, program director and head of the liver, pancreas, and foregut tumor program at Penn State Hershey Cancer Institute, and holder of an R01 grant, “It is becoming very competitive to obtain R01 funding and having the PhD degree definitely set me apart and gave me an edge in obtaining the appropriate funding for my research.” (Personal communication with Dr. Hamed, February 10, 2012.)

Many surgeons with MD/PhD degrees maintain busy and productive research labs, and at the same time have active clinical practices. The MD/PhD degree is the most common dual degree among the department of surgery chairs of the top 50 medical schools named by U.S. News & World Report, and the most common dual degree in the 303 surgeons appointed to either the ACS Board of Regents or Board of Governors.¹³ These data suggest that despite the added time required to succeed in research, these surgeons succeed in managing their time to also incorporate administrative work and leadership positions in national surgical societies.

Conclusion

Research in organizational behavior and business administration indicates that people making the transition from individual contributors to leaders find that the experience of leading differs significantly from what was anticipated and is substantially more challenging.¹³ Surgeons interested in leadership positions have multiple options for development. “Good leaders develop through a never-ending process of self-study, education, training, and experience.”¹ Obtaining a dual degree is one way to accelerate and focus these processes.

---

References

1. Jago AG. Leadership: Perspectives in theory and research. Management Science. 1982;28(3):315-336.
2. Chemers M. An Integrative Theory of Leadership. Mahwah, NJ: Lawrence Erlbaum Associates; 1997.
3. MacEachern, MT. Hospital Organization and Management. Chicago, IL: Physicians Record Co; 1935.
4. Gunderman R, Kanter SL. Perspective: Educating physicians to lead hospitals. Acad Med. 2009;84(10):1348-1351.
5. Association of MD/MBA Programs. Available at: http://mdmbaprograms.com. Accessed March 23, 2012.
6. Parekh SG, Singh B. An MBA: The utility and effect on physicians’ careers. J Bone Joint Surg Am. 2007;89(2):442-447.
7. Freudenheim M. Doctors discover the benefits of business school. The New York Times. September 6, 2011. Available at: http://www.nytimes.com/2011/09/06/business/doctors-discover-the-benefits-of-business-school.html?pagewanted=all. Accessed March 23, 2012.
8. American Medical Student Association’s MD/MPH joint degree programs. Available at: http://www.amsa.org/AMSA/Homepage/About/Committees/CEH/MDMPHPrograms.aspx. Accessed March 23, 2012.
9. Harris R, Kinsinger LS, Tolleson-Rinehart S, Viera AJ, Dent G. The MD-MPH program at the University of North Carolina at Chapel Hill. Acad Med. 2008;83(4):371-377.
10. Eckhert NL, Bennett NM, Grande D, Dandoy S. Teaching prevention through electives. Acad Med. 2000;75(7 Suppl):S85-89.
11. Centers for Disease Control and Prevention. Past CDC directors/administrators. Available at: http://www.cdc.gov/about/history/pastdirectors.htm. Accessed March 23, 2012.
12. Association of American Medical Colleges: Summary of MD-PhD Programs and Policies. Available at: https://www.aamc.org/students/download/62760/data/faqtable.pdf. Accessed March 23, 2012.
13. Hill L. Becoming a Manager: How New Managers Master the Challenges of Leadership. 2nd ed. Boston, MA: Harvard Business Press; 2003.