Teaching and learning the physician manager role: Psychiatry residents’ perspectives

Abstract

Background: Despite widespread consensus that additional training in administration is needed to prepare physicians for practice, little is known about how best to teach managerial competencies and how to integrate teaching into existing postgraduate curricula.

Aim: This study aimed to elicit resident perspectives on administrative curriculum development following exposure to a pilot physician manager curriculum at the University of Toronto.

Methods: The authors held five focus groups of psychiatry residents at the University of Toronto during 2008, engaging 40 trainees. Resident perspectives on barriers to teaching and learning administrative skills, preferred curriculum content and format and suggestions for integration of administrative training into the residency programme were elicited.

Results: Identified barriers to learning include lack of physician manager role clarity, dearth of learning opportunities and multiple competing demands on residents’ time. Residents value a formal administrative curriculum and propose additional opportunities for experiential learning such as elective rotations and mentorship opportunities. Suggested strategies for integrating administrative teaching into residency include faculty development, rotation-specific administrative objectives and end of rotation resident evaluations.

Conclusion: Our findings provide valuable learner input into an emerging educational framework aiming to address barriers to teaching administrative skills during residency and facilitate longitudinal reinforcement of learning.

Introduction

In Canada, the Royal College of Physicians and Surgeons (RCPSC) has adopted a framework of seven core competencies, called the CanMEDS roles, and has identified the physician manager role as one of the essential competencies for specialists physicians. The CanMEDS guidelines state that, ‘as managers, physicians function as integral parts of healthcare organisations, organise sustainable practices, allocate resources and contribute to the overall effectiveness of the healthcare system’ (Frank 2005). In a similar fashion, in the United States, the Accreditation Council for Graduate Medical Education (ACGME) has recently launched a training framework of six competencies, including that of expertise in systems based practice (ACGME 2009).

Despite widespread consensus that additional training in administration and health systems is needed to effectively prepare physicians for practice management and positions of leadership (Alexander 1991; Bogdewic et al. 1997; Kiel 1999; Forbes et al. 2004; Somers et al. 2004; Frank 2005; ACGME 2009), teaching and learning in this competency area remains intermittent and limited in most graduate programmes. Not surprisingly, both practicing physicians and physicians in training report deficiencies in their administrative and leadership training. Surveys of recent graduates indicate that physicians starting in practice quickly recognise the importance of specific training in medical management (Cantor et al. 1993; DeWitt et al. 2001). Furthermore, 74% of members surveyed by the Society for Physicians in Administration report that teaching business administration skills during the residency years would have helped them feel more prepared to practice (Kiel 1999). Finally, resident surveys suggest that administrative training should begin during residency years and that a variety of activities organised during both academic and practicum years can be introduced successfully into residency programmes (Cordes et al. 1996; Sinai & Hodges 1999; Sockalingam et al. 2007; Sockalingam et al. 2008).

Innovative curricula and training opportunities have been described for a small number of specialty training programmes, including lectures, case scenarios, committee participation, administrative and programme assignments and community rotations with administrative training (Alexander 1991; Iverson 1993; Cordes et al. 1996; Custalow et al. 2000; Paller et al. 2000; Babich 2006; Gruver & Spahr 2006; Moore et al. 2006; Hemmer et al. 2007; Stergiopoulos et al. 2009). Little is known, however, about how best to integrate administrative training into existing curricula and how to achieve longitudinal reinforcement of learning during training. In particular, the literature on trainee perspectives on teaching and learning administrative skills is scant.

We have previously described the development and implementation of a physician manager curriculum for psychiatry residents at the University of Toronto (Stergiopoulos et al. 2009). The curriculum consists of a junior and a senior toolkit, of four workshops each, and longitudinal quality improvement projects (Table 1). Following implementation of the pilot curriculum at our residency programme, we sought to examine, using focus group methodology, the views of residents about barriers to teaching and learning administrative skills and preferences about curriculum content and format. In addition to informing the refinement and further development of our own curriculum, this information may be helpful to others engaged in the development and dissemination of administrative medicine training materials, an important endeavour with the growing recognition of the central importance of these skills for practicing physicians.

Table 1.  Pilot physician manager curriculum framework

Junior toolkit/PGY-2	PGY-3	Senior toolkit/PGY-4
Teamwork	→Quality Improvement Projects	Mental health and addictions reform
Conflict resolution and negotiation		Leadership skills for managing change
Measurement-based quality improvement in psychiatry Self and career development		Programme evaluation: a strategy for understanding programme performance
		Organisational structures in mental health

Table

Practice points

Clarifying the physician manager role and its clinical relevance may be an important early task for educators. Residents value a formal administrative curriculum that is contextually relevant. Formal administrative curricula need to be augmented with opportunities for longitudinal reinforcement of learning, such as elective rotations and mentorship experiences. Faculty development and effective train the trainer programmes may be instrumental in order to integrate teaching and learning administrative skills into clinical rotations. Resident evaluation in administrative knowledge and skills may be an important driver of teaching and learning.

Methods

The study was conducted at the University of Toronto, home to the largest psychiatric residency programme in Canada, with over 700 faculty and 124 residents training in one of the seven main affiliated sites. The study received approval from the Research Ethics Board at St. Michael's Hospital and the University of Toronto.

The pilot curriculum

A pilot physician manager curriculum, extending over 3 years of training (Table 1), was successfully introduced at the University of Toronto in 2006 and rated very highly by our residents (Stergiopoulos et al. 2009). Our goal has been to develop, in active partnership with learners, a course that meets the demands of residency and early career practice and heavily emphasises interactive learning. The course addresses the core physician manager competencies identified by the RCPSC as essential for all practising physicians and complements a transition to practice seminar series offered to fifth-year residents, with a focus on financial and practice management. The curriculum includes four junior workshops, offered to second-year residents, and four senior workshops, offered to fourth-year residents, as a mandatory part of their training. Third-year residents undertake longitudinal quality improvement group projects. Each workshop follows the same general format of didactic teaching and small groups or other interactive techniques. The workshop leaders provide references and reference materials to the residents for use in their daily practice. Clinical illustrations are used throughout.

Following exposure to the pilot curriculum over two academic years, we sought to examine resident perceptions about barriers to teaching and learning this role, as well as the ideal curriculum content and format. Resident socialisation to the physician manager role through exposure to the pilot physician manager curriculum ensured resident familiarity with basic administrative concepts and their relevance to practice and enabled residents to provide knowledgeable input into the study questions.

Focus groups

Five resident focus groups were held at our main clinical sites between May and June 2008. Focus groups were conducted by an experienced research assistant, and lasted 60 min each. Participants were asked standardised questions based on the identified tasks: their understanding of the physician manager role; barriers to teaching and learning this role during residency; and resident perspectives on administrative curriculum content and format, including strategies for integrating administrative training into the residency programme. To recruit focus group participants, we extended an invitation to all chief residents to host a ‘resident lunch and focus group’ at their site. All eligible residents were invited to participate. We did not pre-select or invite individuals nor did we influence the composition of the groups in any way. It was hoped that holding the focus groups at the residents’ clinical sites would reduce anxiety and produce more informative sessions. All participants signed an informed consent form.

Analysis

Focus groups were audiotaped, transcribed and analysed using NVIVO 8.0 software. Grounded theory analysis was used to analyse the transcribed data (Glaser & Strauss 1967; Charmaz 2004). The process involved coding transcripts line by line, forming categories of concepts using a constant comparative method and forming higher order categories by identifying categories with unifying conceptual themes. This type of analysis was selected to ensure that the emergent themes were not based on preconceived ideas or biases of the researchers. The queries that guided the coding process and assisted in the identification of conceptual themes was informed by the questions probed during the focus groups and individual interviews. The first two transcripts were coded independently by two of the authors (VS and JM), and consensus was reached before further attempting to analyse the data. The consensus framework that emerged was used as the basis of comparison for the remaining transcripts, coded by a research coordinator and the first author.

Results

Table 2 shows the characteristics of study participants. Forty residents participated in one of five focus groups, ranging in size from 4 to 10 participants. Of the participants, 52.5% were female. There was good representation from all levels of training among both male and female residents. Our findings are presented using the categories of our main questions: barriers to teaching and learning the physician manager role; resident perspectives on administrative curriculum content and format; and integration of administrative training into the residency programme.

Table 2.  Characteristics of focus groups participants

	Level of training
Study participant	PGY2	PGY3	PGY4	PGY5
Male	9	1	5	4
Female	7	5	5	4
Total N = 40	16 (40%)	6 (15%)	10 (25%)	8 (20%)

Barriers to teaching and learning

Study participants identified several barriers to teaching and learning administrative medicine, including lack of administrative role clarity and relevance, a dearth of teaching and learning opportunities in their current settings, and multiple competing demands on their time. Collectively, these barriers lead to ‘lost opportunities’ to socialise trainees into administrative concepts and managerial demands and expectations. For many of the residents, addressing these barriers merits priority consideration.

Role clarity and relevance

From the resident perspective, teaching and learning begins after trainees are introduced to the diverse administrative competencies and appreciate how administrative knowledge and skills apply to their clinical settings. As one resident offered:

‘I genuinely have a lack of clarity in my mind about what the physician manager role is … It is difficult to create a learning objective for myself and a strategy for reaching it if I don’t really know what it is I’m trying to do and why … I’m suggesting that the residents should know what a manager is and does and they should know that early’.

Making explicit how the broadly defined managerial competencies apply to each specialty practice also may be essential, if these competencies are to become relevant to teaching and learning in the clinical setting. As another resident commented: ‘Strangely it seems not very relevant at times … it seems far off and distant and not that immediate to psychiatric practice …’

Lack of teaching and learning opportunities

Further to clearly defining the role and making it relevant to learners early in training, residents identified the need to create teaching and learning opportunities during their core clinical rotations. One resident offered:

‘Taking a step back, I think it's one of the roles that's hardest to teach and with some of the fewest opportunities … unfortunately in practice the staff are so used to doing things themselves that they don’t let you do that much … some supervisors do not discuss or reinforce the physician manager role or do not seem knowledgeable’.

The transitory nature of clinical rotations, with residents leaving their clinical settings every 6 months, was identified as an additional barrier, limiting opportunities for residents to assume meaningful administrative roles or acquire the necessary managerial skills.

‘Just because we’re there on a relatively short basis … it's difficult when there are already people there who know more about the system than you do … these people are experts on how the team works and how the system works and what resources are available and it would be very hard to manage that without having a clearly defined role …’

Finally, hesitation to discuss ‘sensitive’ issues in supervision was another identified barrier. As one resident explained:

‘ …. if there's a problem on the team with a certain staff member, how often do we actually get an honest discussion with the staff of how they're dealing with it? We don’t often have frank discussions about these things’.

Time constraints

Another barrier to teaching and learning administrative knowledge and skills identified by residents is the difficulty in managing multiple competing demands, including clinical duties, research interests, extracurricular pursuits and the additional learning requirements across the CanMEDS domains. As the emphasis during training remains on the traditional biomedical curriculum, the time remaining to solidify administrative knowledge and skills, perceived as less important, is limited. As one resident voiced:

‘The residents are already overwhelmed with the workload … clinical responsibilities are a major barrier … And even if opportunities to learn the managerial role were available, this would come at the expense of some more critical work so you end up not taking them’.

Administrative curriculum content and format

In identifying how to best teach administrative knowledge and skills, residents confirmed that exposure to the components of the formal physician manager curriculum at our site was very helpful, and identified several ways to make such a curriculum a springboard for further learning. Regarding formal curriculum delivery, residents found the workshop format appropriate for their learning needs. They recommended additional opportunities for experiential learning through elective rotations and mentorship opportunities.

Perceived need for a formal administrative curriculum

The residents agreed that a formal administrative curriculum is an important component of teaching and learning administrative competencies.

‘I think there definitely is a need for it. At some point we have to be able to manage resources, manage a variety of other things including managing our own time. And so it's important to think about this in an organised way and then to have an opportunity to try things out in a safer environment before we go out there and make a mess of it’.

In addition to increasing knowledge and comfort in the selected topic areas, such a curriculum may serve to raise awareness among trainees, such that ‘ … we’re just not in the dark as to what we’re doing. So it may not ostensibly change anything we do on a day-to-day basis, just being more aware of how and why we’re doing it’.

Curriculum delivery

Residents identified several elements characterising the ideal administrative curriculum. First, they felt that awareness of administrative roles and competencies should begin early in training:

‘There should be a 15 minute learning module on the computer that you do early on that talks about awareness of the manager role, what to expect, whatever elements we decide … where we could really raise awareness by designing something that wouldn’t take very long and would set the stage …’

Regarding a formal curriculum, the workshop format was found to be effective, provided that workshops are kept interactive and that clinical illustrations are drawn from resident experiences:

‘The workshop leader brought her own situation to discuss, which was very specific to her role as chief of staff. I think it would have been more helpful to create a scenario that would have been more relevant to our own context’.

The residents commented that in addition to topic areas relevant to their needs, they would value continuity of teaching throughout their clinical years and opportunities for longitudinal reinforcement of learning. Shadowing of experienced administrators, mentorship opportunities and elective rotations are among the choices suggested for those wishing to complement mandatory training with additional experiences.

‘There should be opportunities for residents to get additional exposure for people who are interested in those things – so not just electives like going away for a month but longitudinal half a day electives through the year, and matching junior residents with mentors with administrative and leadership skills’.

Integrating the administrative curriculum into the residency programme

Residents would favour better integration of the administrative curriculum to the rest of their teaching and learning activities. As one resident commented:

‘I think the challenge is to establish the level of competence in all of these roles and to integrate seamlessly into the day-to-day training rather than parse it out ‘today is manager for three hours and tomorrow you’re going to be an advocate’.

Residents provided rich input on what might be some necessary steps to integrate an administrative curriculum into the residency programme. They perceive faculty development and resident evaluations as crucial steps in this process to take advantage of the many teachable moments that are present in their daily work. As one resident explained: ‘Ideally you’d be learning it on the fly on the ward, but staff don’t give enough tips or direction …’

Integrating teaching and learning into clinical rotations

Residents suggested that in addition to the workshops or other teaching modules, teaching and learning should be integrated into their clinical activities to provide the context for skill acquisition and knowledge consolidation. They suggested that the beginning of each clinical rotation might be an opportunity to ‘generate a list of administrative objectives so that the clinical supervisors know what they should try to get across, and the students know what they need to learn over the course of the rotation’. Setting clear objectives and expectations at the beginning of each clinical rotation would highlight the opportunities to acquire administrative knowledge and skills during each rotation and provide the trainee and supervisor with a framework for experiential, specialty-specific learning.

Faculty development

Faculty development was felt to be essential if integration of learning into daily practice were to take place allowing for continuous and contextual learning.

Residents commented that "there should be a teaching of a managers curriculum for the teachers" to better prepare clinical supervisors to identify and make use of teaching and learning opportunities in the clinical settings and incorporate discussion of administrative issues into regular clinical supervision.

Resident evaluation

There was consensus that the current end of rotation evaluations are inadequate as they do not capture rotation-specific or level of training managerial knowledge and skills with adequate behavioural markers or anchor points for a meaningful assessment. As more than one resident commented: ‘I have never had staff sit down with me and go over the physician manager role or administrative knowledge and skills’.

Residents suggested several ways of augmenting current evaluation methods, including self evaluation, short essays/reflection papers in selected rotations, quality improvement projects and interdisciplinary team evaluations, offering opportunities to allied health staff to provide feedback and suggestions on resident performance in this area of training. One resident suggested:

‘I wonder if a way to bring it into everyday practice would be at some point early during your residency you were supposed to write and turn in a short paper on what you did as a manager, what you perceived as a manager. That would just make solid that people know what the manager role is and when they’re doing it. And I wonder if that might be the most useful thing and it's not really something which is that extra’.

Discussion

The physician manager role is one of the most difficult to integrate into postgraduate medicine programmes and little has been written about resident perspectives on managerial knowledge and skill acquisition. In our study, we used focus group methodology to examine resident perspectives about barriers to teaching and learning this role, and about administrative curriculum content and format, following exposure to a pilot physician manager curriculum at the University of Toronto.

Our main study findings both support and are supported by previous research. Our residents identified several barriers to teaching and learning administrative knowledge and skills. Perceived barriers include lack of role clarity and relevance, limited opportunities for teaching and learning in this area and multiple competing demands on their time. Unlike other trainees, residents have little formal contact with managers, and few role models to ground their understanding of what managers do or help them develop a managerial identity. The fact that residents are excluded from decision-making processes and not evaluated on managerial competencies only exacerbates these difficulties. Further clarifying the physician manager role and how it applies to practice may be an important early task for educators. Furthermore, resident time for educational opportunities outside the traditional biomedical curriculum is becoming increasingly scarce, necessitating that any new educational programme developed be well integrated into the rest of the residency experience. This is in keeping with previous suggestions that it may be important to integrate managerial content into existing courses rather than trying to carve out new time (Cox et al. 2004) and to present such content in a scholarly, rigorous and reasonably comprehensive fashion (Iverson 1993). Additional barriers identified in the literature include lack of adequate texts and instructional materials in the new topics and lack of department ownership of the managerial competencies, neither of them applicable in our programme (Halpern et al. 2001).

Our study participants suggested that a formal curriculum and early introduction to clinically relevant managerial concepts, including the ones taught in our pilot curriculum, would facilitate the acquisition of knowledge and skills during residency training. They further suggested that teaching and learning should draw from their clinical experiences and include opportunities for longitudinal reinforcement of learning. Assignment of junior residents to manager mentors, shadowing of seasoned administrators and elective rotations may be needed additions to a formal course and workshop format. Indeed, although lecture and workshop formats are effective for presentations on many administrative topics, others ideally require a one-to-one interaction between the resident and a faculty preceptor who is experienced in administrative medicine.

Other investigators have similarly suggested early introduction of management concepts during training, and described opportunities for experiential learning such as special projects, committee participation, the introduction of management and administrative topics into the grand rounds format, and community placements with an administrative component (Iverson 1993; Cordes et al. 1996; Kiel 1999; Paller et al. 2000; Hemmer et al. 2007; Thompson et al. 2008).

There was broad consensus among the residents that integration of managerial training into clinical rotations through rotation-specific objectives and end of rotation evaluations of managerial knowledge and skills was of paramount importance. One concern expressed by our residents was the limited opportunity to rehearse the skills and remember the core concepts learned through a formal core curriculum. Other residents expressed concern that some of the competencies described under the physician manager role represent skills that require an experiential learning environment. To address these difficulties, residents suggested that faculty development was urgently needed, as they perceived their clinical supervisors to lack knowledge and awareness in this area. Few among our clinical faculty have specific training or expertise in administration, and administrative issues rarely are discussed in clinical supervision. Furthermore, faculty with senior administrative responsibilities and leadership roles within departments are often shielded from teaching responsibilities. Continuing medical education experiences and train the trainer programmes have been proposed as means of strengthening faculty members’ knowledge and ability to teach these topics (Halpern et al. 2001). In Canada, Train the Trainer Programmes are being introduced for all CanMEDs roles and will hopefully address the need for local curriculum and faculty development over the next few years (Frank JR, personal communication). Other investigators have suggested that rather than investing in faculty, curricula and resources, residency programmes can take advantage of distant education, utilising videoconferencing, taped lectures and the internet (Kiel 1999). Although such an approach might alleviate the pressure for a formal curriculum, it does not address the need to support bedside teaching and learning, which was identified by our residents as critical for their learning. One approach that merits further exploration is interprofessional teaching of managerial competencies by nonmedical staff, such as nurse managers.

Our study, using qualitative methodology to elicit learner input and assist in the formative evaluation of our programme, has several limitations. Our residents come from a single residency programme, potentially limiting generalisability of the findings. We chose, however, to elicit the perspectives of residents already socialised into administrative concepts and training, as we felt they would provide rich input into the questions raised by this research. Furthermore, the University of Toronto has the largest psychiatry residency programme in Canada, accounting for 126 of the 587 psychiatry residents in the country. A previous survey of psychiatry residents at the University of Toronto on physician manager perceived gaps in knowledge and skills provided findings that closely paralleled those of a national survey of psychiatry residents (Sockalingam et al. 2008) and a national survey of residents across postgraduate training programmes in Canada (Stergiopoulos et al., in press).

The physician manager curriculum is work in progress. Our findings support previous suggestions of a learning model that is continuous, performance driven and flexible (Griffith 2003; Thompson et al. 2008). We will continue to make revisions to the curriculum based on the educational framework that is emerging from this research and advances as new healthcare concepts and local priorities dictate. The ongoing challenge includes converting the relevant competencies to specific lessons and experiences sequenced for level of training, and addressing barriers to teaching and learning through strategic and operational planning. New learning modalities may have an important role to play, as previously suggested (Cordes et al. 1996; Halpern et al. 2001; Griffith 2003).

Our curriculum has not been in existence long enough for us to determine how it influences resident knowledge and skills, and this is the focus of current research. Similarly, resident evaluation in managerial competencies is at its early stages of development, and is another area of study by our group. However, the very existence of the curriculum and its strong support by the postgraduate director and department chair demonstrate how far residency programmes have evolved. We have been encouraged by the ongoing dialogue with our resident body and hope that this study will contribute to the evolution of a paradigm where learners are empowered to actively contribute to the design and implementation of teaching and learning activities.

Acknowledgements

The authors thank Dr Ari Zaretsky, postgraduate programme director, and Dr Don Wasylenki, chair, Department of Psychiatry, University of Toronto, for their support of this project. The authors would also like to thank our two research assistants, Dr Saima Khan and Ms Tutsirai Mukawaza for their invaluable contribution to managing this project. The study was funded by a 2007 RCPSC CanMEDs Research and Development Grant.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.