Turning to the dark side
An increasing number of doctors are becoming managers, and Lynn Eaton finds that the two might become synonymous
Most doctors would say the last thing they went into medicine for was to become a manager. Instead, they want to concentrate
on using their clinical skills and dealing with patients, and not have to worry about resources or local politics. And the
animosity between doctors (for which, read “good”) and managers (“bad”) is legendary.
But all that could be set to change. Undergraduate medical degrees and postgraduate training could soon include explicit training
in management skills as a key component of their courses, possibly from as early as 2009.
No formalised training
Even as trainees, doctors have to face managerial issues: working with other people; making clinical decisions in an environment
of resource constraints; and dealing with difficult people in a team. As they progress to more senior roles, a handful of
them may become senior clinical directors. Yet despite all their years of training, doctors have no formalised training in
management skills.
“To be a good doctor requires you to be more than just a clinical expert, which was perhaps the view of previous generations,”
says John Clark, director of medical leadership with the NHS Institute for Innovation and Improvement.
The institute is charged by the government with, among other things, ensuring world class leadership within the NHS. It has
been working with the Academy of Medical Royal Colleges to formalise what, Mr Clark says, is often happening informally on
both undergraduate medical courses and postgraduate training. It is just not labelled as such.
“Doctors need to recognise the impact their behaviour has on other people, how to work in a team and to understand that sometimes
they will be a leader of the team and at other times a follower. They need to be clear about their role in terms of the quality
of care provided.”
What’s been lacking to date, he argues, is a clear framework for the training that doctors should expect to receive in managerial
skills, and at what level. “The coverage has been highly variable,” he says. “It would be unfair to say there isn’t some coverage,
but it is generally on an ad hoc basis.”
Blueprint for competencies in management
The institute and Academy of Medical Royal Colleges have drawn up a blueprint for the competencies in management that a medical
student or doctor should be able to demonstrate at undergraduate level, in postgraduate training, and for up to five years
after receipt of the certificate of completion of training.
This 70 page document, Medical Leadership Competency Framework, covers areas such as personal qualities (for example, self management, acting with integrity), working with others (developing
networks, working in teams), managing services (planning and managing people), improving services (critical evaluation), and
setting direction (making decisions and evaluating impact).
The institute does not expect doctors to acquire all these skills from day one. At undergraduate level, for example, medical
students should be able to show competence in two main areas: personal qualities and working with others. At postgraduate
level they would be expected to add to this by showing competence in managing services and improving services. At post-specialist
certification level they would be expected to show skills in setting direction.
The institute has already been in contact with five medical schools—Dundee, King’s College London, Peninsula, Warwick, and
Sheffield—to see how their proposals might work within the existing syllabus. The intention is that the schools should teach
management skills as part of the clinical curriculum, not as a separate course. Given the already crowded syllabus, this would
not only be impractical but also be unlikely to appeal to students, says Isobel Down, the project lead.
“If you start developing curricula that say come to a leadership lecture on Monday morning not many are going to turn up.”
To demonstrate skills in acting with integrity, for example, a medical student who had been criticised for taking a domineering
and overbearing approach with patients might review videos of their patient interviews. They would then discuss their communication
style and learn how their style affected others.
At postgraduate level a doctor in training for general practice might have to show how they handled a complaint from a non-clinical
member of staff that one partner at the practice behaved inappropriately by standing too close to them or touching them too
often.
The framework does not set out how to teach these skills, leaving this for the universities and postgraduate training bodies—the
royal colleges—to decide. But it does set out what skills should be demonstrated at the end of each stage.
“It is not for us to determine how they create the learning environment in which doctors learn these competencies,” says John
Clark. “We are not going to proscribe the training.”
Isobel Down believes doctors have a key place at the management table, particularly in an organisation like the NHS, where
there is constant change. But it’s not about creating a super breed of clinician-managers.
“This is about sowing the seeds at the right time,” she says. “We don’t expect them all to come out with an MBA [master of
business administration].”
Warwick Medical School has already run a short module on leadership skills that, says Neil Johnson, course director, was well
received by students. They have looked at whether the proposed framework could be integrated in the existing course.
“A lot of what is being discussed we were already teaching, but not in the sense of leadership,” he said. “The amount of significant
new content was really small.”
At postgraduate level, he suggests, it might entail consultants taking a specialist registrar to a management meeting “so
they can see what is going on. If you talk to consultants in their first two years, many will say the area they felt least
prepared for was managing a service.”
Following proposals with interest
Both the General Medical Council in its consultation Tomorrow’s Doctors and the Postgraduate Medical Education Training Board discussion paper Future Doctors provide perfect vehicles for these changes. The early signs are that the proposals are likely to be positively received by
the two bodies.
Luke Bruce, director of policy and communications with the Postgraduate Medical Education Training Board, said they were “following
the proposals with interest.” The board would be launching new standards for training in 2010, and he envisaged management
training would be part of that.
And Tammie Lawrie, senior policy analyst with the GMC, said that many of the competencies set out in the framework related
to aspects that are already present in Tomorrow’s Doctors.
“In light of this, we anticipate introduction might involve a change in emphasis in the way we set out the outcomes we expect
graduates to achieve,” she said. “In some cases it may be highlighting to students that the skills they are developing—that
is, teamwork skills, self awareness—are also management and leadership skills.”
With some leading clinicians on board the institute’s steering group—the GMC’s president, Graeme Catto, and Gill Morgan, outgoing
chief executive of the NHS Confederation, among them—it seems highly likely that demonstrating some management skills will
become an essential requirement for all doctors in future.
The MBA route
Formal training for clinicians in management is, at best, patchy and at worst non-existent. Some short courses are available,
including those by the British Association of Medical Managers, which is launching a masters degree in medical management
at Loughborough University starting in October.
Paul Shannon, now working as a locum consultant anaesthetist with Doncaster and Bassetlaw NHS Trust, was asked several years
ago by the trust if he would like to apply to become its assistant clinical director. He said he would—but only if he could
have some management training. But there was nothing directly relevant to his work.
“I looked around and found out that the gold standard was an MBA. The trust paid for me to do one part time. I had no idea
about management. It was a culture shock to me to find that management was a profession that had a knowledge and literature
and was evidence based.”
Too many doctors in the NHS are constantly thwarted in their attempts to introduce changes that might improve the service
to patients, he says, recalling his own experiences earlier in his career. “If you ever wanted to change anything you would
be told ‘no you can’t.’ That it would cost too much. Doctors are constantly receiving the message ‘no, no, no.’”
As people in the front line, and responsible for spending resources, doctors are often in a situation where they believe they
can improve efficiency, but they just don’t know how to put the case forward correctly, he argues.
“Managers would say you’d have to put a business case together for changing that practice, but most doctors wouldn’t know
what that means. They just see it as barriers put in the way to making change.”
His MBA helped him learn not only how to write a business case but also how to build networks outside his own professional
group, including information technology professionals who can help improve clinical efficiency.
“Doctors tend to have this strong feeling that they are fighting the whole world themselves, rather than understanding there
are other people out there who are also trying to change things for the better.”
This article was first published in BMJ Career Focus (2008;336:145-6; 10.1136/bmj.39545.511944.CE)
See also “Management and leadership skills for doctors” (BMJ Career Focus, 2008;336:148-9; 10.1136/bmj.39553.827222.7D).
Lynn Eaton freelance journalist London
leaton@bmj.com
Student BMJ 2008;16:236-237 | 18
