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Journal of Healthcare Leadership 2016:8 19–29
Journal of Healthcare Leadership Dovepress
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open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/JHL.S68068
Health care leadership development and training: progress and pitfalls
Roberta e Sonnino1,2
1Department of Surgery, Division of Pediatric Surgery, wayne State University School of Medicine, Detroit, Mi, USA; 2ReS Coaching LLC, Locust Hill, vA, USA
Correspondence: Roberta e Sonnino ReS Coaching LLC, 185 Brandon Point Road, Locust Hill, vA 23092, USA Tel +1 804 286 9174 email [email protected]
Abstract: Formal training in the multifaceted components of leadership is now accepted
as highly desirable for health care leaders. Despite natural leadership instincts, some core
leadership competencies (“differentiating competencies”) must be formally taught or refined.
Leadership development may begin at an early career stage. Despite the recognized need, the
number of comprehensive leadership development opportunities is still limited. Leadership
training programs in health care were started primarily as internal institutional curricula, with
a limited scope, for the development of faculty or practitioners. More comprehensive national
leadership programs were developed in response to the needs of specific cohorts of individu-
als, such as programs for women, which are designed to increase the ranks of senior women
leaders in the health sciences. As some programs reach their 20th year of existence, outcomes
research has shown that health care leadership training is most effective when it takes place over
time, is comprehensive and interdisciplinary, and incorporates individual/institutional projects
allowing participants immediate practical application of their newly acquired skills. The train-
ing should envelop all the traditional health care domains of clinical practice, education, and
research, so the leader may understand all the activities taking place under his/her leadership.
Early career leadership training helps to develop a pipeline of leaders for the future, setting the
foundation for further development of those who may chose to pursue significant leadership
opportunities later in their career. A combination of early and mid-to-late career development
may represent the optimal training for effective leaders. More training programs are needed to
make comprehensive leadership development widely accessible to a greater number of potential
health care leaders. This paper addresses the skills that health care leaders should develop, the
optimal leadership development concepts that must be acquired to succeed as a health care
leader today, some resources for where such training may be obtained, and what gaps are still
present in today’s system.
Keywords: leadership competencies, leadership traits, leadership skills, health care, training
Introduction Health care organizations are complex environments that require strong, compre-
hensive, and collaborative leadership. Over the past 15–20 years, awareness of the
importance of leadership in health care and of formal leadership training has increased
dramatically. Historically, advancement to leadership positions in medicine was
based on the candidate’s academic or clinical accomplishments, with no expectation
of knowledge in the so-called differentiating competencies, such as finances, team
building, communication skills, and emotional intelligence. The concept of leadership
has evolved from the top-down, paternalistic model, where the leader is in complete
control and demands performance from others, to a more collaborative approach,
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where the leader helps his/her team develop a vision and
empowers them to accomplish the stated goals.1 Many have
suggested that formal training in the multifaceted components
of leadership is necessary and should begin at an early career
stage;2–4 yet still today, the number of comprehensive leader-
ship training opportunities, at any career level, is limited.
While the literature on the topic of leadership has
increased substantially, reports on comprehensive health
care leadership training programs (including interdisciplin-
ary programs) are still scarce, no doubt a reflection of the
paucity of such programs.2 Most publications on the subject
of leadership training concentrate on a specific sector of
health care, or a stage of professional training, and describe
group-centered curricula that are often devised for internal
constituencies. Several reviews of the literature on leader-
ship training programs have appeared,5,6 but few describe
the major national, comprehensive health care leadership
training opportunities.7
Leadership training programs in health care were started
primarily as internal institutional curricula, with a limited
scope, for the development of faculty or practitioners.8
More comprehensive leadership programs were developed
in response to the needs of specific cohorts of individuals.
Programs for women (both comprehensive and specialty-
specific)9–11 were among the first to appear in an attempt
to increase the ranks of senior women leaders in the health
sciences.12 The long-existing programs such as the Executive
Leadership in Academic Medicine (ELAM) program have
shown that10,13,14 the health care leadership training is most
effective when it takes place over time, is comprehensive
and interdisciplinary, and incorporates individual/institu-
tional projects with immediate practical application of newly
acquired skills.2,15
Particularly important is the notion that the training
should envelop all the traditional health care domains of
clinical practice, education, and research, so the leader
may understand all the activities taking place under his/her
leadership and whether or not he/she is personally engaged
in all of them. A leader must be able to engage the various
interprofessional communities within the hospital, academic
affiliate, or health care system.
Leadership training for students and medical residents is a
rising topic of discussion,2 with some programs implementing
short leadership retreats for rising senior or chief residents4,16
and others incorporating leadership training in their regular
trainee curriculum. If uniformly implemented, these early
career programs would be of great value in developing a
pipeline of leaders for the future. Early career programs
would likely be insufficient to create the leadership skills
necessary for senior career opportunities but may establish
the foundation for continued development. More develop-
ment programs are needed to make comprehensive leadership
training more widely accessible. Better coordination among
disciplines, and expanded availability of comprehensive
leadership development opportunities, would result not
only in better prepared senior health care leaders but also
in improved interactions between hospital administrators,
practicing professionals, and academicians, with a culture
of true collaborative or shared leadership.
This paper will discuss the skills that health care leaders
should develop, the optimal leadership training concepts to
succeed as a health care leader today, some resources for
where such training may be obtained, and what gaps are still
present in today’s system.
Types of leadership The historical definition of leadership in the dictionary17 was
“the position or function of a leader, a person who guides or
directs a group”, with synonyms18 that included “adminis-
tration”, “management”, and “control”. This definition has
evolved over time, and today, we recognize different styles
of leadership, each with their own definitions. In health care,
three of these types are prevalent and most identified:19
• Transactional leaders, who work within the boundaries
and the existing standards of the organization. They are
usually not risk takers, but focus on efficiency, control,
stability, and predictability.
• Transformational leaders, who raise one another to higher
levels of motivation, making changes and shaping the
future.
• Servant leaders, who focus on the service aspect first as
they have a natural tendency to help others.20
Each of these types has its place in health care, but
transformational and servant leaders are more likely to help
the institution advance, while transactional leaders are most
qualified to maintain the status quo.
Today’s leaders require two general types of behaviors:
“task” behaviors and “relationship” behaviors. Task behav-
iors allow the individual to accomplish his/her goals and
enable leaders to guide others in achieving their objectives.
Relationship behaviors involve the ability to interact with
peers and subordinates in a way that all feel comfortable
with themselves, with each other, and their specific setting.19
A leader may be more task oriented in certain situations and
more relationship oriented in others. Therefore, individuals
are, by necessity, becoming more aware of their own leader-
ship styles and the way they communicate, usually through
feedback from others. Physicians, for example, are not
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Leadership development in health care
usually trained to concentrate on leadership or think about
their own behavioral style.21 By the nature of their profession,
they tend to focus on outcomes rather than the processes
involved in achieving those outcomes. Yet, leadership is an
intrinsic part of the practice of medicine, even in the interac-
tions with patients and their families. Gabel22 examined how
all physicians take on leadership roles at some time in their
careers, whether formally or informally. He discussed the
characteristics of formal and informal leaders and concluded
that it is important to expand the scope of leadership training
so that both types of leaders are included.
Different health care leaders may arrive at their posi-
tions via different personal paths. Rogers19 published an
analysis of the communication and leadership styles of
health care leaders in each major area within an academic
health center, that is, medicine, nursing, and administration.
She studied the importance of linking leadership styles to
individual professions. She concluded that physicians,
nurses, and administrators must have an increased aware-
ness of self and individual leadership style and that each
of these health care leaders must be engaged in practices
of reflection.
In nursing, reaching a leadership role is often an expecta-
tion or at least an aspiration for a large number of individuals.
It should therefore be no surprise that the nursing profession
has embraced leadership training earlier than others in health
care.23,24 Likewise, hospital administrators are usually “big
picture” leaders, having come up through the administrative
ranks. They likely have managerial experience, so the transi-
tion to leadership is fairly natural, as long as they are able to
also have vision in addition to their managerial skills. One
cannot, however, assume that these individuals possess all
the traits that will make them effective leaders in a large and
complex health care system: the development of integrated
leadership processes throughout health care delivery systems
is needed.23
For physicians, the transition to becoming true modern
leaders is a major accomplishment,25 often requiring a move
outside their comfort zone. In fact, many cringe at the thought
of having to be a leader.23 Senior physicians, in particular, do
not always have a system’s perspective, which is an important
competency for a health care leader. Arroliga et al state that
failure to train our healthcare leaders could have a long-term
negative impact on society. He argues that the traditional
means of selecting leaders (by virtue of age, productivity
or other academic skills) was inadequate, as these individu-
als simply emulated their predecessors, but had no formal
development of the personal and professional qualities and
skills required by a leader.2
Thankfully, this may be changing as educational
standards for trainees evolve. In 2002, the Accredita-
tion Council on Graduate Medical Education (ACGME)
launched their outcomes project, a competency initiative
that included six core competencies that residency programs
use to evaluate their residents. One of these is systems-based
practice. These competencies, now included in the ACGME
accreditation system as performance milestones,26 began the
task of introducing this topic into medical education, albeit
at the graduate level. As a result, many medical schools have
elected to incorporate these skills in their medical student
curriculum as well. Hopefully, the trend of investing in the
leadership growth of physicians from their earliest develop-
ment will allow them to acquire the skills to become better
collaborative leaders, with a vision for the entire realm of
health care.
Traits of health care leaders Contrary to the old image, today’s leader must possess
the skills of listening, empathy, awareness, persuasion,
conceptualization, foresight, stewardship, commitment to
the growth of people, and building community. Stoller27
observed that health care leaders must also possess commit-
ment, integrity, altruism, and authenticity. He listed some
of the skills and traits that physician leaders, in particular,
must have or acquire. These include a technical knowledge
of insurance and reimbursement issues, how to balance
expense with quality of patient care, health care regulations
(including the Affordable Care Act), legal issues in health
care and public policy, problem-solving skills, communica-
tion skills, emotional intelligence, and a commitment to
lifelong learning. In his editorial in the American Journal
of Medicine, Alpert28 defines qualities that are important for
leaders. These include commonly mentioned themes such as
equity, justice, role modeling, work ethic, balancing work and
personal life, organization, and prioritization. Developing all
these skills may be a challenge for many individuals.
In the early years of recognition that health care profes-
sionals required some form of leadership training, degree
programs such as MPH and MBA were thought to be the
solution.24 These programs provide knowledge in specific
areas (global health, epidemiology, financial skills, etc),
together with managerial and administrative skills. But experi-
ence has shown that these additional degrees do not necessar-
ily turn an individual into a leader. Managers, administrators,
and leaders are not one and the same. While an individual
may encompass all three of these descriptors, often that is not
the case. As described by Curtis et al,29 managers administer,
maintain, control, have a short-term view, and initiate. Other
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managerial roles include planning and budgeting, organizing
resources, and problem solving. Leaders, on the other hand,
“innovate, develop, inspire, challenge the status quo, and
focus on a long-term vision”. Kotterman30 defines manage-
ment as dealing with procedures, practices, and complexity
and leadership as dealing with change.
While the skills acquired through various Master’s pro-
grams are indeed highly desirable in many leadership roles,
comprehensive leadership programs are necessary for the
development of broad leadership skills – the “differentiating
competencies.” A program at Duke31 for medical residents
who have already obtained graduate management training
(eg, MD-MBA) combines the benefits of formal MBA train-
ing with training and experiential learning in the leadership
competencies and may represent a new model for early career
leadership development.
Souba32 discussed the changes that have occurred in
health care leadership over the years. He described the shift
in traits from those that made an individual a leader in the
“old” days to those accepted today. Business and admin-
istrative acumen, a foreign concept for a clinical leader of
the past, is now a necessity. The ability to engage others
in creating a common vision and building teamwork is in
stark contrast with the old image of the leader as a despot,
commanding from above. Strong communication skills were
always appreciated but are often lacking in the leader: lack
of communication today is likely to derail a leader. Possibly,
the most dramatic change in required skills is the concept of
emotional competence – the ability to look within oneself,
recognizing not only the feelings of others but also one’s
own. The concepts of awareness and authenticity have gained
wide acceptance. Empathy and the ability to develop others
through mentoring and coaching are, today, among the traits
that truly differentiate a leader from the rest.
The need for formal, comprehensive health care leadership development While some individuals are “born leaders” with good
instincts, some formal leadership training in the differentiating
competencies is needed – many skills must be learned or
refined. This may include rules, laws, governance, or the
personal competencies that are not innate in all. Leaders
who believe that they can do it without any formal training
often succeed for some time but eventually will encounter
critical situations that they are not prepared to handle alone.
Then they urgently seek the resources to help them succeed,
often too late to salvage a career. The fact is that when the
need for a leader in a given role presents itself, taking an indi-
vidual who has demonstrated mastery of his/her profession’s
skills and expecting her/him to become a leader intuitively,
is no longer a satisfactory (or successful) model. We need a
pipeline of emerging leaders, both in the purely clinical health
care realm and in academia, who have already mastered the
additional skills through formal experiential training and
will have greater odds of success when asked to step into a
new leadership role. It would be preferable for all if training
in the key knowledge and skills were more easily accessible
and therefore acquired before a major institutional and career
failure dictate the need for more education.
These needs are global: the Foundation for Advance-
ment of International Medical Education and Research
(FAIMER),33 based on the ELAM model10 and cofounded
by the Founding Director of ELAM, demonstrated that
leadership and management can be taught across cultures
and that this has enhanced the ability of the leaders in the
served countries to maintain alignment with their local
needs, developing trust in their own abilities and avoiding
persistent dependency on other countries. This is a unique
example that appears to validate the principles of leadership
training developed for American health care as they apply
to the global health care community.10,34
Warren and Carnall35 from the UK noted that their national
health care system has also neglected leadership training for
physicians. They encouraged physicians to develop skills and
a level of understanding that go beyond technical expertise in
their specialty, including the ability to create and communicate
their vision and set clear direction. Warren and Carnall con-
cluded that leadership training programs were most successful
when the participants were given the opportunity, during the
program, to work on some of the “real time” challenges they
faced at their home institution. They also concurred with the
opinion that programs spanning longer periods of time, allow
the participants to absorb and reflect on their new knowledge,
and incorporate it in their daily activities.
What should training include? Because leadership development is needed for all the pro-
fessions from which health care leaders emerge (medical,
dental, public health, nurses, allied health providers, and
administrators), the ideal curriculum would be interdis-
ciplinary and applicable to as many as possible of these
groups. Such a program should include essential and
universal leadership skills (conflict management, negotia-
tion, financial skills, etc), as well as strategies to develop
personal traits. Table 1 lists a compilation of the essential
elements of leadership development and the competencies
considered the most important skills to be developed in
health care leaders.
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Table 1 Optimal elements and competencies of health care leadership development
Pretraining assessment MBTi 360 feedback Differentiating competencies Finances and economics Team building Communication skills emotional intelligence Conflict management Negotiation Personal competencies Personal professional development introspection – getting to know oneself Listening empathy Awareness Persuasion integrity Authenticity Altruism equity Justice work ethic Role modeling innovation: develop, inspire, challenge the status quo, and focus on a long-term vision Foresight Stewardship Commitment to continuous improvement and lifelong learning Balancing work and personal life Task-oriented knowledge (may differ for individuals in different areas of health care) Business and administrative acumen and skills Technical knowledge of insurance and reimbursement issues How to balance expense with quality of patient care Health care regulations (including the ACA) Legal issues in health care and public policy Problem-solving skills Being a change agent emerging issues and strategic planning Organization and prioritization, time management Leadership development training concepts Didactic teaching using different methods – adult learning Mentorship and coaching experiential leadership opportunities Reinforce/build a supportive and safe culture Networking ensure high-level sponsorship and involvement integrate all features of the program Offer extended learning periods with sustained support encourage ownership of self-development
Abbreviations: MBTi, Myers Briggs type indicator; ACA, Affordable Care Act.
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Leadership development in health care
Some general concepts are universally important for
leadership development. For an effective program that will
give leaders insight into themselves and others, pretesting
for learning style and personality characteristics are a must.
These include identifying each individual’s Myers Briggs
type indicators and completion of formal 360 feedback
evaluations. Learning how to use the information obtained
from these assessments is a key to develop the insight to
one’s own characteristics, as well as learning to interact
effectively with individuals very similar or very different
from oneself.
An ideal leadership development program would include
a basic curriculum of general, comprehensive health care
concepts, presented with diverse methodologies, including
didactic teaching, mentorship and coaching, and experiential
leadership opportunities. In addition, there should be spe-
cific elements for each individual’s area of leadership, be it
hospital administration, a clinical setting, or academia. Even
more detailed specialty-specific topics may be appropriate, if
feasible. For example, surgeons, operating room nurses, and
allied health providers need to learn operating room-related
leadership skills and information, whereas clinic nurses and
outpatient-based physicians and pharmacists need to learn
skills specific to their ambulatory setting. Basic research-
ers have an entirely different set of skills required to run
a major research program, and educators need the proper
tools to lead curriculum development, innovative practices
in education, etc.
Training about leadership styles and situational leader-
ship should be a component of the curriculum for emerging
health care leaders, allowing them to understand and be
able to interact with individuals with different styles from
their own.
Among the competencies that should be included in most
comprehensive leadership curricula, the most significant
include finances and economics, emerging issues and stra-
tegic planning, personal professional development, adaptive
leadership, conflict management, time management, ethical
considerations, and personal life balance. In addition, devel-
oping a well-defined project that will have an impact on the
institution provides a practical, on-the-job application of skills
learned that are therefore more likely to become ingrained.
Blumenthal et al3 suggested that the common elements
of effective leadership development programs include
reinforcing or building a supportive culture, ensuring high-
level involvement and mentorship, using a variety of learning
methods, offering extended learning periods with sustained
support, encouraging ownership of self-development, and
committing to continuous improvement. These concepts are
echoed by others, such as The University of Minnesota Medi-
cal School Emerging Physician Leaders Program (EPLP).34
This 3-year program for young physicians applies principles
that are of universal value:
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• Leaders develop personal resilience through continual
learning. Lifelong learning is essential to success as a
professional.
• Adult learning includes discovering the personal mean-
ing of ideas. Opportunities for applying learning to one’s
experience must be meaningful, varied, and frequent.
Learning shared with a cohort of fellow learners enhances
the discovery process: adults can learn as much from
each other as they do from formal instruction. Learning
is also enhanced when participants share common work
experiences.
• While learning is unique to each person, learners need
consistent methods of reviewing and improving learning
outcomes.
• Learning is reinforced by mentoring and coaching and
becomes embedded when participants are able to utilize
what they have learned in a timely manner.
Mentoring36 deserves special attention. It is right-
fully considered a key component of leadership training,
especially at the emerging leader level. The guidance of a
more experienced individual allows the emerging leader
to safely experiment with his/her developing style and
knowledge. A mentor is a “a trusted counselor or guide”17
who will direct the mentee in navigating institutional politics
and processes, help with specific tasks such as manuscript or
grant preparation, and keep the individual on a steady path
of upward career development. Mentors are not reserved for
emerging leaders: one is never too old or too senior to benefit
from good mentorship.
The next step, which in my opinion should be a required
component of senior leader development, is exposure to exec-
utive coaching. Coaching differs from mentoring in that it is
directed at enhancing performance in specific areas. It is goal
oriented and may be a relatively short-term process, although
many successful leaders avail themselves of a coach for their
entire careers. A key distinction is that the coach is there not to
direct (as a mentor may do) but to provide a “third opinion”,
by asking pertinent questions and helping the leader arrive
at the recognition of the right steps or decisions to make.37
Velsor et al state that individuals who receive coaching remain
responsible for communicating their learning needs to their
coach, and for implementing the plans developed together. It
is their responsibility to assure that the topics of discussion
are appropriate to their needs and address any feedback they
may have received. The coach does not set the agenda, but is
there to assure that it is developed properly.38
This is the ultimate example of “sustained support” that
is purely within the control of the leader.
Finally, the environment in which the training occurs plays
an important role. It must be understood to be “safe”, a place
where everything is open for discussion, without repercussions,
honesty and candor, is welcome and respected and, above all,
will remain confidential within the confines of the training
partners. A long-term benefit of longer training programs, not
to be underestimated, is the networking and peer mentoring
that inevitably develops. It is often stated that “it is lonely at the
top”: the relationships developed during these types of intense
training often result in a continuation of that safe environment
long after the program has been concluded. What emerge are
life-long relationships and networks of trusted peers that can
provide strong, safe, and valued support.
Examples of leadership development programs Many programs have been developed to enhance culture- or
situation-specific skills. Training may occur in different for-
mats, ranging from self-directed to team training or formal
curricula of variable duration. Of the programs described
in the literature, a large number are directed toward gradu-
ate medical education (residencies), mostly in response to
requirements by the accrediting body (ACGME). Most of
these programs have short and intense components (eg,
day-long retreats) that may be followed by small elements
disseminated throughout the training period.4,16,31
Devising a curriculum at the professional school level
is a greater challenge: the curriculum is tightly planned;
therefore, such early career programs are most successful
when integrated in the core curriculum, over the course of
the entire duration of the degree program or planned during
breaks from school. Most of the integrated programs are
targeted to students who are enrolled in dual degree pro-
grams, such as MD/PhD39 and MD/MBA or MD/MPH,40
and therefore already have the expectation of a longer
overall timeline. Other programs for health care students in
medicine, dentistry, and nursing have been described.23,41–43
Public health schools have also started to address this need
by offering specific leadership tracks beyond the core cur-
riculum for public health that by its nature already includes
some leadership components.44
Institution-based leadership programs directed toward
faculty (usually at the junior level) are emerging with
increasing frequency. Some examples include the University
of California at San Diego National Center of Leadership
in Academic Medicine,45 the Emerging Physician Leaders
Program34 at the University of Minnesota Medical School,
the University of Virginia Leadership in Academic Medicine
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Leadership development in health care
Program,46 the multidisciplinary Woodruff Leadership
Academy at Emory,47 the Primary Care Faculty Leadership
Fellowship for Family Medicine at the University of Texas
Health Science Center at San Antonio,48 The University of
Washington Teaching Scholars Program,49 and the Cleve-
land Clinic Academy.26 The latter program has a structure
that includes freestanding “a la carte” courses on a variety
of leadership topics available to all physicians, nurses, and
administrators, as well as leadership development workshops
for all incoming chief residents and developmental coaching
for newly appointed chairs, thereby providing training at
different career levels.
In more recent years, a number of specialty organizations
have also developed specialty-specific leadership programs.
A few examples include the American College of Surgeons
Leadership Course for Surgeons,50 covering topics such as
the attributes of a leader, aligning values and leading change,
building and maintaining team effectiveness, and leading
oneself. The American Academy of Pediatrics, together with
the Johnson and Johnson Pediatric Institute, developed the
Pediatric Leadership Alliance’s Young Pediatric Leaders for
the 21st Century Training Program to provide leadership
skills to pediatricians who are ,40 years old or have ,5 years
in practice.51 The Association of American Medical Colleges
offers a variety of development programs annually, including
those for Early and Mid Career Women, Minorities, Aspiring
Leaders, GME Development, and Executive Seminars for
Associate Deans and Department Chairs.11
These types of targeted programs are important and play
key roles in the development of students, trainees, junior fac-
ulty, and practitioners. Nevertheless, there is a need for more
national-level interdisciplinary and comprehensive leadership
training programs: these are still relatively scarce as are
leadership training opportunities for senior career individu-
als who have already attained administrative and leadership
roles. National programs have access to a broader cohort of
participants from diverse backgrounds and attract some of the
best individuals in the country. This enhances the experience
as participants and faculty bring their diverse experiences
to the program and the networking element is expanded to a
broad area. Programs available at this time include a selec-
tion of excellent general leadership training programs (albeit
mostly not directed toward health care) offered by the Center
for Creative Leadership, based in Greensboro, NC;37,38,52,53 the
Harvard Macy Program for Educators in Health Professions;54
and the Harvard leadership programs55 (Program for Chiefs
of Clinical Services, Leadership Development for Physicians
in Academic Health Centers, The International Leadership
Development Program for Physicians, Leadership Strategies
for Evolving Health Care Executives). These programs are
intense and relatively short (1–2 weeks duration).
Few comprehensive leadership programs have under-
gone formal evaluation. Stoller26 noted that “true return on
investment analysis of a leadership development program
has yet to be done.” One exception is the ELAM. Now in
its 20th year, ELAM is the most comprehensive national
(and international) program available today, albeit specific
to the academic sector, and open only to women. ELAM
enrolled its first class in 1995 and has to date trained almost
900 senior-level women in academic medicine, dentistry, and
public health. Evaluation has been an integral component of
the program since its onset.10,12–14 The most recent report10
shows that
Leadership skills and knowledge increase after participa-
tion; a greater proportion of ELAM alumnae advance to
higher levels of academic leadership than do comparison
groups; and medical and dental school deans view the
ELAM program as having a positive impact both on their
schools and on participants.10
In fact, 63.5% of the ELAM graduates report having
achieved positions of department chair or greater. These
included, at the time of publication, 14 of the 26 women deans
at US accredited medical schools, seven of the eleven women
deans at US dental schools, and one of the 13 women deans at
US public health schools. Twenty-eight ELAM alumnae have
held or currently hold positions of vice president, provost, or
president of an academic institution of higher learning, and
seven hold equivalent leadership positions in organizations
outside academia (foundations, pharmaceutical industry).
The ELAM model has also been applied to two independent
leadership programs: FAIMER,33 as mentioned earlier, and
Nonprofit Executive Leadership Institute,56 through the Bryn
Mawr College Graduate School of Social Work and Social
Research. The documented outcomes from ELAM suggest
that similar programs, open to a wider population of senior
health care leaders, would help in resolving the deficiencies
described by many reports in the literature.
Benefits and pitfalls of leadership training Over the past 20 years, we have made considerable progress
in the field of leadership development.
Leadership is a common topic of conversation in health
care today, and there is an increasing body of literature and
awareness of leadership development needs and opportunities.
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Sonnino
As noted earlier, a very significant step forward is that
outcomes of comprehensive leadership training programs
are being evaluated both in the academic environment10 and
when the emphasis is on clinical providers.49
Graduates of these development programs are highly
recruited nationally, and their knowledge is spread to diverse
geographic areas. As a consequence of the experience dur-
ing a development program, there is greater acceptance of
executive and leadership coaching. This has finally created
a culture where leaders no longer feel that they have to “go
it alone.” Hopefully, this will also help to erase the long-
standing perception that coaching is primarily a remedial
tool, when one is “in trouble.” The availability of input from
a trusted coach may prevent egregious errors, potentially sav-
ing a career, such as the situation of a department chair who
wished to discuss reorganization of the clinical service with
the hospital CEO. She had not discussed it with her boss, the
medical school dean. Her coach reminded her that blindsiding
a superior is never a good idea. The chair therefore shared
her ideas with the dean before discussing them with the CEO
and discovered that the dean had different ideas. The chair
changed her strategy to align with the dean’s vision, which
resulted in a plan that was acceptable to all. Given the impact
of the reorganization, had she moved forward without first
consulting the dean, it is likely that she would have been
removed from her chair position.
Formal leadership development resources are growing
in number and quality: the benefits of formal training are
many and usually evident, albeit not always documented
with objective data. Institutions and health care in general
directly benefit by the increasing numbers of individuals
already in leadership roles with formal training. With the
rise of programs for students and postgraduate residents and
fellows, a pipeline of physicians, nurses, and administra-
tors with some formal leadership training is being created:
this bodes well for succession planning and sustained
organizational success of our health care systems. There
are immediate benefits as well: development programs
directed toward junior-level health care providers and/or
faculty members have the added benefit of enhancing par-
ticipants’ career and organizational satisfaction that often
results in better retention, even if not all choose to advance
to leadership roles.45,57 Leadership development courses can
also be innovation incubators for the organizations: several
programs, such as ELAM, the Emerging Physician Leaders
Program, and the Cleveland Clinic Academy require that
participants develop and implement a project to enhance
institutional performance.
Significant individual benefits include personal growth,
career satisfaction and advancement, and, very importantly,
networking: participants who spend significant periods of
time learning together often develop a special camaraderie,
which encourages ongoing collaboration and synergy among
colleagues and institutions.
Relying only on leadership training programs to develop
new leaders is not free of risk to both the individual and the
institution. First, not all leadership programs address the dif-
ferentiating leadership competencies (especially emotional
intelligence) that set true transformational and servant leaders
apart, giving them the personal tools needed to move health
care forward. Programs may not include key components that
are covered by the more comprehensive curricula. Reliance
on such a program alone may not truly prepare the individual
for a proposed leadership role: in these cases, it may be wise
for an individual to fill any gaps by participating in more
than one training opportunity.
A second pitfall is the cost of training in times of lim-
ited resources: even short programs require significant
resources and time away from work for both course faculty
and participants. This becomes even more significant for a
curriculum that follows the recommendation of providing
opportunities to practice and implement new knowledge
during the program itself. Leadership theory (from didactic
teaching) alone is not sufficient to “make” a leader nor is a
practice/apprenticeship without the proper knowledge back-
ground: both must take place concurrently for concepts to
become imprinted, but this requires that the program last an
entire year or more (such as ELAM and EPLP). Obviously,
this impacts costs significantly, whether covered by the insti-
tution or the individual. In either case, a substantial sum is at
risk, should the participant not develop into a true leader, or
not secure a position where the new skills may be applied. To
my knowledge, there has not yet been an analysis comparing
the costs of offering a program (including everything from
faculty and administrative support to food, facilities, and time
away from work) with the revenue savings that may result
from the enhanced skills of the participants.
Stoller21,26 asked the questions: “What is the evidence that
acquiring these competencies ties to better organizational and/
or personal performance? What are the best strategies and
learning formats in which to cultivate these competencies
in emerging physician-leaders, and, at what point in one’s
training are the competencies best developed?” Research
carried out on the institutions and participants in the ELAM
program gives some insight into the first question,10 with
data that support the conclusion that both the organization
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Leadership development in health care
and the individuals do in fact perform better. The authors
found that “for the post-ELAM survey, composites of lead-
ership knowledge and skills showed significant differences
from presurvey means for all composites except Diversity
Competence” (where fellows had initially rated their compe-
tence very high). The authors concluded that the data suggest
that “confidence in knowledge and readiness for leadership
increased between program start and the posttest, and that
this increase is a predictable outcome of participation in the
program.” Their quantitative and qualitative research also
found that both the women who participated in the ELAM
program and the institutions served by ELAM graduates had
received significant benefit from the program. From their
data, the concept of a “Leadership continuum” emerged,
encompassing four elements such as 1) preparing for leader-
ship, 2) transitioning into leadership, 3) sustaining success in
a leadership position, and finally 4) transitioning again into
another leadership position.
Stoller’s second question is more difficult to answer.
Strategies and learning formats are as diverse as the programs
themselves. However, some commonalities seem to emerge:
programs that adopt diverse learning formats, adaptable to
the different personality types of the participants and those
that are spread out over time are more likely to allow the
principles to be “lived” and experienced in such a way that
they become second nature. Furthermore, as noted earlier,
programs that require the implementation of a project of
importance to both the trainee and his/her institution allow
for a safe first experience in using the skills that will be
important in future leadership roles.
The optimal timing of training is less clearly defined:
Should leadership training take place early during profes-
sional school?28 If so, should it continue in some form through
postgraduate and early faculty/practitioner experience?46 Or,
should leadership training be reserved for later phases of a
career, when experiences have already created a subconscious
leadership mentality, clinical skills are mature and the health
care providers can devote their full attention to developing
new leadership competencies?10 We have not yet answered
these important questions, but it is possible, even likely, that
a combination of both may be ideal. Early career training
happens at a time when many experiences that will shape the
individual have not yet occurred. This limits the individual’s
ability to completely comprehend and absorb those skills.
However, generic competencies are readily understood and
embedded at that time. Training as a more seasoned profes-
sional works upon a personal infrastructure where many of
the building blocks are already in place. It is logical to assume
that taken in sequence, both would have the greatest impact,
over the course of career maturation, in developing highly
skilled health care leaders. Such a model does not exist yet,
but it is possible that some of the students who were exposed
to early career training programs will eventually participate in
senior leadership development courses as well. Tracking those
individuals, if feasible, may provide valuable information.
Conclusion We have made a great deal of progress in the acceptance and
implementation of leadership development programs, although
there is no uniformity of career stage, timing, duration, or
curriculum. With some broad, comprehensive programs reach-
ing maturity and evaluation data covering a 20-year period,
there is more information available and more formally trained
individuals in our health care systems, who are able to dissemi-
nate and role model the information they have learned. There
are data to support the optimal methodology, and opportunities
are increasing, although not yet reaching all individuals who
might benefit. With resources and expertise, these obstacles
may be overcome in reasonable time. Health care systems,
academic institutions, and the practitioners themselves would
be well served to find ways to make formal leadership devel-
opment accessible and part of the routine career evolution for
emerging health care leaders.
Disclosure The author reports no conflict of interest in this work.
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