Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 DIVISION CHIEFS: CHALLENGES AND SUCCESSES TRANSITIONING INTO PHYSICIAN LEADERSHIP ROLES Denise Outlaw, DM Peirce College, Business Administration (Human Resou ces Management), Adjunc Faculty r t United States Denise_Outlaw@yahoo.com Abstract This qualitative phenomenological study explored data that will be useful in evaluating the advantages and disadvantages of external recruitment versus internal development. The study identified challenges faced by the division chiefs with respect to their transition to leadership roles at an academic medical center. The occupational group interviewed included 20 division chiefs located in a northeastern Pennsylvania academic medical center. Because of these data collected and analyzed, four thematic categories emerged including (1) challenges to incoming faculty promoted to leadership positions; (2) methods to create potential new leaders; (3) competencies useful to ascending leaders; and (4) identification of potential internal candidates. The majority of the participants believe that understanding the key components to managing a business would have been helpful before or after the transition to leadership. Other key findings were the recommended strategies to identifying and developing internal talent for upward mobility. Key Words: Transition, leadership, development Topic Groups: management consulting, management education, training and development, human resource management and career development INTRODUCTION Academic healthcare organizations have division chief leaders with responsibilities for managing various clinical and research departments within the institution. Responsibilities include management of clinical areas, physicians, and scientists; teaching; and administrative responsibilities. Leaders in internal medicine have many responsibilities, which include educating medical students, residents, and fellows; patient care; and academic research (Nettleman & Schuster, 2007). BACKGROUND OF THE PROBLEM Organizational leaders will recruit externally to fill leadership positions rather than promoting from within. External recruitment efforts are increasing, and the talent and skills required for some positions can be found through external recruitment efforts (Gandossy & Kao, 2004). Leaders in healthcare organizations recruit externally to hire talented physician leadership to ensure continued infusion of external talent and knowledge into the organization (National Center for Healthcare Leadership, 2006). The leaders of the academic medical center studied initiate an external recruitment process for physician leadership positions because maintaining a strong presence and communicating ongoing physician leadership opportunities increase the possibility of recruiting talented physician leaders across the country (Chen, 2005). 119 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 Although the preferred recruitment method is external, administrators of academic medical institutions are being challenged by the available pool from which to choose physician leaders. The impact of baby boomer retirement has affected all organizational recruitment, including physicians (National Center for Healthcare Leadership, 2006). Merritt Hawkins and Associates (as quoted in Evans et al., 2006) stated, “Approximately 80 percent of physicians age 50 or over are considering retiring from full-time clinical practice over the next five years” (p. 10). The percentage of physicians retiring in a few years may also be a factor in the number of physicians from which to select. The problem is that internal senior-level physicians are rarely promoted to division chief positions, resulting in high turnover (Ricketts & Randolph, 2008). Additionally, baby boomer retirement is resulting in a shortage of workers across industries, including available senior- level physicians (Sheldon, 2007). In this qualitative phenomenological study, the challenges and successes of senior-level physicians transitioning into division chief positions within academic medical institutions were explored. The results of these data may reveal information to executive leaders regarding skills and competencies for developing internal talent to use during recruitment replacements. Individuals within organizations develop new skills and abilities by modeling others and distinguish themselves by reacting to challenges and opportunities in the work environment (Ulrich, 1984). Along with baby boomer retirement, officials of academic institutions are faced with competing academic institutions and shifts in healthcare that are potential impacts on recruitment. More specifically, the number of non-physician providers has increased, limiting the need for general care provided by physicians. The responsibilities of non-physician providers continue to broaden. Many states have allowed non-physician providers to expand their scope of responsibility (Evans et al., 2006). Although the paradigm shift may be viewed as a negative change by some physicians, using nonphysician providers for general care may result in more opportunities for physicians to develop the administrative skills needed in senior-level management roles (Evans et al., 2006). In today’s work environments, businesses are faced with an increase in global competition, which may continue to cause shifts in the workplace (McCauley & Wakefield, 2006). Because of the potential for limited numbers of physicians to fill leadership positions, internal development and succession planning may be options for academic healthcare institution officials (Benson, 2009). Senior-level physicians selected for division chief positions must demonstrate leadership abilities. The physician population that worked in small practices will need to build and develop new skills to manage a large number of employees, particularly in complex medical institutions (Henochowicz & Hetherington, 2006). According to Kaplan (2006), to lead large complex organizations, leading and motivating staff are critical. Along with managing administrative responsibilities, the division chief must focus on the development of staff, which requires leadership abilities. Furthermore, the development of staff can be used in succession planning to build an internal talent pool for open positions that arise. Developing charismatic leadership increases leaders’ abilities to become role models for employees. Additionally, followers trust, respect, and admire those leaders. Senior-level physicians following charismatic leaders may develop skills and abilities, including leadership abilities, through imitating physician leaders (Conger, 1999). Along with developing charismatic leadership skills, transformational leadership abilities are critical to success in executive leadership positions. According to Avolio, Bass, and Jung 120 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 (1999), the six-factor model for transformational and transactional leaders includes “charisma/inspirational, intellectual stimulation, individualized consideration, contingent reward, active management by exception, and passive-avoidant leadership” (p. 444). Although charismatic leadership is only one aspect of the model, the importance of developing transformational leadership abilities is important to effective leaders. According to studies of the value of a transformation leader, continued change within an organization demonstrates the importance of building and developing transformational leadership abilities (Krishnan, 2001). As Bass (as quoted by Krishnan, 2001) stated, “Superior performance or performance beyond normal expectations is possible only by transforming followers’ values, attitudes, and motives from a higher plane of arousal and maturity” (p. 1). Transformational leadership abilities may be competencies and skills that can be used to develop senior-level physicians. STATEMENT OF THE PROBLEM Academic medical center administrators recruit externally and fill vacant physician positions with external candidates (National Center for Healthcare Leadership, 2006). While the external recruitment process can be effective and address organizational leadership gaps, hiring externally can have a negative impact on retention (Ricketts & Randolph, 2008). Other factors, including, cost/reimbursement issues, global trends impacting healthcare, and nursing shortages can affect physician retention (Cohn, Bethancourt, & Simington, 2009). The external recruitment process is another factor; therefore, internal development of physicians may present an opportunity to have a positive impact on retention (Ricketts & Randolph, 2008). Senior leaders within academic healthcare organizations spend more time and money on developing the skills and abilities of recent graduates with doctorate and medical degrees than on mentoring and developing high-potential senior-level physicians (Chen, 2005). According to Gray and Armstrong (2003), faculty early in their careers needs good mentors to build their skills. Effective mentoring and development of all physicians may result in upward mobility and a decrease in the loss of talented staff. Because of the external recruitment process, academic healthcare institution officials have high turnover in senior-level physician positions. Pediatric departments have high turnover in leadership positions. Therefore, individuals holding these positions should develop leadership ability and have their personal and professional qualities assessed to determine potential leadership gaps. Identifying competencies and skills may potentially result in retention of physician leaders. (Stapleton, Jones, & Fiser, 2005). In this qualitative phenomenological study, the research explored the perceptions and lived experiences of division chiefs in an academic medical center in northeastern Pennsylvania to understand better their successful or challenging entries into leadership roles. These data may result in useful information for senior leaders in academic medical centers in the identification of leadership competencies that can be used to develop faculty for potential advancement to division chief positions. SIGNIFICANCE OF THE PROBLEM The qualitative phenomenological research will be a contribution to the current body of knowledge as well as the basis for useful data to be used by hiring managers seeking qualified physicians to fill division chief positions. As the war for talent continues and baby 121 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 boomers retire, hiring managers may need to expand their recruitment process to include internal development of physicians. Although recruitment challenges exist, academic medical institution officials want to ensure that the right candidate is selected for the division chief position. Organizational leaders want to have talented staff on board, possibly requiring leaders to review the organization’s recruitment process and review of talent (Gandossy & Kao, 2004). In 2011, the baby boomer generation will approach age 65, which may present gaps in the available pool of qualified physician leaders. Organizational leaders in academic medical centers may need to focus more attention on internal development versus externally recruiting for physician leadership roles (Institute of Medicine, 2008). In addition to the data being useful in support of recruitment processes, these data will be useful in ensuring successful entry into leadership positions, whether the candidates are recruited externally or internally. Researching the leadership abilities and challenges of current division chiefs will result in leadership development framework for an effective performance management system, succession planning, and talent management process. Individuals within organizations develop new skills and abilities by modeling others and distinguish themselves by reacting to challenges and opportunities in the work environment (Ulrich, 1984). Administrators in the northeastern Pennsylvania-based academic medical center recruit externally to hire talented staff and remain an employer of choice for skilled medical professionals. However, the potential gap of recruiting qualified physician leaders should be considered. These data may be useful in developing a leadership development process to retain qualified staff and address future shortages of qualified physician leaders (Institute of Medicine, 2008). SIGNIFICANCE OF THE STUDY TO LEADERSHIP Although healthcare organization administrators find value in obtaining new and creative ideas through hiring external talent, challenges exist with external talent entering leadership positions within the organization (Gilmore, 2003). In this study, the research explored the leadership challenges that externally hired division chiefs experienced while transitioning into leadership positions. Although knowledge from other institutions is valuable, external hires have a learning curve that can result in gaps in the leaders’ abilities to demonstrate competency in the leadership roles. Leaders hired external to the organization may take longer to learn the business of the organization than an internal candidate. Internal hires are familiar with the healthcare organization; however, external institutional knowledge may be limited (Gilmore, 2003). The results of the study may be used to support the development of staff internally to fill vacancies rather than hiring externally. The challenges that both internal and external hires have experienced may reveal details regarding the areas of focus for developing staff internally. According to Garman (2006), hospitals may seek to be recognized as particularly innovative, or alternatively as particularly customer focused. Each of these goals may suggest a profile of specific behaviors that would be important for leaders to master. More specifically, in the case of innovation, leaders should be particularly open to cutting-edge approaches and should foster a climate of creativity and a sense of safety in trying new things. (p. 14) FINDINGS This section presents the results of the phenomenological analysis of the participant interviews. The fluid nature of phenomenological research and the data collection process provides distinct advantages, and it is important to note that the chief advantage is that 122 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 responses to interview questions may touch on thematic characteristics of the research that are not specifically covered by any single research question or interview question, thus allowing new information to emerge. The characteristic of phenomenological research is an advantage because it does not confine the interviewee to a narrow set of answers; instead, he or she is allowed to express more fully individual perceptions, beliefs, and lived experiences. Lived experiences are especially relevant to this study because, many times, the experiences that are acquired in one context can spill over into other contexts. The lived experiences become paramount in the context of this particular study because of the diversity of people interviewed. There were division chiefs from many different departments and specialties, and many of them had very different experiences surrounding their promotions to division chief. Therefore, the information compiled expresses a wide range of thoughts, feelings, and experiences about promotion and leadership challenges within the hospital. FOUR THEMATIC CATEGORIES Four thematic categories were identified when the invariant constituents were clustered and thematized. The four thematic categories were (1) challenges to incoming faculty promoted to leadership positions, (2) methods to create potential new leaders, (3) competencies useful to ascending leaders, and (4) identification of potential internal candidates. This section contains a review of each thematic category and the most significant invariant constituents of which they are composed. Table 1: Challenges to Incoming Faculty Challenges # of participants to offer experience % of participants to offer experience Transition to business 12 60% Getting subordinates to “buy in” 4 20% New ideas 3 15% Large scale organization 4 20% Table 1 presents the most important invariant constituents that resulted in the first thematic category. The category contains a representation of the common challenges that the physicians faced when they were promoted to the role of division chief at the hospital. Participants reported many different challenges, but among those many, there were several that stood out as common and representative of the challenges that could be faced in any division. The most common invariant constituent in this category was the challenge of transitioning to business, which had 12 participants (60%) address it. The analysis posed significant challenges because 19 of the participants were medical school graduates and one participant was a PhD. All the participants lacked many of the skills and training involved with business operations that are required of the division chief to run a hospital department. The next two most common constituents both had 4 participants (20%). The first was trying to get subordinates to get on board with the new division chief and allow her or him to implement a particular style of management. Dealing with a large-scale organization was also a particular challenge that several of the participants had to deal with when ascending to the role of division chief. The last constituent discussed here is that of getting people to 123 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 accept new ideas. Three participants (15%) noted that they had trouble convincing people within their divisions to go along with the new ideas that they were trying to institute. Table 2: Methods to Create Potential New Leaders Methods # of participants to offer experience % of participants to offer experience Leadership training 10 50% Personal skills 9 45% Business training 8 40% Table 2 displays the major invariant constituents that resulted in the second thematic category. This category illustrates the various ideas that the division chiefs had about models the hospital could employ to help the growth of high-potential physicians at the hospital. The most common suggestions, feelings, and opinions from the participants are illustrated below. The need for leadership training was a very important part of the model for 10 participants (50%). This need was important, according to participants, to give potential leaders introductions into some of the more difficult parts of the leadership that comes with being a division chief. The various aspects of the training would include conflict resolution, managing many people, and training potential candidates to be comfortable dealing with problems that may arise in leadership roles. The need to create a model to help potential candidates work on personal skills was also seen as very important by 9 participants (45%). Business training, such as familiarity with spreadsheets, budget balancing, and grant writing, was mentioned by 8 participants (40%) as something that the potential future leaders would need to engage in order to be effectively prepared for the role of division chief or other similar leadership positions. The third thematic category, which is illustrated with the most common invariant constituents in Table 3, consists of particular skills that the participants identified as important knowledge that they would have liked to have had before they became division chiefs or competencies that were being targeted during their early tenure as chief. As with the challenges, the most important competency that the participants noted should be targeted was that of providing business skills. The better understanding of budgetary concerns and business management was seen by 12 participants (60%) as the most important thing that a new leader should be confident with. The next highest was having a broad understanding of the system, which 7 participants (35%) noted was important. This would help new division chiefs to understand how the hospital system, in general, worked and how their divisions interacted with it. People management skills, which, included interpersonal skills and conflict resolution, were considered important by six participants (30%). Five participants (25%) thought that leadership training would have been more helpful when they were beginning in their new roles as division chiefs. The final thematic category was made up of the invariant constituents that represented the ideas that the participants had about the identification of internal candidates that would be ideal for leadership positions. Table 4 outlines the most common invariant constituents. 124 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 Table 3: Competencies Useful for Ascending Leaders Competencies # of participants to offer experience % of participants to offer experience Business skills 12 60% Broad understanding of the system 7 35% People management 6 30% Leadership training 5 25% Table 4: Identification of Internal Candidates Methods to identify # of participants to offer experience % of participants to offer experience Lower level leadership positions 8 40% Identifying leadership qualities 6 30% Mentoring 5 25% Providing potential candidates with lower level leadership positions was favored by 8 participants (40%). The results could mean giving them leadership positions in departments and providing opportunities to practice skills and to be included in decision making with the chiefs. Having the hospital create ways to identify leadership qualities in current employees was considered important to 6 participants (30%). The next most common constituent was creating ways for mentoring programs to identify potential candidates and provide them with mentors that could be advocates for the potential candidates within the hospital structure. Five participants (25%) favored this method. LINK TO SPECIFIC AND GENERAL PROBLEMS Organizational leaders continue to seek external candidates to fill leadership roles because of the different perspectives and skills that new talent can bring to a team (Chen, 2005). The results of external recruitment can have an impact on internal staff and cause low morale and low retention. Specifically, academic medical institutions recruit externally to fill division chief roles rather than establishing an internal leadership development model to consider internal talent (National Center for Healthcare Leadership, 2006). The results of this study indicate that leadership development can assist physicians who transition from physician to physician leader. These data from this study demonstrate that division chiefs, whether recruited externally or internally, have challenges assuming physician leadership roles. The subjects identified specific leadership development needs that should be provided to physicians to prepare them for division chief positions. Many of the participants provided data that can assist with the identification of high-potential physicians as well as recommendations for providing leadership training while working as a clinician. IMPLICATIONS This study contributes to the understanding of the experiences of division chiefs transitioning to leadership positions in an academic medical center. These data and analyses may provide useful information to hiring managers while considering the appropriate recruitment process 125 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 for filling physician leadership roles. While new talent and skills can be found through the external recruitment process, external candidates may take longer to learn the organization (Gandossy & Kao, 2004; Chen, 2005; Gilmore, 2003). Hiring managers can use these data to focus on specific areas of development that may assist with successful entries into the leadership roles. The platform used for this study can be used for future analysis in other academic medical centers so that recruitment of the most qualified leaders for the post of division chief may improve the overall level of hospital administration. As a result, these data may directly contribute to the well being of society. The use of a new population would expand the existing research base (Creswell, 2002). While these data provide information on the challenges that division chiefs experience in transitioning to leadership positions, these data may assist senior leaders within an organization with developing physicians within the organizational setting. External recruitment of physician leaders may present challenges to leaders because of the baby boomer retirement, which will also affect the academic medical community (LaMascus et al., 2005; Sheldon, 2007; Swartz et al., 2007). Understanding the current challenges of the division chiefs’ perceptions and lived experiences can assist with future recruitment efforts and developing internal staff. Furthermore, developing internal physicians to prepare them for future leadership opportunities may assist with the academic medical institution’s retention efforts (Ricketts & Randolph, 2008). SUMMARY Division Chiefs in academic medical institutions have many responsibilities including teaching, clinical care, and research (Nettleman & Schuster, 2007). Such multiple responsibilities can limit the physician’s ability to develop leadership skills. Along with multiple responsibilities, the approaching baby-boomer retirement may present challenges for filling open division chief positions vacated by current physician leaders. Because of the multiple responsibilities of physicians and the baby boomer retirement, leaders within academic medical institutions may be challenged with recruiting qualified physicians to transition to division chief positions ((Nettleman & Schuster, 2007; Institute of Medicine, 2008; Gilmore, 2003). This study has offered a phenomenological analysis of the perceptions and lived experiences of division chiefs. Participants identified multiple challenges during their career transitions. The aligned perceptions were described as four themes of the study. The analysis led to the identification of the challenges, feelings, perceptions, opinions, and experiences of new division chiefs during their transition into leadership positions from clinical positions. Furthermore, physicians agreed that the transition from the academic and clinical arena to administrative duties was challenging. This study indicated that physicians needed training to perform managerial and administrative work. Working as an associate division chief was identified as an important way to acquire leadership skills and managerial experience. Further, these data collected may be beneficial to senior leaders in academic medical centers and may assist with the recruitment of future leaders and potential internal leadership development programs. Although these data contained in this study focus specifically on the division chief population, the research framework provides a structure that may be useful outside of academic medical institutions with a focus on other organizational leadership positions. Additionally, these data collected include recommendations for identifying leaders internal to the organization and designing leadership development programs for identified staff. These recommendations 126 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 provide future opportunities for implementing new programs for new and existing leaders and conducting research to measure the results. REFERENCES Avolio, B. J., Bass, B. M., & Jung, D. I. (1999). Re-examining the components of transformational and transactional leadership using the Multifactor Leadership Questionnaire. Occupational and Organizational Psychology, 72, 441-462. Benson, A. (2009). Time and space to think. Nursing Management, 15 (9), 10-11. Chen, K. P. (2005). External recruitment as an incentive device. Journal of Labor Economics, 23 (2), 1-25. Cohn, K. H., Bethancourt, B., & Simington, M. (2009). The lifelong iterative process of physician retention. Physician Relations, 54 (4), 220-226. Conger, J. A. (1999). Charismatic and transformational leadership in organizations: An insider’s perspective on these developing streams of research. Leadership Quarterly, 10 (2), 1-28. Creswell, J. W. (2002). Educational research: Planning, conducting, and evaluating quantitative and qualitative research. Upper Saddle River. NJ: Merrill Prentice-Hall. Evans, C. A., Ellis, M. S., Blight, C. O., Brooks, N. H., Johnson, H., Levin, S., et al. (2006a). An environmental analysis report: Healthcare trends. Chicago: American Medical Association. Gandossy, R., & Kao, T. (2004). Talent wars: Out of mind, out of practice. Human Resource Planning, 27 (4), 15-19. Garman, A. N. (2006). Leadership competencies: An introduction. Journal of Healthcare Management, 51 (1), 13-17. Gilmore, T. N. (2003). Making a leadership change. New York: Authors Choice Press. Gray, J., & Armstrong, P. (2003). Academic health leadership: Looking to the future. Proceedings of a workshop held at the Canadian Institute of Academic Medicine meeting Quebec, Canada. Clinical Investment Medicine, 26 (6), 315-326. Henochowicz, S., & Hetherington, D. (2006). Leadership coaching in health care. Leadership and Organization Development Journal, 27 (3), 183-189. Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce (Report brief). Washington, DC: National Academies Press. Kaplan, A. S. (2006). Climbing the ladder to CEO part II: Leadership and business acumen. The Physician Executive, 32 (2), 48-50. Krishnan, V. R. (2001). Value systems of transformational leaders. Bradford, 22 (3), 1-7. LaMascus, A. M., Bernard, M. A., Barry, P., Salerno, J., & Weiss, J. (2005). Bridging the workforce gap for our aging society: How to increase and improve knowledge and training. Report of an expert panel. American Geriatrics Society, 53, 343-347. McCauley, C., & Wakefield, M. (2006). Talent management in the 21st century: Help your company find, develop, and keep its strongest workers. The Journal for Quality and Participation, 29 (4), 4-7. National Center for Healthcare Leadership. (2006). Best practices in health leadership, talent management, and succession planning. Chicago. Nettleman, M., & Schuster, B. (2007). Internal medicine department chairs: Where they come from, why they leave, and where they go. The American Journal of Medicine, 120 (2), 186-190. Ricketts, T. C., & Randolph, R. (2008). The diffusion of physicians. Health Affairs, 27 (5), 1409-1415. Sheldon, G. G. (2007). Workforce issues in general surgery. The American Surgeon, 73 (2), 100-108. 127 Advances in Business-Related Scientific Research Journal (ABSRJ) Volume 1 (2010), Number 2 Stapleton, F. B., Jones, D., & Fiser, D. H. (2005). Leadership trends in academic pediatric departments. Pediatrics, 116, 342-344. Swartz, J. E., Swartz, T. A., & Liang, P. (2007). Market meltdown: Recruiting qualified business faculty. Journal of Education for Business, 82, 337-342. Ulrich, W. L. (1984). HRM and culture: History, ritual and myth. Human Resources Management, 23 (2), 117-128. 128