key: cord-031777-gy1lc2jz
authors: Gjosteen, Frederic
title: Acknowledging leadership as a constituent of medical practice : an international outlook
date: 2020-09-11
journal: Bull Acad Natl Med
DOI: 10.1016/j.banm.2020.09.025
sha: 
doc_id: 31777
cord_uid: gy1lc2jz

nan

The author declares no conflict of interest related to this publication.

In France, enforcing clinical leadership within hospitals has once again run into its « glass ceiling »: the lack of academic and professional recognition of management as a part of medical practice, alongside clinical expertise. A look at other countries provides insights into how to achieve such an endorsement.

In the wake of the COVID-19 epidemic, several medical unions or interest groups in France have stressed the need to increase medical involvement in hospital decision making. The general public mostly welcomes the idea of having medical doctors "run" hospitals; yet it remains an exception in France. Upon request of the Ministry of Health, Pr Olivier Claris [1] recently published a report on hospital governance, which duly recommends to give greater emphasis on management issues in medical training; it also points out the need to strengthen management skills among medical doctors, thereby helping them assume clinical leadership. Such recommendations, however, seem to have been expressed time and again. Special requirements for medical department heads have existed since the beginning of the 1960s, when the current standards of medical practice were being defined for France's public sector hospitals. Ten years later, a major law on hospital reform expressed concern over the "lack of involvement of medical staff in the responsibilities of management". As public-sector hospital budgeting switched to DRG-based payments in 2005, another law was passed in order to promote medical intrapreneurship and therefore increase the self-determination of clinical departments ("pôles") ; since 1 , head physicians are required to follow at least 60 hours of initial training when newly promoted. Today, most university or large-scaled hospitals provide leadership programmes to medical doctors assigned to new responsibilities as department heads. Pr Claris' report specifies that gateways do exist for medical doctors wishing to become executive officers, but scarcely attract candidates. Increasing doctors' initial training and adding skills will not solve the underlying problem: healthcare management needs academic and professional endorsement, alongside the other clinical and public health specialties. A quick international survey shows that France is lagging behind on this aspect [2] [3] [4] [5] [6] [7] . In Germany, for instance, the association of medical hospital executives has been active since 1912, and is hosted by the federal Medical Association. It provides Continuing Professional Development in healthcare management with the same level of requirements as expected for clinical CPD 2 . In the UK, the Faculty of Medical Leadership and Management was created in 2011 with similar assignments; it is endorsed by all other Royal Academic Colleges and Faculties. In Portugal, the national medical association sets standards for qualifications and training within health services management. The European Association of Senior Hospital Physicians [9] published a statement on clinical leadership in 2015 and has assigned a permanent working group to promoting it towards national medical associations. Outside Europe, the Japanese Association of Medical Sciences includes a specific Society for Healthcare Administration. The Royal Australasian College of Medical Administrators (RACMA) was created in 1968 and extends beyond Australia to New Zealand and the Asia Pacific Region; it considers medical administration as a specialty. In the US, the American Medical Association includes a Section called « Organized Medical Staff » which started issuing a Code of Conduct in 2017, after the AMA adopted an ethical opinion stating that health professionals have a "responsibility to address situations in which individual physicians behave disruptively.". The AMA considers that such behaviour can impede high-quality care and may be a manifestation of physician burnout, which top management must address. Given its greater share of senior executive positions held by medical doctors, Norway [10] provides some other insights. Within their national medical association, a section is dedicated to management since 1961: its official policy states that "all medical activities imply responsibilities as a leader" [11, 12] . The section publishes guidelines on medical conduct when engaging reorganizations and best practices on clinical leadership. Moreover, the medical association insists on the importance of anticipating the switch back to clinical practice through training packages; and of providing adequate compensation, as a prerequisite of sufficient authority among peers.

As these examples show, the way clinical leadership is acknowledged may vary according to national settings: as a section of the Medical Association in some countries, as an academic Society in others. However, they all share two aspects in common : firstly, peer group recognition ; secondly, using CPD as their major lever for improvement. Pondering this fact, it seems that French institutions could resort to CPD, rather than focusing on initial training, in order to promote clinical leadership among its medical staff. With regards to clinical practice, CPD has successfully led medical communities to engage in lifelong learning, with a strong focus on three-yearly, peer-based evaluation of professional practice. French authorities have been cautious to avoid the pitfalls of "top-down" guidelines : through its accreditation process for training programs, CPD is gradually enforcing a framework, in which every specialty identifies "good practice" based on medical evidence. All healthcare professionals are involved regardless of age. The dynamics of change that CPD has harnessed among medical specialties could be applied to clinical leadership ; in particular, evaluating managerial practice based on the self-assessment methods used in CPD (called "EPP" in France) could prove very insightful. Such methods would have to be transferred with specific attention on crossdisciplinarity and on patient safety. Evaluation as applied to management would encourage the production of guidelines and promote evidence-based approaches to clinical leadership. Medical simulation should have a great part to play ; in the long run, it would benefit entire healthcare teams. Pr Claris' report recommends that the Centre National de Gestion, an authority in charge of coordinating the careers of public sector physicians nation-wide, be entrusted with the task of defining the training requirements for new department heads. Based on the insights above, it seems the CNG may only partially succeed if left on its own. Greater change is at hand, if clinical leadership is granted the academic recognition it requires. How to achieve such an endorsement remains to discuss, and would imply several French institutions such as the Medical Association, the Academy of Medecine, the Federation of medical specialties (FSM) and the Higher Health Authority (HAS). It could serve as a landmark for further change, as technology and innovation frees medical doctors from front-end delivery of care, and sets a new focus on patient journey and health services organization.

Le professeur Olivier Claris a remis son rapport de recommandations sur la gouvernance de l'hôpital à Olivier Véran

Royal Australasian College of medical administrators

Set clear rules to stop bad behavior that worsens morale

Agence nationale du développement Professionnel Continu

Association Européenne des Médecins des Hôpitaux (AEMH)

Engaging Doctors in leadership