|Year : 2010 | Volume
| Issue : 12 | Page : 580-585
Views of West African surgeons on how well their educational and professional backgrounds may have prepared them for health leadership roles
Abdulraheem O Mahmoud1, Dennis Nkanga2, Adeola Onakoya3
1 Department of Ophthalmology, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, Nigeria
3 Guiness Eye Centre, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||9-Nov-2011|
Abdulraheem O Mahmoud
P.O. Box 13834, Ilorin 240008
Source of Support: None, Conflict of Interest: None
Background: Because of the appalling health indices in West Africa, Physicians there need to be at the forefront of the organizational challenge in managing and improving health systems. Aim: To collate the views of West African surgeons on how well their educational and professional backgrounds may have prepared them for leadership and managerial roles in health care, and draw appropriate policy implications. Material and Methods: Filled structured questionnaires from 110 surgeons that were attending an annual conference were analyzed. The respondents' bio data, professional, educational, health administrative backgrounds were probed. Their views on justifications for physicians' involvement in health managerial roles, probable influence of some physicians' characteristic traits and professional attributes on health leadership roles, and suggestions for improvement were also collated. Results: 71.8% of the respondents had held or were then holding health-related administrative posts; 90% had attended different varieties of management courses; 95.4% identified physicians as the inherent leaders of the health care team; but only 28.4% adjudged their health management role "strongly important" (28.4%) among their multi-faceted roles; and they largely agreed that some stated professional and characteristic traits of physicians tend to make them poor leaders and managers. Conclusions: Our findings suggest that the preparations that the respondents got from their formal and professional education for leadership and managerial roles in health care were not optimal. We recommend for a paradigm shift for physicians on health leadership issue which is to be facilitated by a well-focused short time duration health management course for all physicians, particularly specialists.
Keywords: Physician leadership, clinical leadership, health management, West Africa.
|How to cite this article:|
Mahmoud AO, Nkanga D, Onakoya A. Views of West African surgeons on how well their educational and professional backgrounds may have prepared them for health leadership roles. North Am J Med Sci 2010;2:580-5
|How to cite this URL:|
Mahmoud AO, Nkanga D, Onakoya A. Views of West African surgeons on how well their educational and professional backgrounds may have prepared them for health leadership roles. North Am J Med Sci [serial online] 2010 [cited 2020 Nov 24];2:580-5. Available from: https://www.najms.org/text.asp?2010/2/12/580/86427
| Introduction|| |
The centrality of physicians to the leadership of the health care management has been increasingly better recognized in the developed world since the 90s. Over the years there, arguments for this have been made more compelling ,,, , their exact roles better defined ,, , and both the content and behavioral competencies that are needed for physicians for their leadership and managerial roles better articulated ,,, . To sum up, it was increasingly better recognized that the changes occurring in health care demand that physicianns expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects that were absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, have become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care  .
In West Africa, there is even a greater need for physicians to be at the forefront of the organizational challenge in managing and improving health systems because of the appalling health indices enumerated below. The persistent crippling burden of disease in the African region as a whole can be attributed to many causes that include: weak national and district health systems; human resources for health crisis which has been exacerbated by internal and external brain drain; 47% of the population in the Region having no access to health services, and about 50% have no access to essential drugs  ; about 59% of pregnant women delivering babies without the assistance of skilled health personnel  ; 64% of the population lacking sustainable access to improved sanitation facilities and 42% lacking sustainable access to an improved water source  ; out-of- pocket expenditures constituting 51%-90% of the private health expenditure in 14 countries and 91%-100% in 24 countries  ; 38.2% of the people in sub-Saharan Africa living below the international income poverty line of US$1 per day  ; low investment in health development; and poor governance  . Those challenges are compounded by weak national health research systems, which hinder the generation of new information and knowledge for diagnosing and providing solutions; monitoring of health system performance; development and production of new technologies and health products for tackling priority diseases and health conditions; and innovating ways of accessing and putting into effective nationwide use the existing cost effective promotive, preventive, curative, rehabilitative and care interventions  . Additionally, peculiar challenges such as non-streamlining of the hazy constitutional guidelines on the control and funding of health care and lack of coordination and harmonization of care at the various levels of the administrative health care hierarchy (national, regional and district) - a country which has about half of the population of the West African sub-region- exist as well as well in some countries like Nigeria  .
Right from the early seventies, it had been recognized that medical education in developing countries need to produce a physician who has been trained for uncertainties, who is resourceful and adaptable, and who is able to manage health care team to the best advantage within a limited financial budget; in short a health manager  . Physicians' top echelon which is comprised largely of specialist doctors particularly surgeons, constitute the managers and leaders of health institutions including government ministries, health regulatory agencies, and health care facilities. But do these physicians have the necessary capabilities to meet the organizational challenge in health system? Are there impediments in their educational and professional background to their being efficient result-oriented managers and leaders? We aim in this study to seek some answers to some of these questions through the collation of the views of some surgeons that were attending an annual scientific conference in West Africa.
| Materials and Methods|| |
The primary approach used to collect data of the study reported in this paper was a structured questionnaire. The period of the dispatch and collation of questionnaires was during the 50 th Annual Scientific Conference of the West African College of Surgeons, which was held in Calabar, Nigeria, from 6 th to 12 th , February 2010. One hundred and fifty copies of the study questionnaire were distributed to surgeons that consented to participate in the study. The self-administered and anonymous questionnaire was distributed after full confidentiality of the data collected was ensured to all the study participants and the assurance that the results of this study would not be presented either at an individual study participant level. Pre-testing was done prior to the definitive study, when the questionnaire was administered to a sample of surgeons at a University Teaching Hospital in Nigeria in order to assess comprehension and feasibility. Ethical approval for the study was obtained from the University of Calabar Teaching Hospital, Calabar, Nigeria.
This study is part of a wider study on physicians' health leadership and management roles. This aspect of the larger study being reported in this communication comprised 14 questions in the study questionnaire. The first six probed the study participants' bio data and general professional back ground; four probed the health administrative background and educational preparations for physicians' involvement in health managerial roles; one on justifications for physicians' involvement in health managerial roles; two on their views on probable influence of physicians characteristic traits and professional attributes on health leadership roles. The last question rated the degree of agreement with some stated suggestions on the ways forward. The format of the responses was generally on a scale of 0-3, with 0 representing none/never/lowest/least and 3 representing most/highest/greatest/always/strongest depending on the specific context of the question posed with the respondents' choosing appropriate responses among the already supplied options.
All analyses and statistical tests were conducted using the Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc, Chicago, Ill, USA). Simple descriptive statistics was used to generate frequencies, percentages, and proportions. Where relevant Chi-square test was used to determine any significant difference and a p value < 0.05 was regarded as significant.
| Results|| |
One hundred and ten out of the 150 questionnaires distributed were filled and returned giving a response rate of 73.3%.
The age range of the respondents was from 35 to 63 years with a mean of 43.15 and SD of 5.957. Ninety-three of the 110 respondents were males and 17 were females (M: F = 5.5:1). Of the 108 who stated their nationalities, 84 were Nigerians, 19 Ghanaians, 2 Senegalese, 2 Guineans, and 1 a Togolese. Of the 53 respondents who indicated their years of their ophthalmic practice experience, 25 (47.2%) were less than 5 years, 8 (15.1%) 5-9 years, 11 (20.8%) 10-15 years, and (17.0%) over 15 years. The specialty distribution includes: 31 obstetricians and gynecologists, 24 general surgeons, 16 ophthalmologists, 10 orthopedics, 7 anesthetists, 6 plastic and reconstructive, 4 pediatric surgeons, 3 urologists, 3 cardiothoracic, 3 Ear-Nose-Throat (ENT) surgeons, 2 radiologists, and one responder did not indicate his/her specialty. A hundred of them practiced in government-owned facilities, 4 in privately-owned ones, 3 in missionary hospitals, and the 3 remaining ones did not specify the ownership profile.
Administrative & Educational Background
Seventy-nine respondents had held or were then holding these health-related administrative posts: unit/divisional heads (29), heads of departments (28), directors/chairmen of medical advisory committees of hospitals (8), hospital medical directors (8), health program coordinators (8), commissioner/minister of health (1), while 31 others indicated not having held such posts.
[Table 1] gives the details on the question of relative importance with which West African surgeons held management role in relation to their other roles. Management role was adjudged the least "strongly important" (28.4%) among their multi-faceted roles, well behind clinical (88.0%), research (79.8%), teaching (79.8%), and community service (36.1%).
|Table 1: Relative importance with which West African surgeons held management role in relation to their other roles.|
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Ninety-nine respondents had attended these management courses: seminars/workshops lasting 2 weeks or less (74), certificate courses of 3 months duration or less (14), diploma courses of one year duration or less (7), Masters in Business Administration (MBA), and Masters in Public Health (MPH) (4).
The adequacy of preparation for health leadership as perceived by the respondents increased with succeeding higher levels of education [Table 2]: for primary schools, 32.7% of the respondents perceived the preparation as adequate or very adequate, 60.6% at the secondary school level, 74.6% at the medical school, 78.1% at the residency training level, and 87% at the level of a professional leadership/management/business course.
|Table 2: Perceived adequacy with which different levels of educational institutions had prepared West African Surgeons for health leadership roles.|
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[Table 3] illustrates the degree of identification with some justifications for the involvement of physicians in health leadership and management roles by respondents. An overwhelming majority identified or strongly identified with these justifications: that physicians are the inherent leaders of the health care team (95.4%), that health care has become businesslike and hence managerial experience is needed (90.8%), that physicians would be easier to train as managers compared to trying to train business executives as physicians (85.4%), that the analytical capabilities of physicians are assets for them as managers (90.9%).
|Table 3: Identification with some justifications for the involvement of physicians in health leadership and management roles by West African Surgeons.|
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[Table 4] gives the details of the degree of agreement with the notion that some attributes of the medical profession tend to make physicians poor leaders and managers by respondents. The reaction from the respondents on this issue was mixed. While 39.8% did not or only mildly agreed with the notion of the authoritarian nature of the medical profession is an impediment for physicians to be successful leaders and managers of the health care team, 60.2% agreed or strongly agreed. Corresponding figures are as follows for hierarchical nature (43.5% versus 55.5%), Intimidatory nature (50.5% versus 49.5%), competitive nature (52.5% versus 47.5%), and humiliatory nature (59.2% versus 40.8%).
|Table 4: Agreement with the notion that some attributes of the medical profession tend to make physicians poor leaders and managers by West African Surgeons.|
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On the question of the notion that some characteristic traits of physicians are responsible for the tendency to make them poor leaders and managers of the health care team, the respondents largely agreed with the only exception being the "accusation" that they are resistant to health authorities. Sixty two point seven percent agreed or strongly agreed that their craving for autonomy tend to make them poor leaders and managers, 57.9% on their high sensitivity to criticisms, 64.5% on their being compulsive perfectionists, 60.7% on their impatience. Only 39% however agreed or strongly agreed with the notion that their resistance to authority made them poor leaders and managers [Table 5].
|Table 5: Agreement with the notion that some characteristic traits of physicians tend to make them poor leaders and managers by West African Surgeons.|
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The respondents "strongly" agreed with the listed suggestions for increasing the capabilities of physicians in leadership and managerial roles by the respondents in the following order: health management component during residency training to be broadened (82.4%), undertaking specific, stand-alone health management courses (80.4%), health management component during medical school to be broadened (67.6%), need for physicians to broaden their human relationship by "relating better" and "socializing more" (66.4%), and lastly the need for physicians to be given more opportunities to serve in management posts in order to learn on the job (53.7%). [Table 6] gives more details on this question.
|Table 6: Agreement of West African Surgeons with some suggestions to increase leadership and management capabilities of physicians.|
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| Discussion|| |
Nigerian surgeons constituted over three-quarters of the respondents being that the conference venue was in Nigeria which made attendance easier and cheaper for them .The demographic data on the respondents, male preponderance, surgical specialty distribution, and the ownership profile of the health institutions in which the respondents practiced were therefore more of reflections of what generally obtain among Nigerian surgeons. The findings from our study are best discussed within the frame work of the 3 Ps that are essential for successful leadership: perception, passion and persistence.
These facts that over 70% of the respondents had ever served or were serving in one health managerial post or the other, that 90% had attended one specific management course or the other, and the identification with the various justifications for the involvement of physicians in leadership and managerial roles would ordinarily suggest that the respondents had the correct perception i.e. the knowledge, attitude and power of observation on health leadership. But the worrisome finding that they still regarded their managerial role the least among their multi-faceted roles would raise doubts about the correctness of the knowledge that they might have learned and their attitude to health leadership. For one, their near-unanimity (95.4%) in their being the inherent leaders of the health team and the constant air of such monarchical bearings appear to goad the other professionals in the health team such as nurses, pharmacists, laboratory technicians into ruinous antagonistic postures which often translate into sub-optimal health care output and crippling shutdown of hospitals during industrial strike actions for such improbable demands as parity in wages and equal administrative/leadership privileges with physicians. Though superiority of physician executives in the teaching hospital setting over non physician executives has been attested to in a United State study  but physician leadership is not only to enhance the meaningful identity of the medical profession but also to create effective linkages with other health care professionals and stakeholders  . Much as the authors do not recommend to physicians to make any apology for being the inherent leaders of the health team, we would however suggest that physicians start "earning" this privilege by according this role an increased importance and go about it with greater passion (the 2 nd P) and circumspection. With passion in place, there would be need for persistence (the 3 rd P) such that physicians would learn from the obstacles they might encounter along the way and not just give up. We would not agree less with the admonition that "clinicians ought to be playing a central role in making the changes in health care systems that will allow the system to offer better outcomes, greater ease of use, lower costs, and more social justice in health status"  .
The mixed responses on the agreement with the notion that some attributes of the medical profession tend to make physicians poor leaders and managers by the study respondents who appeared to be on the defensive, should be regarded as representing some tacit admission that the transition of a dyed-in-the-wool physician to a physician manager would require a paradigm shift. A management team functions best in a collegial and collaborative sprit in sharp contradistinction to the authoritarian and deferral to "superior authority" milieu in which physicians have been trained to honor. It is however heart-warming that 61%% of the respondents did not agree or only mildly agreed with the notion that their resistance to authority made them poor leaders and managers as a core function of a physician manager is to serve as mediator between his/her fellow physicians and the owners of the health institution in order to minimize miscommunications and maximizing agreement and understanding  . Physician leadership is also critical for attaining balance among conflicting pressures for quality of care versus cost containment, prevention versus high technological medical intervention, and application of specialized versus primary care  . What really matters is whether or not a hospital has a culture that supports quality improvement work or an approach of flexible implementation  . Perhaps the biggest barriers to innovative approaches are the incumbent leaders of health systems who have risen within the hierarchy based on command and control methods  . The individual physician should not wait until he or she is in the higher rungs of the managerial ladder before imbibing the quality improvement approach. An individual's contribution in the form of a health system research using the total quality management approach was readily found useful by a tertiary eye-health institution in Nigeria to pin-point the exact post where the delays occurred in the emergency health care delivery process and this subsequently led to better service delivery after the root causes of the delays were identified and necessary corrective measures taken  .
An analysis of the suggestions for the way forward made by the respondents was quite revealing. Their agreement with the suggestion that the health management component of the curricula of both the medical school and residency training be broadened could be interpreted to mean that the existing ones are probably inadequate for their needs. Much more so it would appear to be the need for specific stand alone health management courses, rather than the less focused ones such as Masters in Business Administration (MBA), Masters in Public Health (MPH), etc. By also agreeing on their need to "relate better", there is hope for more harmonious inter-professional relationships with non-physicians members of the health care team.
| Conclusion|| |
Despite the apparent adequate managerial educational preparations and past service of the study respondents in health managerial role, it is quite worrisome that they regarded their managerial role as the least important among their multi-faceted roles. Tenaciously-held notion of inherent leadership of the health care team, some attributes of the medical profession, and some characteristic traits of physicians all need to be re-appraised as part of the needed paradigm shift to make physicians good leaders and managers of the heath care delivery. Findings from our study suggest that the preparations that physicians got from their formal and professional education for leadership and managerial roles in health care were sub-optimal. We recommend for a paradigm shift for physicians on leadership issue which is to be facilitated through a comprehensive but highly focused three month long health management course package to be made mandatory for physicians at the beginning of their specialist career, and made "highly recommended" for other groups of physicians. Also the medical school curricula should be combined with a suitable package of managerial science for future physicians.
| Acknowledgement|| |
Dr. A. O. Mahmoud conceived and designed this study, the data collection and analysis, and the write up of the manuscript. Both Drs. D. Nkanga and A. Onakoya participated in the design, data collection, and the write up of the manuscript. There is no known or potential conflict of interest. The study was funded from out-of-pocket expenses jointly contributed by the three co-authors.
We are grateful to the local organizing committee for the 50 th Annual Scientific Conference of the West African College of Surgeons, which was held in Calabar, Nigeria, from 6 th to 12 th , February 2010, for permitting us to carry out this survey during the conference. We are grateful to our colleagues who consented to and also found time to fill our questionnaire. It is our fervent desire that the outcome of our study would be found useful in making physicians more effective leaders and managers of the health care team.
| References|| |
|1.||Guthrie MB. Challenges in developing physician leadership and management. Front Health Serv Manage 1999; 15(4): 3-26. |
|2.||Lane DS, Ross V. Defining Competencies and Performance: Indicators for Physicians in Medical Management. Am J Prev Med 1998; 14: 229-236. |
|3.||Dowton SB. Leadership in medicine: where are the leaders? Med J Aust 2004; 181(11-12): 652-654. |
|4.||Schneller ES. The leadership and executive potential of physicians in an era of managed care systems. Hosp Health Serv Adm 1991; 36(1): 43-55. |
|5.||Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organisations. BMJ 2001; 323: 746-749. |
|6.||Berwick DM. Eleven Worthy Aims for Clinical Leadership of Health System Reform. JAMA 1994; 272(10): 797-802. |
|7.||Xirasagar S, Samuels ME, Stoskopf CH. Physician Leadership Styles and Effectiveness: An Empirical Study. Med Care Res Rev 2005; 62(6): 720-740. |
|8.||Wenzel FJ, Grady R, Freedman TJ. Competencies for health management practice: a practitioner's perspective. J Health Adm Educ1995; 13(4): 611-630. |
|9.||Schwartz RW, Pogge C . Physician leadership is essential to the survival of teaching hospitals. Am J Surg 2000; 179(6): 462-468. |
|10.||Aluise JJ, Vaughan RW, Vaughan MS. The new health care civilization: integration of physician land and manageria. Physician Exec 1994; 20(7): 3-8. |
|11.||World Health Organization: WHO medicines strategy: Framework for action in essential drugs and medicine policy 2000-2003. Geneva 2000. |
|12.||World Health Organization: The World Health Report 2005: making every mother and child count. Geneva 2005. |
|13.||United Nations Development Programme: Human Development Report 2004: cultural liberty in today's diverse world. New York 2004. |
|14.||United Nations Development Programme: Human Development Report 2005: International cooperation at a crossroads: Aid, trade and security in an unequal world. New York 2005. |
|15.||Transparency International: Global corruption report 2006. London: Pluto Press; 2006. |
|16.||Kirigia JM, Wambebe C. Status of national health research systems in ten countries of the WHO African Region. BMC Health Services Research 2006, 6:135. (Accessed August 14, 2010, at http://www.biomedcentral.com/1472-6963/6/135). |
|17.||Mahmoud AO, Kuranga SA, Ayanniyi AA, Babata AL, Adido J, Uyanne IA. Appropriateness of ophthalmic cases presenting to a Nigerian tertiary health facility: implications for service delivery in a developing country. Nigerian Journal of Clinical Practice 2010; 13(3): 280-283. |
|18.||Akinkugbe OO. Role of Teaching Hospitals in a Developing Country. BMJ 1973;1: 474-476. |
|19.||Shortell SM, O'Brien JL, Carman JM, Foster RW, Hughes EFX, Boerstir H, O'Connor EJ. Assessing the Impact of Continuous Quality Improvement/Total Quality Management: Concept versus Implementation. Health Services Research 1995; 30:2: 377-401. |
|20.||Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organizations BMJ 2001; 323: 746-749. |
|21.||Mahmoud AO. Using the Total Quality Management (TQM) tool in solving the problem of delays during emergency eye care consultation process in Kaduna, Nigeria. Nigerian Journal of Ophthalmology 2006; 14: 1-4. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]