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World J Surg (2018) 42:1655–1665 https://doi.org/10.1007/s00268-017-4370-3

SCIENTIFIC REVIEW

Competitive Advantage of MBA for Physician Executives: A Systematic Literature Review

Anthony D. Turner 1,3

• Stanislaw P. Stawicki 2

• Weidun Alan Guo 1

Published online: 20 November 2017 Socie´te´ Internationale de Chirurgie 2017

Abstract In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians are pursuing a Master in Business Administration (MBA) degree. The value of such proposition remains poorly defined. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician executives (PEs). We hypothesized that physicians who supplement their clinical expertise with business education gain a significant competitive advantage. A detailed literature search of four electronic databases (PubMed, SCOPUS, Embase and ERIC) was performed. Included were studies published between Jan 2000 and June 2017, focusing specifically on PEs. Among 1580 non-duplicative titles, we identified 23 relevant articles. Attributes which were found to add value to one’s competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication. We found that competitive domains deemed to be most important for PEs in the context of MBA training were leadership ( n = 17), career advancement opportunities ( n = 12), understanding of financial aspects of medicine ( n = 9) and team-building skills ( n = 10). Among other prominent factors associated with the desire to engage in an MBA were higher compensation, awareness of public health issues/strategy, increased negotiation skills and enhanced work–life balance. Of interest, the learning of strategies for reducing malpractice litigation was less important than the other drivers. This comprehensive systemic review supports our hypothesis that a business degree confers a competitive advantage for PEs. Physician executives equipped with an MBA degree appear to be better equipped to face the challenge of the dynamically evolving healthcare landscape. This information may be beneficial to medical schools designing or implementing combined dual-degree curricula.

Introduction

Medical schools have traditionally emphasized the mastery of the basic medical sciences and patient-centered care. However, this narrow focus has created deficiencies in broader topics affecting, not infrequently in a negative way, healthcare professionals today. In 1935, approxi mately 35% of US hospitals were headed by physicians, whereas in 2008 that percentage was estimated to be 4% [1]. The next generation of providers is projected to be challenged in areas including leadership, finance, health care policy and organizational management. Without mastery of these areas, tomorrow’s physicians will be at a

This work was presented as a quick shot oral presentation at the 12th Annual Academic Surgical Congress on February 7–9, 2017, in Las Vegas, Nevada.

& Weidun Alan Guo waguo@buffalo.edu

1 Department of Surgery, SUNY-Buffalo, Buffalo, NY, USA

2 Department of Research and Innovation, St Luke’s University Health Network, Bethlehem, PA, USA 3 Present Address: Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA

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significant competitive disadvantage compared to profes sional administrators with advanced management skills. As the US healthcare system undergoes rapid reforms, the physician executive (PE) will be responsible for shaping the practice of medicine in this country. In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians have embarked on the pursuit of a business degree. One of the most popular options among US trainees is the Master of Business Administration (MBA) or equivalent diploma. There were only six formal MD–MBA programs nationwide in 1993, which expanded quickly to 33 in 2001 and 51 in 2009 [2]. Among over 130 allopathic medical schools in the USA, more than 50 cur rently offer a combined MD–MBA option to their gradu ates [3]. However, the added value of such proposition remains poorly defined. Although this trend appears to be generally positive, many potential PEs are often ‘‘lost to medicine’’ even before their residency training begins. The end of medical school is a critical branch point for MBA educated students to decide to invest in clinical training or to forgo clinical care for the myriad other opportunities available to them [2, 4]. Therefore, better understanding of factors that play the most influential role in the development process of PEs will allow medical programs working to recruit interested stu dents to best support their interest. In addition, more medical students, physicians in training and even physi cians in practice may become attracted to this opportunity as a result of observed tangible benefits [5]. Given this understanding, we seek to identify the value added in receiving an MBA dual degree. The goal of this literature review was to assess which particular skill sets are most likely to be gained from such exposure. We hypothesize that multiple assets are acquired by those physicians who supplement their clinical expertise with business education. Search Strategy and Inclusion Criteria. We conducted literature search from the following four large electronic databases. 1. Biomedical: 1. PubMed; 2. SCOPUS; and 3. Embase (Excerpta Medica dataBASE). 2. Educational: ERIC (Education Resources Information Center). The key words/phrases used for conducting electronic database search were: medical education, physician healthcare executives, MD/MBA dual degree, clinician administrators, physician leadership and finance. The Methods

search was initiated on July 9, 2016, and was last updated on July 9, 2017. We included all articles from the above-mentioned database from January 2000 to July 2017. Articles pub lished in non-English languages were excluded. We then conducted full text review to assess for relevance. Several studies were not included because they were considered to be outside of the scope of this study. To guarantee the reporting quality and provide substantial transparency for the articles selected for this review, we followed the recommendation of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [6]. We adopted a protocol that has been recommended as part of the reporting guidelines for conducting a survey with questionnaires [7, 8]. Briefly, articles were assigned a validated index score to assess the quality of studies selected for this review. The following factors were used to calculate a score for every article: (a) size of the study, (b) justification of research method, (c) explicit objective, (d) replicability of the study, (e) representativeness and (f) response rate. Article quality assessment

Data analysis

We were unable to conduct a meta-analysis due to the following limitations within our source manuscripts: (a) large variations in survey; (b) diverse participant pop ulations; and (c) varying levels of career advancement before achieving the MBA (i.e., medical student, resident physician and attending physician).

Results

A total of 492 articles were found on PubMed, 696 were identified on Embase, 366 on SCOPUS and 26 on ERIC. Most studies were deemed irrelevant for this review and outside the scope of this topic. Forty-one articles were selected for further full text review upon reaching criteria for relevance, full-access and date of publication. Ulti mately, 23 articles met our predetermined inclusion crite ria. A schematic diagram of our article inclusion procedure can be visualized in Fig. 1. Shown in Table 1 is a summary of each article’s quality assessment score. Additionally, Table 2 provides a quick glance of characteristics of the study type, number of participants and study findings of these 23 articles.

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Fig. 1 Flow diagram of the literature search procedure

Organization management

suggest that dual-degree trainees gain leadership skills to enable them to influence the direction and future of their healthcare system. Interestingly, Goldman et al. [13] found that graduates of MD/MBA programs reported receiving more leadership offers than their counterparts. Ackerly et al. [2] and Keogh [14] also postulated that developing both clinical and management skill sets during MD/MBA graduate medical education holds the promise of creating a bench of talented future PEs. Both Satiani [15] and Spehar [16] have recognized that appointment of clinically skilled physicians as leaders without specific training in the areas described in the MBA program could result in failure. The MBA training is likely to enable PEs to provide much needed leadership to an evolving medical care system, thereby addressing a pressing societal need, according to Krupat [17]. Hall [18] agreed that MBA graduates will be optimally positioned to assume leadership positions in healthcare institutions and industry. In that same vein, Butcher [19] found in their studies that MD/MBA students learn the tools necessary to become more effective leaders.

Leadership (n = 17)

The importance of leadership development was empha sized as providing added value to physicians in 17 of 23 studies. According to Orlando et al. [4] the current state of health care and its ongoing reforms will require physician leaders to take on greater management responsibilities, which will require a unique set of organizational and leadership competencies that traditional medical education does not provide. Sherrill [9] reports that leadership assets gained during the pursuit of an MBA provided physicians with the confidence to influence others and their environ ment as leaders. Furthermore, physician executives were able to blend clinical and management skills into an effective vision for healthcare delivery [10]. Zheng et al. [11] stated that the dual-degree training may help surgeons more effectively interact with hospital administrators, investors and patients alike. In addition, Sherrill [12] pointed out that MD/MBA student surveys

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Table 1 Summary of quality assessment scores of articles

Authors

Study size

Justification of research method

Explicit objective

Replicability Representativeness Response rate

Quality score

Ackerly

2

1

1

2

1

NA

7

Attri

1

1

1

1

1

NA

5

Butcher [29]

3

1

1

2

3

1

11

Butcher [19] 2

1

1

2

3

1

11

Frich

2

1

1

3

3

2

12

Goldman 2

1

1

3

2

NA

9

Hall

3

1

1

2

3

2

12

Koegh

3

1

1

3

3

NA

11

Krupat

2

1

1

1

1

1

7

Larson

3

1

1

2

3

2

12

Lazarus

1

1

1

1

1

NA

5

Love

2

1

1

1

3

1

8

Lusco

3

1

1

2

3

3

13

Orlando

2

1

1

1

1

2

8

Parekh

3

1

1

3

2

2

12

Patel

3

1

1

2

1

2

10

Pham 3

1

1

1

3

NA

9

Satiani [27] 3

1

1

2

2

1

10

Satiani [15] 2

1

1

1

2

3

10

Sherrill [9] 3

1

1

2

2

4

13

Sherill [12] 3

1

1

2

2

4

13

Spehar

2

1

1

1

2

NA

7

Zheng

2

1

1

2

2

NA

8

Scoring system: justification of research method, and explicit objective: 0 or 1 point depending on whether these were specifically addressed in the article Study size: small ( \ 20): 1 point, medium (20 B 100): 2 points, large ( [ 100): 3 points Replicability: difficult to replicate: 1 point, could be replicated with some difficulty: 2 points, easily replicable based on the methods section: 3 points Representativeness: only studied one institution: 1 point, 2–10 institutions: 2 points, [ 10 institutions: 3 points

Response rate: \ 40%: 1 point, 40 \ 59%: 2 points, 60 \ 79%: 3 points, [ 80: 4 points Quality score: takes all factors into account equally. Maximum score: 15, minimum score: 5

assessed knowledge and expertise, while Love [23] and Parekh [24] identifies leadership as a core competency gained by the MBA for successful healthcare executives.

As reiterated by Larson [20], the most fundamental question raised by this research addresses the effectiveness of the MD/MBA program in creating skilled physician managers and competent leaders. According to Patel et al. [21], the leadership skills gained from the MBA program will benefit graduates with tangible career acceleration, professional flexibility and credibility in multidisciplinary domains as compared to their counterparts. The few neg ative remarks were focused on the opportunity cost of time and how peers in one discipline may negatively perceive the role of the other discipline’s degree. However, there remains a definitional heterogeneity within this area. For example, Frich [22] states that physician leadership development programs are associated with increased self

Team building/human resources (n = 10)

The role of team building as an added value of the MBA was explored by ten studies. Parekh [24] found that a large majority of dual-degree holders reported improvements in working in a team setting. Furthermore, Koegh [14] iden tified that the dual degree enabled a ‘‘practice field’’ for team-building experiences and conceptual roadmaps for achieving high-functioning dynamic teams for physician managers. In that same vein, Butcher [19] discovered that

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Table 2 Characteristics of included studies

First author

Article type

Factors

Participants (n)

Findings

Ackerly Prospective

L, C

MD/MBA residents at a single institution (32)

By developing both clinical and management skill sets during the graduate medical education, the MBA holds promise for future leaders of health care at an early career stage Study reports that at least 20% of the physician executive’s time was spent in dealing with OR conflict which reached resolution with improved communication and problem solving efforts Physicians who hold MBAs reap rewards in higher starting salaries and greater job satisfaction than counterparts The physician executive salaries were not necessarily higher just because they went to business school, but they were doing interesting and creative things with the MBA portion in addition to practicing Physician leadership development strengthened organizational performance and collaborative, interdisciplinary work MD/MBA graduates tend to receive higher starting salaries in their careers due to their leadership roles in organizations and ancillary business ventures than traditional physicians MBA graduates will be optimally positioned to assume leadership positions in healthcare institutions and industry 81% of physicians with MBA degree believed their business degree was useful in the advancement of their careers Joint programs train physician leaders to address complexities in improving healthcare delivery Graduates of the MD/MBA report improved applicability of managerial principles in the medical practice Physician executives are change agents for healthcare and quality improvement Physician executives will require a new set of skills in finance and population management to navigate the complex healthcare environment Strengthening business education of residents will equip young surgeons to take a more active role in improving the economics of medicine Physician leadership is necessary to develop high-performance healthcare teams that can deliver top-quality care at a reasonable cost The physicians stated that the most pertinent skills they had acquired were related to systems operations and implementing improvements, learning how to be an effective leader, working within a team, comprehending financial principles and negotiating effectively Graduates with an MD and MBA report mostly positive attitudes toward their training, and many are pursuing leadership and primarily non-clinical roles later in their careers Respondents gained an understanding of healthcare market trends such as financial pressures from reimbursement rates and rising practice costs This study found that the average surgeon perceives himself or herself to be poorly equipped to understand basic financial accounting principles, financial markets and economics of healthcare Respondents reported improved leadership skills, improved negotiation skills and more self-awareness of leadership style

Attri

Survey

T, N Attending surgeon respondents at a single institution

Butcher [29] Butcher [19]

Survey

C, I, W, P MD/MBA graduates at 48 universities (108)

Survey

L, C, T, I, W

MD/MBA students at 12 universities (92)

Frich

Retrospective cohort

L, F, T, N, P

Residents and attending surgeons at 11 institutions (45)

Goldman Survey

L, I, W MD/MBA attending physicians (55)

Hall

Survey

L, C, I, P MD/MBA attending surgeons (133)

Koegh

Retrospective cohort

L, C, F, T, P

MD/MBA graduates at 52 universities

Krupat

Survey

L, C, T MD/MBA students at a single institution

Larson Survey

L

MD/MBA students (329)

Lazarus

Prospective cohort

C, P

MD/MBAs in the American College of Physician Executives (12)

Love

Survey

L, F, T Analysis of C-suite executive focus group (39)

Lusco

Survey

F, P

Program directors in general surgery (189)

Orlando Prospective cohort

L, F, T, N Physician executives at a single institution (74)

Parekh Retrospective cohort/survey

L, C, F, T, I,N,W, M

Physician graduates at three East Coast business schools (161)

Patel

Survey

L, C, W MD/MBA graduates at a single institution from 1981 to 2010 (247)

Pham Survey

F

Physician executives at 12 institutions (107)

Satiani [27]

Survey

F, I, M Surgeons at institutions in 12 Midwest states (133)

Satiani [15]

Prospective cohort

L, C, N Physician executives at a single institution (24)

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Table 2 continued

First author

Article type

Factors

Participants (n)

Findings

Sherrill [9]

Case control

L, C, I

MD/MBA and traditional medical students (202)

after completing the MBA program. Similarly, Koegh [14] conducted a study in which nearly 86% subjects reported a greater financial understanding following the MBA dual degree. Likewise, Frich [22] found that financial manage ment knowledge was cited as contributing particularly strong value added to the overall benefits of the MBA degree. According to Orlando [4], the MBA curricula incorpo rate key financial concepts and economic principles that should enable physicians deal effectively with chief financial officers, interpret financial statements as well as create effective and sustainable cost/payment structures. Zheng [11] also points out that the MBA may be helpful in understanding how funds get channeled through depart ments and hospitals, and how different institutions operate internally. Lusco [26] agrees that the MBA is becoming an increasingly essential asset in teaching some basics of accounting as well as personal financial responsibility to educate practicing surgeons and surgical residents. Furthermore, Satiani [27] and Pham [28] both report that surgeons gained fundamental knowledge in the areas of strategic financial planning, cost concepts and financial mathematics. Among key components of the curriculum is the ability to evaluate investment in equipment and tech nological enhancements by employing established methods of calculating net present value, book rate of return, pay back periods and internal rate of return. [27] The concepts of assigning fixed and variable costs, sunk costs, depreci ation, opportunity cost and time value of money have helped surgeons make sound decisions for the future. In fact, Love et al. [23] suggest that the business back ground better prepares physicians for changing indicators of financial performance such as ‘‘satisfaction, medical error rates and infection control.’’ Others have shown that Dual-degree MD/MBA students rated most highly factors such as career opportunities, opportunity for innovation, opportunity to be a leader in medicine and opportunity to make a difference in medicine Dual-degree MD/MBA students acquired advanced skills in business strategy, finance and organizational management Respondents reported relying on their resources of professional skills and experience in negotiation with staff in clinical environments MD/MBA respondents believed that their business degree sharpened their leadership skills and helped navigate the complex healthcare environment within their surgical career

Sherill [12]

Case

L, C, I, W, P

MD/MBA and traditional medical students at six medical schools (154)

control/survey

Spehar

Survey

L, T, N Physician executives at

Norwegian public hospitals (30)

Zheng

Survey

L, F, T, N MD/MBA graduates at six institutions (87)

Factors: leadership (L), career advancement (C), finance (F), team building (T), income (I), negotiation (N), work–life balance (W), malpractice litigation (M), population health (P)

the MD/MBA graduates learned that there is no success without collaboration and teamwork which equips physi cian executives to better achieve greater buy-in and collect everyone’s input. Meanwhile, Krupat [17] asserted that dual-trained physicians were able to function more effec tively as part of increasingly large and complex organiza tions. Frich [22] found that the MD/MBA promotes collaboration and interdisciplinary work with physician leadership to ensure high-quality health care. Orlando’s study [4] mentions that participants worked together and forged bonds that facilitated more effective in problem solving and long-term, sustainable professional relationships. Zheng [11] added that team building and human resource management are skills acquired by sur geons with a background in business. Love [23] reports that both physician and employee job satisfactions are impor tant clinical indicators of excellence, thus reinforcing the importance of teamwork. Spehar [16] found that MD/MBA graduates are taught principles of coalition building, and have a better ability to gather influential people together, thus playing a vital part in building power and influence. In addition, Attri [25] found that dual-degree graduates are taught that quality of patient care depends on effective teamwork for which multidisciplinary communication is an essential part.

Understanding of finance (n = 9)

The value of an MBA degree in preparing aspiring physi cians to adequately understand the clinical implications of each financial decision was addressed in nine articles. Parekh [24] conducted a survey indicating that 67% respondents reported gaining a better understanding of the financial and business aspects of the healthcare system

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population health in the USA. According to Koegh [14], over 50% of graduates reported that improved problem solving and decision-making skills learned gave them confidence in addressing public health issues. Hall [18] discovered that MD/MBA graduates had a better under standing of how to appropriately evaluate and implement data findings and study design to population health prob lems, with particular emphasis on addressing issues of access to care, quality and cost. In addition, Sherrill [12] asserts that the dual degree prepares PEs to make influen tial changes in the future of medicine in this country. Frich [22] reports that the MBA curriculum addresses health care and strategy to improve population health in the USA. Likewise, Butcher [29] postulates that dual degrees create opportunities for healthcare operations research in which clinical researchers and healthcare administrators are better able to identify ways to improve healthcare delivery. Both Lazarus [30] and Lusco [26] argue that the value of the MBA to PEs is well demonstrated through research of organizational performance which showed that PSs improved the quality and effective of services while plac ing greater emphasis on population health. The value of career advancement among dual-degree graduates was identified by 12 studies. Parekh [24] and Koegh [14] identified that [ 80% of medical graduates reported the MBA had been essential to, or very useful in, the advancement of their careers. According to Butcher [19], the MBA gives physicians a level of credibility to pursue advanced leadership jobs. Additionally, Krupat [17] discovered that dual-degree graduates found continued upward professional trajectories within the realm of med icine while, at the same time, gaining unique new per spectives and skills. Hall [18] reported that MBA graduates will be optimally positioned to assume leadership positions in healthcare institutions and industry. Likewise, Sherrill [12] reported significantly higher incomes for MD/MBA graduates, as well as the attainment of higher leadership positions (e.g., CEO or medical director) being highly associated with the dual degree. Furthermore, Sherrill [9] found that the MBA presented unique career opportunities for innovation, influence and leadership. Satiani [15] emphasizes that business training enables PEs to close the gap between their basic medical skills and abilities and those needed for higher-level positions. Patel [21] reported unique offers for job opportunities both clinical and non-clinical, including consulting, Personal and lifestyle Career advancement (n = 12)

physicians with dual degrees in business contribute favor ably to the financial well-being of an institution.

Negotiation/conflict resolution (n = 7)

The importance of conflict resolution as a benefit of MBA training was examined by seven studies. Parekh [24] reported that 32% of survey respondents felt that they were able to negotiate more effectively after completing the degree. Satiani [15] found that dual-degree graduates attained the knowledge required to effectively address issues such as achieving buy-in from employees, over coming resistance and constructing a change plan. Frich [22] identified that the MBA promotes a culture of accountability and alignment toward conflict resolution for PEs. Similarly, Orlando [4] found that graduates were more efficient at negotiating for specific results or outcomes and were more effective in terms of developing teams and resolving conflict. Zheng [11] identified that the MBA facilitates that development of both analytical and soft skills, such as negotiations and conflict resolutions. Graduates report the ability to communicate more clearly and negotiate more effectively with other hospital administrators and execu tives. Likewise, Spehar [16] emphasized that PEs are taught not to exclusively rely on their professional exper tise and experience in negotiations with staff. Furthermore, Attri [25] identified that surgeons are informed about the importance of respect and role recognition with their anesthesiologist counterparts to prevent suboptimal or tense social interactions intra- and extra-operatively which may affect the patient experience. The knowledge gained by MD–MBA’s relating to the cost burden of malpractice litigation on the healthcare system was investigated by two studies. Parekh [24] asserted that MD/MBA’s were equipped with the skill set to better survive in the climate of increasing malpractice litigation. Meanwhile, Satiani [27] found the burden of litigation was cited as an unfavorable condition which knowledge of business principles could help alleviate through enhanced communication and conflict resolution skills. Interestingly, this point was not very well supported by other literature sources. Medical malpractice (n = 2)

Healthcare strategy

Public health (n = 7)

The following seven studies examined the added value of the MBA in applying strategies to issues regarding

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graduates and 93% considered the dual degree to have had a ‘‘significant ROI’’ in terms of job flexibility. Sherrill [12] reports that physician executives found a balance between clinical and non-clinical opportunities and expressed satisfaction from being able to pursue the per sonal interest that the doctor had for gaining business knowledge. Goldman [13] concluded that 89% of MD/ MBA graduates reported being very satisfied with their careers and their lifestyles. Butcher [29] and Patel [21] studies found that PEs reported being very satisfied overall in terms of their career, lifestyle and home life. Figure 2 is a heat map summary of findings from the current study, organized according to publication (hori zontal axis) and the competitive benefits of an MBA degree for PEs (vertical axis). In this literature review, we identified multiple areas in which value was added by completing the MD–MBA dual degree in this literature review study. In terms of impor tance, leadership was most commonly identified among other ‘‘value-added’’ categories as a motivator of supple mental degree pursuit by physicians or physician trainees. Finance, healthcare strategy and organizational manage ment were among other key motivating characteristics according to our literature summary. The MBA education was found to provide additional assets in areas regarding population health, team building and conflict resolution. To the best of our knowledge, this is the first systematic review to summarize the added value gained from the MD–MBA dual degree. Our review found evidence in support of leadership as a value-added benefit to students pursuing the MD–MBA dual degree. The importance of leadership development is being increasingly valuable for hospitals looking to employ PEs. As discovered in our review study, physicians are often identified and promoted to leadership positions based on their career achievements and distinction, with less emphasis on their management skills and experience. Instead, a career trajectory that includes a balance of clinical practice with early and continuous experience as a leader and manager should define the new model of physician executive development. Along this continuum, studies recommend that targeting graduates of joint doctor of medicine (MD) and MBA programs as they enter resi dency training provides the most opportunity to identify potential leaders early and cultivate the careers of future PEs. [2]. A strong, positive correlation was determined between receiving the MBA training and developing effective leadership skills. The tangible benefit provided for Discussion

investment banking, hedge fund managing and venture capitalism. Ackerly [2] identified particular development of clinical and managerial skill sets prepared physician executives to engage in critical issues as future leaders in health care. In addition, Butcher [29] found that MD/MBA graduates have significantly higher starting and average salaries, as well as received a mix of different offers for responsibilities such as department heads or entrepreneurs. Similarly, Lazarus [30] adds that many of the 50 most powerful physician executives in 2010 were physicians with MBA degree. The increased likelihood of higher incomes was reported by eight studies which compared MD/MBA graduates to their traditional medical school graduate counterparts. Parekh [24] reported that enhanced personal finances were cited as one of the top three benefits of physician graduates surveyed from three East Coast business schools. Mean while, Butcher [19] and Hall [18] found that physicians achieved higher starting salaries by supplementing their clinical responsibilities with high-level leadership roles in organizations or with ancillary business ventures than tra ditional physicians. According to Goldman [13], the aver age starting salary for the MD/MBA survey respondents was $292,500 compared to $192,196 for a medical spe cialist without an MBA during the same time period. Sherrill [12] and Butcher [29] studies revealed that the MBA degree increased the probability for higher lifetime earnings for PEs. As the demand for physician executives increases, compensation levels tend to rise in parallel. Sherill [9] concluded in a recent compensation survey that compensation packages for physician executives were reflected well above the median for clinically based prac ticing physicians. Satiani [27] found that 85% of physician respondents viewed the MBA as a positive return on investment (ROI) throughout their career cycle. The higher level of work–life balance achieved was reported by six studies. According to the study done by Parekh [24], physician executives reported a 20% increase in time allocated to administrative tasks. Their practice patterns change significantly after completion of the MBA, which helps account for the satisfaction gained from greater involvement in non-clinical activities and decision making. Similarly, Butcher [19] asserts that PEs achieve higher personal satisfaction through improved patient care through better management of the healthcare delivery model. Additionally, Butcher [19] surveyed MD/MBA Higher income (n = 9) Work–life balance (n = 6)

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Fig. 2 Heat map summary of findings from the current study, organized according to publication (horizontal axis) and category type (vertical axis). Legend: type of study: P prospective, R retrospective, CC case control, S survey. Asterisk indicates studies that only included MPH degree. Survey sample key: M medical student/fellow, R resident, A attending physician

has indicated that this is best achieved using the best practices to influence clinical decision making and mea suring outcomes to improve the process. With an under standing of financial and public health concerns, the MD/ MBA is prepared for evaluating improvement in overall outcomes, including high physician satisfaction, increased patient satisfaction, reduced costs and improved clinical process and outcome measures across multiple diseases [28]. Furthermore, a recent focus on quality and account ability has been seen in US healthcare. Our investigation has led to the findings that physician reimbursement is shifting from a fee-for-service to quality-based metrics model. We have found that MD/MBAs are prepared to face new challenges to the traditional reliance on structural aspects of healthcare delivery. The business curriculum caters to new goals of reaching higher provider account ability, reducing litigation costs and maximizing consumer satisfaction. Additionally, our review suggests that team-building skills are among the most important value-added benefits for students pursuing the MD/MBA dual degree. The ability to work as part of a team is widely acknowledged to be a critical skill for healthcare providers. This attribute of team building is a key component of promoting patient safety and improving the efficacy and efficiency of care. However, studies have found that the medical profession in particular lags behind other fields in understanding, assessing and supporting teamwork [31]. Therefore, the responsibility becomes the physicians to articulate goals for collaborative cohesion. Zwarenstein et al. [32] found that greater coordination and communication was achieved by the MD/MBA’s in interprofessional groups.

institutions is derived from a number of cost drivers and financial performance factors. Several studies have con cluded that hospitals with the most clinician involvement in management affairs performed 50% higher on drivers of performance, such as effectiveness of overall management, performance management and leadership as compared with hospitals with little clinical leadership. Combining leader ship skills and training with their clinical expertise, PEs have the potential to become influential leaders capable of breaking down silos, team building and creating a new vision of healthcare delivery [15, 16, 20]. Our study has discovered an increasing trend in the number of US medical students completing the MD/MBA dual degree. As mentioned, we believe that students are identifying many of value-adding skills eluded in this study before making their decision. Our investigation also dis covered benefits were gained from the long-term implica tions of receiving the educational training. Under the current climate, at least six of the top seven sources of physician dissatisfaction are influenced by the leadership of healthcare organizations. These include cost cutting by hospitals, scant opportunities for teaching and research, hospital utilization review and declining autonomy for making both medical and non-medical decisions. [1] Fur thermore, 81% of physicians with MBA degree believed their business degree was instrumental in career advance ment and important in overall job satisfaction [14]. The MD/MBA student is trained to add value to pro cesses by identifying areas of cost inefficiency and for mulate strategies for improvement. The key principles of continuous quality improvement (CQI) and disease man agement utilize a model for healthcare improvement that focuses on designing the best practices. Our investigation

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This review has several important limitations. Many articles were surveys which may have associated acquies cence and social desirability bias. The investigation pri marily focused on medical students pursuing the MD/MBA dual degree with little consideration for resident or physi cian entry level into such programs. In that same vein, little consideration was shown for similar value-added skill sets obtained by the MD/MPH dual degree. It would be rea sonable to conclude that MD/MPH dual degree would report higher public policy in healthcare exposure as compared to the MD/MBA. Finally, although important trends have been identified as a result of our work, the overall level of evidence is low, thus precluding the ability to conclude any associations or causative effects. Further, high-quality, prospective research will be needed to better elucidate such relationships. The authors identified improved work–life balance was achieved. While it is reasonable to conclude that having an MBA improves the lifestyle balance because it provides greater opportunity to obtain a PE job, which is higher paid than an MD. It remains controversial as it has limitations on adding value in the sphere of lifestyle for those who are not looking for that type of job. Therefore, we see this as an area for continued investigation in examining how the MD/ MBA and all traditional MD report finding lifestyle bal ance, outside of the context of PE. Additionally, the perspective of the study was analyzed through the lens which the authors saw the results as favorable or unfavorable to the physician executive. It is for this reason that we reached the conclusion that two degrees, particularly one with an MBA would be helpful. However, it is possible to look at this from the perspective of all physicians (i.e., those who practice medicine and are not executives). Based on the value-added skills found in this study, we believe that similar conclusions could be deduced for all physicians not just physician executives for improved overall performance. Universal assets such as strong leadership qualities, conflict negotiation and team building skills can be translated to every physician’s practice of medicine. The above notwithstanding, the authors would also like to acknowledge that the MBA degree should not be con sidered mutually exclusive for the development of the skills sets listed above. We strongly emphasize that the core elements of every medical school and residency training program should include facets of leadership development and team-building skills necessary to develop competent physicians. Therefore, this study should be a supplemental testimony for a secondary degree in addition to the core curriculum provided through medical education. It is our belief that these skills are important elements for the success of all physicians.

Fig. 3 Word cloud illustration of the values conferred upon by a MBA degree

In conclusion, this review contributes to the overall knowledge of value-added qualities gained from medical students pursuing the MD–MBA dual degree. This study will be beneficial to medical programs designing the dual degree curriculum by eluding key assets to prepare students for emerging challenges in the healthcare field. While an increasing trend has been seen in interested students pur suing the MD–MBA dual degree, this review article may peak further interest through supportive evidence for value added skills gained. Effective physician executives equip ped with a MBA degree represent a unique and highly valued group that collectively holds the promise of reshaping the landscape of our ailing healthcare systems, many of which await well-rounded, knowledgeable and clinically trained leaders. We conclude that multiple assets are gained by supplementing medical education with business training including leadership skills, financial acumen, public health strategies and team-building skills. In closing, we present a word cloud (Fig. 3) to illustrate the frequency of attributes studied in the literature review.

Authors’ contributions W.A.G. conceived and led the study. A.D.T. conducted the literature search. All three authors (W.A.G., A.D.T. and S.P.S.) contributed to analyzing the data, writing and revising the article and approved the final version of the article.

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Research Report

The Role of MD and MBA Training in the Professional Development of a Physician: A Survey of 30 Years of Graduates From the Wharton Health Care Management Program Mitesh S. Patel, MD, MBA, Vishal Arora, Mamta S. Patel, BBA, June M. Kinney, MA, Mark V. Pauly, PhD, and David A. Asch, MD, MBA Downloaded from http://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4X

Mi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 02/11/2024

B y 2010, nearly 40% of U.S. medical schools had established a medical doctorate (MD) and master of business administration (MBA) dual-degree program, a fivefold increase since the mid 1990s. 1–3 Although many have speculated about the role of the MD and MBA degrees on physician career development or more broadly within society, 4–6 to our knowledge there has been little examination of its use after training. The Wharton School at the University of Pennsylvania established a full time MBA program in health care management in 1971 and has since produced over 250 physician graduates. In addition to core MBA curriculum Abstract Purpose The number of medical schools offering MD and MBA training has increased fivefold in the last two decades. The authors evaluated graduates’ perceptions of the role of such training on their career and professional development. Method In 2011, the authors surveyed physician graduates from the Wharton School MBA Program in Heath Care Management at the University of Pennsylvania from 1981 to 2010. Survey responses were analyzed and evaluated using grounded theory. Results Among 247 eligible graduates, 59.9% (148/247) completed the questionnaire Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Patel, 423 Guardian Dr., 1303B Blockley Hall, Philadelphia, PA 19104; telephone: (734) 355-0817; e-mail: mpatel@upenn.edu.

including accounting, finance, marketing, and strategy, students in the Health Care Management Program enroll in a diverse range of health care-focused courses that cover health economics, management, and policy. By 2010, the program offered more than 15 health-care-focused courses including an immersive field application project where students are paired with health care companies to address real-world problems. The objective of this study was to evaluate graduates’ perceptions of the role of MD and MBA training on their professional development and career. The Health Care Management Program at the Wharton School of the University of Pennsylvania provided e-mail contact information for all living physician or medical student graduates since its incep tion in 1971. We sent all graduates from 1972 to 2010 up to three e-mail correspon dences using contact information from Method Study sample and 89.9% (133/148) of them provided free-text responses. Approxi mately 85.1% (126/148) of respon dents were male and 79.7% (118/148) entered residency training; however, both rates declined slightly over time. Among respondents within their first decade after graduation, 46.2% (24/52) reported clinical practice as their primary work sector compared with 39.5% (15/38) among respondents 11 to 20 years after graduation and 19.2% (5/26) of respondents 21 to 30 years after graduation. Overall, graduates reported mostly positive attitudes and often noted the benefits of career acceleration, professional flexibility, and credibility in multidisciplinary

the Wharton alumni database. If possible, nonresponders were additionally con tacted through online professional net works. Ultimately, we excluded graduates prior to 1981 from analysis because of a small sample size of only 16 respon dents. Study coauthors (Mitesh S.P., D.A.A.) were also excluded from the sample. Study design We administered a two-part question naire electronically from September to December 2011. Part one requested sociodemographic characteristics, training history, and current pro fessional activities. Part two requested free-text responses to the following open-ended questions on the role of MD and MBA training on respondents’ professional career and development: • Please describe how (if at all) you use your MD and/or other medical training in your professional life; • Please describe how (if at all) you use your MBA in your professional life; are pursuing leadership and primarily nonclinical roles later in their careers. These findings reveal new insights for policies affecting physician workforce. Further study is necessary to evaluate whether similar trends exist more broadly. domains. The few negative remarks were focused on the opportunity cost of time and how peers in one discipline may negatively perceive the role of the other discipline’s degree. Conclusions Graduates with an MD and MBA report mostly positive attitudes towards their training, and many

Acad Med. 2014;89:1282–1286. First published online June 20, 2014 doi: 10.1097/ACM.0000000000000366

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