Unexpected change makers: the need for medical learner education on hospital governance.

Many medical learners are passionate to create positive change in the clinical environment and beyond. In many cases, they are encouraged to participate in micro-level changes (patient advocacy, communication, and social support) that can be accomplished in short time frames and within their control, as opposed to larger macro-level changes (organizational policy and protocol redesign).

University of Toronto’s MD program regularly includes teaching on the Canadian healthcare system structure and funding.[1] However, as is common across many schools, material focused on hospital structure and governance is scarce. Indeed, quality improvement (QI) initiatives are embedded in the curriculum but when medical learners enter a hospital setting, there is a disconnect between theoretical QI implementation in microsystems, and process-levels decision making (e.g., quality committee and board meetings).

With the increasing complexity of the healthcare system, physicians need to be expert navigators—constantly adapting to management structure changes, budget updates and even political cycles for healthcare funding priorities—in addition to their clinical responsibilities. We need to be aware of where, how and by whom policy and governance decisions are being made to do well by our patients. A study of seven OECD countries, revealed that the degree of involvement of physicians in hospital governance positively correlated with that of hospital performance indicators (quality improvement, better patient outcomes and lower costs).[2] While this is only an association, medical students can be better prepared for physician-leadership and effective management when they understand the governance, culture, and organizational strategy.[3]

We did not find any published articles regarding undergraduate medical student education concerning hospital governance. However, some researchers examined the effectiveness of including content aimed at increasing student knowledge in specific areas outside the traditional curriculum.[4],[5] This then raises the question: “As a result of the lack of formal training on hospital administration, how confident do medical students feel about raising their patient safety and quality care concerns to the correct individual in the hospital leadership world?” Nonetheless, this highlights a potential avenue to increase medical student knowledge regarding specific content.

Appropriate undergraduate medical education is not a silver bullet. It would serve to provide increased knowledge of hospital governance and management, providing learners with the opportunity to serve as vital agents of change at an organizational level. Students often come from diverse undergraduate backgrounds, levels of education and experience, and due to the traditional medical hierarchy, their creative insight into resolving macro-level issues may go unnoticed by culture-bound clinicians and administrators. Medical education may promote a quality improvement mindset and foster hospital-physician intrapreneurs who create user-defined values. It is the very essence of medical students being at the bottom of the traditional hierarchy that makes them an ideal target for effective intervention. By gradually introducing education at the beginning of medical training, these future physicians will have increased learning experiences and understanding of the complexity of the healthcare system, as opposed to introducing such topics towards the end of residency training. Explicit education rather than serendipitous learning from the hidden curriculum offers the opportunity to proactively shape their understanding and ability to make an impact. Moreover, this knowledge may supplement trainees’ ability to function more optimally in the increasingly complex system as trainees.

What we conclude from current studies is that at a minimum, learning about hospital structure and governance will likely increase awareness. We need further research to identify the most effective way of delivering this information; however, we can rely on the groundwork of similar work as a road map to move forward. Canadian medical school curricula do not include hospital governance and leadership roles. If students are even briefly taught organizational structure and the roles of leadership (e.g., CEO and vice presidents, directors) in a hospital or larger system setting, they would be better equipped to collaborate with other like-minded agents of change with a larger network—ultimately optimizing how they work in the system and enhancing their career opportunities. Imagine if they learned more! Empowering medical students to improve the system begins with developing their understanding of the system through an effective curriculum and engaging them in experiential governance activities. Only then can they more effectively advocate for improved patient care in a stronger healthcare system, maximizing their potential as agents of change.