The CanMEDS Manager Role

Essay on Curriculum Issue: The CanMEDS Role of Manager
The Manager Role, as defined by the CanMEDS framework, is an important part of medical practice. According to the Royal College, “Postgraduate programs have a mandate to ensure that learners are well prepared for the specific managerial responsibilities that their graduates will be expected to fulfill.” (Razack S and Dath D, 2006. The CanMEDS Assessment Tools Handbook: An introductory guide to assessment methods for the CanMEDS competencies. Ottawa. The Royal College of Physicians and Surgeons of Canada.) It seems reasonable that preparation for this role should begin during undergraduate medical training, with an introduction to the competencies associated with management at the organizational and personal level.
Despite its importance, the Manager Role is also recognized as one of the most challenging of the Roles to teach and assess. One study found that programme directors across a variety of specialties were less satisfied with the way they assessed the Manager and Health Advocate Roles than they were with the assessment of other Roles such as Medical Expert. Despite the fact that the CanMEDS Assessment Tools Handbook suggests that oral examinations are not the best way to evaluate trainees on their performance in the Manager Role, 31.5% of respondent programs were doing so. The authors concluded that there was “some urgency in the need to examine the Manager and Health Advocate Roles, what they mean in various specialties, and why they appear to be difficult to assess.” (Chou S, Cole G, McLaughlin K & Lockyer J; CanMEDS evaluation in Canadian postgraduate training programmes: tools used and programme director satisfaction Medical Education Sep 2008, Vol. 42 Issue 9, p879-886)
In defining the Manager Role, CanMEDS recognizes management responsibilities as core requirements for the practice of medicine. Responsibilities exist at the organizational level, such as developing and implementing processes and policies related to patient care, and at the individual level when physicians make decisions about how to allocate their time among professional and personal priorities. Elements of the Manager Role include collaborative decision-making, quality assurance, managing change, leadership, administration, and time management. Career development is also included as one of these elements, and the ability to manage career and practice effectively is considered a Key Competency. (Frank, JR. (Ed). 2005. The CanMEDS 2005 physician
competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada.)

Teaching the Manager Role

Instructing learners about the Manager Role can be difficult due to the lack of exposure to this role in training settings. Clinical rotations do not usually provide the opportunity for trainees to participate in activities that contribute to organizational effectiveness. Strategic planning, quality assurance, budgeting, accreditation, and other activities are routinely carried out alone in a physician’s office, in committee meetings, and in other administrative settings that may not be accessible to residents or medical students. Because of the way residency and clerkship are structured, most learners spend only a limited time on a clinical service, which makes it difficult for students to contribute meaningfully to, engage in, or even understand discussions around management issues. In clinical training, patient management skills are generally taught through modelling and practice. For the Manager Role, these naturalistic learning opportunities are largely absent in most clinical rotations. Even when students observe practice management on the part of preceptors, it seems likely that there is seldom explicit teaching or discussion about competencies such as setting priorities, implementing processes to ensure personal practice improvement, or justly allocating healthcare resources.
An alternate way to develop managerial skills would be to involve trainees in organizational activities in which they could participate in over a longer period of time than would be available on clinical rotations. Residents and medical students can be asked to sit on committees of the departments or medical school. Student organizations can be another venue for practical exposure, and students who take leadership positions could be given specific training in leadership and management skills. This approach poses its own challenges, particularly with regards to evaluation, but it does provide an authentic experience of what the Manager Role looks like in practice.

Evaluating the Manager Role

The CanMEDS Assessment Tools Handbook suggests that the preferred tools for assessing the Manager Role include multi-source feedback and peer evaluation, simulation, and use of portfolios, as well as direct observation. Multi-source feedback can include specific questions that elicit information regarding key competencies of the Manager Role. Complex simulations may be designed to develop skills in planning, delegation, communication, providing feedback, and other tasks. Assessment portfolios can include items such as committee work, practice organization innovations, audits and quality assurance projects, along with reflections generated by these experiences. The inclusion of narrative reviews of discussions with academic mentors is also suggested (Razack and Dath, 2006).
The authors of the Handbook suggest supervisors in clinical scenarios can assess learner’s managerial skills by observing the resident’s capacity for time management, effective mobilization of health care resources, and appropriate delegation of tasks related to patient care (Razack and Dath, 2006). While it may be possible to comment on how learners perform in these areas of individual practice management, such observations provide little information about how they are fulfilling other aspects of the Role, such as developing their careers, gaining leadership skills, and participating in the organizational dynamics of the health care system.

Future Directions

In addition to the practical challenges of teaching and evaluating the Manager Role, there are other questions that need to be addressed. Managerial skills training falls outside of what has traditionally been seen as the mandate of residency programs or undergraduate medical education, which traditionally focussed only on the Medical Expert Role. There are potential financial costs, and concerns that that CanMEDS-based education might detract from trainees’ time to provide service and gain exposure to patients (Frank J, Danoff D. 2007. The CanMEDS initiative: implementing an outcomes-based framework of physician Competencies. Medical Teacher 29: 642–647).
It is possible that the Manager Role is one that becomes more relevant to physicians as they move forward in their careers. A recent study of emergency room physicians in two academic centers found that the Manager Role was identified as one of three professional development priorities along with Medical Expert and Scholar, while Communicator, Collaborator, Health Advocate and Professional were less highly-rated. (Sherbino J, Upadhye S, and Worster A. 2009 Self-reported priorities and resources of academic emergency physicians for the maintenance of competence: a pilot study. CJEM: Journal of the Canadian Association of Emergency Physicians. Vol. 11;3 (230-4) It may be that increased efforts to provide continuing medical education regarding the Manager Role would be the most effective way to develop competency within the profession as a whole.
In developing the Manager Role, it seems logical to incorporate knowledge that his been developed within other fields, particularly business administration. There is a surprising lack of literature to suggest that efforts have been made to integrate business teaching models into programs training physicians to fulfill managerial roles.
Conclusion
The Manager Role represents an important function for physicians if we wish to make a significant contribution to the effectiveness of our health care systems. Our medical schools and training programs require physician educators with excellent managerial as well as teaching skills in order to meet the needs of learners and the community at large. Career development skills, as well as the ability to achieve personal and professional balance, can help doctors enjoy more rewarding lives. Despite the challenges, there are great potential benefits in incorporating education in the Manager Role into our medical training programs.

Bibliography
Chou S, Cole G, McLaughlin K & Lockyer J; CanMEDS evaluation in Canadian postgraduate training programmes: tools used and programme director satisfaction Medical Education Sep 2008, Vol. 42 Issue 9, p879-886

Frank, JR. (Ed). 2005. The CanMEDS 2005 physician
competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada.

Frank J, Danoff D. 2007. The CanMEDS initiative: implementing an outcomes-based framework of physician Competencies. Medical Teacher 29: 642–647

Razack S and Dath D, 2006. The CanMEDS Assessment Tools Handbook: An introductory guide to assessment methods for the CanMEDS competencies. Ottawa. The Royal College of Physicians and Surgeons of Canada

Sherbino J, Upadhye S, and Worster A. 2009 Self-reported priorities and resources of academic emergency physicians for the maintenance of competence: a pilot study. CJEM: Journal of the Canadian Association of Emergency Physicians. Vol. 11;3 (230-4)