Keywords
leadership development program - ophthalmology - leadership
Leadership development programs (LDPs) are important vehicles for the cultivation
of leadership talent in the managerial realm.[1] These programs offer invaluable skills for aspiring leaders, allow opportunities
to network with current leaders, and create a talented and prepared pipeline of future
leaders. Physician LDPs are increasingly prevalent at academic health centers,[2] state medical societies, specialty societies, and national medical associations.
However, LDPs specifically targeting physicians are difficult to evaluate given marked
heterogeneity in structure and protocols across organizations.[3] Despite the lack of clarity in LDP evaluation in the literature, there are books
written on methods for measuring success of LDPs.[4] LDPs are often evaluated based on some version of Kirkpatrick's four level tool
for the evaluation of training programs,[5] which looks at subjective or objective outcome measures of reaction, learning, behavior,
and results. While meta-analyses of physician-targeted LDPs using these categories
have demonstrated positive outcomes in all included studies, system-level results
and long-term outcomes are studied[6] infrequently. This corroborates with other systematic reviews of leadership training
in medical education[7] at academic medical centers.[8]
[9]
Physician leadership can positively impact hospital quality.[10] There are multifarious leadership roles beyond clinical practice management and
departmental chairpersonship including organizational development, medical education,
research, editorial scope, politics, advocacy, and quality improvement. Technical
skills, emotional intelligence, communication, conflict resolution, negotiation, and
advocacy are teachable skills required for successful physician-leaders.[11] As a result, there is a compelling need to define specific leadership competencies
and expand and evaluate emerging LDPs.[12]
Moreover, there are important gender,[13] race, ethnic,[14] and other disparities in ophthalmology that may become more concentrated at the
leadership level. These disparities need to be addressed from pre-leadership and preophthalmology
programming. For example, the Minority Ophthalmology Mentoring (MoM)[15] program and Rabb-Venable program[16] were developed to address pipeline issues into ophthalmology training. Recruiting
talent is insufficient to address these disparities. Rather, investment in human capital
with strategic talent management through formalized programs appears vital.
Given the importance of intentional leadership programs within the field, the American
Academy of Ophthalmology (AAO) founded its LDP in 1998. Additional ophthalmology-specific
LDPs have emerged in the last two decades; however, the specific outcomes and degree
to which these LDPs contribute to the field of ophthalmology have been minimally described
in the literature. As a result, the authors sought to survey the current state of
LDPs in the field of ophthalmology and evaluate the evolution of these LDPs and their
changing demographics.
Methods
Identification of LDPs targeting ophthalmologists was found by routine search engine
querying for “LDP” and “ophthalmology” ([Table 1]). We assessed programs as per their target outcomes following a modified version
of Kirkpatrick's four-level evaluation[5] with the following categories: reaction (Level 1), knowledge or learning (subjective;
Level 2A), knowledge or learning (objective; Level 2B), behavior/expertise (subjective;
Level 3A), behavior/expertise (objective; Level 3B), system results/performance (subjective;
Level 4A), and system results/performance (objective; Level 4B), which was sourced
directly from prior evaluation of LDPs for physicians.[6] Categorical levels and representative outcomes are described in [Table 2].
Table 1
Leadership development programs (LDPs) targeting ophthalmologists
|
Program
|
Society/Institution
|
Size of program
|
Length
|
Year founded
|
|
AAO leadership development program
|
The American Academy of Ophthalmology (AAO)
|
18–20 participants
|
1 y
|
1998
|
|
PAAO Curso de Liderazgo
|
Pan-American Academy of Ophthalmology (PAAO)
|
16–18 participants
|
1 y
|
2004
|
|
European Society of Ophthalmology leadership development program (EuLDP)
|
European Society of Ophthalmology (SOE)
|
30 participants
|
2 y
|
2005
|
|
AIOS leadership development program
|
All India Ophthalmological Society (AIOS)
|
10–22 participants
|
1 y
|
2008
|
|
APAO leadership development program
|
Asia-Pacific Academy of Ophthalmology (APAO)
|
19 participants
|
1 y
|
2009
|
|
RANZCO leadership development program
|
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO)
|
Unlisted
|
1.5 y
|
2014
|
|
AOC leadership development program
|
African Ophthalmology Council (AOC)
|
17–20 participants
|
2 y
|
2015
|
|
ARVO Women's leadership development program
|
The Association for Research in Vision and Ophthalmology (ARVO)
|
9–12 participants and their mentors
|
1 y
|
2016
|
|
AUPO Academic leadership development program
|
The Association of University Professors of Ophthalmology (AUPO)
|
10–14 participants
|
1 y
|
2020
|
Table 2
Outcome measures for leadership development programs (LDPs) targeting ophthalmologists
|
Program
|
Capstone project categories
|
Alumni leadership roles
|
Awards to LDP
|
Evaluation categories[a]
|
|
The American Academy of Ophthalmology (AAO) leadership development program
|
Advocacy Projects (26.39%), Leadership Development Projects (2.89%), Membership Projects
(14.23%), Ophthalmic Education Projects (8.25%), Ophthalmic Training Program Projects
(6.60%), Organizational Development Projects (7.84%), Practice Management Projects
(5.57%), Public Information/Public Service Projects (13.81%), Quality of Care Projects
(6.60%), Website Projects (7.84%)
|
“277 served as Academy committee members, Councilors or Academy representatives to
outside organizations. 25 served on the Academy's Board of Trustees or Committee of
Secretaries including 2 Academy Presidents, 242 have served as president of a state,
subspecialty, or specialized interest ophthalmology society.”
|
“2013 Academy's Special Recognition Award 2001 trophy in the American Society of Association
of Executives' Gold Circle Awards”
|
Level 1, Level 2A, Level 3A, Level 3B, Level 4A, Level 4B
|
|
Pan-American Academy of Ophthalmology (PAAO) Curso de Liderazgo
|
Capstone projects
|
N/A
|
N/A
|
Level 4A, Level 4B
|
|
European Society of Ophthalmology leadership development program (EuLDP)
|
Capstone projects
|
N/A
|
N/A
|
Level 4A, Level 4B
|
|
All India Ophthalmological Society (AIOS) leadership development program
|
Capstone projects
|
N/A
|
N/A
|
Level 4A
|
|
Asia-Pacific Academy of Ophthalmology (APAO) leadership development program
|
“Patient care enhancement, Training and education, Research and development, Community
work, Leadership development, Advocacy”
|
N/A
|
N/A
|
Level 4A
|
|
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) leadership
development program (LDP)
|
Self-directed project
|
N/A
|
N/A
|
Level 4A
|
|
African Ophthalmology Council (AOC) leadership development program (LDP)
|
Projects to benefit participants' nominating society
|
N/A
|
N/A
|
Level 4A
|
|
The Association for Research in Vision and Ophthalmology (ARVO) Women's leadership
development program
|
N/A
|
“62% are currently serving on an ARVO committee, 73% of the 2018–2019 class plans
to pursue a leadership role at their institution within the next 2 y.”
|
N/A
|
Level 1, Level 2A, Level 3A, Level 3B
|
|
The Association of University Professors of Ophthalmology (AUPO) Academic leadership
development program
|
N/A
|
N/A
|
N/A
|
N/A
|
a Evaluation categories:
Reaction (Level 1).
Knowledge or learning (subjective; Level 2A).
Knowledge or learning (objective; Level 2B).
Behavior/expertise (subjective; Level 3A).
Behavior/expertise (objective; Level 3B).
System results/performance (subjective; Level 4A).
System results/performance (objective; Level 4B).
Additionally, looking specifically at the AAO LDP, participant demographic changes
over time were assessed using previously validated software for gender (Gender-API,
2020) and race or ethnicity (NamSor, 2020).
Systematic Review of Existing Literature
For context on current analyses of LDPs, a systematic review of publications related
to leadership development and ophthalmology was performed through a modified PRISMA
protocol with qualitative analysis[17] using the electronic databases of PubMed—Legacy, Web of Science, and ERIC (Education
Resources Information Center). The search was limited to English publications. Inclusion
criteria were initially intended to capture any discussion of LDPs in ophthalmology.
Studies exploring leadership across specialties, with specific stratification for
ophthalmologists, were included. Exclusion criteria included (1) individually written
interviews, personal reflections, or lectureships; (2) articles that were published
in languages other than English; (3) reference to leadership personnel without discussion
of the concept of leadership; (4) articles with no specific reference to ophthalmology.
As no protected health information was required to conduct this study, IRB approval
was not required.
The initial query focused on LDPs in ophthalmology ([Appendix A]), which yielded no results in any database. The query was expanded to include the
more inclusive phrases of “leadership” AND “ophthalmology” ([Appendix B]). Institutional Review Board approval was not required for this literature search
study.
Results
LDPs are offered by: AAO[18]; Asia-Pacific Academy of Ophthalmology (APAO)[19]; The Association for Research in Vision and Ophthalmology (ARVO)[20]; The African Ophthalmology Council (AOC)[21]
[22]; The Royal Australian and New Zealand College of Ophthalmologists (RANZCO)[23]; European Society of Ophthalmology (SOE)[24]; All India Ophthalmological Society (AIOS)[25]; Association of University Professors of Ophthalmology (AUPO)[26]; and Pan-American Association of Ophthalmology (PAAO).
The earliest LDP identified was the AAO LDP founded in 1998. Since then, four additional
multinational LDPs and two national LDPs have emerged, predominantly with large national
or international scope. When reported, program size ranged from 9 to 30 participants.
Programs typically spanned 1 to 2 years, and were composed of meetings, forums, networking
events, and/or capstone projects. LDPs were primarily funded by cost-sharing mechanisms
with a nominating society or the individual participant, with support from industry
partners.
Statements from organizational webpages as well as several AAO LDP capstone projects
suggest these large multinational LDPs are in fact part of a larger “Global LDP” network
([Fig. 1]). For example, the following multinational and national LDPs were founded either
directly from AAO or based on the AAO LDP: AIOS LDP was founded by S. Natarajan, MD
(AAO LDP VIII, Class of 2006)[25]; the APAO LDP was founded by Philip Lam, MD and Catherine Green, MBChB FRANZCO MMedSc
in 2009[27]; the PAAO LDP was founded by Zelia Correa, MD (AAO LDP V, Class of 2003)[28]; Stefan Seregard, MD cultivated the European-SOE LDP (LDP VI, Class of 2004) after
the 2004 AAO-SOE joint meeting; the RANZCO LDP was founded in collaboration with the
AAO and APAO[29]
[30]; the AOC LDP is based on the AAO LDP[29] with leadership from Michael Brennan, MD and Sidney Gicheru, MD for Anglophone,
Francophone, and Lusophone Africa.[22] The Global LDP network of multinational organizations was defined as the first generation
of ophthalmology-specific LDPs, whereas the national LDPs and societal LDPs comprise
the second generation.
Fig. 1 Elaboration of the Global LDP from the AAO LDP. AAO, American Academy of Ophthalmology;
LDP, leadership development program.
In addition to these international programs, two programs in the United States were
identified, which targeted specific demographics of female scientists or faculty (ARVO
Women's LDP) and academic ophthalmology leaders (AUPO Academic LDP). These two programs
comprise the second generation of targeted ophthalmology-specific LDPs within the
United States ([Fig. 2]).
Fig. 2 Schematic of LDPs within the United States. LDP, leadership development program.
Importantly, the gaps in gender and academia have been addressed by both the ARVO
Women's LDP and the newly emerging AUPO Academic LDP. Additionally, AAO LDP capstone
projects have focused on diversity, including exploring barriers to a successful match
for minorities and surveys to characterize interest and increase underrepresented
minorities in ophthalmology. These efforts have led to encouraging trends when examining
the demographics of AAO LDP participants. There has been a significant increase in
the proportion of female LDP participants, which began with roughly 13% women, and
has increased to 40 to 65% women from 2015 to 2020 (n = 389).There has also been an increasingly diverse membership since inception of
the program with representation from all around the world ([Fig. 3]).
Fig. 3 Demographic distribution of AAO LDP participants over time. AAO, American Academy
of Ophthalmology; LDP, leadership development program.
All LDPs alluded to discussion of self-improvement, learning, and behavior changes
in their mission and goals; however, specific outcome measures were rarely delineated.
The AAO LDP provided the most comprehensive evaluation category information with subjective
evidence from select participants as well as capstone abstracts with organization-level
outcomes. The AAO LDP information included all four levels of evaluation; however,
objective information regarding learning, which would be acquired from testing of
participants, was not present. The ARVO Women's LDP highlighted key outcomes for participants,
and provided subjective information on personal growth, but no organization-level
outcomes were included. In contrast, the LDPs from the APAO, SOE, AIOS, PAAO, and
AOC primarily included a reference to capstone projects without any indication of
personal development outcomes. Importantly, project abstracts are available for the
AAO LDP, EuLDP, and PAAO programs. These abstracts can be considered Level 4B outcomes
(objective organizational-level metrics).
Supplemental Literature Review
Twenty publications were consistent with inclusion and exclusion criteria. In terms
of primary categorical leadership content, academic leadership (journal editorial,
academic, or departmental, research funding) was discussed in 55% of articles, with
the remaining literature focused on global or international leadership (10%), professional
society leadership (5%), post-graduate or surgical leadership training (10%), and
private practice, industry, MBA-ophthalmologist, or general health care leadership
(20%). Most publications addressed gaps in leadership in ophthalmology, with discussion
of gender disparity, which was the primary focus of 60% of articles. With the exception
of one study using a curricular intervention,[31] 95% of studies were either cross sectional, review or descriptive report, or observational
and retrospective in design. Outcome measures, when available, included gender proportion
as well as demographic, professional, and academic profile statistics of specific
leadership categories. Publications that were included in the final qualitative analysis
are described in [Supplementary Table S1].[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
Discussion
Ophthalmology-specific LDPs are similar to current LDPs at academic health centers[2] in size, structure, and lack of robust performance metric reporting. The first generation,
Global LDP, represented a critical expansion of the AAO's leadership development training
internationally. As evidenced by the leadership ophthalmology literature, as well
as needs-based capstone projects, cultivation of leadership in specific demographics
is needed. Attempts at addressing these gaps are being made by both the ARVO Women's
LDP and the newly emerging AUPO Academic LDP, creating more opportunities for women
and underrepresented minorities in these programs.
Given the national and international scope of the LDPs identified, we sought to characterize
the availability of leadership programs within ophthalmology subspecialty and state
societies. While several societies offered honors or awards for leadership, there
were no specific LDPs identified, from a nonmember routine internet search, for subspecialty
or state ophthalmology societies. Instead these societies utilize the AAO LDP to train
and cultivate leaders for their organizations. With estimates of 17,000 ophthalmologists
registered for centers for medicare and medicaid services (CMS),[51] the AAO LDP program can serve 0.12% of ophthalmologists in the United States, annually.
Adding the ARVO and AUPO LDP offerings would increase this offering to 0.27%. Although
leadership training is intended to have far reaching impact beyond the individuals
trained, there is a clear dearth of LDPs catered specifically to ophthalmologists.
Fortunately, the AAO LDP develops a tremendous leadership capacity for ophthalmology,
and AAO LDP graduates have and can continue to create second and third generation
programs.
Codifying LDP outcomes will undeniably facilitate the expansion and optimization of
second and third generation programs, and provide quantifiable return-on-investment
information for organizations that may be hesitant to invest in less empirically validated
strategic talent management programs. Empiric evidence for system-level improvement
should track clinical, financial, and other organization-specific goals to evaluate
the efficacy of LDPs.
There is evidence for significant gender disparities in ophthalmology leadership positions,
which is well represented in the literature. For example, department chairs remain
predominantly held by men,[40]
[46] which may be due to gender disparities in National Institutes of Health funding
in ophthalmology,[41] or a historical lack of women in leadership positions at ophthalmic publications[42] that remains an important topic of discussion in 2020.[32]
[33]
[52] In fact, there has been a compelling call for gender diversity in ophthalmology
leadership due to the disparity between the number of practicing women ophthalmologists
and the proportion of women in leadership roles.[52] This trend is improving but is representative of the gender disparities in national
medical societies across specialties.[35] Despite apparent gender parity in residency, academic leadership is disproportionally
male, regardless of chairperson and residency program director gender.[44] The increasing presence of women in LDPs demonstrated here is an encouraging initial
step in creating gender equality in academic leadership. Further targeted LDPs such
as the Women's LDP from ARVO can help foster retention of gender diversity in academia
through dedicated mentorship.
Similarly, minority groups underrepresented in medicine comprise 30.7% of the U.S.
population, but the proportions of practicing ophthalmologists, ophthalmology faculty,
and ophthalmology residents are only 6, 5.7, and 7.7%, respectively.[14] Therefore, the issue of equity will require early and active intervention. Landmark
efforts from the AAO and AUPO, with sponsorship from major ophthalmology societies,
to create the MOM program[15] as well as the National Medical Association's Rabb-Venable[16] represent an important step in targeted mentoring. These programs may contribute
to the third-generation efforts for undergraduate and graduate medical education.
Expansion of these efforts must focus on gaps in the pipeline with subsequent and
continuous leadership training for later-career ophthalmologists.
U.S. academic ophthalmology department chairs are reportedly 90% male and predominantly
fellowship-trained in Cornea, Vitreoretinal Surgery, and Glaucoma.[37] The “triple threat” of roles as a clinician, researcher, and educator remains relevant,
and previous leadership roles are described as invaluable for department ophthalmology
chairpersons.[40] However, the duties of the academic chairperson are dynamic, reflecting an ever-changing
health care landscape; therefore, LDPs are vital to provide the newer generation of
leaders with necessary skill development. Navigating the political and hierarchical
complexity of these organizations may require significant mentorship for aspiring
ophthalmologist-leaders. There is a promising opportunity to augment the reach and
influence of current leaders through formalized mentorship and expansion of LDPs.
Meta-analyses of LDPs at academic health centers suggest most programs are targeted
toward early-career physicians, with no programs targeting physicians in top-level
leadership roles,[6] though the AAMC and other organizations provide mid- and early-career leadership
training.[53]
[54] Leadership development capacity will need to be personalized both to specific demographics
and level of career development. Because executive-level ophthalmology mentors are
inherently in short supply, top-down LDP and mentorship networks will need to be designed
to optimize access and impact.
Conclusion
There is a paucity of outcome measures for LDPs catered specifically to ophthalmologists,
which parallels the lack of peer-reviewed literature describing leadership and ophthalmology.
The first generation Global LDP in ophthalmology was spearheaded by the AAO and followed
by targeted offerings from ARVO and AUPO. These new programs help address important
gaps in ophthalmology leadership described in the literature such as disparities in
gender, race, and ethnicity, with a predominant focus on academic ophthalmology leadership
roles. Further expansion of formalized leadership training programs is needed to serve
a growing population of ophthalmologists facing an exceedingly complex health care
landscape. As these programs emerge, detailed research on outcomes from existing LDPs
can ensure equity and diversity and allow for successful replication and growth for
second and third generation LDP offerings.
