Most healthcare leaders view their roles as a professional calling, and many health systems support administrative fellowships as an important rite of passage into the profession. Historically, fellowship programs have not received as much oversight and governance as clinical leadership roles. But as the country’s health systems struggle to reinvent themselves and strengthen their leadership ranks, the approach to early career development for Administrative fellowships is beginning to change.
While medicine and other clinical disciplines developed nationally coordinated systems as early as the 1940s, healthcare management continued as a fragmented system. Efforts to change that date back to at least the early 2000s, when a group of health system CEOs tried to agree on a uniform application cycle. Peter Butler, CEO of Houston Methodist at the time, remembers the effort well. “It took a lot of time and a lot of meetings,” Butler recalls, “and there was a time when we thought things were good to go. But one of the health systems decided to pull out at the eleventh hour, and things just fell apart from there. At that point we just sort of assumed it couldn’t be done.”
Hope was resurrected in 2012, when a group of graduate program directors — suppliers of fellowship applicants — started their own discussion about the need for a coordinated system. Long frustrated with the needless extra work of the process, they were now seeing a new threat: diminishing interest from students. As the application “arms race” began moving deadlines earlier and earlier, and pressure tactics from sites became ever more aggressive, many of the most talented students were opting to forgo applying altogether, choosing instead the quicker path to a higher salary that consulting and other sectors seemed to offer.
When graduate program directors and fellowship site directors were first brought together, they quickly found common ground: everyone wanted a better experience for the student applicants. They also agreed that a coordinated system would require two things: (1) a clearly articulated ‘code of practice’ that spelled out everybody’s expectations, and (2) a third-party oversight body to uphold this code. They agreed to establish a dues-supported National Council on Administrative Fellowships (NCAF) to make this happen.
Over the next several years, the founding NCAF members moved quickly to establish a centralized application service, annual meetings for members and prospective applicants, and an educational webinar series for NCAF fellows. Membership grew quickly, as did the benefits. “In terms of supporting our students, the difference a coordinated system has made has been night and day,” according to Julie Robbins, MHA Program Director for The Ohio State University and Chair of NCAF’s Benchmarks & Metrics committee.
But the challenges continued. As more organizations signed on for coordinated approach, the easier it became for other sites to undermine it. “Some systems have found it beneficial to target top students, weeks before the uniform offer date that has been established for the benefit of students,” said Ajani Dunn, administrator at Mayo Clinic and chair of NCAF’s membership committee. “With early, high-pressure offers designed to discourage students from interviewing elsewhere, these sites advance their own provincial interests at the expense of the greater good of the profession.”
“It’s a classic prisoner’s dilemma,” notes Gina Cronin, executive director of Cleveland Clinic’s Global Learning Institute and chair of NCAF’s Advisory Committee. “Self-interested programs can do well for themselves in the short run by undercutting the process, but in doing so they are putting the whole system at risk.”
While some graduate program directors caution their students about high-pressure offers, there is only so much they feel they can do to promote coordination on their own. The supply of applicants still far exceeds the number of fellowship slots available, and fellowship or not, program directors need to help their graduates find employment.
Today, fellowships remain the exception rather than the rule. According to CAHME data, of the 2,574 graduates from accredited graduate programs in 2017, only 262, about 10 percent, were placed into fellowships. But NCAF hopes to change that. “There is a growing body of research suggesting that these programs benefit not only the fellows, but also the health systems who host them,” said Nitasha Kassam, NCAF’s program coordinator. “For systems interested in starting fellowship programs, NCAF makes resources available to help them get going and we have seen an uptick of new programs willing to start a fellowship because there is a coordinating organization that can help that is serving the field.”
Will fellowships continue to flourish under a nationally coordinated system, or will the rogue actors prevail? “Only time may tell,” said Andy Garman, CEO of the National Center for Healthcare Leadership, NCAF’s parent nonprofit. “But for a health system so frequently described as fragmented, if not outright broken, national efforts to strengthen the healthcare leadership needed to address these challenges can’t arrive soon enough.”
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