As every physician will face leadership challenges, the aim of this article is to elaborate on one of the seven CANMeds' competencies on the matter. It describes leadership as a distinct discipline in which many physicians lack sufficient training and experience as it requires not only soloist but communal decision making. Evidence from physician executive leadership is elucidated and ultimately structural challenges to overcome obstacles to a desired clinical-leadership equilibrium are addressed.
I have stopped counting the numerous times I have heard the above sentence expressed in a conversation regarding physicians becoming administrative leaders. The second most frequent quote might be: “Don’t you miss working with patients?”
I would therefore like to shed some light on my thoughts going into this field. And why it is of paramount importance for the future of our public health care system that is under an increasing pressure in terms of securing adequate capacity and staff attachment.
Many physicians have difficulties acknowledging leadership as a discipline – but if you dig a bit deeper, you will find many aspects of not only management but also leadership in the daily clinical work that resembles that of higher levels in the health organisation.
Leadership as a skill – and a discipline
As a physician we undergo training for many years and obtain a specialized, scientific basis for clinical decisions. This training makes doctors excellent soloists who can take a high degree of responsibility at short notice.
But leadership skills are something completely different from clinical skills. As a leader, results are achieved through processes with others, and you must be able to zoom in and out and watch the organization as a whole. The ability to create inclusive processes and listen to the input of other professional groups is crucial and calls for knowledge and methods from other professional disciplines, which often see the world through different scientific lenses than the more exact ones of the natural sciences.
So, beyond being a medical expert, the physician is increasingly being called upon to exhibit leadership competencies to navigate the complex landscape of modern healthcare.
It is therefore natural to examine one of the seven competencies in the clinical curriculum closer – the role as a leader:
CanMEDS[1] describes several features of general leadership skills for all clinicians no matter the position. The essence is about collective (as opposed to individual) ownership among many stakeholders and stewardship within the health care system. It encompasses four key competencies:
Contribute to the improvement of health care delivery in teams, organisations, and systems;
Engage in the stewardship of health care resources;
Demonstrate leadership in professional practice;
Manage career planning, finances, and health human resources in a practice.
Physicians should therefore already in their training – and possibly as early as medical school - enact both leadership and management skills, where management can be considered actions that enables local organisational matters and leadership is the drive for change. Physicians therefore have a special responsibility in managing and leading the health care system.
The difference between leading and managing lies in a physician developing the insight in the complex world of health organizations, seeking to preserve a homeostasis when appropriate (managing), and disrupting for change when also appropriate (leading). It is developing this balance through critical, reflective supervision, that is the core aim of the CanMED’s Leader role curriculum.
Are doctors the best leaders?
London based Goodall et al[2] has proposed a theory that leaders should have expert field knowledge of the organisations they are to lead. After initial research in university departments, hospital performance was scrutinised. The researchers found that the chief executives in the highest rated (American) hospitals were more likely to be physician-leaders rather than of other professions. The presence of a physician-chief executive was shown to be associated with better hospital quality scores: physician-led hospitals achieved 25% higher quality scores. A related British study[3] focused on management practices in National Health Service (NHS) Trusts. The study found that both the best managed hospitals and the best performing hospitals were those with a high proportion of managers with clinical degrees.
The chair of the “Education Institute” at the Cleveland Clinic in Ohio, USA, James Stoller, emphasises that physicians are trained as a medical expert but not to same extent in leadership and management, which is why most feel ill-prepared to handle these roles[4]. He stresses that leadership training should begin early in clinicians’ careers as to create not only interest in the importance hereof but also acquire sufficient competencies.
In the Capital Region of Denmark hospitals often appoint psychiatrists as a head of clinic that report to executive directors who are non-psychiatrist professional leaders. Stoller again points out in his research that the success of this role depends on the head of clinic having the right experience and training in leadership skills. On top the executive and head of clinic need to work closely together to create an effective partnership. Problems can - according to Stoller - occur if the head of clinic does not have a voice in executive forums.
It is also essential that consultants, residents and other junior doctors view the head of clinic as “among equals”, because they originate from the collegial group. Having been “one of us” signals credibility, which can extend a leader’s influence. An expert leader will thus be more able to understand the culture, values, incentives and motivations of the physicians and other core professionals “on the floor”.
Structural challenges
In Denmark many consultants struggle with balancing the need for carrying out their daily clinical work, management of the department and leadership. As the number of patients steadily increase, competing tasks of eg. quality assurance, patient safety and documentation demands pile up on the consultant’s desk, the required time for reflection, strategic thinking and necessary process planning diminishes.
Therefore, the Danish Medical Association has taken steps to secure consultants who are interested in taking on more leadership responsibility the appropriate time for the purpose[5].
A new title was therefore introduced in 2021, and two tiers of consultants created. The “classic consultant” remains – with continued focus on mainly management in the clinical work but some time allocated to leadership and development of eg. new standards, workflow, or educational actions.
“The leading consultant” on the other hand is supposed to spend a minimum of half the working week on more strategic leadership work in close collaboration with the head of clinic and the remaining time on maintaining clinical competencies.
This is still a new construction, and we are slowly but progressively gaining experience from the physicians venturing into the field. It is no secret that many consultants are sceptic to the solution – they prefer the smaller departments and fear they will have an even greater workload if they take on the same duties in a greater area.
The point is – the job is not the same. Clinical duties for the leading consultant are handed over to other colleagues and releases time for the more strategic and administrative work. A solution – or consequence – is that clinical tasks are solved across departments to allow for more flexibility and use of the right competency level, so the right job is done by the right person at the right time. This will be most likely be the focus of future discussions.
Encouragement
In the above I have tried to illustrate a few prejudices, some research, and many views on the role of leadership as a physician.
Every specialist is expected to enter this field - but not everyone is expected to advance to becoming a head of clinic or executive levels. We perform the best where we sense the energy, feel uplifted and rewarded making a difference when returning home. That makes us get up the following morning when the alarm goes off.
As in the field of the medical expert – training in leadership is also livelong and requires continuous emphasis. This is also why it is strongly recommended to have a trusted mentor with whom one can discuss various aspects of everyday leadership and management challenges.
Leadership takes place on many levels in the hospital from patient discussions to implementing guidelines and new workflows – but it all commences with training and nurturing the interest in future psychiatrists.
So, to answer the initial question: “I am in fact very happy I went into leadership on an administrative level – because I find great purpose in using my acquired clinical knowledge to create influence and improve health care on a broader level” and “No, I don’t miss the patients. Because I work every day for the exact same aim as the clinicians: to generate the best frame and path to the best treatment outcome. That means the patients are very present in my work as well.” □
References by request
https://www.royalcollege.ca/ca/en/canmeds/canmeds-framework/canmeds-role-leader.html
Goodall AH (2011) Physician-leaders and hospital performance: Is there an association? Social Science and Medicine 73: 535–539.
Bloom N, Propper C, Seiler S, et al. (2010) The impact of competition on management quality: evidence from public hospitals. National Bureau of Economic Research (NBER) Working Paper No. 16032. Cambridge, MA: NBER.
Stoller JK (2014) Help wanted: developing clinician leaders. Perspectives on Medical Education 3: 233–237.
https://laeger.dk/foreninger/overlaegeforeningen/presse-og-politik/fremtidens-overlaege