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11 Apr 2019

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA 

It is contended that medical leadership is a mechanism to achieve greater medical engagement in the running of organisations1. Engaged doctors can have a direct day-to-day input on the financial bottom line of hospitals and without medical engagement at a collective level and the individual alignment of doctors, there is no meaningful way to influence variations in practice or care1.

Benefits to employing doctors in healthcare management roles include bottom-up leadership2, greater political influence and improve communication between doctors and senior management. Medical leadership is necessary to link clinical decisions with those of strategic management. Doctors are key to embedding health service improvements1 and overcoming the occasionally lugubrious perceptions of our colleagues. Primary care is no different in that to be successful, quality needs to be defined and measured in ways that are meaningful to general practice; this requires strong and consistent clinical leadership3.

Is there anything to be said against medical leaders?

The argument against medical leadership include doctor over-identification with their professional clinical role, their tendency to be conservative individualists rather than team players, their lack of formal management training and their purported weakness in financial management and organisational strategy. I however believe appropriate training would enable doctors to overcome many, if not all, of these perceived deficiencies. Moreover, there is some suggestion that doctors are more willing to take on leadership roles after formal training4.

Doctor-leaders may have lost some favour initially given the range of leadership styles that effective leaders must be able to deploy situationally. Unhelpfully, doctor leaders have traditionally defaulted to a ‘command and control’ style that fosters the concept of doctors as heroic, gladiatorial lone healers. The perverse effects of ‘command and control’ are that this style conspires against collaboration and tends to be perpetuated as aspiring leaders emulate their predecessors5.  Furthermore, ‘command and control’ is widely considered to be among the least effective leadership styles – what Goleman and Boyatzis call a ‘dissonant style’ as opposed to the four other resonant styles such as visionary, coaching, democratic and affirmative styles6.  Experience in organisations outside healthcare indicates an association between poorer organisational performance and the CEOs having a primary command and control style and conversely, better organisational performance with one of the resonant CEO styles5.

This paradox – the tension between the need for collaboration in healthcare and medical system leadership with doctor’s maladaptation to collaborate (with a focus on autonomous decision-making and personal achievement) – underlines the need to enhance doctor’s leadership competencies4. Formal doctor leadership training also counters the perception that medical influence is diminishing and self-regulation is suffering. This aspect is very important in an increasingly litigious environment in which complaints against doctor are becoming significantly more frequent as regulators and Government strive to appear tough in managing misconduct or malpractice, even though the incidence of this remains stable and quite small.

How to build more credible medical leadership

It was recognised that in regard to the NHS, if they were to achieve a position where medical leadership was of a consistently high standard and embedded throughout the NHS, they needed all doctors to be able to take a macroscopic view on healthcare provision and resource allocation and to understand the political, economic, social and technological drivers for change that would influence this view throughout their careers.

Doctors, who until now had been taught little of the NHS, would need to learn about the funding, organisation, governance and management that are integral to its workings. They need to be supported by well-developed systems, clear lines of reporting and responsibility, and an organisational culture that provides good information and encourages its use as a vehicle for performance improvement. Finally, all doctors, whether they remain predominantly as medical practitioners, move to lead organisations or take on more strategic roles, need to learn more about ‘followership’ – an increasingly discussed concept that recognises the importance of participation and allowing others to lead. Without doing these things, doctors will remain significantly disadvantaged, unable to participate in discussions regarding service delivery, unable to navigate and lead others through the organisation and system in which they work and on occasions perceived, sometimes rightly, to be barriers to change or toxic influences within their organisations.

The profession still has much work to do in order to extinguish discrimination, bullying and sexual harassment completely from the training landscape and workplace. The Royal Australasian College of Surgeons has shown that an evidence-based approach can be brought to bear and that positive change is possible. Significant cultural change remains necessary to make perpetrators aware that their behaviour will no longer be tolerated7. Enlightened and empowered medical leadership is clearly a fundamental step in achieving this. The AMA, Medical Colleges and every doctor individually has a vital role to play in honouring the ‘societal contract’ between the profession and our patients ensuring that discrimination, bullying and sexual harassment are never tolerated. Together we can champion unimpeachable professionalism and integrity through abolishing the disconnect between organisations’ stated values and the explicit professional values we espouse and teach, with the responses in individual cases of alleged abuse.

The goal of producing better qualified and confident medical leaders in order to emphasise the importance of doctor-led healthcare and promote medical leadership with a positive organisational culture is therefore critical.  Acceptance of this need, a profession-wide push in this direction and credible learning opportunities to facilitate it are urgently required. I hope the AMA is going to be able to work with the Royal Australasian College of Medical Administrators to design a program that will achieve exactly this. We have some good examples worthy of approbation already where RACMA has developed such a program in Tasmania and in conjunction with Queensland Country Practice offering a conjoint AFRACMA with rural generalist training. 

Ideally, the leadership program should align with an organisational culture that regards (medical) leadership as being important to success, coupled with the respect garnered from clinical prowess.  This is where the wider profession has a role – we must create this culture where medical leadership is regarded and valued as fundamental. Doctors respond positively to leadership development when the framework follows principles established for continual medical education – there is a growing body of evidence which gives advice on curricula and principles of good leadership and education in this context8. The core realisation for policy makers is that medical leadership development programs increase doctor leadership competencies and add value to healthcare institutions7

It is time to actively reclaim and develop our management potential and not shrink from this important aspect of our jobs.  Let us all please support and/or get involved in medical leadership and be active participants in the running of our practices, institutions or healthcare systems. Robust leadership/management training and profession support for our colleagues in management positions can anneal our collective resolve and capacity to contribute. I genuinely believe Australian health care and our patient outcomes will be better for it – plus it will be a more safely efficient and happier workplace. 

 

References

  1. Spurgeon P et al. Do we need medical leadership or medical engagement? Leadership in health Services. 2015, 28(3):173-184.
  2. O’Sullivan H & McKimm J. Medical leadership: an international perspective. British Journal of Hospital medicine. 2011, 72(11):638-41.
  3. Cavanagh K. Quality, innovation and leadership in general practice – what do they have in common? Australian Family Physician. 2003, 34(1/2):63.
  4. MacPhail A et al. Workplace-based clinical leadership training increases willingness to lead. Leadership in health Services. 2015, 28(2):100-118.
  5. Stoller JK. The Clinician as leader. Annals of the American thoracic society 2017, 14(11):1622.
  6. Goleman D et al. Primal leadership: the hidden drive of great performance. Harvard Business Review. 2001, Dec:42-51.
  7. Watters DAK & Hillis DJ. Discrimination, bullying and sexual harassment: where next for medical leadership? MJA 2015, 203(4):175-6.
  8. Hopkins J et al. Designing a physician leadership development program based on effective models of physician education. Health Care Management Review 2018, 43(4):293-302.

 

 


Published: 11 Apr 2019