Medical followership and managing up

DOCTORS are taught how to be leaders early on as part of medical school. In fact, the concept of doctor as leader is now built into the medical curriculum, and is an expected competency of every medical practitioner. Most Australian medical specialty colleges have training programs that are based on the CanMEDS educational framework, and one of the core competencies is “leader”.

As such, doctors are now basically told that to be a competent doctor, they also need to be a competent leader. They are increasingly expected to lead interprofessional clinical teams, and manage people, processes and occasionally budgets.

And there is good reason for this development. There are clear benefits to having doctors as leaders in the health system, including improved medical engagement, leading to potentially more effective change champions. Doctors who know how to lead are able to achieve much for the health system as a whole. Thus, more doctors today are being taught basic leadership principles and techniques on “managing down”.

However, there are two sides to the leadership equation. As Peter Drucker, one of the founders of modern management puts it: “The only definition of a leader is someone who has followers”. John Maxwell, the leadership author, puts it another way: “He who thinks he leads, but has no followers, is only taking a walk”. Leadership is only half the story. As Aristotle stated: “He who cannot be a good follower cannot be a good leader”

Therefore, the first step of any leadership discussion should start with followership. Effective followership is not blind obedience or passive compliance. Robert Kelley came up with a followership model based on two dimensions: the degree to which followers exercise independent, critical thinking; and the followers’ level of engagement, or how passively or actively they follow. This provides us with four types of followers.

The first type is the “sheep” followers, who are both uncritical and passive, lacking in initiative and sense of responsibility. Secondly, you have the “yes people”, followers who say yes without questioning nor adding value in an active way. Junior doctors tend to fall into these two categories due to their level of experience and perceived inability to influence or exert control, depending on their engagement.

The third group comprises “alienated” followers, who are critical and independent in their thinking, but who are not engaged and are only passively carrying out their roles. These followers are often cynical and “sink into disgruntled acquiescence”. Some senior doctors may fall into this category, being highly intelligent practitioners who are frequently not engaged well by their organisations.

The fourth type is the “effective followers”, team members who are highly independent and critical, as well as active and engaged. Basically, effective followers can think for themselves, take risks, solve problems independently, and can succeed even in the absence of strong leadership.

As a result, we need to teach doctors to be effective followers as well as effective leaders. This includes teaching doctors the value of being the first follower. The first follower is about leadership from the middle, and is the courage to take the first step and be the first to follow your leader and actively support them in a public way. As the first follower, you make it less risky for others to join in, and as more join in, it becomes actually riskier to stay on the sidelines than to become part of the movement.

If part of being an effective leader is about managing down, then being an effective follower is also about learning to manage up. It is an essential part of leadership and followership, but is often a misunderstood concept. Why should doctors need to manage up? Shouldn’t it be up to their managers to manage down?

Essentially, managing up can be defined as being the most effective employee you can be, and can be distilled down into having a successful relationship with your manager through an effective communication strategy to keep your manager informed.

Why is this important? If a team member is ineffective in informing the team leader as to what is happening within the team, the team leader is forced to step in to find out and take control. In other words, if you are poor at managing up, your manager has to manage down. Those of us who already work in management understand this concept intuitively. This interdependent relationship is also known as the “managing up continuum”. Ineffective managing up may lead to micromanagement because of a lack of trust on your competence and ability, due to poor communication.

Therefore, the first step in effective managing up is to “understand your boss”. Knowing the personality, temperament, character, values and leadership style of the person you report to will inform the way you communicate back to that person. Understanding these elements will dictate the medium of communication, the level of detail required and the frequency.

In relation to the content of the message, there are three key principles. Firstly, use data when available, so that decisions that need to be made are evidence-based. Secondly, don’t present just the problems, but offer a choice of solutions with a recommended outcome. Lastly, and most importantly, there should be no surprises: share the bad news, not just the good news, and notify your boss as soon as possible if there has been an error or mistake. The problem will usually not be the fact that the error has occurred, but the delay in ensuring that key people are informed in a timely manner.

At all times, underpromise and overdeliver. As a critically independent and engaged follower, add value by arguing the principle, but never the person. In addition, once a decision has been reached, be an effective first follower by supporting it publicly.

Overall, the key principle of “leading up” as John Baldoni outlines in his book, Lead your boss: the subtle art of managing up, is to make certain that what you want to do complements the mission and strategies of the organisation, so that you can leverage your credibility as someone who can get things done. What you propose to do should be for the benefit of the organisation and patients, and not simply for yourself. In this way, you are not just a passive, disengaged team member, but an effective follower.

As Barbara Kellerman, professor of Public Leadership at Harvard University, states: “Followers are more important to leaders than leaders are to followers. The truth is that being an effective follower can be just as hard, if not harder, than being an effective leader, because of the perceived lack of authority and positional power. Warren Bennis, a pioneer in leadership studies, puts it eloquently this way: “I am reminded how hollow the label of leadership sometimes is and how heroic followership can be”.

I urge all my fellow doctors to be heroic, not just in their leadership, but in their followership, because you are just as important as an effective follower as you are as a leader.

Professor Erwin Loh is chief medical officer at Monash Health, and clinical professor at Monash University.

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