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Although Australian hospitals follow a Victorian militaristic model of seniority hierarchy, every health care practitioner must be a decision maker when it comes to their patient’s care.
It doesn’t matter who you are in health care, you will be a leader. Apart from being the prime decision maker in your own life, you may be a decision maker in your family, medical practice, organisation, and certainly in patient management. Those you lead will need a vision and motivation. The concept of leadership in health care has been a central dilemma for centuries. On one hand, hospitals (and many medical companies) run on the Victorian militaristic model of a seniority hierarchy, where there is the expectation that there is a leader and subservient followers. On the other hand, every health care practitioner with patient responsibilities must be a decision maker as an independent thinker. To address the dilemma, our consideration of some key questions will help.
Do we need leaders?
I have taught medical leadership for many years and I can tell you that, depending on the activity, the correct answer could be either yes or no. The affirmative is more likely in a crisis and the negative is more likely during a period of stability. How does that help? In Monty Python’s Life of Brian, Reg was asked what had the Romans given us. He replied “sanitation, the medicine, education, wine, public order, irrigation, roads, a freshwater system, and public health”. Xerxes later added “peace”. Reg did not want to acknowledge the leadership shown by the Romans, which until then had been lacking (here).
If we are truthful, we will also acknowledge the need for leaders today. In health care, the three most important factors in the creation of a sustainable and world-leading system are (i) appropriate funding, (ii) policies that are fit for purpose, and (iii) good leadership.
It is the last of these that does not cost us a penny more.
Are leaders the same as managers?
One popular misconception is that your boss is automatically a leader and a manager (here). The understanding of the difference is a “light-bulb moment” for most, and particularly medical practitioners. There are many definitions of leadership, but almost none of them require an ability to read a profit and loss statement. A comparison in Table 1 is based on the opinion of John Kotter, an authority on leadership (here). Unless you are aware of the difference, you may be talking to your manager and not your leader.
| Clinical leader | Corporate manager |
| Respect earned by practice | Respect entitled by appointment |
| Primary goals are patient-focused | Primary goals are resource-focused |
| Influenced by staff and patients | Influenced by budget and managers |
| Innovate for better care | Innovate for resource control |
| Rewards intrinsic | Rewards extrinsic |
| Independent thinking | Dependent thinking (on policy and process) |
| Decisions are budget-independent | Decisions are budget-dependent |
| Visionary | Operational |
Who chooses leaders, or do they choose themselves?
The decisions made by leaders stem from an innate confidence in themselves and “being comfortable in their own skin”. From this emanates a zone of reassurance that others find appealing (here). Very often it involves rebelliousness, which often fails unless coupled with vision and strategy. The emerging leader can then look in the mirror and see someone who has values, can call out injustice and has an appealing vision. Does this description fit your manager? If not, see column 2. Leaders must both be chosen at some point by others in an open forum and they must also choose to be a leader, facing what comes, implying a degree of resilience (here).
How do you say “no” when the leader is wrong?
Having decided whether you have a leader or manager (or even a hybrid), an assessment of their performance is both mandatory and continuous. Without directing the reader, this statement may infer that it is a subordinate that needs the assessment. Not so. Like political leaders, clinical heads are also re-appraised and re-appointed, but by their superiors, not their constituents as in the political arena. Unfortunately, rebels who disagree with managers (hoping to be leaders) are often described as “not fitting the culture” and are then “managed out”. There are ways to exert influence for change. The risk associated with “drinking organisational bathwater” or the “koolaid” is reversion to the mean. Accepting second best is not what your patient or my patient would want. It should be remembered that estimates suggest 50% of companies with five-year plans either fail or have a “Niagara Falls” moment. On your next holiday, I recommend reading an excellent book about the National Health Service and being able to spot failure by Jan Filochowski (here).
Are there criteria for good leaders?
The beginning of this question really came from a discussion about nature or nurture. Most authors on the topic of leadership theory do not believe leadership per se can be taught (here). It may be true that skills, like knowledge can be taught (to some). But it can be cogently argued that behaviour is a critical blend of skill, knowledge and personality.
Stating wildly without references, the “big five” personality traits are 40–60% inherited (here). An optimist would say “leaders are born and can be made better!”. A pessimist would say “he is no leader and no amount of coaching will change that!”. However, there are qualities of good leaders. In many surveys of leaders, it is apparent that emotional intelligence is the most important trait of good leaders. Regardless of how you get it, look up the description and reflect on your capability, as well as your leader (here).
How do we choose better ones?
You may be surprised with the assertion that selection panels can at times have biases, undeclared conflicts of interest and often lack objectivity. The confidentiality that surrounds appointments has value to protect the organisation and participating individuals. Looking under the cover, it is worth a check to see how many have any qualifications in governance or have made conflict of interest declarations. Strangely, we know that many advertised position descriptions do not ask for governance experience, assessment of emotional intelligence or evidence of excellence in performance. Involvement in selection processes is important, as are requests for objective assessments of leadership ability, such as the Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B) (here).
If you are a leader (of anything), could you be doing better?
We have all been to conferences to collect continuing professional development (CPD) points and to network. But what about better performance in leadership and management? It doesn’t mean you are going to “the dark side” and neglecting your expert clinical skills. It does mean that you may have been engaging in the extra-curricular activity of self-reflection (you can read more about this here).
Just ask yourself “why do high performing athletes or sporting teams need coaches?” Answer: because they and their coaches know they can do better with almost no extra effort (here). Thankfully, medical colleges are starting to realise that clinical performance can be improved by encouraging quality audits, training supervisors in a formal sense and acknowledging leadership training. There are few better recommendations for leaders than Colin Powell’s principles (here). You could do worse than print them out and put them on your whiteboard at work.
John Wilson AM is an Adjunct Clinical Professor at Monash University in Melbourne, a consultant physician and a health policy advisor.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
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Terrific article!
Since my days as a medical student and junior doctor, I’ve seen a quiet erosion of medical leadership in large tertiary hospitals, replaced by professional bean counters with little to no clinical exposure or experience. The medical profession has let its importance influence dissipate as more and more clinical and administrative demands are being placed on us, with increasing levels of burn out. All too often, when a colleague speaks up to corporate managers, he/she/they are told to “stay in your lane” or quietly ignored. This is wrong. As John eloquently stated, “accepting second best is not what your patient or my patient would want”.
As a profession, we should be celebrating and promoting leadership within, advocating for our patients and ourselves. Hospital executive staff, not always known for their high EI, are focused on budget spreadsheets, and it is up to us to lead and to remind them of the needs of our patients. The reductions in quality supportive care, such as good allied health support or reception staff, due to “necessary budget cuts” are usually a false economy and place further stress on medical and nursing staff. Stress, anxiety, depression are on the rise in the medical profession, and COVID was the fuel onto the fire. Not only do we need to advocate for our patients, but we need to look out and improve the lot of our junior staff who often don’t have a voice and are quietly leaving the profession.
We should all improve our leadership skills and consider leadership courses as a vital component of any CPD programs, and work together to improve patient outcomes and physician health.
Thanks for this article, John
Thank you Prof Wilson
I am very aware that you did not say good leadership did not costs, rather you stated it does not cost more.
Leaders can “lead” by commanding and demanding by virtue of position and power they hold, but good leadership need to develop relationships and make sacrifices, and ask others to make sacrifices beyond the usual remit and constraints hence costing more. This is particularly relevant when more healthcare workers are in effect quiet quitting, and increasingly those who are early in their career.
In my opinion, if a organisation (regardless of for profit or public service setting) is run solely on what is done during the prescribed work hours and gazetted roles, job description, it will simply not work well. A good leadership is needed to motivate and empower the entire team (rather than workers or employees) to address things that cannot be predicted or encompassed by what is written down. This is even more relevant in any healthcare organisation where outlier events occurs daily as a norm rather than exception; most are minor issues, a few are major ones. It costs more on the part of good leaders and team members to address them; but the monetary cost to the organisation appears to be the same. Other than compensation for those sentinel events which is inbuilt as costs of running a business/service, most events are resolved, at the costs of the team members or workers; but we will soon see that is not going to be the trend with a evolving change in outlook and perspectives in the upcoming generation of healthcare workers.
We have seen many changes in leadership in healthcare organisation, more so in the last few years. Some (not all) are good leaders. There is a real attrition of leaders (whether they are good or not) but I suspect the personal costs to being good leaders is much more than those acknowledged so far
I do agree with every comment made, including those of Anonymous at 12.36pm, who I presume, is working within the public sector, and has done their best to work within the real constraints we all face in the moment. I found this article to be a terrific explication of the polarity of current medical ethical practice.
As a psychiatrist working in private practice, I get disturbing insights into the dilemmas that those in public practice very often encounter.
At my graduation ceremony in 1989, we were invited to take the Hippocratic Oath, including ‘First, do no harm’. When systemic policy and procedure shifts are made according to financial and political considerations, draped in the language of ‘doing the right thing’, many of us are rendered mute.
John Wilson has provided nourishing food for thought, and I thank him for it.
The best article – especially relevant to rural health
Dear Anonymous,
I do appreciate your reply. Truthfully though, I did not say that good leadership did not cost. My article says that good leadership does not cost more. There is a difference! Bad leadership which many of us have seen actually costs much more. However in healthcare – we care about lives and less about cost. Thank you for your thoughtful reply. John
Prof Wilson penned an interesting opinion which suggests that good leadership “does not cost us a penny more”.
His advocacy for good (or better) leadership cited “emotional intelligence ” as the most important trait. Table 1 lists clinical leaders as making “decisions are budget-independent”.
Perhaps I am an old fashioned old fart but such writings, although enthusiastic, come across as spin to many of us rather than practical advice for working in the real work bureaucracy of hospital management, particularly public facilities.
The fact is that good leadership costs: it costs the leaders time and energy, even if their institutions pay for their leadership and management training (again another real world cost in monetary term). While patient-focused solutions can be “budget-independent”, the reality is that the decision made has to be practical and doable in a limited-resource and rule-based healthcare organisation to be carried out. Being a good leader is not sustainable when the proposals being made requires much ongoing good-will and sacrifice (in monetary and personal terms) of others; afterall, good leadership is not just a matter getting people to do what they are hired and paid to do. A leader needs an inspired team to carry out the vision, not one that is bogged down by over-reach, red-tape and dead-weight.
While emotional intelligence is often found in good leaders, it is not the exclusive domain of this group of individuals. Corporate psychopath may often come across as individuals with high EI but they in fact use this to mimic and manipulate others to their own ends. Machiavellian individuals engaging with dark triad may still appear to have families and friends but this is may in fact serve as props in their position in society and organisations. The assumption that true EI should have empathy as an essential element is flawed, and hence Machiavellistic individuals can still appear to lead well, until their true intentions are revealed, often when its too late.
The supposition that performance of good leaders can be measured by the performance of others under them, would obviously does not subscribe to Ridgeway’s argument that “Not everything that matters can be measured. Not everything that we can measure matters.”
A terrific overview of leadership and it’s importance in the clinical setting, something that all of us working in health care can relate to. We’ve all seen it’s best and worst sides. Thank you for putting text and context to it all, a very enlightening summary of things I knew but couldn’t have necessarily articulated. Indeed, management is not leadership and I think clinicians are more often born to be leaders, not managers.
Thank you John for a wonderful, concise and thought-provoking peace! I wish as many people as possible will read it!
Interesting article! I would be keen to see the table expanded with a third column for “policy managers”. With each new column comes more detachment from bedside clinical realities.