Beyond hospital hierarchies: why each doctor 'must be a leader'

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.

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.