The ‘deployment’ of medical leadership

If there’s a latent theme hiding in this month’s Life & Times, it has something to do with qualities of good leadership.

The theme for the print and online issue is ‘disadvantaged and vulnerable people’. David Misselbrook, in a previous introduction to Life & Times, coined the term ‘The inverse power law’, a notion that the more disempowered someone is by circumstance, the less likely it is that they will shape policy aimed at them (or indeed any aspect of their care).

So how can leadership, autonomy, or even ‘power’ (if you will) be better deployed and distributed?

LEADERS SHOULD NOT BE SHACKLED TO A PROCESS

Saul Miller laments change without progress. Effective leadership requires engagement with difficult and complex details, and not just vision without careful implementation.

Leadership encompasses appropriate reflective learning. Adam Smith famously demonstrated how a factory line approach could be applied to the production of pins to generate epic gains in efficiency, and healthcare leaders might be tempted to apply industry business models to health care. Imagine the patient as a car on the assembly line and the clinicians as robots!

In this issue we have a powerful argument by Lara Shemtob and colleagues that general practice cannot be piecework, because patients are not cars (or even pins). This approach is not only distressing for the service user, but also for service providers as well. People are not things.

Ahmed Rashid notes the lack of openness around industrial technology in relation to machine learning, as well as the benefits of parallel professions learning alongside one another and of medical students having a long attachment to general practice. Communication and community trump industrialisation as a goal of effective leadership in health care.

LEADERS SHOULD LISTEN

Ben Hoban discusses how doctors should listen to what then patient is saying, to acknowledge the patient, not just as a puzzle or an obstacle, but as someone with a reasonable claim on our attention. Some of that listening and respect should manifest as memory of that person and their needs, essential for that element of relationship that GPs claim as a unique selling point of their profession. Emilie Couchman highlights a striking failure of memory in our increasingly fragmented primary care. She describes how patients with mesothelioma can relive the trauma of diagnosis every time they meet a new clinician, notwithstanding that the diagnosis may be well documented. Informational continuity, however, requires that clinicians read the notes and that policymakers allow them the time to do this.

LEADERS SHOULD LEARN

Koot Kotze reviews Moral Leadership in Medicine: Building Ethical Healthcare Organizations, by Suzanne Shale. This text provides a vital account of how the needs of patients and the aspirations of professionals are translated into actions beyond the bedside and should form part of any debate on the future of health care.

Shale talks of five simultaneous proprieties (the opposite of improprieties). Fiduciary propriety promotes the interests of the end user or client. Bureaucratic propriety recognises the needs of the organisation in the service of patients and staff. Collegial propriety taps into cooperation and goodwill rather than outmoded forms of rigid hierarchy. Inquisitorial propriety objectively addresses misconduct and mistakes with candour, fairness, and appropriate regret. Restorative justice is about restoring moral relations after a harm has occurred. Elke Hausmann reviews Our Malady: Lessons in Liberty and Solidarity, in which historian Timothy Snyder reflects on his own critical illness and hospitalisation. Snyder connects the idea of health care as a societal right to the way in which the commercialisation and industrialisation of health care remove personal and political liberty. In stating, ‘We cannot be free without health, and we cannot be healthy without knowledge’, he calls for nations to apply effective leadership through democracy.

WHO CAN BE A LEADER? WE ALL CAN

In this issue we are pleased to publish a ‘lay’ review by Diane Peacock, of topical corticosteroids, the mainstay treatment for atopic eczema in the UK,

It is evident from literature searches, and from communicating with dermatologists, that patient or parental underuse, non-compliance, and steroid phobia have been major concerns for some time. Peacock illustrates how process and industry-driven medicine can be deaf to concerns.

A previously criticised consensus statement on the role of a doctor, supported by the General Medical Council and the Academy of Medical Royal Colleges, began, ‘Doctors alone among the healthcare profession must be capable of regularly taking ultimate responsibility for difficult decisions in situations of clinical complexity and uncertainty.’

We (the medical profession) have been historically very keen to retain a leadership role, but, as the above articles show, perhaps we are missing a trick.

Listening to and respecting our patients and our colleagues, breathing a deep sigh, and reflectively learning when our business models do not fit the context are all about well-distributed and effective leadership.