Leadership

Abstract

Description

Though they become responsible for leading teams and supervising more junior learners early in their career, physicians receive little formal leadership training. The “see one, do one, teach one” approach to behavioral modeling and mentorship does not serve the modern young physician well. The complex nature of modern healthcare demands that physicians learn to work within the teams they will often come to lead. Within these teams, members often look to physicians to fill leadership roles. This review will examine effective leadership as defined by the business community, review attempts to incorporate leadership training into graduate medical education programs and discuss the benefits of leadership training in medical residency programs.

Introduction

In his book, West Point Leadership Lessons, Scott Snair states, “a true leader’s work and turmoil unfortunately are never done. Leadership must therefore be taken with doses of commitment, affection, and wit. It involves [knowing] when to push people and when to leave them to their own pace and resources, and knowing how to point them in a new, important direction.”¹ Leadership can be most easily defined as motivating a team of people to accomplish an identified goal. While it might be difficult to teach an individual to be charismatic, the skills to lead can be and are, in fact, taught.

Physicians are in an unusual situation in that they adopt a mantle of leadership early in their careers. In many programs, interns lead medical students, second-year residents lead interns and more senior residents lead teams. Traditionally, leadership roles are assumed without training or acknowledgment of the need to understand leadership principles. Medicine’s traditional approach to leadership training is a perfect example of the old paradigm “see one, do one, teach one.” We will attempt to explore leadership from the perspective of those who have mastered it and examine how other authors have explored incorporating leadership skills in residency program curricula.

Define Leadership

The job of a leader is to get results. An issue that sometimes befuddles those involved in graduate medical education and the delivery of patient care is what results should be the focus. Medical educators cope with decisions about the curriculum, patient care and the cost of care.

On any given day, a physician leading a team makes a series of decisions on several patients for each of whom a successful result will be different. The differences may vary as widely as success in accomplishing a procedure, discharging a patient or following an evidence-based best practice that results in a shorter length of stay. The successful physician leader will direct their team to achieve the most optimal result for each patient. To further complicate the issue, most physician leaders are middle managers serving in several roles and responding to a matrix of leaders who have different perspectives of successful results.

Regardless of rank, seniority or status, most physicians engage in organized medical practice, report to someone and, in return, direct a team. The visionary who determines the goals and objectives for the organization is often not part of a team charged with delivering care.

Given these facts, physician middle managers take direction from above while administering programs and managing teams to achieve assigned objectives. The organizational leader, the visionary who innovates, delegates tasks to managers. With a clear vision, the leader communicates that vision and their goals to organizational managers who use available corporate resources to establish and administer programs and influence teams to achieve the assigned goal.^2,3 It is the manager’s job to focus the system’s resources to achieve leadership’s vision. This management/leadership dyad is noted throughout the medical hierarchy as well. Chairpersons delegate to section chiefs who manage attending physicians who manage a resident team. While physicians at each level function as managers, it is important that each member of the patient care team learn and understand basic leadership principles.

Styles of Leadership

Daniel Goleman, the author of Primal Leadership and Emotional Intelligence describes six styles of leadership, which he likens to the clubs a skilled golfer uses over the course of a match. The most successful leaders learn to use four or more of these leadership approaches to achieve success.⁴ As part of his research into executive styles of leadership in business, Mr. Goldman and his team at Hay/McBer observed or studied data on the behaviors of more than 3,800 executives to understand how specific behaviors impacted the work environment. Mr. Goldman’s work was based on that of Harvard psychologist David McClelland.⁵

The six “styles of leadership” are techniques successful leaders use to manage people and achieve results. Furthermore, Mr. Goldman and others suggest the successful leader changes their approach quickly and with ease to suit the situation at hand. In the manner that Mr. Goldman uses the word “style”, one might think of the “styles of leadership” as management tools. Because the psychology and business literature refer to these management tools as styles, that convention will be maintained in this manuscript.

The Coercive Style:⁴ The leader demands immediate compliance. There is little exchange between the leader and those who follow. An example of this style would be: “Do what I tell you.” The coercive leader is driven to achieve and gain results quickly. However, coercive leadership is described as the most damaging approach to the work environment as this approach decreases communication, organizational flexibility and discourages new ideas from team members. Employees lose their sense of ownership and feel little accountability for their overall performance. This approach to leadership is useful and appropriate during times of genuine emergency, and it has been noted to help problem employees with whom other coaching methods have failed.

The Authoritative Style:⁴ The authoritative leader mobilizes the workforce toward a vision. An example of this style would be: “Come with me.” The authoritative leader is a self-confident, empathetic change leader who articulates a vision and motivates by virtue of their clear communication style. Authoritative leaders help people understand why their work matters to the organization and the organization’s mission. The authoritative leader maximizes team commitment, uses a mission driven approach, and positively affects the work environment. While the mission driven approach is useful in most business situations, it may fail when working with a team of experts, as the authoritative leader appears overbearing.

The Affiliative Style:⁴ The affiliative approach revolves around people. The leader strives to keep employees happy and create harmony among them. This approach has a positive effect on communication between members of the team and it increases flexibility since these leaders do not impose unnecessary restrictions. Affiliative leadership helps to heal rifts in a team and motivate people during stressful circumstances. If not careful, affiliative leaders can allow poor behavior and mediocre performance to go uncorrected. The affiliative approach is not helpful when people require clear directives. This approach is often used with great success along with the authoritative approach.

The Democratic Style:⁴ The democratic approach forges consensus through participation. Democratic leaders work through meetings and communications to gain consensus from stakeholders and team members affected by leadership decisions. This approach builds trust, respect and commitment while gaining buy-in from stakeholders. Flexibility and responsibility among the workforce are increased, and democratic leaders tend to maintain high morale within their teams. Operationally, this approach is time consuming. It is useful when a leader is uncertain about the best direction to take and needs ideas and guidance from employees, stakeholders or constituents. This approach is not useful during crises or when employees are ill informed or lack competence.

The Pacesetting Style:⁴ The pacesetting leader sets high standards of performance that they exemplify. This leader is obsessive about doing things better and faster and they expect the same from everyone around them. The pacesetting approach should be used sparingly as it destroys work climates since many employees feel overwhelmed by the pacesetter’s demands for excellence. Pacesetting leaders often come to expect members of the team to know what to do without direction. In this environment, flexibility and accountability evaporate, work becomes task focused and commitment dwindles.

The Coaching Style:⁴ Coaches develop their teams by identifying strengths and weaknesses as well as making a connection between team members’ personal aspirations and organizational objectives. Coaches excel at delegation by giving their teams clearly defined and challenging assignments. Of the six styles, this one is the least often used as it is time consuming. Coaches improve results, and the dialogue created improves the working environment.

A leader’s ability to fluidly switch between different approaches has been associated with increased success. Leaders who have mastered four or more approaches to leadership have been noted to achieve the highest level of success. The best working climate is produced when leaders combine the authoritative, the democratic, the affiliative and the coaching approaches to leadership.

How the Leader Motivates the Team

At its essence, leadership is the ability to understand each team member’s notion of success and appeal to internal motivation driven by notions of success through clearly communicate goals and objectives.^7,8 While crude forms of leadership may appeal primarily to monetary gain, the alleviation of fears or external pressures, these methods of leadership are frequently ineffective and create a nonproductive work environment.

Since an effective leader understands that people are complex and are influenced by different internal motivations, it is important for that leader to learn to understand and to respond to the individual characteristics of their team members. Given the need for leaders to appeal to individuals’ internal motivations, it is important that leaders develop emotional intelligence skills to encourage the best team results.

Emotional intelligence is a set of behaviors/skills that improve one’s ability to interact with others in a more collaborative fashion. The five components are self-awareness, self-regulation, motivation, empathy and social skills. The first three characteristics demand an individual learns to regulate themselves and their reactions. The last two characteristics are more outward and reflect an ability to interact with others.

Self-awareness is the ability for an individual to understand their emotions, strengths, weaknesses, biases, needs and drives. It is important that the individual understand their internal biases before interacting with others in order to avoid mistakenly transferring internal attributes to someone else. Self-aware people tend to be comfortable discussing their limitations and strengths with constructive criticism or feedback and are self-confident.

Self-regulation allows an individual to moderate responses that are emotionally charged. People in charge and in control of their feelings and impulses create an environment of trust and fairness. Those who master their emotions are better at managing changes and challenges that occur within their environment. Furthermore, a sense of self-regulation improves an individual’s integrity. Those with the ability to self-regulate emotion tend to be thoughtful, comfortable with ambiguity and change, and display a high degree of integrity.

Motivation is a desire to achieve. Highly motivated people are described as self-starters. They have a passion for the work itself, and they have an energy to get the work done. Self-starters often ask why things are done one way rather than another. They tend to be eager to explore new approaches and they push themselves with stretch goals.

Empathy is the ability to consider the feelings of others. The empathetic person can put themselves in another’s shoes. They attempt to understand someone else’s perspective and give credit to their feelings in a nonjudgmental fashion. A leader that demonstrates empathy often improves talent retention by coming to understand the importance of the team members’ motivations. When dealing with diverse populations, a high degree of cultural sensitivity improves an individual’s ability to be empathetic.

Social skills refer to the ability to manage relationships effectively. A leader with good social skills can move the group with purpose to achieve goals. Good social skills help to build rapport and find common ground. Managers with good social skills tend to be good communicators. They understand their own motivations and emotions and empathize with the feelings of other members of the team.

Leaders with a high degree of emotional intelligence tend to be resilient in the face of failure as their ability to regulate their own emotions and behavior allows them to recover and see beyond the moment. They are also excellent mentors and coaches who help improve performance and assist team members in fulfilling their ultimate career goals. In the hospital environment, improved interpersonal and communication skills have been associated with fewer patient complaints and a possible reduction in medical errors.⁹ These findings may be attributable to the fact that successful communication requires a complex process involving perceiving emotions, managing one’s own reaction and using what one hears to facilitate the interaction.

In addition to generally improving management and leadership skills, emotional and social intelligence appear to reduce stress and burnout while encouraging collaboration and productivity.⁵ Resonant leadership, a combination of social and emotional intelligence, is a framework of leadership and leadership education that relies even more heavily on interactive skills. Key research findings in the fields of medicine, psychology and philosophy have illustrated that leaders employing a resonant approach can achieve greater success. Team members become more civil and empowered. Lower mortality rates have been reported, and staff retention rates increased.¹⁰

Leadership and Graduate Medical Education

Leadership training is not a requirement of graduate medical education. It was thought that modeling the behaviors of those a level or two above an individual’s station will produce successful physician leaders. The ultimate behavioral model was the attending physician who modeled behaviors of physicians they observed over the course of their training. While this approach might have been more successful during an earlier time, the complexity of medical care in the current environment places an emphasis on teamwork and communication skills.

Effective leadership skills have been associated with improved patient outcomes, better financial outcomes, improvements in quality and patient safety, and an improvement in the well-being of trainees.^10–12 As trainees are expected to accept significant leadership responsibilities over the course of residencies or fellowships, the provision of leadership training makes sense. Furthermore, several authors have demonstrated that leadership training within residency programs positively influences the training experience.^10,12,13

Leadership training in military residency programs as well as civilian residency programs has demonstrated positive results.^10,12,13 True et al. introduced a leadership curriculum to second- and third-year internal medicine residents at the San Antonio Uniform Services Health Education Consortium. They introduced a four-week curriculum that was delivered as didactic sessions on leadership, emotional intelligence and conflict resolution as well as team building exercises to help trainees understand the importance of teamwork and how to assign roles within a team. They found that every resident who took the course agreed that the leadership principles should be taught in residency. Almost 90% of the residents said the sessions helped them to understand the importance of their personal roles as leaders. Most agreed the leadership curriculum helped change their perception of the importance of leadership and the need to commit to leadership development.

Doughty et al. report the results of an experiential leadership program for pediatric chief residents in the United States and Canada that was given as a 3- to 4-day training program designed to develop interpersonal skills important to effective leadership.¹³ Topics included personal leadership styles, leading teams, managing conflict, working with hospital administrators and other health care professionals, giving and receiving feedback and building a support system. The program was designed to build skills, encourage experimentation and to allow participants to internalize skills. The authors used a survey to understand the perceived long-term impact on physicians who participated in the program as residents between 1988 and 2003. The authors also surveyed the chairs from programs represented by participating residents to understand the chairs perceptions of the benefit of the training program.

Approximately 363 of 1124 participants completed the survey (a response rate of 37%). The mean number of years since service as chief resident was 7.6 years. Of those who responded, 96% indicated that they were satisfied or very satisfied with the program content, 94% responded that the program was very or somewhat relevant to skills required of a chief resident, 92% reported the program had a positive impact on their year as chief resident and 75% reported the program had a positive impact beyond their years as chief resident. Of 330 program directors and department chairs who sent residents to the training sessions, 121 responded to the survey. Of the respondents, 94% reported sending newly appointed chief residents to the program was very or somewhat worthwhile, and 89% reported they thought the course helped to prepare attendees for future leadership positions.

Within a large university, the members of a college of medicine and business faculty collaborated to develop a leadership training program. Moore et al. report the results of a 12-week leadership program introduced during intern orientation and presented in 12, 90-minute modules over the course of the first year of an internal medicine residency training program.¹⁴ The modules were interactive and designed to allow the participants to practice leadership skills and translate those skills to the clinical environment. Members from each faculty participated in the training. Residents’ acceptance of the program was evaluated through focus groups and surveys. Residents thought the program was an important addition to their educational program. They recommended the program for interns to help in the transition to the second year of residency, and they reported a high level of interest. Resident respondents to the survey noted communication and feedback skills taught during the program were important. A little more than a third of the residents (38%) mentioned leadership training was a factor in their choice of residency programs.

Several studies report the impact of leadership training on resident perception and resident well-being. Few studies report a financial benefit of leadership training to sponsoring health care organizations. Giving a nod to the importance of both management and leadership skills, Maddalena and Fleet describe a program developed in Newfoundland and Labrador, Canada to teach management and leadership skills to aspiring physician leaders.¹⁵ Program participants reported an increased interest in, as well as preparedness to assume, leadership responsibilities. Stakeholders associated with the institutions that sponsored program participants were also surveyed. Responding stakeholders noted positive changes in participating physicians’ overall administrative abilities. Specifically, stakeholders reported increased skills in conflict resolution, problem solving and quality care initiatives.

Developing Residents as Leaders

George, Sims, McLean and Mayer advance the need for leaders to develop a style and approach consistent with their own values and history in their article “Discovering Your Authentic Leadership.”¹⁶ After reviewing more than a thousand studies, the authors recognize that no study has produced a clear profile of the ideal leader. While leaders do in fact use the tools that have been described earlier, leadership appears to come in many different flavors. The authors cite a quote that says, “Leadership has many voices. You need to be who you are, not try to emulate someone else.”¹⁶

The authors go on to describe authentic leadership, a series of tenets important to developing and sustaining leaders. Considering topics taught in the successful graduate medical education leadership described above, the factors presented by George et al. may offer program guidance to medical educators as well.

1. A good leader is insightful and takes time to understand what motivated them to choose their career path. What event or series of events were the primary motivation? This introspection helps a leader understand internal biases and motivations.

2. A leader must be true to themselves. The leader’s practice must be consistent with their values, convictions and principles. A person’s individual leadership principles are their values translated into action. It is important to maintain balance between your values, intrinsic motivation and extrinsic motivation.

3. A good leader needs a support system. No one can do it alone, and the support team helps the leader maintain course and focus. A free exchange should exist that allows the support team to speak without retribution.

4. Balance is important to career longevity. A leader must find a way to integrate the important elements of life and be the same person in their home and professional environments. A successful professional should not require a personality change when they travel between home and work.

5. The most successful leaders understand the importance of empowering others to lead. It is important that leaders empower members of their team and prepare the organization for long term success.¹⁶

Conclusions

Effective leadership is a function of a leader’s ability to appeal to the internal motivation of team members and bring the team together to complete tasks and achieve the desired goals. While several approaches can be adopted to interacting with team members individually or collectively, the primary tools that an effective leader uses are self-awareness, self-regulation, internal motivation, empathy and social skills.

These authors submit that the benefits of leadership training in residency training programs have been well documented. The teaching and application of leadership skills in residency is beneficial to the hospital where the residents train, the patients they treat, and the residents themselves. Residents who participated in leadership training were positive about the experience. Graduate medical education programs that taught leadership skills introduced emotional intelligence, conflict resolution, feedback skills, communication skills and team building. Participants reported that the leadership education helped them understand their roles as leaders, helped with the transition from internship to supervisory roles and gave insight into health care management as well as the roles of hospital leaders.¹⁵

It is suggested that leadership education improves resident well-being and decreases resident burnout. Given the focus on the development of emotional intelligence skills and its emphasis on self-awareness, self-regulation and empathy, it is easy to understand how residents who work to develop emotional intelligence skills become more resilient and develop the ability to maintain a healthier self-image. Additionally, skills gained through exercises teaching how to develop personal support systems prove useful in the management of stress that develops during residency. Of interest, one study reported that approximately a third of the residents who participated reported that leadership training was a factor considered when they were making residency program choices.¹⁴ Leadership training might be an attractive recruiting tool.

Leadership is hard to define, but many people can recognize a good leader when they see one. Leaders are not born; one can learn to the skills and strategies that make leaders successful. As health care teams grow, physicians will continue to be expected to lead teams that achieve desired health outcomes for many organizations. Understanding leadership and human motivation will be more important to today’s medical trainees as they mature to become physician leaders. The ACGME has yet to identify goals and objectives for leadership training. The expectation that residents will assume of progressively higher levels of supervisory responsibility implies a need to address leadership training for program faculty and trainees. As discussed in this review, a number of programs have found the introduction of leadership training to be beneficial.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity.