Abstract
Objectives
There are ongoing challenges in workforce sustainability and service delivery due to the COVID-19 pandemic. Recruiting credible clinical leaders can enhance outcomes through mentoring, leading by example, and creating positive work environments. We investigate the anthropology of, and related research on leadership.
Conclusions
Clinical and anthropological research provides strong grounds for investing in clinical leadership. The stability of ‘prestige-based’ leadership can be contrasted with the outcomes of ‘dominance-based’ leadership that relies on force, control, and threats. Dominance-based leadership increases the risks of bullying in stressed healthcare organisations. In contrast, expert clinical leaders can exert culturally mediated effects on social learning, team cooperation and morale, and patient outcomes.
Keywords: physician leadership, anthropology, workforce
Healthcare systems are under immense strain due to the COVID-19 pandemic. Renewed leadership and enhanced staff morale are essential for maintaining healthcare quality. Advances in anthropology 1 may provide a new perspective on the leadership crisis faced by healthcare systems in high-income countries. 2 Leaders credible based on their expert medical skills may play a role in reviving ailing healthcare systems.
What is known about expert leadership in healthcare
Expert medical leadership can enhance individual healthcare worker, organisational and patient care outcomes. Physician-led large hospital systems receive higher quality ratings and better bed usage rates than those led by non-physicians, with no differences in financial performance.3,4 A systematic review on hospital leadership effectiveness found physicians had a positive impact on financial and operational resource management, quality of care and community benefits. 5 However, further research is needed as to whether other clinicians can provide similarly effective leadership.
Expert leaders signal credibility through their proven track record in the core activity of healthcare 6 and thus have both power and influence among core workers. 5 A study of 3000 hospital physicians in Australia, Denmark and Switzerland reported that doctors, when led by physicians, were less likely to resign and more satisfied with their work based on their supervisor’s effectiveness. 7 The sustainability and morale of healthcare organisations could be enhanced by physician leadership, such as in psychiatric services. 8
Physicians do not inherently have all the necessary leadership skills, so specific skills training may be needed. An important factor in motivating physicians to work in leadership and management positions is the opportunity for positive outcomes that outweigh concerns about administrative burdens, resource shortfalls, fears of burnout, and lack of organisational readiness for change. 9 Outcomes-based approaches to leadership development for physicians are therefore the most effective, demonstrating improvements in individual, organisational, and patient measures. 10 Measures should include individual self-awareness, self-efficacy, leadership knowledge, skills and behaviours, as well as organisational impact and patient outcomes. 10 Effective teaching includes interactive workshops, video simulations, peer and expert feedback, multisource feedback, coaching, action learning, and mentoring. 10 An example of a physician leadership training course that could strengthen skills is https://www.bayes.city.ac.uk/study/executive-education/degree-apprenticeships/executive-msc-in-medical-leadership
What recent anthropology research adds to healthcare leadership studies
Prestige-based status is a basis for social learning and cultural transmission within human societies. 1 The expertise of such leaders, based on competence in culturally valued domains, is signified by the displays of respect by others, as well as a desire to learn from them. 1
Analogously, a credible and prestigious physician leader is rated highly on clinical and academic acumen, regarded as a generous leader willing to share their skills and knowledge, and is held in high esteem by their clinical peers. 11
Cultural transmission occurs through the direct social learning strategy of infocopying, comprising forms of direct social learning from another person. 1 These include imitation (acquiring motor patterns via observation), emulation of goals (inference on behavioural goals via observation) and influence, where the model expresses a view that sways the other person toward it. 1 The costs of individual experimentation to develop skills are often high, so people are motivated to seek potential models from which to infocopy. 1 Humans seek first to learn from others, thus avoiding the cost of redundant innovation, and then temper their skills through individual practice. 1 Such models are sought based on certain cues: the competence of the model in the culturally valued domains (using observable simple outcome measures, e.g. number of research publications); the deference that is shown to the model by others, manifest as status and prestige (e.g. the professional respect accorded by peers); and the model’s observable health and fitness. 1
There is the potential for health system infocopying from physicians with recognised clinical and academic expertise. Such prestige-based expert medical leadership should be embedded at all healthcare levels to facilitate social learning, including ethical and professional standards, as well as expert medical and academic skills. Prestige-based leadership may provide the foundations for team-based cooperation – through the generation of correlated behavioural phenotypes between leaders and followers, as well as among peers. 12
Prestige-based leadership contrasts with leadership based on dominance-based hierarchies using force-threat, evident in primates and other animals, and which exist in parallel with prestige in humans.1,13 Dominance is a human cultural mechanism to attain and maintain high social status through coercion. 13
Dominance hierarchies can manifest in the strict line management of healthcare systems characterised by agonistic interactions, in which some individuals are able to coercively exploit control over costs and benefits to extract deference from others through the form of aggression, intimidation, and threats. 13 Prevalent bullying and harassment in healthcare settings 14 may arise from dominance hierarchies, leading to the opportunity for coercion by doctors of doctors. Formalisation of organisational roles in vast healthcare administration bureaucracies under the control of policy-makers and politicians facilitates the entrenchment of such hierarchies, allowing unscrupulous bosses to bully and control their junior and senior clinicians. 15 Systemic changes, such as requiring hospital boards – including physician leaders – to have as a key performance indicator the psychosocial health and wellbeing of their staff are also needed. 16
Expertise-based prestige and dominance are both means to maintain high social status. 17 However, anti-dominance coalitions can take action to suppress the power of coercive bullies. 18 These instincts can spur doctors to advocate against bullying by line managers, including doctors. Expertise-based prestigious leaders may form more effective advocacy coalitions, especially in partnership with medico-political groups and unions.
The lack of demonstrated effectiveness of interventions to address workplace bullying and harassment in general, 19 and specifically in healthcare, 20 may arise from the lack of accessibility to cultural influences to improve the ethos of health systems. 21 There is the potential to harness prestige-based physician leaders to ethically model and manage to counteract dominance force-threat-based bullying and harassment behaviours, and for example, prosocial prestige-based leadership can foster a cooperative ethos. 12
Future directions?
Anthropologic research on sociocultural learning via prestige based on expertise 1 concords with organisational research that doctors can be credible and effective leaders, through their specific knowledge and skills in healthcare provision. 4 Expert-prestige-based leadership may leaven the effect of dominance-based line management that gives rise to bullying and harassment in healthcare workplaces, 15 and where intervention is needed urgently. 22 The leadership of physicians who are recognised by their peers for both their clinical and academic acumen may exert substantial cultural effects on learning, cooperation and morale in healthcare services during the COVID-19 pandemic and beyond.
Future research should focus on the development of and training in medical expertise; evaluation of education for physicians to be more effective in leading 2 ; and organisational structures and practices that may facilitate social learning from a range of expert health professional role models within healthcare organisations.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics and consent: No ethics approval or consent was required as this paper does not involve research with humans or animals.
ORCID iDs
Jeffrey C L Looi https://orcid.org/0000-0003-3351-6911
Stephen Allison https://orcid.org/0000-0002-9264-5310
Stephen R Kisely https://orcid.org/0000-0003-4021-2924
Tarun Bastiampillai https://orcid.org/0000-0002-6931-2913
References
- 1.Henrich J, Gil-White FJ. The evolution of prestige: Freely conferred deference as a mechanism for enhancing the benefits of cultural transmission. Evol Hum Behav 2001; 22: 165–196. [DOI] [PubMed] [Google Scholar]
- 2.Goodall A, Stoller JK. The future of clinical leadership: evidence for physician leadership and the educational pathway for new leaders. BMJ Lead 2017; 1: 8–11. DOI: 10.1136/leader-2017-000010 [DOI] [Google Scholar]
- 3.Tasi MC, Keswani A, Bozic KJ. Does physician leadership affect hospital quality, operational efficiency, and financial performance? Health Care Manage Rev 2019; 44: 256–262. DOI: 10.1097/HMR.0000000000000173 [DOI] [PubMed] [Google Scholar]
- 4.Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011; 73: 535–539. DOI: 10.1016/j.socscimed.2011.06.025 [DOI] [PubMed] [Google Scholar]
- 5.Sarto F, Veronesi G. Clinical leadership and hospital performance: assessing the evidence base. BMC Health Serv Res 2016; 16(Suppl 2): 169. DOI: 10.1186/s12913-016-1395-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Goodall AH. A theory of expert leadership (TEL) in psychiatry. Australas Psychiatry 2016; 24: 231–234. DOI: 10.1177/1039856215609760 [DOI] [PubMed] [Google Scholar]
- 7.Bäker A, Goodall AH. Do expert clinicians make the best managers? Evidence from hospitals in Denmark, Australia and Switzerland. BMJ Lead 2021; 5: 161–166. DOI: 10.1136/leader-2021-000483 [DOI] [Google Scholar]
- 8.Allison S, Goodall A, Bastiampillai T. Expert leadership - why psychiatrists should lead mental health services. Australas Psychiatry 2016; 24: 225–227. DOI: 10.1177/1039856216644403 [DOI] [PubMed] [Google Scholar]
- 9.Bäker A, Bech M, Geerts J, et al. Motivating doctors into leadership and management: a cross-sectional survey. BMJ Lead 2020; 4: 196–200. DOI: 10.1136/leader-2019-000181 [DOI] [Google Scholar]
- 10.Geerts JM, Goodall AH, Agius S. Evidence-based leadership development for physicians: A systematic literature review. Soc Sci Med 2020; 246: 112709. DOI: 10.1016/j.socscimed.2019.112709 [DOI] [PubMed] [Google Scholar]
- 11.Henrich J. The secret of our success: how culture is driving human evolution, domesticating our species, and making us smarter. Princeton, NJ, USA: Princeton University Press, 2015. [Google Scholar]
- 12.Henrich J, Chudek M, Boyd R. The Big Man Mechanism: how prestige fosters cooperation and creates prosocial leaders. Philos Trans R Soc Lond B Biol Sci 2015; 370: 20150013. DOI: 10.1098/rstb.2015.0013 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chen Zeng T, Cheng JT, Henrich J. Dominance in humans. Philos Trans R Soc Lond B Biol Sci 2022; 377: 20200451. DOI: 10.1098/rstb.2020.0451 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Kline R, Lewis D. The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England. Public Money and Management 2018; 39: 166–174. DOI: 10.1080/09540962.2018.1535044 [DOI] [Google Scholar]
- 15.Allison S, Bastiampillai T. Bullying and depression at work: prevention starts at the very top. Lancet Psychiatry 2017; 4: 96. DOI: 10.1016/s2215-0366(16)30448-5 [DOI] [PubMed] [Google Scholar]
- 16.Moy C. Bullying in the workplace. Canberra, ACT, Australia: AMA, 2021, https://ama.com.au/articles/ama-vice-president-dr-chris-moy-bullying-workplace (accessed 14 May 2021). [Google Scholar]
- 17.McClanahan KJ, Maner JK, Cheng JT. Two Ways to Stay at the Top: Prestige and Dominance Are Both Viable Strategies for Gaining and Maintaining Social Rank Over Time. Pers Soc Psychol Bull 2022: 48, 1516, 1528. DOI: 10.1177/01461672211042319 [DOI] [PubMed] [Google Scholar]
- 18.Cheng JT. Dominance, prestige, and the role of leveling in human social hierarchy and equality. Curr Opin Psychol 2020; 33: 238–244. DOI: 10.1016/j.copsyc.2019.10.004 [DOI] [PubMed] [Google Scholar]
- 19.Zapf D, Vartia M. Prevention and treatment of workplace bullying. In: Einarsen SV, Hoel H, Zapf D. (eds). Bullying and Harassment in the Workplace: Theory, Research and Practice. 3rd ed. Boca Raton, FL, USA: CRC Press, 2020, pp. 458. [Google Scholar]
- 20.Westbrook J, Sunderland N, Atkinson V, et al. Endemic unprofessional behaviour in health care: the mandate for a change in approach. Med J Aust 2018; 209: 380–381. DOI: 10.5694/mja17.01261 [DOI] [PubMed] [Google Scholar]
- 21.Churruca K, Pavithra A, McMullan R, et al. Creating a culture of safety and respect through professional accountability: case study of the Ethos program across eight Australian hospitals. Aust Health Rev 2022; 46: 319–324. DOI: 10.1071/AH21308. [DOI] [PubMed] [Google Scholar]
- 22.Wise J. NHS faces leadership shake-up after review finds evidence of discrimination and bullying. BMJ 2022; 377: o1419. DOI: 10.1136/bmj.o1419 [DOI] [PubMed] [Google Scholar]