The Elusive Leadership Competency

Leadership: The art of getting someone else to do something you want done because he wants to do it.

Dwight D. Eisenhower, The Federal Career Service: A Look Ahead¹

Peter Drucker, the business guru, had it right when he said that “leaders grow, they are not made.”² The trouble is that nobody knows exactly how to grow leaders. Physicians must be clinical leaders as they direct a team, establish clinical goals, align others through communication, and display effective personal attributes.^3–5 If health care teams are to function optimally, resident leadership skills in the clinical setting must be developed and nurtured.⁴ Existing leadership training properly attempts to enhance self-awareness, interprofessional relationships, and skills in conflict management and negotiation.^6,7 Although many key interpersonal attributes have been described for clinical practice, they are not necessarily the same as essentials for leadership.^4–6 Leadership is difficult to demand (and to train for), as it is a combination of definable skills and personal qualities. It is not clear that we can “educate for it” with certainty. Leadership skills, thus, while decidedly important, also appear to be elusive.

Residents seem to understand they must become effective leaders,^6,7; yet, unfortunately, most do not feel confident or competent in essential leadership skills.^7–9 Residents may feel relatively powerless during their training and unsure how to get results, and may not believe they have any natural followers.

In this issue of JGME, Lipstein and colleagues¹⁰ grapple with these issues by assessing resident's insights into their own leadership development. Their study focuses on emergency medicine residents who, with constant clinical demands in a crucible of frequent conflict, must ensure proper implementation of important diagnostic and treatment plans in a timely way. The emergency department setting demands that residents, nurses, attending physicians, technicians, secretaries, consultants, and others work together for the benefit of the patient. Many interventions are time critical. Somebody has to be the leader to establish priorities, give direction, support the team members, and ensure that goals are accomplished. It is appropriate, even essential, to listen to the residents' perspectives about how they develop leadership skills. The residents in the study describe situations in which leadership is needed; they observe their own efforts and assess the challenges. We can derive important insights from this analysis. It seems that self-discovery through real-world circumstances and trials, aided by reflection and discussion, may be important in the development of leadership skills.

As residents' technical skills improve, their leadership abilities are tested as they are tasked to increasingly “take charge” of patient care. The residents in the study clearly recognize they are expected to assume a leadership role: they must bring a team together to function effectively and provide high-quality care. They also seem to understand that feedback from the team helps them grow, and the study emphasizes the role and importance of nurses in helping residents transition from follower to leader. This is a useful insight. Emergency department nurses tend to give frank and immediate feedback that, intended or not, generally lets residents know when they are succeeding or failing as a leader.

In most residency programs there is much discussion about technical skills and typically, much less about the leadership tasks of communication, task prioritization, and goal setting. This may be slowly changing, as programs implement strategies to improve clinical leadership skills.^7–9 It is not clear how widespread such programs are or how long or well they are sustained. Much of this will depend on the program director.

Critical lessons are learned when a real-work situation demands leadership and the resident accepts the burden of leadership. An individual's leadership style emerges from personality and temperament, is molded perhaps by vicarious lessons of senior residents and attending physicians, yet is forged with certainty by the immediate feedback of team members. In the study by Lipstein et al,¹⁰ residents describe challenges, uncertainties, and tough situations as being important to their growth. They learn in the rough and tumble of the real world.

Residents benefit when they discover that leadership is not a dramatic concept, but a practical skill and necessary attribute. Many traditional images of leaders—visionary, charming, extroverted, or conquering—do little to advance our thinking about leadership in clinical medicine. Leadership in patient care should be achieved by physicians who possess the normal, human variety of personalities, temperaments, and attitudes. It does not depend on contrived force, salesmanship, or passionate displays, and we must not expect every doctor to attempt to emulate the heroic “ideal” leader. Rather, each resident must acquire the ability to articulate a goal and lead a team in a way that is authentic for him or her, and meaningful and motivational for the members of the team. Leadership is not about style. It is, first and foremost, about a purpose, with form following function. Effective leadership begins with ethical, patient-oriented goals. Integrity is required, as is commitment to the best interests of the patient, and minimization of self-serving ends. This is the essence of professionalism.^11–12

This journey toward clinical leadership may be elusive, yet it is clearly grounded in technical competency, professionalism, respectful communication, and effective relationships.^13–14 When the clinical leader is effective, people work well together, feel that hard work is recognized and rewarded, and begin to rely on each other. In high trust teams, morale improves, patient safety is enhanced, and satisfaction of everyone increases.^6–9

While leadership may be an elusive skill, it is an important one. All who hope to be effective leaders can draw lessons from Lipstein et al¹⁰ (1) to have open discussions with our colleagues and learners, (2) to receive and integrate feedback from our teams and colleagues; and (3) to spend time in reflection on fundamental leadership attributes. We all would do well to commit to continued growth as leaders, as a never-ending quest.