A Systematic Review of Physician Leadership and Emotional Intelligence

Abstract

Objective

This review evaluates the current understanding of emotional intelligence (EI) and physician leadership, exploring key themes and areas for future research.

Literature Search

We searched the literature using PubMed, Google Scholar, and Business Source Complete for articles published between 1990 and 2012. Search terms included physician and leadership, emotional intelligence, organizational behavior, and organizational development. All abstracts were reviewed. Full articles were evaluated if they addressed the connection between EI and physician leadership. Articles were included if they focused on physicians or physicians-in-training and discussed interventions or recommendations.

Appraisal and Synthesis

We assessed articles for conceptual rigor, study design, and measurement quality. A thematic analysis categorized the main themes and findings of the articles.

Results

The search produced 3713 abstracts, of which 437 full articles were read and 144 were included in this review. Three themes were identified: (1) EI is broadly endorsed as a leadership development strategy across providers and settings; (2) models of EI and leadership development practices vary widely; and (3) EI is considered relevant throughout medical education and practice. Limitations of the literature were that most reports were expert opinion or observational and studies used several different tools for measuring EI.

Conclusions

EI is widely endorsed as a component of curricula for developing physician leaders. Research comparing practice models and measurement tools will critically advance understanding about how to develop and nurture EI to enhance leadership skills in physicians throughout their careers.

Introduction

Successful health systems are actively responding to consumer and regulatory pressures to decrease costs and increase quality and value. Patient-centered medical homes, accountable care organizations, and many other care innovations will have significant impacts on the future of the US health care system. These new models require a high degree of collaboration among physicians, between physicians and organizations, and between health care organizations. However, physicians have been considered “collaboratively challenged,” and relatively little attention has been given to collaboration in the traditional processes of physician education and career development.¹ Physicians also have traditionally functioned in a culture that celebrates the physician as a “lone healer” and independent decision maker, perhaps reflecting the fact that persons attracted to and selected for careers in medicine are characteristically independent, self-directed, and confident.² Additionally, health care systems are often structured like silos or fiefdoms, further undermining collaboration.^{1, 3–5}

In this context, the most successful emerging models will effectively address the shift from a culture of physicians as lone healers to a culture of collaboration and interaction.² Effective leadership in health care will be needed to execute this shift, and many observers have suggested that emotional intelligence (EI) is a critical health care leadership competency.⁶ Indeed, EI has been advocated as a key competency in all clinical settings—from the boardroom and chairperson's office⁶ to the ward and bedside.⁷ EI is “the ability to perceive and express emotion, assimilate emotion in thought, understand and reason with emotion, and regulate emotion in the self and others.”^8,9

Although several models of EI are available and there is disagreement regarding the best instruments to assess EI, a popular model of EI¹⁰ proposes a 2-by-2 table with cells describing self-awareness, self-regulation, social awareness, and relationship management. The cells are populated by 18 component competencies (eg, team orientation, empathy, and optimism) that define EI. The model^10,11 posits that EI, rather than being an inborn trait, is a set of competencies that can be explicitly developed^12,13 to enhance performance. Rather than an ill-defined concept of professionalism or leadership, the EI model is explicit, is teachable, and allows for honest examination and self-reflection to improve leadership skills. Ample evidence supports the importance of EI as a key leadership competency in business leaders,^14–16 though far less attention has been paid to EI as a leadership competency in health care.

In the context of this pressing need for broad-based effective leadership in health care and what appears to be sparse and scattered attention to EI as a health care leadership competency, a systematic review of EI and health care leadership is warranted. We undertook the current study to systematically review available literature regarding the following questions: What is known about EI and physician leadership? What models and measurements exist to develop leadership in the context of EI? Given what is known, what questions remain regarding EI and physician leadership in the context of rapidly changing health systems?

Methods

Three databases—PubMed, Google Scholar, and Business Source Complete—were searched using the terms and/or medical subject headings (MeSH) physician and leadership, emotional intelligence, organizational behavior, and organizational development. The literature between 1990 and 2012 was searched, the former being the year of Salovey and Mayer's¹⁷ seminal initial description of EI. Studies were included if they directly addressed physicians rather than other health care providers, leadership, and the concept of EI or any of its component competencies. After scanning abstracts for these criteria, complete articles that satisfied the criteria were fully reviewed by 1 of the authors (L.J.M.), and a thematic¹⁸ analysis was conducted to identify important themes in the literature and to synthesize what is known about EI and leadership in physicians. These findings were categorized and aggregated to determine the themes that are presented.

Results

Our initial search produced 66 eligible articles in PubMed, 70 in Business Source Complete, and 3577 in Google Scholar. After reviewing the search results and abstracts regarding the study findings, a total of 437 (11.7%) articles were selected by 1 of the authors (L.J.M.) for full-text review, 144 of which met the inclusion criteria (4.0%). The analysis identified 3 themes: (1) EI is broadly endorsed as a leadership development strategy for many types of health care providers and in many medical settings; (2) leadership development practices in health care and models of EI vary widely; and (3) EI is desired and relevant throughout medical education and practice.

table 1 summarizes the types of articles that describe each of the 3 themes in the literature. table 2 summarizes the studies and interventions included in the literature search.

TABLE 1.

Article Types Within Identified Themes

TABLE 2.

Results of Qualitative, Survey, and Pilot Studies Addressing Emotional Intelligence (EI) and Physician Leadership

TABLE 2.

Results of Qualitative, Survey, and Pilot Studies Addressing Emotional Intelligence (EI) and Physician Leadership Continued

TABLE 2.

Results of Qualitative, Survey, and Pilot Studies Addressing Emotional Intelligence (EI) and Physician Leadership Continued

EI Is a Key Component of Medical Leader Development

Eighty-three articles addressed the theme that EI is a key component of developing medical leaders, and most of these articles were expert recommendations endorsing EI in various health care contexts. Many authors endorsed EI as an important component of leadership development for physicians in general,^19–37 for successfully navigating the business of medicine for physician executives,^38–48 in academic settings,^49–51 for developing effective social networks in health care,⁵² as a leadership component across specialties,^53–65 and as a way of partnering with patients.^66,67 Two studies (1 a pilot⁶⁸ and the other a qualitative study⁶⁹) suggested that developing EI could transform the seemingly accidental nature of medical leadership development into an explicit developmental process.

As listed in table 2, EI has been used to analyze and develop leadership in many health care settings and for a broad spectrum of health care providers, ranging from critical care physicians⁷⁰ to community practice physicians⁷¹ and medical students.⁷² A total of 36 citations reflect the range of health care settings and providers. Surveys report that physicians' EI competencies vary within⁷³ and between specialties,⁷⁴ and that the level of EI among medical students does not predict specialty choice.⁷⁵ Finally, it appears that varying leadership styles evolve during residency training.⁷⁶

Leadership Development Practices and Models of EI Vary

Many groups have used EI in the context of leadership development programs for physicians and have offered descriptions of their models. Of the reviewed articles, 31 addressed the practice of EI, which are summarized in table 1. For example, a survey analyzed by Herkenhoff⁷⁷ advocated EI as the basis for enhancing physician communication. The Healthcare Leadership Model was proposed by Calhoun et al⁷⁸ as a way of evaluating and cultivating health care professionals' leadership skills in a wide-ranging set of domains, including EI.⁷⁸ Also, many have used the Leadership Practices Inventory by Posner and Kouzes⁷⁹ to measure clinical leadership, both as a continuing medical education activity⁸⁰ and in their institutions.^81,82

EI has been a part of leadership development programs in hospital systems throughout the United States and Canada. These institutions have described their approaches, which range from discrete interventions to targeting specific practitioners as leaders to institution-wide continuing education and development. These programs have reported success, suggesting that leadership development that includes EI improves team-based and collaborative care. Sambunjak et al⁸³ have recently reviewed the impact of leadership training programs in academic medical centers. Additional programs that have reported on their success include Boston Children's Hospital,⁸⁴ the University of Virginia,⁸⁵ the Cleveland Clinic (including a summary of outcomes after 14 years of leadership program operation),^86,87 the Mayo Clinic,⁸⁸ the University of Nebraska's Administrative Colloquium,⁸⁹ St Joseph's Hospital in Toronto,⁹⁰ and the Columbus Children's Hospital.⁹¹

A fuller description of the curriculum and format for 1 such program is available from the Cleveland Clinic's Leading in Health Care course.^58,87,92 This cohort-based course enrolls 30 to 35 nominated emerging leaders yearly and provides a participatory curriculum in 10 once-monthly sessions that address issues of institutional mission, vision, and values; finance and accounting; and organizational development (including EI with 360-degree feedback and executive coaching, team building, negotiation, conflict resolution, and situational leadership). Although recognizing potential selection bias among nominated program participants, they have consistently reported positive outcomes from their participation, including business plan development, greater leadership roles within the institution, and connection to mentorship resources. This nominated cohort's positive experiences may not fully translate to whole hospital settings, but the promising experience of this program supports giving greater attention to the potential of using EI for leadership development in medicine.

Leadership development programs have also been offered by official medical societies, such as the American College of Physician Executives and the American Orthopaedic Association. Hospitals have also reported success in cultivating emotionally intelligent leadership in different hospital improvement and quality care interventions.^{34,35,73,93–95} EI has been used as a framework for leadership development in wide-ranging specialty practices^96–98 and in primary care.^99,100 A key feature of these interventions is that they were implemented across hospital systems. Programs typically consist of several sessions in addition to supporting materials and staff time dedicated to implementing the skills physicians learn in their educational sessions. Examples of mature programs include the Mayo Clinic's report of an intervention centered on patient safety,⁸⁸ the Cleveland Clinic Foundation's focus on practice and outcome improvement,^87,101,92 and the Boston Children's Hospital's focus on interdisciplinary work and excellence in work environments.⁸⁴

A noteworthy feature of the available studies regarding assessing EI as a health care leadership competency is that, in the absence of consensus regarding a standard assessment instrument or strategy, a variety of ways of measuring and assessing EI have been used. EI has been frequently measured in self-reports, using 360-degree feedback (combining self-assessment and feedback from others), ability-based assessments, and/or informant approaches.¹⁰² An instrument used in 1 psychiatry evaluation was scale-based and empirical, but others have been highly customized to a particular practice,⁹⁷ and still others have assessed progress with interviews and qualitative assessment. Because different measurement approaches may provide different information,¹⁰³ it is difficult to compare findings across studies and interpreting the successes or failure of particular interventions is challenging.^102,103

EI is Desired and Relevant Throughout Medical Education and Practice

Medical educators have been among the many advocates for developing EI as a leadership competency for physicians.^80,104–108 This review identified 30 studies addressing EI in leadership education in medicine. Two groups^109,110 have advocated assessing applicants' EI as a criterion for admission to medical school, and Carrothers et al¹¹¹ have proposed an implementation plan for doing so. Others have questioned this practice based on the variability in measuring EI and on the lack of empiric trials consistently linking EI to outcomes in medicine.¹¹²

As noted in a review¹⁰⁹ and several individual reports,¹¹³ EI has been proposed as part of the curriculum to teach professionalism^114–116 and leadership^117–119 to trainees and senior physicians. Indeed, models of professionalism have been constructed around EI as a leadership skill.^120,121 For example, Lucey and Souba¹²² stated that a new paradigm for teaching professionalism to medical students must include “structured reflection,” which aligns well with the EI competency of self-awareness.

In the context of widespread support for EI as an important competency for aspiring and established physician leaders,^118,123,124 there are disparate views as to when EI should be taught during medical training; some advocate training through all training phases and others suggest training only for faculty. Favoring a more continuous training model, Stoller et al¹²⁵ invoked the concept of a spiral curriculum to emphasize that different EI competencies are especially needed for medical trainees at different phases of training. For example, self-awareness and self-management were deemed to be of greatest interest to interns and residents, whereas interest in altruism was deemed greatest when physicians assume roles as faculty members. Several other articles have also proposed continuous training and have described EI as being especially relevant at specific points during the career cycle,¹²⁶ particularly during residency.^100,124 On the other hand, some programs have proposed EI training only for faculty.

Regarding outcomes of EI training, 2 consensus models suggested that family medicine training benefits from a leadership approach that includes EI.^127,128 Another training program reported positive results in training residents¹²⁹ and attributed the program's success to a longitudinal and skill-based structure that supported the residents in their leadership paths to advocate for children's health. Another small study showed that the Thomas-Kilmann Conflict Mode Instrument predicted Accreditation Council for Graduate Medical Education (ACGME) evaluations of residents,¹²⁹ suggesting the relevance of EI evaluation to ACGME competencies. In contrast, other studies have not shown a benefit from incorporating EI training into graduate medical education training.¹³⁰ Webb et al reported that it was difficult to assure that residents committed time to the training, which highlights the need for trials of EI to be practical and actionable.¹³⁰ During a volunteer intervention, Talarico et al¹³¹ found that EI-focused leadership training did not positively impact resident performance. The finding of mixed outcomes in EI-focused studies is supported by a systematic review that mapped EI to ACGME competencies¹³² and by findings from Lewis et al.¹¹²

Other studies have focused on the role of EI training for medical students and in assessing medical school applicants. Some have advocated assessing the EI of medical school applicants.¹⁰⁹ One report suggested that an EI competency inventory effectively assessed these skills in medical school applicants.¹¹¹ A survey of medical students and faculty suggested that both groups want EI to be a medical school competency,¹³³ and another small trial suggested that simulations are a good way of cultivating awareness of EI and leadership.⁷² In a study that assembled a convenience sample of 64 medical students, Stratton et al¹³⁴ observed that EI decreased marginally during training, which could be mitigated by conducting workshops on EI for medical students.^72,135 On balance, the few studies on EI training for medical students suggest that EI can help build their leadership and empathy skills, which has been a concern for medical students as they enter the clinical years of medical school.^136,137

Discussion

Overall, 3 overarching themes emerged from this systematic review of the literature regarding EI and physician leadership development:

1. EI is widely recommended as a way of developing physician leadership at an executive level in institutions throughout medicine;

2. Wide-ranging strategies have been proposed to develop physician leadership and EI, including models that use both self-created and externally validated measurement methods; and

3. Medical professionals desire EI training, and different aspects of EI may be more important at different points during physicians' career trajectories. A body of available evidence supports the benefits of EI training, though the results have been mixed and vary in methodology and measurement strategies.

This review extends the available literature by systematically compiling and reviewing the available literature regarding physician leadership development and EI. For example, these themes go beyond the more focused context of mapping EI to the ACGME competencies, which has been described by Arora et al.¹³²

The current review shows that many authors from a broad range of medical specialties recommend cultivating physician leadership and including EI training as a component of such training. Although substantial evidence supports the association of EI with business outcomes outside of health care, studies examining the benefits of EI in health care are sparse. This review underscores the gap between advocacy for EI as an essential training competency in health care and the critical need for further rigorous study of the issue. In support of this gap, the bulk of available studies are opinion or perspective pieces devoid of supportive data; several physician surveys are available. Furthermore, the available studies that do measure EI use a range of instruments, thereby threatening generalizability of conclusions across studies. To date, no randomized trial has addressed whether teaching EI confers benefits for enhanced leadership or patient care outcomes. Such studies are needed. In this way, the paucity of studies examining the impact of EI in medical leadership mirrors the lack of rigorous studies of the impact of leadership development in medicine in general.⁸³

On the basis of this review of available literature, perhaps the best available evidence supporting the role of EI as an essential competency for medical trainees and for senior physicians is the experience of programs that have used EI in their leadership development programs over extended periods of time, for example, the advocacy-focused program for residents at the University of California, San Francisco, which reported career and performance benefits from their intervention¹²⁸; the Cleveland Clinic's program, which has generated innovative business plans that helped improve care delivery¹⁰¹; and the Mayo Clinic's programs, which have provided specialized support to program participants and helped them use their new skills and insights in a productive way within their institutions.⁸⁸ Although even these results are incomplete, the favorable experience of these and other programs seems to fuel growing enthusiasm for EI training in health care and justifies further study.^92,138

Experience from these programs also offers insight about critical success factors for leadership training and EI development. First, because the concepts of EI may seem initially foreign to physicians, providing clear institutional support and time for EI training is necessary. As an example of successful support, in the Cleveland Clinic's leadership development program (which has trained approximately 11% of the institution's faculty to date),⁹² attendees are nominated by current leaders to participate and are given sanctioned time for the 10-day annual course commitment. Also, leadership development must be framed for course participants so as not to engender expectations of immediate leadership positions. Without such framing, participating in a leadership development program could prove paradoxically dissatisfying to participants who might see their participation as an anointment to a leadership position. Instead, it appears that the most long-standing and successful programs emphasize that leadership skills are needed for a broad range of physicians' activities within the health care system (eg, from conducting bedside rounds and leading committees to assuming titled institutional roles).

Finally, it appears that linking the curricular programs to mentorship opportunities for emerging leaders and to experiential leadership assignments is especially important for programs to fully realize the leadership pipelines they are designed to support. Classroom learning and mastering a curriculum about leadership skills is but a single component of a full leadership development program.

Conclusions and Future Directions

In summary, the paucity of useful research regarding EI in health care clearly invites greater attention. Studies are needed to further address each of the themes that emerged in this review. In particular, greater attention is needed to establishing and standardizing the measurement of EI in health care providers. Other remaining questions include the following: What are the benefits and shortcomings of the instruments that have been used in health care studies (ie, the Emotional Competence Inventory,¹⁵⁰ Mayer-Salovery-Caruso Emotional Intelligence Test,¹³⁹ the Bar-On model of emotional-social intelligence,¹⁵¹ or specially designed 360-degree evaluations^57,97)? Which components of EI are most critical at specific times during the career trajectories of physicians? How should EI be integrated into the constantly increasing burden of skills and knowledge that competent physicians should have? Should all physicians receive leadership development training, or only those who are specifically recruited/interested? What are the long-term outcomes of EI training on patient, physician, and hospital system outcomes? The answers to these questions will help us navigate the challenging future of health care, which will mandate great leadership.