There is only one difference between a bad economist and a good one: The bad economist confines [oneself] to the visible effect; the good economist takes into account both the effect that can be seen and those effects that must be foreseen.
—Frederic Bastiat, 1873(1)
To get things done, healthcare organizations must have an array of management systems in place. This requires integrating a cadre of leaders into the organizational structure to set vision, develop strategy, and direct personnel.
Unfortunately, not all leaders are created equal, and some leadership behaviors can have a detrimental effect on the organizational members with whom they interact and supervise. In the case of toxic leadership, this impact can have significant trickle-down and carry-over effects on other units within the organization. Left unchecked, these behaviors can set a precedent for others and be further woven into the fabric of the organization. Once this occurs, it is extremely difficult to shift the organizational culture back to a healthy state.
The impetus, then, is on healthcare organizations to put processes in place for monitoring leadership behaviors and to act swiftly and precisely once toxic leadership behaviors become known.
What Is Toxic Leadership?
The concept of toxic leadership has received increasing attention in recent years, so much so that toxic leadership has been characterized as a leadership style in its own right.(2) According to Lipman-Blumen, leaders are considered toxic when they inflict serious and enduring harm on their constituents by using influence tactics that are extremely harsh and/or malicious.(3)
In contrast to other destructive leadership approaches, such as abusive leadership or bullying, toxic leadership describes the accumulation of behaviors aimed at decaying their followers’ morale, motivation, and self-esteem over time. Thus, no single behavior deems leadership as toxic; instead, it is the cumulative effect of demeaning and demotivational behavior on unit morale and climate over time that tells the tale. In this way, toxic leadership most resembles a mosaic — one has to take a step back to see the overall pattern of behaviors and their impact.
As noted by researchers,(4) healthcare is particularly prone to toxic leadership. Healthcare systems are typically embedded within a hierarchical structure, which can shield toxic leadership behaviors from being addressed when individuals are afraid of experiencing negative consequences for speaking up or reporting outside the acceptable chain of command.
Additionally, the long hours, high work volume, and criticality of patient care work contribute to a high-stress environment in which healthcare workers may simultaneously experience reduced resources for regulating their behavior and increased pressure for performing at a high level.
Given its multidimensional nature, scholars(5) have offered descriptive frameworks that break toxic leadership behaviors into eight categories. Table 1 provides an overview of each dimension and example behavioral characteristics. As shown, any of these singular behaviors on their own might be considered in poor form or reflect a leadership misstep. For those employees consistently on the receiving end of behaviors across these dimensions, however, it is clear how their organizational commitment, job satisfaction, and performance might suffer.
The Shadow Economy of Toxic Leadership
Given the multidimensional nature and cumulative effect of toxic leadership behaviors, its presence can often fly under the radar of organizations. An additional paradox of toxic leadership lies in the fact that these leaders may be highly competent and effective in other work domains and outputs, making it extremely difficult for organizations positioned to only collect high-level performance metrics (relative value units, grant funding, academic publications, etc.) to uncover. For these reasons, scholars have described toxic leadership as “similar to a poison that can spread covertly and unnoticed.”(2)
As such, toxic leadership can represent a shadow economy within healthcare organizations. These behaviors operate outside formal performance monitoring and appraisal systems and thus are not typically recorded in organizational operations. Toxic leadership encompasses key elements of a shadow economy; these behaviors are often: 1) unreported and untaxed; 2) difficult to measure; 3) span diverse activities; and 4) thrive when formal leadership opportunities are uncertain or limited.(6)
These elements of the shadow economy cultivate a workplace that can become a breeding ground for toxic behaviors. By disseminating their toxins via counterproductive policies and practices (such as internal divisiveness, inequitable distribution of resources, gaslighting subordinates), employees working for these leaders only have one of two options: 1) comply out of fear of retaliation and ultimately flee the organization or 2) eagerly enable and assist the toxic leader,(7) inevitably becoming toxic themselves out of personal ambition and/or social learning of toxic behaviors. The trickle-down effect in this latter group is most concerning as it reflects the transformation of toxic leadership into becoming the status quo within an organization.
Unfortunately, toxic leadership behaviors have numerous detrimental consequences on the followers, organizations, and those with whom the leaders and recipients of toxic leadership come into contact.(7) Specifically, research has linked toxic leadership behaviors to reduced well-being, job satisfaction, organizational trust, productivity, and organizational commitment among followers of toxic leaders.(8,9,10) Scholars have described this reactive process of detachment, reduced morale, and professional relinquishment as “toxic leadership rot.”(7)
At a higher level, systematic reviews of studies conducted within healthcare have also linked toxic leadership behaviors to workforce instability, organizational inefficiency, and decreased patient safety.(11,12) Given this array of negative outcomes and their substantial costs within an organization, it is imperative that healthcare organizations proactively put processes in place to monitor and respond to toxic leadership behaviors.
Case Study
In just two years, an academic medical division experienced extraordinary turbulence after hiring a new division leader. The leader was aggressively recruited for his reputation in a clinical research area that the institution intended to heavily invest in and become a national leader. Because of this reputation, the organization’s hiring committee “felt lucky” to recruit him and put little to no effort into implementing structured interviews, reference checks, or collecting any relevant information about leader competency.
Unfortunately, only two years into the new leader’s journey, the division experienced substantial personnel loss, with 15 of 56 faculty members leaving (26% attrition). The departures included 14 physicians and one PhD, and disproportionately involved early-career assistant professors (10 of 15), the very group positioned to become the division’s future clinical, research, and education leaders. Nine of the faculty members who left held active research funding, and the group collectively provided more than a year of specialty clinical service annually, underscoring the clinical and scholarly disruption.
Although some departures could be attributed to expected factors such as career advancement and family relocation, many reflected deterioration in the faculty’s morale and lack of faith in the new divisional leadership. Faculty consistently reported loss of control over work, diminished recognition, lack of fairness in decision-making and resource allocation, and weakened sense of belonging — all domains known to predict burnout and turnover intentions.
Rather than learning the established culture and values of the division, the incoming leader attempted to impose their own selfish agenda and pursue power at all costs, failing to build trust or psychological safety among the faculty and trainees they needed to achieve success.
The consequences were profound. Beyond the academic and clinical losses, the financial burden of replacing 15 faculty members is estimated at $4–$14 million, using turnover estimates from Hamidi, et al.(13) This figure does not account for opportunity costs, delayed research progress, erosion of mentoring capacity, or reputational damage experienced by the division. Unfortunately, institutional leadership was unaware of the issues until well after the division experienced these significant consequences.
This case underscores a fundamental principle: Leadership that ignores organizational culture and undervalues faculty contributions can rapidly destabilize even high-performing clinical teams. Effective leadership is not defined by authority, but by the ability to align mission, culture, and people. Failure to do so carries a measurable and lasting cost.
Practical Solutions for Healthcare Organizations
What, then, can healthcare organizations do to reduce the likelihood of toxic leadership behaviors like those previously described? And where in the leader selection and employment lifecycle can organizations be most successful at stamping out these toxic behaviors?
When considering the antecedents of toxic leadership, two main components that breed toxic leadership in organizations have been identified: vulnerable employees and an organizational culture that permits damaging behaviors to flourish and become pervasive.(14) With the power differentials that inherently exist within medical training and healthcare organizations, it is unreasonable to think that any talent acquisition or hiring strategy will magically select out “vulnerable” employees.
Training institutions, for example, will always have a cadre of physicians-in-training within the workplace that represent this “vulnerable” population. The hierarchical nature of medicine, which brings with it an established reporting structure for specific patient care roles, is also unlikely to disappear any time soon, given the benefits of accountability, efficiency, and decision-making.
However, organizations can put processes in place to more equitably empower all employees, provide infrastructure that supports a more positive work environment, and take action when lapses occur. Table 2 provides an array of evidence-based strategies to achieve these aims, ranging from leader selection practices to responding when toxic behaviors are discovered.
In the case of the division head previously described, the institution and its leaders felt fortunate to have hired the renowned researcher, and did not feel comfortable putting him through the “burden” of organizational onboarding to communicate zero-tolerance policies or consequences of toxic behaviors, subjection to intense hiring practices, or requiring participation in typical leadership development programs after hire.
Assuming he had already acquired adequate leadership experience and competency in his prior roles, the institution was eager to announce the successful hire, promote his name across the region, and offer a substantial hiring package.
Implementation of any of these first three strategies might have uncovered value misalignment and/or competency deficits and proactively equipped him with the knowledge and skills to effectively lead. Further, implementation of leadership audits, accountability structures, checks and balances opportunities, and relevant leadership performance metrics could have alerted the organization to the issues before any significant negative consequences could emerge, and moved them into the final strategy of responding much sooner.
Given the widespread impact their toxic behaviors were having on individuals across roles, tenure, and seniority, any proactive effort to collect data and experiences from the entire division in a structured manner (leadership or culture audit, 360 evaluation, peer review, etc.) could have been some of the more valuable strategies in this situation. For any organization bringing in new leaders, regular check-ins with subordinates and peers of those new leaders can likely be one of the most important approaches.
Stamping out toxic leadership cannot occur with one full swing, given the fact that these behaviors are often entrenched within a leader’s deeper personality and attributes, that toxic leadership can be a result of systemic issues such as organizational culture or reward systems, and that robust systems for awareness and accountability may not exist. Similarly, the enduring impact of these behaviors, which can span a range of outcomes such as faculty and staff well-being, team dynamics, and diminished reputation because of potential patient safety incidents, should not be underestimated.
As such, effective approaches will require a multifaceted strategy that encompasses a thoughtful, strategic, and long-term commitment. As shown in Table 2, the recommended strategies and initiatives span an array of responsible organizational units (e.g., communications, human resources, training and development) and vary in their level of effort. Organizations should find encouragement in their ability to make progress in this area to some degree regardless of budget, resources, or sophistication of these various units.
Conclusion
As healthcare leaders, we cannot limit ourselves to the path of the bad economist, focused only on visible effects. Instead, we must anticipate the unforeseen and protect our organizations and culture from the poisonous nature of toxic leadership. We must confront toxic leadership head-on because silence sustains harm, while decisive action builds cultures of trust, respect, and excellence. Stamping out toxic leadership isn’t optional; it’s a moral imperative to protect teams, patients, and the integrity of our profession.
References
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