The concept of leadership in healthcare has undergone significant changes in recent years. Traditionally, a healthcare leader is an individual who has authority over a specific unit, department, or function. Under this model, the leader may seek advice from and collaborate with others; ultimately, however, he or she takes sole responsibility for strategic decisions, operational plans, and total performance.
Recently, this traditional concept of management has given way to newer leadership models. Many hospitals and health systems have replaced individual leaders with collaborative leadership teams that leverage the energy and expertise of multiple experts in diverse disciplines to make decisions and drive performance.
These team-based management models can take many forms. Healthcare management dyads typically pair a business executive with a physician leader.(1) A management triad may bring together an MBA, an MD/DO, and an RN.(2) Performance improvement teams and similar groups may include several administrative, clinical, and technical experts.
For physicians, team-based management is both an opportunity and a challenge. These models give physicians many new options for taking part in organizational leadership. At the same time, team-based management often requires physicians to interact with others in new ways and to adopt new approaches to decision-making. To thrive in a team-based management structure, many physicians need to develop a new set of personal and interpersonal skills.
In this article, we discuss the personal traits and key behaviors that physician leaders must adopt to be effective in team-based management models.
The first step is to understand the forces and developments that are driving team-based management models in healthcare.
Trends Driving Team-Based Management
Team-based management is not entirely new in healthcare. In fact, the dyad leadership model was pioneered by the Mayo Clinic in 1908.(3,4) However, several more recent trends and developments have prompted healthcare organizations to adopt team-based management models. Key trends include:
The transition to value-based care. The transition from fee-for-service reimbursement to value-based payment has raised the importance of delivering comprehensive care that improves patient outcomes while controlling costs. This goal has increased the need for close cooperation between clinical and financial leaders. Research has shown that multidisciplinary teams are key to implementing value-based initiatives at the operational level.(5)
Increased merger and acquisition activity. Hospital and health system combinations have increased significantly in the past decade, and experts predict a surge in healthcare M&A activity as the COVID-19 pandemic winds down.(6) Following a merger or acquisition, the hard work of organizational integration is typically led by an array of multidisciplinary teams composed of clinical leaders, executives, and administrative managers.
The quality movement in healthcare. Since the 1999 publication of To Err is Human,(7) the healthcare industry’s focus on quality and patient safety has deepened significantly. Research has shown that multidisciplinary teams working in an iterative manner are the key to effective change and performance improvement.(8) The benefits also include improved patient outcomes.
Changing generational work styles. The movement of Millennial workers into healthcare management positions has affected decision-making structures within hospitals and health systems. A review of empirical research notes that, compared with older workers, Millennials are more comfortable working in teams; they also expect open communication across organizational levels.(9) Many healthcare organizations have realized that team-based leadership structures are the key to getting the most out of Millennial managers and staff.
Emphasis on diversity and inclusion. Healthcare is currently pushing to include multiple perspectives in leadership structures. The goals are to enable better organizational decisions and to cultivate a stronger sense of belonging among both employees and patients. Team-based leadership models are seen as the key to connecting the dots between these goals and reality. Many organizations are using team-based models to give non-traditional leaders a voice in setting strategy and making key operational decisions.
The advantages of team-based management models are well-documented. Benefits include more effective change management, greater transparency in decision-making, reduced variability in patient care, and increased physician engagement.(10) In addition, team-based leadership models lead to improved patient outcomes, which may result in better performance under value-based payment models for improved quality and reduced cost of medical care.(11)
However, team-based management models also present challenges. The main obstacle is that a successful team management relationship depends on personal dynamics. For example, as noted by participants in a Harvard Business School healthcare executive education program, dyad leadership structures must be built on a foundation of mutual respect and clear responsibilities and accountabilities, and “interpersonal chemistry” remains an important prerequisite.(12) In addition, dyad management partners must share common core values, work toward a common mission and vision, and be transparent with each other (and their organization).(4)
Another challenge is to clearly delineate roles within a team-based management structure. Within a management dyad, for example, the physician lead should be responsible for clinical quality, care standards, provider behavior, and related issues, while the management lead should be responsible for operations, revenue, financial planning, etc. Areas of shared responsibility may include strategy and overall performance.(1)
Team-based leadership can pose distinct challenges for physicians. Most physicians receive little training in leadership skills during their medical education, and opportunities for on-the-job learning are often scarce.
Medical education itself can work against a team approach since physicians are taught to be the “subject matter expert” who takes responsibility for patient health. In practice, this means physicians tend to lead conversations with solutions and end them with instructions. This may be the right approach to patient care, but it is not effective in an environment of change management requiring shared decision-making, consensus, and commitment among a team.
For physicians who must function effectively in team-based leadership structures, the only way to surmount these obstacles is to engage in “self-work” on personal attitudes and communication habits. Based on our experience in healthcare management and the existing literature on foundational leadership skills, the key is to master the spectrum of traits and behaviors that begins with humility and culminates in authenticity.
From Humility to Authenticity
Why is humility the starting point? Why not begin with the “authentic self” as the foundation of effective leadership?
In reality, the qualities of humility and authenticity develop together, and most leaders experience them as mutually reinforcing. However, while authenticity is an essential trait in a physician leader, it is a nuanced quality that can be difficult to attain. For physicians who want to develop team-based leadership skills, it is best to focus on humility, which is a quality that implies a specific set of actions and behaviors.
The case for humility. The Merriam-Webster definition of humility is “freedom from pride or arrogance: the quality or state of being humble.” More concretely, humility is the ability to acknowledge one’s imperfections. It is useful to note that the words “humility” and “human” share a common Latin root (humus, meaning nutrient-rich soil and, by extension, being close to the ground), so it is no surprise that we associate humility with being human.
In studies of healthcare leadership, exhibiting humility has been found to support greater staff engagement and job satisfaction, lower turnover, a more open working environment, better team performance, and improved organizational outcomes.(13) Humility has also been identified as not only important to effective team leadership, but also a key to effective teaching in academic medicine.(14)
The main benefit of demonstrating humility in leadership is that it instills confidence. When leaders display their humility by acknowledging their limitations, the people they work with feel free to experiment. The humble leader supports this environment by modeling the behavior of admitting mistakes and learning from them.
The case for authenticity. Authenticity is the quality of being genuine or real, no matter what the circumstances. When leaders are authentic, they are true to their personality and values regardless of the pressures of the moment.
Yet, authenticity is also a complex phenomenon that can become the root of negative behaviors. In some situations, being “the real me” can be an excuse for sticking to the comfortable and neglecting the challenge of adapting to new conditions; genuine authenticity requires individuals to learn, experiment, and adapt.(15)
The principal benefit of authenticity in leadership is that it creates better relationships within healthcare teams, including team-based leadership structures. Individuals who feel free to be authentic in their workplace are more likely to be engaged in their work, have higher job satisfaction, perform better, and experience less job stress.(16)
Like humility, authenticity breeds trust because authentic leaders are viewed as approachable individuals who are open to the ideas of others. This speaks to the role that humor can play in team leadership.(17) Finding ways to lighten the atmosphere through humor encourages authenticity and establishes flexibility. However, it is important to recognize the difference between positive, upbuilding humor and humor that alienates. Humor should always promote a sense of shared challenges, shared culture, and shared goals.
Overall, physicians who practice and display authenticity are able to establish stronger connections with peer leaders and team members. These personal connections can be a decisive factor in bringing everyone’s contribution to the table, working through conflict, and making effective decisions. They can also support higher satisfaction in leadership roles and combat burnout.
Key Moments and Milestones
The path to humility and authenticity is not straight. It can be a long process of trial and error, progress and plateaus. Physician leaders who want to guide their development as team-based leaders and gauge their progress in humility and authenticity should focus on three key milestones:
1. Vulnerability. As discussed above, the defining aspect of humility is the ability to acknowledge one’s mistakes and failings. In other words, humility emerges when a leader can admit his or her vulnerability as someone who is not all-knowing and not infallible. As leadership author Patrick Lencioni has observed, “Trust is about vulnerability. Team members who trust one another learn to be comfortable being open, even exposed, to one another around their failures, weaknesses, even fears.”(18) Because vulnerability fosters trust — the foundation of any healthy team — it is a key milestone in the development of team-based leadership skills.
To illustrate this milestone, here is an incident that one of us (DL) experienced in a prior role:
As the president of a multispecialty medical group, I was called upon one weekend to make a decision regarding a patient request. A decision was needed quickly, and I was persuaded to dismiss the judgment of a physician colleague in favor of ensuring a good patient experience.
The details are sensitive, but the bottom line is that my decision ended up being wrong. Worse still, my mistake caused problems (albeit relatively minor ones) for a talented and conscientious young physician in my group. At that point, I couldn’t undo my mistake, but I could acknowledge it.
On Monday morning I met with this colleague, owned up to my error, and apologized. She accepted my apology with a gracious, “That’s all right” I replied, “Thank you for saying that, but it’s really not all right I should have taken more time with this, and I should have asked more questions.” In retrospect, my decision to take responsibility for my actions helped build trust with this colleague. When you are vulnerable, you are approachable.
For physician leaders, vulnerability is the true test of courage in decision making. As professor and author Brené Brown has argued, “Vulnerability is our most accurate way to measure courage ... We can measure how brave you are by how vulnerable you’re willing to be.”(19)
2. Emotional intelligence. The concept of emotional intelligence is well known but difficult to define. It includes skills such as the ability to perceive and understand emotions within oneself and others as well as the capability of regulating one’s own emotions.(20)
Emotional intelligence is a milestone in humility because it helps leaders put the needs of others before their own. Emotional intelligence is also a key dimension of authenticity because it allows leaders to act out of knowledge of their own needs. This not only allows them to self-regulate their emotions and manage their own frustrations, but also to build stronger leadership team relationships that are based on their authentic values, strengths, and weaknesses. Emotional intelligence is also an essential capability for resolving conflict within leadership teams.
To illustrate this milestone, here is a case example from Christina Wells, MD, an academic family medicine physician at the University of Illinois, who has extensive experience operating within team-based leadership models:
I was attending a meeting of a leadership board that was chaired by one of my colleagues. During the meeting, another board member started taking over the responsibilities of the chair, essentially taking on a role that wasn’t his. The chair could have responded in so many different ways, but he chose to not respond in the moment. Instead, he kept his composure, continued the meeting and dealt with the business at hand.
The lesson is that it is not always important to assert that you are the leader. What is important is that you sense how your response may impact the team, how it may impact individual team members, and how you may be able to handle a situation in a different way. Because of the way my colleague handled this situation, he actually gained much respect from the team. (Christina Wells, MD, video call, April 5, 2022.)
Wells also has described how emotional intelligence enables physician leaders to manage leadership team dynamics in a way that enables true diversity and inclusion:
Sometimes we feel we want everyone on the team to think like me. The problem is that this does not allow for diversity. It does not allow for creativity. Sometimes we want to silence people’s thoughts and opinions.
But what I have learned is that trying to control the atmosphere typically leads to things being out of control. Rather than avoiding certain topics because they are uncomfortable, we must allow teams to engage. This leads to people being more open and feeling that they can express their ideas. Often people just want to be heard. If you truly engage them, even if their idea is not implemented, at least they can say they were heard. (Christina Wells, MD, video call, April 5, 2022.)
3. Self-awareness. Awareness of one’s own strengths and weaknesses is a key dimension of both humility and authenticity, and it overlaps significantly with emotional intelligence. It is an important milestone for physician leaders because it sets the stage for two important behaviors — leading from one’s strengths and asking for help in one’s areas of weakness.
To illustrate this milestone, we describe a situation that one of us (LZ) experienced while working in a coaching capacity:
An ED medical director was receiving a lot of complaints from nurses about one of the emergency medicine physicians. Staff saw this physician as rude and unruly. However, as I got to know this individual, I was perplexed, yet curious because he seemed like an easygoing person — in fact, the opposite of a disruptive physician.
I asked him, “Knowing what you are like, I am curious about how you show up at work. What do think?” In response, he told me about growing up as the son of an Army sergeant with an authoritarian style. He later attended an Ivy League medical school, a highly competitive environment dominated by big egos, where he was driven to outperform others and always be confident in what he said. When he later started practice in the ED, he brought along the belief that he needed to be in charge at all times.
But he also shared that he was not comfortable with his professional persona. I asked him, “How do your friends see you?” He answered, “Funny, kind, warm.” I said, “That’s how I see you, too. So why do you need to be someone else at work?”
After that, not much more coaching was needed. Self-awareness gave him permission to “be himself” at work and feel comfortable acting from his personal values and his true strengths.
People in leadership positions often wear different masks; however, it is wise for physician leaders at times to question the masks they wear and the reasons behind them. Self-awareness can help leaders understand which masks serve only to project an image of power and provide ego protection.
Taking off these masks lets leadership colleagues see the “real you.” For many healthcare leaders, this a major shift from when they first entered the workforce, when humility may have been seen as a weakness rather than a strength and the unofficial motto was “never let them see you sweat.”
Development Path for Team-Based Leaders
Learning team-based leadership abilities is essential for physician executives. Unfortunately, there is no instruction manual for developing humility, authenticity, emotional intelligence, and other positive traits. Physician leaders can elevate their skills through self-study (books, podcasts, behavioral profile tests, etc.) or through outside assistance by working with a coach, mentor, or trusted colleague. One effective approach is to focus on emulating a set of three concrete behaviors:
Model accountability. Whenever you make a mistake or fail in some way that affects others, own up to the misstep and take responsibility for the consequences. This practice will often feel uncomfortable, but it will rapidly cultivate humility in you and promote culture change in your leadership group.
If you are not making any mistakes, it may mean you are not experimenting enough. Alternatively, it may mean you have not yet developed self-awareness sufficient to perceive your own shortcomings.
To remedy this situation, invite feedback from others and respond honestly to any negative feedback. This can be as simple as asking your trusted leadership colleagues, “How are you experiencing me?” Again, this could lead to some challenging conversations, but the result will be a transparency that leads to greater trust.
Act from principle. Every healthcare organization today has a vision and a mission; however, simply knowing the mission does not turn physicians into good team-based leaders. You also must identify your own authentic values and skills and understand how they contribute to the overall organization.
Most physician leaders will identify their highest values as quality care and patient safety. Other leaders also prioritize the wellbeing and professional satisfaction of provider staff. In whatever way you formulate your authentic values, it is important to let them guide your interactions with leader colleagues and shape your approach to shared decision-making. Shared principles provide common ground and a rallying point for participants in team-based leadership models.
Elevate others. Humility and authenticity enable you to help leader colleagues and other team members develop their abilities and improve their performance. The key is to understand and value the contributions that others make to team goals.
When confronted with a differing perspective, replace judgment with a sense of curiosity. Avoid “why” questions that put the other person on the spot. Instead, use more open-ended “what” or “how” questions. Or simply say, “I would like to understand your perspective” or “Tell me more about....”
When conflict arises within a leadership team of which you are part, attempting to understand the other’s position will usually uncover common ground that can become the basis of a fruitful decision. Ultimately, the goal of elevating others is to create a situation in which “one plus one equals three” — a synergistic effect where the abilities and output of the team exceed the contributions of individual members.
Conclusion
The growth of team-based leadership models in healthcare presents a unique opportunity for physicians. To thrive as leaders within these models, physicians must develop personal skills that earn trust, facilitate communication, make room for innovation, build interpersonal loyalty, and support strong decision making.
Effective leadership teams start with team members who have cultivated the traits of humility and authenticity. Physician leaders who have developed these traits display a self-knowledge that allows them to act from principle, a positive sense of vulnerability that earns confidence, and emotional intelligence that enables them to resolve conflict and elevate others. By focusing on these traits and behaviors, physicians can pursue an ongoing process of practice, reflection, and refinement that leads to strong team-based leadership skills.
References
Zismer DK, Brueggemann J. Examining The “Dyad” as a Management Model in Integrated Health Systems. Physician Exec. 2010;36(1):14–19.
From Dyad to Triad: Healthcare Management Integration. MEDI Leadership blog. February 28, 2022. Accessed August 9, 2022.https://medi-leadership.org/from-dyad-to-triad-healthcare-management-integration-2 .
Berry LL, Seltman KD. Management Lessons From Mayo Clinic: Inside One of the World’s Most Admired Service Organizations. New York, NY: McGraw-Hill Education; 2017.
Cortese DA, Smoldt RK. 5 Success Factors for Physician-Administrator Partnerships. MGMA. Accessed August 9, 2022. www.mgma.com/resources/business-strategy/5-success-factors-for-physician-administrator-part .
Teisberg E, Wallace S, O’Hara S. Defining and Implementing Value-Based Health Care: A Strategic Framework. Acad Med. 2020;95(5):682-685. doi:10.1097/ACM.0000000000003122
Daly R. More Hospital Consolidation Is Expected Post-Pandemic. hfma. Accessed May 20, 2022. www.hfma.org/topics/news/2020/08/more-hospital-consolidation-is-expected-post-pandemic.html .
Institute of Medicine (US) Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS, eds.). Washington, DC: National Academies Press; 2000. Accessed May 20, 2022. http://www.ncbi.nlm.nih.gov/books/NBK225182/ .
Braithwaite J. Changing How We Think About Healthcare Improvement. BMJ. 2018;361:k2014. doi:10.1136/bmj.k2014
Myers KK, Sadaghiani K. Millennials in the Workplace: A Communication Perspective on Millennials’ Organizational Relationships and Performance. J Bus Psychol. 2010;25(2):225–238. doi:10.1007/s10869-010-9172-7
Buell JM. The Dyad Leadership Model: Four Case Studies. Healthc Exec. 2017;32(5):32–40.
Sfantou DF, Laliotis A, Patelarou AE, Sifaki- Pistolla D, Matalliotakis M, Patelarou E. Importance of Leadership Style Towards Quality of Care Measures in Healthcare Settings: A Systematic Review. Healthcare (Basel). 2017;5(4):73. doi:10.3390/healthcare5040073
Dyad Leadership. Managing Health Care Delivery. Accessed May 20, 2022. https://digital.hbs.edu/platform-mhcdsolutions/submission/dyad-leadership .
Echevarria I. Treating Leadership Injuries with RICE. Nursing Management. 2017;48(6):11–14.doi: 10.1097/01.NUMA.0000516496.78994.fe
Sakran JV, Alshareef MA, Rustin RB. Leading with Humility: Developing a Culture of Success! International Journal of Academic Medicine. 2016;2(1):78–82. doi: 10.4103/2455-5568.183329
Ibarra H. The Authenticity Paradox. Harvard Business Review. January 2015. Accessed May 20, 2022.https://hbr.org/2015/01/the-authenticity-paradox .
Buote V. Most Employees Feel Authentic at Work, But It Can Take a While. Harvard Business Review. May 2016. Accessed May 20, 2022. https://hbr.org/2016/05/most-employees-feel-authentic-at-work-but-it-can-take-a-while .
Aaker J, Bagdonas N. Humor, Seriously: Why Humor Is a Secret Weapon in Business and Life. New York, NY: Currency; 2021.
Lencioni P. The Five Dysfunctions of a Team. San Francisco, CA: Jossey-Bass; 2002.
Jensen E. 5 Takeaways on Vulnerability from Brené Brown’s “The Call to Courage.” USA TODAY. April 19, 2019. Accessed May 26, 2022. www.usatoday.com/story/life/tv/2019/04/19/brene-brown-call-courage-netflix-vulnerability/3497969002 .
Mayer JD, Salovey P, Caruso DR. Target Articles: “Emotional Intelligence: Theory, Findings, and Implications.” Psychological Inquiry. 2004;15(3):197-215. doi:10.1207/s15327965pli1503_02