Today: The Case for Physician Leadership

While the future of healthcare remains problematic, experts agree that physician leaders must be at the table, engaged as principal players among those who will define and shape tomorrow’s healthcare strategies.(1,2) Beyond the considerations of broad strategy and policy, a range of fundamental and immediate factors demand attention. The call for physician leadership arises within a context of competing needs—expanding healthcare demands, system-wide motives for efficiency, and questions about our capacity to respond while maintaining patient-centrality with sound clinical outcomes.

The gravity and complexity of these overlapping needs lead experts to conclude that the emphasis on clinical leadership is an essential reality rather than the latest passing fancy.(3) Increasingly, expert voices declare that “the leadership needed to transform the performance of hospitals and health care systems must come primarily from doctors and other clinicians.”(4)

The Need for Physician Leadership

The need for physician leadership has never been more critical. We begin by considering three reasons. The first, drawn from the insightful work of Harvard professor Richard Bohmer, resonates deeply with clinicians.

Bohmer argues that as healthcare reform intensifies, physician leaders help ensure that patient well-being will not become a subordinate concern in the face of politically charged issues of cost containment and revised delivery models.(5) Physician leaders appear to be our best choice for ensuring that these complicated decisions will be firmly grounded in healthcare’s central mission of patient care and outcomes.

There is no escaping bottom-line reality. Healthcare organizations face far-reaching challenges that demand “increasingly difficult tradeoffs . . . (that) balance the allocation of scarce resources to individual patient care and the care of communities and populations.”(5) Medical leaders are best suited to understand and make these tradeoffs.(5) Expanding on this theme, experts argue that physicians, with their training and practice, bring a mindset of clinical realism that is fundamental when grappling with these tough choices. In short, physician leaders possess “a deep intuitive knowledge about the core business . . . that helps with decision-making and institutional strategy.”(6)

Physicians stepping into new roles as organizational leaders are often underprepared to thrive in this new context.

The second reason physician leadership is needed is more nuanced—imbued with deep behavioral themes. Physician leaders, because of their acquired levels of expertise and credibility, are poised to be key mediators between practicing physicians and the organization’s nonclinical leadership.(7) As potential conduits of understanding, physician leaders can influence an array of interdependent constituencies who may have difficulty envisioning perspectives beyond their own. Of course, this potential is achieved only when physician leaders successfully navigate the tricky maze of interpersonal and politically charged dynamics that makes impactful leadership so challenging.

The third reason has been the subject of extensive and spirited debated. A growing array of experts, however, believes that when doctors are engaged in maintaining and enhancing organizational performance, better financial and clinical outcomes occur.(7-9)

In one of the few empirical investigations of its type, Amanda Goodall examined hospital performance outcomes according to CEO classification—either physician leaders or non-physician leaders. Data were collected from 100 U.S. hospitals (each with top-level rankings) and included 300 CEOs. Quality outcomes were assessed in three specialty areas: cancer, digestive disorders, and heart surgery. The study found a strong positive association between physician leadership and hospital quality rankings.(6)

Physicians have been reluctant or ambivalent about assuming formal leadership roles.

Notwithstanding some obvious methodological constraints inherent in such data, at least three important conclusions can be drawn. First, as noted earlier, physician leaders may experience a success differential because they have a deeper understanding of core clinical dynamics than their nonclinical counterparts do. Second, physician leaders have developed strong connections with the medical staff that should yield important advantages—an understanding ear and informed voice, competency-based trust, and clinical credibility. Third, physician credibility pays dividends in many tangential areas, including the likelihood of attracting talented medical professionals to their organizations.(7)

In the face of such powerful rationales, the call for physician leadership places us squarely on the horns of a dilemma. Although the need for physician leaders is apparent and growing, an insufficient number are poised to engage and succeed in leadership roles. Physicians stepping into new roles as organizational leaders are often underprepared to thrive in this new context. Although medical schools increasingly are adding some leadership components to their courses of study, there remains little in the physicians’ formal training that prepares them for positions of leadership.(10,11) In fact, a recent report drew the dramatic conclusion that “despite evidence supporting the link between leadership and improved clinical outcomes, a significant frontline leadership gap exists in health care.”(12)

Any discussion of the rationale for physician leadership must address an additional complication: experts predict a national shortage of an estimated 90,000 physicians by 2020 and 130,000 by 2025.(13) Jeff Cain, MD, president of the American Academy of Family Physicians, noted a confluence of factors that have dramatically affected the demand for services. Our population is growing and aging—two factors that signal increased healthcare needs. Against this demographic backdrop, add the impact of the Affordable Care Act, which could account for 30 million newly insured individuals seeking primary care.(13)

There is a further complication. The number of new physicians entering the workforce each year has not grown appreciably in the past 20 years. Compounding this, evidence indicates that practicing doctors are likely to retire earlier than previously anticipated. In fact, the Association of American Medical Colleges has estimated that nearly one-third of all physicians —approximately 250,000—will retire by 2020.(14)

In general, physicians have been reluctant or ambivalent about assuming formal leadership roles.(5) Scholars have suggested at least three reasons for this hesitancy: financial disincentives; status disincentives; and training and skill deficiencies.(4) Regarding the latter point, some observers have boldly asserted that “there is nothing in a physician’s education and training that qualifies him (or her) to be a leader.”(4)

What does all this mean for our purposes? As in any situation where demand for services significantly outstrips the supply of talent, we must be careful in the deployment of our talent resources or risk exacerbating the problem. Leadership roles reduce a physician’s time in direct clinical care. Therefore, we must identify physicians who appear to possess both clinical expertise and strong potential for leadership success. Further, we must help this cadre of promising physician leaders develop the perspectives, mindset, and skills (the bulk of which can broadly be classified as interpersonal in nature) to meet the challenges of leadership with insight, authenticity, confidence, and impact.

Arguably, the selection and development of high-potential physician leaders may be one of the most critical challenges facing our healthcare organizations. Drawing from leadership pioneer Jim Collins, part of this challenge will be making sure that we get the right people in the right spots.(15)

Accepting the mantle of leadership, one encounters a landscape that is familiar in nature but strange in complexity. The transition from clinician to clinician leader is behaviorally nuanced and interpersonally intense. And evidence suggests that many physician leaders recognize a formidable gap between the well-honed expertise they possess and the toolkit needed for leadership success.(12) Importantly, we accept that leadership is “an observable, understandable, learnable set of skills and practices”—an arena capable of enhancement and development.(16) Before progressing, however, a deeper understanding of the nature of contemporary leadership is in order.

The Nature of Leadership

In a recent review of clinical leadership, researchers suggested that the “widespread fascination with leadership may be because it is such a mysterious process.”(17) Echoing this thought, leadership pioneer Bernard Bass has noted that “there are almost as many different definitions of leadership as there are persons who have attempted to define the concept.”(18) Indeed. Rather than offer an easily forgotten, all-encompassing sweep, we have chosen to target just a few of the more powerful explanatory attempts.

In refreshingly succinct fashion, best-selling scholar Peter Senge suggested that leaders “inspire” others.(19) There is deep insight and significance to this perspective. Consider the etymology of the word inspire, suggesting that one who inspires “breathes life into” others. Daniel Goleman, Richard Boyatzis, and Annie McKee extended this framing, indicating that “Great leaders . . . ignite our passions and inspire the best in us.”(20)

Apparent in these two definitions is the realization that leadership plays an “expansive role” when it is successful. Indeed, effective leaders have the capacity to bring out the best in others. In our phrasing, impactful leaders “unleash the talent in others so their full potential can be realized.”

Have you ever been to a Bruce Springsteen concert? Whether you are a diehard fan or a take-it-or-leave-it observer, there is no escaping the power of the event. For nearly four hours, the drumbeat never stops and Springsteen never leaves the stage as the E Street Band pours every ounce of raw emotion and energy into the performance. Now here is the key. Members of the E Street Band, all distinguished musicians in their own right, will tell you the same thing. They perform at their very best when they are with Springsteen. That is the image and tone of leadership that is needed—engaging the talent around us so others can perform and contribute at the top of their game.

There is a second key theme. Leaders create and exert influence. This concept of influence is both intentional and directed. In essence, leaders create influence that “touches the feelings, emotions, thinking and actions of others so that goals and visions are realized.”(21) The idea that leadership encapsulates the capacity to create intentional influence is a multilayered process that we will refine in later chapters.

Let’s add another timely perspective. In a classic publication, Harvard professor John Kotter argued that leaders “cope with change.”(22) In this regard, he emphasized three fundamental functions of leadership: establishing direction, aligning people and motivating and inspiring. This forward-looking approach is relevant for all competitive organizations, and speaks to the turbulent reshaping that frames our contemporary health care environment.

Yet Kotter’s version of leadership is often misunderstood. A colleague once opined, with only minimal sarcasm, that “administrators manage chaos, and leaders create it.” The latter phrase is dangerously repugnant. In fact, the finesse of leadership comes in the capacity to move people, teams, and organizations to embrace change precisely without the experience of chaos.

We encourage you to consider a broad view of leadership. We are long past the days when leadership was compartmentalized, the purview of a select few perched at the top of an organization’s hierarchy. Leaders, some with formal designations and some without (informal leaders), are scattered throughout our organizations. When formal leaders misunderstand or minimize the influence that is wielded by their informal counterparts, both efficiency and effectiveness are at risk.

Many of you, drawing from the credibility of your clinical backgrounds and the strength of your personalities, wield influence that belies any formal position or title. At times, informal leadership allows one the freedom and flexibility to behave in ways that may be blocked to those holding formal positions that require stricter adherence to the “company line.”

Excerpted from Inspired Physician Leadership by Charles R. Stoner, DBA, MBA, and Jason S. Stoner, PhD.

References

1. Mountford J, Webb C. Clinical leadership: Unlocking high performance in healthcare. London: McKinsey; 2009.

2. Schwartz RW, Pogge C. Physician leadership: essential skills in a changing environment. Am J Surg. 2000;180:187-192.

3. Darzi A. A time for revolutions: the role of clinicians in health care reform. N Engl J Med. 2009;361(6), e8.

4. Mountford J, Webb C. When clinicians lead. McKinsey Quarterly. 2009;February:1.

5. Bohmer R. The instrumental value of medical leadership: engaging doctors in improving services. The King’s Fund. 2012.

6. Goodall AH. Physician leaders and hospital performance: is there an association? Soc Sci Med. 2011;73:535-539.

7. Falcone RE, Satiani, B. Physician as hospital chief executive officer. Vasc Endovascular Surg. 2008;42:88-94. Guthrie, 1999.

8. Dwyer AJ. Medical managers in contemporary healthcare organisations: a consideration of the literature. Aust Health Rev. 2010;34, 514-522.

9. Stoller JK. Developing physician leaders: a call to action. J Gen Intern Med. 2009;24:876-878.

10. Snell AJ, Briscoe D, Dickson G. From the inside out: the engagement of physicians as leaders in health care settings. Qual Health Res. 2011;21:952-967.

11. Stephenson J. Getting down to business. Management of Health Care. 2009;339:1170-1171.

12. Blumenthal DM, Bernard K, Bohnen J, Bohmer R. Addressing the leadership gap in medicine: residents’ need for systematic leadership development training. Acad Med. 2012;87:513-522.

13. Angle J. Retiring doctors mean problems for newly insured under ObamaCare. Fox News. August 26, 2013. www.foxnews.com/politics/retiring-doctors-mean-problems-for-newly-insured-under-obamacare.

14. Alberti M. Warnings of doctor shortage go unheeded. Remapping Debate. February 16, 2011. www.remappingdebate.org/sites/default/files/Warnings%20of%20doctor%20shortage%20go%20unheeded.pdf

15. Collins J. Good to Great: Why Some Companies Make the Leap . . . and Others Don’t. New York: HarperCollins; 2001.

16. Kouzes JM. Finding your voice. In: Spears LC, ed. Insights on Leadership: Service, Stewardship, Spirit, and Servant-Leadership. New York: Wiley; 1998:322-325.

17. Howieson B, Thiagarajah T. What is clinical leadership? A journal-based meta-review. International Journal of Clinical Leadership. 2011;17(1):7-18.

18. Bass BM. Concepts of leadership. In: Vecchio RP, ed. Leadership: Understanding the Dynamics of Power and Influence in Organizations. 2nd ed. Notre Dame, IN: Notre Dame Press; 2007:3-22.

19. Senge PM. The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Knopf; 2006.

20. Goleman D, Boyatzis R, McKee A. Primal Leadership: Realizing the Power of Emotional Intelligence. Cambridge, MA: Harvard Business School Press; 2002.

21. Stoner CR, Stoner JS. Building Leaders: Paving the Path for Emerging Leaders. New York: Routledge;2013:4.

22. Kotter JP. What leaders really do. Har Bus Rev. 2001;79(11):85-96.