Current leadership culture is based on an outdated command-and-control model that is familiar to all and not inspiring to any. The complex health care system requires a different leadership mindset and physicians who will lead. Complexity leadership may present a palatable alternative for physicians. This model encompasses operational, entrepreneurial, and enabling leadership. Enabling leadership, the focus of this article, encourages space for adaptation between formal and informal processes to allow unique solutions to emerge. Leadership for the knowledge age emphasizes the capacity to engage, encourage creativity, value innovation, and even prompt a healthy tension that capitalizes on knowledge gaps and learning opportunities in a team. Challenging our leaders to adopt a style more appropriate for today’s workplace may result in better alignment with how physicians already function. We need physicians with an enabling leadership style to bridge the formal and informal systems of health care so that the collective intelligence of the team can affect patient outcomes in the best way possible.
KEY WORDS: complexity leadership, physician leader, adaptation, enabling leadership
Numerous forces are converging in Canadian health care to create what some might call a “perfect storm,” which can help or hinder system transformation. Health care spending within provincial budgets has reached untenable peaks, the aging population is beginning to bulge, there is continual pressure on scarce resources, and, in some areas of the country, the relationship between payer (government) and payee (physicians) has soured significantly. This storm cannot be lulled without the active participation of physicians leading the way. Not only can physicians be strongly influential in this transformation when they embrace complexity leadership, but this leadership style also aligns better with the profession than the oft-employed style that may have worked in the machine age but is no longer valuable.
Most physicians don’t enter the profession to become a leader, yet their role in the health care system positions them to act as one. Their knowledge of patient care and health care issues gives them a powerful opportunity to have influence within their practices, their organizations, and their regions; yet, only a minority willingly embrace leadership. Those who do are often highly valued. Top
There are several reasons why physicians resist leadership. A significant one may be that current leadership culture is based on an outdated model, a command-and-control style that is most familiar to all, not inspiring to many, yet dominant in many organizations. The complex system of health care requires a very different leadership mindset. Complexity leadership is better suited for today’s workplace and presents an alternative that is understandable to physicians.
Leading in a complex world
Uhl-Bien and Arena1 describe complexity leadership as encompassing three types: operational leadership, entrepreneurial leadership, and enabling leadership (Figure 1). They position operational and entrepreneurial leadership at opposite ends of the model with enabling leadership between these extremes. This model presents the formal and defined function of leading as operational in nature, relevant to structure, policies, and processes. Opposite that, entrepreneurial leadership encourages growth, exploration, and innovation within an organization.
The critical space in between is where adaptation occurs, where structure and innovation meet and where formal and informal processes combine to allow unique solutions to emerge, cultivated by an enabling leadership style. It is in this space that leadership fits with the dynamics of a complex system, the capacity of the agents in that system, and the recognition that variety in outcomes is desirable. The authors make reference to an order that is new and different from the usual hierarchical responses to managing change to allow something that didn’t exist previously to emerge from novel ideas. Top
The complexity leadership model provides a good analogy to position physician leadership in the context of the current workplace. Operational leadership represents the primarily formal nature of the business of health care, the administrative side focused on the financial viability of the organization and adherence to necessary structure to achieve that. Entrepreneurial leadership allows for physician autonomy, independent decision-making, and the ability to focus on innovative practices.
Both formal (operational) and informal (entrepreneurial) components are valued in organizations; however, the adaptive space in between is likely where the most critical patient care discussions and decisions happen. This space is where care teams collaborate, generate ideas, and use their collective knowledge to have the greatest impact on patient outcomes. A leader who can “foster generative relationships between agents” within that space may very well be the physician who consults, coordinates care, and guides clinical decision-making.2 Two conditions in health care teams already exist to encourage generative relationships: common direction (best patient outcomes) and heterogeneity of participants (different knowledge sets). Top
In health care, ambiguity prevails and the pace of change is unrelenting. Complex systems are not responsive to the linear leadership models that were effective in the industrial age. Bureaucratic-age leaders managed output; the knowledge age requires leaders who can nurture the collective capacity of others to achieve success. Leaders in the industrial era were concerned with technical proficiency of workers, increasing output, and reducing variation, whereas knowledge-era leaders must be catalysts of innovation and continual learners and they must value the adaptability and creativity of workers.3
Drucker3 defines what he refers to as “the next society” as no longer based only on workers’ manual skills to operate machines in factories or in agriculture, but an environment where knowledge is the primary value of workers. Knowledge is distributed among workers, and employees are no longer dependent on what comes from their superiors. Knowledge workers have a new autonomy, and their expertise empowers them in new ways. This new society requires a different type of leadership, one that values the social capital or collective knowledge in an organization rather than just assets and physical capital. Top
Health care is delivered by a team of professionals, with a level of autonomy according to their skill set. It is a very different environment from one in which workers perform similar tasks on a timed assembly line to ensure a consistent product. Although natural complex adaptive systems are composed of seemingly similar agents (e.g., a hive of bees, a flock of geese) all working toward a shared goal, it is the interdependencies and interactions between agents that affect the entire system and can produce unique outcomes each time.
Leadership for the knowledge age emphasizes the capacity to engage, encourage creativity, value innovation, and prompt a healthy tension that capitalizes on the knowledge gaps and learning opportunities in a team, effectively adapting in each situation. Knowledge workers are not easily replaced; their strength lies in their unique knowledge. Leadership in this age is critical to attracting, nurturing, and retaining those who add value to the collective intelligence of the health care team for the most effective patient care. Uhl-Bien and Arena1 refer to the “new reality” of complex systems and note that “it is more essential than ever for organizations to adapt — to pivot in real-time with the changing needs of the environment.” Top
Complexity in the physician’s world
The principles of complex systems are not foreign to physicians who deal with biological systems every day. Brains, bacteria, and immune systems are all complex adaptive systems that are navigated to find solutions to problems. The process is made more complex by the added dimension of compliant or non-compliant human behaviour and acceptance or resistance based on biological factors. It is recognized that physician expertise is limited in some situations when previously successful remedies have not worked. For example, when patients do not take an active role in disease prevention and when biological systems interact to produce undesirable results that defy expectations. Regardless of their significant expertise, physicians are accustomed to not getting it right every time and are familiar with the fragmentation of the broader health care system that presents less-than-ideal resolution for patients with complex issues.
Patient expectations have changed as well, also increasing complexity. Wearable devices, technology that has the capacity to merge patient records for integrated care, and patients who do their own research to add to the dialogue with their provider have an impact on the role that physicians play. Patients expect members of their health care team (doctors, nurses, dietitians, psychologists, etc.) to work together to provide care. Doctors must work as a member of an interdisciplinary team dealing with increasingly complex patients with plans of care that take social determinants into account. Top
Like all complex systems, biological systems present unpredictability and surprise. Physicians are continual learners accustomed to a variety of outcomes. In Senge’s ground-breaking work The Fifth Discipline,4 he notes that our “mental models” keep us from being able to view things differently and that our assumptions and internally held beliefs limit our capacity to learn and grow. As lifelong learners, doctors seek answers on behalf of their patients and don’t assume that each patient’s response to treatment will be the same as the last. Although they may be similarly trained in the techniques of clinical care, physicians are innovative in their application of care, as no two patients are alike.
Challenging the mental model of leadership to adopt a style more appropriate for today’s workplace can encourage increased interest in physician leadership, especially if it is better aligned with how they already function. A recent white paper by Van Aerde and Dickson5 that outlined the collective responsibility for health care transformation suggests that physicians must “challenge their personal mental models” of leadership to realize their leadership potential.
Weberg6 identifies the limitations of traditional leadership thinking, specifically addressing three: linear thinking, lack of awareness of organizational culture, and not being prepared to innovate. He purports that traditional leadership assumes that the world is predictable and that, if leaders are unable to acknowledge the impact that the formal, informal, internal, and external environments have on organizational performance and they are unwilling to adapt through innovative techniques, they are ill-suited to work in today’s complex organizations. Top
In addition to Weberg’s6 list of limitations, we add another: leaders operating within what is thought to be traditional ways can be blinded by their own thinking that they are in control and that they bear ultimate responsibility for outcomes. This attitude, naturally, can sway a leader’s thinking and perhaps assign greater importance to their role and influence. Uhl-Bien and Arena1 describe enabling leaders as those who are also capable of combining “deep conviction with humility,” as their role is partly to allow for risks to be taken within the adaptive space but also to know when to “step back so others can step forward.”
In the classic book Good to Great, a study of organizations that made that leap to great, Collins and his team7 found that the type of leader associated with great companies exhibited an interesting blend of ambition and humility called “level 5 leadership.” He hadn’t intended to look at leadership associated with these companies, as he was not interested in crediting (or blaming) any one person for company performance. However, the researchers couldn’t help but see that those leaders were able to “channel their ego needs away from themselves and into the larger goal of building a great company.” Top
Although physicians take active lead roles in patient care, they also take into account the expertise of others on the care team to achieve a comprehensive understanding of the numerous factors and barriers affecting the patient’s recovery. The space between operational policies, clinical guidelines, and their own capacity to provide innovative answers is often where solutions emerge, as dialogue among professionals leads to improved learning and best outcomes. It is within this adaptive space that complexity leadership enables the collective intelligence of many to share responsibility for positive results. Physicians already play a critical role in this space. Honing the skills that can improve interactions between knowledge workers in this context may allow physicians to view their leadership role differently and as less of the “straitjacket” that Ford8 refers to when describing the focus on the heroic leader. Top
Shifting the focus from lone hero to catalyst of change may make leadership seem less daunting and more intriguing, particularly for physicians in whom disdain for administration and bureaucracy has cultivated an atmosphere of leader aversion.
Physicians as leaders
Physicians who were part of a recent study were fervent in their assertion that physicians need to develop leadership skills, embrace leadership as an opportunity, and, according to one, “recognize that if we as physicians don’t get prepared and develop credibility for leadership roles the system won’t change without us.”9 Physicians work “at the coalface,” have the greatest understanding of what the well-being of patients looks like, and have the most critical knowledge of how to improve patient outcomes.
However, physicians are challenged in their acquisition of leadership skills: from a dearth of leadership training in medical school to an overwhelming clinical practice that leaves little time for leadership courses. Organizations often do not prioritize leadership development for physicians. Therefore, physicians are not drawn to leadership roles or may be reluctant to acknowledge the inherent responsibility that comes with the profession.
Leadership frameworks identify different skill sets as the ideal, and it can be a challenge to prioritize the most important types of leadership competencies required. Enabling leadership, that which provides adaptive space within the complexity leadership model, requires relationship management skills; communication skills that include active listening, reflecting, and providing feedback; and an ability to tolerate the flux and instability that can generate novel outcomes. Top
Like the conductor of a symphony, guiding and prompting instrumental accomplishments through tempo, timing, and volume, the physician leader provides skilled clinical guidance to an interdisciplinary team, harnessing collective knowledge to achieve a successful finale (or outcome for the patient). But just as each musician imbues his or her music with a passion and style that goes beyond just following the musical score, health care professionals adapt to the needs of each patient and each situation.
The complexity of health care requires leadership that recognizes and works with that complexity. Complexity leadership enables space for collective intelligence and acknowledges that fluctuations in outcomes are not only expected but desired. Leadership in complex systems must recognize the many moving parts yet create the conditions for adaptive solutions to be found while working within the formal structure that is the organization, regional government, and practice guidelines. Just as we can no longer exact the same performance from different people to create assembly-line results, we require intelligent, self-directed individuals capable of contributing to uniquely designed solutions for different outcomes each time. We need physicians with an enabling leadership style to bridge the formal and informal systems of health care so that the collective intelligence of the team can affect patient outcomes in the best way possible. Top
1.Uhl-Bien M, Arena M. Complexity leadership: enabling people and organizations for adaptability. Organ Dyn 2017;46(1):9-20.
2.Lane D, Maxfield R. Strategy under complexity: fostering generative relationships. Long Range Plann 1996;29(2):215-31.
3.Drucker PF. Managing in the next society. Oxford: Butterworth-Heinemann; 2003.
4.Senge PM. The fifth discipline: the art and practice of the learning organization. Santa Fe, N.M.: Random House; 1990.
5.Van Aerde J, Dickson G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system. White paper. Ottawa: Canadian Society of Physician Leaders; 2017. Available: tinyurl.com/ht2ykoq
6.Weberg D. Complexity leadership: a healthcare imperative. Nurs Forum 2012;47(4):268-77.
7.Collins J. Good to great: why some companies make the leap… and others don’t. New York: Harper Collins; 2001.
8.Ford J. Going beyond the hero in leadership development: the place of healthcare context, complexity and relationships. Int J Health Policy Manag 2015;4(4):261-3.
9.Grady C. Exploring physician leadership development in health-care organizations through the lens of complexity science. PhD thesis. Faculty of Business, Athabasca University, Alberta; 2015. Available: http://hdl.handle.net/10791/177
Colleen Grady, MBA, DBA, is associate professor and research manager with the Centre for Studies in Primary Care, Department of Family Medicine, Queen’s University. Her research is primarily in the areas of physician leadership development and complexity science.
C.R. (Bob) Hinings is a professor emeritus in the Alberta School of Business, University of Alberta. He is a fellow of both the Royal Society of Canada and the United States Academy of Management and an honorary member of the European Group for Organizational Studies. Bob received an honorary doctorate from the Université de Montréal for his contributions to the discipline of organization theory.
Correspondence to: firstname.lastname@example.org
This article has been reviewed by a panel of physician leaders.