How conversations become culture: physicians leading in complex times

Darren Larsen, MD


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It is not becoming easier to either practise or manage our careers in the current health care system. How can physicians best show leadership in times of great uncertainty? How can they generate a new conversation that keeps them positive, hopeful, and energized in front of their patients, peers, and in their own thoughts? What follows are nine proposals to ensure that physicians remain the best leaders possible and to help move the profession along in a proactive and constructive way.


Key words: physician influence, conversations, communication, complexity, advice


Physicians are part of an influential community, one that initiates, influences, and perpetuates important conversations. These conversations are noticed. They are witnessed publicly when doctors are in positions of leadership, and they occur privately with peers, at meetings, during teaching, and when physicians speak, write, and blog. Top


Doctors can maintain an extraordinarily calm external face. This is the one they put on in front of their patients and practices. With patients, in many cases physicians’ professionalism ensures that the conversation never strays to the negative and stays focused on the needs of the patient and the clinical population. Doctors place their patients’ needs before their own, as they always have. Top


With their peers, however, conversations are somewhat more private, and pessimistic thoughts flow more freely. Here is where stories are told about the challenge of practising medicine in a new era. Physicians express their worries and doubts. In difficult times, the profession’s perspective and level of positivity change. A new critical tone enters private conversations with peers. It is also expressed more commonly in the very public diaries that are accessible on social media and in the blog space. These sour conversations can pose a real threat to physician leadership. Top


What are physicians saying to each other? They speak of being burdened by the increasing demands placed on them in looking after patients as well as being accountable to the health care system. There is dismay at the loss of professional autonomy. Physicians are increasingly being made to feel that they are no longer valued in the system in which they work. They question the value of quality improvement and population health, things for which they are seen to be responsible but over which they have little control. Top


In the press, more and more statistics are presented regarding the “burned out” physician. Research has claimed that, at any given time, up to 50% of resident doctors show one or more symptoms of burnout.1 Other less formal surveys, such as the one publicized recently by a grassroots collective called Concerned Ontario Doctors, state that 78% of Ontario physicians are currently burned out.2 These rates may point to a lack of resilience, which can affect leadership. Different conversations can form part of that resilience. Top


It is not becoming easier to either practise or manage our careers in the current health care system. Physicians — as scientists — are happiest with a certain degree of predictability in their world. They become confident in their clinical skills and the experiences that allow them to make educated informed decisions in guiding patients in battling illness or toward improving health. They understand that the practice of medicine is complicated. What they are perhaps less prepared for, however, is its complexity. The world in which they live and work is becoming increasingly complex. Top


Complicated and complex


The difference between complicated and complex systems was fully explored in Zimmerman and colleagues’ book Edgeware.3 A complicated system is one where the success of an outcome is highly predicted by the outcomes of events that came before it. A perfect example would be launching a rocket into space. Successful launches occur only when modeled over and over again, with each iteration informing the next. Many technical aspects of physicians’ work are complicated. Surgeons, for instance, perform procedures again and again to become adept at the technical aspects and speed required to treat a trauma patient or suture a wound. All specialization depends on complicated issues being mastered through residency and years of work that follow. Top


A complex system is the opposite. The success of one outcome cannot be predicted by the success of any trials that preceded it. An example of complexity is raising a child. The issues surrounding a second child are in no way predicted by the path taken by the sibling that came before.


Not only are our health care systems complex, but they are also adaptive.4 Complex adaptive systems are not like throwing a baseball, where practising again and again to know exactly how much power, spin, and curve are needed to strike out a batter would predictively yield success. They are more like throwing a bird. Once the bird has left your hand, you have no control whatsoever over where it flies.


Our health care systems are increasingly becoming more complex and adaptive. Physicians plan programs for which budgets may be approved months later. Hospitals amalgamate and completely reorganize medical staff structures. Patients consult search engines before they trust their doctor. Sometimes the generalist fares better in this environment, as he or she sees much more in clinical work that is undefined or unpredictable, but even these physicians are challenged in current times. Top


Advice for leaders


How can physicians best show leadership in times of great uncertainty? How can they generate a new conversation that keeps them positive, hopeful, and energized in front of their patients, peers, and in their own thoughts? What follows are nine proposals to ensure that physicians remain the best leaders possible and to help move the profession along in a proactive and constructive way. Top


Show up

When physicians feel as if they are over a barrel for any reason, we hear calls from them to withdraw or reduce services, stop attending meetings, and quit providing system advice. However, when under duress, it may behoove the profession to double down in its activities. A truly adaptive response to leading in this space would be, not just to send one physician representative to meetings that require a voice, but rather two or three! The time to be most present is the time when one’s presence is most threatened. Top


Withdrawal accomplishes nothing other than allowing others’ voices to be heard in one’s place. Change is happening whether individuals like it or not. One can only hope to influence the outcome if one is present and commenting. Absence from discussion and dialogue diminishes physicians’ voices to the point of irrelevance. Clinical service withdrawal is rarely contemplated, thankfully, and in most jurisdictions is highly discouraged by provincial colleges.5


Remain optimistic

In Better under pressure: how great leaders bring out the best in themselves and others, Justin Menkes states: “One of the qualities that sets great leaders apart is their belief that their own actions make a difference — that they can influence outcomes.”6 Top


It is possible to be critical and still maintain an air of optimism. Constructive and reasoned criticism is warranted and, indeed, needed when contemplating large-scale transformation. Careful consideration of possible outcomes with an educated eye and from the front line is always important. But optimism, or hope for the future of these changes, is ultimately required to ensure that others listen to what doctors have to say. Pessimists are frequently ignored and their opinions cast aside as others assume “that doctor never has anything good to say.” Optimists are listened to far more often, and, even when others disagree with them, they do so after listening, hearing, and examining the idea. They are more educated as a result. Top


Never lose civility

In social media, especially, where people feel protected by avatars and a sense of anonymity, they say things about each other that would never be uttered to another person’s face. Private Facebook posts are easily seen by a much larger audience than intended and never go away. Cutting words disparaging a colleague, a bureaucrat, or a local politician will be permanent in this electronic age. They are searchable, saveable, archivable, and can be widely disseminated. Being trusted and heard involves doing a large amount of listening, and this includes listening to oneself. Again, civility is well coded in policies in our self-regulated profession.7 Top


Tell stories

Ensure that great ideas are celebrated and repeated as much as, if not more than, negative ones. Physicians’ minds are a constant stream of consciousness, and stories told quickly become the reality one believes in and conveys to others. Even in difficult times, there are multiple reasons to be happy and trumpet successes that should be expounded upon. This provides necessary resilience to negativity that comes from outside. Top



Leaders must constantly be on the lookout for things that are new, for concepts that have never before been tried, and for creative “outside the box” thinking. True leaders explore these and encourage them in others. They find excitement in building and creating. This excitement is infectious and has the advantage of strongly influencing the work of others. Emmanuel Agbor writes about the power of creativity and innovation in leadership, stating, “for an organization to become innovative and successful, it must benefit from the creativity of all its members. Organizations can achieve this by harnessing all its leadership abilities.”8 Top



Then celebrate the failure by creating a space where the same failure cannot be repeated and others can learn from it. A start-up mentality is required here. Companies that innovate and create expect up to 92% of their big ideas to fall flat.9 But when they fail, they constantly examine and pivot their thinking to move past failures quickly — to find the hot idea that takes off.


Ask “why?” and ask it a lot

Physician leaders are often looked to for answers, and, more often than not, they pride themselves on being able to provide them. But frequently, they do better in difficult situations by asking questions rather than providing answers. This approach, which was explored by Simon Sinek in Start with why: how great leaders inspire everyone to take action,10 is often the hallmark of an effective leader. He or she will not be quick to supply all the answers, which usually ends exploration of a topic, but rather allows it to go deeper by asking more questions for others to think about or respond to.


Build a support system

Leading is tough work, and leadership is often a very lonely experience. According to acclaimed physician health expert, Dr. Mamta Gautam, having a circle of other physicians, not necessarily those who think exactly like oneself, but rather people one trusts, is paramount in ensuring that a physician can maintain the freshness needed to continue to lead well.11 Connections occur in a myriad of ways: random telephone calls, email, quick lunches, or even emoticon-filled text messages! Reaching out to other leaders and sharing ideas is incredibly helpful in ensuring that you remain able to act in this capacity. And if a friend is under attack, this is even more important. Support in this way can be very private, or very public. Top


Learn to be a good follower

Many physicians are used to and encouraged to be constantly at the front of the room or at a podium. Equally important, though, is the creation of a space where others can lead well. This means sitting back and often saying nothing, allowing people to shine in their own spotlight and then encouraging them by reinforcing the greatness you have just witnessed. According to Harvard’s Barbara Kellerman, follower traits for great leadership include awareness, diplomacy, collaboration, courage, and critical thinking.12 Staying involved and following another’s lead as a difficult project moves to completion can be a complete pleasure. Top


Leading in complexity


Effective leadership in an environment of complexity, in a system that is rapidly changing around us, requires tremendous adaptability and resilience.  Really great leaders influence more than they dictate. They remain open to new ideas and resist the status quo. They lead sometimes by doing, but often just by questioning and listening, then allowing others to move ahead. They remain eternally optimistic even in the face of great pessimism. They support their peers and, thereby, support the health system. And they rarely back away from adversity. Top


Most important, though, leaders in complex adaptive systems have given up their need to completely control every environment they work in. For them, leading is much more about the journey than the destination. They tell stories. Their stories are personal and actually change the greater conversation going on around them. Over time, these changed conversations become the culture in which all physicians work, practise, teach, and manage. Even when physicians are feeling the weight of the world on their shoulders professionally, this physician culture can remain imminently positive. It will prepare doctors for strong positions of leadership and ensure that the system represents not just their own best interests, but also those of their patients and the larger health system they work for. Everyone is listening! Top



1. Fralick M, Flegel K. Physician burnout: who will protect us from ourselves (editorial). Can Med Assoc J 2014;2 June. Available:

2. Levy SA. “Alarming” number of docs feeling burnout: Concerned Ontario Doctors. Toronto Sun 2016;29 May. Available:

3. Zimmerman B, Lindberg C, Plsek P. Edgeware: insights from complexity science for health care leaders. Irving, Tex.: VHA Inc; 1998.

4. Begun JW, Zimmerman B, Dooley KJ. Health care organizations as complex adaptive systems. In Mick SS, Wyttenback ME (editors). Advances in health care organization theory. San Francisco: Jossey-Bass; 2003. pp. 253-88.

5. Providing physician services during job actions (policy statement 1-14). Toronto: College of Physicians and Surgeons of Ontario; 2014. Available:

6. Menkes J. Better under pressure: how great leaders bring out the best in themselves and others. Boston: Harvard Business Press; 2011.

7. Physician behaviour in the professional environment — discussion. Toronto: College of Physicians and Surgeons of Ontario; 2014. Available:

8. Agbor E. Creativity and innovation: the leadership dynamics. J Strategic Leadership 2008;1(1):39-45. Available:

9. Marmer M, Herrmann BL, Dogrultan E, Berman R. Startup genome report extra on premature scaling. San Francisco: Compass; 2011. Available:

10. Sinek S. Start with why: how great leaders inspire everyone to take action. Toronto: Penguin; 2009.

11. Gautam M. Irondoc: practical stress management tools for physicians. Ottawa: Book Coach Press; 2004.

12. Kellerman B. Followership: how followers are creating change and changing leaders. Boston: Harvard Business School Press; 2008.



Darren Larsen, MD, CCFP, MPLc, is a family physician with more than 25 years of primary care experience, practising now at Women’s College Hospital, Toronto. He holds a master’s certificate in physician leadership from the Schulich School of Executive Management (York University) and is currently chief medical information officer at OntarioMD.


Correspondence to:


This article has been reviewed by a panel of physician leaders.



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