Australian physician leaders share their insights into why they believe physicians make good leaders, the skills they need, and how to make the transition from clinician to leader.
KEY WORDS: physicians as leaders, clinical background, collaborative skills, transition to leadership
Recently, I had the unique opportunity to interview a number of exemplary medical leaders in Australia. The occasion was provided by the Royal Australasian College of Medical Administrators (RACMA) in anticipation of their 50th anniversary in 2017. Although the interviews had the clear purpose of celebrating and showcasing exemplary leadership, they also provided deep insights into a number of issues that are high profile in the medical leadership field internationally.
Of particular interest are why physicians should be in leadership roles; the collaborative leadership skills physicians need to take on leadership roles; and the challenges of transitioning from clinical expert to medical leader. Through a combination of stories and reflections, physicians provided some fascinating insights on these three topics. Top
Why physicians should lead
Only a few substantive studies show that, when physicians lead health care organizations, results improve.1-3 Although common sense suggests that a physician — with an appreciation of the challenges of medical practice along with excellent leadership skills — would outperform a non-physician with equivalent leadership skills, little evidence backs up that statement. However, let’s explore the “common sense” argument a little further as it relates to what some RACMA leaders had to say on this issue.
It is common sense to recognize that maintaining strong relations with practising physicians in one’s organization will facilitate their engagement in health improvement efforts. Dr. Andrew Johnson, executive director Medical Services at Townsville Hospital in Queensland, said this about how physicians, in leadership roles, retain credibility with their physician colleagues:
[T]he way to maintain credibility is to remember that you’re a doctor, and treat your medical management leadership practice as a doctor. You talk to doctors about doctor stuff, you constantly link what you do back to the patient and patient care, and you demonstrate to your colleagues that you’re interested in what they do. I encourage them to bring the latest and greatest of their thoughts in their field, I remain deeply interested in the clinical practice side of what they do, and I’m very, very careful to not have my own clinical opinion anymore. Top
As Dr. Johnson goes on, it is clear that he has thought deeply about this issue and has combined common sense with experiential wisdom:
So one of the ways that you lose credibility enormously is if you pretend that your clinical knowledge is up to the same level as the people you’re attempting to lead and manage. If you recognise that... whether or not you were a great clinician... you are moving into a different skillset.... I work on the basis that I’m no longer entitled to my own [clinical view]. I use my clinical background as a way to detect anomalies, and because I remain interested in the clinical practice side, I’m very able still to pick up when people are being disingenuous, or I can apply relative weight to their various views and opinions.
Credibility builds trust; trust builds relationships. And the relationship is not between physician colleagues; it is between a physician leader and his or her clinical colleagues. They do come at the world differently, as Dr. Johnson suggests; but the ability to respect the other’s point of view, to acknowledge its importance, and to hear the motive behind its articulation is key to effective decision-making. Credibility and trust grow the “zone of acceptance” of decision-making. As the zone grows, there is greater likelihood that when decisions are made, they will be implemented. That’s the whole point of having a medical director, isn’t it? Top
Dr. Taffy Jones, a retired medical leader, gave a second perspective on the importance of physicians being in leadership roles. He emphasized the quality of patient care perspective:
If you’re going to have any hope of preventing or helping to prevent adverse clinical events, then you need to have your antennae up to pick up any potential problems early in their development rather than wait until the final disaster happens. And the most effective way of doing that is through clinical audit. I used to go to all these medical and surgical clinical audit meetings.... It did alert you early in the piece to problems that were likely to arise unless you’d been forewarned that someone was not managing cases well.... I think this is where my continued clinical work was very helpful.
In today’s modern health care environment, quality and patient safety are the purview of effective clinical governance. Without the ability to know and identify issues relative to enhancing quality improvement and patient safety, a leader is handicapped in fulfilling his or her leadership role. Having a clinical background clearly contributes — from a common sense perspective — to the ability to do that.
The need for collaborative leadership skills
In the literature, discussion about the skills physicians need to be active leaders of health system change revolves around the broad notion of collaborative or shared leadership.4-6, The emphasis is on the ability of doctors to build relationships through which energy and knowledge can flow across boundaries that otherwise create barriers to a patient’s journey. Top
As Dr. Sara Watson, program leader, Women’s Health Strategy Unit, Department of Health, Northern Territory, stated, “Relationships are key.” But collaborative leadership is more than just relationship building: it is also the ability to act as an independent agent to fulfill one’s role and responsibility as a medical leader. Relationships facilitate the second ability; but collaborative leaders must also have the ability to reflect, to know their values and how they must shape decisions, and also have the strength of character to act when necessary. Balancing the need for interdependence (relationships) with the need to be true to the unique challenges of one’s role (independence) is the true challenge of collaborative leadership.
Dr. Watson provided insights into the skills needed to balance independence and interdependence in two contexts. The first was when, as a medical leader, she had to deal with colleagues who had been referred to an Australian Health Practitioner Regulation Agency (AHPRA) review (the sort of review that, in Canada, would be undertaken by the provincial College of Physicians and Surgeons). Stating that such cases “are immensely complex and are embedded within issues of conflict and relationship issues,” Dr. Watson indicated that, as a result of the lengthy processes involved in resolution of these cases, “the clinicians who had raised the concerns, when that case went to AHPRA, their concerns changed from the act of the clinician to the act of the management.” Consequently, it “does make you reflect very, very deeply on the issues of accountability, performance, training, and early intervention.” Her advice is that early intervention is absolutely necessary “when there are clearly signs of difficulty in... [clinical] relationships.” Top
This story clearly demonstrates how the skill of deep reflection in her role as an “independent” medical leader has prepared her for similar responsibilities in the future. She also suggests that early intervention — for example, in the form of constructive but difficult conversations to address issues of poor performance or disruptive behaviour — might facilitate a better result in similar instances.
A second area for collaborative leadership by medical leaders is in policy. In this context, “setting the vision of where a service or where our particular policy or strategy should go” is a key skill. In particular, Dr. Watson says, medical leaders have the ability to establish visions based on evidence. “Whether it be in acute [care]... or in a community-based setting” physicians have the ability to establish evidence-based policy. She believes “that is very much the role in the future,” and clearly a role she feels physician leaders are well-positioned to take on — and in need of mastering. Top
Dr. Michael Cleary, executive director, Medical Services, Princess Alexandra Hospital, also pointed out the importance of collaborative leadership in terms of a policy role. In a recent phase of his career as medical leader, Dr. Cleary took on the position of deputy director general for policy, strategy, and resourcing in Queensland Health and was responsible for the implementation of national health reform, “the biggest change in health in Queensland in 50 years.” He described the fundamental importance of collaboration as:
[S]kills in terms of being able to link in with clinicians and other groups, community and others... the behaviours that you’d like to see in the way you interact with people.... If you’ve got to bring organisations along with you, be they big or small... [the] ability to have good relationships with people so... the values that you have line up with the values that they or their organisations aspire to; things like trust, respect, professionalism, performance accountability, capability development, team building... working in a collaborative manner.
Both Dr. Cleary and Dr. Watson highlight three fundamental skills needed to enable the physician leader to be a collaborative leader, able to facilitate policymaking and implementation. The first is the skill of visioning: being driven by the desired future state of a policy change. The second is the “natural” ability to bring evidence to the table. Physicians do that in their clinical work; they have a predisposition to do so in policy work, once they understand the nature of the evidence needed and its relevance to policy issues. The third is the ability to find an intersection of values: of self, colleagues, and the organization as a foundation for positive relationships and for good policy that will be accepted and implemented. Underlying the ability to do all three is the skill of reflection; the ability to look inward, know what one believes in and stands for, and to be able to bring those skills to the table in both relationship-building and policymaking. Top
Transition challenges: from clinician to medical leader
Moving from clinician to medical leader is not necessarily an easy transition.7 As Dr. Donna O’Sullivan, executive director, Medical Services, The Prince Charles Hospital and Metro North Hospital and Health Services, said in her interview, “not everyone can just be thrown in the deep end and swim; some people sink.... That’s really, really distressing and disturbing.” Top
So what advice do the interviewees give aspiring leaders in terms of facilitating the transition? Dr. Michael Walsh, chief executive officer, Cabrini Health, would say that his most important lesson was to learn to delegate responsibility rather than try to do everything himself. His story:
I became the director of Acute Health Services [in Victoria].... I remember... after three months’ probation, going to speak to the then-secretary of the department.... The thrust of the discussion was... [a] sort of performance agreement, if you like. Top
He said, “Look, I think things are going very well, I’m very happy with the way you’ve settled in, but you’re working yourself into the ground. Now, in a way that’s not my problem, the job’s getting done, but you’ll burn yourself out!” He said, “and when I look at your next line down, the people who are supposed to be supporting you, none of them are working the sorts of hours that you’re working.... Some of them, I think... are not up to the mark, and... I think you need to manage them, and I think you need to get rid of the ones who aren’t carrying their weight, and get some people in who are going to add value, because you are not going to be able to do it all yourself... you’re not really concentrating on the more important strategic and policy things that really we want you to do.”
As I reflected on that comment, it was probably the first time I recognised that I was in a place where I needed to move from doing it myself, if you like, to doing it through others. I think from that time I’ve been passionate about delegation. Top
Dr. Lee Gruner, director, Quality Directions, stated that doctors need to cultivate the passion they have for quality improvement, as well as the patience needed to persevere over time. She said, “It’s really hard to be a leader in anything unless you have a passion for it... be a leader in that.”
Developing patience for the long term is also important. She added, “When we’re trying to implement change, it takes months, years to do these things... [that’s what] we have to teach people. In fact, when I was running a workshop on management one time, a doctor actually stood up and he said to me, ‘You’re really saying that some of these changes might take years and that’s okay?’ I said, ‘Yes. That’s okay if it’s the right thing to do and you need to work it through.’ That is a new concept to doctors who are used to getting results very quickly.” Top
These interview snippets—organized, as they are, around the three themes why physicians should lead, the collaborative leadership skills physicians need to take on leadership responsibilities, and transitioning from clinician to medical leader — are a small sample of the wealth of responses on the same themes. They provide a fascinating look into the career paths of some of Australia’s medical leaders, and, through the rich stories and interview responses, the over-30 transcripts provide an insight into the scope and breadth of the challenges of medical leadership and how to prepare for those challenges. Top
1.Goodall A, Bastiampillai T, Nance M, Roeger L, Allison S. Expert leadership: doctors versus managers for the executive leadership of Australian mental health. Aust N Z J Psychiatry 2015;49(5):409-11.
2.Sanford KD. The five questions of physician leadership. Front Health Serv Manage 2016;32(3):39-45.
3.Berdon B. Physician leadership in a changing healthcare environment. Front Health Serv Manage 2016;32(3):27-33.
4.Lindgren A, Bååthe F, Dellve L. Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development. Int J Health Plann Manage 2013;28:e138-57.
5.VanVactor JD. Collaborative leadership model in the management of health care. J Bus Res 2012;65:555-61.
6.Van Aerde J. Relationship-centred care: toward real health system reform (opinion). Can J Physician Leadersh 2015;1(3):3-6.
7.Comber S, Wilson L, Crawford KC. Developing Canadian physicians: the quest for leadership effectiveness. Leadersh Health Serv 2016;29(3):282-99. doi: 10.1108/LHS-10-2015-0032
8.Lee T. Turning doctors into leaders. Harv Bus Rev 2010;88(4):50-9.
9.Chan MK, de Camps Meschino D, Dath D, Busari J, Bohnen JD, Samson LM, et al. Collaborating internationally on physician leadership development: why now? Leadersh Health Serv 2016;29(3):231-9. doi: 10.1108/LHS-10-2015-0050.
Graham Dickson, PhD, is senior research advisor to the Canadian Society of Physician Leaders.
Correspondence to: firstname.lastname@example.org
This article has been reviewed by a panel of physician leaders.