Building belief: establishing credibility as a medical leader

Lara Hazelton, MD, MEd, and Michelle MacDonald, PhD, MD

 

https://doi.org/10.37964/cr24735

 

Credibility depends upon both an individual’s personal characteristics and how they are perceived. Because a leader’s credibility profoundly affects what they are able to accomplish, establishing credibility can be an important component of leadership development. However, while some factors that affect credibility may be modified through deliberate effort, others cannot. In this article, we explore steps leaders can take to increase their credibility and the limitations imposed by factors beyond the individual’s control.

 

KEY WORDS: credibility, leadership, medical leadership, leadership education, communications, professional identity

 

 

CITATION: Hazelton L, MacDonald M. Building belief: establishing credibility as a medical leader. Can J Physician Leadersh 2021;7(3):101–107.

https://doi.org/10.37964/cr24735

 

It may be that the credibility of leaders has never been more important than it is today. With the impact of the global pandemic continuing to reverberate, life is stressful and the future uncertain. According to attachment theory, we all have an innate desire to be protected and nurtured that begins in early life and continues into adulthood.1 When anxiety levels are high, attachment needs may lead us to seek a greater than usual amount of reassurance and guidance from leaders and authority figures we feel we can trust.2 Yet, knowing who we can believe in can be difficult, especially when news and social media are increasingly factionalized. Top

 

Credibility is defined as the power or quality of inspiring belief.3 It is foundational to building trust, and leaders who are not seen as credible will struggle to accomplish their goals.4 Many factors contribute to whether a person is seen as credible. Some pertain to the leader themself; competency, integrity, and caring are examples of qualities that form the basis of trust and credibility. However, simply possessing certain qualities will not be enough to build credibility if they are not perceived and acknowledged by others. For example, it is important that a leader not only cares about others, but clearly demonstrates and effectively communicates this to those they work with.

 

Unfortunately, others may hold biases that lead them to base their assessment of credibility on irrelevant factors. For example, there are people who, consciously or unconsciously, make judgements about a leader’s abilities, honesty, or integrity simply based on their gender or race, undermining the credibility of those who do not fit that mold. In this situation, establishing credibility may be difficult or impossible, regardless of the leader’s credentials, qualifications, and ability to communicate.

 

Conceptualizing credibility as a combination of actual and perceived characteristics and abilities suggests two key strategies for becoming more credible. The first is through attaining a higher level of leadership expertise, either through formal training or informal experience. The second is by making that expertise visible to others in ways that convince them of your competence and trustworthiness. In this paper, we discuss the tenuous relation between formal training and credibility, briefly explore how an individual’s capacity to build credibility may be limited by external factors (including the biases of others and various forms of discrimination), and suggest steps current and aspiring physician leaders can take to increase their credibility.

 

Formal training and credentials

 

It is not uncommon for physician leaders to worry about their own credibility. In clinical settings, medical expertise is a major factor in establishing credibility, but this can lead to invitations to take on formal leadership positions requiring a different set of skills.5 Characteristics that enable leaders to achieve credibility and success come naturally to some, but will need to be deliberately cultivated in others.6 Thus, academic career advancement and leadership positions represent transitions that can lead physicians to pursue further education.7 Top

 

Although clinical topics still form the basis of most continuing medical education, leadership education has become popular for physicians seeking to develop the knowledge and skills necessary to be effective leaders. Master of business administration (MBA) and other executive education programs associated with medical schools have proliferated, reflecting an increasing recognition of leadership as a key element in physician training.8 In general, it appears that leadership education programs are regarded positively by participants. A recent Canadian study that looked at the return on investment of leadership development in health care found that the most commonly reported outcomes of training included improved communication, self-awareness, “personal qualities,” confidence, and assertiveness.9 A 2012 systematic review of faculty development initiatives designed to promote leadership in medical education found high levels of satisfaction among graduates.10

 

 

 

 

 

In addition to acquiring skills and knowledge, some participants may be seeking to enhance their credibility through acquisition of credentials. According to human capital theory, several forms of capital may be acquired through formal leadership programs.11 Intellectual capital comprises the knowledge and skills that constitute the formal curriculum of most such courses, whereas social capital manifests in the relationships established through networking with other current and prospective leaders. In addition to these, participants may be motivated to take formal leadership courses to attain symbolic or cultural capital, which is the value generated by the prestige and status conferred by a formal credential. Although the possibility of increasing cultural capital is rarely made explicit in promotional materials for leadership courses, it is a potential benefit that may encourage participation. In a survey of Canadian physician leaders, standardized evaluation and accreditation, such as the Canadian Certified Physician Executive credential,12 was believed to be useful for increasing physician leaders’ credibility with peers and administrators.13,14 Top

 

Overall, leadership programs seem to be a worthwhile investment of physicians’ time. Nonetheless, there is limited evidence that having formal leadership credentials will actually make you more credible as a physician leader. In fact, placing too much reliance on one’s credentials might lead to complacency about the other important aspects of building credibility. In an article entitled “Beyond expert credentials: every aspect of credibility counts,”15 Charlotte Morris, a trial consultant who works with expert witnesses, explains how credibility does not depend solely on formal credentials. Although an individual’s competence can be determined by evaluating their training, experience, and reputation, their perceived trustworthiness, competence, and likeability — which includes warmth, empathy, humour, and listening skills — will greatly affect their credibility with the jury. The same is likely to be true of leaders whose actions may speak more loudly than their formal credentials when they interact with others.

 

Limitations on building credibility: the effects of bias and other systemic factors

 

When asked what makes a leader credible, a common response is to list characteristics of the individual, such as skills, character traits, or values. However, credibility is an essentially interpersonal phenomenon that is inextricably dependent on the judgements of others. Leader credibility can be defined as the degree to which followers perceive their leader is competent and worthy of trust.16 Because it relates to perception, leader credibility comprises a range of factors that include, but are not limited to, the personal attributes of the leader. Top

 

We often conceptualize credibility solely in individual terms rather than seeing how it is constructed within relationships. This is a result of the fundamental attribution error, the universal tendency to overestimate how much another person’s personal characteristics influence their behaviours and associated outcomes while underestimating the influence of situational factors.17 The fundamental attribution error arises in medicine when, for example, we attribute poor patient outcomes to physician characteristics without fully considering the context in which they occur.18 Similarly, if we ask why a leader has not been able to establish credibility, we may attribute it to their shortcomings without considering how they may be undermined by factors outside their control. These could include problems inherited from their predecessors, misinformation spread by others or simply bad luck. In addition, the impact of the values, expectations, and biases of colleagues cannot be overstated. For example, significant issues exist in our systems with regard to equity, diversity, and inclusion. Establishing credibility may be impossible when attitudes are negatively influenced by irrelevant factors, such as the leader’s gender or race.

 

When credibility judgements are informed by prejudices, it is necessary for organizational development to complement the work done by individuals. Although professional development may enhance credibility, it is important to recognize that biases exist regarding what kind of leader is, or is not, credible. For women, racialized groups, people with disabilities, and others who may be targets of discrimination, these biases can undermine their credibility in spite of everything they have accomplished or are capable of doing.19–21 To ask them to bear the full responsibility for building their credibility is unrealistic, and education and training that does not acknowledge this is not only likely to be less effective but is also fundamentally unfair. Top

 

In their 2016 paper “The great training robbery,” Beer and colleagues22 questioned the value of training programs in which participants learn skills that they are then unable to put into practice in their jobs because of systemic factors. They emphasize that organizational development that leads to changes in policies and incentives is essential to support the transfer of learning to the workplace. Although their criticisms are not specific to leadership education or health care, the assertion that education alone is insufficient for change to occur is equally true for medical leadership. Fortunately, many organizations and institutions are recognizing the systemic effects of bias and discrimination in medicine and are taking action. Simple steps that have been taken to address these biases include establishing diversity committees,23 education around personal and unconscious biases, and mentorship. However, recent literature argues that more can be done at a systemic level.

 

Kang and co-workers24 reviewed the management literature to identify five “myths” that perpetuate gender bias and, subsequently, five strategies for mitigating it. The authors suggest that intervening at the level of the individual has not proven effective; instead, structural solutions are needed. Interventions must target organizational and systemic change. Five solutions are proposed: treat gender equality as an innovation challenge, change institutional norms, create a culture in which people feel personally responsible for change, implement behavioural guidelines and action plans, and create organizational accountability for change. Similarly, Raj and colleagues25 suggest that achieving gender equality in academic medicine may be attained by establishing institutional support for family responsibilities, protections against harassment and discrimination, and institutional rewards for gender equality and advancement.

 

We are still in the early phases of implementing equity, diversity, and inclusion in academic medicine, and future research will determine whether these proposed interventions will be successful in changing culture.

 

Steps to building credibility

 

Although formal leadership education may be helpful to some and systems change is obviously required, these will require a significant investment of time and effort. Fortunately, there are steps that individuals can take today to increase their credibility. Top

 

Improve your communication

Not surprisingly, improving communication skills is a key component of leadership education.9,26 The importance of communication in leadership has been recognized since ancient times, with Greek philosophers such as Plato and Aristotle among those who were interested in how persuasion could be used for positive — and negative — purposes.27 There can be no leadership without communication, and even the most capable leaders will not be effective if their ideas and intentions are not conveyed effectively.

 

Although there are many aspects of communication that leaders should consider, one of the most powerful and controversial is charisma. Merriam-Webster online dictionary defines charisma as “a personal magic of leadership arousing special popular loyalty or enthusiasm.”28 People with charisma possess an interpersonal style of communication that is highly effective in attracting or influencing others through symbols, emotions, and ideology.29 Charisma is one of the key elements of transformational leadership.16 Choi30 suggests that charismatic leadership has three core components: envisioning, empathy, and empowerment. In one leadership education program that attempted to teach charisma, researchers identified charismatic leadership tactics, which included rhetorical techniques (such as use of metaphors) and communication skills (Table 1). Through videos and intensive coaching on the use of these techniques, trainees were able to significantly improve the ratings they received on their perceived competence as leaders.29

 

However, it is important to note that charisma can also have negative connotations, and leaders may be reluctant to focus on developing charisma because it is seen as manipulative or unethical. Some authors have expressed reservations about the “dark side of charisma,” which can enable narcissistic and psychopathic political leaders to inspire blind trust in their followers.30,31 These concerns reflect the reality that, while good communication skills are essential for establishing the credibility of capable leaders, exceptional communication skills are so powerful that they can at times compensate for a lack of other factors required for truly effective leadership and inspire trust where it is not warranted.

 

Attend to relationships

In addition to the persuasive effects of charisma described above, communication skills enhance the leader’s capacity to build relationships. At an organizational level, empathy on the part of the charismatic leader enhances group cohesiveness and collective identity.30 On a personal level, skilled communicators can build one-on-one relationships that greatly influence how credible they are.

 

When others feel that a leader is invested in them, they become more motivated to achieve organizational goals.6 In their classic book, The Leadership Challenge, Kouzes and Posner32 identify five practices that are characteristic of credible leaders, two of which are enabling others to act and encouraging the heart. Hasel2 writes that “creating a safe environment and showing enthusiasm for the group and the task, combined with the ability to understand how much the individual is able to shoulder, will lead to followers feeling greater levels of trust and motivation.” Warmth and empathy of leaders meets the attachment needs of individuals under stress,1 and leaders who provide nurturing and reassurance are likely to be seen as more credible.

 

Insights can also be gained from research into how medical residents make credibility judgements about their supervisors. During their training, residents receive regular feedback on their performance, but not all of it is equally accurate and helpful. When deciding which feedback merits attention and which does not, learners consider not just the content of the feedback, but also whether their supervisor is credible. This determination is based partly on the clinical acumen of the supervisor, but it is also highly dependent on relational factors, such as whether the learner believes the supervisor has a positive attitude toward them and a commitment to promoting their development.33,34 This research suggests that subject expertise is not sufficient to establish credibility especially when providing disconfirming feedback. Although superior clinical knowledge and the ability to accurately assess a learner’s performance play a role, supervisors must also understand how the learners perceive them. Then, taking into consideration all the factors that influence credibility, they must take deliberate steps, such as cultivating the relationship with the resident, to build their credibility. Thus, any leader who wishes to establish credibility must not forget the importance of the interpersonal relationship, since credibility is enhanced by strong connections.

 

Embrace your identity as a leader

Leadership training may also enhance professional identity formation. Research into medical professional identity suggests that professional identity is established in the formative years of medical education; developing the confidence to be a good doctor is as important as developing the technical competencies.35 Maile and colleagues36 argue that the same is true of leadership identity; opportunities such as leading ward rounds, support and feedback specific to leadership, and formalized training must be provided early on so that leadership identity formation can occur. Top

 

Identity formation may be useful for building confidence and overcoming the insecurity and self-doubt that can occur from medical school on into practice. The term “imposter phenomenon” was first used in 1978 to describe high-achieving women who struggled to own their accomplishments and felt as though they had “fooled” their peers.37 Imposter syndrome is common among physicians of both genders.38 As social identity theory suggests that an individual’s identity is related to their membership in groups, leadership training with peers can help to develop a strong leadership identity39 and lessen insecurity regarding whether one is entitled to claim membership in the group of “leaders.” Leaders who project confidence are then more likely to be perceived as credible by their followers.40

 

Conclusion

 

In their interactions with others, leaders must always be attentive to how they are being perceived. While it is easy to be focused solely on tasks and actions they must take in their roles, leaders cannot ignore the question of whether those who work with them perceive them as credible, since this will be key to inspiring action and motivating change. Avenues to increased credibility may include skill building and formal leadership training. In addition, the literature strongly supports building credibility by enhancing communication skills, cultivating strong relationships, and embracing your identity as a leader. Unfortunately, credibility is in the eye of the beholder, and conscious and unconscious bias can limit our control over others’ perceptions.

 

Understanding the subjectivity of credibility is important for leaders and leadership educators. Even exceptional qualifications may not be enough for leaders who are members of historically disadvantaged groups to be seen as credible. This limits the pool of potential leaders and leads to missed opportunities for better organizational outcomes. Societal change will be necessary before all capable leaders, current and aspiring, will be seen as credible. Perhaps a good place to start is with our own biases, as we are also forming opinions of others based on a variety of factors of which we may not be fully aware. In addition to planning actions to build our own credibility, we should reflect on how we determine who we believe in.  Top

 

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Authors

Lara Hazelton, MD, MEd, FRCPC, is the director of academic faculty development in the Dalhousie faculty of medicine and associate professor and director of continuing professional development in Dalhousie’s Department of Psychiatry, Halifax.

 

Michelle MacDonald, PhD, MD, is a third-year psychiatry resident at Dalhousie University, Halifax.

 

Author attestation: Both authors made substantive contributions to the article and approved the final version.

 

Correspondence to:

lara.hazelton@nshealth.ca

michellea.macdonald@nshealth.ca

 

 

This article has been peer reviewed.

 

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