Physicians who move into leadership roles have the benefit of knowing the physician world and, therefore, are the bridge between the profession and public management. However, such moves are often viewed as a betrayal of the physician identity, a move to the “dark side” by their colleagues. Doubts about their identity may also influence their ability to be confident in their new role.
KEY WORDS: physician identity, negative attitude, physician leadership, cultural identity, ritualized professional identity
One of the most interesting findings from a recent study by the Canadian Society of Physician Leaders (CSPL)1 was that, for physicians surveyed, “maintaining a clinical practice was important for credibility and for staying in touch with reality” when moving into formal leadership roles. In other words, doctors who choose to eschew their clinical practice to move into administration are perceived by their physician colleagues as abandoning reality and shunning their professional roots. Top
The question then arises: is there something “special” about the role of physician, something unique in the doctor’s sense of identity that creates this dynamic, a dynamic that cannot be anything but obstructive when physicians are needed in leadership roles in the health care system? As Thomas Andersson2 states, “the medical leadership challenge is not only a structural and/or competence challenge, it is just as much an identity challenge” (p. 84). Top
The CSPL study described this phenomenon as the presence of negative attitudes within the physician community: when colleagues move into formal leadership roles, their failure to retain a clinical practice is seen as “going to the dark side.”1 A physician I knew once described the dark side phenomenon this way: physicians who move into formal leadership roles go from “comforting the afflicted” to “afflicting the comfortable.” Another way of putting it is that physicians abandon their identity and move to a place where they actually betray that identity. Top
3 Top
Recently, I reviewed a few articles that help shed light on this interesting cultural phenomenon. It is cultural because it is a shared belief among many physicians, a customary or traditional way of thinking that permeates the mindset of many doctors. It is a belief that has almost become a fact, in that for many doctors it appears to describe reality. How has this “reality” arisen? How deep rooted is it, and how open is it to change?
The first article suggests that this attitude begins early within a physician’s career and may well be a result of how physicians are educated in medical school. Doja and colleagues4 make the point that, in medical schools, there is a formal curriculum, an informal curriculum, and a hidden curriculum. Explaining the latter two, they state, “The informal curriculum consists of the unscripted, ad hoc, and interpersonal forms of teaching and learning that take place among faculty and students, as well as between students at different levels of training,” and “the hidden curriculum, in contrast, is a set of influences that function at the level of organizational structure and culture.” Together, the informal and hidden curricula constitute a set of expectations, learning moments, and unwritten rules that are transmitted to students through the attitudes, beliefs, and perspectives modeled by those teaching the programs and then reinforced, culturally, by discourse among medical students themselves. Top
Doja and colleagues4 go on to state that various learning processes have been identified in the hidden curriculum, including “the loss of idealism and adoption of a ‘ritualized’ professional identity.” One manifestation of that professional identity is the deeply ingrained attitude that assigns different levels of status to separate physician groups: in this case, the belief that physicians who move into administration are betraying their clinical roots.
The second and third articles focus on the concept of identity. By definition, identity is a person’s psychological core: the mental and emotional heart of one’s sense of self. It addresses questions such as, “who am I? or who do I want to be? Andersson2 states that identity is “an ongoing, social construction of the self” (p. 85). John Farrell Quinn5 states that a physician “adopts an identity focused on the primary function (as a clinician), which is given a superior priority and distinction” (p. 8). He suggests that identity is constructed through an ongoing discourse among the members of one’s profession and the subsequent discourse regarding that profession’s identity within society. Both authors suggest that if Doja and colleagues’4 description of the hidden curriculum in medical school is correct, perceptions related to the dark side phenomenon are transmitted at the beginning of the physician’s career, from the moment he or she enters medical school. Top
Quinn5 and Andersson2 both agree that the long history — over 2000 years — related to understanding the role and function of the physician within society has given that identify great clarity and emotive depth. Abandoning or trying to change one’s identity is to defy deep-seated beliefs and, therefore, create psychological dissonance. When professionals, such as physicians, share a perception of identity, and that sense of identity is reinforced through an ongoing history of discourse with other professions and groups that reinforce it, it becomes more impervious to change.
Indeed, one interpretation of the concept of identify is that it is the foundation of one’s self-image, which we challenge at our own psychological peril. If elements of identity are then perceived to be tested — by a career shift from doctor to administrator — a natural resistance and even potential demonization can emerge that becomes embedded in the professional culture. In addition, the physician who makes such a shift may well “become stressed and dissatisfied when the behaviors expected in their role are inconsistent” i.e., behaviour of clinician and that of leader,2 when leaders are often construed as “the enemy.” Top
Andersson2 outlines a number of elements that define physician identity. The first is a unique expertise in medical science. The second is an assumption — deeply rooted in the concept of professionalism — of a high level of autonomy and individual responsibility. A third — also grounded in professionalism — is that physicians’ activities are self-governed to a higher extent than in other professions. A fourth is a strong focus on a life-long career, the dynamics of which are negotiated and defined within the profession itself. Emphasizing this point, Quinn5 states, “physicians... [are] confined to a professional group that excludes others... there is reluctance to become subordinate to those outside of their group,” e.g., non-physician administrators and physician leaders themselves, who have the added stigma of abandoning their professional identity. It is deeply self-referential and, therefore, highly internalized. Top
It is instructive to compare these factors that define physician identity with factors associated with the role of leader/manager in the health care system. Doing so illustrates the gulf of difference between the two roles. The very role of manager is relatively recent in a historical sense. What is now called public management (e.g., expressed in Canada through the Canada Health Act and its agents, such as public health systems, hospital boards, primary care networks, and regionalization of health service delivery) is a 40-year-old phenomenon, whereas the role of physician is thousands of years old. Indeed, I once had the privilege of seeing a newly graduating physician proudly standing beside a sculpture of the caduceus in Ephesus, Turkey, which had been found recently during an excavation at the ancient home of Hippocrates, as her parents clicked away with their camera to capture this proud moment.
It is important to note, too, that leader/managers who are employed in the system do not belong to a profession, whereas doctors do — with the attendant rigour demanded of them to qualify to enter and the distinction that belonging to such a profession generates. Doctors who move into leadership roles may be perceived by their colleagues as forsaking that effort. Top
Another major difference is that modern leader/managers are generalists rather than medical specialists. They see their role as building relationships and acting through and with others to get things done, rather than taking pride in the exercise of individual responsibility, as doctors are prone to do. These major differences highlight the identity challenge physicians face, when they choose to become credible and influential leaders in the health system.
The dark side phenomenon is hard to resolve. It is well known in the leadership world that “culture eats strategy for breakfast.” To change that culture is a daunting task. Deeply ingrained notions of physician identity, rooted in thousands of years of construction, are the source of the dark side phenomenon. However, culture can change when the unconscious mindsets and beliefs of people are surfaced. Demonization by some physicians of their colleagues who move into administration is counterproductive. Top
For all these reasons, it is understandable that physicians who move from clinical roles to administrative roles may see that move as both a benefit and a curse. A benefit in that they can use their knowledge, expertise, and influence to serve many patients at once, not just one patient at a time. A curse in that they alienate some of their colleagues in doing so, and may well have lingering doubts about their own identity, which may in some ways influence their ability to be confident in their new role.
This state of affairs is counterproductive. The current health system can only benefit when the physician perspective is brought to bear on the future of that health system. Physicians who move into leadership roles have the benefit of knowing the physician world and, therefore, are the bridge between the profession and public management. It is best to build and grow that partnership, rather than continue to attenuate it. Let’s put the dark side controversy to rest. Top
References
1. Van Aerde J. Understanding physician leadership in Canada: overview of a CSPE/CMA/CHI study. Can J Physician Leadersh 2015;1(4):30–2. Available: http://tinyurl.com/ol54vqa
2. Andersson T. The medical leadership challenge in health care is an identity challenge. Leadersh Health Serv (Bradf Engl) 2015;28(2):83–99.
3. Shakespeare W. The tragedy of King Lear (act 3, scene 4). Open Source Shakespeare. Available: http://tinyurl.com/o9tssjg
4. Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: a cross-sectional qualitative study. Med Teach 2015;Aug 14:1–9.
5 .Quinn JF. The affect of vision and compassion upon role factors in physician leadership. Front Psychol 6: 442. Available: http://tinyurl.com/p9g8ry3
Author
Graham Dickson, PhD, is professor emeritus at Royal Roads University and CEO of LEADSchange Consulting Group in Victoria, British Columbia.
Correspondence to: graham.dickson@royalroads.ca