Crossing the threshold: physician leadership and liminality

Lara Hazelton, MD, MEd

 

 

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In becoming leaders, physicians leave the familiar world of clinical medicine and assume new identities. Providing education and training in leadership may not address their reluctance to take on leadership positions if we do not also acknowledge the psychological processes involved in becoming a formal leader and the psychosocial phenomenon of liminality.

 

KEY WORDS:  leadership training, leadership development, transition, liminal state

 

How often have you heard a physician colleague protest that he or she cannot assume a formal leadership role because of lack of training? It is a common justification for the discomfort many feel when contemplating a new position. In focus groups conducted by the Canadian Medical Association (CMA), participants spoke of feeling unprepared to assume leadership roles as they lack education in leadership.1

 

In response to this perceived need for more education, numerous programs have been created for physicians, and there is increasing emphasis on leadership education for residents2 and medical students.3 Yet, providing education and training may not address the reluctance of physicians to take on leadership positions if we do not also acknowledge the psychological processes involved in becoming a formal leader and the psychosocial phenomenon of liminality. Top

 

The meaning and impact of liminality

 

The term “liminality” comes from the field of anthropology where it has been used to describe the status of community members undergoing a rite of passage. It derives from the Latin word for threshold, the structure that is crossed when passing through a doorway from one place to another. In his 1964 article, “Betwixt and between: the liminal period in rites de passage,” sociologist Victor Turner4 wrote of liminality as both a state and a process of transformation. The concept has been extended beyond its original use in anthropology to describe the transitions between states experienced by individuals and societies across a broad range of settings. In their book, Managing Transitions, Bridges and Bridges distinguish between change and transition, the former being situational and the latter psychological.5 Both pose challenges to organizations and individuals. Top

 

Understanding how liminality, identity, and role transition have an impact on new and aspiring leaders can help to account for challenges in engaging and retaining physician leaders. In becoming leaders, physicians may enter a liminal space, leaving the familiar world of clinical medicine and assuming new identities. As Skinner6 writes, “Identifying oneself as a leader is another social role that individuals can adopt, and one that is open to the personalized meanings that they ascribe to it” (p. 40).

 

Becoming a leader can resemble the transformations of identity that take place when medical students become residents or residents become independent practitioners. Although the imparting of medical knowledge and the development of procedural skills are obvious components of medical education, there is increasing recognition of the importance of professional identity formation during medical school and residency.7 This process, which takes time to occur, is not easily quantified or incorporated into competency-based systems that rely on observation of behaviours to assess readiness to practise. Top

 

The transition to leader

 

What is different about becoming a leader is the lack of a mandatory process of training and licensing that legitimizes the new identity. Professional practice in medicine is regulated by colleges and legislation that determine who is qualified to call him or herself a physician. Although they do not entirely assuage the anxiety associated with transitions in practice, clerkship and residency serve psychological and social functions, with credentialing examinations acting as a “rite of passage,” a common means by which cultural entities can integrate newcomers. Learners gradually gain both expertise and status through a process of legitimate peripheral participation that involves ever-increasing levels of responsibility and moves them from the edges of the community toward full participation.8 Top

 

In general, leadership, whether formal or informal, does not have defined qualifications, processes of becoming, or codified certification. Whereas examinations and licensing provide a sense of having successfully completed a transition to full participation in the medical community, becoming a leader is more nebulous.

 

The liminal state has also been used to characterize those who exist between or on the margins of social groups or who inhabit multiple roles.9 Often, the identity of leader coexists with that of physician in an uneasy and often contradictory manner, and, for those who continue clinical practice, there may be conflicted allegiances. These factors may explain why even those physicians who have undertaken positions of formal leadership still sometimes resist applying the term “leader” to themselves. Top

 

Embracing the discomfort

 

In our online Emerging Leaders in Academic Medicine (ELAM) program at Dalhousie Faculty of Medicine, we encourage participants to see the liminal discomfort associated with becoming leaders as something to be embraced rather than avoided. Through moderated discussion boards and webinars, participants are introduced to the idea that the liminal period presents an opportunity and space for the individual to undergo a transition of role and identity. Because the individual is between realities, there are psychological and social uncertainties that can be marginalizing and distressing, but they can also open up possibilities for personal innovation and growth. Uncertainty and insecurity are part of the educative process and are to be welcomed rather than avoided. Bridges and Bridges5 write about the “emotional wilderness” of the transitional state, and caution: “You may be anxious in this no-man’s land and try to escape… To abandon the situation, however, is to abort the transition… and to jeopardize the change”(p. 9). Top

 

Because transitions can be stressful, many societies have structures and rituals to bring together people who are undergoing a liminal phase.8 In designing and implementing leadership development programs for physicians at our medical school, we have been deliberate in our attempts to create an online community of learners who are undergoing a similar process of leadership development. We also provide opportunities for new leaders to connect with more experienced physicians. Participants who complete our online program are invited to attend a leadership forum with senior leaders where opportunities for connection, such as “speed-networking,” are an important component of the face-to-face programming. Top

 

Organizations, such as the World Federation of Medical Managers (WFMM) and its member organizations (including the Canadian Society of Physician Leaders), provide worthwhile venues for recognition of training and credentials in leadership. There may be psychological as well as practical benefits for those who complete leadership programs and attain various forms of certification. Yet, although leadership education should seek to equip physician leaders, we should not judge the effectiveness of programming solely on satisfaction ratings that ask participants how prepared or confident they feel at the end of the course. For many participants, an awareness of feeling unprepared, while disconcerting, may not only be appropriate but also constructive. Leadership educators also need to be reflective when responding to the uncertainty and anxiety expressed by participants and remember that sometimes it will be helpful to thoughtfully explore the (expected) doubts and insecurities associated with taking on a new role rather than rushing in with reassurances or “tips and tricks” that do not promote deep learning. Top

 

For some, the desire to complete a program of training in leadership may be as much a means of gaining legitimacy and identity as it is an opportunity to acquire applicable knowledge and skills. Certainly, it is much easier to be engaged and effective in a role for which one has been prepared and gained a sense of mastery. Nonetheless, participants in any professional course should be encouraged to reflect on the possibility that after leaving the liminal space, the troubling uncertainties and questions that exist there may diminish and with them the opportunities for new insights.5 As Alexander Pope has said, “Some people will never learn anything... because they understand everything too soon.”10 Top

 

References

1.Collins-Nakai, R. Leadership in medicine. Mcgill J Med 2006;9(1):68-73. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2687901/

2.Moore JM, Wininger DA, Martin B. Leadership for all: an internal medicine residency leadership development program. J Grad Med Educ 2016;8(4):587-91. https://doi.org/10.4300/JGME-D-15-00615.1

3.Abbas MR, Quince TA, Wood DF, Benson JA. Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. BMC Med Educ 2011;11:93. https://doi.org/10.1186/1472-6920-11-93

4.Turner VW. Betwixt and between: the liminal period in rites de passage. In Symposium on New Approaches to the Study of Religion:  Proceedings of the American Ethnological Society 1964. Seattle: American Ethnological Society; 1964. pp. 4-20.

5.Bridges W, Bridges S. Transitions: making the most of change. 4th ed. Boston: Da Capo Press; 2016.

6.Skinner S. Build your leader identity: a practical guide to leading authentically from any position. Haberfied (NSW): Longueville Media; 2015.

7.Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med 2014;89(11):1446-51. DOI: 10.1097/ACM.0000000000000427

8.Lave J, Wenger E. Situated learning: legitimate peripheral participation. New York: Cambridge University Press; 1991.

9.Evans CA, Kevern P. Liminality in preregistration mental health nurse education: a review of the literature. Nurse Educ Pract 2015 Jan;15(1):1-6. http://dx.doi.org/10.1016/j.nepr.2014.08.004

10.Pope P, Swift D. Miscellanies in verse and prose. Ann Arbor: University of Michigan Library; 2007.

 

Author

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

 

Correspondence to: Lara.Hazelton@nshealth.ca

 

This article has been peer reviewed.

 

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How often have you heard a physician colleague protest that he or she cannot assume a formal leadership role because of lack of training? It is a common justification for the discomfort many feel when contemplating a new position. In focus groups conducted by the Canadian Medical Association (CMA), participants spoke of feeling unprepared to assume leadership roles as they lack education in leadership.1

Organizations, such as the World Federation of Medical Managers (WFMM) and its member organizations (including the Canadian Society of Physician Leaders), provide worthwhile venues for recognition of training and credentials in leadership. There may be psychological as well as practical benefits for those who complete leadership programs and attain various forms of certification. Yet, although leadership education should seek to equip physician leaders, we should not judge the effectiveness of programming solely on satisfaction ratings that ask participants how prepared or confident they feel at the end of the course. For many participants, an awareness of feeling unprepared, while disconcerting, may not only be appropriate but also constructive. Leadership educators also need to be reflective when responding to the uncertainty and anxiety expressed by participants and remember that sometimes it will be helpful to thoughtfully explore the (expected) doubts and insecurities associated with taking on a new role rather than rushing in with reassurances or “tips and tricks” that do not promote deep learning. Top