A recent study, “Understanding physician leadership in Canada,” reveals that physicians are deterred from taking on leadership positions because of the negative attitude toward physician leaders throughout the medical component of the health care system and the lack of training for leadership available in that complex system.1 Embedding training in leadership skills into the entire health care system, from medical school and residency to clinical practice, would change the perception of physician leaders and be one factor in promoting physician engagement in systemic and organizational leadership.2,3
The study, which was a collaborative effort of the Canadian Society of Physician Executives (CSPE), the Canadian Medical Association (CMA), and the Centre for Healthcare Innovation (CHI) in Manitoba, raises new and fundamental questions on how to prepare physicians for leadership in the best possible way. What leadership styles and skills are most appropriate in today’s complex health care system? What evidence do we have that leadership development interventions make a difference? These questions are timely, not only in view of the study’s findings, but also because of the release of the new CanMEDS 2015 framework, which includes competencies for the role of “Leader” without guidance on the tools needed to acquire those competencies.4 Top
What leadership styles are appropriate?
From a review of the academic and grey literature on leadership and leadership development in health care,5 a few points jump out. Of all leadership styles, transformational and authentic leadership are the two that most predict quality outcomes in health care settings. A small number of studies have identified authentic leadership as essential for building leader legitimacy through honest relationships with followers, valuing their contributions and behaving ethically and transparently. As this approach develops trust, it further enhances engagement and individual and team performance, resulting in better organizational performance.6 Improved organizational performance, in turn, has been linked to a higher level of physician engagement in a reinforcing, positive feedback loop.7 Top
A large number of research studies have shown that transformational leadership, as detailed below, is strongly linked to staff satisfaction and retention, team and unit performance, work–life integration and well-being, patient safety and satisfaction, and a better organizational climate.8,9 Organizational climate is defined as “the shared meaning employees attach to the policies, practices and procedures they experience and the behaviours they observe that are rewarded, supported and expected at work.”10 Academic tradition has focused on leadership in terms of entities, i.e. leaders, followers, and shared goals.11 However, the changing nature of health care organizations and increased ambiguity and interconnectedness arising from the perspective of a whole system approach to patient care require a broader focus and view of leadership as a shared responsibility, guided by three leadership outcomes: direction based on agreement on goals, aims, and mission; alignment achieved by organizing and coordinating systemic knowledge; and commitment, as a willingness to subsume one’s own interests and benefits within the collective benefits and interests.12,13 In such terms, the practice of leadership involves leaders, followers, shared goals, direction, alignment, and commitment. Thus, leadership development should include all those elements and the processes linking them.
In such a model, it is understandable that the transformational style and skills of leadership have proven to be most effective.5 It is the strong interconnection between all the elements of such a system, the collective nature of the whole system, and the complexity of the elements’ interactions that lead to creativity, learning, adaptability, and change,14 without necessarily a central authority. Yet, because of the characteristics of emergence and non-linear dynamics, physicians are often uncomfortable in such complex systems because of feelings of inertia, pressure and pushbacks, contradictory demands, conflict, and inefficiency.13,15 Some of these feelings were also expressed in the recent CSPE/CMA/CHI study.1 Top
A combination of transactional and transformational leadership is required for success. The transformational leader allows processes to develop at the frontline, which may lead to better outcomes. Although this may be seen as a subversive effort to counteract the beneficial policies and procedures developed by those at the top of the hierarchy, and as criticism of them, there is still a role for the bureaucratic or administrative leadership style in the health care system, when standard practices must be executed according to organizational processes.14 In this instance, administrative or transactional leadership16 minimizes variation from evidence-based practices and enhances patient outcomes.
Therefore, there is a tension that is both productive and challenging between the bureaucratic (transactional) and the entrepreneurial (transformational) leadership efforts that should lead to reflection on what response is best, rather than reaction in the familiar bureaucratic style of “the expert.” While the health care system remains under the influence of the administrative approach to analyze and solve problems, with the introduction and reinforcement of policies by those in titled administrative leadership positions, these skills are insufficient to transform the health system: for example, to improve health outcomes of a particular underserved community.
In British Columbia, for example, Divisions of Family Practice empower family doctors to effect change at the local level. In Nanaimo, this has led to several demonstration projects: delivering care for 150 non-insured people with moderate depression and anxiety, transitioning frail elderly from hospital to nursing homes, and other projects that are prioritized collaboratively.17 Top
Which leadership development interventions make a difference?
An extensive literature review on this topic5 found that the widely used, multisource 360-degree feedback via questionnaire, on its own, had only a very weak positive effect on performance improvement in two-thirds of the studies reviewed; in a third of the studies, it had a negative effect.
This approach may be more useful when combined with specific training and interventions for the individual. Such a combination can be found in the developmental assessment centre process, which has a positive effect on subsequent leadership performance. This process is usually spread over three days and involves multi-source feedback, in-basket exercises, aptitude tests, interviews, group exercises, writing assignments, and intensive reflection processes.18 One example is the New and Emerging Academic Leaders (NEAL) program at the University of Toronto.19 However, these centres are costly and often preserved for the most senior executives. Top
There is also variable evidence that action learning is effective, but no evidence that job rotation increases leadership effectiveness. Mentoring, although useful, increases leadership effectiveness only to a limited degree. Some studies on executive coaching claim that this method is effective, but many are flawed and the practice is expensive.20,21
In short, the research literature seems to indicate that there is no best way to develop leaders and good development of leaders is context sensitive.22 Leader development seems best when it’s based on the needs of the individual, linked with the gap between the person’s current capacity and the desired capacity to lead.5
In contrast to the focus on leader development, the development of the capacity for leadership of groups and organizations as a shared and collective process has been explored and researched much less. The available evidence highlights the importance of collective leadership5,13,23 and advocates a balance between individual skill enhancement and organizational capacity-building.24 Table 1 and the example from Nanaimo17 indicate that entrepreneurial or transformational leadership flourishes within the frame of relational coordination, which includes the elements of shared goals, shared knowledge, mutual respect for each other’s role, and accurate high-quality communication.25 Top
When creating programs for leadership development, what moderating factors lead to improvement in performance of the health care team or organizational outcomes? The literature indicates that these factors are: the design of the program, the knowledge and skills of the facilitators, the motivation of the trainees, supports in the workplace, and processes to facilitate the transfer of training.5 A successful program design is characterized by clear learning objectives and meaningful content appropriately sequenced, an appropriate mix of training methods and opportunities for active practice, relevant and timely feedback that promotes the trainee’s self-confidence, and follow-up activities including specific tasks in the organization.26 Processes to facilitate the transfer of training include embedding the practice and maintenance of the newly learned skills into the organizational culture.27
Two health-care-related leadership frameworks were developed in Canada: LEADS, for leadership development in a health systems context28 and, specifically for physicians, the “Leader” role in CanMEDS 2015.4 However, unlike standardized courses and exams to test clinical competencies, we have no universal Canadian framework against which to gauge the competencies and capabilities described in LEADS and CanMEDS 2015. We also have two national organizations —the Canadian Society of Physician Executives and the CMA’s Physician Leadership Institute — that can act as coordinating forces. Top
The preceding arguments bring a number of important questions to mind that need to be answered if we are to move forward on the leadership agenda. Nationally and systemically, we have to ask ourselves how the capabilities of the two frameworks can be rationalized and integrated. How can leaders be developed within a collective, relational context? How can such learning be maximized in the context of health reform and around innovative projects, some of which are sprouting up around the country? Top
There are also questions related to learning. How do we embed leadership learning into existing courses in medical schools, and should we do so without adding a course in leadership, disconnected from all other courses? How can preceptors acquire what is needed to be role models for residents, i.e., walk the talk, and how might they integrate leadership into clinical teaching? How will the creation and delivery of well-designed programs for practising physicians be paid for?
Some questions may be better answered locally. Will physicians and physician leaders be held accountable for leadership skills through credentialing and privileging, not dissimilar from their accountability for clinical skills? How will physicians’ time be remunerated? How can the practice and maintenance of such leadership skills and behaviour be structurally and culturally embedded into a supportive and safe environment in each health care organization, each clinical practice, and throughout the system? Top
In summary, now that we know that there is a need for physician leadership development throughout the entire Canadian health care system,1 and now that we have two models, LEADS28 and CanMEDS 2015,4 with defined competencies and capabilities, we have to determine how physicians can actually develop, practise, and maintain these skills, not differently from what we expect regarding the development, practice, and maintenance of their clinical skills. Only when we resolve this issue will our health care system have a better chance of being transformed sustainably. Top
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Johny Van Aerde is past president of the Canadian Society of Physician Leaders. He is a clinical professor of pediatrics at the University of British Columbia and the University of Alberta and an associate faculty member at the School for Leadership Studies at Royal Roads University in Victoria; he is also on the faculty of the Physician Leadership Institute.
Correspondence to: email@example.com
This article has been reviewed by a panel of physician leaders.