The Staircase of Leadership
Sharron Spicer, MD, FRCPC, CCPE
We should all be grateful that medical leadership training has matured over the past decades. Gone — hopefully — are the days when physicians rose through clinical ranks to take on leadership roles without being selected for or trained in leadership skills. Many physician leaders of the not-so-distant past can recount early experiences when they were reluctantly or unexpectedly placed into leadership roles with inadequate training, scant orientation, unclear expectations, and lack of performance feedback. For many, it was leadership by intuition; worse, it sometimes made for leadership by (poor) example.
We now recognize that leadership involves learned skills and, therefore, we do a better job of training physician leaders. We also understand that leaders hold distinct but overlapping key functions of leadership, management, and facilitation. Frameworks such as LEADS create structure and context around key tasks of medical leadership: Lead self, Engage others, Achieve results, Develop coalitions and Systems transformation.1
The LEADS framework is not unidirectional, but there is a recognition of increasing leadership complexity and competency along its continuum. As leaders mature in skill and experience, they likely move along this trajectory in their degree of influence. At the same time, one never fully masters any one component. As one develops expertise in one area, they may come back and revisit skills in another. There is building, growing, and teaching in a tiered approach within each component, allowing novice, intermediate, and senior leaders to gain skills in each domain over time. The cycle is not linear, not necessarily even circular, but more of a spiral. Top
I suggest that we consider the spiral approach to teaching leadership skills. As we impart skills in each LEADS domain, we can use consistent building blocks and add detail and complexity for the more experienced learners. This may include workshops and mentoring for emerging leaders, perhaps more coaching for those already immersed in leadership roles.
This approach to learning is not unique to medical leadership training. The pedagogy of medical education recognizes the spiral nature of undergraduate clinical knowledge. The Cumming School of Medicine at the University of Calgary, where I teach, describes its initiative to implement a new pre-clerkship curriculum as focused on the spiral delivery of patient-centred clinical presentations, while providing opportunities for self-regulated learning and professional identity, including moral obligation and social accountability, to improve societal wellbeing.2 Top
In the United Kingdom, the National Health Service even has a spiral leadership toolkit. Designed for health care learners, the toolkit aims to help clinicians develop and reflect on key leadership competencies. Similar to LEADS, it links theoretical and practical knowledge in multiple key domains: Managing self, Team and leadership, Managing others, Financial understanding, Risk and governance, Change management and improvement, Confidentiality and data protection, and Medico-legal issues.3
Curious about the concept of spiral delivery of education, I looked to literature in childhood education pedagogy. The aptly named Spiral Playbook4 puts forward a spiral of inquiry. While not intended as a leadership framework, it certainly lends itself to describing steps in innovation and change management. Top
Once you have completed a full spiral, you are well-positioned to do it again with a different focus. Although the stages in the spiral overlap, it is critical that you linger long enough in each phase to do the work that will make the biggest difference for all learners. There can be quick gains along the way, but the enduring benefits accrue over time as you become more familiar with the spiral of inquiry and share your learning in a supportive network.4 [page 22]
Furthermore, the playbook describes how the spiral of inquiry creates a growth mindset:
Researchers… have revolutionized learning theory… with insightful work on motivation, resilience and mindset. Cultivating a growth mindset is key to learning at any age, and key to leading a team, a school or a whole system…. The opposite of a growth mindset is a fixed mindset — the self-limiting belief that we are only as good as our innate abilities, and that our failures are evidence of our limitations. Learners and leaders with a fixed mindset fear failure more than they love new learning. The good news is that a growth mindset can be learned. The spiral of inquiry offers a way to shift from the fixed mindset of sorting and ranking to a growth mindset for deep learning.4 [page 11] Top
This image of the spiral reminds me of the magnificent spiral staircase in Harry Potter and the Prisoner of Azkaban — actually the Dean’s Staircase in London’s St. Paul’s Cathedral. It is an emblem of potential. For medical leaders, learning the skills of leadership is like a spiral staircase. With basic building blocks of leadership components twisting around an axis, one can climb up or down the staircase to learn or refresh any component.
Like the spiral staircase, this issue of CJPL is sure to have something for everyone at all stages of leadership skill development. We have an interview with Dr. Bolu Ogunyemi, highlighting issues of equity, advocacy, and social justice for our colleagues and patients, as well as describing the importance for leaders of enhancing communication skills in writing and public speaking. Pamela Mathura and colleagues describe how engaging physicians in quality improvement leads to direct improvements in patient outcomes. Drs. Mamta Gautam and Scott Comber describe the Canadian Lean Healthcare Canvas, a tool to develop and communicate key messages about innovative ideas in health care. Dr. Malcolm Ogborn shares a condensed chapter from his new book Sudden Leadership – A Survival Guide for Physicians, describing how we can manage conflict without inducing shame. Dr. Debrah Wirtzfeld talks about how coaching can help leaders develop their own self-awareness about styles of conflict and apply that to the “messy” business of leadership. Finally, we have two book reviews by Dr. Johny Van Aerde: Ducks in a Row by Sue Robins and The Premonition by Michael Lewis. Reading these articles, I felt that each has a perspective to provide to the leader at every stage of development. I hope you enjoy this issue of CJPL. Top
1.LEADS framework. Ottawa: Canadian College of Health Leaders; 2021. Available: https://tinyurl.com/3wt8uzb7
2.RIME. Calgary: University of Calgary; n.d. Available: https://tinyurl.com/244yuze7
3.Spiral leadership 2016/17. South London Toolkit, version 1.0. London: National Health Service; 2017. Available: https://tinyurl.com/an9pyazk
4.Kaser L, Halbert J. The spiral playbook: leading with an inquiring mindset in school systems and schools. Mississauga, Ont.: C21 Canada; 2017. Available: https://tinyurl.com/mu2xw53t
Sharron Spicer, MD, FRCPC, CCPE, is a pediatrician and senior medical leader in Calgary. She serves as editor-in-chief of the Canadian Journal of Physician Leadership.