Strategic leadership development for physicians -
Evaluation of the Physician Leadership Development Program at Schulich
Peter Dickens, PhD,
Sandra Fisman, MBCh, and
Kathi Grossman, BA (Hons)
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Spearheaded by the Ontario Medical Association and created by a number of dedicated individuals, the Physician Leadership Development Program has “changed the lives” of its participants. Results of a survey and interviews with physicians from the first four cohorts reveal the program’s key strengths and how it is beginning to have a significant impact on the province’s health care system.
KEY WORDS: physician leadership development, systems change, program design, Schulich Executive Education Centre, evaluation, Ontario, action learning, complexity
In 1999, a dialogue began at the board of the Ontario Medical Association (OMA) about the need for enhanced leadership skills among physicians across the province. Historically, medical school training contains little or no information on the subject, leaving physicians in leadership roles to fend for themselves and learn from their predecessors as best they can. The Canadian Medical Association (CMA) offered specific skills development through its Physician Management Institute (PMI), but what was lacking, according to Dr. Janice Willett, past-president of the OMA, whom we had an opportunity to interview early in our research project, was formal training for leaders who could have an impact on the larger health system. Top
Despite some early resistance from board members who did not feel that leadership development was their mandate, the OMA set out to identify a respected provider who could develop and deliver a program that went beyond simply developing skills of participants to one that was focused on system transformation. They also preferred a “made in Ontario” solution and one that would ensure broad representation both geographically and based on physician specialty. According to Willett, they wanted to break away from the traditional system that focused on high-profile association members and seek out emerging leaders from across the province. From the beginning, they were intentional about limiting the involvement of board members and put a rigorous screening process in place. Top
After a lengthy process, the OMA, in partnership with the CMA, selected the Schulich School of Business, York University, through the Schulich Executive Education Centre (SEEC), to design and deliver the program. Designed by Brenda Zimmerman, the Physician Leadership Development Program (PLDP) had elements that lined up with the OMA’s desire for systems-level leadership.
Orienting the research and researchers
The purpose of this research initiative was to examine the impact of the PLDP on participating physicians in terms of individual self-awareness and reflective capacity as well as broad systems impact. The hypotheses going into the initiative were:
Of the researchers, Dr. Sandra Fisman was a participant in cohort one; Peter Dickens has been a coach and a facilitator in the program from the initial cohort; and Kathi Grossman has been the program coordinator for SEEC from the outset. We acknowledge that there is likely some researcher bias in our perspective, but we believe that our experience and knowledge of the program are important lenses through which to view the outcomes. Top
Schulich was approached about the use of an ethics review board but indicated that, since the research was not being done under their auspices, such a review would not be appropriate. Hence, no ethics review was done.
Results of the survey
We received 60 responses from the 100 physicians who participated in the first four cohorts; three were incomplete, leaving 57. Participants were asked to rate a series of statements on a six-point Likert scale. The statements related to specific concepts taught in the program (Table 1). Top
When given the opportunity to comment on how they had applied key concepts from the program, many participants spoke about the value of a complexity perspective, which was new for many of them. One suggested, “While it may seem simple, the complex system framework continues to be one of the key takeaway messages. It is one that I continue to use in discussions with physician groups. Surprisingly, while physicians deal with complex adaptive systems all the time (humans, hospitals, practices) few of us take that reflective time necessary to realize that these systems are complex and adaptive.”
Several of the “liberating structures”11 to which participants were introduced were also identified as useful, including TRIZ, 1-2-4-All, and Min Specs. These are simple facilitation approaches, many of which were designed by Brenda Zimmerman, that are intended to minimize structure and control and maximize a group’s freedom to generate novel ideas and solutions. Top
Findings from the interviews
We conducted 12 telephone interviews with participants from the first four cohorts. Several potential interviewees self-identified as willing, and we identified other candidates to ensure a balance geographically and in terms of specialty, age, and gender. Each semi-structured interview took about an hour and was framed by the following questions:
Three strong themes emerged from the interview data: self-awareness and the power of reflective practice; a growing sense of self-confidence; and the ability to see multi-level systems. Top
Self-awareness and the power of reflective practice
Several interviewees pointed out that the sorts of physicians who are drawn to a program like the PLDP have a self-admitted pattern of saying “yes” to a wide variety of invitations to leadership roles that are ultimately dissatisfying. Two important and related themes that emerged from the interviews were a new-found ability of participants to focus on strengths and the value of self-reflection, both gleaned from the “reflective best self” (RBS) exercise.12 This, then, gave participants a better method for assessing leadership opportunities in terms of fit.
RBS is a multi-step process that facilitates an understanding of oneself at one’s best, based on reflective analysis of feedback from a diverse group of people who know the individual well. As one interviewee pointed out, “Early in the course, this set the stage for using the self and self strengths to build collaborative relationships.” Another commented, “The RBS was unexpectedly powerful — it provided a lot of rich free-text data.” This suggests the sort of nuanced information that is often difficult to get from surveys or scale-based assessments.
RBS was linked with another main theme: enhancement of self-confidence. “The RBS assessment gave me a lot of confidence; a sense of self and how others see me.” Another perspective was insight into some areas for improvement: “I appreciated the RBS exercise, both for helping me see my strengths [through others’ eyes], but also because it pointed to some of my gaps, which created a framework for learning.” Top
Continuing beyond the course, the application of self-reflection and use of personal strengths continued to influence the personal and professional lives of many of those interviewed. “As a person, I have become much more reflective, I am much more intentional about listening and sensing other people’s emotions, then adjusting my stance so I can best communicate with them.” “I pause to write what I did and what I notice; take a breath.” “I spend less time worrying about my own weaknesses,” and “I am more in touch with my own feelings: I can now label them and thus deal with them more effectively.” One participant commented that, “As a person, self-reflection was very helpful; I learned what makes me tick aside from my professional development.” Top
Professionally, “the power of reflective practice” enabled “movement from a diagnosis and treatment mindset. I learned to get out from behind my own assumptions and to live a more balanced life.”
The prescriptive use of RBS as a foundation of the course’s design had an engaging effect: “It was clever how the program got very bright, but often stubborn people to engage in self-reflection. Part of that was creating a safe environment for dialogue.” The RBS exercise laid the groundwork for another major theme, the value of collaborative relationships, particularly in team building and system change. An interviewee, who was lead in his family health team, said the RBS exercise helped him recognize his strengths and those of others. Top
Several participants contributed variations on the following comment: “I have learned to lead from my strengths and to offset my weaknesses by collaborating with others in order to effect change. I no longer stress about my weaknesses; there are others out there who can do what needs to be done. I used to be the sort of person who would take on more and more stuff, but the program taught me to think in terms of my strengths. That has helped me to let go of the doing that is my instinctive response. I am better able to identify others’ strengths and then encourage/support them in taking on projects that suit their strengths.”
Finally, one early participant noted, “I am more observant of my colleagues’ patterns, and I have learned to be more intentional about celebrating successes: both my own and others’.” Top
A growing sense of self-confidence
A second theme that emerged from the interviews was the impact of the program on individuals’ confidence. This was particularly noted by many women. As one person said, “that alone was worth the whole course.” Another put it this way. “The program gave me confidence in myself. Women in leadership often doubt themselves, but the program gave me a sense of inner credibility. I also see these changes in me in my personal life: increased confidence and a willingness to pursue things I might have avoided in the past.”
Several people noted with surprise that one can be an introvert and still be an effective leader. “Yes it did [change me as a person]. One of the most significant things was that I realized that I am an introverted leader — seeing how I can effect change and that I can still be a leader with my style.”
For several participants, an observable change was an awareness of their expanding circles of influence, as they learned to actively and intentionally engage others. Virtually every interviewee came to the realization that building relationships is the heart and soul of leadership. For people who are used to thinking and working in a very individualistic way, that was quite revelatory.
One summarized it quite nicely: “I learned that ‘me [alone] as the leader’ wasn’t the answer. I had to form connections, build networks, and learn that building support was critical to any change initiative. I will never again just take on a change by myself! It is vital that you really understand the perspectives of others and... their needs. Change requires a significant investment in the social system around the change.” Top
This revelation about themselves and the capacity of others transformed many participants’ approach to leadership and change. Another noted a vital, new question that dramatically increased her confidence: “With whom do I need to engage [regarding a specific initiative]? I became intentional about broadening my scope beyond physicians to other health professionals, the government, and local, provincial and even national associations. By clarifying everyone’s needs, we were able to develop much richer outcomes.”
Seeing multi-level systems
Question 3 led participants to think about the difference the program made in how they view their work. As one family physician noted, “I would have said I used to be much more focused on the micro-system: the one around the patient. I didn’t really think beyond that level.”
Heifetz and colleagues13 offer a useful metaphor to help us make a shift in our thinking. They suggest that effective leaders need to be both “on the dance floor” where they are in direct contact with people and processes and “up on the balcony” where they can see the patterns of change in the whole system. Top
This is what family physicians and others noted: they were more and more comfortable being up on the balcony, observing not only their own system, but that system nested within other systems that impact and influence each other in multiple, non-linear ways. Their patient, the microsystem, was nested within a department or family health team, which was nested within a hospital or local health integration network, which was nested within broader social, economic, and political systems. One ignores the influence of these systems at one’s peril. Instead, they had to learn that “me alone as the leader wasn’t enough,” as one interviewee put it. They had to learn to connect with and truly listen to and understand all parts of the system. Top
As another suggested, “I had to take a macro view and look at various positions, power structures, and governance models. I had to truly understand multiple accountability systems. I had to discern what partnerships I needed to influence. I really needed to appreciate the place others are coming from so that, together, we might adapt change to meet all our needs.” This perspective led a participant to realize that, “I had to have facts about the other systems in which I was embedded. That meant, obviously, getting to know them and understand their different perspectives.” Top
For many, this was a powerful insight, and they realized that their training and experience had led them in the opposite direction. They had been very comfortable in the solitary leader role, and it was a bit jarring for some to realize how vital true engagement really is. Although they acknowledged that it took more effort initially, all of the participants commented on the fact that the systems approach led to much more sustainability.
Several commented on the fact that they had seen various projects and initiatives move far beyond the original parameters because of a systems approach. For many, the key takeaway was learning to ask new questions, often the “wicked questions” that exposed a paradox and forced new ways of thinking. For one, it was questions about the scalability of change; for another, “The key question is, how do we mobilize the right elements of the system for change?” In other words, questions about connectivity and collaboration have become central to their thinking. Top
One of the complex systems approaches that resonated with several of the interviewees was what is often referred to as the “butterfly effect” (first described by EN Lorenz in 1963). That is, the notion that small actions, especially in the early stages of a change, can have disproportionate impact. In other words, systems behave in unpredictable and non-linear ways. As one interviewee commented, “the complexity of health care can be overwhelming but then I remind myself that small changes, sustained over time, can lead to big changes.” In several of the action learning projects discussed, participants saw evidence of this effect as small changes, such as providing colleagues with regular data on their performance, began to have significant impact on departmental behaviours and results. Top
Outcomes of the action learning projects
Although not the most important aspect of the PLDP, the action learning projects gave participants the opportunity to apply their learning to a specific systems challenge and present the results to their colleagues and guests in a poster format. The range of subjects was enormous: some had immediate impact, a few had little impact, and several others had a significant long-term effect on the system. The latter included:
Space does not permit us to list all the outcomes of the projects. Perhaps what is more important is to recognize that program participants now believe that they have the skills, perspectives, and commitment to establish multilateral relationships that will help them push forward with any number of initiatives that will have a significant and sustained impact on the Ontario health system — which was at the root of the intent of the program. Top
The PLDP appears to have been a life-changing experience for many of the participants. Those who were involved in medical education lauded the structure of the program, and the many participants who had never had any form of leadership development are demonstrating ongoing commitment to the learning they acquired.
The OMA has been front and centre in organizing annual reunions to provide ongoing education and support for alumni. In several locations, most notably Ottawa, graduates have self-organized into a learning group that continues to find new ways to work together. It would be worthwhile for the CMA and OMA to look for ways to extend the impact of this sort of program to reach a critical mass of physicians as change agents. Top
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Peter Dickens, PhD, is a principal in the Iris Group, a consulting firm, and an adjunct professor at Tyndale University.
Sandra Fisman, MBCh, FRCPC, is professor and chair, Division of Child and Adolescent Psychiatry, Schulich School of Medicine and Dentistry, Western University.
Kathi Grossman, BA (Hons), MCPM, is senior program coordinator at the Schulich Executive Education Centre (SEEC). She is responsible for coordination and project management of the PLDP and other custom programs developed and organized through SEEC.
Correspondence to: email@example.com
This article has been reviewed by a panel of physician leaders.
KEY WORDS: physician leadership development, systems change, program design, Schulich Executive Education Centre, evaluation, Ontario, action learning, complexity