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Creating Effective Leadership in Medicine


Historically, leadership positions in medicine have been filled too often as a soft landing for an end-of-career doctor or by the only doctor willing to take the job and do the work. We need to recognize the need for trained leaders but we cannot stop there.

The current model isn't working. And it is costing us enormously, both individually and collectively, as well as adversely affecting our ability to do the most for our patients.

Physicians are central to the very idea of medicine, but we have become an afterthought in the increasing national effort to grapple with health care's huge cost and disorganization. We have a seat at the table, but increasingly we are bystanders, a matter of window dressing. So it is left to the body of medical practitioners to realize that physician leadership may be central to the survival of the profession and our mission. Why aren't out leaders more visible, more effective? And what are leaders anyway?

Leaders are not necessarily charismatic or a manager. They provide three vital functions for the group that they purport to lead. The most vital is providing a balcony-view vision of where the group is going, and why and how to get there. The leader must be capable of spreading ideas quickly, effectively communicating them on a broad basis and motivating the group to share that vision.

Secondly, an effective leader must identify and emplace the best possible people to help achieve that vision. And lastly, a leader must make the crucial decisions about the allocation of precious capital.

And leaders must be able to cope with ongoing, often unplanned change. In sum, a leader should be "Challenging the process, inspiring a shared vision enabling others to act, modeling the way and encouraging the heart." You know, connections, relationships, trust, optimism.

"It's amazing what you can accomplish when you do not care who gets the credit," President Harry S. Truman once said.

Historically, leadership positions in medicine have been filled too often as a soft landing for an end-of-career doctor or by the only doctor willing to take the job and do the work. Leaders by accident or by circumstances have too often been the case. But there is a potential advantage to having a physician fill the chief executive offer position in many health-related organizations, if possible. A doctor with clinical insight, with a deeply rooted understanding of the core values in medicine, separates him/herself in that way from a non-physician executive. But, the mere placement of a physician in a CEO position is insufficient.

So how do you identify and/or train a leader? Peter Drucker, the management guru, pointed out "There are born leaders, but too few to depend upon them." Everyone agrees that we need more, a lot more, and that we need them now. But how do we do this?

There is ample evidence that in addition to talent and desire, training, mentoring, experience and practice can produce effective leaders. Aspiration and inspiration alone are not enough. Wiley Souba, MD, the Dean of the Dartmouth Medical School said that "Learning and leadership are inextricably linked." But certainly not as a recent Dilbert cartoon suggested when the pointy-haired boss said, "A big part of leadership is guessing."

Here is the central point I want to make in this column: "There is nothing in a physician's education or training that qualifies him/her to become a leader” (Mathis).

Doctors are trained to tend trees, not forests. Decision-making at an individual level — not the collaborative — while broadly-based thinking and decision-making are now required. But we have, partly by inattention to circumstances racing away from us, come to the point where physician primacy in health care is threatened by civilians just watching the costs. One of our overdue responses must be to train our successors to generate attention to the big picture as essential to effectively managing our patients' health on an individual basis.

There are an increasing number of doctors who are getting post-graduate MBAs, etc., as the awareness and necessity for knowledge outside of traditional physician preparation rise. This is OK as far as it goes, but it is not a general solution. Removing doctors from their practices to learn and train for an effective leadership role is not feasible on any, except an occasional, basis.

The central point that I make in many columns is that medical education and training do not accommodate the essential and central importance (emphasis supplied) of some basic, appropriate understanding of business and organizational functioning or leadership. And this heritage-based under training for the new circumstances that we now function in has become a key reason why health care is disorganized, wasteful, and less effective than it could be.

With our rising awareness, there is need and great opportunity for collaboration and interactive programs with business schools. Dr. Souba, quoted above, for one, happily is leading in this direction.

As the military has learned, the hard way, you cannot have an effective leader unless you have also followers who are trained to understand. And doctors are trained to be the jack-of-all-trades Lone Ranger, not the collaborative, all on the same page, technically skilled professionals we now need today. Dr. Arnold Relman once described "the medical-industrial complex" that is taking over what has traditionally been a mom-and-pop type of medical system..

Yes, we need to recognize the need for trained leaders and, no, we cannot stop there. We must have a new ethos in physicians' general selection and training that will allow leadership to succeed, not be "rope-a-doped" by medical cats resisting herding.

Please do not think that this has been a screed against the hard-working doctors in leadership positions in many of our local and national organizations who share my frustration. I would rather see a discussion accelerate on how to bring the necessary changes about to make our lives easier and our work more productive. After all, we are truly in this together and would all dearly love to see better outcomes, less waste and a more rational setting for doing what we have pledged our lives to do.

There is an old Chinese proverb that applies; "The wicked leader is whom the people despise. The good leader is whom the people revere. But the great leader is seen when the people say ‘We did it ourselves!’”

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Victor J. Dzau, MD, gives expert advice
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