Can physicians lead other physicians into the future? (Servant Leadership).

THESE ARE TUMULTUOUS TIMES FOR PHYSICIANS. Our culture is In dissolution, Competing paradigms are challenging our assumptions, beliefs, values, roles, relationships, and behaviors. How will physicians emerge from this time of transformational change? Why are there so few visible physician leaders? Why is the half-life of leadership positions so short? This article reflects upon some of the dynamics that prevent physicians from successfully engaging change.

As Shell and Klasko (1) have observed, physicians are enculturated to be competitive and hierarchical, and to value personal autonomy. These traits promote distrust and inhibit the formation of collaborative relationships. At this time of growing complexity, when most other industries are developing styles of work based on teamwork, worker empowerment, cross training, and information sharing, physicians cling to the metaphor of the ship's captain, a lone decision-maker and authoritarian possessor of grand knowledge.

The science of medicine is rooted in scientific reductionism, a Newtonian world of universal laws and linear cause and effect. Furthermore, clinical decision-making processes have reinforced a way of thinking that predisposes physicians to think in terms that are personal, anecdotal, linear, and with a short-term frame of reference. Health care is, however, a complex adaptive system, a non-linear world where the future is not only unpredictable, but in fact unknowable. Linear thinking interferes with physicians' ability to negotiate new roles and relationships with persons who have a systems perspective. Indeed, physicians are organizationally impaired.

Valuing autonomy interferes with a willingness to enter into positions of positive leadership. Physicians are reluctant to speak on behalf of other physicians because they would resent others presuming to speak for them. This same attitude precludes followership. The only frame of reference that practicing clinicians have for working together is the formal medical staff structure. This is a place where one person, one vote rules and where managing consensus is paramount. The structure and processes are dysfunctional, and at best serve only to preserve the status quo.

After reading James O"Toole's book, Leading Change, (2) I can understand and appreciate the necessity for organizational resistance to change. Groups share an ideology that serves to define who they are, and to justify their behavior. Because they share these fundamental assumptions, they reinforce each other's interpretation of experience. Those who would challenge these assumptions on behalf of the group are not seen as "offering the prospects of progress, but in fact as giving reproach to the duly constituted social order." (2) Those who don't do what everyone else does, or do what no one else does, threaten the group and must be excluded. Is it any wonder that those who articulate for change are summarily rejected? This is one reason why physicians who take administrative positions are perceived as being outside the group. As they begin to negotiate for new relationships, they are seen as traitors,

Plato's cave

The allegory of Plato's cave is most insightful in explaining the dissonance that exists between leaders and their potential followers. (3) All have spent their lives chained inside a cave where their only reality is that of reflected shadows on the cave's interior wall. One is freed and taken outside where he can see a truer representation of reality.

As he returns to the cave to share his new-found wisdom, he encounters two difficulties. First, coming from the light into darkness, he cannot see the shadows as well as those who remain dark-adapted inside. Secondly, never having been outside, those inside have no frame of reference for understanding what it is the liberated person is trying to communicate. Indeed, they resist any thought of going outside, because if you do, you "return without your eyes.

Plato observes that those who have entered into the light strongly resist returning to their former world of darkness. In attempting to influence colleagues, frustrated change agents often conclude, "They just don't get it!" Those who would lead must find a way to communicate in terms that others can comprehend. In this dialogue, Plato further states that the most effective leaders are those who would not personally benefit from the changes proposed, a reference to servant leadership. (4)

Expectations being challenged

O'Connor and Lanning have written a wonderful article on professionalism wherein they define autonomy as the essence of professional status. (5) Autonomy, the sine qua non of professionalism, is granted by society in exchange for meeting multiple expectations. These expectations include the following, all of which are being challenged:

1. Establishing criteria for admittance and licensure. Two aspects of this function include credentialing and peer review. Because physicians have been reluctant to effectively perform these functions, external agencies have begun to establish criteria that define acceptable standards of practice.

2. Holding members accountable for a level of performance higher than that required by legalities. Here, too, physicians have failed to commit to outcome measurement, and to identifying and applying processes of care that maximize outcomes. Indeed, our only experience with measurement is for judgment and not improvement. (6)

3. Committing to an ethic that holds service to others above economic self-interest. The present climate of concern regarding fraud and abuse reflects society's growing suspicion that physicians may be making health care decisions more in deference to economics than patient welfare. Similarly, data showing wide variation in application of health care resources have called into question the basis for clinical decision-making.

4. Defining how the profession should be organized and how services should be delivered. Having decided that health care resources are no longer unlimited, society has asked for better value. Insurance companies, HMOs, legislatures, and the business community are orchestrating the reorganization of health care delivery, in part because of physician unwillingness to positively respond to this need.

Failure of physicians to perform these functions and thereby satisfy society's expectations risks losing autonomy and, therefore, loss of professional status.

A blueprint for change

Having described several dynamics that limit physician ability to successfully accomplish transformational change, I would like to offer for consideration the following recommendations:

1. Learn to work differently. Changing health care economics are forcing physicians to work harder and longer to maintain their expected level of income. Finding time for meetings is becoming progressively more difficult. One way for physicians to aggregate and successfully influence the reorganization of health care delivery is for them to be willing to delegate this responsibility to those willing to commit the time, energy, and vision necessary for effective leadership. Also, working this hard steals joy from the practice of medicine,

2. Stop trying to manage consensus. All new ideas are imported. Invest in early adopters. Send them out of the cave, expose them to new ideas, and then give them the space, time, and resources to play with these ideas. Their successful adaptation of new behaviors is what will influence the behavior of the early majority, a group that is primarily influenced by what happens locally. (6)

3. Commit to measured accountability. Define excellence, measure for improvement, and demonstrate professionalism. Above all, recommit to service. Society will determine what a physician's services are worth. I firmly believe that physician stature and economic success will be derivatives of a recommitment to service. If economic gain is directly pursued, physicians risk losing professional status.

4. Think systemically. Physicians must not see themselves independent of the system within which they work. For a system to be optimized, no component of the system can be optimized. (7) Physicians must abandon the military metaphor and adopt an ecological metaphor. Future success demands collaboration. This is a process of successful co-evolution and interdependence. We must surrender individual autonomy in order to preserve group autonomy. We must lead from a position of service.

5. Don't make the mistake of thinking that people will follow because you are right. Similarly, while negative vision (crisis) can serve to overcome inertia, it is never sustaining. Leadership is about a transcendent vision that encompasses the needs and aspirations of followers. Leaders highlight the best in their followers, thereby giving them hope, and they help create the vision of a place far better than what the followers could have imagined on their own. (2)

6. Create relationships based on shared purpose and principles. The complexity of medicine and the economics of health care are forcing physicians to aggregate. I am convinced that relationships based on economic self-interest do not endure. Once the marketplace contracts, and as health care approaches commodity status, those trapped in a zero sum game of economic self-interest become exhausted by quarrels over dollars and cents. The relationship is only as strong as the next better offer.

7. Enjoy the journey. The magnitude and the speed of change will only escalate. There is no end point, no fixed destination, The future is unknowable. Purpose and principles give stability and direction. Live in the present. Choices made today help create tomorrow.

Conclusion

Can physicians lead other physicians into the future? Do we have the courage to respond to a call to collaboration around a sense of shared commitment to the pursuit of a vision rooted in the common purpose of service and measured accountability?

As Viktor Frankl has written, life isn't about homeostasis, stability, and responding to circumstances to reestablish a tension-free state. Life is about responsibleness. It is a search for meaning and purpose, a committing to something or someone outside of yourself. (8) The profession of medicine, perhaps more than any other calling, ought to have a built-in sense of meaning and purpose. Yet, how many of us sleepwalk through our day? How many patient interactions have become transactional rather than transformational? How often has the means become the end? Ours is meant to be a life of meaning and purpose. Let's rediscover our history, and decide what is immutable and what is historical artifact. Let's stop viewing change through the eyes of a victim, and rather become leaders and architects of the future.

References

(1.) Shell, G. Richard, J.D., and Klasko, Stephen K. "Biases Physicians Bring to the Table." The Physician Executive. December 1996.

(2.) O'Toole, James. Leading Change. New York, New York: Ballentine Books: 1995, p. 282.

(3.) Gordon Snow (annotator). Plato's Republic Book VII, "The Cave Allegory". (http://www.bluemoon.net/harrsnow/philasst/platocav.html). 1998.

(4.) Greenleaf, Robert K. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. New York. New York: Paulist Press: 1977

(5.) O'Connor, Stephen J., tanning, Joyce A. "The End of Autonomy? Reflections on the Post Professional Physician." Health Care Management Review. 1992: 17(l):63-72.

(6.) Berwick. Donald M. The Ingredients of World-Class Health Care: Distinctive Characteristics of the Puture Outstanding Health Care Organizations. VHA's Physician Leaders Forum presentation, Dallas. Texas. October 24, 1997.

(7.) Senge, Peter M. The Fifth Discipline. New York, New York: Doubleday: 1990.

(8.) Frankl, Vikior. Man's Search for Meaning. New York. New York: Simon and Schuster: 1962, p. 156.

Joseph S. Bujak, MD, FACP, is Vice President, Clinical Resources/Improvement Services, VHA, Inc., Mountain States Office, and Vice President, Medical Affairs, Kootenai Medical Center, Coeur d'Alene, Idaho. He is also an affiliate of Kaiser Consulting Network in Brighton, Colorado and can be reached by calling 208/666-2014, via fax at 208/666-3299, or via email at [e-mail].