Leadership and followership. (Career Management).

In the general literature on leadership, a few traits are highlighted as important for success.

* Projecting a vision

* Being a team builder and leader

* Thinking strategically

* Understanding systems

* Being able to read market forces

These are certainly critical. But let's take a look at some other, less obvious, leadership traits not often noted in the leadership literature. They are not unique to health care.

Demonstrable leadership achievement is a common theme in all of my physician executive search assignments. Those who read my column regularly will recognize that phrase. What does it mean to me?

Over the years, I found myself putting emphasis on several leadership areas that are rarely spelled out in writing.

Balanced leadership

Often, physician executives will claim a key leadership role in the medical community.

Bringing definition to achievement is important in defining candidacy. In one instance, I heard about a physician executive who brought a medical community and hospital closer together.

Under his leadership, the medical community approached the hospital about a high interest in establishing an outpatient surgery center. The physicians were going to partner with some entity to make that happen and they preferred to work with the hospital.

That is precisely what happened. There were no services pulled Out of the hospital or revenue stream. The patients received better care. And the doctors wound up with a substantially better work environment.

In another instance, a physician led the development of what proved to be a profitable, highly workable management service organization for hospital-based physicians. This was seen as a major positive development.

The physicians were able to recruit stronger colleagues with their stability and high care standards. The hospital enjoyed a higher and more consistent level of service from these physicians. And the patients, in turn, received better care.

So-called 'leadership'

In other instances, I hear about leadership that's far more dubious.

For example, an outspoken physician who may be "anti-whatever" when there are new initiatives on the table may be regarded as possessing "leadership."

It is leadership of a sort, as there are many ideas and projects that are defeated early on due to lack of support or even opposition. Medical staffs often rely on a naysayer to block implementation or delay a project.

I have heard more than one aspiring physician executive boast of leading the charge for a vote of no confidence for a departed CEO. There sometimes needs to be a change at the CEO level, but the damage that follows is often significant and it may take years to recover.

Another instance of questionable leadership is when someone structures an approach where none existed before -- with system-wide credentialing or quality improvement, for example.

A void may be filled and an approach created, but no fundamental change in thinking occurs. While certainly this structural work is important, it is not commonly the impetus for changing the way physicians relate to a health care delivery system or how they care for their patients.

Positive followership 

Positive followership is a term for the changes that take place in a health care community that experiences genuine growth and development of patient care systems.

It's what happens when physicians are on board with the changes and the organization performs at a new improved level. The litmus test is always whether the changes enhance patient care.

When possible, the physicians should do better as well, although that is not the original catalyst for change. It is this type of leadership that progressive health care organizations are seeking.

Here are some questions to ask yourself about your leadership achievement:

* Who is your constituency?

Someone actually leads the medical community in your organization -- is it you? Who would the physicians say they look to for leadership? It might be an appointed chief of medicine. It might be the VPMA. Or it might be someone lacking any trappings of power -- but who has the respect (the hearts and minds) of the medical staff by demonstrating courage and commitment to their goals. This is not difficult to establish. Physicians know whom they follow. If you don't have followers, you aren't a leader -- no matter what it says on your business card.

* Are you internally driven?

Externally driven leaders continually need praise and positive reinforcement from others. They may do the right thing, but they may be less able to stay the course when things become complicated or difficult -- when praise is hard to come by. Internally driven leaders are more effective. They provide their own motivations and strength of purpose and don't rely on others to keep going. When you embark on a tough course of action, ire you able to stay focused or do you need the constant approval of others to move forward?

* Do you know when to make a decision -- and when not to?

Health care systems continue to undo decisions driven by market preservation efforts. Decisions were made about physician-owned networks and provider-sponsored health plans by people who took their cues from what everyone else was doing. Some health care systems did neither. Sometimes, the best thing you can do is nothing just hold your own and wait for better times. It can be hard, especially when others are clamoring for action, but leaders can stand firm when necessary. Having the wisdom to resist the siren call of ill-conceived ideas is a key aspect of effective leadership. At the same time, I've worked with physician executives who moved quickly and made outstanding (and serendipitous) decisions. Knowing the difference is everything.

* Are you effective at managing managers?

The best leaders understand the deeply contradictory truth that you hold on to power by giving it away. Leaders who trust the teams they've assembled are both developing new leaders for the future and multiplying their own influence and effectiveness. Functioning at this level is a far cry from the management of a department. It requires a true recognition of what management is about.

* Are you tolerant of diversity?

I'm referring here to diversity of style and philosophy. Yes, it is important to be able to fit in, but accepting true diversity means being open to a wealth of different ideas and approaches that ultimately will strengthen a team.

* Is your sense of humor in good repair?

The strongest leaders love to laugh and they laugh hardest at themselves. Take yourself really seriously at your own peril. So many times, a disarming remark or a light touch can make a positive difference. A lack of humor is always noticeable.

* Are your honest with yourself?

You may have the appearance of leadership, but are you a leader? Be honest and sincere in your self-examination. Don't try to paper over issues or settle for easy answers. If your organization's COO left tomorrow, would you be a viable internal candidate for the job? Would you be taken seriously in competition with talented people at your level from around the country? Are you clearly recognized as a tough proactive leader in this organization? If the answer is an unequivocal "yes, you're ready to take on a leadership role. Your leadership is always defined by how well and how much you are followed, after all.

Mary Frances Lyons, MD, is a senior consultant at Witt/Kieffer in St. Louis, Mo.

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Along with the well-known leadership traits, there ore some subtle characteristics of true leaders. Managing managers, making decisions, tolerating diversity and showing a sense of humor are other marks of leadership that physician executives should possess.