Learning to be a leader.
Leadership has emerged as a crucial factor in effecting successful outcomes in American business today. The concept of a leader has evolved from an autocratic task master to an empowering visionary who uses multiple skills to enable employees to maximize individual and group endeavors, thus improving the organization's performance.
The health care field is in the midst of evolutionary changes; even the definition of health is changing. No longer is the focus on the traditional doctor-patient. relationship. Instead, health care delivery has been transformed into a business whose interest centers on managing the health of "covered lives." In this transition, divisions and relationships between the participating segments, such as hospitals, insurers, and physician groups, become increasingly blurred.
Before health care reform, doctors primarily cared for patients, business managers ran doctors' offices, and business executives ran hospitals and insurance companies. As the business role of health care delivery expands and complex reform is imposed, physicians will need two assume an integral position in the business of successful medicine.
To have the necessary impact, physicians must assume leadership roles and imprint medical expertise on business dynamics. Becoming a leader is an active and arduous process that can no longer be approached haphazardly. To be effective, the physician must plot a course with clear and calculated intent and effort, which requires acquiring organizational tools and administrative skills to innovatively alter medical care for the good of all. Organizations that are truly invested in improving quality of care recognize the crucial role of physician leaders and will recruit them, give them opportunities to learn, and reap the benefits of that investment.
Evolution of physician
Physicians have controlled the practice of medicine and defined the structure of care delivery, acting as managers for the entire system. Until the mid-1980s, physicians' roles in medical management primarily included running a private or group practice and participating, often reluctantly, in the work of hospital committees. Since then, physician managers and executives have functioned in a wide range of settings. Academic institutions have had a more structured hierarchy of management positions for physicians, and state medical associations and industry have seen physicians assume managerial responsibility. The Medical Director position gained popularity, but was often an adjunct position, instead of true part of the management team. From the perspective of the non-physician manager and board, the Medical Director and Vice President of Medical Affairs were looked upon as mediators, buffers, boundary spanners, and persons responsible for the work of other physicians. Many of the "managerial" positions held by physicians did not include input into the financial aspects and were designed for physicians with limited management skills. In the last decade, growth in the number of physician managers and executives has accelerated.
The physician executive is now entering a new world. The physician leader will be a process connector who sees illness as a whole, a knowledge builder who liberates information, a visualizer who sees the future, a strategist who formulates the path to the vision, a project manager, a team builder, a value creator who optimizes the relation between cost and quality, a generalist, a change master, and a market shaper who keeps an eye on customers and competitors.
The reasons physicians enter management positions have varied. Before the last decade, factors leading to a decision to pursue a medical management career included burnout from private practice, easing into retirement, filling a perfunctory role no one else wanted, dissatisfaction with the practice of medicine, and disappointment due to failed job expectations. Recent data show a different inclination.
Lloyd and Lyons suggest the most common reasons a physician becomes a manager now are a passion for leadership, a desire for new challenges, or a classic career change. A 1992 survey of 176 physician executives demonstrated a number of trends. (Please see page 23 of this issue for the 1996 survey on physician executives) The single most important factor was the perceived opportunity for leadership in a medical organization, cited by 87 percent of those surveyed. The desire to affect organizational policies governing medicine was important for 79 percent; 64 percent indicated that they enjoy the management aspects of clinical practice. Less than a third cited financial considerations, but 70 percent believed a need existed for more physician-centered direction in managing medical organizations. In assessing the choice to pursue a management career, 85 percent of respondents reported a high level of satisfaction.
Almost all physician executives describe their job as a management position. Little is mentioned about leadership. Of 15 physician executives described by Curry, only three referred to the importance of leadership; of these, two were in the military, where training presumably stresses the importance of leaders. The direction of future physician participation more properly entails leadership. The transition will not be easy. However, only collaboration between physician and nonphysician executives will engender powerful change. As medicine faces sweeping changes, only strong leadership will enable both the profession and the principles of quality care to survive.
Theories and models for leadership
The plethora of leadership theories have included the "great man or woman idea," as well as those emphasizing traits, behavior, situations, and contingencies. The great man or woman theory highlights the person, who he or she is, and what made him or her that way. Transformational leaders exert influence primarily through charisma, and in this respect, theories focusing on this aspect are similar to great man or woman idea. However, they do not consider the interaction between leader and situation, and are therefore not universally applicable.
Subscribers to the trait theories believe that certain attributes are common to leaders. However, although this association is true of most leaders, traits have no consistent predictive value, which renders the theory inadequate.
Behavioral models accentuate what leaders do, instead of who they are. Yuk listed 14 categories of leader behavior, including: planning and organizing problem-solving, clarifying, informing, monitoring, motivating, consulting, recognizing, supporting, managing conflict, team-building, networking, delegating, developing, mentoring, and rewarding.
The influence of situation on the leader has led to the contingency theories, which stressed that leadership style is determined by task or group structure, employee or group characteristics, motivation systems, and similar factors that force the leader to match leadership style with situation. Expert power stems from expertise or special knowledge.
Is the use of certain skills part of leadership? In on Becoming a Leader, Bennis states that all leaders share guiding vision, passion, integrity, trust, curiosity, and daring. Leadership presupposes many skills and the use of effective tools tailored to the situation at hand. Most leadership scholars would agree that leaders are made, not born. Although intelligence and certain personality traits facilitate the transformation into leader, most skills can be learned. However, Bennis emphasized that character and vision cannot be taught.
Using leadership skills exposes promising people to challenges which further develop them as leaders. Gardner lists nine skills: Defining goals, affirming shared values, motivating, managing, achieving workable unity, explaining, serving as a symbol, representing the group externally, and renewing the system over which the leader presides.
Robert Katz suggested that effective administrators depend on three basic, developable skill - technical, human, and conceptual - and that the relative importance of the different types of skills depends on the level of responsibility, as well as the situation. Technical skills reflect specialized knowledge and analytic ability. Human skills are those "people" skills used to work within a team effectively and to enhance cooperative efforts among members. Conceptual skills relate to the ability to perceive the organization as a whole and promote actions which enhance its welfare.
Regardless of the exact list of skills leadership is predicated upon, many must be acquired by identifying, learning, and perfecting them by practice. Leadership, although considered easy to recognize, remains hard to define and requires persuading others to temporarily set aside personal concerns to pursue common goals important to the group. A leader causes the whole to exceed the sum of the parts.
Factors unique to physicians' training
Many management skills required to succeed in today's health care arena do not come naturally to physicians, because traditional medical training does not prepare doctors for leadership roles or practice management. Yet some abilities and skills physicians use are transferable to the managerial setting. One of the most important is credibility. The well-respected, excellent practitioner who has a "track record" can be most influential with peers and colleagues. The establishment of credibility takes time and must be rightfully earned.
Good doctors also learn how to listen to people and interpret nonverbal cues, important assets in leadership roles: Active listening is an important attribute for leaders. In diagnosing illness, physicians use acumen and analytic ability to assess complex, interdependent conditions and must often consider multiple problems concurrently. Medical school fosters lateral thinking processes which help integrate several pieces of different information simultaneously. Lateral thinkers tend to be creative and resourceful, which helps to enhance managerial performance.
Responsibility for patient lives and care requires self-confidence and ease in having authority over others and in dealing with ambiguity. Physicians in clinical practice often demonstrate a high level of endurance, as well as personal motivation and mental resilience, and are often accustomed to working long, arduous hours. They are used to crises and tension, and remain calm in the face of them. They can also demonstrate interpersonal sensitivity in dealing with patients and families, which helps them develop the people skills that leadership requires.
Special problem areas for physicians
Physicians bring many talents and capabilities to management, but they also have deficiencies. The road from clinical practice to medical management is often difficult and produces disorienting alterations of perception and function. A survey of physician executives found six areas of difficulty in the transition from clinical to managerial medicine including: psychologic adjustment, change from independent to dependent role, change in focus from patient to organization, naivete about organization dynamics, new skill requirements, and change from a controlling role to one of persuasion, from a comfortable relationship with colleagues to one based on authority, and from medical to business competence.
Clinicians sometimes champion individual patient care over institutional goals. Physicians are accustomed to looking at medicine from a quality of care standpoint and are not used to a cost orientation, which can result in conflict when performing administrative functions.
Moreover, most physicians distrust management, which affects the relationship between former colleagues and their new physician managers. Doctors have little respect for authority based on hierarchy and are more impressed by accomplishment. The new physician executive is excluded from the collegial circle, deemed untrustworthy, not taken seriously by other physicians, and experiences a change in social status.
One of the foremost differences between clinical and managerial medicine is that the clinician functions with autonomy and independence, usually works one-on-one, and often has an authoritarian instead of participative style of management. Managers and leaders work in groups and use teamwork work models and skills. Physicians are more discipline-oriented than socially oriented. When solving problems, physicians acquire large amounts of data to be scientific and objective about reaching a conclusion. In contrast, managers often must work with limited information and rely on intuition, experience, and reason. In managing patients, physicians receive immediate gratification, often enjoy instant, tangible results of intervention, and may have difficulty adjusting to the long-term outlook that characterizes the business sector.
Physicians often find that the very skills that served them well in practice are a small part of what is necessary to succeed in business and may hamper and impede management effectiveness. An apparently simple change in career emphasis may actually be a career change. With it, a series of necessary transitions evolve. Therefore, physicians come to management with many advantages, relating to their clinical expertise and credibility, but must quickly and effectively add people-oriented business skills, as well as technical business knowledge, to retain credibility and exert positive influence.
McCall and Clair summarize the "deadly flaws" of physician managers as insensitivity and arrogance, inability to choose staff, over-managing or inability to delegate, inability to adapt to a boss, fighting the wrong battles, being seen as untrustworthy, failing to develop a strategic vision, being overwhelmed, and lacking specific skills or knowledge.
What do successful organizations do to foster effective management and leadership skill? Where in the continuum should efforts be focused - hiring, development, formal education, mentoring? The Executive Resources Questionnaire24 gives some insight into this area. Fifteen of the top firms were selected based on
Fortunel's 1985 Reputation Study, in
which companies were rated by experts on management quality and success at attracting, developing, and retaining talented employees.
This survey covered questions about management quality, as well as practices that affected quality. Firms with superior management perform above average age at all levels - recruiting, developing, retaining, and motivating leadership talent - by using more than a dozen practices. Such companies attract leader candidates with a sophisticated recruiting effort, incorporating direct participation from line management personnel.
At Merck, the CEO personally took part in the process, keeping standards high and paying attention to leadership potential when recruiting. The CEO reinforces belief in the value of leadership and in its recognition and development by ensuring that the corporate culture provides appropriate rewards for those practices.
Another major factor in successful firms was early identification of leadership potential. Attaining a leadership position takes time. Identifying candidates early on allows them to develop appropriately. These companies exert intense effort in planning the leadership development of candidates.
Opportunities include on-the-job assignments, formal training sessions inside the firm or at public seminars university course work, task force or committee assignments, mentoring or coaching by a senior executive, special projects and development jobs, and attendance at meetings outside the candidate's core responsibility. Many firms that use formal training do not see it as a substitute for experience, but as an adjunct that enhances lessons learned and helps employees learn more from future assignments.
Benefits of leadership
A major problem in leadership development programs is measuring leader effectiveness. The true test is the leader's impact on an organization's profitability, the quality of its services, and the market share it gains.
Are leadership development programs able to create effective leaders? Only a few studies suggest that certain characteristics of leaders are associated with enhanced team performance. Several attempts have been made to show that subordinates can relate performance and satisfaction to leader behavior. Although actual experience seems to reflect that effective leadership is measured in organizational performance, the exact association between outcome and leadership is difficult to measure objectively.
Research on physician executives is equally limited. Dunham attempted to show the value of the physician executive role in terms of an organization's effectiveness and performance. This study surveyed physician and nonphysician executives about the importance of physician executives, function in 16 selected organization objectives. The results showed that both groups rated the performance of the physician executives' role highly (more than 80 percent).
If clearly measuring the effectiveness of leadership training programs in the general business sector is difficult, attempting it in the medical sector is doubly so. Except for questionnaires, which subjectively rated the training program, no accurate way of evaluating its effectiveness exists. Program evaluators are convinced that benefits can be gained from these programs, but acknowledge that enrollees must apply the information and tools gained appropriately.
Human behavior is inherently difficult to measure, and this difficulty is compounded when attempts at objective performance outcome measurement are made on a larger scale, such as in measuring an organization's productivity. Seeing whether performance exists is probably easier than measuring its quantity. Thus, initial measurement may be more appropriately made at the personal level than at the corporate level.
Physician leadership model
Although learning by didactics is important, behavior can only change substantially through experience and feedback. Marr and Kusy described a comprehensive program for training and developing physician leaders that focused on three areas of learning: Management, interpersonal - individual and group, and leadership. A guide to some essential leadership elements follows.
Knowing one's style can enhance learning the people skills necessary for leadership. Understanding one's problemsolving approach can be effective for filling team management roles and producing desired outcomes.
Also key is understanding one's value system. Leaders will instill their values into the system, and the organization's culture will reflect their beliefs. if the physician leader is to create a shared vision, the values, beliefs, and attitudes underlying that vision must be clear. because actions do speak louder than words, visions must be translated into action, and the leader must show - by personal example and by surrounding himself or herself with people with similar value - that these values and beliefs are more than words in a vision statement.
Identify potential leaders
For physicians, organizations can range from large industry or governmental bodies to practice groups. In those groups or organizations, the higher-level staff should understand the leadership theories and be aware of physicians who show potential or emerging leadership qualities. This identification process should be active. To show leadership skills, candidates must be put in situations where they can not only learn and improve their abilities, but also use their abilities. The increasing need for leadership in medicine requires the utmost effort to identify those who will take medicine where it must go.
Many successful people can find someone in their past whom they either admired or found inspirational and who therefore enhanced their progress. Clinical medicine is no exception. However, this tool has not necessarily been used in administrative medicine, as can be seen from Curry's account of the 15 physician executives who stumbled onto the medical leadership path.
This tool can extend in both directions: The mentor may seek out the candidate, or the candidate may seek out the mentor. If physicians decide early that administrative medicine is their goal, elective rotations in residency or formal internships with recognized administrative physicians may be beneficial. One hospital formed a committee of former chiefs of staff to not only act as advisors to staff but as mentors encouraging other physicians to participate in staff leadership roles.
The physician with clinical expertise, who is already well known and respected by peers, is most likely to succeed in an administrative position. The process must run its course, and the ability to prove oneself clinically is a must. The minimum practice time required for the management board certification examination is three years.
Most physicians surveyed by Curry and others indicated that a five- to 10-year stint in the clinical sector more accurately reflects what is needed. This preceptorship time not only lends credibility, but also provides valuable working knowledge and an overview of what medical practice and quality of care are all about. Without this perspective, the physician administrator will be powerless to implement the main vision of the venture - to preserve quality of care while performing cost-effectively.
Understand leadership and motivation
Familiarity with leadership theories assists an aspiring leader in more astutely understanding the qualities and skills required for greater effectiveness.
Personal or people skills are probably the most important to leaders, and learning them also requires the greatest effort because physicians often have been counter-trained or have learned opposing techniques through their practice. The most useful "soft skill" is probably communication.[30,31,32] The areas absolutely critical for effective leadership are active listening for effective communication, giving and receiving feedback, conflict management, persuasion, negotiation, influencing others, time management, delegation, team building, and trust building.
Although basic skills can be learned from course work, readings, independent study, continuing education programs, and seminars, learning them really entails personal development, and they cannot be adequately mastered in a short-term training session. The key is to commit oneself to practicing these skills in everyday settings, to continually evaluate outcomes, and to reassess methods for maximizing effectiveness in each situation.
When joining committees or task forces, consider it a learning opportunity, as well as a chance to contribute. Use these settings to explore how well skills work and to hone them thoroughly. Consider volunteering if you're not invited to participate. Day-to-day activities are fertile ground for practicing and developing leadership skills. Another excellent opportunity not only to enhance leadership skills but to help fill social needs is to volunteer to work with a community task force, organization, or agency.
These skills are the bread and butter of management and business - and of today's health care executive. These are perhaps easier for the physician to master because they represent a compendium of knowledge, albeit of a different sort than medicine. Moreover, mastering all these skills may not be necessary because the effective leader retains appropriate experts. Nevertheless, the physician leader must understand, be conversant in, and develop strategies in such areas as finance, marketing, accounting, law, and ethics.
To determine one's effectiveness in using tools and skills to improve performance, feedback on that performance must be obtained. Some feedback can be obtained indirectly by observing the increase in measurable endpoints for the task at hand and by determining how well the organization is performing. However, sometimes leaders must obtain more direct feedback concerning performance by asking supervisors directly or by using survey tools to evaluate performance.
Before the end of this century, health care and its delivery will most likely become unrecognizable to those who ended their practices but a decade ago. Traditional management will be replaced by self-managed, self-trained, and self-motivated workers no longer employed in jobs but working through processes, projects, and assignments in integrative health care delivery systems. Leaders will be needed to take us there and ensure that the vision continually evolves.
Physicians are best equipped to chart the future direction of health care. The health care business is still the practice of medicine. However, to position themselves in crucial leadership roles, physicians must attain leadership. Not only physicians who reach recognizable leadership roles, but every physician at every level should invest effort in becoming a leader.
Medical Leadership Training
Recognizing that a step-by-step path exists toward effective leadership is crucial. Although the benefits of on-the-job leadership training and growth may be overlooked or minimized, this area is probably the most fertile ground. Multiple committee and task force memberships, section head or department chief responsibilities, and day-to-day interaction with colleagues and staff give ample opportunity to practice the skills that make a leader effective.
Many health care organizations have in-house management training programs. The Kaiser Permanente Medical Group in California, has a core managerial curriculum offered throughout the year for all levels of management, including physicians. The program is intended to equip physicians with the skills and knowledge needed to implement strategic goals and make the link between enhanced physician leadership and ensured quality patient care. Courses range from a day to a week. Typical course descriptions include facilitative leadership, influence and collaborating for results, interpersonal communications, managing conflict constructively and negotiating for agreement, confronting tough issues with physicians, team building, time management, and tools for productive meetings. Attendees find the course work useful and recommend the programs highly.
Treister describes the Physician Executive Leadership Program at Sharp Health Care, in San Diego, provided through the University of California at Irvine Graduate School of Management, designed to increase physician input into health care changes. The program consisted of II, eight-hour seminars given monthly on weekends to physicians who expressed interest in medical staff leadership and management roles. The format of the program includes lectures, group exercises, case studies, and real-life problem-solving studies designed to "provide the physicians with knowledge and skills necessary to function as leaders in health care." The learning modules cover communication skills, history of the health care system, strategic planning, organization structure and behavior, financial management, quality and outcome studies, and health care reform.
The Northeastern Ohio Universities College of Medicine offers two on-site programs. The first, "Leadership Education for Physician's," is targeted to physicians who have been practicing for three to five years or are new to leadership roles. Topics covered include motivating staff members, promoting teamwork, conflict resolution, strategic planning, total quality management, financial planning, legal aspects of leadership, and implications of health care reform. Instruction is done by lecture, small group work, discussion, personal assessment and exercises, and outside reading.
The second program, "Fellowship in Academic Medicine," or FAME, is also designed to develop faculty leadership skills to enhance ability in administration, research, and education. Participants meet on four weekends throughout the year to cover topics such as, clinical research methods, education development and instruction methods, and administrative and management skills, including conflict resolution, negotiation, performance management, managing groups, organizational diagnosis, reacting to change, leadership styles, personal development issues, and performance feedback.
Degree and certificate programs
Graduate degree programs in business administration with or without emphasis on health care are readily available. In 1979, a national survey of physicians showed none had a master's of business administration (MBA) degree; today, 9 percent have one, and 38 percent are either enrolled in programs leading to the degree or intend to pursue it. Master's programs in public health, medical management, and medical administration are everywhere. For the practicing physician, such programs may be difficult to attend without sacrificing an element of practice or reducing practice load.
The Graduate School of Management at the University of California at Irvine has established the Health Care Executive MBA Program, designed specifically for the health care professional who wishes to obtain an MBA degree while continuing his or her career. This program is different from typical MBA programs in that it emphasizes the application of business elements to the evolving health care field, focusing on "the core of issues and techniques that are essential" to a health care executive's daily professional experience.
One of the more innovative and flexible curricula available to physicians interested in obtaining further education, as well as a recognized degree, is offered through the American College of Physician Executive: a Master's of Medical Management degree through Tulane University and a Master's of Science in Administrative Medicine through the University of Wisconsin. These programs require completion of the ACPE Certificate in Medical Management before enrollment. Then, through several weeks of on-site training, home study, project completion, and teleconferencing modules, the degree can be obtained. The program's flexibility allows physicians to tailor the pace to their needs.
Certification and credentialing of practitioners who meet expected performance standards is traditional in medicine and in medical management as well. In association with the ACPE, the American Board of Medical Management (ABMM) offers board certification for physicians with expertise in medical management who meet training requirements.
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Carol A. Zaher, MD, formerly with the Department of Electrophysical at Kaiser Permanente Medical Center, in Los Angeles, California, can be reached via fax at 310/471-5725.
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|Title Annotation:||contains related information; physician leadership skills|
|Author:||Zaher, Carol A.|
|Date:||Sep 1, 1996|
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