Physicians Leading | Leading Physicians

Three Starting Points for Physician Leadership

Article · August 7, 2017

Physician leadership has come to be viewed as a critically important role for hospitals, health systems, and physician organizations. Some places have invested in physician leaders for many years, such as the multispecialty physician group practices inspired by Mayo Clinic, including Geisinger Health System, Cleveland Clinic, the Carle Foundation, Lahey Hospital & Medical Center, and Virginia Mason. But most hospitals and other provider organizations not originally structured as physician-led have only recently come to value doctors-as-leaders.

These organizations struggle with how — how to select and groom, nurture, and foster effective physician leadership.

How to Set Up Physician Leaders to Lead

Every physician leader walks a fine line. Executives and administrative leaders rightfully expect that those paid to lead physicians will convey and endorse policy, sanction change, and execute plans — in short, take on the mantle of leadership. Yet physicians have traditionally expected something different of their leaders. Valuing their own autonomy, physicians are reluctant to delegate authority. They see a department or divisional leader as the point person for administrative issues, but not strategic questions. The leader advocates for the department’s needs and buffers the burden of administrivia.

Early in my consulting career, a doctor explained that his chief’s job was to make sure the department ran smoothly, but was not “one millimeter” above himself in the pecking order. I’ve heard variations on this theme repeatedly — the leader as first among equals. It‘s deeply rooted in physicians’ professional psyche.

Deep and fundamental change within organizations is required to morph from having doctor leaders in name only to them gaining respect and functioning effectively.

Here are three issues that need to be addressed:

  • Authority commensurate with responsibility
  • Balance of roles with administrative leaders so that doctor leaders can be empowered
  • Acceptance by rank-and-file physicians of the need for leadership

A Title That Means Something

Full-time managers tend to be hired for their fit with a detailed, written job description, and they expect feedback on their performance of those responsibilities. That’s often not the case for physician leaders. “Do the best you can” seems the implicit — and sometimes explicit — expectation in organizations I’ve visited.

Too often, responsibility is not matched with authority. The common lament of doctors-as-leaders is, “I’m held responsible for results without having the authority to do half of what they expect.”

The currency of leadership in physicians’ eyes is “getting stuff done.” If a leader has little authority to address the “stone in the shoe” issues that contribute to burnout and alienation, he or she can’t be helpful to colleagues and will be dismissed as impotent to solve vexing issues.

A job description that sets out clear responsibilities is the starting point for a meaningful role. And the time allotted to do the job must be realistic — not a multi-page job outline for which five hours a week is designated. Like other managers, physicians deserve feedback on their ability to carry out their responsibilities. It’s not a “real” job if the general attitude is “Thank goodness Dr. Smith is willing to do this messy job. However far Dr. Smith gets in moving things along is much appreciated.”

Getting the responsibility-authority match right is essential for empowered and respected leaders. But this can be a dicey issue. Where there is a history of physician leaders serving primarily as advocates for narrow interests, with little regard for the overall enterprise, the administration isn’t unreasonable to think twice about granting such leaders expanded authority.

Parity Among Administrative and Physician Leaders

In dyad management structures, such as at Mayo Clinic and Carle Foundation Hospital / Carle Physician Group, a physician leader and an administrative leader jointly hold responsibility for a unit’s performance. When the model works well, administrative managers collaborate with and support physician colleagues instead of keeping them at arm’s length.

But that cooperative spirit is undermined when administrators carry the lion’s share of leadership responsibility (that is, power) and clinical department heads see themselves only as protectors of the status quo. Alternately, in some organizations middle managers see themselves as “capes” — superheroes who swoop in to remedy problems. If their lock on status is tied to being “the fixer,” partnering with a physician colleague and nurturing that person’s leadership ability won’t come easily.

For health care organizations unused to the dyad model, developing a collective physician leadership capability requires adaptive change, in the words of leadership scholar Ronald Heifetz. Heifetz distinguishes between two sorts of challenges: those that are technical, where a roadmap to follow exists; and those he labels adaptive, which provoke unease, stress, even anger. Adaptive challenges upend longstanding traditions and deeply held beliefs. They take time and usually a good deal of dialogue about what is changing and why.

Simply appointing a doctor to fill a leadership post isn’t enough. It’s essential that administrators, including the C-suite, understand what they need to let go of in order to gain empowered doctor leadership. For most, that’s an adaptive challenge.

A New View of Leadership Among Physicians

The administrative side of the house isn’t the only one facing adaptive challenges if physician leadership is to add real value to an institution. The physicians being led also have to change.

The herding-cats metaphor so often used to describe physicians has its roots in their deeply held belief that autonomy is central to the practice of good medicine. In this way of thinking, a leader is unnecessary. At most, leaders may be needed to protect “us” from “them” — but not to hold us accountable. This view is toxic for effective physician leadership.

The emphasis on autonomy sometimes makes rank-and-file physicians skeptical of those willing to take on leadership roles. Many a chief or department head has heard the “gone to the dark side” reference. In becoming part of management, a doctor often pays a price; others become suspicious of the real motives for taking on the role.

One way for physician leaders to gain trust and respect is to help their colleagues understand the influence doctors have when speaking with one voice. Physicians gain real currency in delivery organizations when they are able to come together, hash out divergent views, make a decision collectively, and then all abide by their decision. Again, this change often requires a good deal of adaptive change.

A New Compact for Physician Leadership

Physicians have long been used to an implicit social contract that includes the promise of autonomy, protection from change, and status and privileges in exchange for healing, helping, and comforting patients. This compact shapes doctors’ expectations of organizational life, be they employed, contracted, or voluntary members of a medical staff.

For any organization to raise the profile of physician leadership from “whose turn is it to lead the department?” to that of partnership with administration may require an exploration of its implicit compact.

In my consulting work, I have found that shedding light on how existing expectations fit with the organization’s challenges almost always reveals how the compact must evolve. The challenges of health care today require physician leadership and executives pulling together. This new compact should include both physicians’ ceding authority to leaders and administration ensuring that physicians have influence.

A new and transparent compact for health care organizations that includes these elements can serve as the bedrock on which to build empowered and effective physician leadership.


This article originally appeared in NEJM Catalyst on September 1, 2016.

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