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Complementary and Alternative Medicine: ••Fall 2002/Vol. 6, No. 4 |
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Health Systems Physicians
as Leaders:
Are Physicians Really Viewed by Staff to be Leaders?
Moderator: Probably the best way to open this discussion is to make certain that all of us are on the same page. So let me start by asking: Do you all support the premise that regardless of whether or not they have a formal leadership position, all physicians are viewed by the staff as leaders? Marci Clark: I definitely support the premise. Certainly from the work group perspective, physicians are seen as leaders. They set the tone for the work group. It is also true that not all physicians believe they are leaders. Dr Craig Green: It is important to acknowledge that in our society, there is a hierarchy of people, and like it or not, physicians occupy a place that is fairly high up in this hierarchy. For that reason, people tend to defer to us. I believe that physicians should accept that they are on stage and should act accordingly. Emmanuel Chabrier wrote an opera entitled The King in Spite of Himself, and I think that is the way it is with physicians as leaders. Physicians are leaders whether they want to be or not. Dr Jill Steinbruegge: In addition to the hierarchical piece, there are some other very practical issues that put the physician into a leadership position. For example, it is the physician who determines the pace of the workflow. That then causes the staff who support that physician to act or react in certain ways. It is by default a leadership function. Because medical decision making is clearly in the physician's realm, that drives what the rest of the team does and again, by default puts the physician in the leadership position. Dr Green: When I raised this topic with our human resource leaders, they were very pleased to hear that this discussion was occurring, because they have seen the fallout from physicians who are unaware of the influence that they exert every day. What comes to the attention of human resource leaders are examples of how problems are compounded when a physician leads poorly and the people around him or her emulate that behavior. Ms Clark: That all physicians are leaders is important because it places medical leadership at the forefront of the patient's Kaiser Permanente medical care experience, right where it belongs. Dr Patty Fahy: I agree. It is positional authority by nature of the fact that the physicians' credentials put them into that leadership role. The contract between the Health Plan and the Medical Group also puts the physician in the position of authority and makes physicians responsible for the delivery of medical services. So, it is not only through informal leadership and positional authority but also by our medical services agreement with the Health Plan that the physician has authority for making decisions. Dr Green: The problem for many physicians is that they feel powerless--that what they do doesn't make any difference and that nobody listens to them anyway. They don't realize that people are watching and are going to change how they do business on the basis of what they see the physician do. Moderator: In our team development activities in KP Georgia, we are starting to appreciate the importance of all the physicians on the teams understanding and demonstrating good leadership. In our model for team development, we have learned over the years that certain states of readiness must be addressed before embarking on the journey of developing strong, interdependent teams. In addition to having adequate staffing and a strong physician team leader (the formal leader), getting the other physicians on board as informal leaders is a critical step in having a successful team. Considerations During Physician Recruitment Moderator: Do any of your medical groups have a strategy to select physicians who demonstrate leadership competency skills during the recruitment process? Mr McCabe: In Southern California, I would have to say that we have not had such a strategy as part of the overall interview process. However, in the forefront of the process for some area associate medical directors is the search for physicians who buy into the values and ethics of the partnership of Southern California. Although these characteristics may not always be obvious during the interview process, in our experience, these are the physicians who make good leaders. Ms Clark: Although we haven't had a specific recruitment strategy to address leadership skills, we do screen for quality of communication and interaction skills--both very important considerations regardless of the level of leadership we are talking about. In our recruiting process, we are now beginning to focus more overtly on fit with organizational and medical group goals. What Does Informal Physician Leadership Look Like? Moderator: It might be helpful for our readers to hear your description of what it looks like when a physician is a good informal leader in a workgroup. Mr McCabe: Two things come to mind: First, a significant reflection of the level of leadership is the way a physician approaches the care and the service level given to members. The manner in which they treat members demonstrates the essence of Permanente Medicine. Second, the way physicians treat their peers and staff is important. If they treat people with respect and dignity, it is infectious. Dr Green: I agree with Mike and would add another aspect: self-awareness. Physicians who are strong informal leaders know as they go through their day--and as they go through life--they are not in a vacuum. They realize that what they do has an effect on people, either positively or negatively, and so they take steps to channel each hour in a way that has a positive effect on others throughout the organization. Dr Fahy: An article published in the Annals of Internal Medicine2 mentions that the best physician leaders behave as if they have a patient at their elbow. Although the authors are talking about formal physician-leaders, it is also true of informal leaders. They bring the patient's perspective into every conversation. Excellent physicians are strong patient advocates, and they bring this perspective into their department or clinic and balance the needs of their staff and the patient. Dr Steinbruegge: In addition, our recent research suggests that in successful teams, physicians take responsibility for constructively addressing problems and for engaging others to help solve them. As they say in the KP Colorado Medical Group, these physicians lead by initiating courageous conversations. They give both recognition for good work and constructive feedback about what can be improved. That's strong leadership. Informal Physician Leadership in Action Moderator: Can any of you give some examples of when a physician, without a formal leadership title, demonstrated leadership skills? Dr Tom Janisse: Recently, I presented worklife survey data at our All-Physicians meeting. Afterward, one of the physicians and I were talking about interactions with staff and about expectations and roles. He said, "You know, I actually have a clear statement of my expectations for my medical assistant posted right on my door." I said, "That's terrific; at least you are being explicit about it. Most people don't do that. If people would share their expectations, that would be great." He looked up in the air, thinking, and then back at me and said, "You know what, I never asked my medical assistant her expectations of me." That is an example of a physician "taking the lead." Dr Green: Although I don't have a specific example, there is a situation that happens hundreds of times a day: how a physician deals with patients who are late. The physician can set an example by dealing with the late patient in a low-key, understanding, and positive way, instead of grousing or "flying off the handle." It's amazing how quickly the staff picks up on the behavior the physician models and then almost immediately behaves in exactly that same way to the patient and, I am sure, to other late patients throughout the week. In searching for an example of how physicians' behavior models and affects the tenor in the clinic, their reaction to the late patient is one that really jumps out at me. Moderator: Craig, that's an excellent example, because every Permanente physician reading this discussion can identify with the late patient and with the various emotional responses the situation provokes. Team members observe the physician's response. Other thoughts? Dr Steinbruegge: Craig's example brings to mind another situation--namely, how the physician handles adding another patient to an already very busy schedule. Although medically the problem could be handled on the phone, the advice nurse may be caught in the middle between the patient who wants to come in and the physician who says "they don't need to come in. Find some way to take care of them." How a physician supports the nurse and other team members in these situations is a reflection of their personal values, which strongly influence the team's culture. Moderator: Let's say I'm a physician reading this dialogue, and you have convinced me that how I respond to situations will strongly influence how the team responds in the future. Can you help this physician? Are there leadership skills that a physician can learn? Ms Clark: In KP Northwest, we have consultants from our CME and Professional Development groups who will work one-on-one with physicians to provide feedback on how their communication style and body language is coming across to others. Effective communication, both verbal and nonverbal, is critical to successful leadership modeling. Mr McCabe: Although in Southern California we may not do as good a job at identifying the role of the physician in the medical group, we are now looking at our orientation program to make certain it is clear to new physicians that they are leaders with certain expected behavior. This is something that is on our radar screen in Southern California. Dr Fahy: In Colorado, we are encouraging our informal physician leaders to attend our Introduction to Management training class. It is a two-and-a-half-day class with about 20 physicians in attendance. The physicians' leadership experience falls into three groups: those with new administrative roles, experienced physician-managers, and physicians who have no administrative role. They have an opportunity to talk about things like recruiting, performance management, and working in the union environment. That dialogue goes quite a long way toward helping somebody improve his or her informal leadership skills. The Influential Physician People Want to Follow Moderator: It is important to emphasize for our readers that we are talking about physicians having influence over the staff, not heavy-handed control over them. We probably need to clarify that we are not talking about creating authoritarian "little Napoleons" on our teams. We are talking about encouraging Permanente physicians to be strong leaders so people want to follow them. Any thoughts to add? Dr Fahy: It is a baseline understanding that the physicians we are recruiting are collegial and collaborative. We hope that would immunize us against giving the impression that we are encouraging a dictatorial style when we emphasize the importance of physician leadership. Dr Steinbruegge: Leadership means different things to different people, and the most common idea about leadership is a general who tells everyone to "go up that hill." That isn't the kind of leadership we are talking about. In the Advanced Leadership Program, we ask the question, "What does every leader need?" The answer is: "followers." So how does a physician without a formal title get followers? You don't get them by bossing them around and telling them what to do. Dr Janisse: Some of what we are talking about might be titled The Subtle Leaders. Dr Steinbruegge: Or leadership by influence, rather than by fiat or by formal titles. Dr Fahy: You might also consider it "the new leader." It is evidence-based leadership that really works. It is not coercive leadership or Napoleonic leadership, but leadership by influence. Dr Green: There is one other thing that leaders need besides followers: They need a clear goal where both the leader and followers are heading. One of the things all physicians can do is to set a goal for their local unit to do X, Y, and Z for all our patients. This activity is very powerful. Moderator: Karen, I know that you interviewed physicians on adult medicine teams all around the country, and I think some of these comments on being an influential leader are consistent with key observations of your work. Karen Tallman: Yes. The discussion today reaffirms our findings. The Care Experience Project looked at work units with high ratings on patient satisfaction surveys and physician surveys (the People Pulse) in contrast with work units with medium or low ratings on these measures. We observed the importance of physician modeling. Providers and staff form an interdependent system. In strong groups, the physicians set a positive tone for the group. They give recognition and corrective feedback. In high-scoring work units, physicians are inclusive in the decision-making process. By bringing all members of the team into the process, these physicians use the experience of the entire group to gain cooperation. Most importantly, we learned that when there are rich, positive interdependencies, there is less stress in the team and the workday is more predictable. Moderator: Any areas that you identified in your team research that we did not cover in this discussion? Karen Tallman: We found that a physician's management of aspirations affected morale. In some of the teams with low patient and physician satisfaction ratings, people aspired to change things that were outside of their control. This had a demoralizing effect on the work unit. In contrast, the physicians in strong work units were focused on things they realistically could change--issues within their sphere of influence. They started with smaller projects. They succeeded with most of these projects and were able to expand their control over the work environment. Moderator: Thanks, Karen. I would encourage our readers to review your research on page 39 of this edition of The Journal. I agree with you: Today's discussion on the importance of all physicians as leaders mirrors the major findings of your work. I do want to thank the panel for contributing to this dialogue. In many ways, this is just the beginning as we all continue to learn about this subject. Along with our readers, I look forward to your contributions to this topic in future editions of The Permanente Journal. Thanks again. References
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