Doctors and leadership: oil and water?

Richard Smith

Editor, BMJ

What I want to talk about

• Examine leadership

• Look at why leadership is problematic for doctors

• Describe two examples of outstanding doctor leaders

What is leadership?

• There is no simple definition

• My working definition is that leaders have two main tasks:

• To set a path, goal, or vision for the people who are being led.

• To motivate people to pursue and eventually achieve the goal.

What sort of goal do I mean?• To put a man on the moon• To defeat Germany in the Second World War• To create a national health service in Britain• To improve the management of patients with

hypertension in a general practice• To reduce waiting times in emergency departments• All of these tasks have to be done with others - and

that is true of most important tasks

Studies of leadership• Until the late 40s the belief was that

leaders were born not made and had particular traits: intelligence, extraversion, etc.

• From the late 40s until the late 60s the central belief was that it was how leaders behave that mattered. It was a question of style. As such it could be learnt.

Studies of leadership

• From the late 60s until the early 80s the idea was that leadership depended on the situation in which leaders found themselves. Some would be good for some circumstances but not for others.

• Since the early 80s the central idea is that leaders need vision and charisma and that leading and managing are different.

Characteristics of charismatic leaders

• Charismatic leaders through role modelling "represent the values and beliefs to which they want followers to subscribe"

• They build positive images and express ideas that appeal to followers ideologically

• They set high expectations and are confident that followers can reach them

• They arouse emotional responses in followers relative to achieving the goals

Managers and leaders are different

• Managers and leaders are different.

• Power is potentially dangerous, and so large organisations have developed a collective managerial ethic that stifles imagination and creativity.

• Abraham Zaleznik, Harvard Business Review

Managers and leaders

Managers Leaders

Employ persistence, toughmindedness, hard work,intelligence, analytical ability,tolerance, and good will to solveproblems

May be engaged in apsychodrama of power andpolitics.

Goals arise out of necessitiesrather than desires.

Adopt a personal and activeattitude towards goals.

Managers and leaders

Managers Leaders

Limit choices Create new approaches and openup issues

Coordinate and balance Alter moods, evoke images andexpectations, and establishspecific desires.

Like to work in teams but preferlow emotional involvement

Inspire and work with strongemotions

Concentrate on survival Take risks

Max DePree

• A dollar invested in Herman Miller in 1975 worth $4854.60 in 1986

• "Great leaders have the strength to abandon themselves to the wild ideas of others."

• "The art of leadership is liberating people to do what is required of them in the most effective and humane way possible."

Max DePree

• "Leadership is an art, something to be learned over time, not simply by reading books. Leadership is more tribal than scientific, more a weaving of relationships than an amassing of information."

Warren Bennis:

• "Leaders do the right things, managers do things right."

• "The traditional view of leadership is to get people to do what needs to be done. I say it's getting people to want to do what needs to be done."

Warren Bennis

• "Failing organisations are overmanaged and underled."

• "Organisations decline because people forget what is important."

Nelson Mandela

• “I am not a leader I’m a servant.”

Empirical studies on leadership

• Vision

• Communicating the vision.

• Empowerment - giving and sharing power not restricting it

• Trust

• Working with others

Doctors' problems with leadership

• Doctors are used to working primarily as individuals. Guard their independence jealously. They value autonomy highly - but leadership is about working with others.

Doctors' problems with leadership

• Doctors and power: when I use the word power who do you of?

Gandhi

• “We must be the change we wish to see.”

Gandhi

Doctors' problems with leadership

• Doctors feel uneasy about power. Think of it negatively.

• At the same time they are often unwilling to cede power - something that is important in empowering and leading. They are wary of abandoning control to others - yet that is what leadership is often about

Doctors' problems with leadership

• Would think it presumptuous to set a vision for an organisation

• Are not used to systems or organisations anyway

• Have little experience of setting strategy. Have difficulty seeing the broader picture

• Are awkward with teams. Too inclined to try and dominate them rather than lead them.

Doctors' problems with leadership

• To used to telling people (patients) what to do rather than inspiring or empowering them

• Are driven by science and suffering to behave tactically and reactively rather than strategically

• Are too fond of hierarchies

• They are wary of expressing emotion in themselves

Doctors' problems with leadership

• Are inclined to be analytic rather than creative, imaginative, and sympathetic

• Poor at manipulating symbols and creating organisational excitement

• Are often poor communicators

• They are happier with puzzles rather than problems

Doctors' problems with leadership

• Doctors for these reasons have problems being leaders and being led

• "Leading doctors is like herding cats." Warren Bennis

• The University of Hell

• “There is no kingdom too small for a doctor to be king of.” John Green

Do doctors’ problems with leadership matter?

• Doctors have created organisations that are hard to lead and have a tendency to elect compromise candidates and deliberately avoid those who might display leadership.

• This is important because--worldwide--they are too often reacting, usually negatively, to the ideas of others rather than taking the lead, helping to move things forward

Successful doctor leaders

Max Rosenheim

• Born in 1908, educated at Cambridge and UCH. Served in the RAMC during the war.

• Joined the department of medicine in 1946 and became professor of medicine in 1950. Developed an outstanding department.

• Became president of the RCP in 1966 and was president until 1972. He mobilised the college so that it could speak for the country as a whole.

Max Rosenheim

• He made it more responsive to the young and to the regions. The number of fellows increased by 1000 during his time.

• He particularly developed postgraduate education in the college.

• He brought the three colleges together and created the MRCP (UK).

• He created the Faculty of Community Medicine.

• Died in 1972

Max Rosenheim: vision• He had a vision of a much expanded and more responsive

and influential RCP and of improved PG education.

• He had an "indomitable sense of purpose once his mind was made up."

• "He usually had a very clear idea of what conclusions a committee was going to reach even while he was making his short neutral introductory remarks."

• BMJ obit says he "introduced a wind of change into the RCP and transformed it with tremendous results."

Max Rosenheim: communication and trust

• Communication - travelled all over the country, never refused an invitation.

• Tremendous energy

• Trust - ”He was able to engender complete trust."

• "Such was his personality that it generated intense loyalty."

Max Rosenheim: empowerment

• Demonstrated empowerment by giving away power to Faculty of Comunity Medicine, Scottish colleges, new fellows, regions, and the young.

• The essence of empowerment is that by giving away power you increase the total sum of power - and, as the leader, your own power.

Max Rosenheim: working with others

• ”In his unit he was like a father with his children, proud when they did well and not jealous."

• "Max's great strength lay in his warm friendliness and his capacity to get others not only to work well together but to believe that they were helping to shape decisons."

Iain Chalmers

Iain Chalmers• Founder of the Cochrane Collaboration, now a worldwide

movement that is transforming healthcare• As a young doctor, worked for a spell in Palestine• Once an obstetrician in Wales; became worried that much of

what he was doing might be harmful• Learnt epidemiology• Founded National Perinatal Epidemiology Unit, the forerunner

of Cochrane• Now moving into criminal justice, education, and medical

history

Iain Chalmers: vision

• A vision of medical interventions being based firmly on evidence, particularly to avoid the harmful

• A vision of how this might be achieved, through a worldwide collaboration

Iain Chalmers: communication and trust

• A relentless communicator--both through journals and the like and with individuals

• Trusted absolutely: will tell you what you don’t want to hear, in the nicest but most persistent way

Iain Chalmers: empowerment and working with others

• The original “Tom Sawyer”--get others painting the fence and then sleep

• “If you don’t mind who gets the credit there is no limit to what you can achieve.” Mark Twain

• Has created a worldwide network

• An unequalled ability to expect and get the best from people and to make sure they get the credit for what they have done

Conclusions

• Leadership is important to effect change

• Leadership is primarily about setting a vision and motivating people to want to achieve the vision

• Communicating the vision, building trust, empowering people, and working in teams are also important

• Leadership and management are different

Conclusions• Doctors have problems with leadership, both leading

and being led

• But there have been and are outstanding examples of doctors leading

• Leadership is not entirely inborn but nor can everybody learn to lead.

• As a profession we need to think more about leadership and encourage the development of doctor who can lead - or at least not stand in their way.

The BossThe Boss drives his men,The Leader inspires them.

The Boss depends on authority.The Leader depends on goodwill.

The Boss evokes fearThe Leader radiates love.

The Boss says “I”.The Leader says “We”.

The Boss shows who is wrong.The Leader shows what is wrong.The Boss knows how it is done.The Leader knows how to do it.

The Boss demands respect.The Leader commands respect.

So be a leader,Not a Boss.