Current realities

Physicians exercise and manage power by drawing on the multiple bases of power to which they have access.35 See table 1. Physicians hold expert power associated with their professional status by virtue of their knowledge, skills and abilities. Traditionally, they have also possessed information power, although the accessibility of information with technological advances has diminished this. Some may even have referent power, which is based on character, relationships and reputation. The current trend of seeking wider and legitimate power as stewards of healthcare systems makes access to reward and coercive power bases inevitable.

Physicians demonstrate an appropriate and responsible use of power (and influence) when it is for individual or collective patient care. For example, the surgeon who is able to add an emergency case to an overbooked operating room schedule is using her power to fulfil her social contract. Other members of the healthcare team may choose to respect and facilitate this enactment of power when it is in the best interest of the patient. However, if the advocacy for resources for an individual patient is autocratic or unintentional, it may undermine the collegial relationships and well-being of the team. In contrast, power can also be used inappropriately when, for instance, the same surgeon modifies schedules for her own convenience. In both cases, the care of other patients may be negatively impacted if the result is decreased team function.

Abuse of power may be rationalised by the leaders in terms of achieving desired outcomes, especially in organisations without clear policies that support impartiality. PLs with titled roles may consciously or unconsciously bias decision-making processes within the organisation. A department chair who exercises power to affect the decision of a search committee, which should act autonomously, may rationalise the action as necessary to get the ‘best high-potential candidate.’ The candidate, if appointed, may perpetuate this authoritarian/coercive style.

An association exists between narcissism and leadership, with narcissists seeking positional leadership more often and frequently being identified by others as having leadership qualities. Some qualities of narcissists are desirable, such as a propensity towards innovation in a rapidly changing field; however, leaders with narcissistic motivations around power and inclinations towards hubris may show the least compunction about inappropriately exercising power, which can then have devastating effects on their organisations.36 Insecure PLs with low insight may have maladaptive responses to perceived criticism and may become trapped in a vicious cycle of insecurity and injury to self-esteem, which then increases the risk of further misuse of power to maintain or defend one’s leadership position. At the extreme end of the spectrum are leaders with psychopathic or Machiavellian personality styles. Psychopathy, narcissism and Machiavellianism have been termed ‘the dark triad’, and leaders with these personality types have what has been described as a ‘chaotic and precarious managing style’ that can destroy meaning and purpose in a workplace.37

Recognition of the potential for misuse of power has led to the creation of codes of conduct (eg, Hippocratic Oath, Canadian Medical Association/American Medical Association Code of Ethics and the General Medical Council’s Good Medical Practice) and professional standards. Yet, these are sometimes transgressed and not always enforced in day-to-day practice. The actions of role models and teachers may constitute a hidden curriculum about physician power that contradicts the formal curriculum emphasising collaboration. Their tacit messages and unspoken values can influence learners, who go on to exercise power in the same manner as their teachers.38

How it ought to be

For practical and moral reasons, physicians would benefit from learning to responsibly use power. Understanding the concepts of power described above (the structuralist—identifying and managing power bases; the feminist—challenging leaders to be more inclusive; and poststructuralist—using knowledge to construct narratives and discourses) is a useful first step, and topics related to leadership and power should be incorporated into faculty development and medical training at all levels. In addition, there are strategies that may be used to help physicians recognise, accept and optimally leverage their power to support the functioning of complex organisations and improve patient care.

Becoming comfortable with the use of power and transcending liminality

Many physicians and PLs are uncomfortable with the idea of power and find it difficult to acknowledge and use power. It is not uncommon for PLs to talk about feeling like ‘imposters’ when they assume leadership positions.39 The term ‘liminality’ describes the process of transition as well as the emotional state associated with it.40 PLs who accept titled roles may find themselves in a liminal state, caught in the ‘betwixt and between’ space where they exercise the values and standards of both the clinical and the administrative worlds.41 The change in roles and responsibilities from informal to formal power can involve responsibilities and actions that are in conflict with the perceived needs and goals of the individual, or in contrast with their previous professional identity. Discomfort with new formal power may therefore cause leaders to resist and deny this change. However, acknowledging the power inherent in the position is the first step in understanding how to use power to deliver on the position’s mandate. Insecure leaders may succumb to seeking approval for routine decisions leading to delays, unnecessary meetings and doubtful constituents leading to lowered confidence in their leadership. If there is to be hope of mitigating the negative effects of misused power, reflective PLs will need to embrace their new leader identity and move beyond the liminal state.

Acting with integrity to build connections and relationships

Followers can and do create constraints for leaders. Power is mediated by peers’ and followers’ perceptions concerning the fairness with which leaders use power.42 Individuals may respond to leaders based on their own expectations of the leaders and past experiences of power. These factors can be as influential as the reality of the situation, especially if there are problems with trust in the relationship. Therefore, it is important that leaders seek to understand those receiving direction and how they will be motivated to cocreate, collaborate, follow or resist. Addressing these motivations, fostering dialogue, attending to perceived threats and incorporating meaningful rewards could help improve alignment between leaders and constituents. We have slightly modified Yukl’s elaboration of French and Raven’s framework (table 1), which can be used for reflection on how power can optimise outcomes and mitigate harm. There is also a seventh base of power, ‘the power of connections,’ that supports change through influence by proxy-political coalitions alluded to in the Lead Self, Engage Others Achieve Results, Develop Coalitions and Systems Transformation (LEADS) framework that guides exercise of moral power.43

The feminist perspective of power as the collective ability to act in concert7 highlights the exercise of power through connected networks44 and navigating organisational politics (an integral component of organisational dynamics) by seeing politics as power in action.45 Leaders will benefit from presenting change initiatives in an inspiring manner. Commitment and cocreation are more likely if the proposed change is congruent with expertise, time requirements seem reasonable and a high change/effort ratio appears likely. Conversely, opposition can be expected if the outcome is deemed improbable and time demands excessive.

Understanding power bases

Individuals have a combination of power bases: personal (referent and expert) and organisational (legitimate, reward, coercive and information). Leaders select between these by taking into account personal and social (context, needs, people) factors. Legitimate power, while often the most obvious form of power to external observers, covers only a narrow range of influence with boundaries that are inappropriate to overstep.46 Since these power bases are inter-related, the use of one may affect the use of the other. For example, expert power may enhance legitimate power, while use of coercive power may reduce referent power. PLs should be aware that sometimes, soft power may be insufficient, and will be more effective if it is perceived to be backed by hard power. However, the rare situations where the use of authoritarian power is essential (physician discipline47 or quarantine during outbreaks) should be followed by consultation and re-evaluation. ‘Just the right amount of’ assertiveness is crucial as neither too much nor too little is effective over time.48

Creating a right mix of power relationships

The concept of power distance49 refers to how people from different cultural backgrounds, organisations and societies expect and agree to unequal distribution and sharing of power between leaders and followers or constituents. HCOs are both situated in societal cultures and possessed of their own organisational cultures. With increasing cultural diversity in the healthcare workforce, leaders must be aware of how people perceive and react to formal authority. Those who expect a low power distance with flatter hierarchies and less power differential may not react well to a high power distance management style that is more directive and authoritarian. Healthcare governance can cocreate organisations for optimal patient care, whether these be low-power, distance-flat organisations or high-power, hierarchical and centralised organisations. Diversity of thought and talent is known to promote better workplace performance and higher engagement with the organisation. An inclusive leadership perspective50 incorporates respect for diverse viewpoints, facilitating dialogue, serving traditionally under-represented constituents and ensuring careful attention to both privilege and subjugation. Incorporation of feminist perspectives and theories would enrich the strategies for achieving equity, diversity and inclusiveness in health professions education and healthcare delivery.51 52

Planning and executing shared power structures

Sharing power can be a strong and authentic leadership approach. PLs of larger segments of healthcare (with constituents from multiple healthcare professions) may lead diverse groups across multiple intra/interorganisational boundaries, and may serve in dyadic leadership models with coleader backgrounds in administration or other healthcare professions. In these shared/collective leadership situations PLs will need to share power with their dyad partner and also avoid being perceived as leaders who only advance physicians’ interests.25 53 Heifetz’s conceptualisation of targets of power as ‘citizens’ and ‘constituents’ instead of followers54 changes the perspective on the relationship between the leader and the ‘led.’ Based on concordant values, transformational leadership enhances motivation and morale, inspiring those being led to perform at their best and helping to bring leaders and constituents closer together. Transformational leadership helps connect leaders’ visions and actions with their ‘followers’ sense of identity through role modelling, ownership of their work and alignment with organisation’s vision.55 Empowering members of the organisation, enhancing trust and promoting psychological safety are ways that leaders can help others reach their full potential56 and achieve organisational outcomes. Empowerment is a prerequisite for shared, distributed and collaborative leadership models where power itself needs to be shared for joint accountability.57 However, empowerment needs to be balanced with the need to maintain a differential identity between leaders and constituents that recognises the leader’s responsibility to steer the organisation and its constituents towards desired outcomes.

Designing environments and processes that influence behaviour

The Foucauldian perspective8 emphasises the way that leaders use their power for meaning-making. This includes both systematic changes as well as using discourses to shape the thinking of healthcare workers. For instance, PLs successfully spread their influence when they design systems that lead towards cultures of safety and help create organisations that embrace inclusivity and diversity. Relational cultural theory informs healthy coexistence in societal structures through its ‘five good things’ (sense of energy, increased sense of self-worth, increased clarity, ability and motivation to take action, and desire for more connection) required for ‘growth fostering relationships.’58 These changes then hold the power to influence all constituents in the organisation as they come to know ‘the way we do things around here.’ PLs can enhance the positive effects of power by demonstrating behaviour that is in alignment with their change initiatives. They may negatively impact their change initiatives if they do not take into account the emotions and perspectives of others (explained through the Status, Certainty, Autonomy, Relatedness and Fairness (SCARF) model of human social experience and includes status with respect to others, certainty about the future, autonomy, relatedness with others and perceptions of fairness in interactions),59 view others as tools for their own purpose, punish or exclude people for dissenting opinions and ideas, become overconfident or take unnecessary risks on behalf of others. To foster change and demonstrate a balanced approach, PLs must be inclusive of dominant and non-dominant discourses being cognisant of both rights and justice to construct narratives that are truly evidence informed and not biased in favour of the medical profession.

With the gradual shift in the narrative on physician well-being from surface understandings (physician burnout, self-reported measures of wellness, behavioural interventions aimed primarily at individual level) to deeper considerations (framing the phenomena in terms of moral injury and human rights violations) interventions at cognitive and affective levels may seek to reconnect physicians with the core values of the profession such as compassion, and restoring the meaning and purpose of the profession as healers.60 Medical education61 and transformation of individuals and institutions62 for social responsiveness and social justice require a balanced approach to the exercise of power at global and local levels. PLs would benefit from adopting evidence-based practices on leadership interventions such as enhancing autonomy and relatedness at systems level to enhance physician well-being34 and to include physician wellness as a health system quality indicator.63

Avoiding the abuse of power

Power can corrupt and leaders can go astray when they use power for their own gains.64 The exploitation of others for personal goals through actions such as withholding important information, or excluding efficient group members is more likely when the leaders have a ‘dominance’ motivation and perceive their power to be tenuous especially in unstable or transitioning organisations.65 Even in the face of managerialism (regulation and control of professional work by managers), physicians are often able to maintain strong voices due to their expert power.66 Because of this, there are definite risks that scientific bureaucratic medicine can become too entrenched when the managerial and expert power bases come together in the hands of one profession. On the other hand, there is evidence that qualified PLs/managers are not always full participants in decision-making processes,67 suggesting that this may not be a concern in the majority of situations.

Quis custodiet ipsos custodes—who watches the watchmen?

Juvenal’s Satires raised the question of how to ensure the accountability of those in power, which haunts all hierarchical power structures. Hierarchy and power are self-evident in the practice of medicine.68 PLs may need to manage both their power and that of the other physicians. These PLs, like all physicians, are bound by a social contract, which grants them power and status.69 In return, they must have the moral conviction to uphold high ethical standards and regulate themselves and their peers.

However, PLs are carved from what Immanuel Kant called ‘the same warped wood of humanity’ as everyone else70 and are just as fallible. A single approach to accountability is not likely to be appropriate for all hierarchical levels of leadership. The familiar strategy of defining roles, expectations and metrics in an organisational reporting structure risks reinforcing hierarchy without improving accountability.71 A more radical and transformative strategy would require PLs to develop a network of peers to comanage accountability. Strategies might include ‘leadership issues’ rounds, where challenging situations or difficult decisions are discussed. Incorporating ‘liberating structures’ would develop a culture of psychological safety. The attendant transparency and feedback would create a possibility of surfacing that which people would otherwise feel inhibited to share. The goal would be to transform the culture of the solitary, authoritative powerful figure concealing errors to avoid embarrassment to a collaborative group of non-judgemental colleagues who can help improve decision-making.