The case of Dr Brown

Dr Brown (not his real identity) is a respected clinician and academic with acclaimed leadership competencies. He recently applied for a leadership position in a teaching hospital and was one of the candidates that made it to the last stage of a rigorous selection process. As part of the selection procedure, Dr Brown underwent an executive matching assessment and received an unequivocal and positive recommendation by the executive matching firm for the job he was applying for. In addition to being considered competent for the job, the assessment showed that he had a healthy balance between his ‘people-oriented’ and ‘task-oriented’ competencies. ‘People oriented’ as used in this context referred to his capacity to demonstrate compassion and be empathetic with others. Unfortunately, as things turned out, Dr Brown did not get the job although the search committee did acknowledge that he was a suitable candidate for the position and possessed the required competencies needed for the job. The reason why Dr Brown was not offered the job, however, was because the search committee felt that his strong ‘people-oriented’ profile posed a risk to the position he was applying for. The search committee told him that they were looking for a directive and more task-oriented candidate, which meant that his compassionate and empathetic leadership style was not a good match for the position and for the team the search committee was putting together.

To the reader, it is understandable that Dr Brown was disappointed when he found out that he did not get the job. Especially, when we place it into the context that he was specifically cultivating his people-oriented skills to improve his capability as a healthcare leader and prepare himself for a role similar to the one he was applying for. What makes the narrative interesting, however, was the reason the search committee gave to support their decision not to offer Dr Brown the job, that is, their preference for a candidate with a directive and indifferent leadership style for the leadership position. While this explanation was seemingly admissible to the search committee, in the current era of value-based healthcare practices, it was not the sort of explanation expected to be used to rationalise leadership building at the top of a healthcare organisation.5 Furthermore, the evidence in the literature shows that individuals with demonstrable compassion, empathy, and excellent communications skills are those whom we should be recruiting to lead our healthcare organisations.6

Cognitive dissonance and implicit bias

So, what is the reason for sharing Dr Brown’s story? The purpose of sharing this narrative is not because Dr Brown failed to get the job, but rather about the ‘cognitive dissonance’ of trying to understand why he did not get the job. To refresh our memory, cognitive dissonance is that state of mental distress that a person experiences when confronted with two or more contradictory beliefs, ideas or values. The discomfort of cognitive dissonance arises when we face situations where previously held beliefs clash with new evidence that is presented to us and then we are forced to search for a way to resolve the contradiction and reduce the mental discomfort. In the case of Dr Brown’s interview, his being disqualified for a healthcare leadership position because he was ‘people-oriented’ and less directive triggers a cognitive dissonance that does not resonate with the core values of what it is to be a healthcare provider or leader for that matter. Especially, when we link this to the current evidence in healthcare leadership where compassion, emotional intelligence and good communication skills are considered to be essential competencies that every effective healthcare leader should possess.6 7

For the reasons described above and the collective understanding that compassionate and emotionally intelligent leaders are needed in our healthcare systems, disqualifying a candidate based on ‘people-oriented’ qualities do not make sense. Moreover, in Dr Brown’s case, a ‘logical’ explanation for why he was not offered the job after being cleared to be a suitable candidate remains wanting. This leaves the observer with questions about what the real reason could have been, not to offer Dr Brown the job. If we now expand the story to include the fact that Dr Brown was from an ethnic minority group (black), one may then wonder if his ethnicity could have been an underlying reason for not being offered the job (i.e., implicit bias). Worldwide and in several corporate organisations, ethnic minorities are generally underrepresented in top executive positions.8 9 For this group of professionals, it is known that they are regularly exposed to different types of implicit and open biases in their work and also, when applying for promotion or seeking new jobs.10 11 Anecdotal experiences show that in situations where black minorities fail to secure a new job or a request for promotion, the explanation they receive is often vague and barely justifies the credibility of the unfavourable outcome. This in turn fails to eliminate any perceived implicit racial bias or ulterior political motive.12

In Dr Brown’s case, besides his ethnicity, one may wonder despite being cleared by the executive matching firm, if there were other issues that may have influenced the outcome the interview. For example, whether there were issues other than implicit bias that he probably was unaware of and which the search committee was unable or unwilling to share with him. One may also argue whether it was okay for the search committee to decide against his selection following the strongly favourable recommendation of the matching firm. In the same light, if the committee did decide to disregard the executive matching firm’s recommendation, then they should also have been prepared (and willing) to authentically describe the reason for doing so to the candidate. The question though, is who should be privy to this explanation, and do they owe this to the candidate? Ultimately, for Dr Brown, there was no satisfactory explanation to quell the nagging question he had about the outcome of the procedure. The question he kept asking himself was ‘would I have got the job (with the same academic and professional credentials and the same positive assessment from the executive matching firm) if I were white?’.11

Now, while the #MeToo movement highlights decades of pain associated with the struggles for gender equality in our societies, an unintended consequence of this breakthrough is that the plight of other minority groups, for example, ethnic minorities facing harassment in the workplace may be (unintentionally) overshadowed.13–15 Furthermore, racial harassment unlike the harassment of women, affects both sexes with relatively more predominance among men.9 Still, within this line of thinking, we can argue that the insurgence of #MeToo has also brought in its wake, a revival to fight discrimination and the implicit biases meted out to all minority groups in general.16 17 Although a lot has been learnt from the rise of the #MeToo movement, the issue of how to tackle implicit bias and unfair practices in academic medicine is still difficult and unclear. While the recipients of implicit bias feel its impact, the perpetrators of such prejudices lack the ability or willingness to recognise, let alone acknowledge their actions. Furthermore, the complexities inherent to the different contexts make it problematic if not impossible to call out racist behaviours, especially when the person calling it out is the subject at the receiving end.

To support individuals who are hurt, put down, marginalised and abused by bias, we need to recognise the consequences of these biases to them and the patients they serve. We also have to realise that there is a price to pay for racism and the unfair practices associated with it. This price includes the perpetuation of behaviours that do not align with the principles of a just culture and the marginalisation of particular groups within society. It means that there would be a poor representation of ethnic minorities in academic and healthcare sectors and a potential loss of highly qualified individuals from positions where they can contribute meaningfully to the system.9 13 There would also be a loss of diversity in the composition of teams and in the innovation that different individuals inject into academic and healthcare systems.13 On a personal level, there is the psychological stress that it will cost individual practitioners of colour. Therefore, like the #MeToo movement, we need to address the ‘elephant in the room’ regarding racism in our academic and healthcare institutions. We need to recognise and acknowledge the impact of implicit bias on black academics and healthcare professionals (in leadership positions).

As a clinician, educator and healthcare leader, I hold the firm belief that the foundation of exemplary leadership lies in our ability to demonstrate compassion and empathy. The evidence in the leadership literature supports this, showing that leaders who are compassionate, who have excellent communication skills and who demonstrate high emotional intelligence are very successful and are often the most effective leaders.7 18 19 The medical education literature also shows that compassionate and empathetic clinicians with excellent communication skills are often the ones that learners tend to associate with and regard as exemplary role models.20 21