Motivation to lead

While some studies describe physicians’ motivation to be involved in leadership as a way to safeguard their autonomy, identity, status, influence and to resist changes tied to their specialty independent of the organisation’s needs and goals,6 19–24 others emphasise physicians’ drive to make a difference, improve and innovate, and their desire to be engaged, and become good leaders.25 26

Perceptions of management

Managerial and clinical logics are challenging for physicians to reconcile.27–30 Management, perceived as an administrative domain, and the medical domain have distinct cultural differences.31 Physicians are socialised into a specialty with a focus on individual excellence, whereas administrators are team players with diverse backgrounds; clinical decision making has a short time horizon with a single course of action whereas administrative decision-making results in multiple alternatives.31 When clinicians take on managerial roles, they are perceived to occupy a no-mans-land,32 often not meeting the expectations and authority vested in them.33 Many are concerned with losing their credibility among their peers and becoming outsiders,34 with management referred to as the ‘dark side’.27 29 35

Other studies suggest an opportunity to move beyond an adversarial view of management and medicine where management is intertwined with expert knowledge through openness, trust, respect and cooperation, and understood through its impact on clinical practice.20 28–30 36 37

View of oneself as a manager

Medical leaders perceive themselves either as heroes ‘working against the odds’ or as righteous victims ‘struggling in the face of adversity’.27 The heroic narrative is about assuming individual responsibility for achieving one’s vision of the future of healthcare and seeing others, primarily physician-colleagues, in opposition as they are ‘unwilling to change’, ‘pursuing different interests’ and ‘bad communicators’.24

In contrast, other medical leaders see themselves as knowledge brokers who can enhance their physician identities by bridging management and medicine.35 Clinicians and non-clinicians act as partners where understanding is built through communication and presence.31

While some leaders feel it is inappropriate to retain clinical commitments due to a risk of being seen as partisan in relation to a specialty or service,35 most choose to continue clinical practice to maintain a sense of belonging, enhance legitimacy and provide inspiration and insights into daily work, as well as to keep open the option of returning to clinical work in case of failure as a leader.26 35 37 38

Role of managerial strategies

Medical leaders adopt or adapt managerial practices and accept managerial roles as a custodial strategy, referred to as ‘paradigm freeze’.6 19–22 This ‘modernised professionalism’ creates new forms of self-regulation and self-management, such as resisting managers’ attempts to control patient safety programmes; focusing on minimum necessary reporting; selectively participating in managerial meetings; sending out last minute meeting agendas to limit managers’ participation or concealing the significance of certain decisions.20 39 Such behaviours have been characterised as a clinical narrative in medical leaders’ identity where the primary focus is on the exclusive nature of caring for patients, that is, healthcare needs to be safeguarded from non-clinicians.24 Any collaboration with non-clinicians is thought of as ‘making them understand’ or ‘getting them on board’.31

On the other hand, managerial strategies can follow a ‘professional path’, that is, build on medical leaders’ inner drive, resonate with their mental models and be anchored in quality improvement.30 Collaborative leaders surpass organisational and disciplinary boundaries to co-produce care with high quality and cost efficiency, that is, they see the context as a resource that can be collectively adjusted as opposed to individually shaped (heroic leaders).24

As a support, there has been a conscious move to replace the managerial discourse with a leadership discourse.38 40 41 The term ‘medical leadership’ resonates better with professional groups, can remove tensions between operational requirements and visionary aspirations, and potentially influence new work practices.40 41

Outcome of managerial strategies

As clinical managers appear to adhere to managerial control, their clinical identity and professional objectives remain unaffected, that is, loyalty to the profession trumps loyalty to the organisation.20 32 These dynamics result in personal struggles, causing clinicians to disengage from difficult interactions with colleagues and patients, and medical decision-making suffers.42 When ignoring as opposed to engaging with these aspects of professional cultures, professional resistance to change can be triggered.43

When medical leaders choose engagement in management over adherence to managerial control by defining their own and other’s roles, connecting staff, and focusing on goal attainment, they make way for a ‘new professionalism’.30 41 44–46 This has been strengthened by new physician roles (eg, pathway coordinators and hospitalists), which allow physicians to engage in managerial work earlier in their careers,33 and thereby improve their managerial capabilities, including building their social capital and developing different perspectives on problems and solutions.28 30 In addition, the increasingly multiprofessional, team-based service delivery approaches mediate status differences and facilitate knowledge-sharing across professions.25 28 47 48

Organisational attributes

Healthcare organisations are frequently characterised as bureaucratic, policy driven and hierarchical workplaces with poor organisational communication practices, lack of support for innovation, conflicts and incompetence.25 49–51 Matrix organisations and distributed leadership are presented as solutions, yet medical leaders still believe that the real decision-making power lies outside of care environments, is externalised and hierarchical.27 52

Instead, physicians can be given the opportunity to exhibit inclusive leadership behaviours such as explicitly soliciting team input, engaging in participatory decision-making, working with a shared vision, demonstrating compassion, establishing accountability for key outcomes, transparent communication, nurturing an open space for feedback and good working relations.3 25 51 53–56

Performance measurement

Clinicians on different management levels in hospitals and primary care are held accountable for performance measures and organisational issues with neither the authority, staff, budget, time, nor support to actually implement change or to improve.25 27 34 52 57 58 They find the channels to contribute to policy-making processes inaccessible or exclusionary or with an intention to get buy-in as opposed to improve.59 Executives develop a hostile relationship with policy-makers and a protectionist attitude to their work which spills over to the organisation and is reflected in the disengagement of care delivery staff.59 The positive potential of performance measurement, particularly in terms of monitoring quality data, does not materialise due to a lack of ownership over the indicators and also because of problems with access to data and insufficient resources for data collection.34 57 The time-delay between patient safety incidents and quality reports undermine clinicians’ confidence in the data60 and impede accountability for outcomes.42

Instead of being externally imposed, performance measures can be co-designed through continual dialogue to align agendas for quality and safety34 48 61 and through the design of service delivery. 3 27 Similarly, budgetary participation supports accountability through autonomy as it positively correlates with budget goal commitment, use of budget information, and therefore, budgetary performance.62 Tools, such as managerial accounting could co-exist with clinical practice as they are often seen as technical tools without threat to professional autonomy.20

These practices can be described as medical engagement, that is, the ability to (1) decide how work is done, (2) make suggestions for improvement, (3) set goals, (4) plan and (5) monitor performance in activities targeted at the micro (patient), meso (organisation) and/or macro (health system) levels.63

Outcomes of management through ‘command and control’ versus participatory leadership practices

Organisational culture that relies primarily on management through command and control, hamper physician engagement and contribute to a sense of powerlessness.25 27 34 49–52 57 58 The overwhelming number of performance targets and guidelines that are externally imposed conflict with professional values and interests,22 60 and are so demanding that managers tend to focus on compliance, rather than the proactive development of new solutions, and interest in knowledge creation and innovation diminishes.28 60 A lack of internal support makes medical leaders feel that they are alone with their managerial challenges with limited opportunities to discuss and develop ideas for improvement.34 51 This leads them to rely on personality, status and hierarchy—all insufficient for complex tasks.42 64

When given the opportunity to participate in policy-making, clinicians feel their expertise and contribution are valued and that policies are rooted in practice realities.59 Having physicians act as champions of a policy change, can help to get buy-in from other clinicians and thereby facilitate the implementation of a policy reform.65

Participatory leadership practices motivate, provide autonomy, make performance measurement more accurate and meaningful, enable local improvement and can reinforce professionalism in ways that improve the manager–clinician relationship.20 41 47 48 57 66–68 Anchoring quality improvement in professional practice develops a sense of common responsibility in the organisation, and combining it with education and research nurtures positive views on further improvement initiatives.3 21 25 34 41 43 47 48 59 68 69 Budgetary participation improves overall managerial job engagement as it affects managerial self-efficacy, helps to identify with organisational goals, and, along with role clarity, promotes constructive managerial work attitudes.54 62 70 71 Such positive leadership experiences are associated with managerial job engagement, performance and participation in leadership activities.25 51 54–56 Medical engagement results in increased use of quality-of-care feedback reports, improved data quality, efficiency, innovation, job satisfaction and patient satisfaction.63 72

Recruitment of medical leaders

Healthcare organisations require a large number of clinically trained leaders at all levels of the organisation, in particular high quality first-line management.6 32 Despite that interest in leadership can arise from boredom with clinical routine, a desire to take on new challenges,19 or aptitude and energy,73 62% of executive positions in teaching hospitals are filled by external hires, which suggests a failure to identify, develop and promote emerging leaders from within the organisation.38 74 Recruitment of medical leaders most often occurs through informal networks and succeeds through practical reasons such as availability or the persuasive ability of the current managers, without explicit selection criteria or expectations related to performance objectives, goals or measures of success.19 23 26 51 52 When formal recruitment procedures are followed, the process still tends to be ad hoc and lessons learnt by search committees are neither captured nor shared. The consequence of these coercive or ad hoc approaches that generate ‘incidental’ leaders instead of ‘willing’ leaders can be seen early in leadership development, where the latter are more able to ‘absorb’ or construct managerial expertise.38 54 75

To avoid ‘incidental’ medical leaders, recruitment should be formalised with clear financial incentives, identification of leadership potential should start at an early stage by engaging in conversations with front-line physicians, and these future physician leaders should be supported and moulded through opportunities to lead new initiatives.2 19 25 38 51 63 In that process, assessment of professionals’ self-efficacy as a predictor of motivation to lead is recommended.58 Selection of leaders should be part of the overall talent management system74 and the position should have a clear job description that matches the strategic, structural and political contexts.23 34 52 76 Demographics should be considered to avoid management by the ‘old boys’ club’.25 The recruitment process should set clear expectations on what is acceptable professional behaviour as a medical leader, in order to be able to enforce these behaviours in case of a mismatch.76 While the most frequently displayed and among the most valued leadership attributes among physicians is being inspirational, it has the least impact on staff satisfaction.4 Those physicians who demonstrate interest in quality, patient safety, and overall leadership aptitude should be sought.34 52 76 Backgrounds as general internists and practising hospitalists (or other holistic specialisations) seem favourable.28 34

Top management support

Senior leadership teams, particularly Chief Executive Officers (CEO), manage physicians by nagging, arguing and reminding them of their responsibilities, that is, they fail to meaningfully engage medical leaders.50 77 78 CEOs and senior leadership teams tend to crowd medical leaders’ agendas with numerous committees or ‘strategic’ meetings that are filled with operational, not strategic matters.34 40 51

A questionnaire study among staff at the National Health Service concluded that effective leadership practice (eg, engaging staff and collaborators in achieving a compelling vision) is correlated with hospital performance.1 In addition, there is a correlation between how effectively boards work with quality of care and how well executive management teams as a consequence monitor quality and manage operations.61 67 79 Top-level teams should be stable and acknowledge physicians’ medical expertise and academic competence,55 78 and foster collaborative relationships, professional development, effective communication, diffusion of expert knowledge between managers and professionals, and demonstrate a proactive culture for decision making.20 25 60 66 76 80 They also need to remove barriers to medical leadership, for example, reduce the burden of administrative tasks related to information technology, performance analysis and financial management; lack of financial incentives; time commitment pressures; overall lack of support and challenges tied to the timing, location and process of managerial meetings.19 25 26 29 33 37 42 51 This can be done by setting clear expectations,51 introducing collective leadership32 or through hybrid organisations.81 The latter resonates well with the idea of professional bureaucracies where staff has greater influence on decision making than people in formal positions of authority.32

Strategic leadership development

Current undergraduate medical education programmes provide only limited opportunities for professional development and neglect strengthening the ethos and professionalism that would make physicians better fit for the purpose of their work.34 During their clinical careers, they are not sufficiently exposed to professionals who are able to develop their managerial mindset.33 Management skills are perceived to be in conflict with a medical case-orientation and interventionist professional action.43 Previous experiences of being a manager at the unit level are not enough either—physicians still have the tendency to be occupied with small-scale problem solving, which makes it difficult to develop the essential strategic hospital-wide perspective.33 Even if physicians enter management, they see this merely as an intermediate role.37 Medical leaders feel they are thrown into their roles and then expected to learn management on their own and on-the-fly.19 26 Traditional leadership development programmes tend to be offered postpromotion,73 and emphasise the difference between management and leadership, which adds to the problem of translating these to practical situations where they actually are intertwined.40 Leadership training is rarely followed up with concrete opportunities to engage in hospital strategy development.33

The introduction of management competencies needs to start early and focus on taking initiative, organisational and system understanding, becoming team players, communication and shared decision making.33 42 78 Leadership development provides four important opportunities to improve quality and efficiency in healthcare, by (1) increasing the calibre of the workforce, (2) enhancing efficiency in the organisation’s education and development activities, (3) reducing turnover and related expenses and (4) focusing organisational attention on specific strategic priorities.82 Training should improve leaders abilities to address system level challenges and benefit the service, not just the individual.32 83 84 Development initiatives create a space for informal conversations that shape attitudes towards teamwork, safety, management and working conditions.28 40 85 Investments in leadership development should be made at all organisational levels and be seen as part of the strategic development of an organisation.32

Teaching approaches should move from competency to capability development through integration with ongoing improvement efforts where the focus is on participants’ actual challenges as opposed to merely talking about problem solving.19 35 43 75 76 Everyday work practices can become opportunities to develop and test new approaches to service provision and to acquire management and leadership skills (eg, via efficient meetings, medical teamwork, joint decision making and the delegation of responsibilities).21 43 Interprofessional education and training are critical to improve managerial self-efficacy, interest and readiness to be involved in managerial work.25 38 47 58 Through mentoring, coaching and networks, medical leaders with similar roles can share experiences, tools and strategies.25 34 35 38