Misconceiving Medical Leadership

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Misconceiving Medical LeadershipMalcolm Parker

ABSTRACT Medical leadership and leadership education haverecently emerged as subjects of an expanding though as yetuncritical literature. Considerable attention is being given to thedevelopment of courses and electives, together with some proposalsfor generalizing these oerings to all medical students and doctors. This article briey s!etches this development and its derivation frombusiness and corporate leadership models and accompanyingliterature, and subjects its adoption by medicine to critical scrutiny."utative motivations for these developments are discussed, and analternative explanation is oered, tied to the loss of physicianstatus. The nature of leadership as complex, emergent, and

unpredictable has been ignored in the promotion of medicalleadership and leadership training, and this is reected in the falseassumption that leadership in medicine is something that can betaught. #lthough the leadership literature is beginning to recognizethese complex aspects of leadership, so far their implications havenot been ac!nowledged. This article aims to stimulate furtheranalytic discussion of this under$theorized aspect of medicine.


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%& '(C(M)(* +-, the ueensland rural town of Theodore wasooded bythe 'awson *iver and Castle Cree!, necessitating the totalevacuation of itscitizens and destroying the private practice of the town/s general

medical practitionerof 0 years, )ruce Chater 1Theodore Medical Centre +-+2. Chaterwasresponsible for the continuing management of patients during thecrisis, but healso co$led the evacuation and initial rebuilding of the town and wasinstrumentalin maintaining the citizens/ determination not to let the disasterbrea!their spirit. %n the aftermath, Chater stated that the best thing aboutwor!ing inrural towns was the partnerships3 4)etween you and the community.)etween056Misconceiving Medical7eadershipMalcolm "ar!eryou and the patients. %t/s that ability to wor! with people about theirconditionto understand them and hopefully ma!e a dierence8 19emp +-+2.Chater was

recognized by the #ustralian College of *ural and *emote Medicineand the*ural 'octors #ssociation of #ustralia, with an award for his long$term dedicationto the Theodore community, his wor! during the oods, and hisadvocacyfor generalist rural medicine at the state, national, and internationallevels.Chater is clearly a leader among leaders of the #ustralian ruralmedical community,and an inspirational leader within the medical profession in #ustralia

more generally. :et he received no formal leadership training duringhis undergraduateor postgraduate education, something now being advocated as animportantelement of medical education at all levels. # ;uestion that arises inresponse to the recent phenomenon of medical leadership andleadership educationis why this apparent need has emerged, given that there havealways beenrecognized leaders within the medical profession


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This article attempts to answer that ;uestion. The =rst part includesan accountof the perceived need for medical leadership and leadershipeducation,descriptions of dierent leadership models from the general and the

medical literatures,and an update on current medical leadership aspirations, education,andtraining. The second part criti;ues medical leadership andleadership educationfrom a number of perspectives. >rom this criti;ue % derive twocentral assertions.>irst, leadership is not teachable3 it occupies a dierent categoryfrom the variouscompetencies that students and doctors must master and, at leastinitially, betaught. ?econd, the rise of the medical leadership movement ismore of a reactionto the loss of physician status than a justi=ed response to anidenti=ed need.Motivations3 The &eed for 7eadershipand 7eadership (ducationCrises call for leaders. >or example, while fre;uently described as amediocrepeacetime prime minister, Churchill is generally regarded as havingemerged in

response to @erman aggression as the wartime leader parexcellence. %n the currentera of crises


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their attention to producing the medical leaders of the future.Bf course, current calls for medical leadership do not mean thatmedicine hasnot produced leaders throughout its history that medical leadershipis not new

will be one of the themes of this article, particularly in relation to thecall formedical education to become involved in training leaders. %n recenttimes, leaders have emerged in developments such as evidence$based medicine, the greater ac!nowledgment of medical error, andthe conse;uent patient safety agenda 1Cohen -AAD 7eape ++?ac!ett et. al. -AAD ?mall and )arach ++2. "atient safety is nowincluded in many undergraduate medical programs, and dierentways of encouraging student leadership of this curricular elementare emerging, such as via interprofessional learning 1Eoman et. al.+5 Eolmes, )alas, and )oren ++ &ie et. al. +--2. Current callsfor leadership in medicine represent, in part, a sensitivity responseto criticism leveled at the profession for its failures to heed thelessons from other industries


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sciences in the organization and delivery of health care in complexsettings 17arson, Chandler, and >orman+02. %n addition, there is said to be at least some emergingevidence that certain leadership styles may improve healthoutcomes 1Carlson, Min, and )ridges +A ?toller +A2.

Eigher education itself is a system subject to rapid change in recenttimes, and the need for leadership has been identi=ed in relation tothe speed of change, the need to ensure ;uality with diminishingresources 1as with healthcare delivery2, larger student cohorts, andthe exigencies of complex external environments that aecteducation 1Eill and ?tephens +I2.*elated to these changes are the developments in patient$centeredcare and the 4democratization of health care processes andinteractions,8 including the collaborative decision$ma!ing betweenphysicians, other health professionals, and patients that lies at theheart of the patient$centered paradigm 1'onetto +-+2. Theexercise of power in the clinic has been realigned in response tomany factors that have been extensively explored through theliterature of bioethics and patient$centered care, including abuses of clinical and related power and the phenomena of misdiagnosis,adverse events, patient harm, subse;uent litigation, and the demiseof pure models of self$regulation.

#utomatic trust of the medical profession in virtue of !nowledge andsocial status is a thing of the past, and new models ofprofessionalism have been advocated 1%rvine +62.

These are some of the factors that support current calls for moreexplicit and visible leadership within the medical profession. Theapparent urgency of the need for greater and better leadership is,not surprisingly, accompanied by a call for educational changes thatare relevant to new and more complex environments in health$system management and health$care delivery and are expected toprepare the medical leaders of these new institutions 1B/Connell and"ascoe +H2. Types of Medical 7eadership The developments s!etched in the previous section are reected inthe new waves of research into leadership and leadership styles.

(merging typologies of leadership are identi=able, with a more$or$less agreed core, and this is being mapped to the purportedre;uirements of medical leadership. >urthermore, the extent towhich leadership is currently being described, analyzed, andcategorized is interpreted to imply that leadership can be nurturedand taught.#s with patient safety, medicine is ta!ing its lead in developing itsown leadership agenda from other industries, from thecorporateGmanagement world, and from the academic analyses ofleadership that have been enlisted there. Central to these analyses

are the relations between power and leadership, and theconse;uent models of leadership are de=ned by how power is

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enlisted in achieving the goals of organizations and individualactors. These models are now beingapplied to the medical and health$care environments, not only inrelation tocomplex systems and organizations, but also in relation to the

physician$patientrelationship. *elated concepts and practices, such as physicianadvocacy for patients,may also be added to the mix 1(arnest, Fong, and >ederico +-2.0AMalcolm "ar!er"erspectives in )iology and Medicine@abel 1+-+2 lin!s power and leadership conceptually, de=ningleadership as4wor!ing in socially appropriate ways to inuence others insubordinate or followerpositions to achieve principle$driven goals and objectives that theseindividualsmay not have wanted to reach, may not have thought of reaching,ormay not have had the courage or motivation to attempt on theirown,8 andpower as involving 4the strategies used by leaders to inuencethose in subordinateor follower positions to achieve these important goals8 1p. --I02. These are

clearly normative rather than purely factual conceptions of powerand leadership,featuring as they do the fundamental element of inuence that isnecessaryto any conception. 7eaders inuence their followers andsubordinates, and doctorshave certain powers in relation to patients, so we can discern herethe beginningsof an idea that has been exploited in some of the medical leadershipliterature3that doctors are and should be leaders vis$J$vis their patients, as

well aslearning how to be leaders within organizations.Karious leadership styles have been identi=ed and described. Therearevariations in their number and scope, but the central styles asestablished in thebusiness management literature include autocratic, bureaucratic,charismatic,democraticGparticipative, transactional, and transformational1Lohnson +-0

Kector?tudy +-02. Fhile all these styles may be encounteredcurrently, there

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is also a historical dimension to leadership research andimplementation. Thus,the =rst half of the +th century has been identi=ed as the 4@reatMan8 period,with leadership emphasizing 4characteristics such as charisma,

intelligence, energyand dominance8 1?wanwic! and Mc9imm +--, p. +H2. Eowever,theseand other personality traits have not subse;uently been shown todistinguish betweenleaders and non$leaders. #ccording to ?wanwic! and Mc9imm, asubse;uentwave of theory concerning leadership and decision$ma!ing styleswasfound inade;uate to manage the rapid changes in corporatesystems. These theorieswere superseded by the inuential 4transformational leadership8ideas of )ass and others 1)ass -AA )ass and #volio -AAH2, whoemphasized the facilitationby leaders of their followers/ potential, consistent with explicitorganizationalgoals and values 1Eill and ?tephens +I ?wanwic! and Mc9imm+--2.?ome authors see transformational leadership as itself having beeneclipsed by

newer models, such as 4complex adaptive leadership8 styles thatare said to ta!eaccount of the 4complex interactions within dynamic systems8 andof leaders as4catalysts for complex, emergent change within interactivenetwor!s, of whichthey form a part8 1Eill and ?tephens +I, p. -HI2. Eowever, thegeneral transformationalmodel has persisted in many organizations and training courses,including health organizations and health$care training institutions,based on the

idea that dierent situations re;uire dierent dynamic relationshipsand roles,and hence dierent people may emerge as leaders for dierentpurposes, in contrastto a =xed, hierarchical model, where once a leader, always and at alltimesthe leader 1Clar! +-+ @abel +-+2. "art of this notion of leadershipis the abilityto ta!e any position in the health$care team according to the currenttas!,

Misconceiving Medical 7eadershipsummer +-0 volume ID, number 0 0A-

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and thus to lead from behind. % will return to the idea of emergencein the criti;uesection of this article, but it is important at this point to note thatemergenceis also a good illustration of the overlap between some of the

leadershipmodels, as both transformational and complexity models are said todemonstratethis feature 1#volio, Falumbwa, and Feber +A2. 7i!e so manysociologicalendeavors, developing a taxonomy of leadership is far from being amatter of carving nature at its joints.# crucial claim in relation to the transformational theories ofleadership isthat, unli!e trait or 4@reat Man8 notions, and partly because theyare not of thistype, leadership is something that can be learned3 rather than aninborn trait1however deeply in the psyche that trait may dwell2, it is a !ind ofcompetency1Lago -A5+2. This is clearly a presupposition of the numerouscorporate andmedical and health$care leadership development courses 1Mc9immand ?wanwic!+--2. %ndeed, just as the newly discovered need for medical

leadershipoften goes without saying, many articles describing such courses donot botherto justify the claim that leadership can be learned 1Crites, (bert, and?chuster+5 @oldstein et al. +A B/Connell and "ascoe +H Kar!ey etal. +A2. This notion of competency is also consistent with the concept oftransformationalleadership, with its contingent, exible, and situational identi=cationof

appropriate leaders for dierent settings. >urthermore, it isconsistent with theidea that all future physicians should be trained in leadership, anincreasinglycommon proposition of the medical leadership literature.Fhile much of the medical leadership theory, literature, andpractice hasconcentrated on managing and improving increasingly complexsystems of care,notions of leadership have also been applied to the traditional

physician$patient

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relationship. %t is suggested that individual clinicians now maydemonstrate leadershipwithin the spheres of patient$centered care and collaborativedecisionma!ing.>or example, ?chei and Cassell 1+-+2 de=ne clinical leadership as

4theability to accept, appreciate, and channel doctors/ professionalpower into supportfor patient/s autonomous functioning and adaptation to loss8 1p. I02.%n summary, medicine and health care are utilizing theories andmodels thatoriginated in the corporate sector and its academic counterparts tostimulate anappreciation of the need to apply leadership and leadershipeducation in bothincreasingly complex health$care systems and the traditionalphysician$patientrelationship. There is a normative element to the more inuentialleadershipmodels, such as the transformational model, that sees leadership ascontingent,situational, and consistent with explicit organizational goals andvalues, but alsoimportantly as comprising a set of competencies that can belearned.0A+

Malcolm "ar!er"erspectives in )iology and Medicine(ducating for 7eadership The #ustralian Medical Council 1+-+2 recently released its revised4#ccreditation?tandards for "rimary Medical (ducation "roviders and their"rogram of ?tudy and @raduate Butcome ?tatements.8 The outcomestatements are organizedunder four domains3 ?cience and ?cholarship, the medical graduateas scientist

and scholar Clinical "ractice, the medical graduate as practitionerEealthand ?ociety, the medical graduate as a health advocate and"rofessionalism and7eadership, the medical graduate as a professional and leader. These domainsclearly envision #ustralian medical graduates as much more thanneophyte clinicians. They imply that in addition to attaining the basic !nowledge, s!ills,attitudes,

and behaviors essential to the development of their clinicalexpertise, all

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graduates will be proto$scientists, advocates, and leaders. Theindividual outcomestatements under "rofessionalism and 7eadership include familiaritemsli!e commitment to high clinical standards and various ethical

values, understandingof legal responsibilities of doctors, awareness of factors aectingdoctors/health and welfare, and so on. Eowever, in terms of the leadershipfunction,the relevant outcome statement is a rather perfunctory3 4'escribetheprinciples and practice of professionalism and leadership in healthcare.8 The revised standards and statements reect a catch$up alignmentby the #ustralianand &ew Nealand medical education accreditor with internationaldevelopmentsin the Onited 9ingdom, the Onited ?tates, and Canada, although thestatements in the corresponding documents are also low$!ey. >orexample, theOnited 9ingdom/s @eneral Medical Council 1+A2 states in4Tomorrow/s'octors8 that medical graduates should 4'emonstrate ability tobuild team capacityand positive wor!ing relationships and underta!e various team roles

includingleadership and the ability to accept leadership by others.8 &orth#mericanmedical education accreditation through the 7iaison Committee onMedical(ducation recognizes a range of formal de=nitions of the !nowledge,s!ills, behaviors,and attitudinal attributes appropriate for a physician, includingthosefrom the ##MC/s Medical ?chool Bbjectives "roject, the#ccreditation Council

for @raduate Medical (ducation 1#C@M(2, the #merican )oard ofMedical?pecialties 1#)M?2, and the physician roles summarized in theCanM('? +Ireport of the *oyal College of "hysicians and ?urgeons of Canada17iaisonCommittee on Medical (ducation +-+2. Eowever, there is littleexplicit mentionof leadership. The exceptions are in the CanM('? report, where thecompetency

4Fhere appropriate, demonstrate leadership in a healthcare team8appears

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under the 4Collaborator8 category for physicians, and thecompetency4?erve in administration and leadership roles, as appropriate8appears under the4Manager8 category 1*oyal College of "hysicians and ?urgeons of

Canada+I2.Karious modes of educational implementation have been employed.?ome of these are external or joint programs, where existing degreeprograms such asMisconceiving Medical 7eadershipsummer +-0 volume ID, number 0 0A0M)#s are provided by medical education providers at theundergraduate level,or where postgraduates independently or under the auspices andsometimes=nancial support of health$care employers underta!e such programs17arson,Chandler, and >orman +02. "rojects at the undergraduate levelare said tomodel leadership and teamwor!, especially in the context of currentmethods of small$group teaching 1Chen et. al. +A2. (lective and selectivecourses, someof which involve community projects, have also been utilized

1@oldstein et al.+A2. #s with other educational developments, some of theseoperate as pilotprojects for the later exposure of all students to leadershipdevelopment. >orexample, the OM($+- project has collated a number of O.?. medicalschool initiativesin leadership education that vary in their attention to managementandleadership concepts and activities, and include modeling of these inclinical rotations,

wor!shops, and other didactic sessions 1B/Connell and "ascoe+H2. #whole$program curriculum in medical leadership has beendeveloped at the)oonshoft ?chool of Medicine in Bhio 1Crites, (bert and ?chuster+52. #tmy own #ustralian medical school, a Medical 7eadership program forstudentsthat now attracts junior doctors and other participants commencedin +-, featuring

theoretical sessions, seminars with recognized leaders, and projects,leading

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to a @raduate Certi=cate in (xecutive 7eadership 19nowles et. al.+-+Oniversity of ueensland +-+2.?wanwic! and Mc9imm 1+-+2 summarize what has so far beenattempted

as including various theoretical strategies, such as lectures,seminars, and casestudies wor!$based assignments coaching and mentoring andreective writing. They also emphasize the importance of lin!ing these moretraditional 4educational8activities with the development of changes in the organization1medicalschool or health$care organization2 as a whole. Eowever, what is notyetclear is the consistency and coordination of leadership developmentoerings, orthe appropriate stage at which to commence educational eorts andhow tostage dierent approaches and depths of learning 1?toller +A2.Medicine is traditionally a slow adopter of novel ideas, but it is nowrespondingto perceptions that, if the challenges to health$care delivery are tobe managedeectively, if leadership is re;uired at all levels of medical andhealth care,

and if leadership can be taught and learned, then development andeducationshould be introduced promptly and at all levels of the educationalcontinuum1@abel +-+2. &ot surprisingly, there is so far little evidence of aconsistent, systematic,and coordinated approach in either the undergraduate orpostgraduatearenas rather, there have been mainly local, ad hoc responses toperceivedneeds. Bne exception to the lac! of systemic developments is the

Onited 9ingdom/smedical leadership competency framewor! 1&E? 7eadership#cademy+-+2. There has also been some incipient activity in &ew Nealand,based onthe O.9. model. The &E? 7eadership >ramewor! purports to provide a consistentapproachto leadership development for all &E? sta, irrespective of disciplineor role,

0AHMalcolm "ar!er

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"erspectives in )iology and Medicineand explicitly states that leadership is not restricted to those holdingdesignatedleadership roles, since leadership can come from anyone in theorganization

1&E? 7eadership #cademy +--2. The framewor! covers variousdomains suchas "ersonal ualities, For!ing with Bthers, Managing ?ervices,Creating theKision, and so on, with sub$elements and descriptors within eachdomain, in additionto indicators of behaviors at dierent leadership 4stages,8 such asteams,services, wider organizations, and the whole organization.%n &ew Nealand, a Ministerial Tas! @roup on Clinical 7eadershippublished%n @ood Eands 1+A2, which has framed developments inleadership and clinicalgovernance since then. This report appears to have spawned somelocal andregional initiatives, but there is as yet no national clinical leadershipdevelopmentprogram.-Criti;ueuestions concerning the coordination of leadership education, andconcerning

pedagogical approaches, depth, and staging, together with theabsence of widespreadnational initiatives, presuppose the fundamental ideas that medicalleadershipis somehow lac!ing, and that conse;uently a signi=cant neweducationaleort is re;uired to correct the shortfall. %t is to these fundamentalbut largelyun;uestioned assumptions that the following section of this article isaddressed.#s!ing the *ight uestions

# number of ;uestions have focused the minds of academics,clinicians, andothers in the literature of medical leadership and its development. These include3what isGare the best model1s2 for medical leadershipP how can weapplyleadership theories to health care managementGdelivery and theclinical relationshipPand what are the best ways to educate medical students andpostgraduates

for the new leadership roles they will =llP

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The ;uestions that do not appear to have been as!ed andresponded to, so farin the literature on medical leadership, include the following3 what isthe philosophicalGphenomenologicalGontologicalGempirical status of leadershipP if

therehave always been medical leaders, why do we now see such a focuson medicalleadership, and why do students and junior doctors now need to betrained to beleadersP what does the assertion that all studentsGdoctors should betrained to beleaders imply for the nature of the leadership that they will display,vis$J$vis thatof medical leaders of the pastP are the things that are advocatedunder the callfor medical leadership development and education always examplesof leadership,or are they sometimes other things that have simply beenrelabeledP arethere any aspects of leadership per se that can be taught andlearned, or are theMisconceiving Medical 7eadershipsummer +-0 volume ID, number 0 0AI-9. McEardy, >ellow in Eealth 7eadership and %nnovation, 9o #wateaand Eealth For!force

&ew Nealand, personal communication, May -H, +-0.!inds of things that can be taught and learned speci=ccompetencies that someonewho is a proto$leader or indeed a well$recognized leader can usefullyaddto his or her s!illsP what alternative explanations might be given forthe currentphenomenon of medical leadership and the apparent urgencyconcerning itsdevelopment, in the light of the ;uestions aboveP7eadership and Complexity

Fhat health care crisisP uestions about incomplete insurancecoverage, ine;uitableaccess to health care, and social ine;uities in health status are notnew.(ven the demands for high$cost treatments and the pressure thatageing populationswill impose on health care do not amount to a crisis. Crisis languageoften serves political purposes3 for example, political parties ofteninvo!e it inrelation to dierent categories of crime, in order to attract the law$

and$order

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vote. #s with a number of words and concepts, we should use crisiscarefully inrelation to health care, lest we cheapen its meaning. >ew peoplewould disagreethat the bombing of "earl Earbor precipitated a genuine political

and militarycrisis, or that the @reat 'epression constituted a social crisis, or thatthe wars in?omalia and ?yria have spawned humanitarian crises. "erhaps therewould beconsensus that in numerous developing countries there is also acrisis in healthcare. )ut in the Fest, the use of the term in relation to health care isseverelystrained.Complexity is historically relative. (ach civilization is more complexthan itspredecessors, but the conceptual and technological tools formanaging each oneare not restricted to those that were previously available. #sleadership is part of that management process, and it can call on the tools available, itcannot be thecase that greater complexity re;uires 4greater8 leadership. Theneed for managementof complex systems and the need for leadership are sometimes

conated.Complex systems clearly need intelligent managers who can plan,budget,appoint, measure, and so on, but leadership is dierent frommanagement, andit has not changed 19otter +-0 ?wanwic! and Mc9imm +--2.Conceptual Concerns#s suggested previously, once something has been reduced viadescription,analysis, and categorization, it is often tempting to consider that itcan be taught.

>or example, some have suggested that because we thin! weunderstand somethingof what 4clinical wisdom8 or 4clinical intuition8 consists of


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imparting it through formal teaching at early stages ma!es no sense1Moultonet al. +6 ?chuwirth ++2. The same 4teachability temptation8 arises in response to theanalysis and

0ADMalcolm "ar!er"erspectives in )iology and Medicinetypology of leadership3 if we can descry leadership/s elements and!inds, wethin! we can reassemble it within the student. The problem withleadership isnot so much that, li!e clinical intuition, it re;uires time, experience,and practiceto mature, but that it is a contextually emergent phenomenon. FithsuQcienttime and experience, most neophyte clinicians will develop at leastan ade;uateability to recognize patterns, to ma!e what appear to be automaticclinicalassessments, and to ma!e judgments under uncertainty. )ut noteveryoneemerges as a leader, and many leaders only emerge under theappropriate conditions.1Fhile the transformational model of leadership is based to someextent

on a contextual necessity for leadership/s existence, such thatdierent peoplemay emerge as leaders for dierent purposes, this is not the sameas claiming thatthe model can be taught. %n fact, the transformational model/ssupporters, for thereasons % am giving, should argue that if their model is correct, itfollows thatleadership cannot be taught2. L. M. )arrie/s masterful -A+ play The #dmirable Crichton illustratesthis emergence.

Crichton, butler to the aristocratic 7oam household, accepts without;uestion )ritish social strati=cation and his role in it, but when thefamily andsta are shipwrec!ed on a far$ung island, he gradually ta!es overas leader inthe new circumstances, where only he has the resourcefulness andpractical acumento ensure their survival. Bn being rescued, the original positions oflordand butler are resumed, with only Crichton being completely at ease

with

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restoration of the initial relativities. Fhile the play is seen as a light$hearted digat the (nglish class system, it also illustrates the unpredictable andcontextualnature of genuine leadership, such that the idea of training for

leadership becomesnot merely superuous, but odd.#s ?teven ?pielberg commented in a recent interview about thema!ing of his =lm 7incoln3 4% just thin! that the ;ualities of leadership areun!nown evento the leader until he/s tested and given a challenge. . . . )ut younever really!now how good of a leader you are until there is something there isRsicS leadus to, toward or through or to overcome8 1#ustralian )roadcastingCorporation+-02.%f this observation is correct, teaching leadership would amount toconsciouslyattempting to instill, or at least facilitate the development of,somethingthat is already but inchoately 4there8 in an un!nown number ofpeople<despite the fact that even if whatever it is that blossoms intoleadership is

4there,8 it will not necessarily emerge. To imagine that this can bedone generallyseems to be an exercise in hubris, and it also raises the ;uestion asto howleaders in the Crichton?pielberg sense will ran! against those whobecome4leaders8 via formal training and certi=cation. The claim thateveryone can beeducated to be a leader also clearly dilutes the very concept ofleadership3 it isthe reductio ad absurdum of the educational competency model.

>urthermore,the teachability thesis sometimes trades on the fallacious idea that,because it isa mista!e to assume that excellent clinicians will ma!e goodmedical leaders inMisconceiving Medical 7eadershipsummer +-0 volume ID, number 0 0A6virtue of their clinical acumen, it follows that medical leaderstherefore need tobe formally educated or developed.

(ducation for 7eadership

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Thus far, educational endeavors in medical leadership reect thefact that anumber of the ;uestions listed above have not been as!ed. Theperfunctorynature of the statements of educational accreditors and framewor!

producerssuggests that leadership education is more a fad or fashion than awell$thoughtthrougheducational project. This is borne out in some of the selective1nongeneral2training programs, where the only apparent selection criteria appeartobe the demonstration of proto$leadership behaviors andachievements 19nowleset al. +-+2. %n such cases, those who are already emergent leadersare admittedto programs that will teach them about the dierent academicmodels of leadership,in order to produce certi=ed medical leaders of the future.Fhile academic medical education has developed a strong presenceoverrecent years, with academic departments and units, strongindividual and collaborativeresearch, and an increasing literature, there has been little empiricalresearch directed towards answering some of the ;uestions raisedabove 1?trauss,

?oobiah, and 7evinson +-02. >or example, how do training coursesmeasureleadership, in order to !now that they have been successfulP Fhatstudies arebeing conducted, involving leadership trainees and other studentsas controlsPFhat empirical research is being underta!en to compare leaderswho have andhave not been formally trainedP Fhat are the attitudes of students,teachers, clinicians,managers, and leaders to the proposals to generalize leadership

trainingP The dearth of apparent research into such ;uestions may reect theearly stageof this particular educational development, but it may also indicatethat in thearea of leadership, it will prove impossible to answer many of them.&ational %nitiatives The Onited 9ingdom and &ew Nealand oer a more systematic andcoordinatedapproach to leadership education in the postgraduate arena,

although there

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is no evidence as yet of any national plans or outputs in &ewNealand. The +Areport %n @ood Eands is strongly modeled on the &E? 7eadership>ramewor!,so the following comments refer to the O.9. document. #s stated

above, theframewor! does not restrict leadership aspirations or ;ualities tothose holdingdesignated leadership roles, and it includes a number of domains,sub$elements,descriptors, and indicators of behaviors relevant to dierent stagesand roles. The ?ummary document for the 7eadership >ramewor! devotes -Hdenselytyped pages to those various categories and sub$categories, ma!ingany healthcarewor!ers/ coming to grips with their putative obligations a signi=cantburdenin itself. )ut more importantly, it mar!s o two domains 1Creatingthe Kisionand 'elivering the ?trategy2 as focusing more on the roles ofindividualleaders and particularly those in senior positional roles.>urthermore, the major$0A5Malcolm "ar!er

"erspectives in )iology and Medicineity of domains, elements, descriptors, and behavioral indicatorsconsist of capacities,;ualities, and competencies that we would certainly expect to see inallgood leaders, but that are by no means restricted to leaders. Thenotion of leadershipcontained in the framewor! is hence both ambiguous and drained of much of its meaning. Fhile it is true that leadership can come fromanyone inthe organization


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in patient$centered care and its elemental collaborative decision$ma!ingbetween physicians, other health professionals, and patients. Thesedevelopmentshave been stimulated and accompanied by the loss of unearned,

authority$based trust in the medical profession, largely as a result ofexposure, analysis,and institutionalization via the civil rights and bioethics movements,and accompanyingbiolaw 1Kan der )urg -AA62. %t is interesting to now witness theattemptedusurpation of these changes by the leadership movement. #sindicatedabove, for example, ?chei and Cassell 1+-+2 have introduced anotion of clinicalleadership as the ability to utilize doctors/ professional power tosupport patientautonomy and patients/ ability to adapt to loss.#nother author suggests that the ability to advocate for the patient,to respondappropriately to a patient/s refusal of treatment, and to recognizeone/sown limits should be included in the ;ualities exhibited by medicalleaders1@ridley +-+2. )ut these worthy abilities and actions are just the

things thatmedical training has more recently set out to achieve in response tothe criti;uesof medical practice over recent decades within the disciplines ofsociology, theology,bioethics, and law. These abilities and actions now appear to havebeenannexed and rebranded as elements of leadership. Bf course, oncethis occurs,it is then easy to proclaim, as a number of authors are doing, theimportance of

educating all potential doctors to be leaders.Bne of the reasons for the mista!e of believing that doctors mustnow beleaders, even in the clinical consultation, is that leadership iscomplexly tied upwith the exercise of power, so it seems that the doctor$patientrelationship, li!eothers, should be a !ind of leader$led relationship. @abel 1+-+2de=nes leadershipas 4wor!ing in socially appropriate ways to inuence others in

subordinate

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or follower positions to achieve principle$driven goals and objectivesthat theseindividuals may not have wanted to reach, may not have thought ofreaching,or may not have had the courage or motivation to attempt of their

own,8 andsees power as involving 4the strategies used by leaders to inuencethose in subordinateor follower positions to achieve these important goals8 1p. --I02.?inceMisconceiving Medical 7eadershipsummer +-0 volume ID, number 0 0AAinuence is necessary to any conception of leadership, leadersinuence theirfollowers and subordinates, and doctors have certain powers inrelation to patients,it might appear to follow that doctors are leaders of their patients.@abel illustrates this idea with a clinical vignette in which a hurrieddoctorprescribes anti$hypertensive drugs for a patient, warns of a coupleof side eects,and as!s if the patient has any ;uestions. The patient says no,perceiving that thedoctor is in a rush, but she feels anxious and vulnerable. ?he doesnot !eep theone$month follow$up appointment, due to having found the doctor

curt andalso having not contacted the doctor after a rash appeared anddiscontinuing themedication. @abel analyzes the situation as one of the exercise bythe doctor of her 4expert8 power 1diagnosis and prescription2, but failure toexercise 4referent8power, or the power to motivate others through doctor$patientidenti=cation of goals and values and via interpersonal s!ills. @abel/s ta!e on whathappened in

this consultation is that the doctor should have created 4an imageor goals withwhich the patient could identify,8 spent more time with the patient,emphasizedthe importance of treatment to her health, inspiredGmotivated her tobe compliant,and as!ed about related concerns with diet and lifestyle 1p. --ID2.@abel says that all these strategies 4are signs of transformationalleadership81p. --I62. )ut given that the strategies are all described without the

need for

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leadership language, that they all integrate good clinicalmanagement with collaborativedecision$ma!ing, and that this sort of integrated collaborativeapproachpredates the emergence of the fashion for medical leadership, one

can beforgiven for thin!ing that promoters of medical leadership li!e @abelhave gotthe cart before the horse. Many doctors have already adoptedcertain consultationstyles and processes in response to the criti;ues of the morepaternalisticmodels of care of yesteryear, but we are now told that these stylesand processesare features of something new called 1transformational2 leadershipthat nowshould be applied to clinical practice. %t is not that doctors do notwieldpower


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that medical leadership and training for medical leadership havebeen seriouslymisconceived. Medical leadership is nothing new concepts andpractices thatare now placed under the rubric of leadership predate leadership

research and itsliterature and the exercise of power in the organizational arms ofmedicine andin the clinical encounter is not only the preserve of those whoshould reasonablybe considered to be leaders. >urthermore, medical leadershipappears tohave attracted little by way of empirical research to test hypothesesof interest. The 4teachability temptation8 is understandable but highlyproblematic, and theselection criteria for some of the training that does occurpresuppose the 4protopresence8of what is to be taught.Eow are these observations to be explainedP Many of the clues lie atthe surfaceof the leadership literature itself. The more recent models, such astransformationaland complex adaptive leadership, insist on a clearly moral ;uality toleadership, including ideas such as the facilitation by leaders offollowers/ potential,

consistent with organizational goals and values leading from behindinhealth$care teams and eschewing =xed leadership hierarchies. %naddition tothese moral ;ualities are those that point to the diQculty of pinningdown leadershipin anything approaching a scienti=c fashion. )oth thetransformationaland the complexity models emphasize the emergence of leadershipat dierentlevels in dierent contexts, and in particular the complexity model

describesleadership as 4an interactive system of dynamic, unpredictableagents that interactwith each other in complex feedbac! networ!s, which can thenproduceadaptive outcomes such as !nowledge dissemination, learning,innovation, andfurther adaptation to change8 1#volio, Falumbwa, and Feber +A,p. H02.Bn this model, 4leadership is an emergent phenomenon within

complex systems81Eazy, @oldstein, and 7ichtenstein +6, p. +2.

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The interesting irony here is that, having attempted to delineateleadership inscienti=c ways over the past three decades or so, we have arrived ata pointwhere science drops out of the picture. The unpredictability that

characterizesthe most popular leadership models reect ?pielberg/s observationthat the ;ualitiesof leadership are un!nown even to the leader. &o one, includingCrichtonhimself, could have predicted what happened on the island, prior tothe naturalunfolding in those circumstances of his leadership of the group.?imilarly,Chater/s community leadership emerged in response to the oodingof his town.Fhile we might have some expectations of certain individuals inlight of theirexpertise, this is not the same as predicting that a particular expertwill alsoemerge as a leader. %f genuine leadership is unpredictable, a scienceof leadershipappears to be out of the ;uestion. #nd if this is the case, the thesisthat leadershipconsists of some collection of competencies that can be taught andlearned

also evaporates.Misconceiving Medical 7eadershipsummer +-0 volume ID, number 0 H-#gainst this conclusion, it might be claimed that the idea thatleadership isemergent is nothing more than a way of evading the wor! ofdiscovering whatit really is, and how people who do emerge as leaders are formed. %fthe formationprocesses can be uncovered, it might be possible to foster theleadership

;ualities and abilities that are called for in the face of genuinecrises, even if thisis not achieved through formal teaching arrangements. #re theformation processespartly genetically determined, for exampleP This is possible inprinciple,of course, but if there are genetic sources of leadership ;ualities,then fosteringthose ;ualities seems otiose. Moreover, the apparently emergentnature of leadership

suggests that it is something that supervenes on those ;ualities


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people may well display many of the ;ualities that are considered tobe elementsof leadership, but still not emerge as leaders.Bn the other hand, the formation processes may be partly, orlargely, experiential.

'id 7incoln/s formative years help prepare him for eventualpresidentialoQceP ?ince many people who do not become leaders share the!inds of experiences that leaders have had, the prospect of conductingresearch into whatexperiences prepare the ground for leadership seems unli!ely to befruitful.Motivations%n the modern era, the medical profession has contracted withsociety to providemedical care to patients and populations at high standards and in atrustworthyway, and in return has been vouchsafed generally high social statusand remuneration,irrespective of the variations between Festern countries in terms ofthepublicGprivate mix of service delivery. Eowever, the profession hasbeen perceivedby the community to have reneged on the contract in various waysover

the past I or more years, and in response, the profession/s social,political, andeconomic powers have been curtailed in many ways. The professionhas also seenits autonomy eroded signi=cantly by the advent of a managerialculture withinhealth$care delivery and education, with the loss of traditionalcontrols longenjoyed by clinicians and clinician educators. >urthermore, it hasbeen criticizedfor de=ciencies from within its own ran!s and from beyond the

profession.%t is possible that the calls for leadership and leadership trainingrepresent aresponse to the multi$barreled criti;ues leveled at the profession forperceivedfailures, and to the perception that medicine has been tooreactionary and selfserving. The current, more explicit calls for leadership and leadershiptrainingmay reect the profession/s need to convince the community that it

continues

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to deserve its long$held social position and to 4continue to beinvited to ta!ethe reins of clinical services8 1?wanwic! and Mc9imm +-+, p. A02.7i!ewise, the insistence on insinuating the language of leadershipinto the

clinical relationship can be read as an attempt to maintain a positionof powervis$J$vis the patient, a characteristic of the profession that has beensigni=cantlyeroded over recent decades. "roviding 4leadership8 in the clinicalrelationshipH+Malcolm "ar!er"erspectives in )iology and Medicinedoes not sound li!e the na!ed paternalism of yesteryear, especiallyif it is said tobe supporting patient autonomy 1?chei and Cassell +-+2, butlobbing leadershiprhetoric into the clinical consultation !eeps the leader$led dreamalive, undercover of the medical versions of terms such as sharing,communication, leadingfrom behind, goals, values, responsibility, vision, collaboration andso on.ConclusionMedical leadership and leadership training are relatively recent

developmentsthat have received little if any theoretical analysis. 7i!e otherphenomena, theyappear to have been more or less adopted from the corporate world,along withacademic underpinnings that themselves have followed aninteresting trajectory. The leadership literature has provided an essentially descriptive$historicalaccount of leadership models, but at the same time it hasencouraged models of

leadership that feature facilitation of the participation of all indeveloping andrealizing institutional goals and values, and the democratization anddistributionof leadership in contrast to traditional hierarchical models. Mostrecently it appearsto have been 4discovered8 that leadership is a phenomenon thatemergesfrom complex relationships and interactions, is highly contextual,and is hence

unpredictable. Fe appear, to paraphrase T. ?. (liot/s famousexpression, to have

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not ceased from exploration, but at the end of all our exploringarrived wherewe started and to !now the place for the =rst time 1(liot -AH+2. )utothers, li!e)arrie, did !now this place extremely well. 7eadership as emergent

is not a newdiscovery. This emergence and unpredictability of leadership, and hence itsimmunityfrom clear scienti=c manipulation, has crucial implications for allwal!s of lifeincluding medicine. ?omething that is emergent and unpredictableis not reducible,and hence not teachable as a !ind of competency. % have givensomeincipient indications why this is so, and pointed to somecontradictions in relationto the 4teachability temptation8 that deserve further scrutiny,including theconceptually bizarre idea that leadership instruction should beprovided for all.7eadership is also an inappropriate concept for understanding thedoctor$patientrelationship, either in a descriptive or a normative sense. >inally, %have providedsome somewhat speculative, though not altogether unfounded

reasonswhy we have witnessed the development of these phenomena inrecent times,to the eect that they represent a reaction to the erosion of medicalroles andstatus. % hope the paper will stimulate further analyses of medicalleadership andleadership education.Misconceiving Medical 7eadershipsummer +-0 volume ID, number 0 H0*eferences

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Misconceiving Medical Leadership