Leadership is a fundamental skill that all professionals – including physicians – need to succeed. A leader is not defined by a position but by the ability to shift the direction of an organization by influencing others. With the many challenges in today's health care environment, the importance of leadership from family physicians cannot be understated. Influencing policy, trail-blazing new practice models, helping to shift the focus from health care to health, leading effective care teams in clinics, or mentoring students and residents are many examples of the positive impact that family physician leaders can have on our health care system.
The business literature is rich with leadership lessons that most industries – from technology to manufacturing – have readily embraced yet health care has been slow to adopt. This article will share several leadership lessons drawn from the business literature and show how physicians can apply them in health care.
Lesson #1: Leadership has five levels
John Maxwell's classic book The 5 Levels of Leadership: Proven Steps to Maximize Your Potential (New York, NY: Center Street; 2011) demonstrates the various stages leaders typically go through, what motivates people to follow a leader at each level, and what the highest level of leadership looks like.
1. Position: “People follow you because they have to.” This is the lowest level of leadership, and it equates to simply being “the boss.” In certain situations, however, this style of leadership makes sense – for example, a military commander during a time of crisis. Based on your title alone, others look to you as the leader. As a physician, although you may not have a formal leadership or management title, you do have position as the medical authority. Naturally, you will have a major impact on the work environment. Your attitude, positive or negative, will spread much more quickly than anyone else's in the clinic.
2. Permission: “People follow you because they want to.” This level of leadership is achieved by building relationships with those around you – from your receptionist to your medical assistant to your physician colleagues. If you tend to be more task-oriented than people-oriented, this can be a challenge, but it is critical. You must build relationships, understand your team members' personalities, and know how they work together before you can progress to the other levels of leadership. This can be time-consuming; however, it is time well spent. Making support staff feel as though they are valuable members of the team can help raise morale. In addition, if there comes a time when you have to counsel or correct a staff member, he or she is more apt to listen if you have the foundation of a good relationship. One sign of level-2 leadership is that people feel better after talking with you.
3. Production: “People follow you because you achieve.” In sports, good leaders win games. In a company, good leaders develop great products and make profits. In health care, however, the definition of “achieving” can come in many different forms. Physician achievements may include making policy changes, instituting effective training protocols, developing effective medical home teams, surpassing a productivity or quality metric, developing practice leadership curricula for residents, or creating new practice models. In a health care system that is in need of reform, there are many ways to excel as a physician. The one way that all family physicians should excel gets to the root of our profession – to simply be a good family doctor who maintains good relationships with his or her patients. If a physician achieves this on a consistent basis, staff members will notice and will want to be part of that physician's team.
4. People development: “People follow you because of what you have done for them.” Also called servant leadership, this can be one of the most fulfilling parts of being a great leader. Support staff view you not only as someone who is focused on day-to-day processes at work, but also as someone who will help them grow professionally – or even personally. This may involve encouraging your support staff to further their own careers, creating opportunities for them to exercise their strengths, and giving them the confidence that they will gain new skills and knowledge under your leadership.
5. Pinnacle: “People follow you for who you are and what you represent.” It may take an entire career to reach this stage, and only a handful may reach it, says Maxwell. In 20th century world history, Mother Teresa and Gandhi serve as examples of compelling leaders who represented something larger than themselves. In the world of sports, Peyton Manning is an example. After winning the Super Bowl, his teammates spoke about how much they wanted to win for him, just because of what he meant for the game. Reaching this pinnacle of leadership as a family physician means that you have achieved levels 1 through 4 and have developed a reputation as someone who truly stands for something that your followers can take pride in and respect.
Lesson #2: Leaders must adapt their style to the situation
Paul Hersey and Ken Blanchard's Situational Leadership Theory asserts that the most effective leaders adapt their style depending on the needs of their team members. Blanchard's classic book The Situational Leader (New York, NY: Warner Books; 1985) explains the four leadership styles, which all depend on the employee's level of competence and commitment/confidence.
1. Directing or telling. This style of leadership is useful when an employee lacks both competence and commitment/confidence. These are people who need guidance, monitoring, and constructive feedback. In the most difficult cases, the leader may need to make the tough decision to release the employee because it is ultimately the right thing for both the practice and the individual.
2. Coaching or selling. This style of leadership is useful when someone lacks competence but has commitment/confidence. It might be a medical assistant who needs you to spend a little more time showing him or her how to screen a patient. It might be a nurse who needs guidance on protocols for patient refill requests. It might be a resident who needs extra follow-up on his or her reading plan or study methods. These individuals can develop their competency with mentorship and guidance.
3. Supporting or participating. This style of leadership is useful when someone is competent but lacks commitment/confidence. Perhaps it is a competent staff member or colleague who is undergoing personal issues and is in need of some help. It might be a resident who needs more encouragement and mentorship to realize his or her potential. If a person seems competent but not committed, try to investigate underlying causes.
4. Delegating or observing. This style of leadership is useful when staff members have competence and commitment/confidence. These are the people you want to empower and not micro-manage. They are proven in their abilities and can be allowed to develop and grow. During team huddles or clinic meetings, listen to what these folks have to say. You may learn a lot from their input.
Lesson #3: Leaders inspire
Simon Sinek describes how great leaders motivate their teams in his book Start With Why: How Great Leaders Inspire Everyone to Take Action (New York, NY: Portfolio; 2009) and his popular TED talks.
First, great leaders create a “circle of safety” (watch “Why Good Leaders Make You Feel Safe”). The circle of safety helps individuals feel that they belong and that someone is looking out for them, which inspires trust, cooperation, and innovation. In clinic, this can mean developing relationships with your staff, getting them the training they need to succeed, and making them feel valued and supported. In academics, it can mean mentoring students and residents and looking out for both their well-being and their professional development. From an organizational perspective, this can mean protecting your providers' schedules so they can spend more time with patients, simplifying the system to remove administrative burdens, and providing clarity in the midst of change.
Sinek also refers to another circle – the “golden circle” (watch “How Great Leaders Inspire Action”). He describes how most organizations understand what they do (the outer circle), some organizations understand how they do it (the middle circle), but few organizations understand why they do it (the innermost golden circle). For a health care organization, the “what” might be seeing patients in clinic and coordinating their care. The “how” might involve training programs, protocols, policies, workflows, clinic schedules, and quality measures to effectively complete these tasks. However, if the “what” and “how” are all an organization focuses on, then the actual value of the team's work will be lost. Without understanding the “why” – the purpose, cause, or core belief for which your organization exists – you are in danger of becoming a metric, revenue, or policy-centered medical home, rather than a patient-centered medical home. The “why” for a health care organization might sound like this: We believe in developing deep relationships with our patients because that is the best way to achieve the triple aim of better quality, better health, and lower costs. Identifying your “why” will inspire your team to action.
Start leading where you are
Physicians receive little training as leaders in our current medical education system – something that needs to change. With the frustrations and complexity of the current health system, leadership from family physicians at all levels is needed to move things forward. Without it, administrators and policy-makers will be severely limited in their ability to achieve meaningful change.
Physicians have many opportunities to take formal leadership positions, for example, in a medical society, in government, in non-profit organizations, or within a hospital or health system. However, leadership does not depend on being appointed to a formal position. Whether you are an owner of a solo practice or employed by a large group, there are people below, above, and beside you that you can lead. As more family physicians realize and exercise their leadership skills, we will have more opportunities to transform the health care system into something we can believe in, thrive in, and sustain for future generations.