BY: RICHARD B. BIRRER, MD
Dr. Birrer is senior vice president for medical affairs and chief medical
officer, St. Joseph's Regional Medical Center, Paterson, NJ. This is Part 1
of a two-part article; Part 2 will appear in the January-February 2003 Health
Leaders are best when people barely know they exist, not so good when people
obey and acclaim them, worse when people despise them. Of good leaders, who
talk little, when their work is finished, their aim fulfilled, others will say,
"We did it ourselves."
— Lao Tzu
Over the last decade, the physician's role in health care management has become
increasingly important in terms of cost containment, quality assurance, maintenance
of professional standards, and access to care. More recently, the emergence
of a diversified medical-industrial complex has made it obvious to physician
leaders that they must be team players rather than authoritarians.
As clinicians, physician leaders place great value on preserving
their professional identity and autonomy (see Box, below,
bottom). What they determine to be the best interests
of the patient drives their decision making. Physician leaders,
as administrators, on the other hand, serve as participative
agents of the organization through active planning and the delegation
of tasks. These two prototypical roles — clinician and administrator — tend
to be very different and incongruent, a fact that often leaves
the physician leader in a kind of "no man's land."
And yet, in a recent survey of the more than 6,200 U.S. hospitals
that have 25 or more beds, all of those judged to be among the
top 100 had physician leaders at every level of their organizations.1
The survey found that the hospitals' most common characteristic
was the importance their leaders placed on communicating the
institution's goals effectively and working together with all
levels of the organization.
General Job Description
What is a physician leader? First and foremost, he or she is a kind of diplomat
who serves as a liaison between the provider organization and the community's
physicians and medical groups. Because the physician leader usually has no operational
responsibilities, he or she serves as a "minister without portfolio," a tough
job for anyone, let alone a physician.
The role's fundamental building block is trust. The job involves endless negotiations,
some of which may be very sensitive, to reduce the distance that tends to separate
physicians and hospital administrators.
The physician leader's job description tends to be both all-inclusive
and vague. In recent years, the position's duties have grown,
coming to include quality management, case management, credentialing,
medical education (i.e., pre- and postdoctoral education), and
recruitment and retention of medical staff. Occasionally, operational
oversight (e.g., service-line management) is included. The range
of responsibilities can be mind-boggling.
A sense of service, equanimity, courage, focus, kindness, energy,
and vision are some of the key ingredients in successful leadership
(for others see Box, below, top). In the final
analysis, as Lao Tzu noted, a leader will have been successful
when others say, "We did it ourselves."
Is there an ideal behavioral profile for the physician leader?
A number of investigators have attempted to define and evaluate
such leaders' specific personality traits and behavioral patterns.
Most physician leaders, these studies show, have strong comm–nication
skills, are strong leaders, and are "people-oriented." Such
leaders are self-motivated, industrious, and driven by accomplishments.
Approximately 35 percent fall into categories labeled "perfectionist,"
"specialist," and "achiever."2
"Perfectionists" These physician leaders are systematic; they follow
procedures, give great attention to detail, maintain high standards, and are
highly conscientious. When under pressure, they become diplomatic and tactful.
"Perfectionists" are motivated to seek predictable, stable accomplishments and
to achieve them through reassurance, reinforcement, and personal attention.
They are considerate, patient, and always willing to help those they consider
"Specialists" These physician leaders tend to be modest in their demeanor,
are moderate in their approach, and "wear well" with others. Because they plan
their work and tend toward familiar, predictable patterns, they prefer a controlled
environment and the preservation of the status quo.
"Achievers" These physician leaders are industrious, internally motivated,
and diligent. They tend to be "doers" rather than "delegators," to have a strong
sense of accountability, and to reveal an intense, continual striving for accomplishment,
particularly at the personal level.
An additional 35 percent of physician leaders are "developers," "creators,"
"objective thinkers," "investigators," and "results-oriented" people. "Creators"
and "developers" are strong individuals who tend to be self-reliant, seeking
their own solutions through forceful and, at times, critical behavior. Their
efficacy would improve if they were to become more collaborative, employing
empathetic teamwork, patience, and tactful communication. "Investigators" possess
analytic goals and objective natures and tend to be undemonstrative, relatively
inflexible, and individual in their efforts. The same is true of "objective
thinkers" and "results-oriented" leaders, who tend to focus on producing the
The remaining 25 percent of physician leaders include the "agents," "counselors,"
"persuaders," "inspirers," "practitioners," "appraisers," "tights" (people who
are detail-oriented and somewhat inflexible), and "promoters." This group is
characterized by its attention to human relations, particularly the solving
of "people problems," and its reliance on empathy, understanding, and networking.
In general, such people prefer to accomplish their goals through working with
Clinically active physicians tend to be "feeling," "introverted,"
"perceiving," and "intuitive," according to the Myers-Briggs
Type Indicator. Managers, on the other hand, are "thinking,"
"extraverted," "sensing," and "judging." Fortunately, a person's
ability to lead is independent of his or her personality type.
It is true that temperamental individuals usually make poor
leaders, but physician leaders need not be high profile and
The traditional "ambassador of good will" role in health care
has changed in recent years; today such a person is more likely
to act as a messenger for both sides, often in situations involving
specific "deliverables." The physician leader needs an ability
to see the "big picture" and to encourage others to move toward
the organization's goals. The critical skills a manager needs
to be successful are effective communication (which includes
an ability to listen as well as to employ oral and written speech);
an ability to motivate, influence, and persuade others; and
skill in strategic planning (see Box, below, top).
The physician leader needs general leadership skills as well
as technical skills.
The physician leader must be good at dealing with others on
the interpersonal level: smiling, maintaining eye contact, remembering
names, acting like a host or hostess, finding common ground,
and showing interest are all essential elements. Many of these
skills are second nature for physicians used to managing patients
at the bedside. But the physician leader may lose this personal
perspective when he or she is trying to manage teams. Most people
"like to do business with people they like to do business with,"
as the saying goes; successful physician leaders know this home
truth and incorporate it into their styles. Being able to recognize
local opinion leaders and to understand their role in the community
is an essential talent for physician leaders; they will want
to establish informal partnerships with such people, thereby
gaining an advantage for their organizations.
"Servant leaders"* understand that real wisdom comes not from
knowing but from asking. Both group wisdom and participative
leadership are achieved through the question-and-answer process.
This is the route to consensus building, in which the group
arrivesat decisions that everyone can, at worst, live with and,
at best, thrive under. Leadership is exerted rather than imposed.
Unfortunately, physician leaders can become demagogues if they
start to believe that they alone possess the truth — a not uncommon
situation resulting from the clinical perspective that physicians
acquire in the course of one-on-one bedside consultations. Anarchy
can occur if a physician manager should paternalistically hold
that neither the patient nor the team members know the truth.
* The "servant leader" concept was developed by Robert K. Greenleaf, author
of The Servant as Leader, Greenleaf Center for Servant Leadership,
"Servant leaders" have 10 characteristics (see Box
below at right), many of which are building blocks a
physician will require if he or she is to become an outstanding
physician leader. The No. 1 characteristic of such leaders is
service to others (e.g., customers, employees, and community).
From serving others, the physician leader will gain a broader
mindset and more holistic approach to the work environment,
increased opportunities for decision making, and a heightened
sense of well-being and belonging to his or her community. Honesty
and trust are fundamental building blocks from which empathy
and collaboration flow.
A physician leader must give his or her organization not only an agenda for
change but also a sense that it is truly moving forward. This sense of momentum,
a key element of physician leadership success, will be contagious: Movement
Movement can be a good thing in itself. Sometimes a less-than-ideal solution
is better than no decision at all. Even when, in such situations, the leadership
is neither dynamic nor inspired — or even interesting — a sense of momentum can
ensure that decision making occurs, that goals are set, that new ideas are generated,
and that individual staff members take heart from the process.
Talented leaders often make decisions and launch actions in
an "as if" mode — that is, when precise data are not yet available.
Physician leaders, having been trained as scientists, frequently
have trouble dealing with a healthy dose of uncertainty. And
yet Heisenberg's uncertainty principle reigns supreme in medicine
as it does in other sciences. Physician leaders, in particular,
must be able to deal with uncertainty as they approach complex
decisions sure to have an impact on their organizations. Strategic
delegation of tasks and responsibilities is not a "soft" skill,
but it is an essential one for physician leaders. Cohesive delegation
throughout projects is critical to team management.
Knowing One's Limitations
Being truly honest with oneself requires knowing one's strengths
and weaknesses, knowing when to utilize those strengths, and
knowing when to seek help and consultation in areas in which
one is weak. Honesty necessitates knowing when to wait or say
nothing, when to step forward and take a risk, when to lie back
and let others rise to the occasion, when to trust, and when
to let go and just let things happen. Making all these choices
requires an intimate knowledge of oneself.
A physician leader — whether he or she is a chief of service,
medical director of the organizational performance and improvement
operation, CEO, or board member — must understand the level of
responsibility and accountability for the position. Although
physician leaders' decisions are usually not bedside life-and-death
matters, the courage needed to make them is sometimes as important
as the quality of the decision itself. In times of organizational
change, a truly transformational leader will require great courage
to challenge the status quo and counterbalance the resulting
anxiety and resistance. If the leader lacks such courage, his
or her failure to "face the roar" will reduce vision to plans
and programs; his or her leadership will devolve into micromanagement.
Participative planning toward a specific goal is a critical
element of successful leadership. Consensus occurs as a result
of education, regular meetings, dissemination of appropriate
materials, and discussion (both on- and off-line). Voting is
Although the management of physicians has been likened to the
"herding of cats," successful physician leaders usually have
a substantial, committed "followership." Outstanding physician
followers may at times be leaders themselves. Genuinely effective
physician followers are likely to serve as the organization's
conscience, demanding that leaders and other followers be faithful
to its goals, culture, and core values. Effective physician
followers display focus, integrity, commitment, versatility,
responsibility, and competence.
In fact, physician followers may serve physician leaders as
informal advisers. Such people will have already earned the
credibility and respect from those who regularly look to them
for guidance. Once they understand and commit themselves to
the physician leader's initiatives, they will be a positive
competitive advantage for the organization. Physician followers
can influence the acceptance or rejection of new ideas by sharing
their viewpoints in meetings and conversations throughout the
organization. A proven ability to develop a positive "followership" — one
based on honesty, tolerance, a sense of humor, efficacy, decision
making, and self-motivation — is the mark of a leader.
A Catholic Health Care Perspective
The ultimate goal of the physician leader is to transform the
organization into an "oasis of goodness" that not only displays
the best health care practices but also fosters a healthy work
environment through the establishment of high quality and cost-containment
practices, just and inclusive decision and governance processes,
models of sustainable development and environmental support,
empowerment structures that encourage all employees to do their
best, processes that facilitate change management, and entrepreneurship
that allows for creative expression. Physician leaders should
be the primary models of organizational spirituality, demonstrating
it through the way they lead their lives and the way they integrate
spiritual and nonallopathic methodologies into traditional clinical
practice (see Box, below).
Discernment, reflective struggle, and a willingness to relinquish
control allow a leader to proceed without knowing exactly what
lies ahead. For such a person, leadership of the organization
includes service to the community and its members; creating
and nurturing a healing environment that gives caregivers better
involvement in their practice and connection to their patients;
and fostering adaptability and creativity. The physician leader
may be called on to help resolve dramatic issues (for example,
putting the primacy of patient care before corporate needs or
working in an impoverished community) or mundane ones (for example,
settling disputes between a medical staff's "town" — community-based — and
"gown" — university-based — practitioners). Of course, spirituality,
which is different from religion, can be derailed by greed,
a tendency to make excuses, and a hunger for power — temptations
for all executives. But these can be counterbalanced by purity
of intention, clarity, asceticism, right action, and right conduct.
Certainly the tradition of the healing profession lends itself
well to an exploration of the spirituality of leadership. Whether
dealing with death at the bedside or with a calamitous organizational
situation, a physician must face powerlessness and uncertainty
with equanimity and resilience. In both a spiritual and a practical
sense, an organization's soul is an extension of a participative
imagination and belonging derived from a leader's vision.
Bridging the Gap
Clinical leaders, especially those who are physicians, have
an extraordinary opportunity to positively influence both the
governance structure of their own health care organizations
and formation of new integrated systems. Becoming a physician
leader is an arduous process that can no longer be approached
haphazardly. To be effective, a physician leader must plot a
clear course, which requires the acquisition of administrative
skills and organizational tools he or she will need to creatively
alter medical care for everyone's benefit. The physician leader
must bridge the gap between administration and the medical staff.
This is a very different role from that of years past, when
some doctors were seen as representing "the long arm of administration."
Organizations today realize the value of a "physician administrator"
who provides input on operational and governance issues from
the clinical and patient-care perspective.
The author wishes to acknowledge with grateful appreciation the suggestions
of Thomas Royer, MD; Rick Afable, MD; William McGuire; and Ralph Hertz, MD.
- D. O. Weber, "Physicians Lead the Way at America's Top Hospitals,"
Physician Executive, vol. 27, no. 3, pp. 24-29.
- R. W. Singleton, "A Behavioral Profile of Physician Executives,"
Physician Executives, vol. 20, no. 11, pp. 15-18.
Characteristics of Successful Leaders
Successful leaders tend to:
- Be lifelong learners
- Be intelligent
- Have charismatic personalities
- Have self-confidence
- Have good judgment/common sense
- Have boundless energy
- Be assertive
- Be aggressive
- Have creativity and initiative
Leaders tend to:
- Be doers
- Be reactive
- Seek immediate gratification
- Be decisive
- Seek autonomy
- Be independent
- Be patient advocates
- Identify with their profession
Clinicians tend to:
- Be planners/designers
- Be active
- Await delayed gratification
- Be delegators
- Seek collaboration
- Be participative
- Be organizational advocates
- Identify with the organization
Core Leadership Qualifications
At a minimum, a leader should:
- Dossess communication, interpersonal, clinical, and business skills
- Be capable of participatory decision making
- Have a sense of mission and vision
- Act as his or her patients' champion
- Inspire trust
- Be courageous
Characteristics of "Servant Leadership"
A "servant leader" should have:
- An ability to conceptualize
- The ability to listen
- An ability to persuade
- An ability to heal
- A focus on his or her community
- Commitment to others' growth
- A strong sense of stewardship
Spiritual Qualities of a Physician Leader
The physician leader will typically:
- Possess maturity
- Have taken a spiritual path
- Have made good use of his or her unique gifts
- Maintain his or her physical, mental, and spiritual fitness
- Continually seek revitalization and renewal
- Work to expand his or her self- awareness
- Take responsibility for him- or herself and others
- Commit him- or herself to social betterment
Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.