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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 Progress.

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.

Leadership Characteristics
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."

Behavioral Profile
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 friends.

"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 desired "deliverables."

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 people.

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 charismatic.

General Skills
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.

Interpersonal Relations
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.

Service Commitment
"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, Indianapolis, 1998.

"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.

Movement
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 breeds 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.

Courage
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.

Planning
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 rarely necessary.

"Followership"
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.

NOTES

1. D. O. Weber, "Physicians Lead the Way at America's Top Hospitals," Physician Executive, vol. 27, no. 3, pp. 24-29.
2. 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

Physician Prototypes

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
• Empathy
• Awareness
• Foresight
• 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
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