Observations on Physician Leadership

John McCracken, PhD

Over the past twenty-five years, more than five hundred physician leaders from around the country have graduated from the Alliance MBA Program for Physicians. Though their respective practice settings and responsibilities have varied widely, there has been general consensus around many of the issues and challenges they face as physician leaders.

Conventional leadership consists of choosing between competing demands, communicating a vison, and providing followers with actionable, measurable goals. This model, however, is not how leadership works within a physician organization.

The administrative hierarchy found in a hospital or health system is replaced in a physician organization (PO) by more ambiguous and negotiated relationships. For physician leaders, authority is contingent and power is often contested, so leadership becomes more a matter of guiding and persuading rather than directing and controlling.

Successful leadership in a PO requires the consent of the physicians.  As a rule, physicians do not actively resist; they do so passively simply by ignoring the pronouncements of their leaders. Physician leaders maintain authority only so long as the doctors perceive that their leaders  recognize and support their interests, or at least do not attempt to undermine those interests.

POs are in constant tension between the doctors’ individual autonomy and the contingent authority of their leadership. Personal autonomy is a core value of most doctors, derived from their requirement of the right to decide how to use their individual expertise and judgment to deliver care for their patients. They expect clinical autonomy and can become resistant when leaders attempt to restrict or contain it.

Power and Politics

The effective power of physician leaders derives less from their formal leadership title than from the respect and personal relationships that they develop with their colleagues over time. The reward and coercive (carrot and stick) power of a formal leader in a PO is hindered by the frequent absence of well-established performance management systems. Where they exist at all, they are often not in the hands of a single leader but rather are delegated to a committee.

Physicians decry political behaviors while at the same time creating intense political environments. This is not inherently bad; it’s just a fact of life.  In this environment, an effective leader must engage in political behavior while appearing to be apolitical and acting in the best interest of the organization. It requires building alliances, making tradeoffs, brokering consensus, and being perceived as acting with integrity for the benefit of the organization rather than themself. This type of political behavior is the lubricant that keeps the organization running.

Personal Qualities

To advance to a senior leadership role, a physicians must first be regarded as highly competent in his/her chosen field. But to be capable of creating consensus and providing effective leadership, they must also possess four key personal attributes:

• emotional intelligence
• social awareness
• interpersonal influence
• networking ability

These attributes are key to inspiring trust and winning support, and persuading physicians that their leader is acting in the interest of the organization. Such individuals, however, are often relatively inexperienced in the discipline of management. Consequently, they also need to:

• form close working relationships with the management professionals running the functional areas of the organization, e.g., finance, accounting, human resources; and
• learn the language of business, which is what business management programs are all about.

The Leadership Collective

Formal organizational charts are not of much use in a PO. The real power structure is usually opaque to outsiders, and typically includes four groups:

• senior leader(s) with formal role responsibility, e.g., president, CMO
• heads of major functional units, e.g., division or department chiefs
• senior management professionals, e.g., finance, accounting, HR
• key physician influencers, physicians with no formal leadership role but with considerable informal power.

These are all part of the leadership collective, and how well they interact and interrelate with one another will determine organizational effectiveness. Understanding this power structure is critically important in understanding how leadership works in a PO. Failure to understand this that before the fact is what makes the merger integration of multiple POs so difficult.

Dysfunctional Leaders

There are two distinctive personality types that should never be allowed to rise to a leadership position in a PO: narcissists and insecure overachievers. Both are extremely ambitious and attracted to high status and recognition, and both can readily be identified in meetings when, to get their way, they suddenly hurl their rattle and toys out of their stroller.

Constructive narcissists are unable to restrain their strong feelings of envy and self-promotion, and often become excessively demanding and aggressive. Insecure overachievers are the opposite; they have perpetual doubts about their knowledge or accomplishments yet are compulsively driven to succeed. In the competitive working environments of a PO, they are highly susceptible to burnout.

In organizations where narcissists and/or insecure overachievers ascend to leadership roles, the rank-and-file physicians will often become distressed and either withdraw or begin actively seeking other professional opportunities.

Acting Decisively Without Authority

When a PO faces a major change or crisis, a strong and decisive leadership response is often required. But because their leaders often have contingent authority and contested control, POs may find it difficult or impossible to react quickly or decisively. Instead, they must harness the capabilities and support of the respected influencers within the organization.

POs are seldom dependent upon a single leader but rely on an assortment of respected and influential physicians within the organization. This can be a recipe for conflict, but if harnessed effectively by a politically skilled senior leader, it can provide the flexibility and resilience required to steer the organization through a period of crisis. A politically skilled leader will understand how to direct and maximize the contribution of the individuals in this leadership constellation.

Conventional leadership emphasizes action-oriented initiative-taking. Physician leadership, however, may sometimes emphasize the importance of patience and doing things more slowly. Physician leaders invariably lead only with the consent of their colleagues; they may instigate and encourage, but they must allow space for their professional colleagues to accept and adopt. This more passive approach to leadership helps minimize the likelihood of backlash and resistance. In short. effective leaders must engage in highly political behavior without ever seeming to do so.

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John McCracken is Clinical Professor of Healthcare Leadership and Management in the Jindal School of Management, The University of Texas at Dallas.