The Physician Leader: Teaching Leadership in Medicine

Abstract

An integral part of a physician's practice includes being a leader, especially as there is a strong need for skilled leaders to advocate and navigate patient-centered and organizational outcomes. Nephrologists undertake multiple leadership roles, but dedicated leadership training is lacking in medical and postgraduate education. Given the growing need for physician leaders, practitioners in nephrology and beyond must become better equipped in understanding the role of leadership skills in medical practice. Nephrology and the medical community as a whole should focus on intentional and dedicated leadership in medical education training to better groom physicians for leadership roles. In this paper, we define and discuss the components and styles of leadership. We further propose cognitive models that allow one to apply leadership theory in common practice. An integral part of a physician's practice includes being a leader, especially as there is a strong need for skilled leaders to advocate and navigate patient-centered and organizational outcomes. Nephrologists undertake multiple leadership roles, but dedicated leadership training is lacking in medical and postgraduate education. Given the growing need for physician leaders, practitioners in nephrology and beyond must become better equipped in understanding the role of leadership skills in medical practice. Nephrology and the medical community as a whole should focus on intentional and dedicated leadership in medical education training to better groom physicians for leadership roles. In this paper, we define and discuss the components and styles of leadership. We further propose cognitive models that allow one to apply leadership theory in common practice. Clinical Summary•Dedicated leadership training is integral to nephrology physicians' development.•There are multiple leadership opportunities either in formal leadership roles or as part of a team which nephrologists are adeptly suited to fill. Physicians are often recognized as natural leaders by members of the health care team and promoted to leadership roles within a variety of health care settings. With growing emphasis on medical subspecialization and new initiatives in the health care field and care models, more physician leaders will be needed. In many health care organizations, the experiences and inputs from physicians and important stakeholders are integral to development of quality improvement initiatives aimed at improving patient outcomes. Although many physicians possess leadership qualities, this does not innately make all physicians effective leaders. Earlier implementation of leadership training allows trainees and junior physicians to observe a variety of leadership styles and lay the foundation for effective leadership development.1Frich J.C. Brewster A.L. Cherlin E.J. Bradley E.H. Leadership development programs for physicians: a systematic review.J Gen Intern Med. 2015; 30: 656-674Crossref PubMed Scopus (193) Google Scholar, 2Varkey P. Peloquin J. Reed D. Lindor K. Harris I. Leadership curriculum in undergraduate medical education: a study of student and faculty perspectives.Med Teach. 2009; 31: 244-250Crossref PubMed Scopus (63) Google Scholar, 3Taylor C.A. Taylor J.C. Stoller J.K. Exploring leadership competencies in established and aspiring physician leaders: an interview-based study.J Gen Intern Med. 2008; 23: 748-754Crossref PubMed Scopus (67) Google Scholar Leadership training can equip all physicians including nephrologists with requisite skills that places them on a path to become more effective and successful leaders. In this editorial, we discuss the need for physician and nephrology leaders and provide a guide on how to incorporate leadership into medical education for the trainee and training programs. Physicians are already engaged in leadership roles every day through the supervision of treatment teams (ie, advanced practice practitioners or medical trainees), leading patient cardiac and pulmonary resuscitations, and facilitating effective communication among patients, families, and other consulting physicians. Beyond direct patient care scenarios, a skillful physician leader may have indirect effects on patient care through improved team leadership, communication, and morale.4Fernandez R. Rosenman E.D. Olenick J. et al.Simulation-based team leadership training Improves team leadership during Actual Trauma resuscitations: a randomized controlled trial.Crit Care Med. 2020; 48: 73-82Crossref PubMed Scopus (18) Google Scholar Many physicians are asked to fill roles as health care supervisors, chief medical officers, and more. Health care facilities with physician leaders demonstrate “Index of Hospital Quality” scores 25% to 33% higher than those of non–physician-led health care facilities.5Goodall A.H. Physician-leaders and hospital performance: is there an association?.Social Sci Med. 2011; 73: 535-539Crossref PubMed Scopus (203) Google Scholar The Index of Hospital Quality serves as a measure of various aspects of care including clinical effectiveness, patient outcomes, and patient-reported experiences. Hospitals with physician leaders also report lower hospital infection and readmission rates, greater patient satisfaction, and improved financial margins.6Angood P. Birk S. The value of physician leadership.Physician Exe. 2014; 40: 6-20PubMed Google Scholar Additionally, accountable care organizations with physician leaders are more likely to receive Centers for Medicare and Medicaid Services bonuses with a larger margin of savings than their minimum savings rate.6Angood P. Birk S. The value of physician leadership.Physician Exe. 2014; 40: 6-20PubMed Google Scholar Effective health care supervisors also have positive effects on physician retention, reducing the rates of burnout, and improving patient safety, satisfaction, and overall patient care-related outcomes.7Savage M. Storkholm M.H. Mazzocato P. Savage C. Effective physician leaders: an appreciative inquiry into their qualities, capabilities and learning approaches.Leader. 2018; 2: 95-102Crossref Scopus (12) Google Scholar,8Shanafelt T.D. Gorringe G. Menaker R. et al.Impact of organizational leadership on physician burnout and satisfaction.Mayo Clinic Proc. 2015; 90: 432-440Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar Although outcomes cannot with certainty be attributed to the presence of a physician leader, physicians in direct leadership roles can bridge the gap between administrative goals and physician/care teams.9Stoller J.K. Developing physician-leaders: a call to action.J Gen Intern Med. 2009; 24: 876-878Crossref PubMed Scopus (116) Google Scholar,10Youssef N. Student leadership in medical school and its implications for health care and policy-making.Ann Clin Psychiatry. 2021; 33: 187-192PubMed Google Scholar They can help to identify, inspire, and support change and collaborate with other stakeholders. It is unclear how many current physician leaders have undergone dedicated leadership training, but cultivating leadership skills is presumed to be advantageous to the physician leader to help achieve personal and organizational goals. Nephrologists are well poised to take on leadership positions. Patients cared for by nephrologists are often confronted with many comorbidities which demand strong collaboration to optimize care plans and pathways. The very nature of nephrology requires that nephrologists regularly communicate with different medical and surgical subspecialties to achieve common goals in mutual patients.11Gitman M. Bellucci A. Fishbane S. Administrative leadership: nephrologists in non-nephrology leadership roles.Adv Chronic Kidney Dis. 2018; 25: 490-493Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Many nephrologists also have direct leadership experience through their role as a dialysis medical director or dialysis unit chief medical officer. This experience gives nephrologists an intricate understanding of administrative and regulatory forces within medicine and an opportunity to lead a multidisciplinary team.11Gitman M. Bellucci A. Fishbane S. Administrative leadership: nephrologists in non-nephrology leadership roles.Adv Chronic Kidney Dis. 2018; 25: 490-493Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In addition, the nephrology community already has a strong history of leadership. Nephrologists led the way to show that chronic kidney disease and end-stage renal disease are survivable conditions that can be treated with life-sustaining treatments. More recently, transformational leadership in nephrology led to the removal of race-based estimated glomerular filtration rate in many institutions that resulted in significant disparities in care along with advocacy of prescription coverage for kidney transplant recipients.12Schmidt R.J. Leadership in nephrology: Vital to the future of our Profession.Adv Chronic Kidney Dis. 2018; 25: 472-473Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 13Maddux D.W. A history of leadership in dialysis: perspectives from Seasoned leaders.Adv Chronic Kidney Dis. 2018; 25: 474-479Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 14Expanded Medicare coverage of Immunosuppressive Drugs for kidney transplant recipients. Natl Kidney Found.https://www.kidney.org/atoz/content/faq-expanded-medicare-coverage-immunosuppressive-drugs-kidney-transplant-recipientsDate accessed: February 20, 2022Google Scholar Specifically in nephrology, more formal and informal leaders will also be needed. As the burden of cardiovascular disease and diabetes continues to increase around the globe, the number of patients with chronic kidney disease and those who progress to needing renal replacement therapy will rise. As a result, the nephrologist will be expected to lead and advocate for this growing vulnerable population in various capacities ranging from dialysis medical directors to close communication with industry and community partners. As institutions and physicians continue to value subspecialization, leaders will be required to lead initiatives in their own institutions and collaborate on multidisciplinary care teams such as onconephrology clinics, nephropalliative care clinics, glomerular disease programs, nephrolithiasis/uronephrology clinics, pediatric to adult transitions clinics, and more. In light of the Advancing American Kidney Health initiative, nephrology leaders are needed to help spur new research initiatives, advancing home dialysis modalities, and focusing on preemptive kidney transplantation. Leadership training can occur through a formal curriculum or informal self-directed process. Learning leadership is mostly experiential and not driven by data or large studies. However, a proposed roadmap is provided which starts with a basic background on fundamentals of leadership theory and a focus on the experiential learning model which is a continuous cycle that emphasizes practice and reflection (Fig 1). The first challenge of any program is to define leadership and understand leadership theory. This is critically important given the overlapping roles of leadership, mentorship, management, and coaching. Leadership is defined as the ability to inspire and motivate organizations and/or a group of people toward a shared vision or mission.6Angood P. Birk S. The value of physician leadership.Physician Exe. 2014; 40: 6-20PubMed Google Scholar,15Nayar V. Three Differences between Managers and leaders. Harvard business review.https://hbr.org/2013/08/tests-of-a-leadership-transitiDate: 2013Google Scholar, 16Campbell J.M. Kinion E.S. Teaching leadership/followership to RN-to-MSN students.J Nurs Educ. 1993; 32: 138-140Crossref PubMed Google Scholar, 17van Diggele C. Burgess A. Roberts C. Mellis C. Leadership in healthcare education.BMC Med Educ. 2020; 20: 456Crossref PubMed Scopus (16) Google Scholar Leaders have the effect of driving change. The Leadership Challenge mentions 5 important practices and commitments of exemplary leadership (Table 1).18Kouzes J.M. Posner B.Z. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations.5th ed. Jossey-Bass, 2012Google Scholar It is essential to recognize that 1 practice includes setting a good example, which includes being a good follower when appropriate.9Stoller J.K. Developing physician-leaders: a call to action.J Gen Intern Med. 2009; 24: 876-878Crossref PubMed Scopus (116) Google Scholar,16Campbell J.M. Kinion E.S. Teaching leadership/followership to RN-to-MSN students.J Nurs Educ. 1993; 32: 138-140Crossref PubMed Google Scholar,19Barry E.S. Bader-Larsen K.S. Meyer H.S. Durning S.J. Varpio L. Leadership and followership in military Interprofessional health care teams.Mil Med. 2021; 186: 7-15Crossref PubMed Scopus (6) Google Scholar The LEADS framework was developed by Canadian health care practitioners with leadership experience and is now widely adopted in practice in Canada.20Dickson G.S. Taylor D. Hartney E. et al.The relevance of the LEADS framework during the COVID-19 pandemic.Healthc Manage Forum. 2021; 34: 326-331Crossref PubMed Scopus (4) Google Scholar The framework consists of 5 domains (Lead self; Engage others; Achieve results; Develop coalitions; System transformation) and 20 capabilities that provide aspiring leaders with an understanding of what good leadership entails and that application of those skills should be adaptable to context (Fig 2). These practices, commitments, domains, and capabilities highlight the qualities of leaders and leadership to develop a vision and empowering followers and helping to create connections for collaboration and allowing their team to be successful.17van Diggele C. Burgess A. Roberts C. Mellis C. Leadership in healthcare education.BMC Med Educ. 2020; 20: 456Crossref PubMed Scopus (16) Google Scholar Managers focus on the implementation of a leaders’ vision through organization, staffing, and identifying problems and solutions. Mentors are seen as those who teach through example and guide others, whereas coaches help to nurture and cultivate skills to help their players achieve their own personal goals.21Denhard D. Rethink the leader – Manager – coach – mentor – Operator dynamic. Focus: the Company culture & Strategy blog.https://focus.business/blog/leader-manager-coach-mentor-operator/Date: 2020Google Scholar,22Monroe D. Lead, mentor, coach: what’s the difference? HDI.https://www.thinkhdi.com/library/supportworld/2016/lead-mentor-coach.aspxDate: 2016Google ScholarTable 1Five Practices and 10 Commitments of Exemplary Leadership From "The Leadership Challenge”18Kouzes J.M. Posner B.Z. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations.5th ed. Jossey-Bass, 2012Google ScholarPracticesCommitmentsModel the wayClarify values by finding your voice and affirming shared values.Set the example by aligning actions with shared values.Inspire a shared visionEnvision the future by imagining exciting and ennobling possibilitiesEnlist others in a common vision by to shared the for opportunities by the and for to and take by and learning from others to collaboration by and facilitating others by and the by for the values and by a of community in a new An important in understanding leadership theory is understanding qualities of effective and leaders. own qualities and to qualities with effective leaders, and coaches can help trainees what skills to should be that there is not 1 of qualities that make a an effective a different of qualities and leadership this is Diggele C. Burgess A. Roberts C. Mellis C. Leadership in healthcare education.BMC Med Educ. 2020; 20: 456Crossref PubMed Scopus (16) Google Scholar This is also a basic understanding of leadership styles and of leadership is and In the common leadership styles are and A. et proposed shared vision for leadership development for all medical a call from a of medical Med. 2020; 32: PubMed Scopus Google Scholar to leadership styles and qualities identifying leaders in the or what people or to and this their or Leadership R. common leadership styles which are accessed: 20, 2022Google C. common leadership The accessed: 20, 2022Google and on what to be and how should be focusing on and with between leader and be effective in or when are but can be on and with team team first and on and of to of but on to make to and to on identifying and and connections through understanding personal and goals. to and but more emphasis is on and of and and to and to which can but those that more or and has the to into through example by setting for in others will be effective with a team of and the of team members as are others, but also in focusing on leading by example and from and to and them for more positions. be effective in on and with emphasis on and on and (ie, and are can be on on change through and continuous and can lead to team members through are and on those are leading with and team of leaders. More their own a culture of natural problems and in a new of J. The 5 of leadership. accessed: 20, 2022Google team in a new programs should develop a vision for their program and create a for their This will help when learning An of in medical training their to team and leadership develop communication, and and the role of physicians in to quality of and health care and patient Diggele C. Burgess A. Roberts C. Mellis C. Leadership in healthcare education.BMC Med Educ. 2020; 20: 456Crossref PubMed Scopus (16) Google E. M. M. Leadership training and undergraduate medical education: a 2021; 31: Scholar The of medical leadership programs focus on leadership change which includes application of leadership and E. M. M. Leadership training and undergraduate medical education: a 2021; 31: Scholar can to in which can be improved to the of trainees in leadership identifying a and learning and experiences should be to allow Many leadership programs on the of and will on and at In of medical education leadership programs have a and have a E. M. M. Leadership training and undergraduate medical education: a 2021; 31: Scholar Many leadership programs emphasis on experiential learning learning and clinical E.S. Durning S.J. D. D. student leader in an medical field Med. PubMed Scopus (4) Google S. C. et leadership in a a randomized controlled Care Med. PubMed Scopus Google Scholar learning by medical leadership programs in student organizations, on training and and E. M. M. 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Burgess A. Roberts C. Mellis C. Leadership in healthcare education.BMC Med Educ. 2020; 20: 456Crossref PubMed Scopus (16) Google ScholarTable for for of American Leadership of Kidney of Nephrology on various and and and of Nephrology to be a mentor or Leadership in Leadership for Physicians in Health of Nephrology Leaders of Nephrology Kidney of American of Nephrology Leadership programs to a Leadership Leadership of of Leadership Hospitals Leadership in Nephrology Leadership in a new Leadership programs should also how to programs or E. M. M. Leadership training and undergraduate medical education: a 2021; 31: Scholar and leadership skills such as communication can be through such as or of S. R. A. N. in a systematic through the context of the in PubMed Scopus Google Scholar more formal through the Leadership from The Leadership Leadership of and J.M. Posner B.Z. The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations.5th ed. Jossey-Bass, 2012Google E. M. 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