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The Quarterly

Doctors as Managers: Making a Success of a Challenging Career Print E-mail
The EK Yeow oration delivered by Dr Lee Gruner at the Hong Kong College of Community Medicine Conferment Ceremony 

Thank you for inviting me to HKCCM and for your very kind award of the Hon Fellowship. It is indeed an honour for me to be part of the HKCCM and to deliver the EK Yeoh oration. Over the years, I have come to know some of you very well and to understand the health system in Hong Kong and the difficult job many of you face in this complex area.

I have decided to cover a topic that I reflect on regularly and I suppose also shows my rebellious nature. I have never been one to follow the pack. I come to my own conclusions on things and my own decisions on what makes rational sense but always considering the emotional element. I guess, as you will see in my talk, not following the pack but still having a degree of rationality is a trait common to doctors. I think when we deal with doctors all our lives, we are also exposed to considerable emotion amongst our colleagues- not all of it of a positive nature!

So my topic is the present focus on leadership in medicine to the detriment of management skills and the impact that this has in our thinking, our actions and our beliefs. I intend to talk about doctors as natural leaders, doctors taking on executive positions in organisations and what we need to do to assist them to make a success of what I think you will agree can be a very challenging career.

Over the past decade, more and more emphasis has been placed on doctors as leaders. The catch-cry is all doctors need to be leaders. We need to teach them leadership. They need to grasp the nettle and seize the health system and shake it up. They need to show what they are made of and lead our organisations out of the darkness into the light, improve performance and change the world!

The word “management” has gone out of fashion. No-one wants to be a manager, let alone an administrator.  This word is for other people, not for doctors. Doctors’ place in the world signifies them as leaders not managers. We cringe at the name of our Australian college as “Medical Administrators” and believe that renaming it with leadership in the title will make all the difference. We will show who we are, we will gain self-respect, we will be more respected by others and we will be more readily followed by others

But is this what it is all about? When we embark on a career in, let us call it, an executive position in an organisation, what are people expecting of us? Should this matter or should we just go our own way: leadership to the fore!

What is true is that doctors have always been leaders. Of course, not all doctors, but many doctors. If we look at history and many of the discoveries that have been made to improve health care, research into diseases or new equipment. Many of these have been by doctors. They have had a passion to make change, or to prove something is so, or to make things better for patients. And often, they have persisted against the odds to achieve success. And  frequently, they have done this very much on their own or with a small team that they have enthused to follow their lead.

In addition, if one considers the doctor as clinician, he or she is leader of patients. The patient comes with a problem, the doctor provides his or her solution and the patient follows. The patient rarely argues with the doctor’s solution or course of treatment, although of course they may go away and not do what the doctor has asked them to do. Woe betide the patient who requests a second opinion, the doctor- leader often becomes emotional- second opinions are not in the doctor-leader’s script. The patient needs to follow, not think for themselves!

Leadership is often common in quality improvement. I have seen this frequently in hospitals- little pockets of innovation, led by individual doctors and achieving considerable success. Yet often these successes are ignored or even belittled by other doctors. It seems that something of this sort developed by an individual doctor is regarded as insignificant by other doctors. They didn’t develop it themselves, so it means nothing. So there it remains as a pocket of innovation, not spread across an organisation to facilitate real change and if that doctor leaves, the whole effort is likely to dissipate.

The other issue here, is that doctors are extremely competitive. This competitive spirit begins in the preparation for getting into medicine and continues throughout the medical course. The way medicine is taught is competitive, whether at the bedside, in tutorials or examinations as an undergraduate and this goes on in post-graduate years. So it is not surprising that leadership is common in medicine, but it is individualistic  leadership, driven by one persistent person, with an absolute determination to succeed. Doctors expect others to follow, but not to be followers themselves or to acknowledge special skills in others.

And then the doctor suddenly lands in an executive position.

Generally, it is a good doctor, an excellent technician, articulate, intelligent: surely a shoe-in for this job. He or she has shown themselves a leader in their clinical field. They have excellent research skills, lead a strong team in the operating theatre and get good results, all their students pass their exams, they are perfect for leading a larger team and being effective in a larger organisation, aren’t they?

This can be the naïve approach and there is often surprise when it doesn’t work out as anticipated. How to fix this, of course leadership skills- that’s what’s needed! Let’s send them on a course in leadership. They will come back completely changed.

So let us go back to my initial question. Let’s ask ourselves what is really needed, when we put our doctors in executive positions. What do people expect of them in this position? What does the organisation expect? And, what do they themselves expect to be and do in this position?

All medical teachings militate against making a success of an executive position and it is often more good luck than good management that doctors succeed. Some fail in such positions and many others are only partially successful. Many find it very stressful and see their previously supportive colleagues (in a clinical sense), suddenly unsupportive or even aggressive and combative. Why is this so, when they are behaving just like a leader should- coming up with ideas, following them through, putting in the hard work but getting absolutely no kudos?

And to add to the issues, those non-doctors they need to work with, don’t seem enthused by their clinically sound, seemingly well thought out ideas. They want more detailed information. They want a guarantee that the idea will be successful and have the support of the other clinicians and not only doctors, but nurses and allied health. All of a sudden, getting good ideas implemented may take months or even years. This is not how leadership should work in a dynamic organisation. We need to get things done and move onto the next thing. After all if patient care worked like this, waiting lists would be 10 times as long!

A doctor with insight will realise very quickly that all of those skills which are admirably suited to appropriate patient care are no longer enough for success in an executive position or perhaps we should call it what it is “a management position”. And an even more insightful doctor may realise that these clinical skills and this natural individualistic leadership are probably counterproductive in the new role. I have met a few clinicians who gain this insight very fast and change their approach. Many however, only do this in a piecemeal fashion and so their forays into management are not as happy and are certainly more stressful.

A good example involves a colleague who many of you may know. His story is in one of the interviews we recorded for our college Leadership stories.  He talked about his first senior job, which was in government. He came into the position with little if any knowledge of government and immediately began working conscientiously to do the job. He came in early and worked late. He was determined to get things done and show his superior his competence. After a few months, his superior called him in. He had noticed how hard he was working but instead of congratulating  him on this hard work, he expressed his concern at not delegating to his team, not managing himself well and heading for burnout.

It was clear that my colleague at this early stage in his career was still behaving as a clinician: he was able to work hard and consistently, showing that he could do things himself and  better than anyone else.

This, my colleague said, was a seminal moment for him. It showed him that in a management role he needed to change his approach with a lesson learned for his whole career. From then on, he learned to build around him a team with complementary skills, he learned to delegate, he learned to manage work and to develop a collaborative leadership approach. Having seen him in his career over many years, I can attest to the fact that this is his style in both management and leadership.

So why is it important to put leadership aside and understand that in a management position, the first thing you need to do is learn to manage?

It goes back to the expectations that both people and the organisation have of you. This is not about an individual patient, needing an answer to an individual problem and the inequalities of knowledge base and experience. This is not about forming a trusting relationship with that individual so they will follow your advice. The doctor in management now has relationships with multitudes of people and needs to deal in areas where other people, not the doctor, have the expert knowledge. There will be times where he or she will need to defer to the expertise of others and accept decisions that he or she would not have made.

So the doctor who was accountable only to his or her patients and in some cases to his or her clinical colleagues, has accountability vastly expanded to include a multitude of managers and executive and colleagues, the whole organisation, the organisational finances and ethos and needs to consider these in all decision making.  This accountability is a management characteristic and will involve significant followership as well as some leadership in instilling accountability into others.

The doctor who was autonomous in the plans and treatment for patients, determining what tests to run, what medications to prescribe, what reviews to organise, finds this autonomy circumscribed in the management role. Almost every management decision requires consultation with others, writing up business cases and rationales, developing arguments for implementation, going backwards and forwards to make amendments. This can cause enormous frustration as it requires significant people management skills: building relationships, learning how to influence, using different language, gaining rapport. It also requires a great deal of managing oneself, so one doesn’t become hurt, angry, or despondent when things don’t work out or take excessive time to achieve.  Patience and persistence are very often the keys to success.

And then there is the authority. By the time a doctor reaches a substantive management role, he or she is expert in their field, can speak with authority in their clinical field and everyone listens. The patient will do as the doctor says as the doctor is the authority, so will junior doctors and nursing staff, usually with little questioning. In the management role, the doctor is no longer the authority. His or her voice is only one of many in the decision-making process. To get a view across the management doctor needs the right approach, the right language, an understanding of organisational goals, a willingness to bend if needed for the good of the organisation or for patients as a whole. This can be very difficult for the doctor who is certain that he or she is right.

Whilst some doctors with a high degree of insight into themselves and others, quickly work out that they need a different approach and  what this is,   even these doctors will benefit from management skills education.  The majority of doctors taking on substantive executive roles will require management education if they are to have a happy and fulfilling career, as the skills needed here differ from those needed to be a successful clinician.

The first step is to raise awareness that this is so and to have them tease out how the approaches of the clinician and the manager differ. I have recently seen a very clear example of a senior clinician who needed to influence a disparate team of people about a very positive change to health system delivery. This was a good idea, with excellent potential, but sold like a clinician. It was presented as a fait accompli with great enthusiasm and when concerns were expressed, the approach was even more positive and became patronising. The other party was not convinced. The doctor was hurt, upset and clearly didn’t understand what had gone wrong. He continued to express to anyone who would listen how aggrieved he was. The relationships between the parties who need to continue working together was fractured and now work needs to be done to repair these as well as find a better way to work with them to progress the good idea.

The awareness in this case, required an understanding of emotional intelligence, particularly how to manage oneself, and how to listen empathically and respond appropriately to others. This awareness was completely lacking with the doctor continuing to push the same line in the same way until the chair of the meeting called a halt. All of us siting around the table felt extremely awkward and embarrassed for this doctor who had no idea when to stop, take stock and change his approach.

As well as emotional intelligence,  doctors moving into executive positions, must be made aware of what to expect in relation to the three “A” s mentioned before. They need to be clear at the outset, that there will be less authority and autonomy and vastly increased accountability in the new role. Having clear expectations and then some tools to handle the new environment will enable a reframing of how to approach issues and people. This will allow a smoother transition to a management role and some ability to understand and avoid the pitfalls.

And what do we need to teach doctors in management positions about leadership as of course this still needs to be taught.

This also requires a different approach and change from individualistic leadership to a collaborative consultative type of leadership which considers what is best for the wider good. It needs to be made clear what the wider good is: groups of patients, organisational reputation, organisational goals and finances, choosing amongst options to support these, listening and absorbing views of others and being prepared to subsume one’s own goals of the goals of one’s own department for the overall benefit.  In addition, demonstrating leadership in an organisational sense does not mean that you are always the leader, sometimes those in leadership positions will be followers and supporters. Being able to do this shows maturity in career development.

Learning to be humble can be a very useful tool as it shows respect for others’ good ideas and   is likely to assist when trying to get your own good idea across in the future. Sometimes leaders give up their own ideas to others just to get a good idea across, because others are better at influencing stakeholders. They must learn that this is a collegial type of leadership, not the individualistic leadership they have been brought up with as clinicians.

The doctor leading in his or her clinical field compared with the doctor leading in an executive position is in a very different situation. In the clinical field, he or she has gained respect for their expertise over many years by delivering outcomes with individual patients. There is a clear evidence base. Generally, colleagues will ask for advice and so they are in a position where they are free to accept or reject this advice. In most cases, advice from this expert source will be accepted. In addition, the expertise is about individual patients, it is not about treating patients en masse and it is actively sought by the colleague.

However, in an executive position, the dynamic changes. The new executive goes back to zero.The doctor has not proved any expertise in this position. Indeed, just taking on a position of power, will be enough to make others less likely to be amenable. In addition, the actions taken can impact on other clinicians’ mode of work, their working environment, their overall treatment of a patient population and they need to fall into line with any changes made for a vast variety of reasons, patient good being just one of these. This is no longer voluntary or at arm’s length (about a patient), this is about themselves and their own lives, so it is intimate and personal. This requires not leadership, but management skills: how to introduce change, how to transition from a colleague to a superior, how to work with groups of people, not just one, how to change approaches for different people, how to present issues in a way that people understand, how to communicate to influence effectively, how to deal with angry and disenfranchised colleagues, how to build teams and how to manage one’s own emotions.

I have recently seen a clinician in a very senior position, come to grief exactly because he did not understand the basics of management although he was a charismatic and dynamic leader. There was no issue with what he wanted to do and why he wanted to do this, but the change was very poorly managed. He planned very poorly misread the needs of the staff, mishandled the change process, did not recognise the implications of change and ploughed ahead in a very rapid change process without realising the emotional effects on the human beings involved. He believed that enthusiasm and being right was enough to get him through. His removal from the organisation was testament to poor management skills.

Expectations of senior management or boards, also are much more of a management nature, managing budgets, waiting lists, rosters, choosing options to fit budgetary requirements, working with others and not rocking the boat,  or not getting into the media for the wrong reasons as the leader above managed to do. If these things are working well, senior management or the hospital board will regard this doctor as doing a good job and will not require any specific leadership skills. If these things are not working well, no amount of leadership and innovation will overcome the underlying management deficiencies.

Having regard to all of these issues, what do we need to teach clinicians to ensure that they have successful careers as executives?

We need to acknowledge that what doctors in executive positions need to be taught and to understand are the key skills of management and then what collaborative leadership means when taking on this type of position.

As clinicians find their  way through a challenging career, they  need to know that what people expect of them  is to manage well, to get others to work with them  and to work well with others so as to achieve the objectives that make our health services function smoothly and  be efficient and effective.  If we as clinicians only do this in our careers, then we will be regarded as successful.

Doctors need to learn to subsume their tendency to individualistic leadership, their need for autonomy and authority and while managing well, move towards a leadership that is less personally centred and more for the greater good: what can improve the organisation as a whole, patient care as a whole, community health care as a whole.

All of this will need to be in a context of managing and understanding health care financing and organisational objectives, managing groups of people (clinical and non-clinical) and understanding and managing their own emotions and personal ambitions. This is for the good of a larger goal and  will involve not contributing  unselfishly to good decision making but also   following the lead of others on many occasions.

Thank you again for inviting me to be your keynote speaker at this auspicious event. I wish all of the new Fellows well and great success in their challenging careers as managers and leaders.

Dr Lee Gruner

Last Updated on Monday, 25 September 2017 10:18