key: cord-0864272-8vot105e
authors: Stoller, James K.
title: Leadership Essentials for the Chest Physician: Models, Attributes, and Styles
date: 2020-09-19
journal: Chest
DOI: 10.1016/j.chest.2020.09.095
sha: 3af6bf6bc0d06b4160041ce958b90c7b10612583
doc_id: 864272
cord_uid: 8vot105e

In the context that leadership matters and that leadership competencies differ from those needed to practice medicine or conduct research, developing leadership competencies for physicians is important. Indeed, effective leadership is needed ubiquitously in healthcare, both at the executive level and at the bedside, e.g., leading clinical teams and problem-solving on the ward. Various leadership models have been proposed, most converging on common attributes – as described by Kouzes and Posner – of envisioning a new and better future state, inspiring others around this shared vision, empowering others to effect the vision, modeling the expected behaviors, and engaging others by appealing to shared values. Attention to creating an organizational culture that is informed by the 7 classic virtues – trust, compassion, courage, justice, wisdom, temperance, and hope – can also unleash discretionary effort in the organization to achieve high performance. Healthcare-specific leadership competencies include technical expertise, not only in one’s clinical/scientific arena in order to garner colleagues’ respect, but also regarding operations, strategic thinking, finance, human resources, and information technology. Also, knowledge of the regulatory and legislative environments of healthcare is critical, as is being a problem-solver and life-long learner. Perhaps most important to leadership in healthcare, as in all sectors, is having emotional intelligence. A spectrum of leadership styles has been described, and effective leaders are facile in deploying each style in a situationally appropriate way. Overall, leadership competencies can be developed and leadership development programs are signature features of leading healthcare organizations.

Leadership matters. Consider our recent history with the coronavirus pandemic. In general, states whose governors acted both early with full awareness of the epidemiology and risk, and definitively -e.g., by closing schools, mandating masks, socializing the concept of social distancing, implementing testing and contact tracing -experienced flattened curves while states with more laissez faire leadership bore greater disease burden and sequelae. Recognizing that leadership and followership are complementary attributes and are intertwined and that organizational performance also reflects the strength of organizational culture, effective leadership is characterized by discrete, teachable competencies coupled with formative experience. 1 This paper will first review the rationale for great leadership, and then discuss a leadership paradox in medicine, i.e., that the predominant leadership styles -commanding and pacesettingthat have been traditionally celebrated in healthcare are actually antithetical to best leadership practices. Attention then turns to a brief summary of various leadership models, emphasizing that despite using widely varying vocabularies, these models all converge on some core principles and attributes of effective leaders, including the classical virtues. Finally, leadership styles and the model of situational leadership are reviewed, emphasizing the need to pivot one's leadership style to the context and to the characteristics of those being led. The discussion focuses on the applicability of leadership principles for the chest physician, whether practicing as a clinician leading a team of caregivers or serving in a formal, titled leadership role.

This paper is the first of a 4-part series 2-4 that discuss essential leadership competencies for the chest physician. Subsequent papers address emotional intelligence and its primacy as a leadership competency, 2 change management, 3 and teambuilding. 4 Another important leadership competency, conflict and negotiation strategies, have been previously nicely discussed by Nguyen et al. 5 The Ubiquity of the Need for Leadership

The need and opportunities for leadership are ubiquitous. Bohmer 6 has framed the concepts of "small l" and "big L leadership" to cement the idea that leadership is needed broadly throughout healthcare. The concept of "small l" leadership emphasizes the importance of leading in clinical "microsystems," e.g., solving a care delivery challenge on a ward with the ward team, improving reporting on "near miss" events to enhance patient safety. "Small l" leaders can be the bedside nurse, the pulmonary consultant, the nurse clinician, or the medical student. "Small l" leaders may lack a formal leadership title but articulate a vision for providing high quality care that goes beyond the transactional steps of writing orders and reviewing test results. They lead by "being and doing". 6 Like all leaders, both "small l" and "big L" leaders (who are those with formal leadership roles and titles), "small l" leaders envision a better future state and create a culture; they act in ways that are consistent with their espoused values. They also manage, i.e., by establishing accountability and monitoring performance. "Small l" leadership emphasizes that leadership is not limited to "big L" leaders, e.g., those with formal leadership titles like department chair, dean, hospital president, CEO, etc.

Bohmer's characterization of the "small l" leader also invites considering the difference between leading and managing. Leading and managing are complementary 7,8 and share some common attributes; both regard deciding what needs to be done, creating networks of people to J o u r n a l P r e -p r o o f accomplish the stated goals, and establishing accountability to assure that the work gets done. At the same time, leading and managing differ in that managing is about predictability and order and leadership is about envisioning a future state that disrupts the status quo. Similarly, Schein 8 has characterized the distinction between managing and leading: "If one wishes to distinguish leadership from management or administration, one can argue that leadership creates and changes cultures, while management and administration act within a culture." Table 1 summarizes the difference between leading vs. managing. 7

Beyond the importance of "small l" leadership in healthcare, 6 leadership by physicians also matters at higher organizational levels, e.g., at the executive level. Several observational lines of evidence support this view. [9] [10] [11] As part of her "theory of expert leadership," Goodall 9,10 has shown that top-ranking U.S. News and World Report hospital status is significantly associated with having a physician (vs. a non-physician) chief executive officer. Similarly, in an analysis of the 115 largest U.S. hospitals in 2015, Tasi et al. 11 showed that the only significant correlates of high quality ratings and of hospital efficiency (i.e., inpatient days per bed per year) ratings were having a physician CEO. While these data are correlational and therefore cannot establish causality, widely recognized benefits of hospital physician leadership regard the "street credibility" that physicians may uniquely enjoy, the enhanced followership that may result from this "street cred", and an enhanced understanding of the clinical quality issues that are core to organizational mission and success. Further evidence supporting Goodall's "theory of expert leadership" includes concordant observations from other sectors. For example, universities in which the president is an accomplished research scholar have higher degrees of scholarship.

J o u r n a l P r e -p r o o f Formula 1 racing teams in which the principal was a driver him/herself with at least 10 years of driving experience were 16% more likely to gain a podium position than those without a driver principal. In short, when organizational leaders have "walked the walk," organizations tend to perform better.

Healthcare is beset by a paradox of leadership. One the one hand, as will be discussed in the paper on teamwork in this series, 4 outstanding clinical outcomes in healthcare depend on the caliber of teamwork and collaboration among caregivers. [12] [13] [14] Furthermore, patients judge their care on the human (not technical) aspects of their care, especially on how well they perceive their caregivers functioning as a team in service of their getting better. Yet, hospitals are traditionally and characteristically siloed organizations. As an example, the traditional organization of hospitals by "guilds" into departments of medicine, surgery, pediatrics, etc. with subspecialties subsumed within the departments reflects longstanding organization around the doctors' pedigrees and traditional training trajectories. Of course, silos notwithstanding, even in the predominant traditional structure, in the ideal, physicians across disciplines work in a "matrixed" fashion, 15 e.g., in service lines, in which care is directed to specific clinical needs.

Alternative structures that are organized around the patient include models which couple surgeons and internal medicine specialists together in a single institute, e.g., a heart and vascular institute which includes both cardiac surgeons and cardiologists (who frequently overlap in their care of patients with cardiac needs), a genitourinary/kidney institute which includes both nephrologists and urologists, a dermatology/plastic surgical institute which couples dermatologists and plastic surgeons, etc.

Silos in hospitals of any sort -department structures, separation of research from clinical care, separation of education from clinical care, etc. can pose unintended but formidable barriers to collaboration among physicians. The final element of the aforementioned healthcare leadership paradox regards the fact that traditional medical training has cultivated physicians as staunchly independent "heroic lone healers" 16 ,sometimes likened to gladiators or Viking warriors. But gladiators and Viking warriors can be "collaboratively challenged" [16] [17] [18] or handicapped in working easily with others over perceived senses of hierarchy. Weisbord cogently made this observation in a paper entitled "Why hasn't organizational developed (so far) in medical centers" 17 : "Science-based professional work differs markedly from product-based work. Health professionals learn rigorous scientific discipline as the "content" of their training. The 'process' inculcates a value for autonomous decision-making, personal achievement, and the importance of improving their own performance, rather than that of any institution."

The net effect of this paradox is that traditional selection and training of doctors produces physicians who may carry their "heroic lone healer" 16 phenotype to their leadership roles, whether "small l" or "big L", thereby potentially undermining their leadership performance.

Simply put, the paradox is that although teamwork is crucial to produce the best healthcare outcomes, 4, 14 physicians have not been traditionally selected nor trained to be team players.

Clearly, change is required here 3 and thankfully change is occurring, both in undergraduate and graduate medical curricula, which increasingly recognize how important collaboration is for clinical success. Furthermore, physicians who aspire to leadership are increasingly seeking and receiving formal leadership training, whether within their organizations, from professional societies, or from business schools. 12

J o u r n a l P r e -p r o o f and vocabulary. As a tiny sample of the myriad models and their vocabularies or leadership taxonomies, there is "servant leadership" proposed by Greenleaf, 19 "technical" vs. "adaptive" leadership proposed by Heifitz and Linsky, 20 the five levels of leadership proposed by Maxwell, 21 and "level 5" leadership proposed by Collins. 22 While each of these models and the many others unnamed here highlight distinctive attributes of effective leaders, this author's "lumping" tendency suggests that all these models converge on several core features of effective leaders. These core features have been succinctly captured in five leadership commitments Without wisdom, we make flawed decisions. Apathy goes up and so does risk. Without wisdom, our life is devoid of meaning and purpose. Without temperance, we rush to judge and we take J o u r n a l P r e -p r o o f unnecessary risks. We abandon our convictions and we lose credibility. Finally without hope, despair, cynicism, and fragility define who we become. How can we be effective as doctors without conferring hope? We recall the famous quote from the late 19 th century TB physician, Edward Livingston Trudeau "To cure sometimes, to relieve often, to comfort always" 25 

The robustness of the concept that the seven classical virtues and the five leadership commitments of Kouzes and Posner are core to leadership lies in their being independently validated by great thinkers and great leaders over time. 27, 28 For example, the five leadership commitments that Kouzes and Posner derived in their grounded theory research -challenge the process, inspire a shared vision, enable others to act, model the way, and encourage the heart (Table 2 ) -are uncannily similar to observations made a century earlier by one of America's great leaders, President Abraham Lincoln. 27 Similarly, Aristotle and philosopher Will Durant's comments about the virtues -"We are what we repeatedly do. Excellence is not an act but a habit" and "moral excellence is the result of habit or custom" 29 -replicates Heraclitus' observation that "Character is destiny" 30 , Plutarch's comment that "What we achieve inwardly will change outer reality" 31 , and Confucius' statement that "All people are the same: only their habits differ" 32 

Leading effectively in healthcare requires satisfying so-called "threshold" competencies, i.e., in addition to clinical/scientific competence that commands the respect of one's peers, having technical knowledge of operations, strategy, finance, and human resources. Healthcare leadership also requires understanding the regulatory and reimbursement environment of healthcare, including quality and process improvement strategies; having a problem-solver and growth mindset of continuous learning 36 ; and knowing how to negotiate and to communicate in multiple forums: to large groups and one-on-one in difficult conversations. These "threshold" competencies establish one's candidacy to be considered for leadership positions. They "bring you to the table" for consideration to be a leader and these threshold competencies complement what have been called "differentiating competencies," i.e., the attributes that distinguish capable leaders from remarkable leaders. These differentiating competencies, the attributes that cause leaders to be selected and to perform superbly, are those of emotional intelligence. 2, 3 . In brief, emotional intelligence is comprised of 4 broad competencies: self-awareness; the ability to selfmanage; to be aware of one's relationship with others; and to manage those relationships in service of greater effectiveness. 2, 37 

Beyond the common attributes which effective leaders largely share, effective leaders may also demonstrate situationally different leadership styles, depending on the context in which they are leading and the characteristics of those they are leading. Put simply, effective leaders adopt one of a range of leadership styles in order to be most impactful in a specific context. Goleman et al. 38 have proposed a taxonomy of 6 distinctive styles, what they call a repertoire of leadership styles (Table 4 ). These styles include: visionary, coaching, affiliative, democratic, pacesetting, and commanding, as described in Table 4 . Recognizing that effective leaders must know how J o u r n a l P r e -p r o o f and when to deploy each of these styles, Goleman et al. 38 characterize the styles in default as being "resonant" -being "attuned to people's feelings and moving them in a positive emotional direction" -or alternatively, "dissonant" -being "out of touch with the feelings of people in the room and driving the group in a downward spiral from frustration to resentment, rancor to rage."

Though each style has its place in specific conditions, leaders with primarily pacesetting and commanding styles (otherwise called "command and control") tend to produce dissonance whereas those with the other four styles tend to create resonance. Being keenly aware of the various styles and which one to use when is a requirement for the emotionally intelligent leader.

The notion that leaders should adapt their leadership style to the context in which they are leading has also been developed in a model called "situational leadership" 39 . Hersey and Blanchard framed a situational leadership model in which the leader should adopt one of four styles -telling, selling, participating, and delegating -based on the willingness and capability of the individual being led. For the unable but willing follower, the leader should adopt a participating style -encouraging, coaching, incenting, with a high relationship focus. Put in a medical context, imagine you are the attending on July 2 and helping a newly minted intern perform an arterial blood gas. If, as would be usual, the new intern had relatively little prior experience with this procedure, you as an attending would be hovering, watching, and coaching throughout the procedure. On the other hand, when the follower is highly capable and willing, the situational leadership model recommends a "delegation" style, i.e., one in which the follower is entrusted and empowered to act with a high degree of independence. The medical analog of a "delegation" style would be your approach as an attending in seeing a consult with a fifth year pulmonary fellow. The patient needs a thoracentesis and the fellow has performed hundreds of thoracenteses and is deemed to have achieved entrustable professional activity status by her J o u r n a l P r e -p r o o f 13 clinical competence committee. In this circumstance, the fellow would likely be entrusted to perform the procedure with little oversight.

In the context that leadership matters but that traditional medical training generally does not teach or confer leadership skills, leadership development is ever more important for physicians.

Effective leadership is characterized by clear attributes, including acting in ways and promoting cultures that are informed by the classical virtues of trust, compassion, courage, justice, wisdom, temperance, and hope. Developing leaders consists of three key components: offering curriculum regarding leadership competencies, including emotional intelligence, 2 teambuilding, 4 and change management; 3 cultivating coaching and mentoring around leadership; and experiential leadership, i.e., offering emerging leaders successive roles of increasing responsibility to cultivate growth and to assess success, which begets further opportunities. 40 Best-in-class leadership development programs in healthcare organizations offer all three elements. 41 -43 J o u r n a l P r e -p r o o f 

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