Perspective: physician leaders and their bases of power: common and disparate elements

Catholic Ownership, Physician Leadership and Operational Strategies: Evidence from German Hospitals

Previous research has revealed that Catholic hospitals are more likely follow a strategy of horizontal diversification and maximization of the number of patients treated, whereas Protestant hospitals follow a strategy of horizontal specialization and focus on vertical differentiation. However, there is no empirical evidence pertaining to this mechanism. We conduct an empirical study in a German setting and argue that physician leadership mediates the relationship between ownership and operational strategies. The study includes the construction of a model combining data from a survey and publicly available information derived from the annual quality reports of German hospitals. Our results show that Catholic hospitals opt for leadership structures that ensure operational strategies in line with their general values, i.e., operational strategies of maximizing volume throughout the overall hospital. They prefer part-time positions for chief medical officers, as chief medical officers are identified to foster strategies of maximizing the overall number of patients treated. Hospital owners should be aware that the implementation of part-time and full-time leadership roles can help to support their strategies. Thus, our results provide insights into the relationship between leadership structures at the top of an organization, on the one hand, and strategic choices, on the other.

The ecology of program director leadership: power relationships and characteristics of effective program directors

BACKGROUND

Program directors are often perceived as strong and independent leaders within the academic medical environment. However, they are not as omnipotent as they initially appear. Indeed, PDs are beholden to a variety of different agents, including trainees (current residents, residency applicants, residency alumni), internal influencers (departmental faculty, hospital administration, institutional graduate medical education), and external influencers (the Accreditation Council for Graduate Medical Education (ACGME), medical education community, and society-at-large). Altogether, these agents form a complex ecosystem whose dynamics and relationships shape the effectiveness of program directors.

MAIN BODY

This perspective uses management theory to examine the characteristics of effective PD leadership. We underline the importance of authority, accessibility, adaptability, authenticity, accountability, and autonomy as core features of successful program directors. Additionally, we review how program directors can use the six power bases (legitimacy, referent, informational, expert, reward, and coercive) to achieve positive and constructive change within the complexity of the academic medical ecosystem. Lastly, we describe how local and national institutions can better structure power relationships within the ecosystem so that PD leadership can be most effective.

CONCLUSION

Keen leadership skills are required by program directors to face a variety of challenges within their educational environments. Understanding power structures and relationships may aid program directors to exercise leadership judiciously towards fulfilling the educational missions of their departments.

Power and physician leadership

Power and leadership are intimately related. While physician leadership is widely discussed in healthcare, power has received less attention. Formal organisational leadership by physicians is increasingly common even though the evidence for the effectiveness of physician leadership is still evolving. There is an expectation of leadership by all physicians for resource stewardship. The impact of power on interprofessional education and practice needs further study. Power also shapes the profession’s attempts to address physician and learner well-being with its implications for patient care. Unfortunately, the profession is not exempt from inappropriate use of power. These observations led the authors to explore the concept and impact of power in physician leadership. Drawing from a range of conceptualisations including structuralist (French and Raven), feminist (Allen) and poststructuralist (Foucault) conceptualisations of power, we explore how power is acquired and exercised in healthcare systems and enacted in leadership praxis by individual physician leaders (PL). Judicious use of power will benefit from consideration and application of a range of concepts including liminality, power mediation, power distance, inter-related use of power bases, intergroup and shared leadership, inclusive leadership, empowerment, transformational leadership and discourse for meaning-making. Avoiding abuse of power requires moral courage, and those who seek to become accountable leaders may benefit from adaptive reflection. Reframing ‘followers’ as ‘constituents or citizens’ is one way to interrupt discourses and narratives that reinforce traditional power imbalances. Applying these concepts can enhance creativity, cocreation and citizenship-strengthening commitment to improved healthcare. PLs can contribute greatly in this regard to further transform healthcare.

Leadership Roles and Activities Among Alumni Receiving Postdoctoral Fellowship Training in Cancer Prevention

This study was conducted in 2016-2017 to better understand formal and informal leadership roles and activities of alumni from postdoctoral research training programs in cancer prevention. Data were obtained from surveys of 254 employed scientists who completed cancer prevention postdoctoral training within the National Cancer Institute (NCI) Cancer Prevention Fellowship Program, or at US research institutions through NCI-sponsored National Research Service Award (NRSA) individual postdoctoral fellowship (F32) grants, from 1987 to 2011. Fifteen questions categorized under Organizational Leadership, Research Leadership, Professional Society/Conference Leadership, and Broader Scientific/Health Community Leadership domains were analyzed. About 75% of respondents had at least one organizational leadership role or activity during their careers, and 13-34% reported some type of research, professional society/conference, or broader scientific/health community leadership within the past 5 years. Characteristics independently associated with leadership from regression models were being in earlier postdoctoral cohorts (8 items, range for statistically significant ORs = 2.8 to 10.8) and employment sector (8 items, range for statistically significant ORs = 0.4 to 11.7). Scientists whose race/ethnicity was other than white were less likely to report organizational leadership or management responsibilities (OR = 0.4, 95% CI 0.2-0.9). Here, many alumni from NCI-supported cancer prevention postdoctoral programs were involved in leadership, with postdoctoral cohort and employment sector being the factors most often associated with leadership roles and activities. Currently, there is relatively little research on leadership roles of biomedical scientists in general, or in cancer prevention specifically. This study begins to address this gap and provide a basis for more extensive studies of leadership roles and training of scientists.

The Complexity of Patients' Health Communication Social Networks: A Broadening of Physician Communication

Phenomenon: Patients have access to a wide variety of sources of information about their health in their day-to-day contexts. This can sometimes result in discordance between a physician's perception of a patient's health issue and a patient's perception of their health issue. Even after the physician has negotiated an understanding and treatment plan with a patient, subsequent interactions outside the physician-patient encounter may modify the patient's understanding of their health issue. A patient's reinterpretation of his or her health issue can then result in nonadherence of the treatment plan or even alternative treatment plans that the physician perceives as being unsatisfactory. Current models of physician-patient communication do not prepare physicians to manage this phenomenon. Approach: Using an ethnographic and a social network analysis research design, participants' patterns of social interaction around health information were investigated over a yearlong period (2012-2013) in a small rural community in Western Canada. Data included (a) individual interviews, (b) focus group interviews, and (c) field notes. Data were analyzed in a three-stage process: (a) item analysis, (b) pattern analysis, and (c) structural analysis. Findings: The findings highlight how physicians are only one nodal point in patients' broad, multilayered networks of communication. Interactions around health topics were not isolated events but rather occurred in various patterns of social interactions that were longitudinal and iterative. Meaning making around health topics was constructed, shared, elaborated, reconstructed, and interpreted in participants' social networks, as information was distributed through a complex temporal system of interpersonal ties. Insights: Issues concerning physician communication have been a long-standing conversation in the field of medical education. Many competency frameworks have attempted to encompass this core competency in their elaboration of the physician communicator. However, most representations and discussions in the field tend to depict physician communicators as experts who translate their knowledge to patients in a simplified way, in a single moment in time. This study suggests that educational initiatives in physician-patient communication would benefit from contextualizing physicians as part of patients' resource-rich, temporally extended, iterative process of meaning making. This alternative framing has the potential to support physicians' continuing engagement with patients as a meaningful and responsive node in patients' meaning-making networks.

A Qualitative Analysis of Narrative Preclerkship Assessment Data to Evaluate Teamwork Skills

Construct: Students entering the health professions require competency in teamwork. Background: Although many teamwork curricula and assessments exist, studies have not demonstrated robust longitudinal assessment of preclerkship students' teamwork skills and attitudes. Assessment portfolios may serve to fill this gap, but it is unknown how narrative comments within portfolios describe student teamwork behaviors. Approach: We performed a qualitative analysis of narrative data in 15 assessment portfolios. Student portfolios were randomly selected from 3 groups stratified by quantitative ratings of teamwork performance gathered from small-group and clinical preceptor assessment forms. Narrative data included peer and faculty feedback from these same forms. Data were coded for teamwork-related behaviors using a constant comparative approach combined with an identification of the valence of the coded statements as either "positive observation" or "suggestion for improvement." Results: Eight codes related to teamwork emerged: attitude and demeanor, information facilitation, leadership, preparation and dependability, professionalism, team orientation, values team member contributions, and nonspecific teamwork comments. The frequency of codes and valence varied across the 3 performance groups, with students in the low-performing group receiving more suggestions for improvement across all teamwork codes. Conclusions: Narrative data from assessment portfolios included specific descriptions of teamwork behavior, with important contributions provided by both faculty and peers. A variety of teamwork domains were represented. Such feedback as collected in an assessment portfolio can be used for longitudinal assessment of preclerkship student teamwork skills and attitudes.

The relationship between perceived preceptor power use and student empowerment during clerkship rotations: a study of hidden curriculum

CONTEXT

Medical learners are vulnerable to the social power used by preceptors. Furthermore, an individual's perceived level of personal empowerment has been identified as a predictor of positive behaviour in education environments. The degree to which medical students feel empowered in their clinical environments factors largely into how vulnerable they are to having their professional values influenced negatively by structural and cultural aspects of these environments.

OBJECTIVES

The goal of this study was to explore the relationship between clerks' perceptions of personal empowerment and the social power employed by their preceptors. This research also investigates the prevalence of negative power use as a function of the hierarchical organisation of a clerkship rotation.

METHODS

Validated power use and empowerment surveys were modified for clinical learning environments and administered to clerkship learners across six clerkship rotations. The outcomes of the two surveys were subjected to correlational analyses. Outcomes associated with the use of each type of perceived power were analysed to determine the influence of the relative involvement of residents and staff physicians in preceptorship.

RESULTS

Correlational analyses revealed strong relationships between clerks' perceptions of preceptor power use and their own personal empowerment. Furthermore, although participants perceived significantly more pro-social preceptor uses of power, clerks perceived a higher prevalence of coercive power on rotations with high involvement of residents as preceptors.

CONCLUSIONS

Clerks' perceptions of empowerment correlate positively with positive power bases and negatively with negative dimensions of preceptor power. This research has implications for the importance of the development of resident and faculty staff as educators, the identification of clerks who are vulnerable to ethical violation, and for a refined understanding of the transactional way in which power is experienced in a medical education context.

Leadership in the clinical workplace: what residents report to observe and supervisors report to display: an exploratory questionnaire study

BACKGROUND

Within the current health care system, leadership is considered important for physicians. leadership is mostly self-taught, through observing and practicing. Does the practice environment offer residents enough opportunities to observe the supervisor leadership behaviours they have to learn? In the current study we investigate which leadership behaviours residents observe throughout their training, which behaviours supervisors report to display and whether residents and supervisors have a need for more formal training.

METHODS

We performed two questionnaire studies. Study 1: Residents (n = 117) answered questions about the extent to which they observed four basic and observable Situational Leadership behaviours in their supervisors. Study 2: Supervisors (n = 201) answered questions about the extent to which they perceived to display these Situational Leadership behaviours in medical practice. We asked both groups of participants whether they experienced a need for formal leadership training.

RESULTS

One-third of the residents did not observe the four basic Situational Leadership behaviours. The same pattern was found among starting, intermediate and experienced residents. Moreover, not all supervisors showed these 4 leadership behaviours. Both supervisors and residents expressed a need for formal leadership training.

CONCLUSION

Both findings together suggest that current practice does not offer residents enough opportunities to acquire these leadership behaviours by solely observing their supervisors. Moreover, residents and supervisors both express a need for more formal leadership training. More explicit attention should be paid to leadership development, for example by providing formal leadership training for supervisors and residents.

Medical leadership is the New Black: or is it?

Considerable resources are being invested in healthcare leadership development programs and there is a new requirement for leadership teaching for Australian medical students. The new attention to medical leadership may be a reaction to loss of medical status and power. There is little evidence for return on investment from such programs. It is simply not clear what kind of leadership training is needed for collaborative work to improve healthcare nor what kind of organisational structures enable productive exercise of medical leadership skills. Caution is recommended. What is known about the topic? Considerable resources are being invested in healthcare leadership development programs and there is a new requirement to add leadership to the curricula for Australian medical students. What does this paper add? The lack of logic in calls for mass leadership training is explored. This may not only be a poor return on investment but also potentially reinforce medical attitudes that are unhelpful for modern healthcare. What are the implications for practitioners? A cautious approach to training large numbers of doctors and students is recommended.

Program directors in their role as leaders of teaching teams in residency training

BACKGROUND

Program directors have a formal leading position within a teaching team. It is not clear how program directors fulfill their leadership role in practice. In this interview study we aim to explore the role of the program director as strategic leader, based on the research-question: What are the experiences of program directors with strategic leadership?

METHOD

We conducted an interview study using the principles of phenomenography to explore program directors' experiences. In the period June 2012-May 2013, 16 program directors from different hospital organisations were invited to participate in an interview study. Iterative data collection and analysis were based on strategic leadership: (1) developing collective mindset, (2) focusing on collaborative learning and (3) designing teaching organisation.

RESULTS

Fourteen program directors participated in this study. We identified four leadership profiles: (1) captains, (2) carers, (3) professionals and (4) team-players. The 'team-players' come closest to integrally applying strategic leadership. For all four profiles there seems to be a preference for developing collectivity by means of providing information. Program directors have less experience with promoting collaborative learning and the designing of teaching organisation is task-oriented.

CONCLUSION

Promoting collaborative learning is the most important challenge for developing leadership within the teaching team.

Leadership in academic health centers in the US: A review of the role and some recommendations

The leadership of the US's most complex academic health centers (AHCs)/medical centers requires individuals who possess a high level of clinical, organizational, managerial, and interpersonal skills. This paper first outlines the major attributes desired in a dean/vice president of health affairs before then summarizing the educational opportunities now generally available to train for such leadership and management roles. For the most part, the masters in health administration (MHA), the traditional MBA, and the numerous alternatives primarily available at universities are considered far too general and too lacking in emotional intelligence tutoring to be particularly relevant for those who aspire to these most senior leadership positions. More appropriate educational options for these roles are discussed: (a) the in-house leadership and management programs now underway at some AHCs for those selected early on in their career for future executive-type roles as well as for those who are appointed later on to a chair, directorship or similar position; and (b) a more controversial approach of potentially establishing at one or a few universities, a mid-career, professional program (a maximum of 12 months and therefore, being completed in less time than an MBA) leading to a masters degree in academic health center administration (MHCA) for those who aspire to fill a senior AHC leadership position. The proposed curriculum as outlined herein might be along the lines of some carefully designed masters level on-line, self-teaching modules for the more technical subjects, yet vigorously emphasizing integrate-type courses focused on enhancing personal and professional team building and leadership skills.

Expanding the scope of leadership training in medicine

All physicians take a leadership role at some point in their career-some exert influence in their practices and communities as informal leaders, and others hold formal leadership roles to which they are appointed or elected. These formal leadership roles convey power to those individuals who hold such positions. Formal leadership, however, is limited in its influence unless it is accompanied by a series of personal and interpersonal competencies that characterize both formal and informal leaders.Many physicians who do not hold formal leadership roles will be called on to provide (or will wish to provide) informal leadership at various times in their careers. Both formal and informal leaders should be trained in the personal and interpersonal competencies necessary for effective leadership to advance the principles-driven and values-oriented goals inherent in the health care enterprise.In this article, the author defines leadership and describes the characteristics of formal and informal leaders, then discusses the types of leadership and the power derived from different leadership roles. He concludes by arguing in favor of expanding the scope of leadership training to include informal as well as formal leaders.