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Challenges for Physicians in Formal Leadership Roles: Silos in the Mind

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Health care systems are among the most complex organisations, facing a wicked intertwining of rapid change in knowledge, cost pressures, in-creased demand for access, for evidence-based medicine, and for more con-nection with patients and their families. Within this world, physicians are called to take up formal leadership positions as directors of quality, chief medical officers, section or department chiefs, deans of medical schools, and senior leadership positions in practices, hospitals, and health systems. Because their training inculcates values of autonomy, learning from ex-perience, and professional distance, physicians see a team (managerial) approach as 'other' and distance themselves from those colleagues who take up formal leadership roles. The consequences are ambivalence and splits, both among leaders and within individuals who accept such leadership roles. A maladaptive strat-egy is often silos in the mind, in which the different bodies of knowledge (clinical and business) are kept too separate, with the latter denigrated. Yet, many of the current challenges require closer linking of substantive med-ical knowledge with sophisticated organisational and managerial know-ledge to invent and implement new systems. Working with case material from US Academic Medicine, which socialises the majority of the USA's future generations of physicians, the article will explore the consequences and some of the challenges of linking these bodies of knowledge in the service of meeting the adaptive challenges facing health care.
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Challenges for Physicians in Formal
Leadership Roles: Silos in the Mind
Thomas N. Gilmore*
Abstract
Health care systems are among the most complex organisations, facing a
wicked intertwining of rapid change in knowledge, cost pressures, in-
creased demand for access, for evidence-based medicine, and for more con-
nection with patients and their families. Within this world, physicians are
called to take up formal leadership positions as directors of quality, chief
medical officers, section or department chiefs, deans of medical schools, and
senior leadership positions in practices, hospitals, and health systems.
Because their training inculcates values of autonomy, learning from ex-
perience, and professional distance, physicians see a team (managerial)
approach as ‘other’ and distance themselves from those colleagues who take
up formal leadership roles.
The consequences are ambivalence and splits, both among leaders and
within individuals who accept such leadership roles. A maladaptive strat-
egy is often silos in the mind, in which the different bodies of knowledge
(clinical and business) are kept too separate, with the latter denigrated. Yet,
many of the current challenges require closer linking of substantive med-
ical knowledge with sophisticated organisational and managerial know-
ledge to invent and implement new systems.
Working with case material from US Academic Medicine, which
socialises the majority of the USA’s future generations of physicians, the
article will explore the consequences and some of the challenges of linking
these bodies of knowledge in the service of meeting the adaptive challenges
facing health care.
Key words
: Professional leadership, projection, splitting, ambivalence.
IINNTTRROODDUUCCTTIIOONN
Health care settings are among the most complex of organisations,
facing rapid change in knowledge, cost pressures, increased demand
for access, innovations in science and services, and pull from patients
and families for more psycho-social attunement in the care and cure.
Organisational & Social Dynamics
10(2) 279–296 (2010)
279
*Address for correspondence: Thomas N. Gilmore, Vice President, CFAR, Suite 600,
1600 John F. Kennedy Boulevard, Philadelphia, PA 19103. Email: tgilmore@cfar.com
Historically, physician leaders were loosely coupled (Orton and
Weick, 1990) to the administrative and service apparatus. The hospi-
tal was regarded as the ‘doctor’s workshop’ and the mere administra-
tive mortals took up their role in support of the priestly work of
healing the sick. Their work took on the character of ‘parallel play’,
each in different realms with different distinctive competencies.
Physicians, especially in academic medical settings, could remain
blissfully ignorant of the cost implications of all their decisions
(admissions, level of care, tests, medications, etc.). Administrators
stayed clear of the issues of quality and medical decision-making
(Gilmore and Krantz, 1990). The result was silos in the organisation
and also in the minds of key leaders.
As the issues in research, education, and clinical care become
more complex, professional and managerial issues become more
intertwined. This creates a double challenge. First, the top team of
the organisation needs to integrate across the professionally and
administratively trained members due to their increased interde-
pendence. Second, for physician executives there is a particular chal-
lenge to integrate within themselves the clinical and administrative
aspects of their roles, what Argyris and Schon (1974) have termed
their first- and second-order professional skills.
This article will explore the dynamics of the ‘managerial other’
within physicians as they take up significant organisational leader-
ship. Many physician colleagues, on the occasion of a clinician’s or
scientist’s ‘promotion’ to a leadership role, express some variant of,
‘You are no longer one of us. You are one of them.’ Physicians wres-
tle with this dual identity, some becoming completely caught up in
the world of organisation and management; others hold firm to their
core professional identity, often at a cost to their effectiveness. If the
challenges increasingly require the integration of first-rate medical
knowledge with advanced skills in leadership and management,
then the working alliance across physicians and administrators
needs to be productive (CFAR, 2010). Physicians need to discover
ways to value both aspects of their leadership roles, rather than hold-
ing the managerial role at a distance. A maladaptive strategy is often
silos in the mind, in which the different bodies of knowledge (clini-
cal and business) are kept too separate, with the latter denigrated.
Heifitz (1994) has distinguished between technical work and
‘adaptive leadership work’. Adaptive work is value-laden, clarifying
and addressing what matters most, surfacing conflicts in values and
gaps between values and reality. Unlike technical work on routine
problems, adaptive work requires changes in people’s values, atti-
tudes, or habits of behaviour. Sometimes those changes are within
280 THOMAS N. GILMORE
themselves, and sometimes they are within their fellow profession-
als, but increasingly they require changes in the working alliances
with non-physicians.
Let us begin by looking at the prolonged socialisation of physi-
cians. A significant period of anticipatory socialisation, as they take
pre-med courses and begin striving to be a doctor, is followed by
four years of medical school and multiple years of residency, while
often being continued by sub-specialisation and fellowships. Until
recently, medical students went straight from college to medical
school and, therefore, had few experiences of coping in the everyday
world of work prior to becoming a physician. From the time of
‘becoming a doctor’ on, they often experience a splitting of their
‘positions’ in Oshry’s (1999) framework – being a ‘top’ as they turn
towards the patient who idealises them versus a ‘bottom’ as they
turn toward the organisation that they are embedded in. Depleted
patients often project magical abilities on to physicians (Main, 1975,
p. 61), thereby debiting the patient’s competence and heightening
the physician’s. Complaints and dissatisfactions get displaced on to
administrative roles rather than risk injuring, in fantasy, the physi-
cians on whom the patient is so dependent (Jaques, 1955). The nature
of the work also makes the physician special. They are authorised to
touch, poke, prod, invade, and even inflict pain in the service of cure
(Gilmore, 1991). Historically, physicians have had high autonomy in
their individual roles and as a profession (Rothman, 1991).
However, as junior members embedded in one of the most com-
plex organisational settings, physicians in training often feel the
lowest on the totem pole. In choosing residencies, they apply, and a
computerised matching system sorts all graduates into residencies.
Salaries and working conditions are given. They take direction from
the attendings in a near hazing environment of stress and long
hours. They spend years in a context that resembles what Goffman
describes as a ‘total institution’. He notes that in such settings, ‘The
self-defining aspects of office [or role] seem to be carried to an
extreme. In becoming a member, one becomes thought of as possess-
ing certain essential traits and qualities of character’ (1961, p. 111).
Thus, in becoming a physician, one is
not
becoming an adminis-
trator, and the differences between these two categories are exagger-
ated. When Dr Richard Klausner accepted the directorship of the
National Cancer Institute, the lead in the
New York Times
was ‘I am
not an administrator,’ as if being in that category would diminish his
standing among his peers or as reinforcing a message to himself that
his focus would remain on the scientific side – not on ‘adminstrivia’.
However, the leadership role requires linking both competencies.
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 281
When people enter into an intensive focus on specialisation as the
mode of advancement in academic medicine, they lack any frame-
works for understanding what leadership is and how it makes a dif-
ference. Within their medical culture, physicians see administrators
as a different category. When they look within their tribe at physi-
cians who have taken formal roles as department chairs, deans, etc.,
they find that their colleagues, both those who are in those roles and
others, often denigrate formal administrative leadership. This split-
ting prevents the linking of professional skills to the adaptive tasks
that the wider organisation faces.
To investigate the linking of the two cultures of medicine and
management, I invited physicians who hold leadership roles in
many different settings to reflect on what was said to them by close
friends upon their first taking up a formal administrative role
(CFAR, 1999). Over 80% of the comments were negative or ambiva-
lent – ‘Congratulations and condolences’, ‘This will be the end of
your research career’, and, ‘Are you crazy?’
Below is a list of some of the other responses.
We’ve lost an ally. You’ve become one of them, the enemy.
You’ll have a wider canvas.
Why are you doing this? For another sentence in your obituary?
It’s the end of your career as a scholar.
Fantastic, you can fix
all
our problems.
You went to medical school and spent twenty years learning and
mastering your craft . . . now you’re an administrator.
You’re no longer one of us . . . you’re one of them.
It’s the best job in medicine (chairperson of medicine).
Economics have taken all the fun from the job.
I hope they (the faculty) don’t cut you off at the knees. You’re
short enough already.
What are you going to do next? (Reflecting the implication that
after serving as dean, there are few paths back to being a real
researcher.)
You’re crazy.
What accounts for the high percentage of denigrating comments?
In corporate settings, many people aspire to move up the ‘ladder’
and their advancement elicits genuine congratulations from real
friends. It is not just what people say to physicians, but, as they take
on the administrative role, people react to them differently. A psy-
chiatrist who stepped into the position of chair noticed that, while
on rounds, the questions he was asked became more administrivial
– as if he was less of an expert in treatment of patients. A scientist
282 THOMAS N. GILMORE
taking the head position of a pharmaceutical laboratory had a simi-
lar sense that his colleagues began coming to him less for substan-
tive science issues. He noted, ‘It was like my IQ had been debited 15
points.’ Thus, the complexity of taking on managerial roles triggers
an inner resistance that interacts with external reinforcements, lead-
ing to holding it as ‘other’ – inside one but not the real me. Identity
changes often have this lag.
The role shapes how people think about aspiring to it or accept-
ing it if offered. Few people will acknowledge having an early aspi-
ration to become a dean or a chairman. It is as if the entire enterprise
is led by people who explain their presence in a leadership role as
‘accidental’, and then tell some story about how they fell into it. I
worked with a powerful (at least, as seen by outsiders) vice dean
who, after ten years, still regarded himself as ‘interim’ and that his
identification was with being back in the laboratory. One impact of
this stance is suppressing one’s comfort with power in acting in the
service of the organisation’s goals, in part to maintain one’s col-
leagueship with one’s peers in the professional frame (Zaleznik,
1970). Historically, with a slower pace of change, this ‘loose cou-
pling’ may have had few costs, but with the complexity of today’s
healthcare system, the leadership processes may not be requisite to
the speed of required change. In probing physicians’ stories about
how they got into these positions, it was striking how passively they
phrased them.
‘I was trapped into administration.’
‘The president asked me and in a moment of weakness I said
yes.’
‘The faculty convinced me to put my name in for dean.’
‘It was either retire or accept the deanship,’ and someone
responded, ‘Aren’t they the same thing?’
No one owned up to actively seeking the role. As one physician exec-
utive was talking, he prefaced his comments with the phrase, ‘When
I was chosen or put forward for an administrative post . . .’. What was
intriguing was the lack of aggression in comparison to most other
organisations where people
seek
positions of executive leadership. It
was as if it were illegitimate (at least publicly) to be hungry for a posi-
tion of power in a professional organisation, even when harnessed to
a higher purpose (Mant, 1983); it was as if the paradigm in profes-
sional organisations was Cincinnatus being persuaded to put down
the plough and, for the good of the country, step into a leadership role.
Isaacson, an executive recruiter who works extensively in acade-
mic medicine, identifies three key leadership skills: hunger, speed,
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 283
and weight. Speed is intelligence and the ability to quickly learn
new bodies of knowledge. Academic physicians have this in excess.
Weight is the sense of how one carries one’s authority. In the med-
ical culture, weight from their sense of status within the medical
hierarchy often does carry over to leadership positions. Hunger,
Isaacson defines as follows:
Hunger is the marriage of imagination to ambition. Hunger is having a
rich fantasy about what one wants to accomplish and the will to struggle
to realize it in the world. Hunger is the drive to make a mark, to build a
monument, to make something out of nothing. It is the capacity of a mature
mind to tap the irrational and intuitive depths of personality and to har-
ness those darker powers to moral pursuits. T. E. Lawrence described this
quality: ‘All men dream . . . but not equally. They who dream by night in
the dusty recesses of their minds wake in the day to find that all is vanity,
but the dreamers of the day are dangerous men, for they act their dream
with open eyes, to make it possible’. (Gilmore, 2003, p. 73)
Might this lack of aggression for taking on the role be related to
the difficulty of exercising socialised aggression or power in the
role? In a sense, one feels the role itself is depleted by the external
attacks and devaluation of it that are amplified by the ambivalence
of those who accept these positions. Just as we talk in political sci-
ence about a ‘weak’ governor’s office, might we have created physi-
cian–leader roles that are less potent than they need to be to face
today’s challenges? Furthermore, we know that the negative projec-
tions of others on to the leader are not without their influence on the
leader’s experience of his agency. This dynamic creates a ‘learned
helplessness’ (Seligman, 1975) where individuals feel unable to
make changes amid a system of such complexity. To be sure, objec-
tively academic medical centres are incredibly complex internally
and subject to conflicting external pressures from markets, the gov-
ernment, and from patients.
Physicians are understandably ambivalent about taking an admi-
nistrative role, as they are aware of the losses from giving up some of
the satisfactions of clinical care or research. However, when some-
one has accepted, he or she needs to be connected to the part of him
or herself that really wanted the job and the driving reasons, or
‘hunger’, for accepting – a combination of dreams and the commit-
ment to make those dreams real. Without the moral authority from
those dreams, it is hard to make the difficult decisions that today’s
challenges require. Given that the ‘managerial other’ within the
physician is held in low regard, when others attack them it is easy to
collude with the contempt. As the following cases illustrate, leaders
284 THOMAS N. GILMORE
often pre-emptively attack or denigrate ‘the administrative func-
tion’ to join in a colleague frame. This ambivalence becomes what
Fairbairn (Trist, personal conversation) termed ‘an internal saboteur’
relative to the challenges they face.
The dynamics of projection locate various traits of leadership and
management in ‘the other’ in ways that estrange physicians from
seeing how many of the skills they already have within themselves.
We worked with paediatric interns in their first year, helping them
to make sense of the nearly obliterative experience of a tertiary chil-
dren’s hospital (Gilmore, 1987). One significant complaint was the
lack of feedback from supervising faculty. We noted that since the
interns went on their rounds as small teams with one another and
had many interdependent tasks in managing the same patients
across shifts, they had considerable relevant information on one
another. They could give feedback on their bedside manner, the
quality of their collaboration with other physicians and with nurs-
ing, their skill at working with parents, or even their different clin-
ical competences. The near-total group resistance to giving one
another feedback was overwhelming. One immediately said, ‘What
are we supposed to do? Go around and say “turkey, turkey, star”?’
Here are physicians who, every shift, are working to perfect their
differential diagnostic skills in working with patients, completely
splitting off this observational skill from its managerial analogue of
giving constructive feedback to co-workers. Keeping the profes-
sional skills in a silo in the mind protects them from the contami-
nation of feelings surrounding administrative processes of feedback
and appraisal.
Several years later, we had the experience of working with the
chairs of medicine of forty medical schools. After a week of being
together in an intensive executive-development programme, we in-
vited them to give feedback to one another. The resistance was just as
intense as from the interns. In the area of organisational design, when
invited to create an idealised redesign of departments of medicine,
teams created significantly different structures from the present, but
felt unable to risk making those changes in their organisations.
To recapitulate the argument, physicians are socialised in a two-
culture organisation – professionals and administrators – in which
traits associated with leadership, management, and administration
are projected predominately into the other group and kept at a dis-
tance. One effect of this dynamic on physician administrators is to
tend less to the many behaviours, frameworks, and skills within
their core training that are similar to their administrative counter-
parts in the other half of the house.
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 285
A second effect is that physician administrators lack rich frame-
works for learning or observing leadership in either their physician
colleagues or lay leaders. In particular, they have an underdeveloped
sense of issues of role, authority, and organisation in a managerial
frame. Research on physicians as negotiators suggests, because of
their socialisation and the power of ‘doctor’s orders’ when facing
patients, they often are weak at working through differences to har-
vest integrative value (Shell and Klasko, 1996).
A third effect is that when they do actually step into roles with
some managerial and leadership component, they do so ambiva-
lently and do not have a significant amount of their identity tied to
their success in those aspects of the role. Many continue to be active
in patient care or basic science work. They frame the transition as
‘ordinary’ (Trist, Higgin, Murray and Pollock, 1990) and do not apply
their considerable learning-from-experience skills to the phenomena
of leadership, followership, strategy, delegation, and influence.
The cycle gets repeated as the leaders model ambivalence about
taking the roles and exercising the skills, to the point that the next
generation repeats the cycle of entering those roles ambivalently,
and tending less to their own relevant skills. Mentoring and teach-
ing is overly concentrated in the realm of first order skills, with lit-
tle reflection and learning about leading change, creating teams,
working through conflicts, and innovating new delivery systems.
TTWWOO
VVIIGGNNEETTTTEESS
Two cases illustrate the challenges of leaders to be effective in such
settings where these de-authorizing dynamics are so prevalent –
both for the leaders themselves and for their followers.
A chair runs the annual meeting of his fellow chairs
The first case was a prominent academic specialist who was serving
as the president of his speciality’s organisation of chairs. He had
overseen a strategic planning process in which they recrafted the
mission and developed some new initiatives. He was presenting this
work to the full group at their annual meeting. At the event itself,
only fifty people showed up when he had estimated 150 and the
administrator had said to prepare handouts for eighty-five. Slowly,
people arrived, meeting in small informal groups with almost all the
people sitting in the back half of the room, enacting their ambiva-
lence at being fully present (Kahn, 1992).
The leader began, pleading ineffectually with people to move for-
ward. He did not frame the meeting effectively, increasing the sense
286 THOMAS N. GILMORE
that people would experience it as fragmented issues with no con-
nective tissue (unlike the systemic perspective he would bring to
patient care). A report on an issue concerning training programmes
was discussed with no links to the strategic plan, or flagging the
challenge to get the residency programmes to act collectively and
hold one another accountable for the good of the whole speciality
field. He next presented the strategic plan, assuming none had read
the brief document, nor using the core group that had been involved
in its development. He repeatedly used words like ‘spirited, active,
positive, thoughtful’ to describe the retreat where the plan had been
developed, when the here-and-now dynamic felt funereal. He spoke
candidly of the sense of the organisation floundering and the need
to make a choice to either disband or re-energise itself. However, he
was not sufficiently up to the adaptive challenge to note the enact-
ment of this floundering in the current meeting. They voted unani-
mously (and in flight) to support the new mission. I was struck by
the parallels between the depleted sense of the association’s annual
meeting and the same issues reflected in the individuals (all of
them chairs) taking on leadership roles in their home institutions
(Table 1).
One might argue that this is a special case because, in the associ-
ation, people are only colleagues during meetings but much of lead-
ership in academic medical settings is exercised in peer contexts,
where one does not have formal authority over the participants.
Below, we describe an even more powerful role of a dean with his
faculty.
A dean engages his faculty
A medical school had experienced years of turmoil. A new dean
was appointed and was a good enough steward during this compli-
cated period, dealing with the university structure, complex rela-
tionships with a separate health care system, and trying to rebuild
the school.
With the dean’s support, a task force designed a faculty develop-
ment day-long workshop that came shortly after the conclusion of
the successful resolution of several key institutional issues. The day
was scheduled to begin at 8.30 a.m. with coffee and a talk with the
dean, then a series of workshops. Over 100 people signed up. When
the dean walked in at the designated start time, there were less than
forty people, all seated in the back left of a large, tiered lecture hall.
He began his talk with a humorous statement about not giving a test
and then said:
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 287
There are not great medical schools because of deans or administrators,
we are up there pushing paper, etc. Great medical schools exist because
of you, the faculty. People who are passionate about their teaching, about
their research, and about their clinical care.
He then proceeded to interview people skilfully about changes they
had experienced over their careers, from being a student to being a
resident, and what had attracted them to academic medicine. It was
288 THOMAS N. GILMORE
Table 1
. Parallels between the dynamics of the association meeting and
their departments back home.
Feature Association Role in home institution
Leadership President did not have fun. Sense that much of the role
Acted in a pleading way. is being ‘done to’ versus
doing.
Weakened role.
Transitions Poorly managed: Underattention to people
New members. crossing the boundary.
My entry as a speaker. Each person takes care of
The transition to the new him or herself,
leadership team for the self parenting.
association.
Administrator– Staff in disengaged and Staff kept in separate
professional reactive role. status.
relations Not in a productive Less effective collaboration
harness. than would really support
the enterprise.
Accountability Assumed people did not Management by guilt.
of followers read the plan – no holding Expecting people to be
them accountable. competent individual
No aggression in working contributors.
their mood, dynamics and Few direct conversations.
passivity. Complaints behind
people’s backs.
Low accountability when
people underperform.
Reflection/ No thoughtful evaluation Mortality and morbidity
learning or reflection on the meeting, conferences for learning
harvesting insights or about clinical errors, no
improvements. comparable after action
reviews of organisational
changes or actions.
a lovely discussion that engaged the community as people learning
from one another about how long they had been there, and their per-
ceptions of the changes. He was modelling effective leadership
engagement and large group skills.
What puzzled me was why he would denigrate himself (and the
others in the audience who held leadership roles), especially in the
wake of the enormous leadership work he had been doing to create
the context for faculty to thrive. What in that culture made it impos-
sible for him to ask for, or accept, acknowledgement for the achieve-
ments of his team over the past few years? Why, when many of the
participants and one of the tracks for the faculty-development day
were looking at issues of management and organisation, would he
join with the cultural denigration of all things administrative and
managerial? He spoke as if all of leadership is a hygienic factor
rather than a motivator (Herzberg, 1966) and only acknowledged
when it is absent but not affirmed when it is present.
When I discussed his behaviour with the dean, he responded that
he wanted this to be the faculty’s day, that he wanted to join with
them. Yet, many in his audience, like him, were both faculty and in
administrative positions. Furthermore, many of the purely faculty
had experienced many past and current effects of his leadership (both
positively and negatively), so for him to be self-effacing was likely to
trigger feelings of his hypocrisy rather than humility. Furthermore,
when I was giving feedback to the dean, I found myself inducted into
a culture of indirection, easing in. I said, ‘I hope I am not being too
harsh’, rather than saying, ‘I hope you take my feedback seriously.’
The pull of the culture is to mute aggression, even when in the ser-
vice of performance and worthy goals.
It was also not necessary. It would have been honest, appropriate,
and developmental for him to express his concern that recent events
had so embroiled him that he was at risk of losing touch with the
core mission of the medical school. The new world was going to
require less splitting or stuffing of all the financial and administra-
tive issues into scapegoated administrators. It would be necessary
for all to collaboratively create the context to support great teaching,
great research, and deliver high-quality clinical care.
The impact of his self-denigrating comments was to continue to
de-authorise the role of the dean and create disinformation about its
scope and contributions. If he had made his role more transparent,
and his own hungers more visible and confrontable, he could create
a more lively academic culture and work with the faculty in pro-
ductive ways that link both the academic mission and the leadership
and management challenges.
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 289
TTOOWWAARRDDSS AA DDIIFFFFEERREENNTT FFUUTTUURREE
In closing, I want to look at what it might take to break this vicious
cycle of de-authorisation and splitting when the imperative of the
challenges academic medicine faces requires the integrating of first-
rate science and medicine with first-rate organisation, management,
and leadership.
There is a long tradition of scapegoating leaders, even as there is
awareness that the issues may be as much, if not more, embedded in
the team (Gamson and Scotch, 1964). Kernberg (1980, p. 238) writes,
It can happen that most of the energy of an institution seems to be spent
on ‘curing’ its leader. It may well be that the astonishing capacity of so
many people in so many places to tolerate an unsatisfactory situation over
an extended period of time indicates how gratifying it is to attribute the
cause of all problems to the administrator, rather than to focus upon the
painful and complex interaction of the various systems involved in bring-
ing about his behavior.
The first skill of a leader is to hold a psychologically-informed
systems view and to be aware that feelings inside him or herself may
belong to others and vice versa. Eisold (unpublished working paper,
p. 18) has written, ‘having authority in a system often means enjoy-
ing the right to displace anxiety onto others, away from oneself’.
Leaders have to be attentive to the various attacks, what Kernberg
(1980) calls a ‘healthy paranoia’. Heifitz and Linsky (2002, p. 48) out-
line some of the dangers facing leaders who take up adaptive chal-
lenges. ‘Seduction, marginalisation, diversion and attack all serve a
function. They reduce the disequilibrium that would be generated
were people to address the issues that are taken off the table (by
these tactics)’. They articulate five principles to help prevent this.
1. Identify the adaptive challenge.
2. Regulate distress.
3. Maintain disciplined attention.
4. Give the work back to the people.
5. Protect voices of leadership from below.
This work begins by seeing or framing the task as an adaptive chal-
lenge, showing that shifting from a professional role (educator, clin-
ician, or researcher) to a leadership role is not trivial both for oneself
and for key others with whom one will work within new authority
relationships. It is not ordinary. Trist and co-authors (1990) identified
‘the assumption of ordinariness as a denial mechanism’. Working
with a case of change in the coal mines, they note the leaders framing
a change as ordinary was:
290 THOMAS N. GILMORE
a means of psychological defense against elements in the situation they
were unwilling to confront . . . [the changes] were treated throughout as
a production unit under difficulties, rather than perceived for what it was
– a training and development project working under the stress of full pro-
duction. (Trist, Higgin, Murray and Pollock, 1990)
A case that illustrates the importance of leaders who embrace the
adaptive challenge is a study of the adoption of a new technology by
surgical teams in comparable medical schools (Edmondson, Bohmer
and Pisano, 2001). Sixteen teams were studied as they took up a new,
minimally invasive way of doing cardiac surgery. Those that em-
braced the change as both a technical–professional and organisa-
tional role learned faster and had better outcomes. Those that saw it
as only technical experienced significant difficulties, as they did not
tap the important different perspectives from nursing, perfusionists,
and others. The successful teams realised that this change was not
‘ordinary’, and, therefore, selected the team with an eye to the learn-
ing agenda. They defined roles flexibly and engaged in significant
preparation and dry runs with offline practice under conditions of
safety and a climate of encouraging feedback. In the actual surgery
itself, the leader actively pulled observations from team members
and encouraged thinking and observing beyond the narrow confines
of their roles. Afterwards, there was an explicit reflective session to
review the data and experience and make appropriate modifications.
In the unsuccessful teams, the group was not specially formed.
There was no full-team rehearsal and communication was suppres-
sed. A perfusionist gave the following report:
We were having trouble with the venous return, and I mentioned it. The
surgeon said, ‘Jack, is that you?’ I said yes. He said, ‘Are you pumping
[being the first rather than the second, or assisting perfusionist] this
case?’ I said, ‘No, I’m assisting.’ ‘Well in the future, if you are not pump-
ing the case, I don’t want to hear from you.’ (Edmondson, Bohmer and
Pisano, 2001, p. 704)
Contrast this with a comment from the same role on a successful
team in another hospital.
The surgeon empowered the team. That’s why I’m so excited about [the
new procedure]. It has been a model, not just for this hospital but for car-
diac surgery. It’s about what a group of people can do. (
ibid
., p. 699)
Note that the comment here is not just about the personal leadership
of the surgeon, but accurately sees it as contributing institutionally
to an emerging model, both for the local institution and the wider
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 291
field. What is powerful about this case is the linking of the core pro-
fessional skills with second-order skills of leadership and manage-
ment: setting the tone, selection, and management of the creation of
the team, thinking ahead in a climate that encourages all perspec-
tives to be active contributors, creating a real-time environment of
effective two-way communication, and having reflective learning
sessions after the event. These are all concrete examples of skills that
arise close to the professional craft, yet are generalisable to many of
the other broader management and leadership tasks. They are work-
ing at the front line level in ways that model what Hecksher,
Rubinstein, Flynn, Erhardt and Boniface (2008) have framed as the
‘collaborative model’ in contrast to the historic models of auto-
nomous professional and bureaucracy.
There are many other bridges from the silo of one’s core profes-
sional knowledge to leadership and management skills that link
rather than split them. For example, epidemiological thinking has
been powerfully used in management worlds to help managers
become better problem solvers and pattern detectors based on data.
As noted earlier, the differential diagnosis is a framework that can
inform coaching and appraisals by exploring differences between
when a colleague is particularly effective versus ineffective, or across
experiences of a team. Effective communication with anxious patients
and families is applicable to dealing with the resistance to significant
changes in organisational routines. Managing ambiguity in the face
of conflicting signals about key trends in the environment is analo-
gous to managing a treatment course with uncertainty about diagno-
sis and/or the treatment. Learning from experience itself is a core skill
that crosses both the professional and the managerial worlds but re-
quires the mental linking of grand rounds, morbidity, and mortality
conferences to their managerial equivalent of the after-action review.
In any hierarchy, if people are mindful (Langer, 1989) and have
insightful frameworks, there are relevant analogous experiences. For
example, chairs are often surprised to learn that their division heads
see them in ways that are similar to those in which they, in turn, see
their dean. The negative aspects that they see so easily in the dean’s
behaviour are less easily owned as part of their role as a leader in a
smaller, but still complex, unit of a department. They may be intimi-
dated by the dean, but attend less to how they, in turn, intimidate.
They may see the dean as not transparent in resource allocation deci-
sions, but not see their opacity with their division heads.
Cohen and Ettin (1999, pp. 68–69) write about the process of self-
differentiation through productive dialogue. Depersonalizing pro-
jections, frequent in academic medicine, often cause a withdrawal or
292 THOMAS N. GILMORE
a (real or imagined) retaliation rather than correction via direct talk
and dialogue. It can be equally distorting when positive attributions
go uncontested, as they often do in academia, regarding the per-
ceived power of leadership roles – which are often seen as far more
powerful and well resourced from afar than by the people in the
roles. Note the leadership required in the above surgical team cases
to set the climate for this two-way communication.
Both successful and unsuccessful occupants of a role leave a
shadow on the role itself. Just as effective individuals seem to add
new dimensions to the role they occupy and, thereby, create new
standards and expectations for those who follow, another leader
may actually subtract credibility, confidence, and other qualities
from the role itself. In the surgical cases, as leaders step up to the
adaptive challenges, they create new expectations for the team
leader role, and, over time, can create both superior and follower
pressure on any new team leader to meet the new role expectations.
Conversely, those who continue to split the professional and the
managerial damage the role itself. In the way that we talk about a
‘weakened presidency’ in political discourse, a leader from any field
of endeavour can leave behind a shadow that subsequently impairs
the exercise of authority itself. This type of shadow can have a dev-
astating impact on both the new leader and the organisation. All
occupants need to see themselves as stewards of the roles that they
occupy in academic medicine and work to leave them with the req-
uisite authority for the challenges that they face by more effectively
linking the professional and managerial realms.
We are seeing some of the elements of change within academic
medicine. Most powerfully, the patient safety movement has brought
management tools of Six Sigma into the clinical space, using teams of
physicians, nurses, pharmacists, and administrators, working closely
with the front line practices of the organisation. We often observe an
initial rigid rule-following of the new processes, but, in the best set-
tings, this is transitional towards it becoming an integrated part of
how these leaders see the issues, linking clinical phenomena with
management processes. One leader of a medical speciality society
recently noted that in the professionalism frame of counting on
autonomous roles, doing the right thing can only get us 60% of the
way towards collective goals, and that systems thinking and organi-
sational changes are needed to approach bold goals such as no pre-
ventable deaths or major redesign of clinical care systems.
From the top level, mission-based management (a relative of man-
agement by objectives) is a campaign to more explicitly link re-
sources and management to specific aspects of the academic mission.
CHALLENGES FOR PHYSICIANS IN FORMAL LEADERSHIP ROLES 293
A hallmark of the process is transparency, so that budgets are seen
by peers and dampen the often-rampant fantasies about who got
what based on what criteria.
Process clarity and transparency are developmental. If people
know who is making a decision and by when, and perhaps what the
criteria are, this can substitute for not knowing what the actual deci-
sion is and increase leaders and followers holding one another ac-
countable. In a retreat of an academic medical centre, when we called
for a fishbowl meeting of the executive–management group, there
was considerable confusion about the membership of that group
from both outsiders and a few in the group (Gilmore, 1997, pp. 40–41).
This situation does not enable followers to hold their leaders account-
able or for the leaders to receive acknowledgement from their faculty.
CCOONNCCLLUUSSIIOONN
The challenge is large. Moore (1990, p. 19) has thoughtfully framed
the challenge.
Medicine and business management are fundamentally different cul-
tures. Employing doctors in managerial roles will yield good results only
when we recognize and find means to deal with the radically different
values and ideologies of medicine and management.
This paper argues that the first step is to build links between these
‘two cultures’ and invite physicians to see the opportunities in close
proximity to their practice. As always with developmental processes,
the progress is uneven with a mixture of new emerging practices in
the social ground, with uneven support, and with leadership from
above. As people begin to make the links across these silos of pro-
fessional and managerial, the rate of change will increase. People fill
a role differentially. Kahn (1992, p. 322) suggests that being ‘fully
there’ in one’s role is rare, and involves four dimensions: attentive-
ness, connection, integration, and focus. It is sobering to compare
the difference between how physician leaders fill their professional
roles versus their formal organisational roles. No talented surgeon
would enter the operating room without scrubbing, reviewing all
the available diagnostic information, and checking the infrastruc-
ture and the team’s readiness. Yet, that same surgeon, as a chair
going into a meeting, will grab a folder from his secretary and skim
it en route to the conference room three doors down from his office
and begin a meeting with no acknowledgement of absent members,
and differentiating between those who, respectful of community
life, informed the leader and those who simply did not turn up. The
leadership of the meeting often ignores the interdependency of the
294 THOMAS N. GILMORE
various items to one another and to the overall well-being of the in-
stitution. What Langer (1989) calls ‘mindfulness’, when brought to
the adaptive challenge facing academic medicine, will go a long way
to bringing the inherent intelligence and aggression in physicians
core training to the leadership task.
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