Physician leadership during the current crisis in healthcare: A perspective drawn from anthropological and clinical leadership research

Abstract

Objectives

There are ongoing challenges in workforce sustainability and service delivery due to the COVID-19 pandemic. Recruiting credible clinical leaders can enhance outcomes through mentoring, leading by example, and creating positive work environments. We investigate the anthropology of, and related research on leadership.

Conclusions

Clinical and anthropological research provides strong grounds for investing in clinical leadership. The stability of ‘prestige-based’ leadership can be contrasted with the outcomes of ‘dominance-based’ leadership that relies on force, control, and threats. Dominance-based leadership increases the risks of bullying in stressed healthcare organisations. In contrast, expert clinical leaders can exert culturally mediated effects on social learning, team cooperation and morale, and patient outcomes.

Healthcare systems are under immense strain due to the COVID-19 pandemic. Renewed leadership and enhanced staff morale are essential for maintaining healthcare quality. Advances in anthropology ¹ may provide a new perspective on the leadership crisis faced by healthcare systems in high-income countries. ² Leaders credible based on their expert medical skills may play a role in reviving ailing healthcare systems.

What is known about expert leadership in healthcare

Expert medical leadership can enhance individual healthcare worker, organisational and patient care outcomes. Physician-led large hospital systems receive higher quality ratings and better bed usage rates than those led by non-physicians, with no differences in financial performance.^3,4 A systematic review on hospital leadership effectiveness found physicians had a positive impact on financial and operational resource management, quality of care and community benefits. ⁵ However, further research is needed as to whether other clinicians can provide similarly effective leadership.

Expert leaders signal credibility through their proven track record in the core activity of healthcare ⁶ and thus have both power and influence among core workers. ⁵ A study of 3000 hospital physicians in Australia, Denmark and Switzerland reported that doctors, when led by physicians, were less likely to resign and more satisfied with their work based on their supervisor’s effectiveness. ⁷ The sustainability and morale of healthcare organisations could be enhanced by physician leadership, such as in psychiatric services. ⁸

Physicians do not inherently have all the necessary leadership skills, so specific skills training may be needed. An important factor in motivating physicians to work in leadership and management positions is the opportunity for positive outcomes that outweigh concerns about administrative burdens, resource shortfalls, fears of burnout, and lack of organisational readiness for change. ⁹ Outcomes-based approaches to leadership development for physicians are therefore the most effective, demonstrating improvements in individual, organisational, and patient measures. ¹⁰ Measures should include individual self-awareness, self-efficacy, leadership knowledge, skills and behaviours, as well as organisational impact and patient outcomes. ¹⁰ Effective teaching includes interactive workshops, video simulations, peer and expert feedback, multisource feedback, coaching, action learning, and mentoring. ¹⁰ An example of a physician leadership training course that could strengthen skills is https://www.bayes.city.ac.uk/study/executive-education/degree-apprenticeships/executive-msc-in-medical-leadership

What recent anthropology research adds to healthcare leadership studies

Prestige-based status is a basis for social learning and cultural transmission within human societies. ¹ The expertise of such leaders, based on competence in culturally valued domains, is signified by the displays of respect by others, as well as a desire to learn from them. ¹

Analogously, a credible and prestigious physician leader is rated highly on clinical and academic acumen, regarded as a generous leader willing to share their skills and knowledge, and is held in high esteem by their clinical peers. ¹¹

Cultural transmission occurs through the direct social learning strategy of infocopying, comprising forms of direct social learning from another person. ¹ These include imitation (acquiring motor patterns via observation), emulation of goals (inference on behavioural goals via observation) and influence, where the model expresses a view that sways the other person toward it. ¹ The costs of individual experimentation to develop skills are often high, so people are motivated to seek potential models from which to infocopy. ¹ Humans seek first to learn from others, thus avoiding the cost of redundant innovation, and then temper their skills through individual practice. ¹ Such models are sought based on certain cues: the competence of the model in the culturally valued domains (using observable simple outcome measures, e.g. number of research publications); the deference that is shown to the model by others, manifest as status and prestige (e.g. the professional respect accorded by peers); and the model’s observable health and fitness. ¹

There is the potential for health system infocopying from physicians with recognised clinical and academic expertise. Such prestige-based expert medical leadership should be embedded at all healthcare levels to facilitate social learning, including ethical and professional standards, as well as expert medical and academic skills. Prestige-based leadership may provide the foundations for team-based cooperation – through the generation of correlated behavioural phenotypes between leaders and followers, as well as among peers. ¹²

Prestige-based leadership contrasts with leadership based on dominance-based hierarchies using force-threat, evident in primates and other animals, and which exist in parallel with prestige in humans.^1,13 Dominance is a human cultural mechanism to attain and maintain high social status through coercion. ¹³

Dominance hierarchies can manifest in the strict line management of healthcare systems characterised by agonistic interactions, in which some individuals are able to coercively exploit control over costs and benefits to extract deference from others through the form of aggression, intimidation, and threats. ¹³ Prevalent bullying and harassment in healthcare settings ¹⁴ may arise from dominance hierarchies, leading to the opportunity for coercion by doctors of doctors. Formalisation of organisational roles in vast healthcare administration bureaucracies under the control of policy-makers and politicians facilitates the entrenchment of such hierarchies, allowing unscrupulous bosses to bully and control their junior and senior clinicians. ¹⁵ Systemic changes, such as requiring hospital boards – including physician leaders – to have as a key performance indicator the psychosocial health and wellbeing of their staff are also needed. ¹⁶

Expertise-based prestige and dominance are both means to maintain high social status. ¹⁷ However, anti-dominance coalitions can take action to suppress the power of coercive bullies. ¹⁸ These instincts can spur doctors to advocate against bullying by line managers, including doctors. Expertise-based prestigious leaders may form more effective advocacy coalitions, especially in partnership with medico-political groups and unions.

The lack of demonstrated effectiveness of interventions to address workplace bullying and harassment in general, ¹⁹ and specifically in healthcare, ²⁰ may arise from the lack of accessibility to cultural influences to improve the ethos of health systems. ²¹ There is the potential to harness prestige-based physician leaders to ethically model and manage to counteract dominance force-threat-based bullying and harassment behaviours, and for example, prosocial prestige-based leadership can foster a cooperative ethos. ¹²

Future directions?

Anthropologic research on sociocultural learning via prestige based on expertise ¹ concords with organisational research that doctors can be credible and effective leaders, through their specific knowledge and skills in healthcare provision. ⁴ Expert-prestige-based leadership may leaven the effect of dominance-based line management that gives rise to bullying and harassment in healthcare workplaces, ¹⁵ and where intervention is needed urgently. ²² The leadership of physicians who are recognised by their peers for both their clinical and academic acumen may exert substantial cultural effects on learning, cooperation and morale in healthcare services during the COVID-19 pandemic and beyond.

Future research should focus on the development of and training in medical expertise; evaluation of education for physicians to be more effective in leading ² ; and organisational structures and practices that may facilitate social learning from a range of expert health professional role models within healthcare organisations.