Perspective
Expanding the Scope of Leadership Training in Medicine Stewart Gabel, MD
Abstract 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
All physicians take a leadership role
at some point in their career; while most exert influence in their practices and communities as informal leaders, some are appointed to formal leadership roles with great responsibility. These physicians, whose authority comes from their position in an organization, must possess specific personal and interpersonal qualities to lead others in advancing the values-oriented goals of the health care enterprise. Those in informal leadership roles also must possess the same personal and interpersonal skills to be effective in advancing care. In this article, I define leadership, differentiate between formal and informal leadership, and argue that leadership skills, applicable regardless of future role as a formal or informal leader, can and should be taught to medical trainees using established leadership paradigms, such as the transformational leadership model. The case scenario in Box 1 presents an illustration of informal leadership in
Dr. Gabel is professor of psychiatry, University of Colorado Medical School, Aurora, Colorado, and teaching professor of psychiatry, State University of New York, Upstate Medical University, Syracuse, New York. Correspondence should be addressed to Dr. Gabel, 1776 S. Jackson St., Denver, CO 80210; telephone: (303) 669-8447; e-mail: [email protected]. Acad Med. 2014;89:848–852. First published online March 21, 2014 doi: 10.1097/ACM.0000000000000236
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competencies that characterize both formal and informal leaders.
values-oriented goals inherent in the health care enterprise.
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
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.
medicine. Throughout this article, I refer to this scenario to answer questions such as, Should leadership skills be taught to medical trainees, like Dr. D., who currently have no formal position and may choose to have no formal position in the future?
department chair, residency training director, and more. These leadership positions are examples of individuals whose formal authority is derived from an appointment or election. Many reports have discussed the characteristics, approaches, and styles that are important in such formal leadership positions.3–8
Defining Leadership
Many definitions of leadership exist. Yet, most probably would agree with the definition derived from social psychology; it is not specific to a particular field or profession but instead considers leadership to involve social influence.1 In the case of health care, leadership involves the appropriate and ethical influence exerted by one individual to alter, modify, or change the reactions, attitudes, or behaviors of other individuals to maintain or further core values of the health professions.1,2 These core values, such as beneficence, nonmaleficence, autonomy, justice, and confidentiality, have been emphasized for many generations in numerous oaths and declarations in the health care field.2 Often, individuals whose behaviors or attitudes have been affected by the efforts of a leader were indifferent, resistant, or perhaps opposed to the particular changes prior to the successfully applied influence.1 Formal or positional leadership roles in health care take many forms, including academic dean, hospital executive, medical staff president, academic
However, most physicians and other health professionals do not hold formal leadership positions, and they may or may not aspire to them.9 These physicians and health professionals nonetheless may work in settings that require their leadership, defining the term as the ability to exert social influence to achieve health-carerelated or other socially desirable goals. Whereas formal leadership is based on an individual holding a position through an appointment or election, informal leadership is based on an individual’s ability to inspire others to alter their attitudes and/or behavior by identifying with the leader’s personality and convictions, rather than by being influenced by his or her appointed or elected position. For example, the multidisciplinary health care team that may not have appointed leaders but must develop particular clinical or programmatic directions for individual patients or programs requires informal leadership.10,11 Another example is a group practice in a private or public health care setting in which no official
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Box 1 Case Scenario: An Illustration of Informal Leadership in Medicinea A group of family medicine residents was discussing their recent pediatrics rotation. One resident commented that the workload was made worse by the difficulty she had contacting subspecialty consultants who were based at the academic health center, while she and many of her fellow residents had clinical rotations at a community hospital. She spoke of spending hours over a weekend trying to obtain a neurology consultation for a 10-year-old boy with multiple problems who also was being evaluated for possible seizures. When one attending finally did respond to her request, he did not know who was on call for the community hospital. The problem seemed to be that each department kept its own call list, and there was frequent trading among the consultants. Separate lists also existed for the academic health center and the community hospital network. Fortunately, the boy’s condition was not acute, but the resident felt abandoned without guidance. Another resident said that he had had a similar experience and told the residency director (Dr. B.) that this problem made him reluctant to recommend the residency training program to others. Finally, Dr. D., a third resident, said that she doubted that talking about the extra time spent, the lost time with family, or the insensitivity of the subspecialist programs would get them very far. Rather, it might be brushed off or even considered to be “complaining.” “What if we spoke directly about what should matter to our supervisors and to us?” Dr. D. asked, “The issue is patient care and respect for the child and his parents,” all of which suffered under the current disorganized system. “What if we spoke to Dr. B. and told him in an appropriate way that the current system potentially hinders patient care and has been disrespectful to patients and parents?” She went on to say that this disorganization had been a long-standing issue and asked if the group could come up with new ideas to present to Dr. B. One of the residents then said: “What about videoconferencing? We have the capability. We send EKGs and EEGs electronically for readings. Consultants could at least talk to parents and patients and begin the consult here.” Another resident offered another idea: “What about developing a s ystem-wide consultant call list that would be disseminated to all residents taking call each month? Everyone then would know who was on call, and the information would not be confined to only members of individual departments. Changes would have to be communicated electronically to all those serving on call.” “Those are really good ideas,” said Dr. D. “Let’s decide how we should approach Dr. B.” This case scenario does not represent an actual situation but was formulated as an illustration of informal leadership based on the author’s experiences. The scenario illustrates how one individual, Dr. D., a resident whom some might argue has little power in a complex academic health center, is able to act as a leader, potentially effecting significant changes in the behavior and attitudes of others.
a
hierarchical distinctions exist among members. Some professional societies, nonprofit organizations, and other health care advocacy groups also work mainly by consensus even though they have formally appointed leaders. In all of these situations, physicians, by virtue of their professional standing, play crucial roles as informal leaders in effecting change. Yet, most of these informal leaders have not been trained in providing successful leadership. Characteristics of Informal and Formal Leaders
Pielstick11 studied the characteristics of formal and informal leaders using ratings on a leadership profile that had been developed from an earlier work based on transformational leadership, a wellrecognized form of leadership discussed in more detail below. The major themes that Pielstick studied were shared vision, communication, relationship, community, guidance, and character. He found significant differences between formal and informal leaders on all six dimensions, with informal leaders, perhaps surprisingly, achieving higher ratings on each dimension.
What are the characteristics that make informal leaders successful, and how do those characteristics compare with those that make formal leaders successful? A comparison of the qualities and characteristics of formal and informal leaders is presented in List 1. Below, I discuss specific similarities and differences.
Downey and colleagues9 also studied the characteristics of informal leaders, in nursing specifically. They found that these leaders employed many of the same characteristics as formal leaders, at least formal leaders who emphasized relationship-oriented approaches to
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leadership. These informal leaders felt that it was their calling to provide the health care services they offered; they maintained a broader perspective, felt responsible for outcomes, focused on getting the job done, and were active problem solvers. They expressed team values and helped to establish norms; coordinated group efforts, communicated well, and maintained strong relationships; understood how their organizations work; and wished to be involved and engaged. Informal leaders also expressed themselves on relevant issues and said what they believed, and they listened to and valued the opinions of others. Many do not seek formal positions or titles but, rather, value recognition. Some informal leaders see such formal titles as a detriment that would affect their ability to create a trusting environment. Snell and colleagues12 interviewed about 50 physicians who had attended leadership courses at a leadership development institute. The authors did not determine whether these physicians aspired to formal or informal leadership positions, although their attending a leadership institute would suggest at least an interest in attaining a formal leadership position. The goal of the study was to learn what increased physician engagement and leadership in health-carerelated changes in their environments. The authors found very similar personal and interpersonal attitudes and behaviors in these physicians as in those assessed formally through transformational leadership ratings (see the discussion of transformational leadership below) and as the characteristics reported by Downey and colleagues.9 Snell and colleagues12 found that these physicians had always wanted to work for the greater good.12 In addition, they were motivated to make a difference and to improve patient care, their professions, and their environments. For many, “being a physician was a natural step.”12 Regardless of their role, the physicians felt that ultimately their purpose should be to improve the quality of life for their patients. They recognized the importance of good communication skills, relationship building, consultation, and involvement with others. In addition, they valued encouraging others to think about and do things differently, leading by example, recognizing others
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List 1 Qualities and Characteristics of Formal and Informal Leadersa Both formal and informal leadersb • • • • • • • • •
Demonstrate a strong commitment to the values and principles of medicine and health care Demonstrate a strong commitment to the mission of the organization Demonstrate the ability to communicate their values and principles to others Demonstrate the ability to communicate directly and clearly, to listen, and to include others in problem solving Demonstrate the ability to inspire and motivate others to share their commitment to principledriven goals and objectives Serve as a model for others, regardless of position Demonstrate strong personal qualities of honesty, integrity, focus, and perseverance Demonstrate the ability to recognize others for their accomplishments and contributions and to build relationships based on trust and genuine concern Demonstrate the ability to recognize differences in viewpoint, to negotiate differences, and to help resolve conflicts. Take pride in their own accomplishments and value the recognition of others but do not require personal recognition for their mission-driven efforts. The latter is especially true for informal leaders, while only sometimes true for formal leaders.
Formal leaders • Must master additional competencies in technical, financial, regulatory, and personnel aspects of their formal positions • Influence is based on positional power, reward and coercive power, and (in some cases) expert and informational power. Referential power is also crucial for increased effectiveness. • Recognize formal organizational lines of authority, while also recognizing the importance of working collaboratively with informal leaders • May have recognized clinical competence (which produces expert and informational power) • Recognize that they receive rewards (social and material) when organizational goals are met and that severe consequences (e.g., loss of position) may occur when organizational goals are unmet Informal leaders • Influence is based on expert, informational, or referent power (the power that derives from the personal qualities of the individual and his or her ability to become a reference point for others) • Have no appointed position or title that relates to the issue at hand, and therefore have no authority based on position; reward and coercive power are minimized and, when used, are social, not material in nature • Recognize organizational lines of authority and are able to work collaboratively with formal leaders • Have recognized clinical competence • May or may not seek or accept a formal leadership role • Will likely receive less recognition from others when organizational goals are met and face fewer consequences related to positional security if organizational goals are unmet Based in part on the work of Downey and colleagues,9 Snell and colleagues,12 Raven,13 and Bass and Riggio.21 Depending on the particular situation, formal and informal leaders may use their shared characteristics differently. For example, negotiation and conflict resolution skills are necessary for both types of leaders, but the context in which they use these skills will vary. The inpatient unit will have different issues than the residency group, which in turn will have different issues than the executive team. The inpatient unit will benefit from the skills of both formal and informal leaders, the residency group from the skills of informal leaders, and the executive team from the skills of formal leaders.
a
b
for their efforts, and possessing change management and negotiation skills. The authors also emphasized that physicians tended to require that their leaders master established clinical competencies to maintain their standing in the group. Finally, the study found that physicians felt that change occurred through influence, not through authority, because “doctors don’t respect lines of authority.”12 In sum, many of the personal and interpersonal qualities and characteristics
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that formal and informal leaders possess are the same. While both types of leaders depend on many of the same personal and interpersonal characteristics for success, informal leaders, who cannot rely on positional power for their influence, tend to depend more heavily on these qualities and characteristics. Formal leadership positions have benefits and drawbacks, including financial rewards, greater accountability, and specific reporting structures and supervisory responsibilities. In contrast, while
informal leaders must complete the duties of their own positions, they are not weighed down by the administrative, financial, and personnel decisions and responsibilities that are part of formal or positional authority. Thus, informal leaders potentially are freer to express their views and ideals and to motivate others to their cause. This freedom may allow informal leaders to be more authentic than formal leaders.11 Formal positional authority is weak and ultimately unsuccessful when it is not accompanied by the behavioral, emotional, and interpersonal competencies demonstrated by both formal and informal leaders who are able to influence positive change. Leadership and Power
Another way to clarify the differences between formal and informal leaders is to consider the issue of power—specifically, what types of power (if any) are available to these two types of leaders. Leadership, as discussed earlier, involves social influence, which derives from power.13,14 Over the last 50 years, French and Raven and then Raven and colleagues have described six major categories of power: (1) legitimate or positional power, (2) expert power, (3) informational power, (4) reward power, (5) coercive power, and (6) referent power.13,15–18 These categories are not mutually exclusive. Leaders holding elected or appointed positions have legitimate or positional power based on the authority vested in their positions. Physicians and other health professionals who do not hold formal positions must rely on other forms of power to influence the attitudes or behavior of others. Expert and informational power, for example, result from the expertise and knowledge that physicians and other health professionals bring to the health care encounter. Reward and coercive power are as their names suggest. When tasks are completed successfully, individuals are rewarded in material or social ways (e.g., praise). When tasks are not completed successfully, individuals face negative consequences or are punished (e.g., not given a promotion, fired). Referent power is probably the most overlooked; it derives from the characteristics and personality of the
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individual exerting his or her influence. Those who demonstrate energy, commitment, and enthusiasm for a particular issue in ways that draw others to them and to their aspirations and goals exhibit referent power. Informal leaders, such as Dr. D. in the case scenario, rely heavily on referent power to influence others. Forms of Leadership
Many forms of leadership exist, including authoritarian, democratic, and group decision making,3 but not all forms of leadership are likely to be effective when used by informal leaders. The servant form of leadership, for example, is commonly associated with physicians and other health professionals. Robert K. Greenleaf19 described servant leaders in this way: “The servant–leader is servant first.… It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead.” (italics in original). Greenleaf19 described numerous qualities associated with the servant–leader, such as the ability to listen, understand, persuade, and communicate, as well as acceptance, empathy, foresight, and awareness. Although it is intuitively appealing, and its relationship orientation and emphasis on the core value of service to others suggest that informal leaders would have an affinity for it, servant–leadership has not been studied extensively enough to have definite support in the literature.20 Transactional leadership is possibly the most common form of leadership employed in various types of organizational settings.21 It forms a part of what Bass and Riggio21 call the full range of leadership model. Transactional leaders essentially influence and manage their subordinates’ productivity, behavior, and task completion by providing rewards and consequences. Although researchers have found transactional leadership to be reasonably effective empirically,21 it would be of very limited value to informal leaders who do not and cannot employ tangible reinforcements or coercive behaviors to influence others. Transformational leadership is the most widely studied form of leadership, and it appears well suited to the health care environment and to the efforts
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of informal leaders. Transformational leadership21,22 is principles-driven, relationship based, and empirically supported,2,23 and it has been shown to have a number of positive outcomes, such as an increase in subordinates’ satisfaction with their leaders,24–26 a reduction in burnout,27,28 and the improved motivation and performance of staff.21,29 The four core principles of transformational leadership are (1) idealized influence, (2) inspirational motivation, (3) intellectual stimulation, and (4) individualized consideration.21–23 These principles reflect leaders’ perceived commitment to higher ethical standards and values, their ability to exemplify, communicate, and inspire others with these values, along with their demonstrated interest in the accomplishments, success, and development of those they supervise. Leadership Training for Informal Leaders
Often, positional leaders have been trained in particular forms of leadership. For example, transformational leadership has an established training program and good leadership change outcomes post training.21 Given the many similarities between formal and informal leadership characteristics, established training programs in transformational leadership (and perhaps those in other relationshiporiented leadership forms) should be appropriate for both formal and informal leaders. Although this hypothesis has face value, it has yet to be tested empirically. Education and training in both formal and informal leadership can take several forms, including seminars, lectures, facilitated case discussions, on-site shadowing, and observation. During training, educators must clarify the responsibilities, benefits, and drawbacks of both formal and informal leadership roles (see List 1). In addition, leadership training for both formal and informal leaders should emphasize the importance of understanding one’s organizational structure. Training in various administrative, financial, and regulatory roles is important for formal leaders, even though they usually do not find that these areas provide the greatest challenges.30–32 Rather, the interpersonal aspects of leadership are generally viewed as requiring the most attention.33
The use of case scenarios in education can be particularly helpful. The case scenario presented in Box 1, for example, illustrates the importance of the core principles of transformational leadership in developing informal leadership skills. Dr. D.’s suggestion to emphasize the values-oriented principles of medicine rather than the residents’ personal needs is in accord with the first principle of transformational leadership—idealized influence. Her approach is likely to be more effective than the legitimate, but selforiented, concerns of the other residents. In addition, Dr. D.’s suggestion that the residents all work together on new solutions to this long-standing problem illustrates another core principle of transformational leadership—intellectual stimulation. She asks how a situation or problem can be addressed creatively with new solutions. She also emphasizes that the situation, while frustrating, calls for problem solving rather than the residents voicing only grievances or implied threats to Dr. B. Finally, an informal leader like Dr. D. should facilitate a discussion regarding how learners perceive the roles, challenges, and agendas of others, such as Dr. B., and how they might engage him in further problem solving to improve their overall experience and promote the larger health care mission of providing highquality patient care. In Conclusion
Formal leaders in health care are able to affect change in part through the power of their positions. Although this positional power is important, it is often limited by the various personal and interpersonal competencies of the leaders. Although informal leaders do not hold this positional power, they do share and exercise many of the same types of personal and interpersonal competencies as successful leaders who hold transformational and other r elationship-oriented roles. Many physicians who do not have formal leadership roles will be called on to provide (or will wish to provide) informal leadership at various times in their careers. Thus, all medical students, residents, and those in the early stages of their careers must be trained in the personal and interpersonal competencies necessary for effective leadership in both formal and informal roles.
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Perspective Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.
References 1 Gabel S. Leaders and Healthcare Organizational Change: Art, Politics, and Process. New York, NY: Kluwer Academic/ Plenum Publishers; 2001. 2 Gabel S. Transformational leadership and healthcare. Med Sci Educ. 2013;23:55–60. 3 Bass BM, Bass R. The Bass Handbook of Leadership: Theory, Research, and Managerial Applications. 4th ed. New York, NY: Free Press; 2008. 4 Taylor CA, Taylor JC, Stoller JK. Exploring leadership competencies in established and aspiring physician leaders: An interviewbased study. J Gen Intern Med. 2008;23: 748–754. 5 Lee TH. Turning doctors into leaders. Harv Bus Rev. 2010;88:50–58. 6 Detsky AS. How to be a good academic leader. J Gen Intern Med. 2011;26:88–90. 7 Warren OJ, Carnall R. Medical leadership: Why it’s important, what is required, and how we develop it. Postgrad Med J. 2011;87:27–32. 8 Nowill DP. Lessons of experience: Key events and lessons learned of effective chief medical officers at freestanding children’s hospitals. J Healthc Manag. 2011;56:63–79. 9 Downey M, Parslow S, Smart M. The hidden treasure in nursing leadership: Informal leaders. J Nurs Manag. 2011;19:517–521. 10 Griffin RW. Fundamentals of Management. 5th ed. Boston, Mass: Houghton Mifflin Company; 2008. 11 Pielstick CD. Formal vs. informal leading: A comparative analysis. J Leadersh Stud. 2000;7:99–114.
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12 Snell AJ, Briscoe D, Dickson G. From the inside out: The engagement of physicians as leaders in health care settings. Qual Health Res. 2011;21:952–967. 13 Raven BH. The bases of power and the power/interaction model of interpersonal influence. Anal Soc Issues Public Policy. 2008;8:1–22. 14 Gabel S. Perspective: Physician leaders and their bases of power: Common and disparate elements. Acad Med. 2012;87:221–225. 15 French JRP Jr, Raven B. The bases of social power. In: Cartwright D, ed. Studies in Social Power. Ann Arbor, Mich: Institute for Social Research; 1959. 16 Raven BH, Schwarzwald J, Koslowsky M. Conceptualizing and measuring a power/ interaction model of interpersonal influence. J Appl Soc Psychol. 1998;28:307–332. 17 Wilkes M, Raven BH. Understanding social influence in medical education. Acad Med. 2002;77:481–488. 18 Rodin J, Janis IL. The social influence of physician and other health care practitioners as agents of change. In: Friedman HS, DiMatteo RM, eds. Interpersonal Issues in Health Care. New York, NY: Academic Press; 1982. 19 Greenleaf RK. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. New York, NY: Paulist Press; 1977. 20 Reed LL, Vidaver-Cohen D, Colwell SR. A new scale to measure executive servant leadership: Development, analysis, and implications for research. J Bus Ethics. 2011;101:415–434. 21 Bass BM, Riggio RE. Transformational Leadership. 2nd ed. Mahwah, NJ: Erlbaum Associates; 2006. 22 Bass BM. Two decades of research and development in transformational leadership. Eur J Work Organ Psychol. 1999;8:9–32. 23 Antonakis J, Avolio BJ, Sivasubramaniam N. Context and leadership: An examination of the nine-factor full-range leadership
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theory using the Multifactor Leadership Questionnaire. Leadersh Q. 2003;14:261–295. Larrabee JH, Janney MA, Ostrow CL, Withrow ML, Hobbs GR Jr, Burant C. Predicting registered nurse job satisfaction and intent to leave. J Nurs Adm. 2003;33:271–283. Spinelli RJ. The applicability of Bass’s model of transformational, transactional, and laissez-faire leadership in the hospital administrative environment. Hosp Top. 2006;84:11–18. Failla KR, Stichler JF. Manager and staff perceptions of the manager’s leadership style. J Nurs Adm. 2008;38:480–487. Weberg D. Transformational leadership and staff retention: An evidence review with implications for healthcare systems. Nurs Adm Q. 2010;34:246–258. Corrigan PW, Diwan S, Campion J, Rashid F. Transformational leadership and the mental health team. Adm Policy Ment Health. 2002;30:97–108. Xirasagar S, Samuels ME, Stoskopf CH. Physician leadership styles and effectiveness: An empirical study. Med Care Res Rev. 2005;62:720–740. Stoller JK. Developing physician–leaders: Key competencies and available programs. J Health Adm Educ. 2008;25:307–328. Taylor CA, Taylor JC, Stoller JK. The influence of mentorship and role modeling on developing physician–leaders: Views of aspiring and established physician–leaders. J Gen Intern Med. 2009;24:1130–1134. Williams SJ. What skills do physician leaders need now and in the future? Physician Exec. 2001;27:46–48. McKenna MK, Gartland MP, Pugno PA. Development of physician leadership competencies: Perceptions of physician leaders, physician educators and medical students. J Health Adm Educ. 2004;21: 343–354.
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Expanding the Scope of Leadership Training in Medicine Stewart Gabel, MD
Abstract 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
All physicians take a leadership role
at some point in their career; while most exert influence in their practices and communities as informal leaders, some are appointed to formal leadership roles with great responsibility. These physicians, whose authority comes from their position in an organization, must possess specific personal and interpersonal qualities to lead others in advancing the values-oriented goals of the health care enterprise. Those in informal leadership roles also must possess the same personal and interpersonal skills to be effective in advancing care. In this article, I define leadership, differentiate between formal and informal leadership, and argue that leadership skills, applicable regardless of future role as a formal or informal leader, can and should be taught to medical trainees using established leadership paradigms, such as the transformational leadership model. The case scenario in Box 1 presents an illustration of informal leadership in
Dr. Gabel is professor of psychiatry, University of Colorado Medical School, Aurora, Colorado, and teaching professor of psychiatry, State University of New York, Upstate Medical University, Syracuse, New York. Correspondence should be addressed to Dr. Gabel, 1776 S. Jackson St., Denver, CO 80210; telephone: (303) 669-8447; e-mail: [email protected]. Acad Med. 2014;89:848–852. First published online March 21, 2014 doi: 10.1097/ACM.0000000000000236
848
competencies that characterize both formal and informal leaders.
values-oriented goals inherent in the health care enterprise.
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
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.
medicine. Throughout this article, I refer to this scenario to answer questions such as, Should leadership skills be taught to medical trainees, like Dr. D., who currently have no formal position and may choose to have no formal position in the future?
department chair, residency training director, and more. These leadership positions are examples of individuals whose formal authority is derived from an appointment or election. Many reports have discussed the characteristics, approaches, and styles that are important in such formal leadership positions.3–8
Defining Leadership
Many definitions of leadership exist. Yet, most probably would agree with the definition derived from social psychology; it is not specific to a particular field or profession but instead considers leadership to involve social influence.1 In the case of health care, leadership involves the appropriate and ethical influence exerted by one individual to alter, modify, or change the reactions, attitudes, or behaviors of other individuals to maintain or further core values of the health professions.1,2 These core values, such as beneficence, nonmaleficence, autonomy, justice, and confidentiality, have been emphasized for many generations in numerous oaths and declarations in the health care field.2 Often, individuals whose behaviors or attitudes have been affected by the efforts of a leader were indifferent, resistant, or perhaps opposed to the particular changes prior to the successfully applied influence.1 Formal or positional leadership roles in health care take many forms, including academic dean, hospital executive, medical staff president, academic
However, most physicians and other health professionals do not hold formal leadership positions, and they may or may not aspire to them.9 These physicians and health professionals nonetheless may work in settings that require their leadership, defining the term as the ability to exert social influence to achieve health-carerelated or other socially desirable goals. Whereas formal leadership is based on an individual holding a position through an appointment or election, informal leadership is based on an individual’s ability to inspire others to alter their attitudes and/or behavior by identifying with the leader’s personality and convictions, rather than by being influenced by his or her appointed or elected position. For example, the multidisciplinary health care team that may not have appointed leaders but must develop particular clinical or programmatic directions for individual patients or programs requires informal leadership.10,11 Another example is a group practice in a private or public health care setting in which no official
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Perspective
Box 1 Case Scenario: An Illustration of Informal Leadership in Medicinea A group of family medicine residents was discussing their recent pediatrics rotation. One resident commented that the workload was made worse by the difficulty she had contacting subspecialty consultants who were based at the academic health center, while she and many of her fellow residents had clinical rotations at a community hospital. She spoke of spending hours over a weekend trying to obtain a neurology consultation for a 10-year-old boy with multiple problems who also was being evaluated for possible seizures. When one attending finally did respond to her request, he did not know who was on call for the community hospital. The problem seemed to be that each department kept its own call list, and there was frequent trading among the consultants. Separate lists also existed for the academic health center and the community hospital network. Fortunately, the boy’s condition was not acute, but the resident felt abandoned without guidance. Another resident said that he had had a similar experience and told the residency director (Dr. B.) that this problem made him reluctant to recommend the residency training program to others. Finally, Dr. D., a third resident, said that she doubted that talking about the extra time spent, the lost time with family, or the insensitivity of the subspecialist programs would get them very far. Rather, it might be brushed off or even considered to be “complaining.” “What if we spoke directly about what should matter to our supervisors and to us?” Dr. D. asked, “The issue is patient care and respect for the child and his parents,” all of which suffered under the current disorganized system. “What if we spoke to Dr. B. and told him in an appropriate way that the current system potentially hinders patient care and has been disrespectful to patients and parents?” She went on to say that this disorganization had been a long-standing issue and asked if the group could come up with new ideas to present to Dr. B. One of the residents then said: “What about videoconferencing? We have the capability. We send EKGs and EEGs electronically for readings. Consultants could at least talk to parents and patients and begin the consult here.” Another resident offered another idea: “What about developing a s ystem-wide consultant call list that would be disseminated to all residents taking call each month? Everyone then would know who was on call, and the information would not be confined to only members of individual departments. Changes would have to be communicated electronically to all those serving on call.” “Those are really good ideas,” said Dr. D. “Let’s decide how we should approach Dr. B.” This case scenario does not represent an actual situation but was formulated as an illustration of informal leadership based on the author’s experiences. The scenario illustrates how one individual, Dr. D., a resident whom some might argue has little power in a complex academic health center, is able to act as a leader, potentially effecting significant changes in the behavior and attitudes of others.
a
hierarchical distinctions exist among members. Some professional societies, nonprofit organizations, and other health care advocacy groups also work mainly by consensus even though they have formally appointed leaders. In all of these situations, physicians, by virtue of their professional standing, play crucial roles as informal leaders in effecting change. Yet, most of these informal leaders have not been trained in providing successful leadership. Characteristics of Informal and Formal Leaders
Pielstick11 studied the characteristics of formal and informal leaders using ratings on a leadership profile that had been developed from an earlier work based on transformational leadership, a wellrecognized form of leadership discussed in more detail below. The major themes that Pielstick studied were shared vision, communication, relationship, community, guidance, and character. He found significant differences between formal and informal leaders on all six dimensions, with informal leaders, perhaps surprisingly, achieving higher ratings on each dimension.
What are the characteristics that make informal leaders successful, and how do those characteristics compare with those that make formal leaders successful? A comparison of the qualities and characteristics of formal and informal leaders is presented in List 1. Below, I discuss specific similarities and differences.
Downey and colleagues9 also studied the characteristics of informal leaders, in nursing specifically. They found that these leaders employed many of the same characteristics as formal leaders, at least formal leaders who emphasized relationship-oriented approaches to
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leadership. These informal leaders felt that it was their calling to provide the health care services they offered; they maintained a broader perspective, felt responsible for outcomes, focused on getting the job done, and were active problem solvers. They expressed team values and helped to establish norms; coordinated group efforts, communicated well, and maintained strong relationships; understood how their organizations work; and wished to be involved and engaged. Informal leaders also expressed themselves on relevant issues and said what they believed, and they listened to and valued the opinions of others. Many do not seek formal positions or titles but, rather, value recognition. Some informal leaders see such formal titles as a detriment that would affect their ability to create a trusting environment. Snell and colleagues12 interviewed about 50 physicians who had attended leadership courses at a leadership development institute. The authors did not determine whether these physicians aspired to formal or informal leadership positions, although their attending a leadership institute would suggest at least an interest in attaining a formal leadership position. The goal of the study was to learn what increased physician engagement and leadership in health-carerelated changes in their environments. The authors found very similar personal and interpersonal attitudes and behaviors in these physicians as in those assessed formally through transformational leadership ratings (see the discussion of transformational leadership below) and as the characteristics reported by Downey and colleagues.9 Snell and colleagues12 found that these physicians had always wanted to work for the greater good.12 In addition, they were motivated to make a difference and to improve patient care, their professions, and their environments. For many, “being a physician was a natural step.”12 Regardless of their role, the physicians felt that ultimately their purpose should be to improve the quality of life for their patients. They recognized the importance of good communication skills, relationship building, consultation, and involvement with others. In addition, they valued encouraging others to think about and do things differently, leading by example, recognizing others
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List 1 Qualities and Characteristics of Formal and Informal Leadersa Both formal and informal leadersb • • • • • • • • •
Demonstrate a strong commitment to the values and principles of medicine and health care Demonstrate a strong commitment to the mission of the organization Demonstrate the ability to communicate their values and principles to others Demonstrate the ability to communicate directly and clearly, to listen, and to include others in problem solving Demonstrate the ability to inspire and motivate others to share their commitment to principledriven goals and objectives Serve as a model for others, regardless of position Demonstrate strong personal qualities of honesty, integrity, focus, and perseverance Demonstrate the ability to recognize others for their accomplishments and contributions and to build relationships based on trust and genuine concern Demonstrate the ability to recognize differences in viewpoint, to negotiate differences, and to help resolve conflicts. Take pride in their own accomplishments and value the recognition of others but do not require personal recognition for their mission-driven efforts. The latter is especially true for informal leaders, while only sometimes true for formal leaders.
Formal leaders • Must master additional competencies in technical, financial, regulatory, and personnel aspects of their formal positions • Influence is based on positional power, reward and coercive power, and (in some cases) expert and informational power. Referential power is also crucial for increased effectiveness. • Recognize formal organizational lines of authority, while also recognizing the importance of working collaboratively with informal leaders • May have recognized clinical competence (which produces expert and informational power) • Recognize that they receive rewards (social and material) when organizational goals are met and that severe consequences (e.g., loss of position) may occur when organizational goals are unmet Informal leaders • Influence is based on expert, informational, or referent power (the power that derives from the personal qualities of the individual and his or her ability to become a reference point for others) • Have no appointed position or title that relates to the issue at hand, and therefore have no authority based on position; reward and coercive power are minimized and, when used, are social, not material in nature • Recognize organizational lines of authority and are able to work collaboratively with formal leaders • Have recognized clinical competence • May or may not seek or accept a formal leadership role • Will likely receive less recognition from others when organizational goals are met and face fewer consequences related to positional security if organizational goals are unmet Based in part on the work of Downey and colleagues,9 Snell and colleagues,12 Raven,13 and Bass and Riggio.21 Depending on the particular situation, formal and informal leaders may use their shared characteristics differently. For example, negotiation and conflict resolution skills are necessary for both types of leaders, but the context in which they use these skills will vary. The inpatient unit will have different issues than the residency group, which in turn will have different issues than the executive team. The inpatient unit will benefit from the skills of both formal and informal leaders, the residency group from the skills of informal leaders, and the executive team from the skills of formal leaders.
a
b
for their efforts, and possessing change management and negotiation skills. The authors also emphasized that physicians tended to require that their leaders master established clinical competencies to maintain their standing in the group. Finally, the study found that physicians felt that change occurred through influence, not through authority, because “doctors don’t respect lines of authority.”12 In sum, many of the personal and interpersonal qualities and characteristics
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that formal and informal leaders possess are the same. While both types of leaders depend on many of the same personal and interpersonal characteristics for success, informal leaders, who cannot rely on positional power for their influence, tend to depend more heavily on these qualities and characteristics. Formal leadership positions have benefits and drawbacks, including financial rewards, greater accountability, and specific reporting structures and supervisory responsibilities. In contrast, while
informal leaders must complete the duties of their own positions, they are not weighed down by the administrative, financial, and personnel decisions and responsibilities that are part of formal or positional authority. Thus, informal leaders potentially are freer to express their views and ideals and to motivate others to their cause. This freedom may allow informal leaders to be more authentic than formal leaders.11 Formal positional authority is weak and ultimately unsuccessful when it is not accompanied by the behavioral, emotional, and interpersonal competencies demonstrated by both formal and informal leaders who are able to influence positive change. Leadership and Power
Another way to clarify the differences between formal and informal leaders is to consider the issue of power—specifically, what types of power (if any) are available to these two types of leaders. Leadership, as discussed earlier, involves social influence, which derives from power.13,14 Over the last 50 years, French and Raven and then Raven and colleagues have described six major categories of power: (1) legitimate or positional power, (2) expert power, (3) informational power, (4) reward power, (5) coercive power, and (6) referent power.13,15–18 These categories are not mutually exclusive. Leaders holding elected or appointed positions have legitimate or positional power based on the authority vested in their positions. Physicians and other health professionals who do not hold formal positions must rely on other forms of power to influence the attitudes or behavior of others. Expert and informational power, for example, result from the expertise and knowledge that physicians and other health professionals bring to the health care encounter. Reward and coercive power are as their names suggest. When tasks are completed successfully, individuals are rewarded in material or social ways (e.g., praise). When tasks are not completed successfully, individuals face negative consequences or are punished (e.g., not given a promotion, fired). Referent power is probably the most overlooked; it derives from the characteristics and personality of the
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individual exerting his or her influence. Those who demonstrate energy, commitment, and enthusiasm for a particular issue in ways that draw others to them and to their aspirations and goals exhibit referent power. Informal leaders, such as Dr. D. in the case scenario, rely heavily on referent power to influence others. Forms of Leadership
Many forms of leadership exist, including authoritarian, democratic, and group decision making,3 but not all forms of leadership are likely to be effective when used by informal leaders. The servant form of leadership, for example, is commonly associated with physicians and other health professionals. Robert K. Greenleaf19 described servant leaders in this way: “The servant–leader is servant first.… It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead.” (italics in original). Greenleaf19 described numerous qualities associated with the servant–leader, such as the ability to listen, understand, persuade, and communicate, as well as acceptance, empathy, foresight, and awareness. Although it is intuitively appealing, and its relationship orientation and emphasis on the core value of service to others suggest that informal leaders would have an affinity for it, servant–leadership has not been studied extensively enough to have definite support in the literature.20 Transactional leadership is possibly the most common form of leadership employed in various types of organizational settings.21 It forms a part of what Bass and Riggio21 call the full range of leadership model. Transactional leaders essentially influence and manage their subordinates’ productivity, behavior, and task completion by providing rewards and consequences. Although researchers have found transactional leadership to be reasonably effective empirically,21 it would be of very limited value to informal leaders who do not and cannot employ tangible reinforcements or coercive behaviors to influence others. Transformational leadership is the most widely studied form of leadership, and it appears well suited to the health care environment and to the efforts
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of informal leaders. Transformational leadership21,22 is principles-driven, relationship based, and empirically supported,2,23 and it has been shown to have a number of positive outcomes, such as an increase in subordinates’ satisfaction with their leaders,24–26 a reduction in burnout,27,28 and the improved motivation and performance of staff.21,29 The four core principles of transformational leadership are (1) idealized influence, (2) inspirational motivation, (3) intellectual stimulation, and (4) individualized consideration.21–23 These principles reflect leaders’ perceived commitment to higher ethical standards and values, their ability to exemplify, communicate, and inspire others with these values, along with their demonstrated interest in the accomplishments, success, and development of those they supervise. Leadership Training for Informal Leaders
Often, positional leaders have been trained in particular forms of leadership. For example, transformational leadership has an established training program and good leadership change outcomes post training.21 Given the many similarities between formal and informal leadership characteristics, established training programs in transformational leadership (and perhaps those in other relationshiporiented leadership forms) should be appropriate for both formal and informal leaders. Although this hypothesis has face value, it has yet to be tested empirically. Education and training in both formal and informal leadership can take several forms, including seminars, lectures, facilitated case discussions, on-site shadowing, and observation. During training, educators must clarify the responsibilities, benefits, and drawbacks of both formal and informal leadership roles (see List 1). In addition, leadership training for both formal and informal leaders should emphasize the importance of understanding one’s organizational structure. Training in various administrative, financial, and regulatory roles is important for formal leaders, even though they usually do not find that these areas provide the greatest challenges.30–32 Rather, the interpersonal aspects of leadership are generally viewed as requiring the most attention.33
The use of case scenarios in education can be particularly helpful. The case scenario presented in Box 1, for example, illustrates the importance of the core principles of transformational leadership in developing informal leadership skills. Dr. D.’s suggestion to emphasize the values-oriented principles of medicine rather than the residents’ personal needs is in accord with the first principle of transformational leadership—idealized influence. Her approach is likely to be more effective than the legitimate, but selforiented, concerns of the other residents. In addition, Dr. D.’s suggestion that the residents all work together on new solutions to this long-standing problem illustrates another core principle of transformational leadership—intellectual stimulation. She asks how a situation or problem can be addressed creatively with new solutions. She also emphasizes that the situation, while frustrating, calls for problem solving rather than the residents voicing only grievances or implied threats to Dr. B. Finally, an informal leader like Dr. D. should facilitate a discussion regarding how learners perceive the roles, challenges, and agendas of others, such as Dr. B., and how they might engage him in further problem solving to improve their overall experience and promote the larger health care mission of providing highquality patient care. In Conclusion
Formal leaders in health care are able to affect change in part through the power of their positions. Although this positional power is important, it is often limited by the various personal and interpersonal competencies of the leaders. Although informal leaders do not hold this positional power, they do share and exercise many of the same types of personal and interpersonal competencies as successful leaders who hold transformational and other r elationship-oriented roles. Many physicians who do not have formal leadership roles will be called on to provide (or will wish to provide) informal leadership at various times in their careers. Thus, all medical students, residents, and those in the early stages of their careers must be trained in the personal and interpersonal competencies necessary for effective leadership in both formal and informal roles.
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Perspective Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.
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