Management as Leadership

CanMEDS Manager

Management as Leadership

Much of what comes to mind when we think of management positions are actually leadership roles. Physicians demonstrate leadership all the time in clinical environments, so why aren’t we better at management??

“Learning to lead is no small undertaking. Physicians, as bright, well-trained, and dedicated as they may be, are no better prepared to lead than anyone else. In a sense, choosing a managerial career is, for a doctor, starting over. It means, sooner or later, leaving clinical practice behind. Unlike potential managers in exemplary corporations, physician managers seldom operate in an infrastructure designed to identify and develop leadership talent. They are left largely on their own, to sink or swim.” [1]

Physicians can end up in management positions in a variety of ways and the six most common in order of frequency are:[1]

Evolution – “it starting with small administrative responsibilities and ... one thing led to another and here I am” If you aren’t interested in management – beware of the gateway responsibilities (almost as dangerous as gateway drugs!). If you have a strong sense of loyalty or responsibility or an inability to say no you might be vulnerable to ending up in a management position by default
Stardom – excelling in a (likely) non-administrative role led to reward with a managerial position "you are a famous nephrologist - come and take over this programme in turmoil!"
Default – there was nobody else, the spirit of volunteerism or a knowledge that you would be better than the person who will get the position if you don’t do it. "If I don’t do it then Dr. Evil will become our department head and that will make my life more miserable than just doing the job myself"
Choice – because of the desire to have positive impact, or less altruistically the desire for position, power, more sociable working hours a person chooses the managerial role, not out of a desire to do administration work. "Even though I hate committee work, if I take the medical director position I won’t have to do so much night call... sign me up!" "I hate how poorly we serve our isolated populations, if I move into an admin job I can change that, and it will only be for 2 years and then I can come back to the clinical work that I love"
Takeover – this is often related to the corporatization of health care and imposition of a corporate structure on medicine. This is even more of an issue south of the border
Cultivation – being groomed and mentored for management over time, including skill development opportunities – the least common of these pathways. If you are interested in management and want more experience, start early and be intentional about your own skill development, you will not learn all you need to know by staying in a medicine only environment. [1]

Medicine values autonomy and independence, clarity of thought and decisive action, there is not a lot of time to arrive at consensus before critical decisions in medicine. Physicians often equate teams and leadership with sports teams and seem to be happiest when calling all the plays. Leadership and management are about finding common ground and bringing out the best in other people.

Six transitions for physicians becoming managers have been identified, these can be divided into psychological adjustment and skill acquisition.[1]

Psychological adjustments:

From hard-earned independence as a clinician to dependence as a manager.
From identity as a physician focused on individual patient care to identity as a manager focused on the institution.
From naivete about organizational dynamics to acceptance of organizational realities as part of managerial life.

New skills or abilities:

From command and control in a clinical setting to persuasion and ambiguity in a managerial role.
From comfortable relationships with professional colleagues to authority-based, boss-subordinate relationships with former colleagues.
From competence in medicine to competence in business.

Medicine can be seen as a fairly logical world, based on fact with (usually) logical and predictable consequences. The range of possibilities, options and outcomes are fairly limited “the world has one kind of order, based on fact, linearity, and logic.” “The world of management and organizations seems to have a different basis for its rationality. One of the first shocks any new manager faces is that logic and rationality, as defined in other professions, are not the same in management.” “It is a jolt that facts alone don’t always triumph, that people don’t automatically rally around logic, that power and position and differing perspectives all influence outcomes.”[2]

Stepping into management takes us, as physicians, outside our comfort zone, the skills that we value and that have served us well don’t seem to work as well and our expert knowledge is no longer needed. The hierarchies in management differ from hierarchies in medicine

Working outside of comfort zone – leadership and critical thinking are the valued skills not unique expert knowledge of the problem at hand.

It could be argued that the medical approach to problems - history, physical, investigations and frequent reevaluation is a framework that could be applied to any problem or situation but given the difficulties we, as a profession, have had moving into management positions it would seem that the transferability of our skills is neither automatic nor intuitive.

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