THE IMPORTANCE of leadership has been increasingly recognized in medicine (Lee, 2010; Stoller, 2009), and numerous authors have described characteristics or competencies that are important for successful leadership (eg, Detsky, 2010; Harolds, 2011; McKenna, Gartland, & Pugno, 2004; Stoller, 2008; Warren & Carnall, 2011). Considerations of leadership, for many, however, focus on those individuals with specific positional authority in health care organizations such as medical directors of health care organizations, academic department chairs, residency training directors, or others. Leadership, however, has been defined in many ways. One definition that would be broadly acceptable considers leadership from social psychological perspectives as the ability to influence and motivate others to pursue goals or tasks that they would not otherwise have wanted to pursue, would not have considered pursuing, or would not have felt themselves capable of completing successfully (Gabel, 2001).
Using this definition, it can be seen that physicians are leaders and have the potential to exert leadership much more commonly than is usually recognized. This is true in numerous situations, such as through their roles in leading health care teams in office or clinic settings or supervising medical students and residents.
Bass (2008) describes a number of leadership styles. Different types of leadership are potentially useful in different situations. Transformational leadership is a form of leadership that has been assessed empirically across a broad range of settings (Bass, 2008; Bass & Riggio, 2006). It has been applied in numerous health care settings, but to a more limited degree (Xirasagar, Samuels, & Stoskopf, 2005). It nonetheless appears well suited for the health care arena (Xirasagar et al., 2005). Transformational leadership emphasizes that the leader is an instigator and facilitator of organizational or programmatic change and of personal development and growth in subordinates. Transformational leaders model higher level human potentials based on values, principles, and morals. They are able to motivate followers through their ability to articulate and communicate a vision of growth and change that is based on these principles and values. Transformational leaders challenge followers to formulate solutions to problems and to challenge existing assumptions. They attend to the individual growth and developmental needs of followers (Bass, 1999, 2008; Bass & Riggio, 2006).
This article will describe transformational leadership further, elaborate on its essential characteristics, and provide scenarios to illustrate how it may be used beneficially in medical practice settings, in physician education, and in the physician-patient relationship.
Transformational leadership has had its impetus through the work of Burns (1978), who identified 2 basic leadership types: transactional and transforming. Transactional leadership is considered the more common form of leadership, albeit a less potent form (Burns, 1978). Andronakis, Avolio, and Sivasubramaniam (2003) describe transactional leadership as “an exchange process based on setting objectives and monitoring and controlling outcomes” (p. 265). Transactional leaders rely almost exclusively on the fulfillment of behavioral expectations by their subordinates. Success is rewarded; failure results in negative consequences (eg, criticism, demotion).
Transforming leadership, on the other hand, “occurs when one or more persons engage with others in such a way that leaders and followers raise one another to higher levels of motivation and morality....” (Burns, 1978, p. 20, italics in original). Transforming leadership “ultimately becomes moral in that it raises the level of human conduct and ethical aspiration of both leaders and led, and thus it has transforming effect on both.” (Burns, 1978, p. 20, italics in original)
Bass (1999) describes transformational leadership as occurring through a series of processes that involve “moving the follower beyond immediate self-interests through idealized influence (charisma), inspiration, intellectual stimulation, or individualized consideration.” (p. 11). These essential components of transformational leadership are described in the Table.
Research in the health care environment has shown that transformational leadership compared with other forms of leadership is associated with greater staff satisfaction (Failla & Stichler, 2008; Larrabee et al., 2003; Spinelli, 2006; Weberg, 2010), improved sense of leader effectiveness (Xirasagar et al., 2005), and reduced rates of burnout (Corrigan, Diwan, Campion, & Rashid, 2003; Weberg, 2010). The issue is not necessarily transactional or transformational leadership, however. The 2 forms of leadership can be used together (Bass, 2008). Weberg (2010) argues that transformational leadership “has the potential to transform healthcare from the bedside up.” (p. 257).
Transformational leadership also offers the opportunity to study physician leadership using an empirical, theory-driven framework. Aiding this effort is the Multifactor Leadership Questionnaire (MLQ) that has been developed to assess in a standardized manner the degree to which leaders are experienced as being transformational, transactional, or laissez-faire (i.e., largely uninvolved; the worst type of leadership) (Bass, 2008). In its current version, the MLQ has 45 items, with most representing 9 leadership factors and the others representing leadership outcome scales (Antonakis et al., 2003). Menaker and Bahn (2008), for example, studied academic medical center faculty members' perceptions of their physician leaders (division leaders or department chair) using the MLQ. Higher scores on transformational leadership were associated with greater faculty member satisfaction with particular leaders.
The following scenarios do not represent actual situations; they were developed from the author's experience to illustrate how leaders, using aspects of transformational leadership, can further health care and educational goals while enhancing the professional growth of individuals who are colleagues or trainees.
1. A family physician was conducting rounds with a group of residents at a regional hospital that was an important site for the family practice residency program. The group approached the bed of a frail, elderly woman who had been admitted for congestive heart failure several days before. She had shown some improvement. At this time, she was asleep. The resident who had been caring for the patient shook her shoulder slightly. Raising his voice and leaning toward her, he said, “Millie, wake up. Some of the other doctors are here to see you.”
The elderly woman opened her eyes. She seemed uncertain as she looked around at the strange group of people in the confusing hospital environment.
The family physician felt some unease at the interaction between resident and patient. She checked the patient's name on her chart and then stepped closer to the woman, extended her hand to shake hers, and said, “Hello, Ms Jones, I am Dr R. I am the doctor in charge of your care, along with Dr B. (the resident). How are you feeling today?”
It is the responsibility of the physician supervisor conducting rounds to demonstrate and model appropriate professional ideals and behavior to the residents, thereby furthering the idealized influence that would be attributed to her as supervisor/leader. The senior physician does this as she models respectful professional behavior by introducing herself, speaking directly to the patient, and addressing the patient using her last name, thereby treating her with the respect that is socially recognized as appropriate to her age. She avoids the overly familiar and infantilizing use of first names for elderly people in vulnerable positions who sometimes are spoken to as if they are children. As a leader whose purpose is to influence in a positive way the professionalism and training of both the resident who addressed the patient in a less than respectful manner and the other residents in the group, she must be committed to various principles of appropriate social interaction in medical practice, including the principle of “respect for autonomy” that can be interpreted in different ways, but has been strongly influential in numerous oaths taken by graduating medical students (Orr, Pang, Pellegrino, & Siegler, 1997). The supervisor's discussion of the interaction with the residents later can further “influence” them and support these views.
2. There was an opening for family physicians in a moderately sized practice in an urban community that often drew new physician members from the graduating residency class of the nearby university. This particular practice had been founded years before by a family physician who was recognized as being an inspirational leader who stressed through his own statements and actions that private medical practice should welcome members of minority groups, the disadvantaged and those with developmental disorders in the same manner as it did more advantaged groups, and those without handicapping conditions. This was at times done despite the expenditure of additional resources and added time from practice members that resulted in some loss of income compared to other groups in the area. The practice and physicians in it were recognized in the broader community for their work with and advocacy for the disabled and had been honored by medical and nonmedical groups for this commitment.
Although some graduating residents preferred other settings, there was a substantial number of residents who had received some of their training and supervision by the practice group leader and whose own inclinations were influenced by him and other members of the practice setting. These residents eagerly applied for the open positions and the opportunity it gave them to work within this practice despite a relatively lower income than could be anticipated through work in other practices in the state.
The practice group leader in this illustration is a “leader” in a transformational sense because his values and commitment influenced his community and the career objectives of others. He provided what would be termed idealized influence. Through the attitudes and behaviors he expressed, he served as a role model for others and supported their development and commitment to a particular type of medical practice. As in the previous example, he demonstrated strong principles, in this case, the principle of beneficence, the desire to help those who seek the physician's aid. Principles such as beneficence and justice have been embodied in ethics codes, such as the Hippocratic oath, for centuries (Rancich, Perez, Morales, & Gelpi, 2005). This physician also provided inspirational motivation by articulating and demonstrating successfully the commitment he and members of his group made to an inclusive medical practice that provided for all regardless of developmental disorders and handicapping conditions. Graduating residents had been “inspired” to share his vision.
3. A resident rotating through a group practice was exasperated. She, along with a family physician who was a new member of the practice and a senior physician member of the group, were covering urgent cases who did not have appointments on a Friday afternoon. The resident had just treated a 5-year-old with an upper respiratory infection, slight wheezing, and a painful ear that turned out not to be otitis media.
“Why does this always happen on Friday afternoons? Parents bring their kids who aren't very sick for urgent care when they could have waited? It's such a poor use of resources. That child could have waited until Monday; her symptoms might have been gone by then.”
“It definitely does seem to happen more on Friday afternoons,” agreed the newer physician member of the practice. People could wait longer and see how it goes over the weekend, and if it gets too bad, they could call then.”
“Why do you think people act more that way on Fridays?” the senior physician asked.
“Maybe the parents want to have a good time over the weekend and don't want to have to stay home with a sick child” the resident said, smiling.
“I think that might have something to do with it in some cases,” the senior physician said, but I think there is more. People become more anxious on Fridays because they anticipate the weekend coming and they think there will be fewer supports available and fewer people to take care of them and their children. They come to take care of things ahead of time or to ask for reassurance that they will be able to make it through the weekend.”
“When I think of it that way,” he continued, “I still think resources are being used poorly, but it bothers me less because I know that I am being called on to provide a service that some people need even though it is not strictly “medical.” I do wonder, though, if we could develop a stronger support system in our practice that helped patients feel secure enough that they did not have to use resources inappropriately. Do you have any ideas about that? We should talk about this more at our next week's practice meeting.”
The resident and junior member of the practice said nothing at that point, but the resident seemed less impatient with the next patient and was observed to spend more time with her. At the end of the day she expressed her appreciation to the senior for his supervision.
The resident in this example (and possibly the junior physician also) take the parent and child's behavior at face value. There is a mild medical illness. By coming to the office for an “urgent” appointment they have misused health care resources. The senior physician accepts this explanation but points out that comprehensive medical treatment seeks to relieve suffering broadly and to understand the full nature of patients' concerns, in this case by recognizing the anxiety some patients may feel as they anticipate diminished support over a weekend. He thereby models an approach of tolerance and understanding in the face of patient vulnerability (idealized influence). He also challenges the resident and new practice member to explore other reasons for the utilization of an urgent care appointment at that time and to envision ways to provide patients the support they need without having to misuse resources (intellectual stimulation).
Leadership involves the ability to motivate and influence others to accept, embrace, and/or follow a particular vision or goal that had not been appreciated, recognized, or chosen previously. The physician leaders in all of the scenarios here can be considered transformational leaders who foster change in others in pursuit of value-driven health care goals. They employ 1 or more of the 4 core themes of transformational leadership: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration.
As pointed out earlier, there are numerous theories of leadership and approaches to the study of leadership. Leaders have been characterized by their personal attributes, traits, and styles. Various leadership types have been described and compared (eg, autocratic and authoritarian versus democratic or egalitarian) (Bass, 2008).
Transformational leadership, the approach described here, has most often been compared with transactional leadership and laissez-faire leadership (Bass, 2008; Bass & Riggio, 2006). Transactional leadership is probably the most common form of leadership and one that is relatively effective. When using transactional leadership, the leader essentially manages subordinates' productivity, behavior, and task completion by providing rewards and consequences. Transactional leadership has 2 subtypes: contingent reward and management by exception, which itself can be active or passive. In contingent reward, followers are rewarded for successfully completing assigned tasks or reaching defined goals. In management by exception, consequences or punishments occur when the follower does not fulfill expectations for performance. The failure to complete tasks may be brought to light by active processes (eg, checking all reports for errors) or passive processes (eg, learning of subordinate errors when complaints are registered). In laissez faire leadership, leaders are hands-off and uninvolved in important planning or day-to-day activities. They avoid or do not recognize the need for their involvement.
Research consistently has shown that transformational leadership is the most effective of the 3 types of leadership, followed by transactional leadership, and then by laissez faire leadership, which sometimes is ineffective or worse. Most good leaders use a combination of transformational leadership and transactional leadership, with a greater emphasis on transformational leadership (Bass & Riggio, 2006).
Leadership is, and will continue to be, crucial to health care organizational change in our society. This will be true for those who hold executive, academic, or organizational leadership positions, but it also is and will be true for those who hold lower-level positions or no formal position at all. Members of these latter groups must also be leaders, able to influence others to achieve higher levels of motivation and performance. Transformational leadership, with its emphasis on principle-driven approaches and personal transformation in subordinates (and sometimes in the leader), appears well suited for health care organizations, settings, and personnel, where ethical principles have always influenced and guided professional efforts.
Medical education has increasingly recognized the importance of training in leadership (Battistella, Hill, Levey, & Weil, 2005; Levey, Hill, & Greene, 2002; McKenna et al., 2004; Stoller, 2008, 2009; Warren & Carnall, 2011). Undergraduate and graduate medical training in transformational leadership can be helpful in fulfilling this goal. Transformational leadership focuses on several crucial aspects of physician leadership at all levels: adherence to basic principles and values (such as beneficence, respect for autonomy, espousal of lifelong learning) (Rancich et al., 2005), the ability to communicate these values in a manner that inspires others, the ability to instill in others the desire to take responsibility for their own learning, and the ability to promote the personal development of others who look to the physician as a leader. These 4 areas can be further operationalized and curricula developed to support their incorporation into medical training. Transformational leadership can thereby provide a framework within which physician activities in numerous patient- and non–patient-related areas can be assessed, studied, and remediated if needed.
Transformational leadership is a form of social influence that has broad applicability in medicine and other health care fields. Transformational physician leaders are in some ways consummate physicians, adhering to ethical principles of medicine, inspiring others to follow these same paths, and challenging others to improve on current conditions, while focusing also on the growth and unique developmental needs of those who are influenced by the physician leader. Training in transformational leadership should be incorporated into pre- and postgraduate medical education.
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Leadership; leadership in healthcare; transformational leadership; transformational leadership and primary care
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