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Demystify Leadership in Order to Cultivate It

Dhaliwal, Gurpreet MD; Sehgal, Niraj L. MD, MPH

doi: 10.1097/ACM.0000000000000489
Responses to the 2014 Question of the Year

Dr. Dhaliwal is professor, Department of Medicine, University of California, San Francisco, and staff physician, San Francisco VA Medical Center, San Francisco, California.

Dr. Sehgal is professor, Department of Medicine and Center for the Health Professions, University of California, San Francisco, San Francisco, California.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Dhaliwal, San Francisco VA Medical Center, 4150 Clement St. (111), San Francisco, CA 94121; telephone: (415) 221-4810 ext. 4150; fax: (415) 750-6982; e-mail:

Graduate medical education programs need to develop physician–leaders who can address our broken and unsustainable health care system. But “leadership” suffers from a branding problem among trainees, who often equate it with official positions of authority. The essential function of a leader is to produce change. To make leadership an accessible and appealing goal for all trainees, it requires a redesigned brand as a multifaceted construct: an everyday instinct, a set of skills, a menu of options, and a professional obligation.

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Everyday Leadership

Trainees—like all frontline clinicians—periodically notice processes and systems that are so inefficient, inequitable, or unsafe that they interrupt their clinical routine to contemplate changing the status quo in their local environment. Leadership should be presented as the way to transform those thoughts into results. Training programs need to highlight clinicians who have capitalized on an impulse that arose in the course of their daily clinical work. Such messaging can help overcome internal resistance to leading change by emphasizing that leadership arises from direct patient care and can be a time-limited (i.e., manageable) adjunct to that work.

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Leadership as a Skill Set

Leadership training equips trainees with a core set of skills, including self-awareness and emotional intelligence, communication, teamwork, change management, and systems thinking. Trainees can only develop a full appreciation of this skill set when it is integrated into their training experience, particularly in the clinical environment. Residents who lead inpatient teams are faced with the challenges of managing relationships with nurses, pharmacists, and social workers; teaching younger physicians; leading family meetings; negotiating care plans with consultants; and making decisions about health care resource utilization.1 Attending physicians need to focus as much on their residents’ skills as effective team leaders as they do on their residents’ clinical decision-making skills. How did the resident establish values and norms on the ward team? How did she manage conflict? How did she achieve her team metrics of high-quality care?

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Leadership as a Menu of Options

When most trainees hear the word “leader,” they think of a program director, division chief, clinic director, or physician executive. A far broader menu of roles that inspire action and change need to be labeled as leadership. Whatever legal, economic, and policy changes may come, the improvement of health care delivery will ultimately fall to the physicians, nurses, pharmacists, social workers, and therapists on the front lines. Physicians’ ability to lead within those teams, often without formal authority, needs to be messaged as the single-most-needed form of leadership, and the one to which every doctor must aspire. Trainees should be exposed to multiple examples and role models of this “leadership with a small ‘l’” who are celebrated for their accomplishments in improving wards, clinics, and practices,2 and it must be communicated that it is leadership on this scale that we expect them to demonstrate during their training years. Influencing positive change does not have to happen within the confines of a training institution. If residents want to develop health care technology applications, engage in public medical writing, or direct a research laboratory, we should make sure they are able to apply their newly acquired leadership skills to ensure success in those endeavors.

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Leadership as a Professional Obligation

The modern physician is defined as one who cares as deeply about the patient sitting in front of him as he does about the population from which that patient came.3 Unfortunately, physicians leading this shift toward population management and a transformed health care delivery system are often labeled as “administrators,” which carries a negative connotation. Our narratives around these duties must change so that they are seen as acts of integrity that align with our core professional values rather than as bureaucratic intrusions. As Blumenthal et al1 write, “Providers, educators, and administrators need to dispel the myth that clinical and managerial responsibilities are inherently at odds with one another.” Outstanding physician–leaders who do both in training institutions need to be cultivated and celebrated.

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Training programs must balance the time spent delivering leadership curricula with a commitment to transforming the culture of the training environment. Only through these complementary strategies can we establish leadership as a multifaceted construct that sits at the core of our professional identity. Success will come when trainees see leadership as an essential part of their development as a doctor, not just a career option after they become one.

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1. Blumenthal DM, Bernard K, Bohnen J, Bohmer R. Addressing the leadership gap in medicine: residents’ need for systematic leadership development training. Acad Med. 2012;87:513–522
2. Bohmer R. Leadership with a small “l”. BMJ. 2010;340:c483
3. Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173:1639–1643
© 2014 by the Association of American Medical Colleges