There has been a long-standing debate about whether leaders are made or born. A recent study reported on NPR concluded there may be a genetic basis, because leaders all share one key trait:
“Leaders make decisions for a group in the same way that they make decisions for themselves. They don't change their decision-making behavior, even when other people's welfare is at stake.”
The study, published in Science, was done at the University of Zurich, Switzerland, and was focused on trying to understand the neurobiology of leadership. Their starting observation was being in a leadership role means having to make decisions that will impact on other people. Some people seem to be able to deal with this and others do not. The summary of the study methods was provided.
“[They] had volunteers come to the lab and gave them questionnaires that are widely used to predict whether someone is likely to be in a position of leadership. They also collected information about people's real-world leadership experience, such as what rank they'd achieved in the military (which is compulsory for men in Switzerland) or in the popular Swiss Scouts organization. They had volunteers come to the lab and gave them questionnaires that are widely used to predict whether someone is likely to be in a position of leadership. They also collected information about people's real-world leadership experience, such as what rank they'd achieved in the military (which is compulsory for men in Switzerland) or in the popular Swiss Scouts organization.
The player could choose to either make the choice alone, or defer the decision to a majority vote. The games were played under two conditions: Sometimes the decision affected only the individual player's winnings and other times the decision affected what the entire group received.”
The study authors concluded people in general avoided taking responsibility for what happened to others, particularly when it impacted their pocketbook.
“But the people who changed their decision-making behavior the least were the ones who generally served as leaders in the real-world and scored high on leadership questionnaires. Unlike others, they did not require more certainty before being ready to personally make a decision that would affect the whole group…"On average, people tend to increase the certainty threshold when the choices affect the entire group. But higher-scoring leaders just keep their thresholds almost constant," says Edelson, who says preliminary work using MRI brain scanning supports the idea that leaders and followers differ in how their brains process information about gains, losses, and risk in the context of thinking about others.”
Since their focus was on the neurobiology, the study does not report anything which describes the leader in behavioral terms. But since that is my focus, I want to speculate a bit. Other evidence suggests successful leaders engender trust in their followers. Perhaps we are programmed to note if leaders make decisions for us the same way they make decisions for themselves. A leader who is consistent is more likely to obtain followers, for better or for worse.
The question of what makes for leaders and followers was the subject of a book by Garry Wills entitled Certain Trumpets: The Call of Leaders. He notes leadership requires followership, but the leader must issue a call that is actionable by those who would follow. And for the call to be actionable, the call occurs in reaction to specific circumstances. In other words, leadership does not occur in a vacuum. Given the fact that leadership is always constrained by specific circumstances, he goes on to describe 16 different kinds of leadership, illustrated by a figure remembered by history contrasted by a contemporary who failed. His central thesis is that the goals of the leader matter, and to be successful, those goals most align with moral forces—it is not just the exercise of power for its own sake. Leaders must make the call, but the call has to evoke a positive response.
So, what are the implications of these two different kinds of analysis for medical organizations and why have I juxtaposed them this way. First, we must acknowledge not everyone is “hard-wired” to be a leader, because they are willing to make decisions for other people. Consider the way physicians deal with critical decision-making in patient care. The paternalistic model, where the physician decides by him or herself, is, for good reason, out of favor, but what has replaced it? I have seen two basic approaches. In one, the physician simply provides data and lets someone else, either the patient or the most assertive family member, make the decision. In the other, the physician and patient/family engage in discussion trying to derive goals for therapy where the physician makes an active recommendation. I predict physicians in the former group shun leadership positions, while those in the latter group might be willing to give it a go. A similar analysis could be done for administrators.
The Wills approach suggests there are different types of leaders, so assuming medical leaders are going to look like some other type of leader, business leaders for example, is a mistake. This is not to argue that one type is better than the other—it is simply to point out they are different. Yet if medical organizations are to be successful, both business and medical leadership must be present and interactive. Unfortunately, failure to recognize the differences in culture and style are common. One recent commentary by an experienced health care administrator noted that many efforts to align the two fail. His experience suggests:
“…there is one issue as deeply rooted somewhere at the heart of any struggling or failed alignment: the impositions of health system decisions and programs inflicting deep and lasting wounds with physicians…[often a kind of moral injury]…Maybe moral injury produces lack of trust. But I think it needs to be recognized as a critical attribute of alignment on its own.”
This is not to argue that hospital executives are evil, but to indicate the unintended consequences from failure to arrive at a deep understanding of both the similarities and the differences concerning how clinicians and administrators view the world. Only after deep understanding is reached will it be possible to build operational structures allowing both groups to operate together. On some issues the clinicians should lead, and the administrators should follow. In other cases the reverse will be true. This is a tough dynamic and requires a lot of patience to achieve. In today’s hyperkinetic environment, where everyone wants change to occur this quarter, it is hardly surprising many medical enterprises are in trouble.
3 September 2018
 Greenfield Boyce, M. What Makes A Leader. 2 August 2018. https://www.npr.org/sections/health-shots/2018/08/02/634639437/what-makes-a-leader.html. Accessed 3 August 2018.
 Wills, G. Certain Trumpets: The Call of Leaders. (New York: Simon & Schuster, 1994.)
 Sobal, L. Hospital-Physician Alignment Post Mortem. https://www.linkedin.com/pulse/hospital-physician-alignment-post-mortem-sobal-mba-mha-facmpe/. Accessed 31 August 2018.
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