The Costs of Leadership
 
            Perhaps it is the vituperation and recrimination of the political season as it comes to an end this week, but I am reminded of the costs of leadership. (Don’t misunderstand—I don’t think many politicians exhibit leadership. Most seem to have a keen sense of the tides of opinion and do their best to stay out in front of them. Underneath the rhetoric, I suspect most are “birds of a feather.” They are just attuned to different trends.) There are a lot of definitions of the difference between leadership and management, but one I am fond of the one which states leadership is about getting people to do something they weren’t planning to do, while management is about coordinating the efforts people were going to make anyway. Here I want to consider organizational, not political, leadership, although the former includes plenty of the latter.
            A few weeks ago, I was having a session on leadership with a group of head nurses. One question I asked each of them was what aspect of the job was most unpleasant—paperwork excluded? While the answers varied, the theme seemed to be the isolation of the job, which took two forms. Some expressed the separation, or distance, from the team created by being in charge. As the inspirational poster has it:
 
           A true leader has the confidence to stand alone, the courage to make tough decisions, and the compassion to listen to the needs of others. A person does not set out to be a leader, but becomes one by the quality of one's actions and the integrity of one's intent. In the end, leaders are much like eagles...they don't flock, you find them one at a time.[1]
 
            Perhaps not surprisingly, this expression of isolation was more common in the younger people and those with less experience, although the “veterans” in the group, some with decades of experience, could share they had felt that earlier in their career. The other way the isolation was expressed was in dealing with the fact they could not “please” their staff in their decision-making. Perhaps this is a particular issue for nurses, who may have personality traits that make them more concerned with people-pleasing, but I don’t think so. It may appear in other people as avoidance—not dealing with troublesome issues, delaying action, passive-aggressive behavior, etc. From my reading and experience, all of these negative behaviors are widespread in organizations of all sorts, and may explain why so many are not considered good places to work.
            We then turned briefly to the question of motivating staff to provide excellent clinical care. We ran out of time to consider the question thoroughly, but will hope to do so in the next session. So, perhaps it is reasonable for me to sketch out an answer. First, I think motivation is intrinsic—some people are only in it for the paycheck. I am not sure it is possible to “motivate” such a person, although you can fire them. On the other hand, I think most people come to work wanting to do a good job, but may have no particular idea what that means. Consider a buzz phrase we use all the time in medical organizations—we want to provide excellent clinical care. What does that look like? How do the leaders make the definition real once it is agreed upon? We have considered this issue in detail in other articles on this website, so let me just say that each organization must define high quality care for itself, being careful to be as granular and specific as possible. Too often, I fear, we opt for platitudes that sound good, but have no working definition, and certainly no way to insure they are incorporated as a matter of routine.
          Do leaders reward those exhibiting the desired behavior? The medical leadership groups I am most familiar with tended to assume good behaviors and outcomes were the norm, and certainly what was expected, so they were not rewarded, while deviations from standards were punished. This creates a negative bias that may be demoralizing over the long term. How many times do we identify “outliers” as opposed to exemplars? Don’t misunderstand—there is a need for accountability, but isn’t it possible that sometimes leaders rush to hold staff accountable so they, in turn, won’t be held accountable for their decisions which contributed to the bad outcome? As one senior nurse leader put it to me once, “Nurses will eat their young.” Another cost of leadership, then, means defining and making operational a working definition of the organization’s goals.
          It is tempting to assume that the “younger” generations are unduly cynical, conditioned as they are by advertising and social media. They are often thought of as unmotivated. But I think that is a mistake, too. My early experience was in the Army and the young privates always had the “B.S. meter” turned on when the senior officers spoke. While they were quiet (polite?) due to military behavior standards, it did not mean they accepted what they heard as gospel. Staff in all organizations have a “B. S. meter,” and it is usually both sensitive and specific. So, another cost of leadership is that, to be effective, the leader must personally exhibit (at all times) the behaviors being promoted by the organization. In medical organizations, that means the leader has to exhibit personal skill at whatever tasks are usual for the position as well as modeling compassion, communication skills, and caring behaviors. Said another way, you want your leaders to be competent clinicians.
          But this creates tension for the individual. If they are good clinicians and the leadership tasks are seen as different and divorced from clinical tasks, or too costly, they will likely choose to avoid the leadership role. The non-clinical leadership has to design the clinician leadership tasks in a way that can be executed without creating too much tension. This means, of course, that medical leadership likely looks and feels different compared to non-medical leadership in the organization.
          To summarize, there are costs to being the leader, including isolation, being a role-model, and dealing with the conflict between doing and leading others to do. It behooves senior organizational leadership to develop leadership groups and exploit the role-model aspects for clinician leaders while reducing conflict between the clinician role and the leadership role. If this were easy, everyone would be doing it. Unfortunately, organizations exhibiting the sort of excellence I have sketched here are also eagles, which don’t flock and don’t overbreed.
 
6 November 2022


[1] Galen R. Is Leadership a Lonely Place to Be? 20 March 2018. https://rgalen.com/agile-training-news/2018/2/19/is-leadership-a-lonely-place-to-be. Accessed 6 November 2022.

Further Reading

Leadership in Medical Organizations

Leadership Lessons From the Military
Lessons from leading the military in Afghanistan have implications for which medical organizations will thrive in the current turmoil.

Leadership Skills That Are Commonly Lacking
Good clinical care depends on small unit leadership, but most organizations do not foster the necessary leadership skills.

Making Leaders
Is leadership nature or nurture? Probably both.

Perspectives on Physician Leadership
Physician leadership is receiving more attention. Three recent articles illuminate the need for and the challenges to physicians leading.