Leadership lessons

Clinicians can bring to leadership a deep understanding of patients’ needs and the expertise to make a real difference

In the year I turned 40, I was appointed director of a children’s rehabilitation service and became a clinician manager. I had a role description, some natural skills and a growing pile of “how to be a leader” books, but little formal training. From being responsible for my patients and their families and taking a collegiate interest in my peers, I now felt responsible for a whole team, all the patients, and was accountable for centre costs and clinical outcomes. It was terrifying. I suspect that, like other clinicians turned managers, I was a little naive when I pushed “send” on my job application.

Ten years later, my rehabilitation medicine colleagues asked me to give a short presentation on health service management at a trainee workshop. I reflected on my leadership journey and identified the ten things I learned about leadership in 10 years, which I would like to have told my younger self.

Lesson one: walk the walk, do not just talk the talk

Leadership is all about authenticity.1 When I think about the leaders I identify as mentors, they have in common honesty, genuine commitment and humility. Leadership exists through a combination of leading and following,2 and followers can see through a fake in a heartbeat. A vision and a strategic plan is nothing without the ability to inspire the team to make it happen. Mentorship can help us recognise our shortcomings and improve because of them.

Lesson two: every health care worker is there for the patient

Around my second week as the director of the service, I received a frightening letter from the health department. The service had been established as a project with time-limited funding that was about to run out. The letter said (not in these words): “your mission, should you choose to accept it, is to review the 5 years of operation of the service and convince us why we should continue to fund you”. Our multidisciplinary leadership team burned some midnight oil and we responded with an evaluation report, which I proudly took to a meeting with the really smart departmental experts. Not only did our report not have the answers they wanted, but also we had not even understood the questions. Then, I learned one of the most important lessons. I looked around the room and said to these expert administrators: “I need your help to get what we need for our patients”. I think they were just waiting to be asked. Those who work in the health department care just as much about patients as front-line clinicians do. I may feel that my role in the lives of patients is special, but patients are the focus and the responsibility of everyone working in health, from the hospital porter to the top bureaucrat, and every contribution is essential.

Lesson three: find your ethical framework to manage competing priorities

In health, there are always competing priorities. Early on, I developed a basic hierarchy for decision making. Put the patients’ interests first, then the needs of colleagues and staff, and then the hospital and the broader organisation. This simple algorithm has usually helped clarify my thinking. The challenge is that identifying what is in your patients’ best interests is not always straightforward. Having to prioritise may not satisfy everyone in your team. Achieving the best outcome may require the ability to weigh all options and say no, constructively and kindly — a hard but necessary leadership lesson.

Lesson four: read widely, keep up with trends and learn to write well

I collect all sorts of documents: strategic plans, white papers, inspirational news articles. When it comes to writing a business case, it is incredibly useful to have your finger on the pulse of the organisation and the broader interests of the community. Nurturing your networks, reading widely and keeping an open mind will help to write a business case that taps into “what’s hot” and uses language that commands attention. That does not mean you have to start spouting jargon. Writing well — using language that is sophisticated but without jargon — is a skill worth practising. Imagine your reader to be a well educated professional but not a clinician, and aim for your writing to be informative and enriching. Whether your intended audience is your hospital administrator, a politician holding the purse strings for your next big project or your hospital board, they need knowledge to do their jobs well. You want your reader to be sufficiently informed and engaged to discuss it at a dinner party. Actively seek feedback by giving your documents for proofreading to someone you respect. I have a saying: if you write well and knowledgably and share it in a Word document with someone in a position of power, your words will make their way into important documents; a subtle opportunity for influence.

Lesson five: stay off the front page of the paper

Personally, I would aim to be no closer than page five of the paper or the last 5 minutes of the evening news, just before the sport. Unless you win the Nobel Prize for medicine, being the lead story in the media is a high risk strategy. Clinicians may feel that taking concerns to the media is being a patient advocate, but I respectfully disagree. Of course, advocate for your patients, but do so within your organisation’s code of conduct. Otherwise, you risk losing the trust of your leaders and your influence in the organisation, which you need to help your patients, and which can take a long time to win back. The media is a critical agent of transparency and can certainly be your patient’s friend, but consider the impact on the people who stand in the glare of media attention. They may later regret the exposure of their personal affairs. I have, unfortunately, witnessed damage done to patients’ lives in the process of becoming temporarily “famous”.

Lesson six: never victimise your patient

This lesson may relate to lesson five or be more subtle. I think we should avoid using the “poor patient” phrase as a bargaining chip in an application for resources. In the short term, they may thank you for getting them that new piece of equipment or jumping a waiting list, but at what cost? I find it more effective to advocate using a solid evidence base. A privilege of our relationship with patients is the influence we have in their lives, and I firmly believe that we should never disempower them, not even for their own benefit.

Lesson seven: genuinely support and be loyal to the leaders above you

Have you ever heard a manager openly criticise the administration? Well, guess what? That is me, and if you are a clinician manager, it is you. For a large and complex organisation such as a health service to make meaningful advances in culture, leadership alignment is essential. I may not be across all the facts that have shaped my leader’s perspective. If I don’t agree with my leader, I need to ask questions and be honest and courageous in raising my concerns. Ask permission to provide feedback and do so in a way that is respectful, thoughtful and constructive.

Lesson eight: teamwork is critical

With leadership comes the power to get things done,3 but do not let it go to your head. I need to recognise my personal limitations and build a team to compensate for my weaknesses. Leadership is a team sport and sometimes, a dance. At times, I need to step back and let someone else take the lead and, importantly, let them take the credit for success. Other times, I need to step up and be unafraid to say: “I will make the tough decision and take responsibility for it”. This is a critical lesson. If it goes well, it is their win; if it does not go well, it is, at least in part, likely to be my failing.

Lesson nine: pay attention to what keeps you awake at night

I have been incredibly fortunate to be involved in successful business cases to develop new services. I am convinced that sleepless nights worrying about children whose hips were silently dislocating provided motivation for us to achieve funding for our cerebral palsy service. What you are passionate about and what keeps you awake at night creates energy to keep going to achieve what you know is important.

Lesson ten: have an open door policy

Successful leadership relies on being approachable and giving your team opportunities to provide input to decisions and solving problems, and being attentive to their personal and professional concerns. That requires an open door, literally, and preparedness to spend that precious commodity: time. My children were young when I took on the full-time director role. Like all working mothers, I faced a mountain of guilt every day. I used to say: “I bought a dairy farm and I have to milk the cows every day”. What I meant was that there are privileges and responsibilities that come with leadership that are not part-time, even if the job is part-time. I cannot be a leader only in the hours set aside for my management tasks. If this level of commitment is a burden, maybe dairy farming is not for you.

Considering the challenges of leadership, would I make the same choice now that I made 16 years ago? The answer is a resounding yes. Clinicians can bring to leadership a deep understanding of patients’ needs, risks and opportunities particular to our field, the expertise to interpret evidence and to navigate shifts in practice. Team members of all disciplines will welcome a leader who understands and is deeply committed to working together. Being a clinician leader has been a career highlight and a privilege.