Is Leadership a Physician Competency?

Screen Shot 2015-03-02 at 3.26.32 PMAre physicians “leaders”? Put another way, is “leadership” a necessary or even desirable attribute of the aspiring or practicing medical doctor? The recent revision of the competency framework of the Royal College of Physicians and Surgeons, and specifically the proposal to change the “Manager” competency to “Leader” has sparked some interesting conversation on this issue. The root of this controversy appears to be a sense that the term “Leader” implies an assumption of authority or superiority within the healthcare community. On the surface, this change may appear somewhat presumptuous and concern is understandable. Some recent discussions on parallel issues that have been undertaken at our school may provide some relevant and very timely insights.

The issue of student Resiliency has become a growing focus of interest in our school, with the goal of providing students with awareness of its importance and methods to promote its development. Review of the available literature, and our own discussions, have defined a number of attributes and attitudes that characterize the resilient personality. These include:

  • Personal well-being. Resilient people are healthy and energetic, and adopt personal practices that promote well-being, such as attention to personal health, nutrition and fitness.
  • A sense of purpose. Resilient people are driven by a deep and abiding sense of purpose that allows them to overcome adversities.
  • Perseverance. Willingness to commit to goals and work steadily to completion
  • Self-reliance. Acceptance of personal accountability.
  • Equanimity. The ability to face both adversity and success in a balanced way, without loss of perspective or purpose.
  • Ability to engage adversity effectively. Resilient people are able to not only face adversity without loss of purpose, but learn from those experiences.

Almost at the same time, a number of students have expressed interest in examining the components of Leadership. In the development of teaching material on that topic, a number of component attributes have been developed for discussion. These include

  • Stamina. Personal energy and drive.
  • A sense of purpose that is aligned with the objectives of the organization they are leading, and which they communicate effectively to members.
  • Diligence. Also called “drive”. Leaders tend to be the engines and drivers of innovation and change within their organization.
  • Self-assurance. Leaders have and display confidence in themselves and in their organizations that is not “cocky” or pretentious, but apparent and clear to all. Outstanding leaders are able to combine that confidence with a sense of humility that allows them to accept advice, balance opinions and change course when it’s in the best interests of their organization.
  • Fairness. Leaders are unfailingly fair in the application of their authority. Their fundamental integrity is unquestionable and clear to all.
  • Ability to engage adversity effectively. Leaders are able to guide their organizations through tough times and challenges. They do so by maintaining a focus on the core objectives and values, communicating clearly, and providing support and encouragement.

Do these two sets of attributes sound similar? One can’t help but conclude that resilience and leadership go hand-in-hand. Our leaders are resilient people, and failure in leadership can often be traced to a deficiency in one or more of the resiliency attributes.

Now let’s extend to the Physician’s role, and focus on the application to patient care:

Screen Shot 2015-03-02 at 3.18.44 PM

It would seem that there are numerous parallels between the attributes of the resilient leader pursuing the interests of their organization, and the effective physician promoting the health and interests of their patient. The qualities, values and attributes are very similar. The focus of those efforts simply shifts from a group or organization, to an individual, the patient. It’s therefore no surprise that so many physicians become effective leaders in our various academic, community and political structures. The Royal College is absolutely justified in embracing the “Leader” competency.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education



8 Responses to Is Leadership a Physician Competency?

  1. Gerhard Dashi says:

    Hi Dr. Sanfilippo,

    Thank you for this blog. I totally agree.

    Last summer I did some research in OR’s at KGH looking at the effects of different types of leadership on team members and patient outcomes. Turns out certain leadership behaviours lead to higher psychological safety among team members, as well as less blood loss, shorter hospital stay, fewer complications, and fewer post-operative healthcare visits for patients.

    The importance of effective leadership has also been shown in other healthcare areas, such as implementing Lean processes to deal with ED overcrowding, so I think this is a pretty well established field. However, I think the concept of better followership among all healthcare professionals, especially doctors, needs to be developed further.

    Can we expect formal leadership, followership, or resiliency training to pop up in the Queen’s curriculum any time soon?

    Thank you.

    • Thank you Gerhard, for pointing out the positive outcomes that can be attributed to leadership attributes. I think you can certainly expect a greater emphasis and more overt representation of both resilience and leadership not only at Queen’s but within medical education at all Canadian schools.

  2. Russell Hollins says:

    Hi Tony,

    Thanks for your thorough summary of the attributes of leadership and resiliency. I’ve been interested in leadership skills for a while and have pursued further understanding and skill development since assuming a leading role in my department. I agree these are attributes our students should reflect on and develop as part of their education here. That being said, I’m not sure I understand the impetus to change the Manager role to Leadership. These are two very different skill sets and while there is certainly overlap between them, their purposes are not the same. In a sense, managerial responsibilities often underly leadership roles. Managerial skills are perhaps more granular, while I view leadership attributes as somewhat broader in scope. As such, while they are not mutually exclusive, they are different enough that if the Royal College wants to incorporate Leadership into the CanMeds Roles, it should be viewed as a separate entity for those purposes.


    • Thanks Russell. I would agree that these are not mutually exclusive terms, for the reasons you cite. My sense, however, is that the term “leadership” is more all-encompassing and better captures the essence of both elements. Whether it should be regarded as an additional or integrated competency domain is debatable, but I’m inclined to agree with bundling and not expanding.

  3. Darren Nichols, Associate Professor, University of Alberta says:

    Very interesting! My colleagues at the Patan Academy of Health Science in Nepal (a member of The Health Equity Network of schools, which includes NOSM, defined a Leadership Competency 2 years ago, and it incorporates many of the elements above. They are unique in that their medical graduates will be in the position to be nation builders, not only medical professionals. They will be the managers and builders of a health system; they will be leaders.

    Their summary of the competency was thus: “Leadership is recognized is recognized when a physician uses the moral authority derived from personal integrity to define, and persist in accomplishing, a shared vision.”

    Yes, big words. This is servant leadership writ large. Moral authority is the right to do what is good for the wellbeing of others. But never independently. The vision and the work is always shared, requiring engagement of the community. This may sound at first like top down leadership but is in fact the opposite. And resilience comes not from “self-reliance” or “stamina” (overvalued north american attributes that leads to far too many physicians acting as ‘lonely heros’ and burning themselves out, in my opinion) but from persisting, in community, according to shared purpose.

    I agree with you that this is the missing competency in our Colleges, described in various places, but not yet coalesced.

    I fear, however, that we just may conflate Leadership with Hierarchy, or Strength, or Leading the Charge, or Executing the Plan. We need engagement and not enlistment. It might just be that we need to drastically overhaul our innate notions of Leadership – or choose a different word, not that I have one to suggest. But as we sort our what leadership is to us as physicians and physicians-to-be, the wisdom of Mr. Peter Senge may have something to offer: he describes System Leadership. (more here This type of leadership prefers the group over the individual, wisdom over knowledge, and culture over process. And if we want to be effective Managers, this is the Leadership that is required.

    Thanks for the discussion, Dr. Sanfilippo.

  4. The answer to the question above depends on how you define leadership now doesn’t it?

    Physicians graduate from their medical education process thoroughly programmed with a less than optimal leadership skill set. It’s not taught consciously, it comes with the territory. It’s a legacy of generations past and normal fallout from our workaholic, superhero, perfectionist, Lone Ranger programming.

    We all learn to be top-down leaders who must have all the answers and give everybody orders – expecting either compliance or obedience depending on weather were ordering a patient or a staff member. Is that leadership? The answer is yes. This is leadership and its colored by a very specific style. It even works in some settings – for instance, if the doctor is actually running a code and coordinating the activities of the team under extreme circumstances.

    However, it is a gloriously dysfunctional leadership skill set for anyone attempting team-based care. I would even submit the physician is the biggest obstacle to true team-based care because they’re simultaneously unaware of these limitations in their leadership skill set.

    That’s why physician leadership academies and training programs are all the rage. It’s remedial education to bring them into a more collaborative, context based leadership style – something the author only touches on above. To take them from being tyrants to true team captains. To teach them how to lead by setting a vision and asking questions, rather than giving orders.

    Should this collaborative leadership skill set be expected of modern-day physicians? Expect away, however, the reason we don’t turn out these leaders in the first place is there’s no room in medical school or residency for anything other than teaching them how to be an adequate clinician. Leadership is a completely separate skill set that requires a completely separate educational and experiential curriculum. And we need physician leaders like this as never before. The physician burnout epidemic itself has its source in the physician leadership vacuum that allows non-clinicians to design our workplaces.

    We can create these physicians/leaders. The skills are teachable. We have de-program them first AND this is not impossible. The physicians of the near future will have to lead in a different fashion. There’s simply not enough superhero/workaholic to go around.

    My two cents,

    Dike Drummond MD

    • Thanks. You certainly raise some intriguing points. Would certainly agree that more deliberate curriculum regarding leadership should be in place, and I think we’re beginning to see that. This change in the Royal College nomenclature should help. I would suggest the consciouness that you describe should extend to our admission processes. I would challenge the assertion that all those entering medical education are “top down” leaders. I see examples every day of students who embody the more collaborative model of leadership you describe, but would agree we could be much more deliberate about identifying these qualities in our applicants.

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