The challenges physician leaders confront today call to mind Odysseus’ challenge to steer his fragile ship successfully between Scylla and Charybdis. The modern Scylla takes the form of ever-increasing pressures to provide more resources for professional liability, compliance, patient satisfaction, central administration, and a host of other demands. The modern Charybdis takes the form of ever-increasing pressures to procure resources when fewer are available and competition is continuously increasing the need for resources, including managed care, hospital administration, payers, employers, patients who are uninsured or underinsured, research funding, and philanthropy. This publication provides physician leaders with guidance for identifying and managing common leadership challenges on the basis of the professional responsibility model of physician leadership. This model is based on Plato’s concept of leadership as a life of service and the professional medical ethics of Drs John Gregory and Thomas Percival. Four professional virtues should guide physician leaders: self-effacement, self-sacrifice, compassion, and integrity. These professional virtues direct physician leaders to treat colleagues as ends in themselves, to provide justice-based resource management, to use power constrained by medical professionalism, and to prevent and respond effectively to organizational dysfunction. The professional responsibility model guides physician leaders by proving an explicit “tool kit” to complement managerial skills.
Physician leaders are confronted by numerous challenges on a daily basis. These range from making decisions about improving patient safety to managing disruptive physician behavior, the allocation of organizational resources, securing cooperation from reluctant colleagues for the use of evidence-based guidelines, and obtaining vital resources from organizational leaders who promise prompt action and then obfuscate and delay. These challenges require effective management, which includes attention to the ethical issues at the core of many of these leadership challenges. The purpose of this article is to provide physician leaders with guidance for identifying and managing common leadership challenges on the basis of the professional responsibility model of physician leadership that is based on the professional responsibility model of obstetric ethics.
The professional responsibility model of physician leadership emphasizes leadership as a way of life. In short, leadership is a philosophy. To articulate leadership as a philosophy and explicate the professional responsibility model, we draw on the work of historical figures that is relevant to the ethics of physician leadership (the Table , in which figures are listed in the order in which their ideas are utilized). We then deploy the professional responsibility model of physician leadership to provide guidance for physician leaders at the individual and organizational levels.
| Philosophical figure | Dates | Relevance |
|---|---|---|
| Plato | 424-348 BCE | Commit to the life of service |
| John Gregory, MD | 1724-1773 | Maintain professionalism in the clinical setting |
| Thomas Percival, MD | 1740-1804 | Maintain professionalism in the organizational setting |
| Immanuel Kant | 1724-1804 | Respect persons, especially those subordinate to one’s power |
| Aristotle | 384-322 BCE | Pursue justice in the allocation of resources |
| Thomas Hobbes | 1588-1679 | Prevent the calamity of irresponsibly managed power |
| Niccolo Machiavelli | 1469-1527 | Analyze and address dysfunctional organizational cultures |
Leadership as a philosophy
Leadership as a philosophy includes the ability to articulate a vision and implement strategies requisite for accomplishing the mission, managerial competence, and, especially, appropriate ethical values. Management knowledge and skills are essential components of leadership. It cannot be overstated that health care organizations are no exception to the general managerial dictum that revenues must exceed expenses. In the absence of excess revenues, no physician leader can capitalize an organization’s future and the organization’s viability will decline and possibly cease to exist. In addition, physician leaders must develop, implement, and enforce policies and practices that ensure both the quality and service in a cost-efficient manner. Physician leaders must not lose sight of the fact that medicine is not primarily a business but they also must be committed to the competent management of the business aspects of medicine.
The core component of leadership as a philosophy is appropriate ethical values. Ethical values should shape mission and requisite strategy and guide management decisions. Plato (424–348 BCE) articulated perhaps the most influential philosophy of leadership in the Western tradition in his classic work, Republic ( Table ). For Plato, the best leader is the philosopher king, someone who has been rigorously trained for years in the life of service to those subordinate to his power. This is a demanding way of life, in which the philosopher king understands his own interests entirely in terms of the interests of the citizens of the republic, who are subordinate to his power. In the technical language of ethics, the philosopher king has the fiduciary and fundamental responsibility to protect and promote the interests of subordinates and keep self-interest systematically secondary. This commitment provides direction and purpose to the leadership role. Without this commitment to the life of service and the direction it provides, Plato rightly feared that leaders will become predatory and subordinates unacceptably harmed.
A modern expression of platonic leadership philosophy can be found in the work of one of the most highly regarded scholars of management science, Peter Drucker (1909-2005). Drucker succinctly summarized leadership as a philosophy in a way that Plato would instantly recognize: “Leadership without direction is useless … As the pace of change in our world continues to accelerate, strong basic values become increasingly necessary to guide leadership behavior.”
The professional responsibility model of physician leadership
Two physician-philosophers articulated the ethical concept of medicine as a profession and the professional virtues that should guide physician leaders. John Gregory (1724-1773) addressed medical professionalism in the practice of medicine ( Table ). Thomas Percival (1740-1804) addressed medical professionalism at the organizational level ( Table ). They did so to correct the entrepreneurial, self-interested, and guild-interested practice of British medicine in the mid and late eighteenth century and forge medicine into a profession worthy of the name.
Gregory trained at the medical schools in Edinburgh and Leiden. Both medical schools were deeply influenced by the scientific and clinical teaching of Hermann Boerhaave (1668-1738). Boerhaave’s conception of medicine and teaching were steeped in Francis Bacon’s (1561-1626) philosophy of medicine. Bacon called for physicians to improve medicine on the basis of “experience,” the accumulation of data from carefully observed processes and outcomes of patient care. Gregory repeatedly cited Bacon as a major influence.
Gregory became Professor of Medicine in Edinburgh in the last 7 years of his short life, where he gave extended lectures on medical ethics before taking students to the Royal Infirmary of Edinburgh for their clinical instruction. Gregory turned these lectures into the first text in English on professional medical ethics, in which he introduced the ethical concept of medicine as a profession. One of his motivations was to replace the marketplace model of relentless self-interest, which resulted in rampant distrust, with the life of service to patients, which will earn patients’ trust. For example, “man-midwives,” physicians trained in obstetrics and exclusive users of the then-advanced technology of forceps, competed intensely with female midwives for the small market of well-to-do women who could afford to purchase their services. Gregory’s concern was that pregnant women were ill served by this competition unregulated by professionalism, which is not acceptable. Competition guided by professionalism is acceptable.
His concept of medicine as a profession has 2 components. The professional physician commits to intellectual excellence by becoming and remaining scientifically and clinically competent and then practicing medicine to exacting scientific standards. Using the language of Bacon, Gregory called for physicians to submit clinical judgment and practice to the discipline of experience-based reasoning. In doing so, Gregory anticipated by 2 centuries what is now known as the deliberative, evidence-based practice of medicine. The professional physician also commits to moral excellence. The physician does so by committing to the protection and promotion of the patient’s health-related interests as the physician’s primary concern and motivation and to keeping self-interest consistently secondary. The physician also commits to moral excellence by keeping the group interests of physicians, expressed for example in attempts by man-midwives to ban female midwives from obstetrical practice, systematically secondary. Percival captures this component when he called for physicians to treat medicine, not as a merchant guild, but as a “public trust.”
Percival complements Gregory’s focus on clinical practice by addressing organizational ethics. Percival was an accomplished scientist, public health advocate, moralist, and community leader. His Medical Ethics was the first book thus entitled in the global history of medical ethics. Percival’s Medical Ethics became the inspiration for the first modern national code of medical ethics, the 1847 Code of Medical Ethics of the American Medical Association.
Percival was concerned about the fierce competition among the physicians, surgeons, and apothecaries at the Royal Infirmary of Manchester, England, which, at times, resulted in profound organizational dysfunction. He called for the creation of an organizational culture of professionalism, based on the mutual, evidence-based accountability of physicians and surgeons, who were still separate guilds (known as the Royal Colleges), to improve the quality of the processes and outcomes of patient care. He also called for organizational resources to be based primarily on the ethical principle of beneficence and not primarily on economics.
One distinctive feature of Gregory’s and Percival’s medical ethics is that they identified the clinical implications of the concept of medicine as a profession by appealing to 4 professional virtues. The leadership counterparts of these professional virtues constitute the professional responsibility model of physician leadership. Together the professional virtues give ethical substance and direction to the physician leader’s role, complementing managerial skills.
The first is self-effacement , which obligates physician leaders to be unbiased. They should not show favoritism to their own specialties or friends in a health care organization or on the basis of gender or shared academic pedigree. Nor should they show favoritism in decisions about resources in a merged institution, in which they were formerly in a leadership position in one of the components. The second is self-sacrifice , the willingness to risk individual and organizational self-interest, especially in the economic domain. Physician leaders must pay attention to the bottom-line (no margin, no mission) but they should not focus exclusively on the bottom-line. They should, instead, value economics as a tool rather than an overriding value. The organization’s mission should be the guiding value. Self-sacrifice obligates physician leaders to take risks for the organization’s legitimate fiscal self-interest when necessary to accomplish mission, eg, in securing funding for essential clinical services that do not make a profit. The third is compassion , which obligates physician leaders to be aware of and respond with appropriate support to the distress of colleagues and staff. To fulfill this obligation, physician leaders should routinely ask, “What can I do to help?” The fourth, and bedrock, virtue is integrity , which obligates physician leaders to make management decisions on the basis of intellectual and moral excellence. Intellectual excellence requires clinical care, research, and education to have a strong evidence base. Moral excellence requires putting the interests of patients first and keeping individual and organizational self-interest systematically secondary. Adherence to self-effacement, self-sacrifice, and compassion is the key to achieving moral excellence. Indicators of integrity in physician leaders, by which they should be judged, include open and honest communication, accessibility, and accountability.
The ethical concept of medicine as a profession emphasizes a reality of which Percival was especially aware: physicians will be able to achieve sustainable professionalism only in the context of a supportive organizational culture. Physician leaders bear the responsibility for creating sustainable cultures of organizational professionalism, permeated by the effects of routinely fulfilling the obligations of the 4 professional virtues of physician leaders.
The professional responsibility model of physician leadership
Two physician-philosophers articulated the ethical concept of medicine as a profession and the professional virtues that should guide physician leaders. John Gregory (1724-1773) addressed medical professionalism in the practice of medicine ( Table ). Thomas Percival (1740-1804) addressed medical professionalism at the organizational level ( Table ). They did so to correct the entrepreneurial, self-interested, and guild-interested practice of British medicine in the mid and late eighteenth century and forge medicine into a profession worthy of the name.
Gregory trained at the medical schools in Edinburgh and Leiden. Both medical schools were deeply influenced by the scientific and clinical teaching of Hermann Boerhaave (1668-1738). Boerhaave’s conception of medicine and teaching were steeped in Francis Bacon’s (1561-1626) philosophy of medicine. Bacon called for physicians to improve medicine on the basis of “experience,” the accumulation of data from carefully observed processes and outcomes of patient care. Gregory repeatedly cited Bacon as a major influence.
Gregory became Professor of Medicine in Edinburgh in the last 7 years of his short life, where he gave extended lectures on medical ethics before taking students to the Royal Infirmary of Edinburgh for their clinical instruction. Gregory turned these lectures into the first text in English on professional medical ethics, in which he introduced the ethical concept of medicine as a profession. One of his motivations was to replace the marketplace model of relentless self-interest, which resulted in rampant distrust, with the life of service to patients, which will earn patients’ trust. For example, “man-midwives,” physicians trained in obstetrics and exclusive users of the then-advanced technology of forceps, competed intensely with female midwives for the small market of well-to-do women who could afford to purchase their services. Gregory’s concern was that pregnant women were ill served by this competition unregulated by professionalism, which is not acceptable. Competition guided by professionalism is acceptable.
His concept of medicine as a profession has 2 components. The professional physician commits to intellectual excellence by becoming and remaining scientifically and clinically competent and then practicing medicine to exacting scientific standards. Using the language of Bacon, Gregory called for physicians to submit clinical judgment and practice to the discipline of experience-based reasoning. In doing so, Gregory anticipated by 2 centuries what is now known as the deliberative, evidence-based practice of medicine. The professional physician also commits to moral excellence. The physician does so by committing to the protection and promotion of the patient’s health-related interests as the physician’s primary concern and motivation and to keeping self-interest consistently secondary. The physician also commits to moral excellence by keeping the group interests of physicians, expressed for example in attempts by man-midwives to ban female midwives from obstetrical practice, systematically secondary. Percival captures this component when he called for physicians to treat medicine, not as a merchant guild, but as a “public trust.”
Percival complements Gregory’s focus on clinical practice by addressing organizational ethics. Percival was an accomplished scientist, public health advocate, moralist, and community leader. His Medical Ethics was the first book thus entitled in the global history of medical ethics. Percival’s Medical Ethics became the inspiration for the first modern national code of medical ethics, the 1847 Code of Medical Ethics of the American Medical Association.
Percival was concerned about the fierce competition among the physicians, surgeons, and apothecaries at the Royal Infirmary of Manchester, England, which, at times, resulted in profound organizational dysfunction. He called for the creation of an organizational culture of professionalism, based on the mutual, evidence-based accountability of physicians and surgeons, who were still separate guilds (known as the Royal Colleges), to improve the quality of the processes and outcomes of patient care. He also called for organizational resources to be based primarily on the ethical principle of beneficence and not primarily on economics.
One distinctive feature of Gregory’s and Percival’s medical ethics is that they identified the clinical implications of the concept of medicine as a profession by appealing to 4 professional virtues. The leadership counterparts of these professional virtues constitute the professional responsibility model of physician leadership. Together the professional virtues give ethical substance and direction to the physician leader’s role, complementing managerial skills.
The first is self-effacement , which obligates physician leaders to be unbiased. They should not show favoritism to their own specialties or friends in a health care organization or on the basis of gender or shared academic pedigree. Nor should they show favoritism in decisions about resources in a merged institution, in which they were formerly in a leadership position in one of the components. The second is self-sacrifice , the willingness to risk individual and organizational self-interest, especially in the economic domain. Physician leaders must pay attention to the bottom-line (no margin, no mission) but they should not focus exclusively on the bottom-line. They should, instead, value economics as a tool rather than an overriding value. The organization’s mission should be the guiding value. Self-sacrifice obligates physician leaders to take risks for the organization’s legitimate fiscal self-interest when necessary to accomplish mission, eg, in securing funding for essential clinical services that do not make a profit. The third is compassion , which obligates physician leaders to be aware of and respond with appropriate support to the distress of colleagues and staff. To fulfill this obligation, physician leaders should routinely ask, “What can I do to help?” The fourth, and bedrock, virtue is integrity , which obligates physician leaders to make management decisions on the basis of intellectual and moral excellence. Intellectual excellence requires clinical care, research, and education to have a strong evidence base. Moral excellence requires putting the interests of patients first and keeping individual and organizational self-interest systematically secondary. Adherence to self-effacement, self-sacrifice, and compassion is the key to achieving moral excellence. Indicators of integrity in physician leaders, by which they should be judged, include open and honest communication, accessibility, and accountability.
The ethical concept of medicine as a profession emphasizes a reality of which Percival was especially aware: physicians will be able to achieve sustainable professionalism only in the context of a supportive organizational culture. Physician leaders bear the responsibility for creating sustainable cultures of organizational professionalism, permeated by the effects of routinely fulfilling the obligations of the 4 professional virtues of physician leaders.
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