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Globally, healthcare systems are under increasingly complex environmental pressures — namely population aging of the Organization for Economic Cooperation and Development (OECD) countries, staggering costs of public healthcare insurance programs, and the exponential advancement of medical technologies and pharmaceutical therapies.1 These pressures and the need to create transdisciplinary synergy to improve the efficiency of delivery care are recognized as overpowering stress factors in which the medical profession has to evolve. As urologists, we deal with these stressors on a daily basis, with increasing demands to find ways to cut costs on the wards and in the operating room without compromising the quality of care. Consequently, it becomes clear that our healthcare system requires innovative and mobilizing leadership. As urologists working in our respective healthcare systems, what potential roles and responsibilities could and should we take on in the actualization of this imperative leadership?
Notwithstanding the area of professional activities, the development of the leadership requires, at minimum, the use of one of the three informal sources of power: political, charismatic, and professional.2 Dynamics of exercising influence are presented in Fig. 1.3 Generating political power requires taking advantage of contingencies and specific situations in order to reach set objectives. Contingencies are defined in this context as the needs and expectations of others and external characteristics, such as cultural diversities and local demands. Exercising political power involves using a specific skill, the capacity to coordinate mindful actions (derived from contextual awareness), resulting in foreseeable reactions of others. Using rational persuasion (logical and organized presentation of evidence-based data) and inspirational appeals (provoking positive sentiments like a sense of pride, usefulness, and allegiance), seeking consultation (resorting to a specialist), referencing to a higher purpose (calling forth their sense of duty and professionalism), and encouraging collaboration (bringing together individual strength) are recognized as among the most common generic influence tactics.
It is interesting to note that several studies have concluded that physicians consider themselves more as clinicians and academics rather than administrators or managers. Consequently, many physicians demonstrate little or no interest functioning in leadership roles.4 At the same time, physicians voice their net preference to be led by another physician whom has experienced the same day-to-day medical practice.4
Furthermore, physicians struggle with the tension between two concurrent organizational logics: their medical professionalism and the “business-like healthcare.”5 The first refers to their medical expertise and the second to their capacity to respond adequately to the demands of the population within the economic constraints of the health system. While medical professionalism requires mastering the formal intelligence, “business-like healthcare” entails situational intelligence — the ability to identify, analyze, and comprehend the critical elements of an ongoing situation.
Exercising insightful leadership in healthcare involves adding to medical professionalism the “business-like healthcare” behaviours. Perhaps the most widely known published work on the science of persuasion and influence is by Dr. Robert Cialdini. His six principles of influence are shown in Fig. 2.6 Political skills have been defined, by Ferris et al, as the ability to effectively understand others at work and to use such knowledge to influence others to act in ways that enhance one’s personal and organizational agendas.7 These authors have also differentiated four dimensions to these abilities, namely: social astuteness, interpersonal influence, networking ability, and apparent sincerity.7
Social astuteness or social awareness refers to the ability of knowing when and how to interact or influence coworkers (dynamics of social relationship) by accurately assessing one’s own behaviour (high self-awareness) and that of others in social situations. This skill allows for identification of incentives and agendas driving the different individuals. Assessment and consideration of the competing priorities of the hospital, their employees, physicians, and patients will improve the leadership abilities of physicians. One only has to think about the quest of physicians for innovation, specialization, and professional autonomy in contrast with the need for efficacy of services, accessibility of care, and the hospital administration financial accountability.
Interpersonal influence solicits the capacity of adapting one’s behaviour to different situations and eliciting the desired response from others. This ability implies great behavioural flexibility to modulate your actions to the personality, reactions, and expertise of your colleague and to the situation. It also requires the aptitude to put others at ease and good communication skills, both with your colleagues and your superiors/directors. Imagine, for example, debating with another surgeon and an anesthetist which of the two patients to prioritize on a semi-elective surgical list. Being able to predict the reactions of the other surgeon and anesthetist and adjust your attitude and argument accordingly would probably result in your patient getting his operation earlier.
Networking ability entails leveraging diverse relationship networks to both create and take advantage of opportunities, resulting in win-win situations.8 This facilitates obtaining critical or rare resources to attain organizational or personal objectives. Focusing on building a diverse network helps provide access to different and unique viewpoints, resources, and opportunities.
Apparent sincerity refers to one’s perceived integrity and genuineness by one’s social environment. It leads to trust and reliance because one’s actions are not assumed to be manipulative or coercive. This skill requires becoming aware of how one is perceived (high self-awareness) among colleagues. Completing commitments, allowing one to show one’s natural range of emotions, and avoiding the appearance of retaining information contribute to revealing this ability. Distribution of available operating time is a sensible issue within a surgical service or department. Being recognized as the person to go to in order to get fair allocation of this valuable resource would constitute such an attribute.
Organizational structure determines the distribution of power and authority.9 It also regulates resource allocation and service dispensation.10 Traditionally, organizational structures were quite hierarchical and included many decisional and authority levels, as well as coordination by a top-down approach.11 Governments are good examples of this organizational structure. To some extent, it also applies to hospitals and universities with formalized authority, although these institutions have a certain degree of vertical decentralization of the authority to provide autonomy to professionals. They constitute the classic example of Mintzberg professional bureaucracy.12 The changing external environment has forced organizations to modify their structure in order to be efficient, flexible, and innovative.1,11 To gain this agility, many institutions have reduced the number of intervening management levels between staff and managers, promoting employee involvement in a decentralized decision-making process. Hospitals and universities have embraced this tendency, both to adapt rapidly to the changing environment and for cost-saving purposes.5 The trend in flattening organizational structures opens the door to make a difference as physicians using political skills, leveraging relationships, aligning and gathering resources to create synergy, and engaging colleagues to collaborate around a common objective within a more decentralized decision-making process.
Several members of the scientific community believe that mastering political skills constitute a strategic behavioural tool socially advantageous at work.13 Specifically, networking ability, interpersonal influence, and apparent sincerity have been shown empirically to be positively associated with task performance.14
Surprisingly, most physicians fulfilling important administrative positions do not realize the direct relationship between exercising their leadership — of which political abilities are an important component — and managerial efficiency.15,16 For a long time, managerial competencies have been neglected during medical coursus.17–19 More recently, the CanMEDS framework implemented by the Royal College of Physicians and Surgeons of Canada has integrated the leadership role, including administrative functions, as one of the seven competencies required to become a competent physician by meeting the healthcare needs of the people they serve.20
Often considered as the “dark side of the force,” political power and influence management hold a pejorative connotation. Nevertheless, it is necessary to recognize that political power is inescapable considering the current changes in the organizational environment as described, and is commonly underutilized. This particularly fits physicians struggling with two conflicting realities of medical practice: expertise/innovation vs. cost-efficiency. To better exercise their leadership and informal authority, physicians would benefit from mastering some of the political skills presented in this article. Having said that, however, one should be alert to possible misuses or even abuses of this power and its associated skills, which really constitute the “dark side” of this potentially powerful tool to become an effective leader.
Competing interests: Dr. Beiko has received sponsored travel, lodging, and honoraria from Cook Medical. Dr. Oake has been an advisor for and has received honoraria from Boston Scientific. Dr. Davies has been an advisor for Allergan, Boston Scientific, and Pfizer; and has received grants/honoraria from Allergan, Astellas, Boston Scientific, and Pfizer. The remaining authors report no competing personal or financial interests.
This paper has been peer-reviewed.