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  1. Leadership education in medicine and science

    Kouzes and Posner (1) once wrote that "The domain of leaders is the future. The leaders unique legacy is the creation of valued institutions that survive over time. The most significant contribution leaders make is not simply to today's bottom line; it is to the long-term development of people and institutions so they can adapt, change, prosper, and grow."

    As Warren and Carnall (2) stated, medical leadership is important for delivering high-quality healthcare to patients and to function across professional boundaries in an environment that is becoming increasingly complex. Physicians are well educated academically and clinically, but training in leadership lags somewhat behind. There also appears to be a gap in leadership capabilities between junior and senior doctors. The authors suggest several approaches to develop the non-technical, often called "softer" skills in physicians, including mentoring by establishing a relationship that will support personal and professional development, coaching to enhance the performance in specific areas, and action learning to solve jointly "real-world" problems that arise at work. There is also formal and informal networking with peers and/or senior leaders, and experiential learning through exposure to new environments, assignments, etc., which trains the individual to work outside their comfort zone. The authors also discuss participation in specific programs, schemes, fellowships, and courses aimed at developing medical leadership skills.

    As a scientist, I found myself in a similar situation as many physicians: I did not receive any kind of training in management and leadership during my education. Yet, after graduation with a Ph.D. in microbiology, I was expected to lead a research laboratory, instruct students in the classroom and guide them through their thesis experience, and to professionally interact with administrative staff of the organization as well as representatives of research funding agencies. So, how did I do it? I essentially studied the way how others (e.g., mentors, senior peers, and selected role models from the literature) lead people, then "copied" certain leadership behaviors, and put a "personal touch" on my leadership attempts. I used the principle of "trial and error." Not surprisingly, it did not take me long to realize that this way of leading was a superficial attempt to be effective and to "survive" in the highly competitive field of biomedical science. Most significantly, I lacked authenticity and did not know the tools needed for self-observation and self-discovery. As it turned out, I was not alone in my leadership insecurities as several of my young colleagues expressed similar soft- skill deficiencies.

    Since the science curriculum (apparently similar to the medical curriculum) does not include management and leadership courses, I eventually decided to enroll in business graduate programs to formally study this subject matter. I was surprised how much I learned from books and articles, group discussions, and case studies about interpersonal and intercultural communication, management techniques, theories and elements of leadership practice, strategic thinking approaches, ethics in action, and organizational behavior, among many other topics. I realized that what I have learned in business school I could immediately apply to many aspects of my work in science. I greatly improved my understanding of leadership and, I believe, it also made me a more attentive person in private life. I know now that leadership is a process, which means a transactional event that occurs between the leader and followers (3), thus it is a collective activity (4), and undoubtedly a real challenge worth taking on (1). Leadership is a universal phenomenon, it is real and not a figment of the imagination, and it has a substantial effect on organizational outcomes (5). Providing good leadership requires a willingness for continuing learning (6), an understanding of the importance of effective and efficient listening to others (7), and the capability and opportunity for deep introspection and self-reflection (8, 9). One must understand that developing and refining leadership skills takes time and requires from the individual passion, commitment, and endurance.

    In hindsight, I wish that I would have taken management and leadership courses much earlier in my scientific career. In this regard, I strongly support the notion that leadership training should become a part of medical and science education. I believe that resources dedicated to leadership education would pay off immediately during the time students spend in medical and graduate school as well as prepare them well for every stage of their professional life. Last, but not least, leadership training can have positive effects on the development of one's personal life.

    I would like to conclude my letter with another citation from the book by Kouzes and Posner (1): "Leadership is important not just in your own career and within your own organization. It's important in every sector, in every community, and in every country. We need more exemplary leaders, and we need them more than ever. There is so much extraordinary work to be done. We need leaders who can unite us and ignite us."

    REFERENCES

    1. Kouzes MJ, Posner BZ. The Leadership Challenge. 3rd edn. San Francisco, California: Jossey-Bass, 2002.

    2. Warren OJ, Carnall R. Medical leadership: why it's important, what is required, and how we develop it. Postgrad Med J 2011;87:27-32.

    3. Northouse PG. Leadership: Theory And Practice. 4th edn. Thousand Oaks, California: Sage Publications, 2007.

    4. Noonan SJ. The Elements Of Leadership: What You Should Know. Lanham, Maryland: Scarecrow Press, 2003.

    5. Bass BM, Bass R. The Bass Handbook Of Leadership: Theory, Research, And Managerial Applications. 4th edn. New York: Free Press, 2008.

    6. Preskill S, Brookfield SD. Learning As A Way Of Leading: Lessons From The Struggle For Social Justice. San Francisco, California: Jossey- Bass, 2009.

    7. Treece M. Successful Communication For Business And The Professions. 6th edn. Needham Heights, Massachusetts: Allyn and Bacon, 1994.

    8. Cashman K. Leadership From The Inside Out: Becoming A Leader For Life. Provo, Utah: Executive Excellence Publishing, 1998.

    9. Palmer PJ. Let Your Life Speak: Listening For The Voice Of Vocation. San Francisco, California: Jossey-Bass, 2000.

    Conflict of Interest:

    None declared

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  2. Making the most of medical communities.

    The identification of leadership as a key skill for doctors is a positive step, however have we undervalued the medical community's assets when considering the development of medical leadership?

    Green Templeton College is a graduate college in Oxford, specialising in subjects relating to human welfare and social, economic and environmental well-being in the 21st century. GTC has taken a more local approach to management and leadership, making use of the diverse college community to provide a middle road between a broad compulsory training and intensive course for the high flyers. We have launched a programme for doctors in training who are interested in developing their management and leadership skills. Optional Saturday morning workshops are provided free of charge; informal talks, participative workshops and facilitated case studies are steered by doctors and managers linked with the college, aiding the sharing of skills and knowledge among those interested.

    Feedback has been positive, creating a wish-list remarkably similar to that described by Warren and Carnall, including "softer skills", career planning events, case studies, formation of a case book, opportunities for shadowing, mentoring and extended projects or management electives. We plan to expand this programme to regular monthly workshops, demonstrating that this demand can be met within an existing community.

    The explosion of the leadership culture through the medical world has brought many valuable strategies from the sphere of management, but should we take a step back and value what we have already? Commercial leadership courses, action learning and coaching have their role, however it might be worth recognising what we already do well and to focus on sharing the mix of skills, so often found in medical communities, more effectively.

    Conflict of Interest:

    None declared

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  3. Some comments on mentoring and leadership

    What do we mean by leadership? Is it identical with the occupation of a medical management, or other management, role within the NHS or some other organisation? Most of this article seems to assume that it is.

    Should all doctors be leaders?

    Doctors are members of an expensively trained practical and scientific community. We have all, with varying degrees of awareness, opted to take on a role which involves among other things providing leadership. This we may do well, or badly. It is a relief to read that an improvement in medical leadership "will require doctors to develop strong personal and professional values". All doctors need strong personal and professional values, and the majority have them, so it would be difficult for any medical leader who was lacking in this area to command the respect of their colleagues.

    It is certainly true that standards of leadership have varied, as has the quality of policies pursued, sometimes with dreadful results. This is also true of leadership at the highest levels of the NHS organisation and at the level of political leadership.

    Most people working in the NHS identify themselves quite strongly exactly in that way and have a commitment to the principles of having a National Health Service despite all its failings. It is not surprising that many people working in the National Health Service find it difficult to stomach some of the changes which are being driven upon us.

    It must be important for somebody providing leadership within the National Health Service to have a good understanding of the reasons why such a service was created in the first place and how it has developed under a whole range of political, social, technological and professional influences. Such an understanding is not sufficient for providing medical leadership, but it is certainly necessary.

    Of course it would be perfectly possibly to provide a different argument, but that simply shows that the direction of travel for Britain's National Health Service is a contested matter.

    One view of leadership in the NHS might be that it is about developing a cadre of doctors who will take up management positions of one kind or another within the various structures of the NHS, and to varying degrees being able to shape and having to transmit policy which is decided on fundamentally political grounds and often with threadbare scientific justification. (Of course there are many important matters which have to be resolved despite a lack of scientific evidence, but then that should be openly admitted, and not hidden behind a cloak of "science").

    Mentorship

    Perhaps we will reach a time where every doctor in training has an educational supervisor, a clinical supervisor, a mentor, a coach. Perhaps these roles will be performed by people who have formal qualifications as clinical supervisors, educational supervisors, mentors and coaches. These structures may be organised by Medical Leaders who have taken time out from their clinical work on fellowships or clinical advisor schemes.

    Perhaps amongst all this some time will remain for gaining clinical experience, that is working with patients.

    In practise, it is likely that implementation of such proposals, even if it was desirable, would be patchy and not sustained. With time at a premium, it is surely more productive to harness existing procedures for clinical and educational supervision, which are becoming more strongly established, to help all doctors to understand and realise effectively their role as leaders. Formal educational supervision is well entrenched in the training of psychiatrists in the UK. The disadvantages of mentoring can be exaggerated. Any doctor in higher training should be exposed to the influence of at least three different trainers, and in any case those trainers will usually be part of a group of reasonably supportive collaborative and reflective senior medical specialists. I have supervised trainees from ethnic minority and majority groups, both UK and overseas trained, both female and male.

    I offer some illustrations about how to address matters of leadership within a mentorship setting, based on my own experience as a medical manager and an educational supervisor for higher trainees, over the last 13 years. I am confident that many of my colleagues could provide similar examples.

    * Firstly, I aim to help them towards achieving a good standard of clinical competence, and confidence in taking clinical decisions, based on attending carefully to a wide variety of patients. Any doctor lacking in this area will have difficulty in providing leadership to their colleagues, however much they want to perform that role.

    * Secondly, it is essential to have a good grasp of epidemiology as this must form the basis of all planning of health services, allied to that would be an awareness of debates about the limits of psychiatry and of its philosophical strong and weak points.

    * Thirdly, I see it as part of my role to train prospective consultants to work, and provide leadership in the National Health Service. I therefore hold it essential that they understand something about the history of the National Health Service, why it was originally established and about its pros and cons and those of alternative models. I think this should come well before immersion in the latest version of Department of Health policy, but it will provide a sound basis for following and responding to the kind of change and the kind of leadership which is current in the National Health Service at the beginning of 2011.

    * The attributes which have led and do lead to success, often for long periods for different leaders are many and varied. One currently very effective tool of political leadership is to appeal to the lowest common denominator. Presumably this is not the form of leadership we are seeking from doctors in the NHS today.

    * It is possible to list quite easily some fairly obvious helpful attributes. These could include:

    1. a clear set of principles which one holds fairly fundamental and about which one is honest with colleagues and patients 2. curiosity and willingness to listen 3. far sightedness, the ability to take a long view 4. a wide field of vision, the ability to see particular problems in a wider context 5. perseverance 6. the ability to practice masterly inactivity and hawk- like observation 7. decisiveness when it counts 8. humility 9. lack of preoccupation with the trappings of leadership. 10. a leader has to be prepared to stand up for their views even if this puts them in a minority or isolates them for a while. It is part of the duty of leaders in general to point out how things really are, even when this is unpalatable.

    The reason these things are obvious is because they are what would make most of us trust, and possibly even be inspired by, someone's leadership in a given situation.

    Some succinct and highly relevant, considerations about leadership are contained in the writings of Niccolo Machiavelli, the essays of Francis Bacon and On War by von Clausewitz.

    In the sense that leadership is an art, it should not be surprising that much of what can be learned about it in theory has been known for some considerable time. I would recommend a reading of a selection of these texts, followed by group discussions, as a much cheaper and more effective learning experience for higher trainees in psychiatry than an awayday in the company of self-proclaimed modern experts on leadership, including possibly a talk from the boss of a company which has made a lot of money.

    * Individual acts of leadership may have very long term consequences, so a historical perspective is of central importance. This is also because what matters is not the theory of leadership but how people lead and have led in particular concrete circumstances. We can therefore learn useful things from historical examples.

    What do the following have in common: George Godber, Archie Cochrane, Aubrey Lewis, Archibald McIndoe, Joseph Schorstein? They are all examples of the many doctors who led the way within the new British National Health Service after 1948. It is likely that none of them ever attended a leadership course (although some of them had been in the Army!). This took place in a context created also by many people from outside the medical profession, with equal commitment and often greater vision.

    We can learn a great deal about leadership from considering a range of examples from all walks of life. My own current favourite selection would include Jayaben Desai, Ernest Shackleton, Lenin, Florence Nightingale, Claudia Jones and Martin Luther King.

    Conflict of Interest:

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