Leadership Qualities: What Makes a Great Leader?

August 2020 Issue

  1. Ashley Shilling, MD Associate Professor of Anesthesiology and Orthopaedic Surgery, University of Virginia Department of Anesthesiology Author


When my chairman of 15 years announced at a faculty meeting that he would be stepping down as chair, the room went silent. If you knew our verbose, lively, passionate, and communicative department, you might better understand how profound this was. We are never silent. He went on to clarify: WE are the department, he merely had the word “Chair” by his name on the faculty roster… WE would always be the department, no matter who led it… he didn’t worry about our stability or trajectory because we are a strong and cohesive group of 62 capable physicians with a history of perseverance and success. While these things were mostly true (he was/is much more than a faculty member with “Chair” written by his name), I was still left with a sense of disorientation and inquisition about what I would most miss about our leader and who we would be without him. What made him such a beloved leader, and how could we replace him? 


While defining “leader” may be a challenge, identifying when someone is or isn’t an effective leader is much easier.


The Merriam-Webster dictionary defines LEADER as a powerful person who controls or influences what other people do; a person who leads a group, organization, country, etc. Words like “powerful,” “control,” and “influence” were not the descriptors I was seeking. As I continued to try to write about and define leadership, it began with a literature search. What do the data show? Is there evidence of what makes an effective leader? 

While defining “leader” may be a challenge, identifying when someone is or isn’t an effective leader is much easier. Within the specialty of anesthesiology, what helps leaders in regional anesthesiology and pain divisions succeed? Is there a prototype of a best leadership style? How can a leader unite a department and foster respect and collegiality between so many different personalities both within and outside the department? While there are hundreds of different leadership types and descriptions, one inclusive list defined nine different leadership types[1] (Table 1).

Table 1: Nine styles of leadership.[1]

Leadership Style

Primary Characteristic(s)

Transformational

Inspires and encourages others to create the changes needed to progress and grow; motivate others

Transactional

Provides more organizational and supervisional support and uses rewards as a motivator

Servant

Focuses on the premise that leaders serve others and embody empathy, listening, stewardship, and building community

Autocratic/authoritarian

Makes decisions based on their own ideals with little input from others

Democratic/participative

Involves group participation in decision-making

Bureaucratic

Leads based on administrative needs of organizations with rules and clear definitions of authority

Laissez-faire

Employs a “hands-off” style of leading

Charismatic

Emphasizes personality and ability to influence and inspire

Situational

Adapts and uses different leadership styles based on the environment 

Transformational leaders are frequently defined as leaders who inspire and encourage others to create the changes needed to progress and grow. They are motivators of others. Transactional leaders tend to provide more organization and supervision and use rewards as a motivator. Servant leadership focuses on the premise that leaders serve others and embody empathy, listening, stewardship, and building community. Autocratic leadership, or authoritarian leadership, involves the leader making decisions based on their own ideals with little input from others. Democratic leadership, also termed participative leadership, involves group participation in decision-making. Bureaucratic leadership is based upon administrative needs of organizations with rules and clear definitions of authority. In contrast, laissez-faire leadership is a hands-off style of leading. Charismatic leadership is a trait-based leadership theory that emphasizes the leader’s personality and ability to influence and inspire others. Finally, situational leadership refers to leaders that can adapt and use different leadership styles based on the environment in which they are working. 

Although many leaders embody multiple leadership styles, are there salient and specific characteristics that create the most proficient leaders? And if so, how do we, as individuals, refine and improve these in ourselves? A study of more than 75,000 people spanning 11 years and 6 continents identified four adjectives as the most important characteristics in a leader they are willing to follow: honest, forward-looking, competent, and inspiring.[2] While a leadership course may teach managerial skills and vision creation, how do we embody and grow into these or other characteristics that make us great leaders? 

An excerpt from Scemama and Hull’s Anesthesiology article entitled “Developing Leaders in Anesthesiology: A Practical Framework” gives hope that there is no specific mold for leadership and that leadership can be fostered in each of us.[3]

Recent research into high-performing organizations has shown a consistent shift away from top-down authoritarian environments toward leadership cultures where everyone, at all levels, is required to be a role model and an agent of change. No longer will it suffice for a clinical leader to wait until he or she has been promoted to a formal position of power to start developing leadership skills. Leadership exists as a potential within everyone: male or female, junior or senior, titular boss or underling. In fact, there is now considerable evidence that effective leaders are not always grand visionaries but are just as likely to be humble, self-effacing, emotionally stable, diligent and resolute, and that leadership is needed at every level of an organization (pp. 652-3).

The question then becomes not can we become a leader, but, are we willing to be a leader.

Brene Browne, a social psychologist and professor at the University of Houston, has redefined leadership after a seven-year study with the intention of creating identifiable and measurable qualities in leaders. Her 2018 book, Dare to Lead, defines a leader as “anyone who takes responsibility for finding the potential in people and processes and has the courage to develop that potential” (p. 4).[4] She describes four pillars of courageous leadership: 1) rumbling with vulnerability, 2) clarity and living into our values, 3) braving trust, and 4) learning to rise. As defined by Browne, courage is “less about who people are and more about how they behave and show up in difficult situations” (p. 11).

Vulnerability, emotional exposure, uncertainty, and risk are critical in leadership. Leaders must be willing to take risks and be vulnerable, and they also must provide an environment where their team can be vulnerable. Providing an environment where others feel safe, respected, and free from discrimination and judgement is critical for a leader. This allows team members to take risks and remain motivated to participate. With that, identifying clearly defined values that define individuals and organizations is necessary. Values guide us and help us deal with adversity. 

Within our specialty of medicine and anesthesiology, we are lucky to have the Hippocratic Oath to bond us in our mission and values: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” Despite this, physicians are often faced with conflicting pressures and demands. Choosing the most important values (ie, quality of care, patient safety, and education) can guide leaders and organizations, and it can also be translated into behaviors.

Trust, which is Browne’s third pillar of leadership, is the fundamental component of connection. Browne defines specific behaviors of trust that are measurable. She calls these seven elements of trust “BRAVING”, which stands for: Boundaries; Reliability; Accountability; Values; Integrity; Nonjudgement; and Generosity. 

Finally, Browne’s fourth pillar, “learning to rise,” describes resiliency and the potential to manage failure and persevere. Her message is a powerful roadmap of redefining leadership in the workplace by daring greatly.

Like Brown, Scemama and Hull define major themes of leadership and the need to break out of unproductive beliefs and learn new behaviors in “Developing Leaders in Anesthesiology: A Practical Framework.”[3] The three themes include 1) self-awareness, 2) creativity, and 3) relationships. They describe the significance of leadership and self-awareness and the need to exhibit emotional intelligence. This includes bridging the gap between how we perceive ourselves and how others perceive us. This also involves being receptive to feedback. After self-awareness is present, the authors note that to affect change, the next critical step is creativity, defined as “the willingness to experiment, to break through barriers in relating to others, and to be open to innovate ideas” (p. 654). Not only do leaders need to generate creative ideas, but they need to nurture the original and creative ideas of others. Finally, the authors note the importance of leaders engaging in high-quality relationships. The authors note that trust is a fundamental and integral component of successful leadership.

Mets writes about “Leadership Challenges in Academic Anesthesiology” with a focus on shared values and a departmental mission of education, research, and patient care.[5] Accompanying values is the need for individuals to embrace a strategy and commitment. The premise of leadership being about relationships and occurring at multiple levels echoes many of the same ideals as Browne. Souba noted that effective leaders do the following: 

  1. Listen to the environment and people.
  2. Exemplify and embody core values.
  3. Applaud others.
  4. Deal with problems.
  5. Empower, enable, and inspire others.
  6. Seek results.
  7. Serve others.

These seven characteristics form the mnemonic: LEADERS.[6] This creates a framework in which to act with the intention of being an effective leader.

How do anesthesiologists within our specialty define values and act as leaders? Dr. Edward R. Mariano, a leader in the field of regional anesthesia (who also generously shares and leads through social media) presented a short list of learned lessons on leadership on his blog post entitled “To the Next Generation of Physician Leaders.”[7] These include:

  1. Be a good doctor.
  2. Define your identity.
  3. Consider the big picture.
  4. Promote positive change.
  5. Be open to opportunities.
  6. Thank your team.

Mariano emphasizes many of the same ideals of being open to new ideas, taking risks, crediting and involving others. In another blog post, “Tips for Future Physician Leaders,” he wrote, “In healthcare, a leader should set a good example of professionalism in clinical care, communications, and administrative work. A leader creates a shared vision for the group with a clear direction and celebration of the group’s accomplishments. A leader first invests in his or her staff members to develop them individually so their greater potential can benefit the group. A leader is inspired by his or her staff and is constantly listening and learning.”[8] 

Dr. Jennifer Szerb, an anesthesiology professor in Halifax, Canada, describes trying to “lead by example in my commitment to each patient, dedication to the learners’ experience, support for my colleagues, and acknowledgement of the contributions of our incredibly hardworking block room staff.”[9]  

Another leader in the field of anesthesiology, Dr. Joseph Neal, nicely summarized, “Those with the most professional satisfaction seem to derive great pleasure from taking good care of the people they exist for—their patients or trainees at work and their family at home.  There is interest and motivation to stay involved in something beyond just themselves …”[10]

Ultimately, what I found and want to share is NOT “A guide to becoming the next departmental chair or division head.”  What I learned is this: there is no one right kind of leader. And, leaders are needed everywhere, at every level of medicine. We are all leaders, need to be leaders, and have the potential to become better leaders. Despite effective leaders taking so many different forms, leaders who place emphasis on creating and living out solid values and doing so with emotional intelligence, openness, and prioritizing relationships prevail. This is true regardless of who is leading or what they are leading. 

An anesthesiologist leader is nothing without a connection to the people around him or her, and every encounter provides an opportunity to lead. Whether guiding an operating room through an uneventful surgery, teaching medical students the basics of endotracheal intubation, or overseeing a prolific pain clinic, there are daily opportunities for self-reflection, betterment, and growth as a leader. 

“The world is moved along, not only by the mighty shoves of heroes, but also by the aggregate of the tiny pushes of each honest worker.”

— Helen Keller

References

  1. The Executive Connection. Common leadership styles. https://tec.com.au/wp-content/uploads/2018/10/9-Common-Leadership-Styles.pdf. Published 2018. Accessed July 8, 2020.
  2. Kouzes JM, Posner BZ. The Five Practices of Exemplary Leadership. 3rd ed. United Kingdom: Wiley; 2003.
  3. Scemama PH, Hull JW. Developing leaders in anesthesiology: a practical framework. Anesthesiology. 2012;117:651-6. https://doi.org/10.1097/ALN.0b013e3182632358
  4. Browne B. Dare to Lead: Brave Work. Tough Conversations. Whole Hearts. New York, NY: Random House; 2018.
  5. Mets B. Leadership challenges in academic anesthesiology. J Educ Perioper Med. 2005;7(1):E033.
  6. Souba WW. The job of leadership. J Surg Res. 1998;80(1):1-8. https://doi.org/10.1006/jsre.1998.5480
  7. Mariano ER. To the next generation of physician leaders. EdMariano.com. https://www.edmariano.com/archives/1058. Published October 21, 2015. Accessed July 8, 2020.
  8. Mariano ER. Tips for future physician leaders. EdMariano.com. https://www.edmariano.com/archives/829. Published January 15, 2015. Accessed July 8, 2020.
  9. Ip VHY. Interview with a prominent female leader in regional anesthesia in Canada. ASRA News. https:/www.asra.com/asra-news/article/177/interview-with-a-prominent-female-leader. Published May 2019. Accessed on July 8, 2020.
  10. Neal J, Schroeder K. Interview with a leader in field: Joseph Neal, MD. ASRA News. https://www.asra.com/asra-news/article/78/interview-with-a-leader-in-field-joseph. Published August 2017. Accessed on July 8, 2020.

Tags: leadership, service

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