Maybe you started practice just a couple years ago, and this morning you were asked to serve as chairman of your hospital's department of family practice. Or maybe you've been in practice for a few years and the senior partner has asked you to chair your group's quality improvement committee. Maybe you are the organizing leader of a new independent practice association (IPA) that you have decided is essential for family physicians in your community to survive in managed care. Or perhaps you are a career family medicine educator, and you have just accepted an appointment as director of a new family medicine residency program. Or maybe, like me, you have accepted an appointment as chairman of a medical school department of family medicine.

In each case, you are or will soon become a leader. But when the glow you felt from the honor of being offered the new position wears off (in my experience, this took about a millisecond), the responsibility of your new job starts to sink in. You wonder what skills you have to help you succeed. You wonder if you can plead temporary insanity as a way to back out of your agreement to accept the new leadership role.

Take heart! A growing number of family physicians are being invited to lead clinical and academic medicine in ways we have not previously experienced. And more and more are finding the challenges of leadership to be very satisfying, even fun.

James Kouzes and Barry Posner, authors of The Leadership Challenge, describe five fundamental practices of exemplary leadership. They contend that leaders achieving their personal best in leadership “challenge the process, inspire a shared vision, enable others to act, model the way and encourage the heart.”¹ While you may not have extensive experience or formal training in leadership, you can build on the skills you use daily in clinical practice to become a highly effective leader in any setting.

Imagining the possibilities

No one in medical practice needs to be told that the environment is changing more rapidly now than it has in decades. This is especially true for family physicians in academic health centers. Teaching hospitals are merging with former competitors. Medical schools are restructuring their curricula at all levels. Faculty practices are scrambling to compete by providing integrated services to targeted patient populations. Medical centers are gearing up to conduct health services and outcomes research that they ignored completely until very recent times. The tension between the business and academic functions of academic health centers is acute. Medical school departments are undergoing as much change as any part of the institution. No one really knows what medical practices, academic health centers, medical training programs, clinical services or research will look like in five years, let alone 25 years from now.

In a time of such turmoil, it is especially important to be able to imagine, quickly and in detail, possible sequences of events leading to a very different organization than currently exists. It is important to understand the mission, needs, strengths and weaknesses of one's own organization and quickly create a favorable scenario out of rapid change.

How can your new IPA serve your community with improved efficiency and quality of care? How can your hospital department of family practice better serve its members, improve the quality of care in the hospital, and partner with other departments to lower cost of care? How can your family medicine residency adapt to the growth of managed care and to the need for primary care in your community? A family physician leader must ask questions like these and imagine a range of possible answers before selecting the right goals for his or her group at a particular time and place.

Imagining is not a new skill for family physicians. We routinely imagine better futures for people with chronic problems such as depression, pain, addiction, diabetes and marital conflict. It is often our confidence that a better future is possible that gives patients the hope and patience needed to work toward it.

Leadership is an inherently creative process, but the imagination of one individual is not enough. A family physician leader must cultivate this skill in his or her team to enable the best possible thinking. One of the best ways to do this is to engage the group in discussions and role-playing that explore a wide range of circumstances and possibilities. For example, how will your practice respond if one of the major hospital chains opens a large new competing primary care practice in your community? When do you think managed care will dominate your community's health insurance market, if it doesn't already? What is your group doing to prepare? What can you do to ensure that your group will be one of the survivors rather than one of the casualties of the transformation? How will you document your group's quality and efficiency of care to remain providers for your community's largest insurance carrier? What would you do if the major hospital you admit to is bought by a for-profit chain?

These and many other questions can demand rapid response. Successful response by a group to such sudden and unexpected situations depends on the ability of the group, not just one individual, to quickly envision and evaluate a wide range of scenarios. Such skill must be developed in advance because it is not possible to predict when specific events will occur and, once they do, the group must act quickly. Family physician leaders must practice imagining, and they must help their teams learn to imagine to prepare for such crises. These moments define institutions and, far more than day-to-day operation, determine their success.

Using good communication skills

The most important day-to-day task of a leader is to communicate effectively with all sorts of people. Family physicians routinely develop excellent communication skills. Such skills are necessary to work with the wide range of patients we see.

It requires a high level of interpersonal skill, for example, to set a five-year-old child at ease for an examination and take a history from the parent while also attending to the parent-child relationship. It takes a very different set of behaviors to communicate with a dramatic, somatizing adult with multiple symptoms and another set to treat a compulsive, hard-driving patient with hypertension, smoking, depression and colon cancer. It takes yet another set of skills to communicate comfortably with colleagues from a range of disciplines using appropriate vocabulary and style for the setting and problem. Yet family physicians do these things routinely and shift easily from one to the other.

Such skill translates well into the world of leadership where family physicians must learn to understand and communicate effectively in many different settings, using a variety of formats. Speaking before a legislative committee, for example, requires very different skills from speaking at a continuing medical education meeting or explaining to a lawyer your group's concerns about a contract. Family physicians developing leadership skills should study and practice effective communication in the widest possible array of settings. They should listen, read, talk and write as often as possible.

Helping others realize their potential

The primary goal of a leader should be to help others achieve maximum effectiveness in their jobs. An effective leader will define the leadership role as not so much to do the work of the group directly, but to create the conditions that enable others to do it. According to Margaret Mahoney, former president of the Commonwealth Fund, the key to effective leadership is having the right person in the right job encouraging desirable behavior in others. “This sharing of responsibility injects dignity into the relationship,” Mahoney writes. “This, indeed, may be the major role of the leader — to make self-worth and dignity possible in others.”²

The benefit of working with a group of people comes when the synergy among members allows the group to achieve what no individual could do alone. An unstructured group of individuals is just a herd; a group that is led to become more than the sum of its members is a team.

Psychotherapist and educator Carl Rogers spoke of the interpersonal relationship in the facilitation of learning, suggesting that the teacher exhibit “realness or genuineness, caring for the learner and empathic understanding.”³ Although he was applying lessons from psychotherapy to teaching, they transfer well to the role of the leader.

A leader must understand what the members of the organization need to be effective, must encourage emotional and personal growth, and must facilitate concrete skill acquisition. To do this, he or she must know the people — their strengths, weaknesses, motivations, personalities, ambitions, hatreds and dreams. This knowledge is the basis for helping individual members reach their own goals while also contributing to the shared goals of the group.

A family physician leader must be prepared to spend a great deal of time negotiating relationships. Who is happy or frustrated with whom, both within the group and outside its borders? Where can effective teams be developed? Who in the group is ready for greater responsibility or to lead others? Who needs encouragement? Addressing these issues effectively calls for good listening skills and strong organizational and supportive abilities.

A new generation of leaders

The discipline of family medicine grew on the efforts of our founding fathers and mothers, many of whom came out of private general practice to start new professional organizations, certifying bodies, hospital and medical school departments and residencies. We now see leadership transferring to the next generation, consisting largely of residency-trained family physicians.

We need family physician leaders at all levels, from hospital committees and departments to professional societies, medical school deans' offices, department chairs, residency and predoctoral education directors and medical directors at individual clinical practices.

Family physicians should think of themselves as natural leaders in evolving medical organizations. Accepting such roles may require some soul-searching, but family physicians must cultivate the attitudes and skills to take their rightful place in the leadership of medicine for the 21st century.