Leadership is defined as the act of guiding people and organizations  . Despite various sources attempting to define this term precisely, its conceptualization remains inconclusive  . It is often used interchangeably with the term “management”, but they are slightly different as Peter Drucker once claimed, “management is doing things right; leadership is doing the right things”. Hence, a leader is someone who envisions a principle-driven change and subsequently realizes it by influencing others, while a manager focuses more on achieving a specific outcome through a standardized process, demonstrating contrasting approaches in goal achievement  - . Concluding its definition from different perspectives, leadership essentially describes one’s ability to direct a group of individuals to achieve a shared goal collaboratively by being motivational, inspirational, and influential in initiating a beneficial change in the current systems   .
Leaders are seen everywhere in all professions, and it is not merely the role played by a designated person but everyone involved in the context, namely a shared leadership   . Leadership is also demonstrated in medical students whereby they practice such skill in project-based learning and simulations, guiding others in completing tasks    . In healthcare settings, clinical leadership inherently defines a physician who actively engages in a guiding role in improving the healthcare system apart from fulfilling the responsibility of carrying out regular clinical duties . The exact roles played by medical leaders are still indeterminate; therefore, this may hinder the effective teaching of such skills to others. Nevertheless, medical leaders are the primary physicians undertaking managerial roles or informal chief in daily clinical practice   . They also need to be specific and confident and updated regarding their own roles as they are required to adapt to the ever-changing advances in technology, financial structuring, and societal standards  .
Furthermore, they are involved in evaluating programs, decision-making, and establishing networks between colleagues    . Traditionally, there is a clear division between professionals and managers; however, the concept of medical leader has been introduced to strike a balance between the forces mentioned above    . Studies also demonstrated better hospital performance when being led by physicians   . Therefore, the cultivation of leadership skills is effective with an explicit understanding of leadership roles and concepts.
Healthcare systems are evolving to become much more intricate as the current healthcare involves multidisciplinary care in which interaction with multiple professional groups, doctors of different specialties and departments are inevitable . Hence, this emphasizes the importance of involving physicians with leadership skills to maintain the desired high standard of care to patients as well as to further enhance the efficiency and productivity of the health system despite its complexity . Moreover, its significance is also attested by studies demonstrating that work satisfaction is increased when an empathetic and supportive leader is present, thus creating a conducive working environment and indirectly improving organizational performance    . These desirable outcomes are also achieved through the constant drive for improvements and initiatives as encouraged by a leader   .
National Health Service (NHS) competency framework is well-known, and it consists of several domains that healthcare leaders should develop, for example, exhibiting the ability to manage themselves and communicate with others effectively, strategizing a plan for constant improvements of the organization as well as setting the vision and direction for change . To date, numerous leadership styles exist, and different individuals adopt distinct styles which deem most suitable to them, but each style is associated with different outcomes in different settings. Hence, it is imperative to identify the most appropriate style to achieve optimal outcomes   .
The most discussed styles in literature are transformational and transactional leadership (TRL). Transformational leadership (TFL) describes a leader who inspires the followers through values whereby they will adapt to the leader’s way and achieve mutual goals consistent with their personal growth. There are four characteristics delineated in TFL described by Bernard Bass and colleagues, idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration     . On the other hand, TRL focuses more on self-interest, whereby followers are motivated through rewards, while laissez-fair leadership is passive in which the leader is not involved in decision-making   .
Leadership is increasingly being recognized as a significant requirement in today’s society, as attested in the residents’ requirement in the Accreditation Council for Graduate Medical Education from the United States   . Not only are practicing doctors having an increasing desire for higher leadership roles, but more junior doctors are demonstrating interest in such development as they believe in making a difference in their working environment apart from improving their patient’s care . The research studies investigating leadership development activities are still variable in quality and lack exploration of subsequent learners’ feedback and subjective outcomes     . As aforementioned, the distinction between the concept of medical leadership and specific roles taken by medical leaders remains unclear  .
Hence, we aim to carry out this review to further clarify the concept of leadership and collate studies that included leadership development strategies to provide insights into improving current leadership status as this has not been widely implemented. Furthermore, we intend to identify the impact of leadership styles on factors such as patient health outcomes and employee job satisfaction so that the appropriate leadership style that yields the most desirable outcomes to the system can be chosen and practiced. In this review, we analyzed various strategies in engaging medical practitioners in developing leadership and the effect of leadership styles on different factors, for instance, job satisfaction, hospital performance, and quality of patient care.
2. Educational Strategies in Medical Leadership
Educational strategies include enhancing the development of leadership via educational interventions such as adaptation into curricula, the introduction of programs and workshops  . A review paper written by Chadi reinforced this by stating that the existing medical curricula must incorporate leadership training to provide adequate cultivation of such skill. Besides, most Canadian medical programs are beginning to encourage students in taking up management classes as elective credits. Apart from focusing on undergraduates, continuous medical leadership training must also be offered to practicing doctors. In addition, McGill University developed a joint Doctor of Medicine and Masters of Business Administration (MD-MBA) program in Canada since 1996 to prepare physicians as managers in the healthcare settings  . Another article by Sonsale also discussed the need for leadership skills to be incorporated in the undergraduate medical curricula to standardize the essential skills needed in medical students in the United Kingdom (UK)  .
Moreover, leadership and management were suggested to be included as a combined intercalated degree which is attested in Birmingham Medical School whereby an intercalated Bachelor of Science (BSc) in Health Management and Leadership is offered. This educational program allows more medical schools to be aware of such integration hence follow suit in implementing strategies to promote leadership . The effectiveness of having doctors graduated with managerial training was also demonstrated in Clay-Williams et al.’s systematic review in an analysis done byXirasagar et al. whereby leaders are graduating with degrees, for instance, Masters of Business Administration (MBA), Masters of Health Administration and Masters of Public Health, are more effective leaders   .
The study conducted by Denis and Gestel also reported implementing an improvement program as an initiative to engage physicians in leadership, namely, the Accelerating Excellence program in Canada, which drives initiatives for health system improvement. According to the Champions for Quality Improvement, medical associations and colleges collaborated with the government to improve doctors’ adherence to the program  . Chadi also stated the importance of hospitals in arranging workshops to allow physicians to adapt to the leadership structure. Furthermore, the Canadian Medical Association began offering programs and workshops through its Physician Manager Institute to provide intensive training regarding leadership  .
2.1. Implementation of Guidelines and Frameworks
Several studies identified that guidelines and frameworks paved a structured path for healthcare workers to meet the current complex demands of the healthcare system. In Chadi’s paper, it was stated that the Royal College of Physicians and Surgeons of Canada officially published the Canadian Medical Education Directives for Specialists (CanMEDS) standards in 2005, whereby essential domains that a doctor should have competence in were listed. Apart from guiding physicians regarding leadership, especially through the CanMEDS Manager Role in which active participation in decision making optimizes the function of the healthcare system, it also serves to guide the adaptation into medical curricula  . It was also briefly discussed in Sonsale’s article whereby CanMEDS outlined the requirements of a physician possessing the ability to lead while practicing evidence-based medicine with the aim to attain cost-efficient care and how these values influenced the UK, leading to the formation of Medical Leadership Competency Framework (MLCF), thereby supporting the implementation of General Medical Council Outcomes in Leadership and Management  .
Moreover, the General Medical Council guidelines on “Leadership and Management” devised in 2012 emphasized the roles of doctors beyond clinical work, specifically in leadership, thus further directing current medical personnel into adopting leadership skills. Subsequently, in 2013, the existing framework in the UK was augmented with the introduction of the “Healthcare Leadership Model”, which focused on the concept of shared leadership hence enhancing the intra-professional network in the organization  . Chadi’s review also mentioned the NHS competency framework among the initiatives to integrate leadership into daily practice as it delineated five domains that are essential for physicians to develop . The five essential domains prescribed in the medical leadership competency framework include demonstrating personal qualities, working with others, managing services, improving services, and setting direction, and all these factors are leading to the effective delivery of health services .
Furthermore, Denis and Gestel illustrated that the “Integrated Medical Specialist Organization” model was created to build a joint responsibility between medical specialists and executive boards of hospitals. To further support this movement, Care-Wide Governance Code was established by the joint Health Care Sector Organizations. Organizations in the Netherlands widely applied this model, and it ensured adequate supervision on healthcare personnel as well as upholding great management standards. Similarly, the “Quality Framework” was published in 2010 by the “Order of Medical Specialists”, which investigated the link between medical specialists and boards strengthening its importance and the system’s awareness in improving this aspect .
2.2. Involvement of Health Executives
The involvement of one with a medical background in healthcare executive positions not only bridges the communication gaps between medical professionals and management team, but it also acts as a role model for others to follow suit in becoming leaders   . Chadi confirmed this as the role of Chief Medical Officers (CMO) had been empowered in Canada due to the impossibility of hiring a Chief Executive Officers (CEO) who is ideal in management and simultaneously possessing a medical degree. Moreover, the Canadian ministries must actively seek opportunities in increasing CMO positions . Clay-Williams et al. also reported in the systematic review that the first survey of Accountable Care Organizations (ACOs) in the USA demonstrated that most doctors were leaders as attested in 51% of the healthcare settings. In addition, having doctors on boards improved the quality of care as if a doctor substitutes one member from a standard 10 person boards, it increases the uncompensated care by 19%. With CMO or Vice President of Medical Affairs on the committee, it significantly raises the process of care scores (85.3% vs 81.0%, p < 0.05) and lower risk-adjusted mortality rates (5.6% vs 7.3%, p < 0.05) as compared to those hospitals with the absence of such roles. Another analysis in the article also showed that in higher performing hospitals, doctors either took up a bigger portion of the boards or acted as CEOs .
Apart from executive positions, committees should also be created, as evidenced in Chadi’s paper. The physician advisory committee was established to link managers and professionals, thus creating a conducive environment for leadership development. Furthermore, Denis and Gestel stated the establishment of the Shared Care Committee in 2006 in Canada, whereby the main purpose is to support initiatives among healthcare professionals in improving the health system. This committee was governmentally funded, and it incorporated medical leadership into the improvement agenda. It was also noted that structural arrangements involving creating governmental and regional medical advisory or planning bodies as well as executive positions could be made .
2.3. Implementation of Policy, Acts and Reports
Policies can be developed considering the change to be implemented in the health system whereby clinical leadership is integrated  . This is evidenced in Denis and Gestel’s article, whereby in British Columbia, Canada, both policymakers and professionals have established a pact to involve physicians beyond their clinical duties. Ontario also proclaimed the “Excellent Care for All Act” in 2010, in which a scheme involving incentives and specific roles of doctors to improve the quality of healthcare had been devised. Another leadership enhancement strategy would be the production of reports that reflect and document the current issue faced by the system. Once awareness is heightened in this aspect, initiatives can be devised and later on implemented in ameliorating the condition. For instance, the Council for Public Health and Care expressed their opinion on the significance of involving responsible physicians in governance via the report “Governance and Quality of Care” (2009), which is further supported by an advisory letter “Relationship between the medical specialist and the hospital in the light of the quality of care”. Similarly, the policymakers and professionals’ opinions are expressed in the reports on “Evaluation of the Quality-of-Care Institutions” (2009) and “Beyond permissiveness. Control and monitoring of quality and safety” (2009) reflected on the inadequacy of the current monitoring of standards and safety of patient care which subsequently had been adapted into the improved regulatory framework .
3. Leadership Styles
Choosing the appropriate leadership style allows inspiration and innovation, which further translates into improved quality of healthcare delivered timely  . Durowade et al. discussed the link between leadership styles and job satisfaction in which productivity will increase with the satisfaction of the healthcare workers’ needs, thereby ultimately boosting patient’s care. Several studies from various countries and different settings were quoted in the article in supporting the positive association between transformational leadership (TFL) and job satisfaction, for instance, in Malaysia, Jordan and Libya. Idealized influence, which is one of the components in TFL led to higher job satisfaction as evidenced by the higher mean score of 10.99 [+ or −] 0.97 among hospital leaders as assessed via Multifactor Leadership Questionnaire (MLQ), which can be interpreted as leaders are usually visualized as respectable role models.
However, laissez-faire leadership style reported a negative association with job satisfaction in healthcare workers (r = −0.084; P = 0.094), which is supported by an Iranian and Malaysian study. Inspirational motivation, intellectual stimulation, individual consideration which are components of TFL while contingent reward which is utilized in TRL were shown to be positively correlated with job satisfaction in healthcare workers . Furthermore, Sonsale also briefly stated the significance of utilizing TFL, replacing the conventional TRL to meet the current demands of the healthcare system . Besides, Jodar et al. also discussed about various aspects of leadership styles whereby the study showed both aforementioned leadership styles correlated highly with efficiency and job satisfaction (r = 0.724 and r = 0.710 respectively) . The major study findings of the selected important articles are displayed in Table 1.
Table 1. List of selected articles with the main findings and conclusion.
Leadership skills can be cultivated in many ways through different roles played by society, for instance, governmental authorities, healthcare institutions, and medical schools. Taking other countries like Canada, the UK, and Netherlands as examples, integrating leadership training and managerial course into the medical curricula should be implemented.
Workshops and programs must also be organized to engage healthcare personnel in leadership consistently. Opportunities for practicing physicians to continue their medical education should also be offered, especially in management, to produce more medical leaders bridging the communication gap between managerial and professional members. Introducing health executive positions and encouraging policies, frameworks and reports must also be devised so that an up-to-date and systematic guide is available for doctors to follow in meeting the current fluctuating demands of the healthcare system.
There are currently numerous leadership styles existing and transformational leadership has shown a positive association with job satisfaction, thereby indirectly improving the healthcare system. Nonetheless, more studies should be analyzed to find the most appropriate and effective strategy to be implemented in enhancing leadership.
The authors would like to acknowledge Monash University for providing us access to the extensive sources of full-text articles required in completing this review paper via Monash University Malaysia’s library. Furthermore, Monash University also permitted us in utilizing Endnote software in removing duplicated articles.
List of Abbreviations
ACOs: Accountable Care Organizations;
BSc: Bachelor of Science;
CanMEDS: Canadian Medical Education Directives for Specialists;
CEO: Chief Executive Officers;
CMO: Chief Medical Officers;
MBA: Masters of Business Administration;
MD-MBA: Doctor of Medicine and Masters of Business Administration;
MLCF: Medical Leadership Competency Framework;
NHS: National Health Service;
TRL: Transactional leadership;
TFL: Transformational leadership;
UK: United Kingdom.
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