May 15, 2008  

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The New Physician
  
Leadership Skills and Training

Today's primary care doctor is as central to the community as the general practitioner of one hundred years ago. However, the contemporary doctor plays a more complex role in the process of ensuring the community's health. Advanced medical knowledge, sophisticated public health research and interventions, and sleek citizen organizations are all tools that can be employed by primary care physicians in attending to community priorities.

Unfortunately, training for generalist physicians to provide community leadership is informal at best. The demands of being a competent medical practitioner as well as a community leader are too rigorous for most to assimilate in a casual manner. As a result, many generalists shy away from a role in which they could make a tremendous impact.

Drawing on interviews with student leaders, primary care residents, attendings and residency program directors, this Project-in-a-Box will present a list of important skills to prepare primary care doctors to be community leaders. It will discuss different methods of how a primary care physician-in-training can educate himself or herself on becoming a community leader.

Medical Leadership
Primary care leaders distinguish themselves by knowing the community in which they practice. A community-oriented primary care (COPC) physician uses his or her knowledge of the local socioeconomic environment in managing patient care. The doctor-patient relationship forms the basis of primary care. This means that the doctor develops a relationship with a patient over a span of years, coming to know the patient's family, workplace, and neighborhood. A physician with community awareness recognizes the relationship between mental and physical health, and diagnoses and treats often-covert mental illness in the context of family and community. The community physician also promotes health through preventive behaviors. The Institute of Medicine refers to this component of primary care services as "information intensive." Clinical Preventive Services is a comprehensive guide to disease prevention and screening, published by the Department of Health and Human Services (DHHS) in 1997. Finally, physician leaders serve as a knowledge base of common medical problems and evidence-based treatments.

Table 1: Two excellent guides to managing common outpatient disease are available on the Web:

The University of Iowa's Family Practice Handbook
http://vh.radiology.uiowa.edu/Providers/ClinRef/FPHandbook/FPContents.html

The Stanford-UCSF Primary Care Teaching Module
http://www.med.stanford.edu/school/DGIM/Teaching/Modules

Utilization of the health care team is paramount in addressing social and behavioral factors that exacerbate disease. A variety of health care professionals are often available for counseling and treating patients with social, behavioral, and rehabilitation concerns. Important team members include mid-level practitioners, such as physician assistants

(PAs) and nurse practitioners (NPs), who have outpatient clinical training. Social workers are linked into a tremendous network of community services. Therapists can aid in the rehabilitation of deconditioned patients. Behavioral counseling may be offered locally for concerns such as smoking cessation. Home nursing services are often available for patients who are unable to maximally carry out a therapeutic regimen. A COPC doctor knows the available resources and which patients would be best served by the resources. For more information, check out The Primary Care Team Project-in-a-Box or contact AMSA's Resource Center at (703) 620-6600, ext. 217.

Knowledge of Public Health
Physicians recognize epidemiology as a tool for assessing and monitoring the natural history of diseases and as a method for evaluating medical interventions. The community-oriented generalist takes this one step further. The community doctor uses public health data to identify concerning trends in disease--such as a cluster of children with high blood lead levels. Then, he or she forms and motivates a team to initiate, design, and evaluate a disease intervention. This is also called applied epidemiology.

Leadership in the Community
Practicing physicians are called into leadership positions every day. Within the community, physicians often become the focal point in organizations and activist groups. Effective leadership in the community requires a vast array of skills that can be acquired or assimilated through practice. Several key skills for physician leaders include abilities in team building and running meetings, public speaking, and media advocacy. Physicians-in-training can develop leadership qualities by assessing their abilities, seeking training resources, and practicing leadership skills.

Many primary care physicians have the experience and interpersonal skills to become natural leaders. "Teaching is at the heart of leadership," write Eli Cohen and Noel Tichy.1 "Leading starts with getting others to size up the realities of a situation and to understand what responses are needed. Then it is getting them energized and motivated to deliver those responses effectively and efficiently." Medical education's emphasis on didactic study and decisive action in response to new data introduces the physician to these important teacher-leader skills.

Building on this foundation, physicians will find that many community activities and interventions demand a leader who can effectively run meetings and create a team that is motivated, focused, creative, communicates effectively, and carries out its goals. One place to start in running meetings is by organizing the agenda. Some leaders rely on a standard format, such as parliamentary procedure, to conduct meetings. Toastmasters International is one organization that teaches members how to organize and structure meetings. Check out the web site http://www.toastmasters.org or call (800) 9WE-SPEAK to learn more about conducting meetings.

A second task in running effective meetings is promoting substantive discussion. This requires that individual members become comfortable with each other and the meeting environment. A good leader creates an environment conducive to discussion and participation. One important skill is actively listening to all participants and assuming that each member can make a legitimate contribution. Showing that you follow a participant's remarks by occasionally summarizing what he or she is saying gives helpful feedback to the participant. Excellent quick-reference handouts on building team communication are available on the Marquette University web site, at http://www.uwm.edu/Dept/SOAR/Lead/Leader.html For more hints on getting meetings rolling, see Table 2.

Table 2: What if nobody says anything? Some hints on getting meetings rolling. (Planned Approach to Community Health: Guide for the Local Coordinator. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.)

Environment: Create a setting that facilitates communication and participation. Use small tables or a circle of chairs.
Engage the group: Ask open-ended questions frequently; avoid talking more than participants. Thank participants for their comments.
Participation: Make participation an expectation. Consider giving small assignments in advance, with work to be shared during meetings. Talk with quiet participants during breaks and work out helpful ways to share their opinions.
Teams: Create opportunities for participants to work in teams.

Common problems:
No participation: Ask for opinions, then remain silent. Thank participants for sharing views.
Off the track: Interrupt the discussion, remind participants of the original topic of discussion. Suggest that the newly introduced issue be discussed at a later time.
Too much talk: At the outset, ask participants to set a time limit for individual contributions and appoint a timekeeper.
Disputes: Remain neutral, allow the participants to disagree. If the dispute must be resolved, encourage the group to reach a consensus.
Unyielding participants: Give the group a chance to bring them around. Majority opinion may cause participants to reconsider their point of view. Offer to discuss the issue further after the meeting.

Team action is promoted through explicit goal setting and program planning. Useful goals have challenging yet realistic aims, a target date for completion, and measurable results.2 Program planning involves determination of facilities, funding, logistics, speakers, publicity, event timing, and delegation of responsibilities. Table 3 lists several Web resources to learn more about these activities.

Teams should expect to encounter conflicts as individual personalities with different expectations and coping behaviors begin to work together. A leader recognizes the strengths and weaknesses in each individual member of the team. In the business world, teams are turning to personality inventories to understand and better employ the different

personality qualities on the team. A commonly used personality inventory is the Myers-Briggs Type Indicator. This system is based on the work of German philosopher Carl Jung, who identified the four human character qualities as artisan, guardian, rationalist, and idealist. Jung believed that human beings have characteristics in each of these four groups, but will gravitate towards one of the groups.3 Knowing an individual's personality type is helpful in understanding responses to issues and planning programming for the group. A number of self-assessment modules can be employed by teams looking to learn more about themselves. For examples, check out the National School Board Association site at http://www.nsba.org/sbot/toolkit/P&LDev.html.

In addition to a basic understanding and acceptance of human nature, conflict resolution also requires negotiation skills. A good leader tries to be fair and objective above all. This means listening quietly, not taking sides and not becoming emotionally involved. The leader assumes that each member has something legitimate to say and contribute, and remembers the value of individual differences. All emotions and expressions on the team member's part should be allowed to be aired.4

For more hints on meeting-related activities such as team-building, goal setting, program planning, and conflict resolution, check out the Web sites listed in Table 3. For more in-depth coverage of these issues, a number of on-line journals and articles are archived on the Web. Table 4 has a few of these more detailed references.

Table 3: Hints on team-building, goal setting, program planning, and conflict resolution, and links to related resources include the following:

Table 4: On-line journals and articles on leadership development issues such as empowerment, communication, team-building, and motivating include:

Public Speaking
Undeniably, great leaders are great public speakers. Public speeches, roundtables, lectures, and discussions are some of the most direct ways to inspire, energize, and motivate a community around serious concerns. However, Cohen and Tichy1 point out that "Until you can articulate your knowledge to others, you won't succeed as a leader." Few physicians are trained in public speaking, and formal public speaking is not routinely practiced in day-to-day clinical medicine. Future primary care leaders acknowledge this deficit and can seek out practice in this crucial area.

One way to learn about and practice public speaking is through an organization like Toastmasters International. At Toastmasters, participants learn by speaking to groups and working in supportive teams. Participants also practice conducting meetings and give impromptu and prepared speeches that are evaluated by the team. To find a local club, contact Toastmasters at (800) 9WE-SPEAK, or on the Web at http://www.toastmasters.org. Table 5 contains Toastmasters' 10 hints for public speaking.

Another way to gain public speaking experience is to provide opportunities for students to practice public speaking in your school. Organize a seminar on ethical, health policy, or public health issues and require each student to give a presentation to the class.

Alternatively, encourage students to make presentations during AMSA chapter meetings on issues relevant to the chapter. Additional resources for public speaking are listed in Table 6.

Table 5: Toastmaster offers 10 tips for speaking in public:

    1. Know the room
    2. Know the audience
    3. Know the material you'll present
    4. Relax!
    5. Visualize yourself giving the speech - confident
    6. Realize people want you to succeed
    7. Don't apologize
    8. Concentrate on the message, not the medium
    9. Turn nervousness into positive energy
    10. Gain experience

Table 6: More Public Speaking Resources

Media Advocacy
Employing public relations tactics is a third important component to community leadership. As in the case of public speaking, very few physicians utilize public relations or media advocacy on a day-to-day basis in clinical practice. However, the community leader understands the importance of publicizing to his or her group's activities and uses the media to recruit support and personnel for the cause. Students should try to build media advocacy into AMSA chapter activities. Work on publicizing upcoming initiatives and celebrating successful events through print, radio, and televised media.

Table 7: Public relations resources to get started:

  • Wallack L, Dorfman L. "Media Advocacy: A Strategy for Advancing Policy and Promoting Health." Health Education Quarterly 23 (1996): 293­317.
  • Sheloy SP. "The Use of Media to Impact on Legislation." Pediatric Annals 24 (1995): 419­420, 422­425.
  • Wallack, Dorfman et al. Media Advocacy and Public Health: Power for Prevention. Thousand Oaks, CA: Sage Publications, 1993.
  • Soden, G. Hook, Spin, Buzz: How to Command Attention, Change Minds, and Influence People. Princeton: Peterson's, 1995.
  • Advocacy Institute: http://www.advocacy.org
  • Midwest Academy: http://www.mindspring.com/~midwestacademy
  • Adbusters: http://www.adbusters.org

How else can physicians-in-training gain these skills? Many medical academicians believe that the optimal learning environment for physicians-in-training allows learners to participate "as real members of the health care team."5 Didactic interactions between attendings, residents, and medical students help solidify learning from patient care activities. Primary care leadership training should similarly involve hands-on learning that is supplemented with formal instruction.

A local public health issue is an excellent platform for primary care physicians-in-training to develop community leadership skills. Interaction with the public health department or county epidemiologist can provide hands-on exposure to community health trends and interventions in progress. Further exploration of public health issues can be conducted in the seminar or classroom setting. Two great resources for public health information are the Public Health Foundation at (202) 898-5600, http://www.phf.org, which has links to state and county health departments, and the American Public Health Association, at (202) 789-5600, http://www.apha.org.

One way that public health interventions can be designed and conducted is through a service-learning curriculum through medical school. Service-learning, which is gaining recognition among university educators, is believed to be an effective way to teach students formal skills in community outreach and leadership. Examples of service-learning

projects include teaching of health education in public schools by medical students at Oregon's Health Sciences University. At the George Washington University in Washington, DC, medical students link up with community agencies to develop health promotion programs. For information on projects that are underway now and information on how to start a project, consult Coalition for Healthier Cities and Communities, at (312) 422-2620 or http://www.healthycommunities.org.

Involvement in outreach simultaneously exercises skills in public health intervention and community leadership. At the Lawrence Family Practice Residency in Massachusetts, residents work in community settings that address teenage pregnancy, substance abuse, tuberculosis, and domestic violence. Supplemental training in community problem-solving is provided. To reinforce and practice community leadership skills, the resident plans and implements a community project that is carried on throughout three years of residency training. This project gives the resident longitudinal experience in running meetings, public speaking, and recruitment and motivation of community participants.

A helpful, comprehensive guide to the community outreach process is Collaborating to Improve Community Health, published by the Healthcare Forum, 425 Market St., 16th floor, San Francisco, CA 94105, (415) 356-4400, http://www.healthforum.com. Another good source is From the Ground Up: A Workbook on Coalition Building and Community Development, available from AHEC/Community Partners, 24 S. Prospect Street, Amherst, MA 01002, (415) 253-4283.

Leadership skills can also be taught in intensive workshops or conferences offered for students, residents, and physicians. The Resident Physician Leadership Symposium, developed by the C. Everett Koop Institute, is an example of a weekend program to teach leadership skills to future physicians. The symposium combines a day's worth of didactic lectures and discussions on graduate medical education issues with interactive sessions in public speaking, influencing public policy, and public speaking. The interactive sessions seek to build residents' leadership skills.

A second example of an intensive conference is the week-long Leadership Training Program, developed by AMSA. The program offers didactic sessions on issues relevant to primary care clinical practice. Leadership skills in team building and team interactions are stressed with daily feedback sessions.

Both of these programs blend two major elements: an educational component built around lectures and discussions, and a practical component in which participants actively develop leadership skills. Most medical students have a wealth of didactic resources at their disposal, but the interactive learning sessions provide a chance to learn and practice skills that are rarely taught or practiced.

A student leader can develop a similar event with both didactic and interactive elements at his or her medical school. In planning for such an event, the leader should consider obtaining funding from the student affairs office, or from the state medical society or pharmaceutical representatives. An event theme based on a specific community need or intervention can be developed, and speakers can be recruited to teach and lead discussions. Leadership building activities --particularly programming that builds skills like facilitating meetings and public speaking--can be conducted by the workshop coordinators. Publicity for the event and recruitment among fellow students should be built into event planning.

The Future for Leadership in Communities
Future generalists should strive for an education that addresses the spectrum of roles a primary care doctor can play. The ideal program to train primary care physicians to become community leaders has multiple components, including longitudinal, hands-on experience in a clinical and community setting, primary care medicine experiences, experience with public health issues, development, implementation and evaluation of community projects, and leadership skills training.

A medical student or resident must play a strong role in his or her own education. Students can learn about leadership skills and techniques through the resources discussed in this Project-in-a-Box. These skills can be taught to other students in short, student-run workshops and conferences to provide a basis for leadership development. Skills can be practiced through ongoing community projects and activities coordinated by medical student organizations.

Sustained knowledge and leadership skills will come only through longitudinal training. This means that the most effective curricula will be established within medical schools, either from medical students and residents planning and implementing leadership training programs or from curriculum committees stepping forth to train future physician leaders.

Schools can practice a service-learning curriculum, designing ambulatory rotations or primary care preceptorships with community leadership training and experiences to introduce future generalists to community leadership skills. Only such broad training can ensure that today's physicians-in-training become tomorrow's community leaders.

Table 8: Leadership Books: Where to Start

  • Bennis, W. On Becoming a Leader.
  • Cohen, E, and Tichy, N. The Leadership Engine: How Winning Companies Build Leaders at Every Level
  • Covey, SR. Seven Habits of Highly Effective People.
  • Lipman-Blumen, J. Connective Edge: Leading in an Interdependent World.
  • O'Toole, J. Value-based Leadership: Leading Change.
  • Tuchman, B. The March of Folly

Check out the BookWatch, a Web site that lists and reviews hundreds of books on leadership, at http://webtrax.com.au/BB/ListS.bbp

References

  1. Cohen, E, and Tichy, N. The Heart of Leadership.Healthcare Forum: http://www.healthforum.com
  2. Resources for Leadership and Organizational Development, Student organizational development center, University of Michigan.
  3. Big Dog's Leadership Page: http://www.nwlink.com/~donclark/leader/leader.html
  4. University of Nebraska student leadership page: http://www.unomaha.edu/~wwwsold/index.htm
  5. Bowen JL, et al. "Defining and EvaluatingQuality for Ambulatory Care Education Programs." Academic Medicine 72 (1997): 506­510.
 

 
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