Highlighting theoretical underpinnings of leadership will encourage and stimulate our collective thoughts on how they may promote leadership study in our profession.
At Physician Leadership Journal, we aim to publish some of the most progressive bodies of work that inform our evolving profession and provide evidence of the unique contributions that physician leaders bring to patients and populations.
While physician leaders have been influencing healthcare for decades, empirical data supporting their unique contributions are still lagging. Fortunately, a large body of leadership knowledge has been created outside the physician realm. The theoretical underpinnings of this body of knowledge can also be applied to study physician leadership as our profession advances.
Highlighting a few of these theoretical underpinnings will, I hope, encourage and stimulate our collective thoughts on how they may promote leadership study in our profession.
Relevant Leadership Theories
During the past century, leadership has been extensively studied across industries. While there are many definitions of leadership, Gardner defined leadership as “the process of persuasion or example by which an individual or team induces a group to pursue objectives held by the leader or shared by the leader and his or her followers” (Gardner, 1990).
Each leader has their own unique approach to work, grounded in family, lifestyle, socioeconomic status, education, and experiences, personal and professional. Many of the personal characteristics cited as essential for successful leadership are rooted in the individual’s development from early childhood through adolescence and adulthood (Fitzimmons and Callan, 2016) and depend on the socioenvironmental contexts in which they were raised (Brofenbrenner, 2009).
According to Gardner (1990), characteristics like decisiveness, people skills, and courage differentiate leaders; however, a host of additional traits and characteristics that also may be relevant to leadership success often are not highlighted. Further, inherent characteristics drive leadership behaviors that ultimately result in attaining leadership positions like medical director, chief medical officer, or chief executive officer.
Physicians and non-physicians alike may share leadership traits and behaviors, so the presence or absence of these attributes cannot alone explain the imbalance of physicians and non-physicians in leadership positions. Hence, there must be other important characteristics innate to physicians’ experiences that distinguish them as effective leaders.
Two theoretical examples provided here represent foundations with which to further study this notion of physician leadership.
Role theory has its origins in the last century and suggests that individuals are prescribed specific roles based on societal beliefs. These roles govern their behaviors and attitudes during their leadership development (Van der Horst, 2016). Over time, this theory, particularly as it relates to physician leaders, has become less structural than interactional, recognizing that people often integrate multiple roles, physician and leader, and can adapt these combined roles as they interact with others.
As physicians evolve as leaders, role theory provides an important theoretical backdrop because it suggests that certain attitudes and behaviors that we develop as we mature in our medical profession may also be important for leadership. From a contemporary perspective, while role-based biases may still exist at the societal level, how we educate and train physician leaders in a more interactional way may be relevant to enhancing a leader’s outcomes, which are the benchmarks for evaluation and success.
Role theory proposes that expectations are associated with the role as a physician and those expectations correspond to stereotypes that are important to consider, particularly as physicians take on additional leadership roles beyond healthcare.
For example, the 117th Congress includes 4 physicians in the Senate, 14 physicians in the House, plus 5 dentists, a number which far exceeds the two physicians who served in the 101st Congress in 1990. When physicians take on roles that are considered nontraditional for their profession, such as politician, they must break through the social stereotypes. This is often a double-edged sword, however. When physicians in political leadership roles demonstrate characteristics that are perceived to be inconsistent with the physician role that society ascribes to them, they could be criticized for breaking with societal norms.
Similarly, if a physician demonstrates characteristics that are typically less political in their characterization, such as listening intently, speaking softly, or looking toward teamwork and collaboration to solve problems, they be may perceived as too much of a physician and incapable of achieving political goals.
These biases highlight the important influence of role theory in studying physician leadership because these biases are based on the powerful perspective that society has of all physicians regardless of the additional roles they may take on.
Upper Echelon Theory
In 1984, based on the lack of a comprehensive framework to understand why organizations act as they do, Hambrick and Mason (1984) developed a model entitled upper echelon theory (UET) to link the overall strategic choices organizations make to the values and cognitive bases of their leadership.
This theory suggests that leaders’ background traits or personal characteristics impact organizational decisions, performance levels, and outcomes. The theory also proposes that leaders tend to rely on their personal traits and behaviors, which have been developed and conditioned over time, to make more complex decisions, such as prioritizing strategic initiatives. This theory proposes that strategic decisions and operational effectiveness require an appreciation of the demographic, experiential, educational, and psychological characteristics of the senior most members of the team responsible for making those decisions (Hambrick and Mason, 1984).
The rationale underlying the theoretical concept is that leadership teams are unable to fully appreciate all the variables that go into formulating an organizational strategic direction; hence, the lens that the team applies is selective, based on the criteria deemed most important to the team, and interpretive, based on historical constructs of their leader (Hambrick and Mason, 1984).
While Hambrick and Mason in their original work did not explicitly test the role of any specific trait or characteristic, such as being a physician, they did imply that there was a relationship between the traits of top leaders and the strategic choices that a leader makes and hence, the outcomes that result from those choices.
For example, as physicians participate more fully on leadership teams, it may be important to evaluate their ability to contribute to the team’s decision making across a range of domains. A dyadic leadership model where a physician and non-physician leader partner and are responsible for the clinical, operational, and financial outcomes of the assigned service highlights UET’s relevance.
The dyad team represents the upper echelon of the leadership structure for the service. The personal and professional experiences of both dyad members contribute a broader and more complementary set of experiences to a shared mission, vision, values, priorities, and outcomes of the service line.
The use of UET as a theoretical underpinning for guiding physician leadership research may be relevant as one seeks to identify the selective biases, both positive and negative, that may influence the outcomes associated with physician leaders.
As physician leadership continues to mature as a profession, empirical data generated through research that helps to identify the leadership contributions of physician leaders is necessary and important. A framework for studying these contributions depends on the numerous theories that may have relevance in creating a conceptual model that guides the research.
Role theory and upper echelon theory represent examples of leadership theories that may have relevance as we build conceptual models in research to study physician leadership contributions within and beyond healthcare.
Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge. MA.: Harvard University Press;2009.
Fitzimmons TW, Callan, VJ. Applying a Capital Perspective to Explain Continued Gender Inequality in the C-Suite. The Leadership Quarterly. 2006;27(3):354–370.
Gardner J. On Leadership. New York, NY: The Free Press;1990.
Hambrick D, Mason P. Upper Echelons: The Organization as a Reflection of Its Top Managers. The Academy of Management Review. 1984;9(2):193–206.
Van de Horst M. Role Theory. In: Sociology. Oxford Bibliographies. Oxford, UK: Oxford University Press; 2016.