By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The fact that we have the term “servant leadership” means to me that the definition of leadership is broken. To lead is to have a service orientation.”

–Stephen Shedletzky, author of Speak Up Culture

Job interviews for leadership positions often include the question, “what is your leadership style?” How does one answer such a question? Formal leadership training programs invariably include content on leadership styles which have been described and analyzed over the last few decades.

Before considering these, I will digress and note that there are centuries of writings in non-western cultures examining leadership frameworks with roots in the different cultural values in other societies. Descriptions of leadership are all frameworks that may ring true for some cultural and organizational settings, but are dependent on the place, time and mindset of the leaders being considered. This is an area of great interest to those working in companies with a multinational workforce. An excellent review article on this topic was written in 2019 by Vietnamese education scholar Nhung-Binh Ly.

The English-language leadership literature collectively includes more than 20 different leadership styles, although several are similar enough to be grouped together. Most authors select three to eight styles and describe these in more digestible comparisons. Here is a list of leadership styles that might apply to leaders of clinicians based in California:

1. Top-down Leadership: Autocratic, Authoritarian, Bureaucratic, Coercive, and Commanding

These styles are more common (but not universal) in military, veterans administration, and large, bureaucratic organizations. In these cases, leaders make decisions themselves with little input from anyone else. This works best if the leader’s knowledge and experience is much greater than that of their followers, when decisiveness is critical (such as emergency settings), and when following a hierarchy or dogma is highly valued. Downsides include stifling of innovation and feedback and disengaging of employees. In a setting of clinician shortages where clinicians are free to change jobs, this will lead to turnover in staff. Several years ago, a medical school classmate of mine had an autocratic leader of a community health center in Washington state; the entire clinical staff quit simultaneously.

Turnover is less likely when there is a significant penalty for a clinician to leave a position, such as a military enlistment contract, restrictions associated with immigrant visa status, a requirement to pay back a sizable advance or loan, or loss of large retirement benefits (sometimes called golden handcuffs). There is a cost to such binding covenants: those who stay in a position unwillingly will often be less efficient and empathetic towards patients.

2. Minimal Oversight: Laissez-faire, Delegative, or Absentee Leadership

These “hands-off” approaches assume that each clinician has their own way of practicing medicine and organizing their work which can be allowed to exist without interference. Many clinicians are partial to bosses who have this approach, feeling that their autonomy and expertise are being honored and respected. This comes with a cost, however: wide variation in practice styles leads to lower office productivity and office staff dissatisfaction associated with the mental gymnastics of meeting many different individual clinicians’ idiosyncratic “rules.” Similarly, improving quality of care across a practice requires standardization of processes, which is difficult in a delegative leadership environment.

3. Bottom-Up Leadership: Participative, Consensus-based, Collaborative and Democratic

Inspired by the ideals of egalitarianism, in these leadership styles, team members are encouraged to work together and give meaningful input into policies, decisions, and strategic direction. In the absence of consensus, the leader makes the final decision. This approach allows more engagement than the top-down leadership styles, but with more standardization than the minimal oversight styles. Ideally, decisions are made based on facts and quality of arguments presented by participants. In reality, there is often a social hierarchy at play with the participation process, with some participants having more sway than others not just due to the quality of the ideas presented, but by the social standing of each participant, and their desire to influence that social standing. If this social hierarchy is unchecked by a leader who is aware of these factors, the decisions made may be suboptimal.

4. Transactional Leadership

In this leadership style, tangible rewards and punishments are used to achieve goals. In the realm of leading clinicians, the tangible rewards may be financial (e.g. productivity incentives or quality incentives), or non-financial, such as allowing clinicians more flexible schedules or non-clinical administrative roles. Behavioral economic studies show that punishments are twice as effective at eliciting changed behavior than rewards of equivalent value but using punishments on individual clinicians often leads to turnover, so it is less likely to be useful in a setting of clinician scarcity.

5. Evangelical Leadership: Visionary, Charismatic, and Pacesetter

These focus on the leader themselves convincingly connecting the clinician work to a larger cause. Visionary leaders focus on the future state of the organization, and may or may not be able to connect that vision with the operational steps and staff motivation needed achieve that vision. Charismatic leaders tap into the human-mirror neuron system, building an unconscious desire to please the leader. Pacesetting leadership involves a hard-driving leader pushing followers to ever higher levels of excellence with no tolerance for mediocre effort or results.

6. Positive Leadership: Affiliative, Coaching, and Servant

These are hands-on styles that seek to promote longevity and performance by being supportive of clinicians. There are some important differences in the three subtypes. Affiliative leaders seek to create emotional bonds with followers, which can lead to hesitancy to have difficult conversations about performance and lack of feedback to leaders about organizational challenges. Coaching is important for new clinicians, but experienced clinicians may not see their boss as having the experience to be worthy of being a coach. Servant leaders attend to the needs of their high-performing staff, yet can give constructive feedback and have difficult conversations. Servant leadership was first described in 1970 in an essay by Robert Greenleaf, and many books have subsequently described and celebrated it. It has become so popular that author Stephen Shedletzgy implies in the quote above that all effective leaders are servant leaders.

7. Integrating Leadership: Adaptive, Situational, and Transformational

In real life, clinician leaders use elements of several of the above leadership styles, depending on the situation and the characteristics of the clinician they are supervising. Having an awareness of the usefulness and limitations of each style can help a leader of clinicians choose the best leadership style for a given situation. Transformational leaders use the best elements of several of the earlier leadership styles simultaneously, conveying the vision effectively, taking input from the team, using charisma to build trust and buy-in, while serving their employees and setting an expectation of excellence.

Returning to the quote by Stephen Shedletzgy, does all leadership require a service orientation? Not necessarily, although effective clinical leaders are more likely to choose to leverage a servant leadership style, much of the time.

I close with two questions for clinician leaders to reflect upon:
•   Which leadership style do you most see yourself using?
•   Which leadership style do you want to strive to use more often?