Junior Doctor Journal

ISSUE 1 | DECEMBER 2011
VICTORIA ISSUE
Australian Junior
Doctor Journal
The Leadership Issue
Australian Junior Doctor Journal Australian Junior Doctor Journal
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CONTENTS
Editorial
Welcome to this rst edition of the Australia
Junior Doctor Journal. The broad aim of the
publication is to involve, inform and inspire junior
doctors about a wide range of issues affecting
life as a doctor and healthcare in general. It is
hoped that the Review will promote thoughtful
discussion and debate within the junior doctor
community.
This inaugural publication focuses on the
topical and important theme of leadership.
A denition of leadership is both elusive and
contentious. Leadership is personal and should
be continually challenged; therefore, denitions
of leadership will evolve. A particularly visionary
denition comes from Alan Keith, who states that
leadership is ultimately about creating a way
for people to contribute to making something
extraordinary happen.
At a time of uncertainty and great challenge, the
need for leadership in healthcare across all levels
is unprecedented. It is increasingly recognised
that junior doctors are well placed to make a
valuable contribution to the future direction of
the healthcare system in which they function.
Were excited to bring you a great selection of
thoughtful, thought-provoking and inspirational
articles from a diverse range of healthcare
professionals.
The publication would not have been possible
without the help of our sponsors and advertisers
and we acknowledge their contributions.
What is truer than the truth? Answer: A Story.
We hope and trust that you will enjoy the stories
shared in these articles and draw on them to
create inspiring stories of your own.
Dr Karina McHardy - Editor in Chief
CONTACT US [email protected]
1 Calling all leaders:
Your (health) world needs you!
3 Clinicians in Hospital Management:
The need and their role
6 Medical Leaders
8 JMOs as leaders of change
10 Leadership with a small i
12 The Junior Doctor
Dening our Future Leaders
16 JMOs as Functional Leaders
19 RACMA Leadership
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1 December 2011
Australian Junior Doctor Journal
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If we are to improve our healthcare systems and
the health outcomes of our communities, and if
this progress is to be sustained in the context of
an ever-changing world, there must be a strong
drive for effective global health leadership.
Whilst a lot of hands position themselves
prominently up in the air when we discuss the
various problems facing the health sector, there is
often an eerie silence (coupled with some nervous
side-gazing) when the next step i.e. possible
solutions is considered. A recent news item
1

covering the fall out from The Lancet Infectious
Diseases publication on the discovery of the
new superbug (NDM-1) highlighted the shameful
lack of genuine leadership on issues concerning
global health. In such situations, a clear, rational,
consistent, politically neutral and authoritative
voice is essential. Yet this voice is virtually absent.
So, to whom are we listening?
There is much power (and
responsibility) up for grabs, but
it seems that no one wants it.
How can this possibly be, and
what can be done to inspire the
emergence and continuation
of authentic leadership in the
global health arena? How can we
take away some of the chairs and
instead force talent to its feet?
Brain power is not the issue: there are numerous
frighteningly clever individuals working in this
area. Resources will always be a concern it
is highly unlikely that we will ever practice in
an environment that oozes a surplus of, well,
anything we really need. But, that said, this
is an area that gets a lot of attention. To use
the UK as an example, although there is an
1. http://www.channel4.com/news/drug-resistant-superbug-threatens-uk-hospitals
Dr Karina McHardy
Global Health Tutor and DPhil Candidate
University of Oxford
involved in an adverse outcome,
complaint or claim? what should I do?
1. dont panic!
Becoming involved in an adverse outcome complaint or claim is more common than you think and it will
happen at some stage of your career. What is important is how well you manage the situation.
2. protect your interests
If you receive or are served with a writ (formal litigation) or receive a letter of demand, immediately contact
your Medical Defence Organisation (MDO) immediately.
3. be honest and open with your communications
If your patient has an unexpected or adverse outcome, you have a responsibility

s RECOGNISE WHAT HAS OCCURRED
s ACT IMMEDIATELY TO RECTIFY THE PROBLEM n SO SEEK ASSISTANCE AND ADVICE
s EXPLAIN EVERYTHING TO YOUR PATIENTS AS PROMPTLY AS POSSIBLE IN RELATION TO WHAT HAS HAPPENED AND THE
anticipated consequences
s ACKNOWLEDGE ANY PATIENT DISTRESS AND PROVIDE APPROPRIATE SUPPORT
4. contact your MDO
following an unexpected or adverse outcome to notify them of the incident. Failure to do so may prejudice
your cover. Remember they are there to help you.
5. comply
with any relevant policies, procedures or reporting requirements that your employer or practice might require
and ensure patients have access to information about the process available to them to make a complaint
e.g. relevant health care complaints commissions or the Medical Board.
6. complaints
should always be taken seriously and addressed professionally however trivial they may seem. Be empathetic
and dont be defensive. Acknowledge concerns and agree on the next step.
7. apologise, but be careful not to admit liability.
be sure to apologise, but beware not to admit liability before speaking with your MDO and your employer to
protect yourself
8. ensure that medical care continues
IF IT IS NOT YOU ASSIST TO FACILITATETRANSFER CONTINUITY OF CARE INCLUDING TRANSFER OF MEDICAL RECORDS
9. act quickly
never dwell on receipt of a writ, claim or complaint. Always get the advice of your employer, MDO or mentor
who will guide you through this difcult period.
Medical Indemnity Protection Society
p. 1800 061 113][email protected]]www.mips.com.au
CALLING ALL LEADERS:
YOUR (HEALTH) WORLD NEEDS YOU!
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almost unfathomable level of national debt and
despite the announcement of unprecedented
cuts in public spending, the current Coalition
government has spared both healthcare and
international development aid spending. It is
not a stretch to realise that these are signicant
decisions that send an unambiguous message
about where current priorities lie. Additionally,
all things considered, the global health
resource situation is not that dire. Those Gates,
together with other individuals/philanthropists,
associations, national and multi-lateral
organisations have changed and continue to
change our perception around what we have
access to and what can be done in this eld.
When we also consider that weve actually got a
decent amount of existing reliable information to
work with in the form of good quality evidence
that often stems from multiple international
settings (therefore widening the research base)
and that has been produced over time (kindly
providing us with some valid longitudinal trends)
- our access to broader resource looks ever
more promising.
So, when we peer into our global health lunch
box, we nd a hearty portion of piping hot
smarts and a delicious side of freshly squeezed
knowledge. There is even some moreish cash for
dessert. So far, so good. But, though these are all
satisfying, we need something else.
We need effective leadership.
We need people who will stand up, stand tall
and communicate the issues to the world -
preferably in an articulate, engaging fashion.
We need people who are not afraid to outline
direction, to establish priorities, to identify where
responsibility lies and to demand and enforce
both transparency and accountability. We need
generous helpings of basic common sense
coupled with enough bravado to think outside
the proverbial square. Oh, and a distinct ability to
detect and then waive all semblance of tolerance
for crap would be good too.
The famous Vince Lombardi quote is true:
Leaders are made, they are not born. As we
invest in global health education and research,
we must also keenly invest in leadership training.
Here, active steps are necessary to secure the
presence of prominent gures at the helm of
this ship. Without this, all of the brains, good
evidence, scal resource and energy currently
seen in this area will be lost for want of direction
a supremely wasteful and tragic outcome. We
must identify and subsequently enthusiastically
throw our weight behind those with passion,
vision and real strategy. Note that this does
not mean those who merely shout warnings, or
even just shout. Let us now commit to giving
individuals with the capacity to enact legitimate,
meaningful change the platform from which they
may do just that.
Our profession, indeed our world needs them.
CLINICIANS IN HOSPITAL
MANAGEMENT:
THE NEED AND THEIR ROLE
The need for clinical management in hospitals
Public sector organisations have become
increasingly managerialised in recent times.
This trend has led to the development of a
relatively specialised public management
workforce which has brought management
behaviours, practices and techniques into the
public sector. The health sector has not been
immune to this trend.
There are multiple factors supporting the need
for clinical involvement in hospital management.
The 1983 Grifth Report called for the
introduction of general management to drive
value for money and accountability within the
United Kingdoms NHS. Moreover, this report
explicitly called for the involvement of doctors in
this management structure. Whilst public hospital
management structures have primarily been
concerned with the operational and nancial
domains and accountability in these areas,
medical professionals have traditionally remained
encapsulated within the clinical domain.
There is evidence to support that a divide has
developed between clinicians and management
within hospital settings and that this has contributed
to decreased performance and potentially also
to decreased quality. The manner in which
management and clinicians derive power and
By Dr Lloyd McCann
Director of Clinical Strategy (EMEA)
Carefx
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inuence within a hospital setting would support
the creation and maintenance of this tension.
Managers generally rely on positional power to
exert inuence, whereas clinicians have relied on
expert and personal power to exert inuence.
One major driver for clinical
management therefore appears
to be improving the relationship
between management and
clinicians to enhance overall
hospital performance.
The concept of moving accountability closer to
the patient is supported by involving clinicians
in management. Clinicians are involved in
making day to day decisions relating to patient
care; therefore the same people should play a
part in making wider management decisions.
The rapidly expanding quality agenda within
healthcare also acts as a driver for increased
clinician involvement in management. Ultimately
clinicians are well placed to link quality and
performance agendas within the hospital setting.
From a clinical point of view, two major
drivers for increasing interest and involvement
in management activities are: (1) a lack of
understanding and subsequently a lack of regard
for general management; and (2) the need to
maintain autonomy as medical professionals by
exerting some inuence in this sphere.
The nature of the role of clinician managers
The role of a general manager in the acute
hospital setting is multi-factorial and spans
across a variety of domains.
Factors inuencing the involvement of clinicians
in management will be explored later, however it
is appropriate to note at this point that clinicians
do not generally receive formal management
training prior to undertaking management roles.
Therefore, this current model immediately
implies that a clinician manager, without further
specialised training, may not have the knowledge
and skills to perform all the required roles of a
general manager.
Within the hospital setting clinician managers do
full some roles of a true manager or leader. There
is however a wide range of evidence to suggest
that clinician managers would full the role of a
gurehead, rather than a true leadership role.
On the international scene, multiple reviews have
shown that many clinician managers can perceive
their role as a leader in title rather than a true
leader per se and that decision-making in these
peer groups is largely guided by consensus.
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In terms of the decisional category, the
evidence tells us that clinician managers have
a limited function within this area. Anecdotally,
clinician managers have the ability to resolve
disputes and performance manage within their
professional area, but have been reluctant
to involve themselves in inter-professional
conicts and issues. Furthermore, despite an
apparent situation of nancial control, many
clinician managers still feel that they do not
truly control budgets and have an inuence on
bottom-line decisions. A contributing factor
may be that, ultimately, budgets are largely
centrally retained in the provider setting, despite
the fact that accountability for nances does
appear to be devolved to a local level. Finally,
clinician managers ability to contribute to
entrepreneurial strategy appears limited due
to a perceived lack of education, skills and
understanding within this area.
On a more positive note, the role of clinician
managers can be viewed as a boundary
or bridging position between medical
professionals and management. By virtue of
their position, clinician managers are able to
participate in both management and clinical
activities. The clinician manager role therefore
spans across the entire spectrum of activities
within the hospital. These activities can
broadly be broken down into the provision
of healthcare (clinical activities) and the
management of the organisation (hospital
management activities).
Clinician managers may not take part in the
full spectrum of management roles within
the hospital, however they still have greater
access to information, meetings and input
into decision-making. Clinician managers are
able to bring the clinical perspective to the
management table and are in a position to take
management practices and thinking back to
the clinical environment. This places clinician
managers in a commanding position, given that
they can use expert, personal and positional
power to exert inuence within an organisation.
7 December 2011 December 2011 6
patient care still have a duty of care to the patients
within their health service, and that they must
ensure the effective and competent delivery of
health services by clinical staff for whom they are
responsible or associated.
In Australian and New Zealand it is the Royal
Australasian College of Medical Administrators
(RACMA) which is the recognised body that denes
competence in medical leadership, providing training
and offering ongoing professional development to
medical practitioners who have moved into clinical
leadership as their chosen medical specialty.
There are a plethora of didactic learning
opportunities that are available to assist
the clinician gain knowledge in the science
of leadership, however the attainment of
competencies in clinical leadership requires
practical workplace based problem focused
learning accompanied by a structured mentoring
programme. It is this practical supervised
experiential programme that RACMA provides.
The College expects the competent medical leader to
be able to:
Articulate a clear vision
Lead teams to drive improvement in service
quality and safety
Engage constructively and effectively with
management and planning functions
Maintain a contemporary knowledge of health
and management issues
Manage a high quality clinical service in an
environment of limited resources
Maintain strong professional and ethical
standards
Encourage and assist with the education and
research activities in health
Fellowship with RACMA offers specialist registration
in medical administration with the Medical Board of
Australia and the Medical Council of New Zealand.
Medical leaders are an integral and vital part
of an effective health service. While mainly
engaged within health service delivery
organisations, they are also critical to the
formulation of effective health policy,
governance of clinical practice, health service
purchasing and the monitoring and reporting of
health outcomes.
While not directly involved in the diagnosis and
treatment of patients, it is the clinical skills and
knowledge inherent in medical training that
separate medical administrators from health
service executives. In making day to day decisions
in health service management, the medical leader
is applying their clinical knowledge to assess the
impact, risk and clinical outcome of decisions.
It is the role of the medical leader to apply
clinical medicine to the development of policy,
strategy, service design, behaviour change and
determining effective clinical outcomes.
The focus, orientation and language of the clinician
are very divergent from that of the health service
manager or executive. Yet for a health service
to function effectively and efciently, these two
groups must work collaboratively. It is the role of the
medical leader to bridge this gap in orientation and
interpret the impact of change across the divide.
To be an effective clinical leader a doctor must
possess a range of skills and competencies that are
not taught at medical school. This body of knowledge
should include an understanding of health law,
health economics, health care nancing, health care
organisation, human resource management and the
management of change in a complex organisation.
Unless a clinician is uent in the language of
executive management they face a very real risk
of frustration and marginalisation from strategic
decision making.
The Bristol Royal Inrmary enquiry reinforced the
principal that practitioners working outside direct
MEDICAL LEADERS
CLINICIAN
M
E
D
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C
A
L

L
E
A
D
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HEALTH
EXECUTIVE
Patient Focus Service Orientation
Clinical Outcomes Fiscal Outcomes
Patient Safety
Organisational Risk
and Assurance
Clinician
Performance
Organisational
Performance
Risk of Harm to
patient
Media and
Reputational Risk
Patient Need Ministerial Priorities
Evidence Based
Practice
High performing, peer
organisations
New Technology Facility maintenance
Patient Satisfaction
Data collection and
reporting
To be an eective clinical leader
a doctor must possess a range of
skills and competencies that are not
taught at medical school.
This body of knowledge should
include an understanding of health
law, health economics, health care
nancing, health care organisation,
human resource management and
the management of change in a
complex organisation.
Dr David Rankin
Senior Advisor
Child, Youth and Family
I have since reected on the process and
thought about what I could have done better:
Managers and IT people work to budgets and
numbers. I could have calculated the potential
cost saving from an effective list. Six House
Ofcers arriving 15 minutes early every day
to create lists, at a per hour cost of $60 =
$32,850 per year. Im sure this simple gure
would have caught the attention of managers
and provided a compelling argument to
invest a little money required for the lists. It is
shocking to think about the nancial cost of
such a silly and simple process of creating a
patient list. Imagine what could be done with
that money.
There is a well-entrenched hierarchy in
surgical specialties. On reection, I should
have held strong and should not have allowed
the surgeons to impose what were impractical
and ill-considered views. This is difcult,
particularly as they are the gatekeepers to
training programs and write our appraisals.
The purpose of the list should have been
communicated more effectively.
Once the list was implemented, I could
have performed a follow up survey to elicit
feedback on how they could be improved. As I
had moved department, I should have offered
this opportunity to a colleague.
Related to the above point, I should not
have given up when I did. Hospitals can be
bureaucratic beasts and change takes time
and patience.
JMOs are faced with opportunities for
improvement every day. It is easy to accept
the status quo, but this is not good for our
healthcare system. It requires leadership to take
the initiative to improve systems. We are ideally
positioned to do this as we work at the coalface
and hence experience the pain of inefciency
rst-hand.
We should not wait for hospital
management to ask us about how
improvements can be made. We
need to stand up and voice our
opinions for change, and help
push them through.
In the short term this will be a painful process
as hospitals simply dont know how to deal with
JMO-lead initiatives. But, with persistence and
time, managers will learn about the important role
JMOs can play in leading improvements in our
healthcare systems.
At the end of the day all parties need to work
together towards a common goal. It often seems
as if managers dont want to work with us. It is
up to us as JMOs to take the rst step as leaders
of change.
Why do some locums get paid top dollar to
sleep on a quiet night rotation? Why does
every ward have a different set up? Why do
I need seemingly hundreds of passwords to
access computer systems? Hospitals are
peculiar beasts where many things dont
make sense to the mind of an JMO.
One such question troubled me during my
1st year as a House Ofcer. The various
departments in the hospital I was working
seemed to have no channels of communication
between each other. I completed a General
Medicine rotation where my teams patient
list would magically appear at a printer every
morning it was great. My next rotation was
General Surgery where I had to arrive 15 minutes
every morning to create a list by taking screen
shots off a nursing list, pasting into Word,
cropping and then repeating if the list ran over
one computer screen. Everyone agreed that this
was ludicrous, but predictably nothing was
ever done about it.
So, I set out to nd why Gen Surg couldnt simply
copy the Gen Med process.
Mistake #1: assuming that this would be a
simple process!
I had moved onto my next rotation by the
time this ordeal came to its bitter end.
Understandably, I was left bemused and
disheartened by this attempt to improve the
system.
JMOS AS LEADERS OF CHANGE
Dr Manoj Patel
MBCHB, MBA (Harvard Business School)
Management Associate Elsevier
1 . Find the IT department responsible
for developing the Gen Med patient
lists. Incidentally, this department
was not based in the main hospital.
2. Learn that the creation of such a
patient list required a work order.
3. This work order required approval
from the departmental head.
4. Develop and conduct a survey of what
the ideal Gen Surg patient list might
look like
5. Arrange a meeting with the
department head to present the
survey ndings and request the
aforementioned work order.
6. Co-ordinate a meeting between the IT
department and department head.
7. Re-present proposal.
8. Be informed by IT that my proposed
patient list was different from the
Gen Med patient list and hence would
cost a few thousand dollars to
implement
9. The department head thought he knew
best and said we would simply copy
the Gen Med list.
1 0. Despite this, the consultant surgeons
then insisted that their names should
appear in full on the list, together
with their respective titles (e.g.
Associate Professor of Lower GI
Surgery). This column alone took up
one third of the page, therefore leaving
no room for writing notes!
1 1 . The new patient lists eventually
appeared on the wards, but no one
used them because of their poor
layout.
12. All surgical RMOs continued to use
the original copy, past, crop method!
Over a 3-month period this was
the sequence of events that
unfolded:
Australian Junior Doctor Journal
exercised at the level of a ward, clinic, or practice.
Its goal is to create and oversee the local operating
system in which each doctors patients receive their
care. A consultant and a senior nurse on a ward have
such a leadership role. So does a registrar training a
house ofcer, trainee intern, and a medical student; or
a nurse leading a multidisciplinary chronic care team.
Optimising the performance of a small scale operating
system requires both leadership (articulating a vision
and setting direction) and management (assigning
accountabilities and monitoring performance).
An essential leadership task is to frame the clinical
teams work: elevating the staffs perspective from the
immediate activities that consume their day, such as
tests, referrals, and paperwork, to the goals that these
activities are intended to achieve. Clinical care can be
framed as production (execution of highly specied
protocols), problem solving (the search for a unique
solution to the patients problem), or learning (creating
new knowledge from current experience).
Not only is each frame appropriate to a different
setting but each also requires a different operating
system. An emergency doctor who frames the
departments work as stabilise and ship will create
a very different operating system from one who
frames the work as diagnose and initiate denitive
treatment. They will select different policies,
technologies, clinical protocols, and performance
measures and will establish different relations with
the inpatient wards and even different physical
layouts. Hence a clinical leaders second important
task is to help design the operating system in which
their patients are treated, including the mechanisms
by which performance is managed: measurement,
monitoring, and accountability systems. A third task is
to shape the culture that surrounds these structures
and processes. For example, quality and safety
improvement require an environment in which people
feel comfortable sharing unpopular information,
expressing dissent, and admitting mistakes.
Small l leaders perform these tasks by being
and doing. Although much is made of leadership
as being, a leaders actions are also important:
something as simple as a doctors tone of voice has
an important effect on how others will evaluate him or
her. Simple deliberate actionsfor instance, inviting
the input of lower status staff and publicly admitting
your own mistakescan help create a culture that
promotes patient safety.
LEADERSHIP WITH A SMALL I
What exactly do we mean by leadership in
health care? Does it mean to take formal
positions in senior leadership teams in hospitals,
trusts, health boards, ministries of health, and
professional societieswhat might be termed
leadership with a big L? Or does it mean
something ne grained and local leadership
with a small l?
It is tempting to frame the discussion in terms
of the rst, if only because the big issues dealt
with at higher levels in delivery organisations and
governmentsuch as licensure, reimbursement,
malpractice, technology licensing, and working
hoursprofoundly affect the working lives of
so many doctors. But mounting evidence of the
impact of organisations on clinical outcomes is
making the second model of physician leadership
increasingly important. As the growing complexity
of clinical problems is paralleled by increasing
organisational and technical complexity of health
care, medical outcomes have become as much
a function of organisational performance as of
individual doctors skill. Quality and safety failures
are driven by system failures as well as failures of
individual physicians skill and decision making;
and higher performing hospitals are differentiated
by their greater use of organisational interventions,
cultures that support innovation, structures such as
multidisciplinary teams and computerisation, and
highly specied care processes.
Thus for doctors to assure optimal health
outcomes for their patients they now need to
concern themselves with the performance of the
organisation in which these patients receive their
care. From the perspective of an individual doctor
it is the small scale operating system that is most
important in determining health outcomes. This
microsystem is the small group whose members
collaborate to create a clinical outcometheir
information, technology, and physical environments
and the management policies and clinical
processes they follow. Small l leadership is
But perhaps the biggest
impediment is that practising
doctors simply do not think of
themselves as leaders, nor do they
see leadership as vital for the care
of patients.
Richard Bohmer
Senior Lecturer, Harvard Business School
BMJ 2010;340:c483 (Reproduced with permission)
A number of barriers prevent doctors from taking
a greater leadership role: the siloed structure
of delivery organisations, the demands of
clinical practice, and the challenge of managing
autonomous professionals. Moreover, small l
leaders often lack formal authority and control over
resources in their working environments and must
lead by creating consensus, modelling behaviour,
articulating vision, and asking questions. And they
are usually not paid for this work.
But perhaps the biggest impediment is that
practising doctors simply do not think of themselves
as leaders, nor do they see leadership as vital for
the care of patients.
Medical training, in fact, emphasises exactly the
opposite: individual action and accountability.
For most doctors the small l leadership skills
needed to improve the performance of individual
practices, clinics, and wards must be learnt.
Doctors daily work is dened by a collection
of individual activities and transactions; little in
medical and postgraduate training emphasises
the interdependencies between these often
fragmented events, nor the way in which they
are part of a larger system designed to realise a
specic patient outcome. Although some schools
offer joint medical and management training,
most doctors learn little about how complex
organisations work and how they can be made to
work better.
As we call for medical leadership in healthcare
reform, we should not focus solely on big L
leadership and overlook the importance of leading
the micro-systems that have such an effect on care
outcomes. We need for medical and postgraduate
training to prepare doctors to lead at this level. Any
call for leadership should include a call to doctors to
think of their daily work as not only treating individual
patients but also helping create and manage the
small scale operating systems that support their
medical work.
Do you see yourself as a leader? As an intern
attending your rst Code Blue, did you have a
clear understanding of your role and who was
in charge? When faced with an angry patient
attempting to leave against medical advice, did
you improvise and form exible strategies, or
wait for the guidance of others? Leadership is
certainly not easy, but we have chosen to enter
into a profession that necessitates leadership at
various levels of hospital, team and patient care.
When you think of a leader that embodies
greatness and inspiration, who comes to mind?
Muhammad Ali, Mother Teresa and Mahatma
Gandhi all have a unique place in this world, but
also embody critical attributes. They have all
persevered in the face of adversity and display
tremendous moral courage.
Life isnt always easy for a junior doctor. Whilst our
work can be immensely rewarding and meaningful,
we can also encounter anxious and emotional
patients, angry family members and conicts within
the treating team. Medical practice continues
to evolve to become increasingly complex and
team-based in nature. This requires high levels
of coordination and leadership skills. At medical
school we learn many useful skills, but are we
truly prepared for a successful life in the medical
workforce?
Clinical skills are a necessary foundation for a
medical doctor. We cannot hope to be condent
or progress in the workplace without excellent
theoretical knowledge and sound clinical
assessment. However, clinical skills are not enough.
Non-clinical skills such as resource management,
communication, conict resolution and decision-
making are seldom formally taught, yet are equally
important in error management and improving
patient safety. Our role in driving patient care
requires the doctor to act as a leader. This belief is
reected in a recent Australian Medical Association
position statement which supports the emerging
view that doctors value is in their clinical judgement,
diagnostic reasoning and leadership skills
1
.
A great medical leader displays a number of key
attributes. These include: high emotional intelligence;
situational awareness; self awareness; and the
courage to make difcult decisions in the face of
limited information and under high levels of stress.
Interns are not encouraged to make difcult
decisions without appropriate guidance or senior
support. However, as junior doctors transcend into
senior responsibilities throughout their careers,
real-time decision-making and contingency
planning become critical qualities separating
outstanding from acceptable doctors. It is often
difcult to take a step back in stressful clinical
DEFINING OUR FUTURE
LEADERS: THE CHALLENGE
FOR JUNIOR DOCTORS
By Dr Verna Aykanat
HMO II Resident
PMCV JMO Forum Co-Chair
Non-clinical skills such as resource
management, communication,
conict resolution and decision-
making are seldom formally
taught, yet are equally important
in error management and
improving patient safety.
situations and take the
opinions of others into
consideration. However,
this approach allows
valuable opinions
to be heard before
they are obscured or
overshadowed by the
most senior voice.
Sometimes, the most
comforting thing to do in
a tricky situation is to sit
on the fence, but leaders
are required to make
tough calls. As baseballer
Yogi Berra famously
proclaimed, when you
come to a fork in the road,
take it.
CanMeds is an innovative,
competency-based
framework adopted
by the Royal College
of Physicians and Surgeons of Canada in 1996
articulating the competencies required for optimal
patient care and health outcomes. The seven roles
identied are: medical expert; communicator;
collaborator; manager; health care advocate;
scholar; and professional
2
. These roles are
now recognised nationally and internationally
as a benchmark in the art of medicine and
have been adopted by the Australian and New
Zealand College of Anaesthetists for their revised
accredited training program in 2013.
Simulation may have a key role in the education
of leadership skills. Previously, simulation has
been demonstrated to be effective in the training
of procedural skills and in crisis management. It
also has a current role in accredited colleges and
clinical workshops. There is emerging research
into the use of simulation for teaching higher
order clinical reasoning and clinical judgement
skills. However, the simulation of crisis leadership
skills including contingency planning, controlling
ones environment and delegation of roles is a
critical component of training that requires further
development and research validation.
We have discussed the utility of non-clinical
skills in providing optimum patient care, but have
Therefore, as junior doctors we
continue to urge healthcare
providers and key stakeholders to
collaborate on solutions to ensure
that all junior doctors have access
to protected teaching time for both
clinical and non-clinical domains.
We continue to support the existence and further
revision of professional development programs
such as the Postgraduate Medical Council of
Victorias Teaching on the Run program, as well as
the development of new leadership programs, for
which the author would like to welcome input from
you, the reader.
Finally, we need to ensure that this information is
disseminated in a context-appropriate way, such
as via simulation or live workshop to enable the
subtleties and artistry of this information to be
conveyed in its entirety. So whether you hope to
one day be the president of the AMA, director of
surgery at a metropolitan hospital or a rural GP, we
all need to hone the skills of honest self reection
and develop the courage for self improvement to
enable us to achieve our greatest potential in our
professional and personal lives. Only then can we
genuinely be present for those who are struggling,
help lead our colleagues to develop sound moral
and professional codes. Ultimately, we aim to
provide reassurance to our colleagues and the
public that we are deserving and qualied for our
special role in patient care . So ask yourself: What
kind of leader do you want to be?
References
1. Australian Medical Association Doctors in Training. AMA
Position Statement: Role of the Doctor 2011. Apr 2011.
[Available Online: http://ama.com.au/node/6569]
2. Rank JR. The CanMEDS 2005 physician competency
framework. Better standards. Better physicians. Better
care. 2005. Ottawa: The Royal College of Physicians and
Surgeons of Canada
we considered moral
leadership and excellent
bedside manner? What
is the best medium to
convey this information?
After years of books
and lecture notes at
university, junior doctors
value the role of leading
by example by mentors.
This unique insight
is perhaps of most
benet to a junior doctor
and emphasises the
importance of ongoing
support and protected
teaching time for senior
staff in promoting
these educational
opportunities. There is
a further need to train
junior doctors in the skills
of teaching, assessment
and feedback as they embark on their own journey
of mentorship.
Sometimes the best leaders arent the hero of
the day. They do not have to perform the show-
stopping intravenous line when everyone else
struggles for access at a code, or resolve seemingly
impossible logistics in imaging, discharge planning
and theatre schedules. Often, the best leaders take
a step back so that they can critically observe what
is going on around them. Only then will they be
able to offer a hand to a colleague after observing
they are overwhelmed with jobs, or dedicate twenty
minutes of their time to reassure a colleague who
has experienced a traumatic night shift. They
recognise the resident who is starting to display
slight changes in behavior and take the initiative to
ask if they are coping. Sometimes the best leaders
arent obviously apparent, but their unique insight is
testament to why they are invaluable to the team.
As graduating medical student numbers continue
to increase and the training program bottleneck
escalates, it is imperative that we dont ignore the
education gap that lies between medical students
and training registrars: the prevocational years.
Group Dynamics
JMOs are usually thrust into a leadership position.
This may be as the day-to-day leader of a small
medical team, or the chair of an MDT group. Group
dynamics are an important factor in the functional
leadership model.
Every group has specic requirements examples
of these are: cohesion, leadership, principles,
education, a dened role and success. The role of
the leader is to recognise these needs and ensure
that they are met. This is where the rst issue arises
often group needs may be in direct conict with
task needs. Ultimately it falls to the JMO leader to
attempt to balance these needs.
Individual Dynamics
Individuals form the basis of any group or team
- without individuals the achievement of any task
becomes impossible. Individual needs vary from
basic to more specialised (e.g. basic needs such as
food/water/rest versus the need for development
and education). In many group situations, individual
needs are often pushed aside for the benet of the
group and task achievement.
Within the medical setting, basic and more
advanced needs are important. For example, House
Ofcer teaching is something that is mandated and
clearly necessary for personal and professional
development, but this is often in direct tension with
team and task requirements. Again, it falls to the
JMO leader to ensure that balance is maintained,
but also that, where necessary, needs continue to
be prioritised.
When a leader is able to balance task, group and
individual requirements, they can consider themselves
to be in the zone!
A Practical Tool
Now that we are aware of the potential competing needs
JMO leaders must balance, we can focus on applying
a practical tool to lead in our environment. The tool is
based on a New Zealand Army model PICSIE:
These are general steps and provide a process
to follow when approaching a workday/set of
tasks etc. Naturally, we already do plenty of these
things (perhaps subconsciously), but what this
does provide is something to refer back to, in
terms of practical steps that can be applied in a
number of situations.
Planning
This rst step is often overlooked or rushed and
many pay the price later on. Involving your team
in planning and taking time to plan is a great
investment. When your team is involved in planning
there is a higher level of engagement and ownership
the task becomes shared and is therefore more
likely to be achieved. It is imperative during this step
that the leader is clear about the tasks and that
these are expressed with great clarity to ensure
group understanding.
Initiating
Frequently, this involves delegating or
assigning people to perform tasks or
components of a larger task. Never forget that
you are part of the team and can complete
tasks yourself!
Planning
I nitiating
Controlling
Supporting
I nforming
Evaluating
There is ample available literature on leadership
frameworks, leadership styles and leadership
theories. In recent years, the concept of clinical
leadership has come to the forefront within
healthcare systems and healthcare delivery.
Whilst the notion and concept of clinical leadership
remains relatively vague, it is heartening to see that
there has been a return to increasing managerial
responsibility for clinicians. There is also increasing
recognition that clinicians benet from leadership
and managerial training and cannot simply full
leadership roles and management positions based
on clinical credibility alone.
However, a gap remains between clinician
managers, management and leadership training
and the everyday shop-oor leadership required
by clinicians and particularly JMOs.
JMOs will all be thrust into a position of leadership
or coordination at early stages in their careers.
Registrars are expected to competently lead
ward rounds, organise radiology conferences, run
tutorials, chair MDT meetings and lead small teams.
Most learning in these aspects of the JMO role is
learned through osmosis JMOs observe more
senior doctors and other colleagues, including
JMOs, in these roles.
Some medical students and JMOs have the distinct
benet of being involved in student and committee
leadership positions as well as wider positions of
leadership or management through external activities.
This brief article aims to outline some practical
frameworks that JMOs can use in their everyday
work to manage and lead their teams. The
concepts outlined here are all related and based on
Functional Leadership theory.
JMOS AS FUNCTIONAL LEADERS
Functional Dynamics
There are 3 basic components that make-up
the functional leadership framework. Whilst this
is a framework, it provides a realistic view of the
factors anyone in leadership position must attempt
to balance in order to lead successfully (see
functional dynamics diagram).
Adapted from:
http://en.wikipedia.org/wiki/Functional_leadership_model
This framework focuses on how leadership occurs
rather than who is leading. Translated, this speaks
to anyone being able to focus on and exhibit these
behaviours when necessary.
Task Dynamics
Medical work is largely task orientated. The
functional leader must never lose sight of the
task/s to be achieved this has a direct impact on
patient outcomes. This is why many teams will sit
down after a ward-round to conrm the list of jobs
for completion.
In many instances, task needs must be placed
rst in the medical setting as the health outcomes
of our patients rely on investigations being
organised, treatments and procedures being
performed and administrative tasks being
completed. As functional leaders, JMOs must
always have task needs in hand.
By Dr Lloyd McCann
Director of Clinical Strategy (EMEA)
Carefx
FUNCTIONAL DYNAMICS
Task
Team Individual
The Zone
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Controlling
This sounds counter-intuitive - especially
in circles where we tend to operate as
independent practitioners. However, the
leader must maintain control of the task or
situation and ultimately ensure that the group
is moving towards achieving their task. This
relies on communication, seeking feedback on
understanding and progress, and monitoring.
This step is closely linked to supporting.
Supporting
Whilst maintaining control, the leader must make
certain that team members feel supported and are
comfortable with what they must achieve.
Informing
This involves ensuring that the team is aware of
any potential changes in the situation or actual
changes in the task. It is imperative that the leader
provides information and feedback to their team in
a timely manner.
Evaluating
This step is critical and is often overlooked.
The leader must evaluate individual and team
performance to allow for improvement and the
identication of strengths and weaknesses. This
step allows for individual and team development
and ultimately contributes to a teams overall
effectiveness. Here, both real-time and
retrospective evaluations have a place within
this cycle.
So, in a nutshell, there you have it. The more you
think about the functional dynamics and apply the
steps to situations, there more natural it becomes.
Remember that this approach focuses on how to
lead and does not rely on integral qualities or styles
of a leader. Yes, it is important that we are authentic
and apply appropriate styles and behaviours, but
this outline provides a good basis whereby JMOs
can function as leaders in everyday situations.

RACMA LEADERSHIP
Effective medical leadership is recognised as
essential for improving the performance of
health services and enhancing the wellbeing of
patients and the quality of outcomes. A growing
body of literature has also argued that medical
leadership plays an integral part in the success
and effectiveness of organisational change in
the health sector (Ham, 2003).
This is largely because medical practitioners in the
health sector are often viewed as having greater
control over decisions than workers in other areas.
Medical practitioners are more likely to be inuenced
and persuaded by medical leaders to bring about
positive change because they believe they have
walked a mile in their colleagues shoes and view
them as more reliant, trustworthy, and credible.
It has been suggested that medical leaders run
organisations; they dene what the future should
look like, align people with that vision and inspire
them to make it happen despite the obstacles. In
other words, medical leaders engage people who
are difcult to engage, serve as role models for their
peers, and create an environment in which quality
improvements can thrive. For individuals who are
trained to manage individual cases and guard their
professional autonomy above all else, the effect of
being asked to take on these leadership roles in the
consumer interest is considerable, and not often
acknowledged.
Being an eective medical leader
clearly requires a dierent set of
skills from being a good clinician
(Reinersten, 1998).
It is therefore important that medical leaders
are supported and equipped with the high-
level skills required for their role (e.g. leading
and developing multidisciplinary teams,
understanding organisational systems, processes
and interdependencies, redesigning services
and working collaboratively with a wide range
of stakeholders). Indeed, reviews of medical
programs have found that individuals who
participate in leadership training are more likely
to feel empowered to inuence the provision of
patient-centred care, develop a greater sense of
self-awareness and condence to initiate positive
change, and promote better team alignment
(Stoller, 2008).
In the UK, the National Health Service established
the Enhancing Engagement in Medical Leadership
Project in response to the publication of Lord
Darzis NHS Next Stage Review nal report in
2008. This UK-wide project aims to stimulate
creation of a culture where doctors seek to be more
engaged in management and leadership of health
services and non-medical leaders genuinely seek
their involvement to improve services for patients.
The Royal Australasian College of Medical
Administrators (RACMA) was formed in September
1963 to train medical practitioners to use both their
clinical training and experience and their specialist
medical management expertise to lead and
inuence health service delivery.
The Colleges education and training programs
are based on the achievement of a range of
competencies adapted from the CanMEDs
framework, developed in 1996 by the Royal College
of Physicians and Surgeons of Canada. The
Medical Leadership and Management Curriculum
focuses on the specic competencies needed for
medical management and leadership practice.
These competencies are organised around
the seven CanMEDS roles. For the College the
central role is that of Medical Leader based on the
foundation of medical expertise and supported by
competencies embedded in the CanMEDS roles
of Communicator, Collaborator, Health Advocate,
Manager, Scholar and Professional.
Dr Karen Owen
Chief Executive RACMA
1300 889 133
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Webb (2009) looked at the performance of
medically qualied health service executives
working as chief executives, directors of medical
services or department heads. These specialist
medical managers were involved in a broad
range of activities crucial to sustainable health
care delivery and had a direct and immediate
effect on the quality and safety of patient care in
Australian and New Zealand hospitals. Gruner and
Boyd (2006) refer to the inuence that specialist
medical managers have on medical staff based
on their medical expertise. This inuence was
acknowledged by non-medical managers and
was lauded as being instrumental in implementing
successful and cost-effective change.
RACMA is one of a few medical colleges in the
world accredited to offer Medical Administration
as a specialty. While many undergraduate and
postgraduate medical curricula contain elements of
medical leadership these do not equip graduates
with adequate skills, knowledge and experience to
be safe and effective medical managers.
References
Gruner, L and Boyd, R (2006), Factors affecting recruitment
and retention of medical managers in Australian Hospitals,
RACMA Report
Ham, C (2003), Improving the performance of health services:
The role of clinical leadership, Lancet 361:1978- 1980
Mountford, J and Webb, C (February 2009), When Clinicians
Lead, McKinsey Quarterly
National Health Service (NHS) UK, Department of Health
(2008), High Quality Care for All. Also known as the Darzi
report, see www.nhshistory.com/darzinal.pdf.
National Health Service (NHS) UK, Institute for Innovation
and Improvement (2010), Enhancing Engagement in Medical
Leadership Project. See: www.institute.nhs.uk/building_
capability/enhancing_engagement/enhancing_engagement_
in_medical_leadership.html
Reinersten, L J (1998), Physicians as leaders in the
improvement of health care systems. Annals of Internal
Medicine, 128:833-838
Stoller, K J (2008), Developing physician-leaders: Key
competencies and available programs. The Journal of Health
Administration Education 25(4):307-328
The Royal College of Physicians and Surgeons of Canada,
(2005), The CanMEDS 2005 Physician Competency
Framework, Better Standards. Better Physicians. Better Care,
(J.R. Frank, ed.) This replaces the previous version Skills for the
New Millennium (1996)
Using their skill and leadership role the specialist
medical manager draws on a combination of clinical
and management competencies, to form a bridge
between the needs of doctors, other clinicians,
government and business to achieve the operational
needs of health services and deliver safe patient
care outcomes. The integration of medical and
management knowledge enables the medical
administrator to work through others to accomplish
complex outcomes while simultaneously being
accountable and accepting responsibility for medical
services outcomes. While medical management is
not directly involved in the diagnosis and treatment
of patients, the medical manager brings to decisions
a medical lens through which they are able to view
decisions and emerging issues. It is the application
of this medical lens that distinguishes medical
management as a specialty.
Professional medical managers take a global
view of health service delivery and the pathway
to improvement. What they need to know in a
particular specialty, they can absorb quickly
from their medical specialist colleagues to
gain an understanding of what is important in
moving health care forward. This often involves
understanding, absorbing and analysing
information from a variety of specialties
simultaneously to make a decision to benet the
health service or health service delivery as a whole.
Doctors are the most important health service staff
in evaluating new health care interventions and use
of resources.
The empirical evidence supporting the contribution
of the professional medical manager to improved
medical care is primarily qualitative. An analysis
of qualitative case studies by Mountford and
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ISSUE 1 | DECEMBER 2011

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