







































Children and Teenagers 
ISSN 2576-3709 (Print) ISSN 2576-3717 (Online) 

Vol. 2, No. 1, 2019 
www.scholink.org/ojs/index.php/ct 

1 
 

Original Paper 

Successful Leadership in Medicine 

Anthony A. Zehetner1, 2* 

1 Adolescent Medicine Unit, the Children’s Hospital at Westmead, Sydney, Australia 
2 Faculty of Medicine and Health, the University of Sydney School of Medicine, Sydney, Australia 
* Anthony A. Zehetner, Faculty of Medicine and Health, the University of Sydney School of Medicine, 

Sydney, Australia 

 

Received: January 6, 2019    Accepted: January 20, 2019    Online Published: January 28, 2019 

doi:10.22158/ct.v2n1p1                         URL: http://dx.doi.org/10.22158/ct.v2n1p1 

 

Abstract 

Leaders remain as visible, influential and controversial in today’s society and media as ever. 

Twenty-first century doctors are called to be inherent leaders, dependent and determined by their 

surrounding team of staff, organizational hierarchy and health care system structure. This paper 

examines today’s clinician as leader: through differing leadership styles, workplaces, function, how 

they relate to (and are constrained by) the practice of medicine under the Australian health care system 

and asks what makes a good medical leader. The unique setting of General Practice and a woman’s 

perspective are also considered. Sections on Medical Leadership’s Contribution to Change, Risk-taking 

and Tolerating Chaos cover the concepts of unpredictability in medicine and if and how doctors as 

medical leaders attempt to cope with this eventuality. Each assertion raised is supported by current 

business and medical literature referenced data. The reader is encouraged to ponder their own 

workplace committee practices, leadership style and consider areas which they may wish to address 

and improve upon. 

Keywords 

leadership, workplace, risk, change, bureaucracy, transformation, protocol, organization, clinical 

governance 

 

 

 

 

 

 

 



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1. Introduction 

Doctors in the twenty-first century are no longer solely clinicians. They are teachers, researchers, 

advocates, managers, employers, administrators and, most importantly, leaders. Leaders are 

increasingly visible in today’s society, on social media and in the news. Historically and now, they 

remain influential and controversial. Though what makes a good leader and particularly in the field of 

medicine? 

The nature of modern medicine in Australia, where practitioners manage a patient’s health in 

collaboration with one another, necessitates and defines a bureaucratic leadership model. Patients are 

not treated in a vacuum or in isolation. The General Practitioner (GP) coordinates allied health services 

and provides primary care. The subspecialist (secondary tier level of care) relies on referrals from the 

GP to see patients. Hospitals (predominantly university teaching tertiary care sites) refer the patient 

back to local community health services and their GP once treatment is completed.  

Each workplace operates under different environmental conditions and a leader is required to adapt any 

prevailing systemic processes suitably and logistically. To maintain advantage, the organization must 

have unique qualities (chiefly their staff’s skills) which differentiate it from its competitors. The 

effective leader is able to recognize and nurture these. This co-dependent leader-follower relationship 

ensures the organization’s viability and longevity. A strong leader knows their organization’s SWOTs 

(Strengths, Weaknesses, Opportunities and Threats) (Souba, 2000). This aspect of leadership is not 

unique to medicine but vital to its success. 

 

2. Method 

Organizations may have many different leaders within them, each with a different leadership style. 

Bureaucratic leaders with a directed-management approach (Marshall et al., 2003) are most likely to 

succeed in medicine practiced within a hospital-setting. They are able to liaise with multiple 

departments, coordinate their operation, possess agency and meet outcomes, such as Key Performance 

Indicators (KPIs), within fixed resource and budgetary constraints.  

Bureaucratic leaders tend to operate “by the book”, so staff are comfortable with their leadership style 

and know what to expect. However there may be few new changes in the organization’s direction. A 

bureaucratic leader may be a misnomer, because leadership is “by numbers” and protocol (transactional 

leadership). Should there be a precedent, it is referred up the management line for an executive decision. 

This suits a hospital environment as systemic protocols, policies and pathways are embedded in 

workplace culture to maintain safety, operate at a proficient standard (best practice) and routine tasks 

are performed repetitively, consistently and precisely. 

Leaders who adopt democratic or participative styles tend to be seen as more positive (successful), 

though this still assumes that one leadership style is “best”. Certainly this arrangement works well for 



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committee meetings when taking into account different personalities and aligning them to a common 

process. It is less effective consulting staff junior in their roles. This behavioral construct does not take 

into account situational leadership. Clinicians adept at coordinating cardiopulmonary resuscitation in 

the crucible of an Emergency Department may not translate these teamwork skills to the hospital’s 

boardroom. A Nursing Unit Manager may not organize a team of non-nursing staff equally as well. 

Within small private or solitary medical practices, autocratic leaderships tend to flourish. While this 

may prove useful in the context of new and inexperienced staff, it promotes staff becoming dependent 

on their managers and stunts initiative. Over time, autocratic leaders are usually shunned by employees 

as work practices are shaped by negative consequences (less pay or reprimands) and employee input is 

not encouraged. 

Visionary, transformational and charismatic leaders may reinvigorate and motivate any field, including 

medicine. This is usually reserved for large corporate practices as existing clientele (patients) do not 

take kindly to new approaches, which may be considered experimental in their eyes. Quality is linked 

with trust in medicine (Berwick, 2003) and any failed outcomes from unproven new processes can be 

damaging to both traditionalist patients and pressured managers. 

An inflexible, autocratic leader brought into any organization may stifle it if that leader is not cognizant 

of the existing workplace’s culture and needs.  

 

3. Result 

3.1 Why Health Care Leaders and Funding Don’t always Mix 

In Australia, hospitals are funded via the State and outpatient General Practice (Medicare) services 

federally. The total health care budget in Australia is 10.3% of Gross Domestic Product (GDP) with 

two-thirds being derived from government sources and of this, 61% from federal and 39% from state 

funds (Australian Institute of Health and Welfare, 2018). 

The patient population case mix also determines funding rather than absolute numbers. For example, a 

patient undergoing an appendectomy with a history of smoking would receive more funding than one 

without, based upon coding under Diagnostic Related Groups (DRGs) and recently implemented 

Activity Based Funding (ABF). An orthopedic ward with a high turnover of patients may still receive 

less funding than a smaller oncology ward (with less “occasions-of-service”) due to the greater amount 

of comorbidities and treatment complications, even if total patient numbers are higher in the orthopedic 

ward. 

All of these instruments and measures are used to reduce heterogeneity between cases and provide 

effective benchmark comparisons (such as length-of-stay). This is to guide budget and resource 

allocation, optimize patient care (via staffing ratios matched to clinical need) and to predict (and plan 

for) future trends. 



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ABF is less accurate when there is an outlier present to skew results. The long-term ventilated patient 

may increase total length of stay and costs, possibly leading to a financial loss in the immediate term 

but an excess monetary gain in future if the budget is summarily increased but a second “outlier” 

doesn’t then arrive. 

If tertiary hospital A specializes in a specific procedure (e.g., organ transplant), it will attract funding 

dedicated to that specialty in the health budget, and away from hospital B, which does not perform that 

procedure. However, should hospital B wish to establish performing the procedure, resistance may be 

met? This may be because hospital B may be underfunded and cannot provide cost-effective resources 

to provide the new service, as it has not been budgeted for this in the past. There may also be resistance 

from hospital which may be unwilling or unable to relinquish funding, or fear an exodus of trained staff 

to hospital B. 

These cross-divisions and potential lateral tiers of management add another level of complexity to 

current hospital funding. There is a potential disincentive for hospitals to provide greater clinical 

services—does creating a service actually increase demand and potentially unhappy clientele who now 

have to wait for something they wouldn’t previously have been offered? As progress occurs in 

medicine, does availability become the new gold standard of care and thus best practice? If so, savings 

have to be found and the pie of resources carved up into ever smaller slices. 

By changing a reimbursable service from a hospital to a community general practice setting (state to 

federal funding), may result in savings from one sector (here the state health budget) to an increased 

deficit in another (here the federal health budget); while the total national health care expenditure 

remains the same. 

Individuals and departments which are able to make efficient use of their budgets and resources are 

currently stripped away of their “excess” funding and are expected to fulfill the same outcomes in the 

next financial year using this new, smaller budget. This conflict of interest makes a department 

disinclined to save money and operate efficiently. In effect, proficient departments are penalized and 

inefficient ones rewarded! 

Preventative health care also fares poorly under this arrangement. This field deals with potential (or 

virtual) inpatients. Illness prevention campaigns usually require several years to become established 

and beneficial effects on illness rates may take years to be seen (for example, the reduction in 

melanoma incidence with increased sun protection initiatives). Unfortunately the health budget is 

finalized each year and governments can rarely plan for a term in office beyond four years. 

“Fashionable” illnesses in the public limelight of advocacy groups (such as breast cancer, childhood 

cancer and mental health) are also very visible on a political agenda (Australian Institute of Health and 

Welfare, 2018). This influences voters with these illnesses, rather than those too young to vote (or are 

yet to be born!) Unfortunately rare congenital illnesses, such as metabolic disorders, are often 



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overlooked. The health dollars saved through health prevention are frequently channeled into other 

projects (reprioritized spending). Even if those prevention programs pay for themselves over the 

long-term—a healthier population is able to pay more taxes for a longer time—the dollars saved are 

virtual (and not tangible; though are still likely to be spent before they have been collected)! 

3.2 Unique and General Practice 

General Practice is uniquely placed at a junction between small and large business, non-profit 

organization and commercial concern, private enterprise and public service. It has autonomy but 

answers to regulatory bodies (and is defined by them). Funding may be public, private or a combination 

of both. Practices may be established as sole-traders, partnerships, companies or franchisees. Some 

clinics are not for profit concerns and are publically-funded; receiving a monetary allowance from the 

government to operate (e.g., Aboriginal Health Services) (Australian Institute of Health and Welfare, 

2018). 

Within the practice, there may be a single practitioner (autocratic leader), a governing board 

(bureaucratic leadership) or an external one (if the organization is a satellite institution). The staff is 

likely to be diverse—administrative, clerical and clinical; each with differing levels of expertise and/or 

areas of interest. Some general practices include allied health personnel (for example physiotherapists, 

psychologists, dieticians and pharmacists); others employ doctors holding specific skills; such as sexual 

health, addiction medicine, cosmetic medicine and obstetrics expertise. 

All of these factors influence the general practice workplace, the type of leader which is required and 

what sort evolves and thrives. Competing interests of large gross profits are hindered by Health 

Insurance Commission audits if too many patients are seen within a short period of time compared to 

peer benchmarks. Other local general practices are seen as rival competition in the eyes of business but 

as colleagues and friends during area Divisions of General Practice and Continuing Professional 

Development meetings. The autonomic practitioner may be constrained by Health Department 

directives, clinical practice guidelines and public health policy. Similarly, alliances with a 

pharmaceutical wholesaler, pathology testing company or private franchise may also influence 

performance, profitability and scope of services offered. The leader of a general practice may be a 

non-clinical practice manager or a nurse in a co-dependent physician leadership arrangement (Ponte, 

2004). 

3.3 A Woman’s Perspective 

General Practice tends to have a varied workforce demographic, like the arts industry. Within medicine, 

the specialty of general practice has a higher proportion of female workers (who may also work more 

part-time hours), contains more ethnicity minority groups and has diverse practice settings in both rural 

and urban localities (Kilminster, et al., 2007). 

 



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Women comprise the dominant gender within the healthcare industry and are the greatest consumers of 

health care (Kirchheimer, 2007). Female gender dominates part-time employment (Australian Bureau 

of Statistics, 2018). Women remain underrepresented in the top echelons of healthcare leadership. 

Women are more likely to be departmental heads but men are more likely to be Chief Executive 

Officers and corporate presidents. A salary disparity (up to 20% less for women) prevails, even when 

controlling for gender differences in educational attainment, age and experience (Lantz, 2008). Females 

are more likely to voluntarily withdraw from the workforce for a family-related reason, such as spouse 

career move or to raise children, than men. However with respect to patient care, communication style, 

not gender, is more important in determining patient response to a doctor (Aruguete & Roberts, 2000). 

3.4 Medical Leadership’s Contribution to Change  

Change is inherent to leadership, which may be described as an adjective referring to the capacity of 

motivation to change (Fry, 2003). The leader’s vision will define the organization’s culture and attitude 

towards change (contingency theory). 

Change involves loss: to the status quo, predictability and traditions. Leaders need to make the pain of 

change worth the effort (Tichy & Devanna, 1986). This is achieved through clarity of purpose or 

mission (Pietersen, 2002). Honest communication, participation, goal and example setting are the 

currency to allow change to pay off. 

Leaders are reformists under a myriad of guises: service redesign, workplace management, productivity 

review, etc. The clash of innovator and conservative, rather than generating a spark of dynamism, slows 

the winds of change. 

The more established an organization and its philosophy, the slower is the pace of change. A wise 

leader knows how to play the long game, position themselves ideally and achieve permanent change 

through increments, rather than introduce radical maneuvers which may prove a step too far to accept. 

Stand still and they fail too by preventing future innovation from occurring. 

Leadership without direction is useless (Chervenak & McCulloch, 2001). Change provides direction to 

pursue excellence. Visionary leaders can see the benefits for change that others cannot and thus initiate 

it and do not resist it (Ham, 2003). The transforming leader raises the aspirations of his or her followers 

so that the leader’s (or organization’s) and follower’s aspirations are fused (Parry & Bryman, 2006). 

Skillfully handled, this will also apply to change. 

Change is continual and anticipatory (Hindle & Natsagdori, 2002) and conditions need to be in place 

for it to happen (Ham, 2003). Rapid organizational change may cause demoralization and reduced 

quality of care (Gershon, Stone, Bakker, & Larson, 2004). Being diplomatic, leaders can enlist other 

professionals (who may initially be reticent) and engage them in reform top-down. Hopefully over time, 

within the organization a converse bottom-up process of input and reform is established that everyone 

may contribute to. This also has the advantage of the employees generating change themselves and not 



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having it thrust upon them (Ham, 2003). By including this adaptation to change as part of Continuing 

Professional Development, it also becomes integrated into workplace culture, collegially acceptable 

(adopted by existing and new workers), and an industry standard rather than revolutionary. We come 

full-circle back to systemic protocols, policies and pathways embedded in sites such as public hospitals.  

3.5 Risk-Taking in Medical Leadership 

Leadership involves taking risks (Reinertsen, 1998). Good leaders know which risks to take (bad 

leaders don’t). They take calculated risks but not unnecessary ones. An autocratic leader may make 

harmful decisions by not having the foresight and varied perspectives that a bureaucratic leader enjoys. 

Similarly a paranoid mistrusting chief may make large, preventable mistakes (Joni, 2004). However a 

bureaucratic leader may become an endemic “non-risk taker” due to the structure that system employs 

in maintaining the status quo—potentially stifling innovation and creativity (Lok & Crawford, 2004). 

Workplace-leadership discrepancies may arise in situations where an entrepreneur in private practice 

takes over the running of a “not-for-profit” public hospital or when a temperate civil servant used to 

conservative “middle management” policy and decision via consensus, is asked to spearhead 

groundbreaking reforms. 

A leader must know when to take risks with personnel. Excessive loyalty, such as a seniority hierarchy, 

engenders over-protectiveness and may reduce the productivity of the organization (Joni, 2004). It may 

be time for new blood to reinvigorate the organization and challenge established work practices so they 

become more efficient. A true leader does not shy away from self-audit despite the potential pain of 

reality. Responsibility over an organization also implies accountability for it. 

3.6 Risk-Taking in Medicine 

Unlike the military or sporting arenas, the field of medicine is not traditionally seen as one in which to 

take risks. Doctors like to deal with certainties (even though nature itself is uncertain), such as the 

predicted course of a disease or the response rate to a particular chemotherapeutic agent. The science of 

medicine means that doctors tend to remove emotion from decision-making, yet making decisions lies 

at the heart of taking risks. Leaders in-tune with their employees’ emotions tend to be more effective 

decision-makers (Parry & Bryman, 2006). 

Frequently doctors take risks on behalf of others: the patient with cancer, the one about to undergo 

surgery and when allocating spending from public coffers. While consent and the ultimate decision lies 

with the patient, budget signatory, health minister, etc., the way doctors frame risk and expected results 

influences the decisions being made in medicine. Consumers (patients) in medicine are adverse to risks 

being taken for managerial protection and (those managers’) increased personal gain. This 

“customer-as-expert” shares decision making (and risk) with the technical expert (Harrow, 1997). 

Risk-taking is not simply acknowledging potential negative consequences, and weighing the risks 

against benefits, but also recognizing vulnerabilities and having an alternative plan to cope with 



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unexpected problems (McGowan, 2007). This is where leaders shine or fall. 

Risk-taking is not anathema to teamwork. Being able to share risk with an informed team is a critical 

attribute for the modern leader. Here the leader is not seeking self-protection from the team in the case 

of failure, rather gathering support and approval from the team through sharing the same vision, 

benefits and risks of the venture (McGowan, 2007). The leader is captain of the team and is not 

coaching from the sidelines. 

 

4. Discussion 

4.1 Clinical Governance 

Inherent in any leadership position are expected outcomes. Risk-taking is frequently the path travelled 

to achieve these. Risk-taking in an organization is generally not seen as negative so long as it achieves 

results and is supported by effective leadership (Borins, 2000). The concept of clinical governance in 

medicine places risk in a managerial context as something to be viewed openly. Methodology, such as 

root cause analysis, seeks to define risk as a wholly manageable concept which can be negated through 

well-developed systems. While this may lead to greater (and more public) visibility of misadventures in 

medicine, unless remedial approaches are in place, best practice is not delivered and public confidence 

in medicine and its capacity for autonomy is eroded (Donaldson, 1998) (The naive or overconfident 

leader feels that all risk may be negated!). 

Some leaders are risk-avoiders to their peril. Laissez faire (“hands off”) leadership, where free-reign is 

excessively delegated to subordinates, may result in targets not being met and the organization failing 

(a ship without a captain). Staff may feel insecure under this type of leader.  

Management by exception, where the leader avoids giving corrective direction as long as the old ways 

appear to work and performance goals are met (Sarros & Santora, 2001) is similarly destructive. An 

organization stagnates without innovation and self-reflection. The structure of a system remains fixed 

without the input of an effective leader and the potential for entropy increases (Nolan, 1998). 

Without risk and the prospect of failure, achievements lose their meaning. A risk-free workplace 

environment where employees operate through trial and error without consequence defeats the function 

and value of their work (Denis, Langley, & Pineault, 2000)! 

Good leaders don’t have a fear of failure they just have a healthy respect of it. Great leaders learn from 

failure and act differently on subsequent occasions. They blame themselves and transform adversity 

into opportunity. Like risk-taking, learning is another integral part of any good leader. 

4.2 Tolerating Chaos as a Medical Leader  

Chaos may be thought of as change without direction, uncertainty without purpose. Before any new age 

there exists a tumultuous period of change, akin to volcanic activity occurring before the creation of a 

new land mass. Reformation, like evolution, has the tendency to proceed through fits and starts (Denis, 



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Langley, & Pineault, 2000). 

Effective leaders adopt democratic or participative styles. They take into account the bureaucratic 

model but are not afraid to also be transformational or visionary. Such a leader, assisted by charisma, is 

able to motivate an organization, provide reassurance and transcend work practices (and an atmosphere 

of apprehension) during times of chaos, so that employees remain calm and continue to strive for more. 

This empowers employees with morale, encourages dialogue and imbues a dedicated work ethic. 

Modulating organizational performance from effective leadership is achieved through establishing a 

workplace culture (Lok & Crawford, 2004). Good leaders create it, poor leaders don’t. 

Management is primarily focused on short term (transactional) results. As stated earlier, leadership is 

about playing the (transformational) long game: motivating people to change, to achieve long-term 

results (Fry, 2003). Motivation energizes, directs and sustains human behaviour, as well as long-term 

change. By taking ownership of the change, even catalyzing it within the organization, the 

transformational leader may deftly navigate the organization through the storm of chaos.  

Organizations demand of leaders hard evidence, that changes introduced incrementally over time or 

that their navigation through episodes of uncertainty, will truly result in more effective and enduring 

service improvements (Sarros & Santora, 2001); with the organization surviving intact (possibly even 

triumphing) when the period of chaos is over.  

Leaders, being transformational and visionary, may not be able to offer such tangible guarantees, 

despite having a proven track record of taking gambles which pay off (and probably led to them being 

offered the position in the first place). 

4.3 Constancy 

Influence is a tool to enable change intrinsically, authority is the right to do so and power enforces 

change extrinsically.  

An organization led through fear (control and employee compliance, a carrot and stick model) will 

reject change as it is solely extrinsically motivated. Here workers respond only to low order needs, such 

as salary and working conditions, independent to the nature of the task. Intrinsic motivation transcends 

self-interest for group worth. It promotes concern and enjoyment of an activity for its own sake, 

facilitating growth and satisfying higher order needs. In addition to the follower (employee), the leader 

similarly enjoys competence (task-mastery), autonomy (including internal motivation) and relatedness, 

through empowered teamwork. Individuals, who take ownership and are completely engaged, stimulate 

creativity and take pride in their work. They also feel a sense of progress and accomplishment which 

ultimately leads to superior organizational gains and outcomes (Fry, 2003). 

In times of uncertainty and chaos, capable leaders possess an eye for change and a steadying hand. 

They have an enduring vision and the reassurance that change can be mastered (Barker, 2002). The one 

constant in change should be the organization’s leader. 



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Tichy, N. M., & Devanna, M. A. (1986). The Transformational Leader. New York, NY: John Wiley. 

 

 

 

 



www.scholink.org/ojs/index.php/ct                        Children and Teenagers                        Vol. 2, No. 1, 2019 

 
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Published by SCHOLINK INC. 

 

Note 

Dr Anthony Zehetner is a Staff Specialist in Adolescent Medicine at the Children’s Hospital at 

Westmead, a Consultant Paediatrician in private practice and a Clinical Senior Lecturer for the 

University of Sydney. He completed a Master of Medicine (Paediatrics) including studies in medical 

leadership and also has a management degree. 


