Leading from the Top – Chief Medical Officers and Their Leadership Styles

Introduction
Chief Medical Officers are important players within the healthcare industry. They are physician leaders who play a big role in providing high-quality patient care for patients, and they can have a great impact on the overall performance of their hospitals (Angood & Birk, 2014). Because of their importance, this chapter examines Chief Medical Officer leadership characteristics through the lens of three different leadership approaches: the trait approach, the skills approach, and the behavioral approach. The main finding of the analysis of Chief Medical Officer leadership characteristics discussed in this chapter is that there is good consistency between leadership theory and practice exhibited by CMOs.

This chapter first highlights the importance of physician leaders in general and then describes common characteristics of the Chief Medical Officer. I provide an overview of traits, skills, and behavioral approaches to leadership, and then compare each of these displayed by CMOs.

The Role of Physician Leaders
In their paper, The Value of Physician Leadership, Angood & Birk (2014) make several statements that point to the importance of physician leaders. They point out that “[t]oday, approximately 5 percent of hospital leaders are physicians, and that number is expected to increase rapidly …” They also state that “[t]he American College of Physician Executives (ACPE), the nation’s oldest and largest leadership education and career support organization for all types of physicians, champion the view that physicians are best suited to lead clinical efforts to achieve true patient-centered care.” Moreover, “ACPE includes physician leadership as one of its nine essential elements required to provide optimal patient-centered care.” The 2013 U.S. News and World Report rankings show that 10 of the 18 hospitals listed on the “Honor Roll” are physician led, with the top five all having physician leaders. (Angood & Birk, 2014). Goodall’s Physician leaders and hospital performance: Is there an association? study, indicated that “The best-performing hospitals are led disproportionately by physicians” (Goodall, 2011). Overall, evidence suggests that physician leaders play a big role in providing high-quality patient care, and they have a great impact on the performance of their hospitals (Angood & Birk, 2014). Physician leaders can have different titles, like chief medical officer, vice president for medical affairs, or vice dean for clinical affairs, among others (Longnecker et al., 2007). The following sections will mainly focus on the Chief Medical Officer.

Background Information on the Role of the Chief Medical Officer
The role of the Chief Medical Officer was initially created around 1980 with the intent of having a physician on the senior management team who understood both, the medical and administrative sides and could function as a “liaison” between the two. In the late 1990s, the Physician Executive Management Center conducted a survey, asking physicians in senior medical management positions about the value they provide to their organizations. Respondents of the survey believed that they had essential knowledge and experience on the management, as well as the medical side. A solid medical background seemed especially important to be accepted as a leader by other physicians and to be able to function as the liaison between the medical side and management (Kirschman, 1999).

The concept that the CMO has the role of a “liaison” between medical and administrative side is reiterated in many different studies. Longnecker et al. (2007) call this unique positioning an “intermediary” between the clinical and administrative side. Angood and Birk (2014) describe Chief Medical Officers as the bridge between management and medicine. Whereas non-physician executives might tend to focus more on financials, CMOs have that deep clinical knowledge about patient care that can make them more sensitive to clinical staff’s needs, as well as patients’ needs, and it makes it possible for them to work together with other physicians to find a solution collaboratively.

Cors (2009) argues that Chief Medical Officers are able to bridge the gap between management and the clinical side, as well as cost and quality. He adds that while first and foremost Chief Medical Officers are clinicians, they also have training in business, management and leadership, to be able to function as that “bridge.” In their study of 340 physician leaders at 281 different AAMC member association, Longnecker et al. (2007) found that 32% of Chief Medical Officers had degrees closely linked to the business or health care field, like an MBA, MPH, or MHA. Eighty percent of the CMOs with this type of degree believed it had helped them with becoming CMO. They thought it had helped them develop additional knowledge and skills necessary to be successful on the administratively and to build credibility among people on the administrative side.

Longnecker et al. (2007) surveyed physician leaders at different organizations regarding their roles and responsibilities as physician leaders. They asked questions about demographics, titles, qualifications, tenure, reporting relationships, and others. The study showed that CMOs spend most of their time on administrative tasks and CMO duties, with only a small amount of time spent on research, teaching and clinical practice. Within their CMO duties, attention to clinical quality and patient safety, as well as coordination of inpatient and outpatient clinical operations, comprised more than half of their time (52%). The authors identified personal history, stature and relationships with colleagues, as well as senior leadership and executive commitment to the role as factors contributing to success in their position.

Background Characteristics of the Chief Medical Officer
The 1990s Physician Executive Management Center survey asked physicians in senior medical management positions about the value they provide to their organizations. Personal characteristics that seemed important for chief medical directors included judgment, loyalty, rational thinking, common sense, ethics and integrity. When asked what the respondents enjoy the most about their position, the highest response was working with other physicians and in the community, which involves education, mentoring, leadership and being the link between management and physicians. Management duties were mentioned often, especially daily operations, problem solving, implementation of new programs, negotiation, and managing a complex environment were highlighted in this category (Kirschman, 1999).

As described above, CMOs function as liaisons between the medical and administrative side. They have a strong clinical background which provides a shared history and common language with other clinical staff. This unique positioning helps CMOs build trust and support with others around them. It also helps to build credibility among clinical staff, which is essential for clinical integration and change efforts (Angood & Birk, 2014).

In his article “Secrets of a Chief Medical Officer,” Chappell (2004) discusses lessons learned from the perspective of a CMO. He points out that Chief Medical Officers have many conversations every day, displaying integrity and telling the truth will keep them in their job. Chappell also highlights that time references (how frequently decisions need to be made) used by physicians and administrators are very different. While physicians make many decisions daily, administrative decisions take much longer. Functioning as the “liaison” or “bridge” between these two sides, it is important that the CMO understands these differences in time references. Chappell points out that for the Chief Medical Officer it is important to be principled but not inflexible because compromises and negotiations are important parts of the CMOs job.

Moreover, it is important for CMOs to not just rely on stories from others, but to go to the problem and make their own assessments. Additionally, some clinical staff members might feel like that the CMO is not “one of them” anymore, but Chappell highlights that it is important for Chief Medical Officers to remember that they got the job for a reason, and that is because they have the clinical background. Chappell points out the importance of being a life-long learner for CMOs, as well as the importance of continuous development of leadership skills. Lastly, in the CMO role, sometimes, conflict is inevitable and something that CMOs need to be prepared to handle. Here, Chappell highlights that it is important for the CMO to have accurate data, like dates, times and detailed examples of behaviors. Cors (2009) points out that the successful CMO possesses qualities which include being persuasive, being able to communicate excellently, exhibiting passion about quality, possessing trustworthiness, being viewed as supportive of the medical staff and exuding credibility.

According to Angood & Birk (2014) the Healthcare Leadership Alliance has created a list of 300 competencies that are required for effective healthcare leaders. They have grouped them in five main areas. First, knowledge in healthcare. Second, being professional, which includes having ethical and professional standards, having a sense of responsibility to patients and community and a willingness to continuously learn and develop, Third, being able to communicate and interact effectively and build relationships. Fourth, having business skills and knowledge, which includes being able to use business principles, like systems thinking. Lastly, leadership, which includes inspiring excellence, creating and attaining a shared vision and being able to manage change successfully.

In his article “Developing Physician-Leaders: A Call to Action,” Stoller (2009) claims that physicians, due to the nature of their training and history, might be “disinclined to collaborate or to follow,” which are important characteristics of leaders. He elaborates on this statement by discussing the fact that advancement on the medical side is often tied to improving clinical, or academic skills, not leadership skills and competencies. Moreover, he states that a lot of physicians value autonomy.

In his article “Can Physicians Collaborate?” Stoller (2004) points out four areas he found make it hard for physicians to collaborate. First, physicians’ training is long and hierarchical. Second, physicians are usually evaluated on individual performance, not on group performance, i.e., board certifications and competition for residency slots. Third, Stoller believes that physicians may experience “extrapolated leadership,” which means that physicians take their clinical authority and apply it to other fields where it might not be relevant. Fourth, physicians are trained to identify problems or deficits and solve these. It might be harder for physicians to get away from this type of thinking and instead of seeing deficits, to see the potential opportunity for change or development (Stoller, 2004). Weisbord (1976) adds that for health professionals, autonomous decision-making, personal achievement and improving ones’ own performance are highly important. This is different from those people that work in other environments, like the business world.

Approaches to Leadership
Over the last century, different leadership approaches have been developed. Three of the earliest and well know ones are the trait approach, skills approach and behavioral approach to leadership. In short, traits are who leaders are, skills are what leaders can accomplish, and behaviors describe what leaders do and how they act (Northouse, 2015). The following sections break down the three approaches in detail.

1) Trait Approach
The trait approach was one of the first approaches used to learn about leadership. Researchers believed that traits were something people were born with and only those people that were “great” possessed those traits. Because traits were viewed as something innate, they were also largely seen as “fixed” (Northouse, 2015). The earliest study done on leadership traits by Stogdill in 1948 consisted of 124 trait studies between 1904 and 1947. Stogdill (1948) was able to identify important leadership traits that explained how people within groups became leaders and how leaders differed from other group members in eight traits. Those eight traits were intelligence, alertness, insight, responsibility, initiative, persistence, self-confidence, and sociability. Another main finding of the study was that someone was not a leader simply because he or she possessed certain traits, but those traits had to be applicable and relevant to particular situations.

The second important study around leadership traits was conducted by Mann (1959). He analyzed more than 1,400 findings about traits and leadership and was able to identify six main traits that distinguish leaders from others. Those six traits were intelligence, masculinity, adjustment, dominance, extraversion, and conservatism.

In 1974, Stogdill conducted another important study around leadership traits. This time, he focused less on the situation a leader was in and he identified the following important traits associated with leadership: drive for responsibility and task completion, vigor and persistence in pursuit of goals, risk taking and originality in problem solving, drive to exercise initiative in social situations, self-confidence and sense of personal identity, willingness to accept consequences of decision and action, readiness to absorb interpersonal stress, willingness to tolerate frustration and delay, ability to influence other people’s behaviors, capacity to structure social interaction systems to the purpose at hand (Stogdill, 1974).

A more recent study by Kirkpatrick and Locke (1991) found that leaders differed from others through six traits: drive, motivation, integrity, confidence, cognitive ability, task knowledge. A study done by Nichols and Cottrell in 2014 questioned what people desire in their leaders in terms of traits. They found that trustworthiness and intelligence were consistently desired traits across study participants.

Many studies have been conducted regarding traits and leadership, and many different traits have been identified during the last 50 to 75 years. There are five overarching trait themes that can be identified across many of these different studies: intelligence, self-confidence, determination, integrity, and sociability (Northouse, 2015). Leaders have been found to have a higher intelligence than other people; more specifically, this focuses on a leader’s ability to articulate him or herself verbally in a strong way, perceptual ability, as well as being able to reason with others (Zaccaro et al., 2004).

According to Northouse (2015), self-confidence has to do with being certain about one’s own competencies and skills. This includes self-esteem, self-assurance, and “the belief that one can make a difference.” Determination is about wanting to get things done. Northouse states that some characteristics of determination are initiative, persistence, dominance, and drive. According to Northouse, integrity is characterized by honesty and trustworthiness. People with integrity are loyal, others can depend on them, they are not deceptive, they usually have a strong set of principles they adhere to and they take responsibility for their actions. Lastly, sociability is about relationships with others. Northouse describes people that display sociability as individuals that are “friendly, outgoing, courteous, tactful, and diplomatic.” He also describes them as people who are “sensitive to others’ needs and show concern for their well-being,” as well as individuals who have good interpersonal skills and create cooperative relationships with their followers.”

2) Skills Approach
The skills approach focuses on skills and abilities that can be learned and developed. Research around skills and leadership started in 1955 with Robert Katz’s article “Skills of an Effective Administrator,” published in Harvard Business Review. At that time, leadership research was mainly focused on traits, but Katz was able to approach it from a different angle (Northouse, 2015).

The Three-Skill Approach developed by Katz (1955) focuses on technical, human, and conceptual leadership skills. Katz describes technical skills as the “knowledge about and proficiency in a specific type of work or activity.” These types of skills are most important for lower and middle-level management. Katz describes human skills as the ability to work effectively with other people at different levels in the organization, the knowledge about people, the ability to help others work in a cooperative manner, the ability to create an environment of trust, and being sensitive to other peoples’ needs and motivations. Human skills are important at all levels of the organization. The last skill included in Katz’s Three-Skill Approach is conceptual skills, which focus on ideas and concepts. People that have conceptual skills are good at communicating ideas and concepts, they are good at working with abstracts and hypotheticals. Conceptual skills are especially important when developing visions and strategies. Conceptual skills are very important at upper and middle levels of the organization, and they are less important at lower levels.

In the early 1990s, Mumford and colleagues built on Katz’s findings, giving the skills approach in leadership more recognition. Mumford et al. conducted their study over several years with over 1,800 Army officers, examining why some leaders are good problem solvers while others are not. They wanted to further examine what skills distinguish high-performing from lower-performing leaders and how individual attributes, as well as the environment, play a role (Northouse, 2015). The researchers found that problem-solving skills, social judgment skills and knowledge are the three most important competencies in terms of leaders’ ability of effective problem solving and high performance (Mumford et al., 2000). Mumford et al. (2000) define problem-solving skills as the a “leader’s creative ability to solve new and unusual, ill-defined organizational problems. The skills include being able to define significant problems, gather problem information, formulate new understandings about the problem, and generate prototype plans for problem solutions.”

Zaccaro et al. (2000) define social judgment skills as “the capacity to understand people and social systems.” It is about being able to work with others, being able to solve problems and being effective as a leader. This includes understanding other people’s attitude towards certain problems, what motivates them, as well as the ability to communicate a vision to others. These social judgment skills are similar to Katz’s human skills (Northouse, 2015). Mumford et al. (2000) argue that knowledge is an important leadership skill because it is directly linked to the leader’s capacity to define a problem and attempt to solve it.

In addition to the three most important competencies in terms of leaders’ ability of effective problem solving and high performance, the study also found that there are individual attributes that influence a leader’s competencies, like cognitive abilities (a person’s intelligence and intellectual ability), motivation (willingness to take on complex problems and exert influence) and personality. Past experiences and the environment can also influence a leader’s competencies and therefore leadership outcomes. Leaders can improve and develop their capabilities through experience and training (Northouse, 2015).

In 2008, Rebecca Mannel published a series on essential leadership skills. The first part highlights the importance of having a clear vision. She states that a vision is “what could and should be,” and a visionary leader has to “define a problem, identify a solution, and determine what must be done.” Having a clear vision is an essential leadership skill because it challenges people to take action and to bring about change (Mannel, 2008). The second part of Mannel’s series focuses on team building, which she states is necessary to work towards a vision. The essential skills here are honesty and integrity of the leader so that followers can build trust. Mannel’s third part deals with the essential skill of collaboration, which she defines as “an active process that involves creating something to grow.” Collaboration includes “building a climate of trust,” “building relationships” and “giving value to all ideas.”

3) Behavioral Approach
The behavioral approach to leadership focuses on the behaviors of the leader. Behaviors can generally be divided into task and relationship behaviors. Behaviors describe what leaders do and how they act. Two important early studies on the behavioral approach were conducted by two researchers, Blade and Mouton, at The Ohio State University (Northouse, 2015).

Researchers at The Ohio State University conducted a study in the late 1940s, looking at leaders within groups and organizations and how they acted as leaders within that setting. They identified two main themes centered around initiating structure and consideration (Stogdill, 1974). Northouse (2015) explains that examples for initiating structure behaviors are “organizing work, giving structure to the work context, defining role responsibilities, and scheduling work activities.” Consideration behaviors include “building camaraderie, respect, trust, and liking between leaders and followers.” Northouse adds that initiating structure behaviors are closely aligned with task behaviors and consideration behaviors are closely aligned with relationship behaviors.

In the early 1960s, Blake and Mouton developed the “Managerial Grid,” which today is called the “Leadership Grid.” It was developed to aid in explaining how leaders help their organizations reach their goals by looking at two areas: concern for production and concern for people (Northouse, 2015). These two areas are closely related to the two main themes (initiating structure/task behaviors and consideration/relationship behaviors) that researchers at The Ohio State University identified. Blake and Mouton (1964) explain that concern for production deals with organizational tasks. Examples include “attention to policy decisions, new product development, process issues, workload, and sales volume.” They explain that concern for people deals with “building organizational commitment and trust, promoting the personal worth of followers, providing good working conditions, maintaining a fair salary structure, and promoting good social relations.”

According to Blake and Mouton, leaders show concern for production and concern for people on a continuum from low to high. Depending on where leaders fall in these two categories, they display different leadership styles. For example, someone could score very high on concern for production, but very low on concern for people. These leaders view their followers as “tools for getting the job done.” This type of leader is often seen as “controlling, demanding, hard driving, and overpowering” (Northouse, 2015). A leader could also score very high on both ends. Northouse states that the phrases “stimulates participation, acts determined, gets issues into the open, makes priorities clear, follows through, behaves open-mindedly, and enjoys working” could be used to describe such a leader (Northouse, 2015).

Overall, the behavioral approach provides a framework for leaders to examine their leadership style based on tasks and relationships, and it reminds them that “their impact on others occurs through the tasks they perform as well as in the relationships they create” (Northouse, 2015).

Comparison between Leadership Approach Theory and CMO Leadership Characteristics
The following matrix describes the similarities and differences between Traits, Skills and Behavioral Leadership Theory and Chief Medical Officer (CMO) characteristics as described in the CMO and physician leadership literature.

Trait Leadership Theory and the Chief Medical Officer
There is some evidence that Chief Medical Officers also display intelligence, self-confidence and determination. They display intelligence because they are persuasive and they can reason with others. Longnecker (2007) identified stature as a factor to success for CMOs. This could imply self-confidence (although I was not able to determine if CMOs are generally certain about their own competencies and skills), self-assurance, or self-esteem and if they believe in being able to make a difference. In terms of determination, it takes a long time and a lot of training to become a physician, which could imply that a CMO must be determined to become a physician in the first place. I was not able to explicitly find anything written on CMO’s initiative, persistence, dominance, or drive in their leadership role. Two more points that seemed to differ between leadership theory and the Chief Medical Officer literature were that CMO need common sense in their position and they a lot of times are passionate about quality.When comparing Chief Medical Officer traits, skills and behaviors to what theory says about the traits, skills, and behavioral approach to leadership, there are many similarities, and surprisingly few differences.

In terms of the traits approach, I discussed above that theory states that leaders are intelligent, they are self-confident, determined, they display integrity and are sociable. These five traits all describe Chief Medical Officers to some degree. The most overlap occurs for integrity and sociability. Chief Medical Officers display integrity in that they are loyal, they tell the truth, they are principled but not inflexible, they have strong ethics and professional standards, they are trustworthy, and they have responsibility to patients and communities. CMOs display sociability because they value and build relationships with others. Moreover, due to their clinical background, they are sensitive to what clinical staff members and patients need.

Skills Leadership Theory and the Chief Medical Officer
For the skills approach to leadership, theory states that four overarching skills are important for leaders. They have technical skills, or knowledge, they have human and social judgment, they have conceptual skills, and they have problem-solving skills. Chief Medical Officers display all four of these skills. They have a strong clinical background and knowledge in healthcare. At the same time, they have business skills and knowledge, and many times, they have training in business, management and leadership. This shows the high degree of technical skills and knowledge CMOs have.

In addition, CMO’s also possess human and social judgment skills. Because Chief Medical Officers have knowledge of both the medical and administrative sides, they are able to understand the differing needs of people in each department. They are able to build an environment of trust and support and they build credibility. They also have the ability to compromise, work with other physicians collaboratively and handle conflict; they have negotiation skills, and they have judgment. In terms of conceptual skills, different papers highlight CMO’s excellent communication skills.

CMO’s are able to create and attain a shared vision, which to some degree could require being able to communicate ideas, concepts, abstracts, or hypotheticals. Lastly, Chief Medical Officers have problem solving skills. During their medical training, they were trained to identify problems or deficits and to solve them. A lot of time, they also display rational thinking, which can be helpful in the problem-solving process. While a CMO’s medical training has most likely enabled them to identify a problem and come up with a solution quickly, it also trained them to be autonomous decision makers. Valuing autonomy is something that is very different from what theory states a leader looks like under the skills approach. As stated by Stoller (2009), this value of autonomy can potentially disincline CMOs to collaborate or follow. Autonomous decision making can potentially also stand in contrast with being able to work and cooperate with others, which falls under the human and social judgment skills of skills approach theory.

Behavioral Leadership Theory and the Chief Medical Officer
In terms of the traits approach, I discussed above that theory states that leaders have task behaviors, which includes initiating structure and concern for production, and they have relationship behaviors, which includes consideration and concern for people. For this approach, there was more overlap between leadership theory and CMO literature for relationship behaviors than for task behaviors. This approach was also the one in which I identified the most differences. For task behaviors, CMOs implement new programs, they manage a complex environment, and they are involved with many daily operations. These examples of task behaviors are very general, and I was not able to identify more specific task behaviors, like defining role responsibilities, scheduling work activities, and attention to policy decisions.

For relationship behaviors, CMOs display consideration and concern for their people because they act as an intermediary, or liaison, between the clinical and administrative sides, which positions them uniquely to build acceptance on both sides and take both sides’ needs into consideration. They behave in a way that builds credibility and trust, and they build relationships with others. As mentioned in the paragraph above, Chief Medical Officers are trained to be autonomous decision makers, which could potentially disincline them to collaborate or follow. This stands in contrast with relationship behaviors, especially “linking between leaders and follower” and “promoting good social relations.” The Chief Medical Officer literature also highlights that CMOs have to be life-long learners, and they need to continuously develop themselves and their people. Additionally, they inspire excellence in others. These were behaviors not included in the behavioral approach theory.

Conclusion
In summary, physician leaders play an important role in delivering high-quality patient care and the performance of their hospital, overall. The specific type of physician leader analyzed in this chapter was the Chief Medical Officer. CMO leadership characteristics were analyzed through three different lenses: the traits approach, skills approach and behavioral approach to leadership. Chief Medical Officer leadership characteristics overlapped with the three leadership approach theories. One difference that stood out was that CMOs potentially highly value autonomous decision making, which could make them more disinclined to collaborate or follow, due to their type of medical education and training. This stands in contrast to the human and social judgment skills of skills approach theory, as well as with relationship behaviors of the behavioral approach to leadership theory.

In a larger organizational context, it is important for hospital leadership to remember the importance of the Chief Medical Officer role to the overall success of their organization, as well as the impact on patient care. Therefore, it is crucial to recognize and support this role. In terms of hiring decision for Chief Medical Officers, the analysis of CMO leadership characteristics discussed in this chapter can inform hospitals on what leadership characteristics make a successful Chief Medical Officer. The analysis also points out the potential difference of CMOs value of autonomous decision making, which could disincline them to collaborate or follow. Since collaboration is a skill and relationship behavior, it can be learned and developed, which is also important to remember and pay attention to when hiring or developing Chief Medical Officers.