MANAGEMENT AND LEADERSHIP

August 10^th 2013 

Address to University of Newcastle   Master of Clinical Medicine (Leadership and Management)   Workshop Dinner

Stephen Leeder

I congratulate everyone present at this workshop, whether as a fellow in the program or one of the program organisers or managers who support it or as contributors to this workshop. 

What you are all doing is critical to the future of the health service that we all work in.  Without high quality management, without leadership to point to a goal and remind us of why we do what we do, we will not give to the future the best of what we are capable.  But with management and leadership we can seize opportunities and overcome obstacles in ways that may surprise us and that will assure a positive legacy from the commitment of our lives to our profession.

I have followed the progress of the program from conception through birth to infancy and am impressed with it.

I have committed part of my life to medical education, so what is happening in this course is of special interest to me.

You are all great people. 

I know from my experience both in Newcastle and Sydney, with new educational programs, the agony and ecstasy of the first cohort of participants – they get the best and worst, they get the enthusiasm and the mistakes, rather like firstborn children.   

In 1986 I attended a one-day workshop in Sydney CBD on how to become a great leader, run by an American evangelist-type who talked with boundless enthusiasm and sold books and tapes.  At the start he asked us all: “Hand up if you are a first born child!”  Almost four-fifths of us indicated they we were firstborn.  Apparently as firstborn you are born to lead!  So as the firstborn of this new program, you folk are already at an advantage when it comes to leadership!

Your theme at this workshop is leadership and management.  A definition of good leadership that I heard years ago has stuck with me and it is that leadership is helping others achieve more than they thought possible, more than they thought they were capable of achieving.  Leadership provides direction.  It provides hope. It is optimistic.  Leaders take people with them.  Leaders stretch the people they are leading.  They say “Come on!” to the flagging spirits. They say “This way!” to those who are dithering. They say “Take my hand” to those who are stumbling or out of breath.  That’s what good leaders do and that is what good leadership is.

Managers in my experience are enablers.   Managers make things happen.  They understand the process of making decisions, they know how to allocate tasks and resources to match those tasks, they understand spread sheets, they enable, they discipline when needed. 

I have seen leaders who are good managers and vice versa.  I have also seen good leaders who were essentially devoid of management skills, and managers who could not lead. 

A couple of personal observations. 

First, doctors are not exceptionally good managers.  Of course, you can name half a dozen doctors you know, as can I, who are excellent managers.  But our training as doctors leads us to be individualistic, to make decisions in diagnosis and therapy that affect the lives of our patients and for which we and we alone, are accountable. Many doctors lead teams, but often you will find someone else manages those teams.  McKinsey Consulting hires a few – not many – doctors as management consultants.  So the skills of management do not come easily or naturally to many doctors. 

With regard to leadership you will find many doctors who have pioneered new ways of treatment, especially in surgery, that depend on effective leadership for success.  But the big picture, the vision, the attributes of leadership that I described before, are not common among doctors, at least in my experience, even in public health.  Halfdan Mahler, a physician from Denmark, served three terms as director-general of the World Health Organization 1973-1988 and is widely known for his effort to combat tuberculosis and his role in shaping the landmark Alma Ata Declaration that defined the Health for All by the Year 2000 strategy. He was a leader, a visionary man.   

But the eight Millennium Development Goals, established by the UN, were not developed, nor led, by doctors, but by Kofi Annan, the Secretary General of the UN and Jeffrey Sachs from the Earth Institute at Columbia University.  They pushed for a halving of poverty by 2015 through goals that addressed infant and maternal mortality, basic education and aid.  The goal of halving the number of people living on less than $1.50 a day was achieved three years early, in 2012.  That’s what leadership can do, through inspiration, tenacity, clarity of vision and passion.

So by now you’ll be wondering why your course organisers asked me to speak to you this evening as I bring dismal news.  Well, it is not all that dismal!  This is partly because we have many excellent managers, non-medical, in our health service and if you can find and engage with them, you will be very fortunate. 

That’s leadership, but what about management?  In the past two years I have chaired the board of the WSLHD.  We were in serious financial bother and morale was low.  Enter Danny O’Connor our CE who is a wonderful manager.  He has brought order and respect and conversation to that troubled district.  He came saying “I’m a team man” and he has been true to his word.  He has won the respect of clinicians.  He networks well.   And as chair of the board I see my job as being his body guard.  I don’t mess with his management.  I just take a whopping great stick to marauders. 

I have been involved in helping establish a new medical school in Newcastle in the late 1970s and 80s and then the reform of the Sydney medical program in the 90s.  Both required managerial and leadership skills and in many ways I acquired those as I went along.  I have been lucky – really lucky – that in those endeavours I have had wonderful colleagues who worked closely with me and educated me sometimes quite forcefully. 

You will acquire management and leadership skills through this course and you too will be lucky.  A lot of my mistakes are ones you will learn how to avoid. The future of the health service, in my opinion, depends on it being well managed.  One example: the introduction of ICT without change management is an easy way to waste billions of dollars.  Yet we need that ICT to achieve the connectivity that caring for people with chronic problems demands.  We need to manage efficiently or we will continue to do what we are doing now – asking people to pay more from their pockets (a great inequity) to cover the difference between public funding and the inefficient cost.   That this can be done is apparent from our Veterans Affairs health service.  It is also apparent in the US – Kaiser, Intermountain, Harvard, and Mayo for example.

Are there dangers in leadership and management for us as doctors?  Let me identify one risk with management and two with leadership.

We will get ourselves into an impossible tangle if as clinicians we follow our duty of care for patients at the same time as we try to be really smart managers and also do our best by our patients. On some management matters we need to stand aside for managers without clinical obligations. Decisions about resource allocation need to be made at a higher level than in the ward.

As leaders, we can get ourselves into bother if we construct for ourselves a reality that is too far out of common experience.

When I was dean of medicine in Sydney 1997-2002 I used to do a clinic a week at Blacktown to keep in touch with clinical reality.  Fortunately, medical leaders have the chance often of continuing to do some clinical work and that helps keep their reality clear and clean.  

The other danger with leadership is that it is charged with power and this can be used to good or bad purposes.  Hitler was an amazing leader.  Ironically, the Kennedy brothers, all of whom used rhetoric and vision to inspire their audiences, were fond of using a quote from George Bernard Shaw.  It was “You see things; and you say, ‘Why?’ But I dream things that never were; and I say, ‘Why not?’”  But while the quote does come from GBS, in fact it is drawn from a play that he wrote called Back to Methuselah. 

The words were words spoken by the serpent in the garden in the biblical story of Adam and Eve, where the serpent is the embodiment of evil, and it is tempting Eve to disobey God and eat from the tree of the knowledge of good and evil.  Strong words, inspiring words, but an abuse of power!  Leaders beware!

We are very lucky.  All of us – clinicians, managers and others – here this evening know why we do what we do in health care, what our goals are.  We know that our job is to express solidarity with suffering people, to prevent, cure, relieve and comfort.  This vision enables us to lead and be led, to manage and be managed, in pursuit of that vision.

So leadership and management are critical skills for effective future health care.  We need doctors who can lead and others who can contribute to massive management challenges of the future.  That’s YOU! 

I am delighted you are here, delighted you are doing this course, and delighted that our health service will be in such good hands.  I wish you all good fortune in your further careers. 

Thank you.

Potential article of interest on President Obama's Proposed Reform on Higher Education:
http://www.accreditedonlinecolleges.com/blog/2013/obamas-accreditation-reforms-on-higher-education/


 

BIG DATA IS COMING TO A CLOUD NEAR YOU!*

Star Trek: The Next Generation fans will wonder whether the two words Big Data are descriptors for a new sentient android of epic proportion, a supersized upgrade of Lieutenant Commander Data.   As an addicted trekkie, sadly I must quickly disabuse you.  Well, maybe I’m wrong.  There are people who consider that Big Data is every bit (?byte) as exciting as the USS Enterprise’s second officer.

Big Data refers to immense data sets that are collected in fields as diverse as astronomy and genomics.  As Wikipedia tells it, “as of 2012, every day 2.5 quintillion (2.5×10¹⁸) bytes of data were created”, so there is a lot of data about.  The dynamic of Big Data is the search for relationships among these data and teasing out correlations that may not be obvious from the constituent data sets that comprise it. Our technical capacity to search immense data repositories means that correlations can be found in a way never before possible. 

In their new book Big Data: a Revolution that will transform how we Live, Work and Think, Viktor Mayer-Schönberger an Internet governance academic from Oxford and Kenneth Cukier, the data editor of The Economist, recount an interesting example of how Big Data, collected by Google from the three billion search requests it receives each day was used to track influenza in the US 

Google took the 50 million ‘most common search terms used by Americans and compared the list with Centers for Disease Control (CDC) data on the spread of seasonal flu between 2003 and 2008’. After stupendous computer activity, they settled on 45 search terms that were strongly correlated with official figures.  These included many obvious terms such as flu, cough, medications for cough but others that were not so obviously linked.  ‘Unlike CDC, they could tell it in near real time, not a week or two after the fact.’   Although not without their critics and errors, Google flu trends are now available for many countries. http://google.about.com/od/experimentalgoogletools/qt/GoogleFluTrends.htm

Mayer-Schönberger and Cukier accept that there is no universally-accepted definition of Big Data, but rather see the term referring to ‘things one can do at a large scale that cannot be done at a smaller one, to extract new insights or create new forms of value, in ways that change markets, organisations, the relationship between citizens and government, and more.’

Our capacity to collect, link and analyse data electronically is growing exponentially.  Mayer-Schönberger and Cukier draw a parallel between the present and the era that followed the invention of the Guttenberg printing press around 1439.  In the half century starting 1453, they quote an estimate that eight million books were printed, ‘more than all the scribes of Europe had produced since the founding of Constantinople 1,200 years earlier.’ In 2003, following a decade of effort, the human genome was sequenced.  ‘Now… a single facility can sequence that much DNA in a day.’  And because Big Data includes all the data available, population samples will no longer be needed in the way they are today and the work of statisticians will be redefined.

There are many features of Big Data to ponder for medicine.  How will we practise with more information about correlation and less about causation? If Big Data shows that people who take regular exercise have better cancer survival, what will we advise our patients?  Is the correlation sufficient to advise them to exercise, even though the causal pathway is not known?  This will increase our need, and that of our patients, to live with uncertainty.   What meaning does privacy and even confidentiality have in this new age?  We should surely be thinking and discussing these things now.  

(Potential conflict of interest: SL’s son Nick leads Google France.)

*Previously published in MJA Insight on June 24, 2013

BREATHE DEEPLY AND SAY ‘NINETY-NINE’*

On July 4^th 2014, the Medical Journal of Australia will celebrate its centenary, so we are about to turn 99! 

Whatever the outcome of the federal election on September 14^th, new national policies for the financing, governance, quality and scope of publicly funded medical and hospital care will soon be under construction. 

For these policies to work well, the new government will need the participation of those who will implement them, including, quite obviously, the medical profession.  For participation to be at its best, the profession needs access to the information that underpins high quality professional performance.  Throughout its 99 years, the Journal has helped communicate that information amongst the profession and beyond.

The Journal has always played this role. My historian colleague Milton Lewis points out that in doing so it has continued a tradition dating back even further – to colonial days. The first Australian journal was born in Sydney as early as 1846. Lacking adequate support, it soon ceased publication. But the better organised Victorian profession (has anything changed?!) was able to establish a quarterly journal, the Australian Medical Journal, in 1856.

The Australian Medical Journal continued to be published in Melbourne for over five decades until along with the younger, Sydney-based, Australasian Medical Gazette, it was replaced by the national publication, the Medical Journal of Australia.¹ Throughout this time, the other significant source of intra-professional unity (and an effective political player at both State and federal levels) was the British Medical Association, the first Australian branch of which was set up in Victoria in 1879 and the second in NSW the next year.¹ Its successor, the Australian Medical Association, operates the Journal.

The Journal has contributed to the development of medical care and health by providing a place where research and clinical observation is published, where thoughtful opinions based upon experience and evidence from the sciences and practice are offered, where concerns – ethical, political and legal – about health and health care are raised, life’s passage is marked (most often with obituaries), successes celebrated, courage and outstanding professional service recognised. The wit and wisdom of correspondents have entertained and stimulated and the Journal has been a strong component of the professionalisation of medicine in Australia.

The Journal has regularly changed its format and livery but its central purposes have remained largely intact.  Now it is also available online, on mobile phones, laptops and (non-medicinal) tablets anywhere, anytime, as it joins the dance of the Internet. The dynamism that is challenging print media more generally extends its challenge to the Journal.  New business models to sustain it are essential and work continues to develop them. But for a near centenarian it has shown remarkable flexibility, optimism and athleticism!  If only we could all do as well at 99!

This is an excellent moment for the Journal to promote and strengthen the publication of research especially that which assesses clinical effectiveness and new ways of organising and providing care.  Policy-makers, managers and clinical practitioners are hungry for evidence to help them decide. 

As McKeon and colleagues in their review of health and medical research in Australia noted, we spend comparatively little on health care research and development in Australia.² They call for a substantial increase in R&D investment (to 3-4% of government health expenditures) to address the problem of expenditure on health and hospital care, which is rising faster than our willingness to pay.² The Journal is here to publish and disseminate such research.

Medical journals depend heavily on voluntary contributions from doctors and other health service professionals, research workers, patients, politicians, health service managers and experts with an involvement in health and medicine from diverse fields of interest and work.  Without the altruism of colleagues presenting their ideas for others to read and examine critically, there would be no journals.  It is the desire to share insights for the benefit of patients that features strongly among the reasons that include professional advancement why contributors write papers, commentaries, case studies and reviews.  A love of the profession leads others to submit material that sustains the spirit, by way of personal stories, art, poetry or letters.

This is a rich background against which to plan for the future.  The Journal takes those gifts, these contributions given to it in the past and sees them as markers of its heritage and future strength.  They explain why we are optimistic and why we look forward to your company when we celebrate our 100^th in July 2014!

*Previously published in MJA

1.Lewis M, MacLeod R. Medical Politics and the Professionalisation of Medicine in New South Wales, 1850-1901. Journal of Australian Studies 1988; 2: 69-82.

2. Mckeon Report. Strategic Review of Health and Medical Research. Final report Feb 2013. http://www.mckeonreview.org.au/downloads/Strategic_Review_of_Health_and_Medical_Research_Feb_2013-Final_Report.pdf (accessed April 2013).

TAKING HEART FROM INDIAN PROGRESS

India, with its population of 1.2 billion, is planning to build 150 new medical schools in the next five years and at least 250 more in the following five years.  “India,” as Venkat Narayan, a lean, lively and vocal Indian academic who had flown in that morning from Emory School of Public Health in Atlanta to Delhi, put it, “is a place of magnificent chaos, where poverty and wealth co-exist, almost with no self-consciousness, a place where it is very difficult to get things done because of stifling bureaucracy but a place where you can get things done because of the permissive chaos!”  No-one minds a cow slowly crossing the road or minicab drivers lining up and having a pee on the verge even in prosperous neighbourhoods.

“When I was a medical student at Bangalore in 1980, there were two medical colleges and two colleges of engineering.  Now there are nine medical schools and 86 schools of engineering!” Venkat told me, with an energetic laugh. He admits that equity gets rough treatment in India.

I was visiting Delhi as a member of a review panel that has visited India eleven times in the past decade and reports to the prime minister, the minister for health and the ministry to offer informed comment on progress with the National Rural Health Program.  The panel is headed by Jeffrey Sachs, an economist who leads the Earth Institute at Columbia University. He is a valiant warrior for global awareness of poverty.  He has ‘skin in the game’ as his Institute has auspiced the formation of over 40 experimental development villages in Africa where education, health and agriculture capacity building is under way but self-limited to a sustainable budget.  

Sachs has strongly supported a rural health initiative in India to enlist social health workers, respected women in the villages who, with only days of training and no salary, assist young pregnant women to access facilities for safe delivery and neonatal care. There are now 800,000 of these women working effectively in rural India. Mobile phones and bicycles are their basic equipment.  Maternal mortality rates have continued to fall.  Infant mortality rates have been declining in India as a whole (more so in the cities, less so in rural areas) at 6% per annum. 

The rural health program is achieving other goals: there have been no reported cases of polio in India for two years.  Five years ago I recall learning how the polio vaccination team, concentrated around Kolkata, numbered an astonishing 400,000.

And now India, as we have done in Australia, is actively pursuing a program of managed decentralisation of health services.  Expenditure is slowly, slowly rising from 1% to 2% GDP.  Health districts, generally much larger than ours and working on budgets of about $40 per capita per annum, are forming.  It is interesting to see the complex tensions between federal, state and district, so familiar to us in Australia, played out at a mind boggling scale and stupendous complexity.  India gives democracy as a conversation among all citizens powerful and astonishing meaning.

Health statistics are sparse and hard to interpret.  What stats there are point upwards.  As I drove through urban slum areas all my thoughts about chronic disease prevention and primary health care were pounded by rough surf of the social realities of that vast country.  But India is moving and progress is occurring.  No shortage of work for doctors there!

THE APOLOGY – FIVE YEARS ON*

On February 13^th five years ago, the then Prime Minister, Kevin Rudd, and the leader of the opposition, Brendan Nelson, together presented an apology on behalf of the Australian people to our Indigenous brothers and sister.  The apology was offered on behalf also of the parliaments that passed the legislations that led to the forced removal of Aboriginal children from their parents.  http://www.dfat.gov.au/indigenous/apology-to-stolen-generations/rudd_speech.html .  Mr. Rudd explained the reason for the apology.

Let the parliament reflect for a moment on the following facts: that, between 1910 and 1970, between 10 and 30 per cent of Indigenous children were forcibly taken from their mothers and fathers; that, as a result, up to 50,000 children were forcibly taken from their families; that this was the product of the deliberate, calculated policies of the state as reflected in the explicit powers given to them under statute; that this policy was taken to such extremes by some in administrative authority that the forced extractions of children of so-called ‘mixed lineage’ were seen as part of a broader policy of dealing with ‘the problem of the Aboriginal population’.

Mr. Rudd then went on to say:

We need a new beginning—a new beginning which contains real measures of policy success or policy failure; a new beginning, a new partnership, on closing the gap with sufficient flexibility not to insist on a one-size-fits-all approach for each of the hundreds of remote and regional Indigenous communities across the country but instead allowing flexible, tailored, local approaches to achieve commonly-agreed national objectives that lie at the core of our proposed new partnership; a new beginning that draws intelligently on the experiences of new policy settings across the nation.

Let us resolve over the next five years to have every Indigenous four-year-old in a remote Aboriginal community enrolled in and attending a proper early childhood education centre or opportunity and engaged in proper preliteracy and prenumeracy programs.

After Mr. Rudd and Dr Brendan Nelson had completed their speeches they greeted members of the Stolen Generation in the distinguished visitors’ gallery in Parliament House.  The official report of the day http://www.fahcsia.gov.au/our-responsibilities/indigenous-australians/programs-services/recognition-respect/apology-to-australias-indigenous-peoples describes how ‘Aunty Lorraine Peeters [then] presented the Australian Parliament with the gift of a glass coolamon [created by Indigenous artist Bai Bai Napangarti].

Peeters

The coolamon contained a message thanking the Parliament for the apology on behalf of all those affected by removal from their families. In the message Aunty Lorraine explained that the coolamon was a traditional vessel for carrying children, and "a symbol of the hope we place in the new relationship you wish to forge with our people".’ 
‘‘The idea of the empty coolamon was poignant;’ said Brenda Croft, senior curator of Aboriginal and Torres Strait Islander Art at the National Gallery of Australia at the time. “It reinforced the idea of children being taken away from their communities,’’ she says. ‘‘It’s the indigenous form of the cradle. It was no accident.’’  The coolamon, together with the apology documents, are displayed in Parliament House.

How are we doing?  The Australian Bureau of Statistics offers encouragement. Infant mortality is improving.

INFANT MORTALITY RATES:  Aboriginal and Torres Strait Islander and non-Indigenous people 2001–2010

Source: ABS Deaths collection.

It remains the case, though, that we have an incomplete picture of life expectancy of our Indigenous people.  If it mattered to us we would probably do better at measuring it.  At present it is like sending soldiers into battle and not knowing how many are shot dead.  But

‘For those jurisdictions with reasonable information about Indigenous deaths, the median age at death in 2010 for Indigenous males ranged from 50.8 years for those living in the NT to 58.3 years for those living in NSW. These levels were around 20 years less than those for non-Indigenous males, which ranged from 64.9 to 79.6 years. The median age at death for Indigenous females in 2010 ranged from 55.4 years for those living in the NT to 67.1 years for those living in NSW. These levels were also around 20 years less than those for non-Indigenous females, which ranged between 75.2 and 84.9 years.’ http://www.healthinfonet.ecu.edu.au/health-facts/overviews/mortality

We get the parliament we elect:  that’s democracy.  Neither Mr. Rudd nor Dr Nelson lasted long and our parliament has descended from the mountain top to once again concentrate on the things that really matter to us and to them.  But it is a wonder, a treasured memory, that day, five years ago, when the cant, self-comforting delusion and bluster were stripped off the reality of the way in which we had treated Aboriginal Australians, and we said sorry.  Maybe other great days will dawn.  Maybe the coolamon is not empty after all.

*This article has been published in Australian Doctor