The case for measuring the outcomes of what we do

Published in Australian Medicine, February 2014 (https://ama.com.au/ausmed)

Feeling angry? This may be a good start for 2014

Published in Australian Medicine, January 2014 (https://ama.com.au/ausmed)

Interview with Dr Clement Loy (shortened version)

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Election website of The Royal Australian College of Physicians

Voting is currently underway for the Royal Australasian College of Physicians. Place your vote here: https://events.miraqle.com/RACP-2014/Positions-and-Candidates/

Nomination for the position of president-elect of the Royal Australasian College of Physicians

Candidate Election Statement

I nominate for the position of president-elect of the Royal Australasian College of Physicians as a public health and medical research worker, educator and clinician with extensive experience in senior health management, leadership, governance and policy, and with a strong record of contribution to the RACP. As RACP president-elect I would provide leadership that advances Australia’s community of physicians and the health of Australians.

Graduating from the University of Sydney in 1966, I commenced my career in clinical medicine, and continued my clinical involvement in public health medicine and health policy.  Currently I am editor-in-chief of the Medical Journal of Australia and chair of the Western Sydney Local Health District with an annual recurrent budget of $1.4 billion.

My research interests cover all aspects of prevention through to policies for integrated care in chronic disease. With continuous NHMRC support since 1971, I have mentored many public health research workers, supervising 18 PhD students. My subsequent international interests have involved work with the Earth Institute at Columbia University in global health, especially in India.

After moving from McMaster University to Newcastle University, its medical school then in its first decade, to pursue interests in medical education, I was dean of the Sydney Medical School from 1997-2002 during a time of fundamental change to curriculum and admissions policy. I led the development of the School’s research strategy, its rural clinical schools, and its internal reorganisation. 

Throughout my career I have continually engaged with the medical and lay community through speaking in public fora and writing in the specialist and general media. I have chaired a human research ethics committee in western Sydney for 20 years, and served on and chaired many high-level working groups and committees. Senior bureaucrats and politicians of various persuasions have negotiated with me as someone whom they and others trust.

In the 1980s and 1990s I was president of the Public Health Association for four terms. I helped establish the RACP Faculty of Public Health Medicine and served on what became its board of censors and its policy arm.

My experience has impressed upon me several important insights that I consider pertinent to taking the RACP forward. 

First, whatever else a leader does his or her most important function is to be the guardian of the organisation’s core values, the keeper of meaning, ensuring that those values are expressed first in governance, then in management, and most critically in practice. 

Second, non-profit organisations such as the RACP generally work best when diversity is nurtured and all constituent groups within the organisation are supported. To maintain trust among a diverse body of fellows, power is best decentralised, shared and bestowed, and its activities owned by the fellowship.

Third, organisational management and governance, like money, really matter. Ensuring that they align with the organisation’s values is essential. Energy from its top levels is required to maintain effective, healthy management and governance.

The RACP also needs flexibility in adapting to the changing disease profile and work practices of the digital age.  Ensuring its highly visible professional functions – of credentialing, educating, nurturing and supporting physicians – is its prime responsibility. 

I would be very pleased to play a leadership role as president-elect in ensuring that the RACP continues to do that with strength and clarity. 

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/