Doctors as leaders – how essential is leadership training for them?

Purpose – In the management world, leadership is a quality associated with business leaders, social entrepreneurs and political ﬁ gures. Doctors are rarely considered as possessing or requiring leadership skills. With doctors, one thinks of skill and knowledge, but for some strange reason, leadership is hardly associated with doctors. This paper aims to highlight the leadership aspects unique to doctors. This study highlights why leadership training is imperative for doctors, outlines current status of leadership training for doctors in India andsets outproposalsforeffectiveleadership building. Design/methodology/approach – Methodology is based on a two-pronged explanatory approach – the ﬁ rst is review of current literature in the context of leadership training of doctors, and the second is review of circumstances unique to theline ofwork undertaken bydoctors thatshed lightontheneed for leadership. Findings – This paper highlights the imperative need for leadership training for doctors in India. It recommendsleadership trainingona continuousbasis in their career life cycle aswith theother professions. It also calls for involvement of all stakeholders in the medical community to foster leadership training – medical educationalinstitutions, hospitals,medical councils andmembers ofthe medicalfraternity. Practical implications – Akin to leadership training programs conducted for IT and management professionals,this paper recommends that similar programsbe conducted for doctors. Originality/value – There are very few studies conducted in the Indian context on leadership training needs for doctors. This paper explains the importance of leadership training for doctors and suggests ways it can be implemented throughoutthemedicaleducation life cycleof a doctor ’ s career.


Introduction
The journey with regard to the management-related aspects of doctors has just begun in the past few years (Spurgeon et al., 2011). Doctors were earlier taught and trained about the medical skills which are considered very important to succeed in their medical profession. But today medical institutions across the globe are incorporating other professional-related skills such as leadership in their curriculum to build effective leaders in the health-care system (AMA, 2020). It starts at the education level and integrated longitudinally across the doctor's career (Till et al., 2020). Today, the doctors are exposed to both medical and the nonmedical skills. But the professional skills on the nonmedical side such as leadership, team building and interpersonal skills and communication have not been given due importance in India. The objective of this article is to highlight the need for leadership training for doctors as an essential skill not only for their career but for the patients and the health-care delivery system at large (West et al., 2014;Ayeleke et al., 2018). The study has been conducted based on the current literature available on the leadership training for doctors along with the background of a doctor's life in the context of leadership-related situations. Finally, the article shares recommendations on the leadership training implementation across the career life cycle of doctors.

Current studies on leadership training
The study on leadership training that was conducted on residents and faculty of otolaryngology in the USA (Bent et al., 2017) explains that most of the residents are not exposed to leadership instruction and suggested the need for leadership training during residency. Barnes et al.'s study (2020) study also explains that the junior doctors are not aware of the role of leadership in their clinical practice and also recommends focus on building leadership skills. Another study of medical leadership and the medical student (O'Sullivan and McKimm, 2011) explains that leadership development is needed for doctors as a life-long learning process. The study on training for leadership (Rughani et al., 2012) explains why the medical education must put focus on leadership training and its distinction from "managerialism." Leadership is more on the individual context on how he/she influences and drives people to achieve the goals, whereas management is more from an organization context. Another study on leadership for doctors (Wilkie, 2012) explains that leadership skills are as good as the core clinical skills needed for the physicians. (Rotenstein et al.'s (2018) article in Harvard Business Review explains that medicine involves leadership and that which is through the course of a physician's career. All these studies highlight that leadership skill is essential for doctors. The role of leadership is found to be critical for nurturing high-quality care cultures.
In the James Mackenzie Lecture of 2010, Sir Lewis Ritchie addressed the leadership training need in today's world of unprecedented challenges. He defines leadership as "the ability to influence and motivate people" and describes leaders as people who "cope with change, they set vision and direction, and stimulate team members to follow that vision" (Ritchie, 2012). He compared leadership with that of the famous Greek philosopher Plato and explains him "as one who first defined the ideal leader as someone who commits to, and is trained for, a life of service and devotion to their fellow citizens." Another study (McKimm et al., 2015) highlights dimensions such as accountability, engagement with team and evaluating information under leadership. In this context of service, we must also look at the background or the circumstances that call for the leadership need of the doctors in their career lifecycle. The discussion below explains this aspect.

Methodology
A systematic literature review with regard to leadership training for doctors was done across articles in journals, newspaper articles and online posts. Websites related to medical curriculum in the Indian context, such as Medical Council of India (MCI) and state medical councils, were also studied. The literature study was undertaken by means of an explanatory method based on the "realist review" (Walshe et al., 2005) approach. Care was also taken to avoid generalization with regard to management training and studies on leadership training were only looked at. The review of literature was focused on studies conducted in the last 10 years (2010-2020). The paper is based on two approaches of need for leadership training -first based on the current studies done and second the work life of a doctor that calls for leadership through their career lifecycle.

Discussion
In the management world, they say some people are born leaders and some become or are made leaders. The contingency theory of leadership places a lot of importance on the circumstances or environment. This theory applies closely to the daily functions undertaken by doctors. Each day they are faced with new situations, new calamities, newer diseases and now an epidemic. And it is a situation where they cannot make mistakesfor it is a life that is at stake.

Why leadership training for doctors?
In the management world, leaders are mostly thought of from specific sectors such as corporate, army or the political arena. And in these cases, what they do at their workplace is what is studiedfor example, a CEO bringing back the organization from bankruptcy or a commander leading his forces in war. In the case of doctors, there are two scenariosone which is in the hospital and one outside. Their work in the hospital is known to all, but we must also look at those scenarios when doctors are called to lead. In the first case, such as during a surgery, we have a doctor leading the surgery and telling the team what he/she will do and what others need to do. During emergency cases, we have the doctors taking decisions on what to do by whom and when. Similarly, outside the hospital as well, let us take the example of a flight journey when a traveler gets sick, the flight crew goes around asking if anyone is a doctor and then asks them to lead the rescue operation of saving the life of the injured person. There are cases where doctors do not have the right medical equipment also, but still they are able to help. Recently, a doctor couple from Maharashtra saved a passenger's life while travelling back from their vacation. The doctor performed a medical procedure on the sick passenger with the aid of a mobile phone light (Karelia, 2019). This is something that we hear of in flights, boats and sometimes even in public places such as the parks and malls. This calls for the doctors to adapt to the situation and quickly do the needfulan essential trait of leadership.
The second aspect is that age is not a bar for the work performed by doctors. Irrespective of their age, a doctor is a doctor and often reached out to lead. Take the example of a postgraduate doctor in Karnataka who by means of video Whatsapp call helped a woman in labor. It was a situation wherein the woman went into labor at home and the women neighbors were called to help. The doctor through the video call directed them on the processes to follow, which helped the new mother (Pattanashetti, 2020). It was also a proud and happy moment for the women who managed the situation under her guidance. We also have another incident wherein a retired doctor from Karnataka on an international flight reached out to help an emergency situation when a passenger collapsed on the flight (Wangchuck, 2019). He along with another traveler (who was a nurse) worked together and saved the life of the person along with help of the crew members. The ability to tell others what to do in a tough situation and bringing out their best abilities as a cohesive unit is another essential element of leadership.
In the corporate world, leadership is mostly associated with growthpeople become a team leader or a manager wherein they have a team reporting to them and then they get to lead the team to achieve the organizational goals. It is mostly a formal, organizational process and in the political scenario, there is power. In the case of doctors, they do not have nurses or dieticians or paramedics reporting to thembut still they look up to doctors to tell them what to do. This requires the doctors to have the right skills in getting the job done.
Doctors start as junior doctors, become senior residents and then specialists. Their career growth is more of a skill-based and qualification-driven process, and training is all on the medical knowledge side. And at each stage, they are constantly asked to leadbe it an emergency case as a junior doctor in the emergency ward or calming an injured child and the parents to diagnosis based on symptoms as per the conversations with the patient as a specialist in the OPD or acting on an unexpected medical situation in a surgery. They not only need to have the knowledge but also the convictionthis is what is utmost needed in the current situation. Conviction is another essential element of leadership.
Through all the medical processes, tests and diagnosis that doctors undertake with regard to their patients, many challenges are involvedcalming a patient, getting the right information such as symptoms, sometimes seeing adverse situations such as excessive blood and damaged organs. All these actions call for maintaining the right emotional quotient to treat the problem and help the patient at the earliest in the best manner feasible. Emotional intelligence is also needed for leadership. Various studies (James, 2019;Mintz and Stoller, 2014) have also highlighted the importance of emotional intelligence for physician leaders.
In all these situations and the various stages of their medical career, decision-making is an essential part of a doctor's life. It could be as simple as the test to be conducted for diagnosis of the ailment or conditions suitable for surgery, right treatment method in the current scenario of the patient, give a candid or subdued analysis based on the patient type or when to send the patient home. Things are different for every patient type and ailment type. All of which involves making decisions with the information available and present conditions. Decision-making is also imperative for leadership.
All these factors highlight the need for leadership training for doctors. But what is most important is that they need to have this right from the start of their career to be followed up through the years, unlike in other professions. This is because at every stage of their career as shared above involves various aspects of leadership need. Each day, each stage they face a new situation highlighting the need for leadership.
This background of the doctors with regard to their work life and the earlier studies conducted highlight an imperative need for leadership training for doctors. Now that the need is clear, the next step is identifying what is the current status of this in India.

Current status of leadership training for doctors in India
As with other professions, doctors also have the concept of continuing professional development (CPD). The World Health Organization (WHO) set up a task force with regard to the same and in 2002 defined it as "To maintain and develop competencies (knowledge, skills and attitudes) of the individual doctor, essential for meeting the changing needs of patients and the health-care delivery system, responding to the new challenges from the scientific development in medicine, and meeting the evolving requirements of licensing bodies and society" (WFME, 2003). The rationale behind it was that they must practice this through their professional life for the betterment of their career and the people. This was earlier referred to as continuing medical education(CME). The MCI has mandated the concept of a "credit hours" point system with regard to updating knowledge of doctors (MCI, 2002). The onus to implement this system lies with states as health is a state issue. To ensure that medical practitioners stay updated with the latest medical advancements, many state medical councils have mandated compulsory CME, linking the credit hours as a must for renewals of registration. What does this CPD/CME cover? WHO working paper of South East Asia" explains it as wide-ranging competencies beyond clinical update, research and scientific writing, multidisciplinary context of patient care, ethical practice, communication, management and behavioral skills, team building, information technology, audit and appropriate attitudinal change to ensure improved patient outcomes and satisfaction (WHO, 2010). CPD is a broader concept and included both medical and nonmedicals such as professionalism and interpersonal skills (Anshu and Singh, 2017). But the reality is that the CPD/CME in India covers more on the medical aspects rather than the other HR-related aspects such as leadership. Medical curriculum at the undergraduate(UG) have recently introduced attitude, ethics and communication (AETCOM) module (MCI, 2019), which is a great step with regard to building nonmedical but essential professional skill for the doctors. But most of the medical school curriculum in India does not include the essential attributes shared by the WHO with regard to competencies such as leadership (Shrivastava and Shrivastava, 2019).
Various channels, organizations and online platforms that help the doctors with regard to the CPD/CME in line with their hectic schedule also focus on the medical related aspectssuch as conferences, seminars by leading medical experts in the country and from abroad. Omnicurus (omincurus.com), for example, which is popular platform for doctors with regard to CME has programs only regarding the medical field. The HR aspects such as leadership under professional's skills are not included in the same. Another online platform Medtalks (medtalks.com) conducts online video courses, organizes conferences and webinars, but they all are related to the medical field only.
Business schools are much sought out by people from the corporate world and defense, sometimes also in the later part of their career such as 5 to 10 years of experience. But this is not so for doctorsparticularly practicing doctors. Most of the business schools and related institutions do not have a specific course or a methodology exclusively for working doctors with regard to their unplanned and hectic schedules which are different from the others because of the medical emergency part. This is particularly so for leadership training. The Indian Institute of Management, Kolkata, is one of the few institutions that came up with a leadership and management program catering exclusively to the doctors (Economist, 2018).
Leadership training for doctors does not exist in the medical curriculum at all levelsfrom UG (MBBS) level, post-graduate level and through their continuing medical education (such as super specialization) as part of their career. It is also not adopted as a self-learning approach by the practicing doctors.
This needs to be compared with countries. The UK in 2011 set up the Faculty of Medical Leadership and Management (Till et al., 2020), Canada's Royal College of Physicians and Surgeons has a physician competency framework -CanMEDS, which includes it as one of the essential roles of physicians (Chen, 2018). The Association of American Medical Colleges has also included leadership skills among one of the key professional activities in residency (Neeley et al., 2017).

Implications of the study
There is a dire need for building leadership training for doctors in India. The health-care industry is one of the fastest growing sectors in India. According to IBEF, "Healthcare has become one of India's largest sector, both in terms of revenue and employment." And in this workforce, doctors form a large part and continue to do so. The number of registered doctors increased at a whopping rate of 40% in 2018 when compared to 2010 (ibef, 2020). With this large and growing workforce, it is imperative to build leaders who can take this industry ahead, and for this, leadership training is very essential.
Way aheadrecommendations for future The first step is to identify the need for leadership training, and the next step is the right implementation of solutions to achieve the same. In the case of doctors as shared above, leadership training has to be imparted right from the UG level. This could be the introduction of a specific leadership training module similar to the AETCOM one implemented currently in the final year of completion of the UG before they get into internship. This is because internship is the first stage that they will need it. This must also be made mandatory so that the doctors are prepared for it when they enter the intern stage.
The leadership training must also be included in their PG level curriculum because post the completion of the same, they become specialists, which involve more leadership and also because they will be guiding the other doctors and medical staff. At this level, also it must be made mandatory even though the current system is a hectic pace for the doctors. If this is not made mandatory, the doctors would want to skip this, not because they do not want to but because they already face a hectic pace. This will also help the senior doctors and the deans and other leadership members of the doctors to assess their capabilities. Perhaps, the approaches can be different from the typical classroom or the outdoor styles adopted by corporates or the on-job approach in the hospitals. Different approaches and suggestions have been proposed with regarding to imparting leadership training (Shankar, 2019) such as use of cinema. Onus of introduction of leadership training in medical education must be taken up the medical colleges.
As part of the CPD/CME, the state medical councils must also mandate leadership training for the doctors on a regular basis. Today, the process is not uniform across the states. The medical councils and associations must at a central level make this training mandatory at various stages of a doctor's career -specialization, super specialization, etc. They must also encourage the country's top business schools to conduct leadership courses for the doctors specifically. This will go a long way in building the professional skills of the doctors for betterment of their career and for the people being served by them and the health-care delivery system.
Finally, hospitals must also start looking at building the professional capabilities such as leadership of their doctors. This must be looked at in comparison of corporates across other sectors such as IT, financial institutions and manufacturing who constantly organize leadership programs for their employees. Hospitals need to go beyond the realm of the medical world as the most important skill of the job and also focus on additional professional skills that are required by doctors to do their job better and to make the healthcare delivery system more efficient. The armed forces, air force and navy also encourage their personnel to pursue management related courses in business schools. Just as armed forces and corporates offer programs and encourage members of their organizations to pursue management courses, hospitals must also encourage the doctors to pursue management courses at business schools. This will, in the long run, aid in inducing the professional skills such as leadership in doctors. Hospitals are the new age corporates and must adapt to the new needs of doctors and the environment today, akin to the response hospitals have had to technology.

Conclusion
In the current epidemic situation, doctors are the forefront across all nations fighting COVID-19. They are leading the war on health (Harris, 2020;Hesford, 2020). Doctorsjunior, senior and retiredall are rising to the occasion. They are leading across all aspectstelling support staff on what to do, public and government officials on precautions to be taken, symptoms and also on vaccine development, distribution, etc. Every single doctor countsand that is what they are doing now. This only highlights the imperative need for leadership training for doctors across their career lifecycle. Unlike other professions, where people have a choice to lead or follow, doctors do not. They have to rise to the occasion day after day. Leadership training for the doctors must be given from the first level of medical educationthe UG stage and all through their professional career as with the other professions. The focus on leadership training cannot be on a "good to have" basis but must be implemented on a "must have" basis. The onus for this lies with the medical fraternity, councils, associations, medical educational institutions, government and the hospitals. This will benefit the health-care delivery system, which is swiftly growing, and take it to greater heights.