ABSTRACT • Despite leadership roles being critical, we persist with outmoded models of organisations and pay inadequate attention to developing individual leaders and new models of leadership within the medical profession. • New forms of leadership are required. Among many important roles, leaders are called on: • to enhance the meaningful identity of a profession; • to create effective linkages with other healthcare professionals and stakeholders, as well as with healthcare system managers; • to interpret complexity so that their institutions and followers can operate successfully in uncertain times ; and   MJA 2004; 181: 652-654    • to consistently model ethical behaviour

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Professor S Bruce Dowton

S Bruce Dowton

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THE PROFESSIONLeadership in medicine: where are the leaders?
S Bruce DowtonUniversity of New South Wales, Sydney, NSW.
S Bruce Dowton, MD, FACMG, FRACP, Dean of Medicine, and 
Professor of Paediatrics. 
Reprints will not be available from the author. Correspondence: 
Professor S Bruce Dowton, Office of the Dean, Faculty of Medicine, 
University of New South Wales, High Street, Kensington, NSW 2052.
 b.dowton@unsw.edu.auThe Medical Journal of Australia ISSN: 0025-
729X 6/20 December 2004 181 11/12 652-654
©The Medical Journal of Australia 2004
www.mja.com.au
The profession
number of external influences have now altered docto
and the hierarchies within which they practise. T
funding constraints, demand for greater accounta
safety, quality and efficacy of healthcare, and pub
medical inf rmation. The aggregation of hospita
systems has moved management from local clinic
distant bodies. Hospital-based clinicians now often f652 MJA • Volume 181 Number 1ABSTRACT
• Despite leadership roles being critical, we persist with 
outmoded models of organisations and pay inadequate 
attention to developing individual leaders and new models of 
leadership within the medical profession.
• New forms of leadership are required. Among many 
important roles, leaders are called on:
• to enhance the meaningful identity of a profession;
• to create effective linkages with other healthcare 
professionals and stakeholders, as well as with healthcare 
system managers;
• to interpret complexity so that their institutions and 
followers can operate successfully in uncertain times; and
MJA 2004; 181: 652–654
• to consistently model ethical behaviour.n 
ch
staI recent decades, the nature of the profession of medicine hasanged. The profession has been defined through long-nding legislative canons coupled with the status accorded to
individual doctors by society through societal contracts,1 and
deeply entrenched cultural systems arising principally from the
influence of professional craft groups. Before the advent of the
Internet, restricted access to medical information also protected
and contributed to defining the profession. It has been within
these frameworks that leadership roles in medicine evolved. A
rs’ autonomy
hese include
bility for the
lic access to
ls into large
al control to
eel lonely and
isolated in coping with increasingly devolved responsibility for the
actual delivery of care. Among many challenges facing Australian
medicine is developing leadership within the profession.
Leadership has received little attention in Australian peer-
reviewed medical literature. In my survey of articles indexed over
more than 30 years in five Australian journals (The Medical Journal
of Australia, Australian and New Zealand Journal of Surgery, Austral-
ian and New Zealand Journal of Psychiatry, Australian Family Physi-
cian and the Journal of Internal Medicine and its predecessor), I
could barely find 50 articles dealing with leadership. Over the
same time, there are at least 500 and, in some instances, thousands
of articles dealing with each of the national health priority areas2 as
currently defined by the Australian Department of Health and
Ageing. Furthermore, very few of the 50 articles, editorials or
letters dealing with leadership provide substantial information or
commentary on the makings of leadership. One regionally relevant
and accessible electronic archive of medical interest, the eMJA,3
does not index “leadership”, and in over 3800 entries has but three
items with “leadership”, “lead” or “leader” in the title. None of
these, or of the 95 or so items in which leadership is mentioned in
the actual text, deal with the subject in a substantive manner. I can
only surmise the subject of leadership is either unimportant,
uninteresting, or perhaps just too difficult, to warrant more
attention in Australian medical literature. Alternatively, the dearth
of discourse on medical leadership may be the result of outmoded
assumptions about leadership operating in concert with obsolete
organisational models.
Capable leaders are needed in medicine to shepherd and
influence continued evolution of dynamic healthcare systems. The
changes we face are profound and have crept up on doctors and
many professional bodies. The “professional bureaucracy”, charac-
terised by disseminated power, individual autonomy and inflexible
structures,4 has difficulty in responding nimbly to external forces.
For individual doctors, the model of professional work has moved
from control by individuals to constraint by systems, from flexibil-
ity to rigidity of practice, from primacy of an individual blend of
art with science to management by multiprofessional teams, and,
most importantly for many in the profession, stability has been
replaced by uncertainty and ambiguity. Increasingly, formal recog-
nition of status is being replaced by greater attendance to informal
and personal rewards by doctors. This, coupled with frustration
about not being able to deliver care the way they want to and a
desire for a more balanced personal life, is leading to an exodus
from lifetime commitment to clinical practice.
While the changed dimensions of medical practice and profes-
sional life demand and deserve respect, a campaign is needed to
develop doctors as leaders. Clinical mastery or eminence in
discipline-specific research does not necessarily translate into an
ability to lead. Society needs doctors to learn about new ways to
serve the ailing healthcare system as leaders in roles that are
personally meaningful and systemically effective. Doctors and their
professional organisations (especially the Colleges) must be open
to the reinvention of their relevance to medicine’s future. Our
colleagues in the United Kingdom suggest that the profession
needs to give more explicit attention to patients’ rights, public
responsibilities, partnerships, enhanced accountability and advo-
cacy for sufficient resources.5
Leadership is ultimately a social function within an organisation
or a group. Any consideration of leadership which begins with
aphorisms about influence, control, motivation, inspiration, lead-
ing by example, and so forth, avoids the need to consider the
nature of organisations of the modern world. Regrettably, the role
of leaders in modern professional and service organisations often
continues to focus on a hierarchical view of leadership as a part of
a mechanical view of organisations (ie, thinking of an organisation
as a machine in which all parts can be understood in detail). In
such a view, power, control and outcomes arise through division of
labour and differentiation of functions — the command and1/12 • 6/20 December 2004
THE PROFESSIONcontrol model. Significant parts of healthcare systems in Australia
remain locked in this paradigm.
Meanwhile, many doctors wonder where they fit into the
professional calling they entered with altruism, and still yearn to
serve. An all-too-frequent side effect of such a system is that junior
colleagues and medical students are exposed to the apparent
despair of leaders. Should we be surprised that disenchantment is
infecting the next generation of doctors?
Many metaphors beyond that of “machine” have been promul-
gated to describe modern organisations.6 For example, healthcare
systems may be regarded as “political systems” with all the
connotations of factional interest, conflict, power struggle, influ-
ence and compromise. In some ways, our healthcare systems also
resemble “psychic prisons”. In those confines, trapped doctors see
their work through a traditional lens which leaves deep dichoto-
mies between rational and irrational responses to the real changes
brought by external forces. The metaphor of organisational “psy-
chic prisons” cautions us against assuming that all aspects of an
organisation will be understood, and reminds us that dynamic
leadership in healthcare requires exploration of the unconscious
concerns of staff, which, if not addressed, thwart change.
Another metaphor for organisations is a living organism capable
of internal self-organisation.6,7 Such living entities use many
sophisticated and varied repertoires to respond to shifts in their
environments. This image has multiple derivative levels when
applied to complex systems such as healthcare (eg, a state health
service can be viewed as a very complex organism within which a
multitude of elements — ranging from hospitals and clinics to
large diagnostic laboratories right down to small trauma teams in
emergency departments) co-exist. Within such an organic system,
leadership roles are not defined in hierarchical management of
reporting lines, but rather as overseeing components within a
complex of related subsystems forming the wider healthcare
business and social ecology.
In new models of organising healthcare, medical leaders must
help design and supervise the complicated networks within such
systems. The work of leaders should be purposeful, authentic and
professionally meaningful. Explicit strengthening of governance
within our hospitals and healthcare systems will permit leaders to
operate more effectively. The safety and quality movement has
significant potential in this area. However, in many settings,
implementation of sound policy appears to be in danger of falling
into a morass of hierarchically driven bureaucratese, involving
blame-prone audit driven by paper-based compliance. The value
within the profession and healthcare system delivered by educa-
tion and training responsibilities is another area that needs explicit
attention in terms of the leadership of coordinated governance and
oversight.
We as a profession must decide which sort of organisation is
desirable — a machine under the illusion of control or a living,
evolving entity requiring appropriately skilled leadership and
relevant models of governance. The answer should be clear — if
we are planning for further gradual disenfranchisement of the
professional workforces and more public outcries about medical
error, we should rigidly aspire to have mechanistic organisations. If
we want sustainability and capacity to meet the challenging
demands of providing healthcare and promoting health and
innovation in an unpredictable world, we will want to be part of an
endeavour built around new organisational models truly valuing
our purpose. From studies in other settings, the evidence about
sustainability is clear8 — organisations which survive well have
attributes that include:
• sensitivity to their environmental context (ie, the ability to learn
and adapt);
• a sense of cohesion and identity (ie, the ability to build a
community and “persona” for the organisation);
• tolerance and decentralisation (ie, the ability to build construc-
tive relationships with other entities); and
• fiscal conservatism (ie, ability to govern growth and evolution).
None of these are easy for current healthcare organisations to
master, and, in this context, the implications for developing a new
generation of medical leaders and programs for reinventing the
current leaders are profound. Leaders in professional settings such
as healthcare have, I believe, several important roles, described
below.
Championing identity
Eminent Harvard opinion-leader, Howard Gardner, in reflecting
on the power of narrative and stories, writes “. . . leaders fashion
stories: principally stories of identity”.9 As external influences have
supervened and the relevance of professional bodies has waned,
doctors struggle for an identity within complex systems. The role
of the leader is to enhance the identity of each individual as
someone who adds value, be it by delivering care, promoting
health or through research. Gardner also refers to the struggle for
new stories to replace or augment older stories. Our profession
needs to make more time to hear and consider the success stories
from our clinics, hospitals and healthcare systems, often involving
those who are not part of traditional power structures.
Creating linkages
A role of new-style or reinvented medical leaders is to demonstrate
and engage their followers in creating order, not only in their own
work setting, but also through their interdependent work with
other people and with other systems. The capacity to promote
linkages and connectedness involves designing strategy, building
bridges across cultural gaps and empowering action.10
Translating complexity
In highly complex systems, we need leaders who have skills
resembling those of an accomplished orchestral conductor. Such
individuals understand and interpret the score across a wide range
of players. Without having extensively read the score or heard the
piece before, they can, with minimal rehearsal, lead the performers
to great coordinated achievement. Leaders engender comfort in
their colleagues when faced with uncertainty and ambiguity,
especially early in a decision-making process. They encourage
flexible thinking in designing new work practices and intermit-
tently ask their colleagues to contemplate possible futures, making
the previously unimaginable less daunting when it arrives. Leaders
also play a vital role in advocating an appropriate balance between
the professional needs of individuals and their collective responsi-
bilities to the institution, system or society.
Modelling behaviour
Leaders have a responsibility to always show intellectual rigour,
honesty, transparency and integrity in all they do. Their valuesMJA • Volume 181 Number 11/12 • 6/20 December 2004 653
THE PROFESSIONmust be evident, as it is the re-establishment of an explicit set of
professional values which will help remedy the current crisis of
confidence that swirls around us.11
Developing new models of leadership will require sustained
emphasis and attention, beginning during medical student and
postgraduate training and continuing in established professional
circles. Australia needs thoughtful dialogue about the role of
medical leadership in healthcare now and in the future. Our
colonial style of debate, which seems to drive so much of the hasty
setting of health policy through political point-scoring, has no
place in such a dialogue. Rather, we need a deeply thoughtful
discourse to develop frameworks for new models of leadership in
medicine. This important work awaits us — let us begin.
Acknowledgements
I am grateful for critical commentary from Philip Pogson, Mark Brown and Bill
Godfrey.
Competing interests
None identified.
References
1 Cruess S, Johnston S, Cruess R. Professionalism for medicine: opportuni-
ties and obligations. Med J Aust 2002; 177: 208-211. 
2 Australian Government. Commonwealth Department of Health and
Ageing. National Health Priority Areas initiative. Available at:
www.health.gov.au/pq/nhpa/index.htm (accessed Sep 2004).
3 eMJA. Available at: www.mja.com.au/Topics/index.html (accessed Jul
2004).
4 Mintzberg H. Structures in fives. Designing effective organisations. New
Jersey: Prentice-Hall, 1983.
5 Ham C, Alberti KG. The medical profession, the public, and the govern-
ment. BMJ 2002; 324: 838-842.
6 Morgan G. Images of organization. 2nd ed. Thousand Oaks: Sage
Publications, 1997.
7 Griffin D. The emergence of leadership — linking self organisation and
ethics. London: Routledge, 2002.
8 De Geus A. The living company. Boston: Harvard Business School Press,
1997.
9 Gardner H. Leading minds — an anatomy of leadership. London: Harper
Collins, 1995.
10 Wells S. From sage to artisan: the nine roles of the value-driven leader.
Palo Alto: Davies-Black Publishing, 1997.
11 Pendleton D, King J. Values and leadership. BMJ 2002; 325: 1352-1355.
(Received 3 Aug 2004, accepted 29 Sep 2004) ❏654 MJA • Volume 181 Number 11/12 • 6/20 December 2004


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