Physician Leadership Around the World

Despite differences in training, type of healthcare organization, geography, and community demographics, physicians in every culture and country face similar challenges: providing quality, affordable healthcare; working within complex systems of policies and processes; managing people and resources; leveraging technology; and promoting efficiencies across their local healthcare system.

What does physician leadership look like around the world? What motivates physicians to step into leadership positions? What path do they take? We asked several American Association for Physician Leadership (AAPL) international members about their particular experiences and insights into healthcare and physician leadership. Physician leaders in Qatar, Canada, Sweden, Pakistan, Australia, the Kingdom of Bahrain, and India share their stories here.

Administering and Coordinating the Business of Healthcare in Qatar

“With the COVID-19 pandemic unfurling its fury worldwide, I find my role all the more important….”

By Nandakumar G. Pillai, MBBS, MRCGP, FRCP(Edin), FRCPI, FFOM

I am a physician with 24 years of experience in clinical medical practice. The majority of my work was prioritized and directed at the curative aspect of patient management as an internist and as a primary care family physician. Once I started working in the primary care and occupational medicine department, regarding the fitness, ability, and adjustments required at work along with the preventative measures like health promotion activities, health surveillance spurred my interest in the social and preventive aspects of medicine.

To acquire the knowledge and skills, I pursued higher training in family and occupational medicine, which culminated in an MRCGP and MFOM from the Royal College of General Practitioners in the UK and the Royal College of Physicians in Ireland, respectively.

My interaction with the employees and contractors while working for the premier oil and gas companies in Qatar made me aware of the mental health problems prevalent in that subset of the healthy worker population. I understood that multiple determinants, including poor work organization and psychosocial risks, could lead to mental ill-health at work which, in turn, causes absence due to sickness (both short- and long-term), presenteeism, and early retirement.

With the realization that there is a gap in the doctor-patient relationship in managing health issues holistically, I decided to gain skills to undertake a better role in administering and coordinating the business of healthcare.

A certificate course on Managerial Effectiveness of Public Health Care gave me an insight into the management aspects of public health. I started to explore the possibility of integrating mental health as part of routine primary care services, as this would open a lot of opportunities for early intervention and prevention of varied mental health issues.

This thinking led to the transition from providing clinical care to the individual patient to a bigger role in leading a team of physicians and nurses and taking care of the overall well-being of the employees and students.

I am currently an occupational health manager with Qatar Foundation, a nonprofit organization of more than 50 entities working in the education, science, and community development sectors. My responsibilities include taking care of the health and well-being of about 8,000 students and 4,000 employees of the organization.

With the COVID-19 pandemic unfurling its fury worldwide, I find my role all the more important as, according to the United Nations, “although the COVID-19 crisis is, in the first instance, a physical health crisis, it has the seeds of a major mental health crisis as well.”

Postgraduate Medical Leadership Education in Canada

“Just as medical curricula rely on structured learning combined with graded clinical responsibility, so should there be an emphasis on the integration of leadership training…”

By Trevor W. Lee, MD, MMM, FRCPC, CPE, FAAPL

In Canada, postgraduate medicine focuses on career development around the three pillars of academia: clinical excellence, administration, and research. While we have long-established methods of teaching in the clinical and research pillars, the promotion and utilization of the educational pathways available for administrative learning are often considered to be of secondary importance.

Much of the career development in leadership is self-directed, but there is opportunity to integrate leadership education and training along with succession planning within healthcare.

Education and training in medical leadership and administration has an increasingly important role to play in today’s rapidly changing healthcare setting. Encouraging our learners and colleagues to undertake careers in leadership and healthcare management is critical for facing challenges both now and in the future. The requirement for formal leadership credentials when applying for medical administrative positions in Canada is becoming more common, and institutions should therefore prepare graduates with the necessary tools for successful careers in medical administration.

Currently, leadership certification is administered nationally by the Canadian Society of Physician Leaders (CSPL). The most common pathway to qualify for this credential is by completing online or live courses offered by the Canadian Medical Association’s Physician Leadership Institute, in combination with leadership experience that is recognized by the CSPL.

Many Canadian medical colleges play a sponsorship role and host live, onsite courses for clinicians to attend. For those physicians looking for education outside of Canada, the American Association for Physician Leadership, a partner to the CPSL, provides a wide range of courses that can lead to American certification.

In addition to certification, many institutes of higher learning now offer graduate degrees in medical management or business administration with a healthcare focus. Most of the Canadian universities that offer doctoral degrees also offer master’s degree programs with an element of healthcare administration or public health focus. Similarly, many Canadian physicians choose to obtain graduate degrees in medical management from universities in the United States and abroad.

While some believe that leaders are born and not made, others are of the opinion that formal leadership education and training are an essential element of the leadership journey and career development within healthcare administration. Just as medical curricula rely on structured learning combined with graded clinical responsibility, so should there be an emphasis on the integration of leadership training, in concert with exposure to increasingly senior physician leadership roles.

Physician Leaders in Sweden — Making Difficult Choices

“Taking on a leadership position often means they must resign from all clinical work, which discourages many from pursuing these roles.”

By Peter Hovstadius, MD, PhD

There are just over 34,000 registered medical doctors in Sweden. The Swedish Medical Association (trade union and professional organization for all doctors in Sweden) has encouraged its members to pursue leadership roles for many years. They have a dedicated member network for physician leaders, which organizes leadership education, seminars, and networking events.

As in many other countries, doctors in Sweden enter leadership roles late in their careers due to the long clinical training. The percentage of doctors in leadership roles had been relatively stable, about 14%, however a Swedish Medical Association survey showed a decline during the past eight years to 11.4%. The decline is more notable in higher strategic leadership roles. These numbers apply only to the clinical healthcare sector and do not consider the doctors working as leaders in other sectors such as pharmaceutical, health tech, consulting firms, etc.

Doctors in Sweden, like doctors in any country, value and enjoy their clinical work highly. Taking on a leadership position often means they must resign from all clinical work, which discourages many from pursuing these roles.

Also, there has been a trending opinion in the Swedish healthcare system that you don’t need to be a medical doctor to take on a leadership position — you “only” need to be good at leadership and strategy. This has resulted in many non-medics taking on leadership positions across the entire healthcare sector.

The Swedish Medical Association has argued for the importance of having clinical knowledge when leading healthcare organizations and has suggested innovative ways to make it easier for doctors to combine clinical work with a leadership position. The debate is ongoing and sometimes very heated.

Medical doctors dominate the medical director positions in the pharmaceutical industry in Sweden and have a strong network in the Pharmaceutical Industry Association. When I finished my specialty training, I joined the pharma industry due to the good opportunities for leadership positions in Sweden and internationally. For me, 15 years in pharma leadership positions has undoubtedly made me a better leader — but just like so many other doctors who left the hospital, I have missed having contact with patients.

Innovation and Passion — Developing Physician Leadership in Pakistan

“Working in a developing country like Pakistan…I realized the significance of leadership in making our healthcare effective and patient centric....”

By Zakiuddin Ahmed, MBBS, MBA

I became a physician to serve the patient as the ultimate beneficiary of all our efforts. The introduction to telemedicine, at the outset of my career in 1998, convinced me to make the necessary shift from being a clinician to a health systems professional looking at the larger picture. From then onward, I invested my time and efforts in adding value to the health ecosystem by focusing on technology, quality and patient safety, and meaningful research.

Working in a developing country like Pakistan, with extremely limited resources and every type of challenge in our health system one can imagine, I realized the significance of leadership in making our healthcare effective and patient centric. Developing leadership qualities in physicians is as essential as enhancing their clinical skills and acumen.

To help other physicians build their soft skills and leadership qualities, I had to invest in myself first. I became a member of the American College of Physician Executives way back in 1999. Hence, my journey of self-development and leadership began. I not only developed myself by attending most of the globally acclaimed leadership courses, I also got certified in a few estimable programs, including 7 Habits of Highly Effective People and Unconscious Bias by Franklin Covey.

I started training the senior-most physicians from clinical as well as managerial backgrounds using my specially developed courses on healthcare leadership, healthcare communication, and culture and teamwork. My membership with the American Association for Physician Leadership helped me tremendously as I embarked on this journey of helping physicians, CEOs and MDs of hospitals, and senior health officials in government become true leaders.

To institutionalize my efforts, I established the Institute of Innovation Leadership in Medicine, which not only offers individual training programs, but also creates a critical mass of current and future healthcare leaders who could synergize with each other to improve the poor health system of Pakistan. To make our efforts sustainable, we are establishing local Centers of Healthcare Leadership at medical schools, universities, and leading hospitals to initiate change through indigenous efforts.

With the recent COVID pandemic, the whole world has realized how ineffective our healthcare systems have become. Healthcare of today is as inefficient as it can get. With preventable medical errors becoming the third-leading cause of death in the United States, threat of entering the pre-antibiotic era, uncontrollable double disease burden, ever-increasing costs, and physician burnout as some of the bleak indicators, physicians must stand up and take responsibility for leading healthcare with the right purpose and passion to build a patient-centric healthcare system globally.

Connecting Physician Leaders Across Australia

“Anarchy in the AUS, where physicians and other healthcare professionals do as they please, might otherwise ensue without trustworthy stewardship.”

By Thomas Boosey, BSc(Biomed), MBBS, FRACGP, MHA, GradCertHSM, AFCHSM, CHM, CPE, AMA(M) – Candidate for FRACMA

One might be forgiven for thinking physician leadership must be flipped in the land down under. Alas, even an undertaking of universal healthcare is no magic cure for the inherent chaos of coordinating management of human ailments by a complex web of providers.

Anarchy in the AUS, where physicians and other healthcare professionals do as they please, might otherwise ensue without trustworthy stewardship. Enter the Royal Australasian College of Medical Administrators (RACMA) — the AAPL’s sister college, and my medical management and leadership alma mater.

More than just a fellowship training provider, RACMA connects physician leaders between state jurisdictions, across the ditch to New Zealand, and around the world through the Hong Kong College of Community Medicine (HKCCM), the Faculty of Medical Leadership and Management (FMLM) in the UK, and the AAPL, for sharing healthcare governance lessons and management innovations.

Locally, a network of candidates in my home state of Queensland has been nurtured by Fellows of the College honoring their Hippocratic Oath to impart knowledge of the art of medicine. After all, that is what sets physician leaders apart from other administrators.

Recognizing that funded training opportunities in the private sector are hard to come by in this jurisdiction, despite private health competencies featuring prevalently in RACMA’s Medical Leadership and Management Curriculum, a private hospitals statesman established a virtual learning set to help bridge this gap. In the spirit of inclusivity, foundational members could extend the invitation to any college affiliate.

We take turns coordinating the schedule and moderating discussions to ensure content is mapped to private health management elements in the curriculum. The Chatham House Rule (chathamhouse.org), whereby “participants are free to use the information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed” is respected given the commercially, politically, and media sensitive nature of these conversations. This allows learning set members to debate constructively in a psychologically safe and collegial training ground — consistent with the expectation that they WILL prosecute their case and defend their positions to positively influence the collective knowledge of the group.

Pastoral care elements have been borrowed from the Balint group method (www.racgp.org.au) of debriefing on participants’ accounts of interactions with, in this instance, their healthcare followers not just patients. Learning sets like this provide the foundations for career-long networking of like-minded peers.
I commend them to all you physician leaders around the globe.

The American Mission Hospital, Bahrain — A Small Hospital with a Big Mission

“Collaboration with international and local partners to ensure teaching and training for local staff brings to full circle what was begun 120 years ago.”

By George Cheriyan, MD, FRCP, FRCPI, MBA

In 1895, three missionaries from the New Brunswick Theological Seminary had a call to missions in the Arabian Peninsula. This brought them to the small island nation of Bahrain, just off the shores of the Eastern part of modern Saudi Arabia.

The need for medical care was great as there were no hospitals in the region. One of the missionaries, Samuel Zwemer, was married to a nurse with whom the first clinic was established to care for women. The Arabian mission was born and a call for qualified physicians was made and answered with the arrival of the first American physicians. A new hospital called the Mason Memorial Hospital was established in Bahrain in 1902. This was later named the American Mission Hospital (AMH).

With very little resources but hearts of service driven out of compassion and love for the people of the land, the seeds of a lasting friendship between two nations, two peoples, and two faiths were born. Oil was discovered 30 years later that transformed the Arabian Peninsula to what it is today.

Bahrain is a small island nation with a population of just 1.5 million people and is a key strategic partner of the United States through its military and commercial partnerships, which have rapidly developed. The U.S. Navy’s Fifth Fleet is stationed in Bahrain.

For 120 years, AMH had its struggles in delivering healthcare in the midst of a rapidly developing oil economy and in attracting qualified healthcare providers to work in a modern healthcare setting. I came to serve as its 13th chief medical officer and CEO after a 28-year career as a neonatologist. The immediate challenges were to modernize the hospital, to balance its revenues, and to upskill staff on quality and patient safety to a modern healthcare institution.

Ten years on, we have expanded to having three modern ambulatory facilities and currently are building a state-of-the-art fully digitized 120-bed hospital that is futuristic as a flagship hospital for the organization, which remains steadfast on its founding principles as a not-for-profit organization with the generous support of the King of Bahrain. The hospital is Diamond-rated — the highest rating — for its quality and patient safety. Collaboration with international and local partners to ensure teaching and training for local staff brings to full circle what was begun 120 years ago.

AMH, which started as a small mission hospital, stands as a testament to the long-lasting friendship and partnership between Bahrain and the United States.

Physician Leadership in Canada — Its Own Unique Path

“Canadian physician leaders will meet the challenges necessary for positive transformation of the Canadian healthcare system.”

By Edgar G. Chedrawy, MD, MSc, FRCSC, FACS, MHA, CPE, FAAPL

The Canadian and American healthcare systems have some similarities (common medical education standards, similar hospital accreditation mechanisms) but many differences, including different organizational structures and finance models.

The neighboring countries share many similarities in societal culture but each went on its own path for healthcare after WWII, with Canada adopting a single-payer health system (Canada Health Act) and the United States implementing private insurance models except for patients over the age of 65 and the uninsured (U.S. Social Security, Medicare and Medicaid Act).

The fundamental cultural differences in these two health systems have led to diverging evolutions in their respective healthcare leadership cultures. As the United States moves toward more formal and structured leadership models for physicians, Canada lags behind in physician leadership training, empowerment, and recognition.

The single-payer nature of the Canadian system leads to more control in the hands of government or health system administration as opposed to frontline physicians and other healthcare workers. Complicated hospital and government administration hierarchy has led Canadian physicians to feel removed from the decision-making authority and process.

In a 2018 Canadian Medical Forum study (The Evolving Role of the Physician: Leading in Care, Leading in Health Care System Change), Canadian physicians identified barriers to their participating in healthcare system design and change: time constraints (34%), system-level barriers to involvement with governments (18%), remuneration models (lack of compensation) (15%), and inadequate training (12%).

Barriers to advancing physician leadership culture in Canada can be divided into physician-based and system-based barriers. Physician-based barriers mostly relate to physicians not having enough time (or compensation) to spend on leadership issues for healthcare system transformation. Also, most feel they do not have adequate training in the “hard” and “soft” skills of leadership to even have a positive impact.

Physicians involved in leadership are not viewed highly by some of their peers, and physician leadership positions are looked at as a senior or phasing-out type of passive commitment and not as an active role in healthcare delivery.

On the system side, political obstruction from traditional, non-physician health system leaders has led to an increasingly complex system filled with subtleties of academic and political cronyism and, at its core, some may say the healthcare version of the Peter Principle. Multiple layers of administration have caused physicians to believe their voice is lost. Physician leaders themselves feel threatened if they do not fall in line with the non-physician leadership agenda.

Canadian physician leaders will meet the challenges necessary for positive transformation of the Canadian healthcare system. Formal training in leadership competencies and technical skills (through programs offered by Canadian Medical Association, Canadian Society of Physician Leaders, and AAPL) will enhance physician leaders’ abilities to navigate the complex administrative structures in place.

Physician contracts should protect, if not compensate, time for physicians to play active roles in administrative leadership positions. Over time, the attitudes of their peers about physician leaders will improve and reflect the value physicians bring to the healthcare corporate suite. Ideally, proper physician leadership mentorship programs will be formalized and valued from both frontline physicians and non-physician administrators.

Just as the Canadian and U.S. health systems have evolved separately, their physician leadership cultures will evolve to reflect the cultural differences of the individual systems. Canadian physician leadership will have its own unique character yet share some common fundamental principles with the U.S. …. Eh!

I want to thank Dr. James Calvin, executive vice president / chief medical officer at London Health Sciences Centre, London, Ontario; Joe Noora, MD, FRCS, MS, head of cardiac surgery and former president, Professional Staff Association, Trillium Health Partners, Toronto, Ontario; and Ken West, MD, FRCPC, president, Medical Staff Association, Dalhousie University, Halifax, Nova Scotia, for their valuable insight.

Transforming Healthcare in India Through Innovative Leadership

“Being passionate of daily work can help achieve the impossible.”

By Ragupathy Veluswamy, MD, MMM, CPE, FACPE

After four decades of working in United States in various capacities, ranging from junior physician to vice president of renowned hospitals, physician executive education through AAPL provided me a splendid and steady growth in my career.

Back in the year 2015, I joined G. Kuppuswamy Naidu Memorial Hospital (GKNMH), a unit of The Kuppuswamy Naidu Charity Trust for Education and Medical Relief, which was established in 1952 by G. Kuppuswamy Naidu to serve the community with affordable quality medical care.

Like in other countries, in India there exists a public and private healthcare sector. The physicians in the public sector soar up in their career merely based on their seniority of joining the service. However, in the private sectors, though it was the same practice over the years, late in the new millennium appraisal scores began being used to elevate them to different positions and payrolls. In neither sector does a formal or informal network of executive physicians exist.

As the chief executive officer of the renowned hospital managed by a board of trustees, I was given a free hand to execute all my management principles and futuristic strategy to expand the hospital both functionally and structurally. Developing second-level leadership and providing opportunities to aspiring junior physicians to lead the department did break the monopoly of only seniors holding the position. I implemented paperless work in the hospital. Befitting designation and a career pathway was established for departmental personnel’s IT department and its digitizing of medical records — the first in India — is the latest ongoing project.

The day kick-starts with a “flash meeting” of the heads of the department who present the positive aspects of their departmental functions followed with problems faced in the last 24 hours and the amicable solutions for the same.

Patient care experience is the major focus in all our activities and interventions in the hospital. Executive patient rooms with state-of-the-art facilities were constructed in the recent past. The structural design and changes made during the COVID-19 pandemic helped to navigate the patients for COVID care and quarantine thereafter without affecting the general patient flow.

A state-of-the-art holistic outpatient center will be constructed in 14 months using a prefab structure.

My plans are to:

• Create a smart hospital with a paradigm shift from disease treatment to health management that encompasses wellness, healthy living, disease prevention, and rehabilitation.

• Enable the smart patients to have the hospital data whenever necessary.

• Provide digital health via telemedicine services through centers and mobile-based telecommunication applications.

• Implement IOS-based EMR across the hospital for clinical services.

• Create and deliver speciality care to patients by health personnel who have credentials in the respective speciality.

• Create a sound “Tribal Leadership Culture” in our hospital to boost the work culture and focus their passion of care and service par excellence.

I believe “Being passionate of daily work can help achieve the impossible.”

Common Mission, Better Outcomes, Global Impact

Editorial comment from Peter B. Angood, MD, CEO and president of the American Association for Physician Leadership

Over the millennia in different ways, society has called upon physicians, and their profession as a whole, to lead. For nearly 50 years, the American Association for Physician Leadership (AAPL) has answered this call by enabling physicians to better create personal, professional, and organizational transformation — thereby enhancing clinical operations, creating multi-faceted value, driving industry innovation, bettering patient outcomes, advancing workforce wellness, and improving population health.

As evidenced by this sample of accounts from physicians around the world, AAPL’s influence is not only an American initiative, but a global initiative. AAPL typically has members from 40 or so countries, and we are grateful for the contributions to this article from physician leaders located in Qatar, Canada, Sweden, Pakistan, Australia, the Kingdom of Bahrain, and India. Thank you!

The most effective physician leaders are those who recognize the importance of collaborating with colleagues locally, across the country, and across the globe to help lead the profession — and our healthcare industry — forward. Leadership during these uncertain times is challenging, but as these contributors emphasize, physician leaders are providing that leadership with courage, innovation, passion, and commitment to better patient care. An opportunity is in front of us all to create significant positive influences in our industry.

All physicians, at some level, are leaders — so let’s embrace the moment as leaders to lead; to help lead the industry in new directions that ultimately improves patient care and outcomes.

Thank you to the contributors for sharing their physician leadership stories from around the world.