Australasian Anaesthesia 2011 - Australian and New Zealand ...

210 Australasian Anaesthesia 2011Leadership in Anaesthetic Departments: A Surgeon’s View 211CHANGES IN HEALTHCAREThe growth of the centralised bureaucracy in health, in my view, is a major cause of a disenfranchised medicalprofession and has been a large deterrent to doctors engaging and volunteering for service roles in their hospitals.It is worthwhile considering the changes in governance of our public hospitals and the health system in Australia.Prior to 1972 and the advent of the Whitlam government, public teaching hospitals in Australia were the predominantplace for surgical intervention and hospitalised medical treatment. Over the ensuing years this preeminent positionhas shifted. In a report in 2008, the Federal Department notes that of the 2.1million surgical procedures performedin Australia only 908,000 were in public hospitals. 3 The public hospitals, where the largest departments of anaesthesiaare found, have been eroded over the last two decades in more important ways than can be measured numerically.An important and fundamental shift away from traditional allegiance to public hospitals by specialists occurred asa result of the doctor’s strike of 1985, at the introduction of Medicare during the Hawke government. This era alsocoincided with the rise of centralised bureaucracy.The rise of centralised bureaucracy has created a divide between clinical departments and hospital administration;the latter now looks centrally to the state bureaucracy, rather than being accountable to local clinician power. Thereport into the state of hospitals in NSW by Peter Garling SC perhaps summarised the basic issue most succinctly:“During the course of this inquiry, I have identified one impediment to good, safe care which infects the wholepublic hospital system. I liken it to the Great Schism of 1054. It is the breakdown of good working relationsbetween clinicians and management which is very detrimental to patients. It is alienating the most skilled in themedical workforce from service in the public system. If it continues, NSW will risk losing one of the crown jewelsof the public hospital system: the engagement of the best and brightest from the professionals who are able toprovide world-class care.” 4The Workplace Research Centre at the University of Sydney in its submission to the Garling Report in 2008found that only 17% of doctors and 33% of nurses in public hospitals trusted their managers. The national workplaceaverage is 70%. 5In his submission to the Garling Report, Professor Michael Cousins, previous President of the Australian andNew Zealand College of Anaesthetists said 6 :“After 50 years of observing this hospital, I’m sad to say that over the last 10 to 12 years there has been aprogressive and, I would have to say, increasing erosion of morale, commitment and loyalty to the institution….I, like many others, are on a knife edge, of feeling that we’ve just about tolerated as much as we can and we areconsidering leaving…I would feel an enormous sense of loss – not loss for myself, but a sense of loss for whatmight happen to the service that I have tried so very hard to build...one of the key issues is a lack of delegationof decision-making…We still bear the responsibility for the clinical services, quality and the safety...The problemfrom my point of view (is) it’s been very difficult to get a decision.”Partly, the issues outlined by Cousins and others relate to the nature of bureaucracy. According to Germansociologist, Max Weber, 7 writing in the late 1800s, bureaucracy has fundamental characteristics:• centrally controlled and hierarchical,• it is policy driven, ie one size fits all,• it is budget driven, even budget obsessed,• rules are implemented by neutral officers, it is highly impersonal,• risk averse.To these characteristics, Cyril Northcote Parkinson, a British naval historian, added that bureaucracy was selfreplicative. 8 In fact he created a much quoted law of bureaucracy that ‘All work expands to fill the resources andtime available for its completion’. A corollary of this law is that bureaucracy is self perpetuating.If one compares these characteristics to the practice of medicine, one sees an almost opposite set of characteristics.These fundamental characteristics of bureaucracy make it unsuitable as a paradigm for the management andrunning of health. Consider that medicine runs in an almost opposite milieu:• control is devolved to the point of care. Ultimate control is at the end of an injection of Propofol,• each case is completely different,• spending is emotional,• it is highly personal,• it is risky.The National Health and Hospitals Reform Commission has tried to address this chasm through the creation ofsmaller health governance district boards. This may bring about nothing more than further local accountability withdelegation and decision making being kept central. Time will tell.BAD LEADERSHIPRegardless, there is a need to interface with the bureaucracy, and the medical profession can no longer sustain aGhandi-like non-participation policy. We need to take up the challenge. To steer all clinical departments, includinganaesthetic departments, through these changing and stormy times we need good leaders and leadership. Whatdoes make good leadership? I think the obverse is probably easier to answer. Bad leadership is clear to any whohave struggled under its burden. Each of the bad leaders I have observed in my career thus far tends to exhibit afatal flaw, a deadly sin that causes them to be less effective. These sins fit into the seven cardinal sins first outlinedin 590 AD by Pope Gregory the First. He was the first monk to become a pope and is credited with indirectlyconverting the pagan English, the Anglo Saxons, to Catholicism. He categorised sins into the venial (everydayforgivable sins) and the cardinal sins (those that relegate the sinner to eternal hell).Some bad leaders exhibit the sin of pride which is about a feeling or desire that they are more attractive andimportant than others. These are the leaders whose first order of business after being appointed is to design andprint good quality business cards, have the signage in the department changed and order a new computer and, ifthe budget allows, new office furniture. Often, coupled with the sin of pride, is a lack of insight into their ownperformance and more importantly, a lack of insight into the bemusement in which they are held by their department.Other leaders I have met exhibit the sin of envy where they believe that another person has something theyperceive themselves as lacking, and wish the other person to be deprived of it. These are the leaders who areconstantly whispering in corridors and hatching Machiavellian games to destroy others in order to self promote.They are amusing in the short term and tiresome in the medium to long term. These leaders are so busy with thepolitics that they fail to achieve tangible advances and benefits in their departments.Wrath is also a cardinal sin. These leaders display impatience with any of the processes that actually can advancetheir departments. They advocate withdrawal of services as a first line strategy when dealing with the hospitaladministration and believe business plans are a waste of time. They see cooperation with hospital administrationas weakness and believe that the media is a viable and sustainable forum for their venomous views about theirperceived lack of resources. Meanwhile, their departments and their areas suffer. The bureaucracy is not averse tousing their own strategies to negate the media attention these leaders generate.Then there are the leaders with avarice as a cardinal sin. Avarice also includes greedy behaviour, disloyalty, anddeliberate betrayal, especially for personal gain. This is the leader who takes the best lists for themselves and usestheir position for their own personal gain. In other words, they are disloyal to their colleagues in order to benefitthemselves. Sometimes this type of leader will enter pacts with the administration on how to control members oftheir department. This behaviour engenders distrust among the department which quickly becomes ineffective.A related sin is that of gluttony. This is about over-indulgence to the point of waste. I have seen this often indepartments that have a leader with a strong subspecialty interest. All other departmental pursuits and prioritiespale into insignificance when the subspecialty of the departmental leader requires more resources. There are theresearch nurses, the offices and the laboratories - meanwhile the rest of the department struggles for a meetingplace or lounge.The next cardinal sin is lust which is exhibited by the leader who uses their current post to achieve the next.They take on the leadership of the department as a means of achieving a job in administration, state bureaucracyor even the pharmaceutical industry. Their every action aims to add to their burgeoning curriculum vitae. They arein it for themselves.Finally, there is sloth. This is the most common of all the cardinal sins. The appointment is made by lookingaround the department to spot the anaesthetist who has not yet had a turn at being head of department. Thisreluctance to be appointed is used as an excuse to avoid hospital meetings at which their departmental budget isbeing decided. The world is run by those who turn up and these slothful leaders do not turn up, much to thedisadvantage of their department.GOOD LEADERSHIPSo let us turn now to trying to answer the more difficult question of what makes a good leader. There is muchwritten about the characteristics of good leaders but all seem to agree on three characteristics. Garry Wills, writingin the Atlantic Weekly in 1994 outlined these as integrity, the ability to listen and finally the ability to create a sharedgoal or vision. 9 Hogan found that leadership is a survival tool for an organisation, is vital for its success andfundamentally is about convincing individuals to give up their selfish goals in order to pursue a common and sharedgoal. 10When we consider the characteristics of good leadership it becomes clear that anaesthetists are naturallyselected leaders. They minimise distractions among the staff, registrars, patients and theatre administration toachieve the shared goal of completing the day’s work with efficiency and safety. More importantly they are calledupon to coordinate, counsel, arrange, cajole and organise surgeons! No greater test of leadership exists.