Servant Leadership in the Doctor-Patient Relationship
by Peter Balfour1, Ralph Lewis2, David Compton3, Katie Reginato Cascamo4 and Mitzi Wyman5
Peter Balfour is a highly motivated doctor of medicine (Birmingham, 1983) with a strong scientific background (BSc in Medical Biochemical Studies and MSc in Immunology. In addition to training in management and computing (MInstLM and ECDL) he passed the written papers of the MRCPsych exams (struggling only with the practical exam). Specialising in Addiction Psychiatry he remains fascinated by the biochemical and neurophysiological mechanisms that allow us to function but, at the same time is keen to help people of all kinds lead healthier, happier and more fulfilled lives through a combination of compassionate support and judicious prescribing.
1.CGL Doctor, Mansfield, CGL New Directions (contactable via peter.balfour@cgl.org.uk)
2.Chair Greenleaf Centre UK
3.Team Leader, Hatfield, CGL Spectrum
4.Founder and CEO, Courageous steps, California, USA 5.Experienced Nurse with much experience of working in the NHS
Conflicts of interests: we are all interested in promoting Servant Leadership (in some cases deriving direct financial advantage from it) and two of us are employed by CGL.
Abstract
Coined by Robert K. Greenleaf in 1970, the term “Servant-Leadership” is a contraction of “The Servant as Leader” and is centred on the idea that the purpose of the leader of a group of people is to serve that group.
This has prompted much thinking about what the purpose of leadership is and has had a profound effect on management structures. Application in health care has so far been limited and largely confined to management, but we suggest that the rationale might be applied more widely, especially in clinical contexts.
Introduction
After a 38-year career Robert K. Greenleaf retired from AT&T (where he worked on leadership development programmes) and went on to describe “Servant-leadership” (Greenleaf, 2002) as follows:
“The servant-leader is servant first. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And what is the effect on the least privileged in society; will they benefit or, at least, not be further deprived?”
Although his ideas were anticipated as far back as 600 BC by Lao Tse, who wrote “...The best ruler stays in the background, and his voice is rarely heard.
When he accomplishes his tasks, and things go well,
The people declare: It was we who did it by ourselves." (Seddon, 2018). It is only since the 1970s that a movement has been developing throughout the world to promote Servant-leadership (including at the largely virtual UK Greenleaf Centre - see References for contact details), but organisations elsewhere have based themselves on similar ideas - for example the Buurtzorg Nederland (home care provider) model for district nursing founded in the Netherlands in 2006/07 (Royal College of Nursing Policy and International Department, Policy Briefing 02/15, 2016).
The idea of helping others selflessly does not come easily to everyone, but many people do not shy away from the idea and the valuable contribution of people that are willing to subjugate their own wishes to serve a larger plan is increasingly being recognised. At the same time, recognition that authority which is too forcefully implemented can have a stifling effect on employees has led to many attempts to flatten the “hierarchical pyramid” (as discussed, for example, by Edwin Ghiselli and Jacob Siegel [Ghiselli and Siegel, 1972]).
It is recognised in the business world that an important part of leadership is encouraging people in order to bring out the best in them (Lagarde, 2019) but, Medicine has been slow to adopt this. In recent times, however, many medical professionals are beginning to embrace the idea.
What is Servant Leadership?
Servant-Leadership is about serving a group of people and leading them at the same time (McNerney, 2012); ten characteristics that exemplify it have been suggested by Larry Spears (Spears, 2010): listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people and building community.
There is significant overlap, but the ones that are, perhaps, most pertinent to the health professions are listening (the start of a healing relationship), empathy (which is helped enormously when relative “status” in the consultation is disregarded), healing (“Many people have broken spirits and have suffered from a variety of emotional hurts...servant leaders recognize that they have an opportunity to help make whole those with whom they come in contact”) and persuasion (convincing others, rather than coercing them into compliance).
The practitioner of Servant-leadership needs to act both as leader (for example presenting clinical treatment options) and as servant (prioritising patients’ wants). Often criticised as a soft skill, there are times when firmness and clarity need to be demonstrated and boundaries set very clearly. Mutual respect is central and respect for oneself critical if one is to avoid “compassion fatigue” [Tee 2018]).
Helping patients relax facilitates clinical interview and many techniques can be used. Shaking hands and using both first and second names when introducing oneself are good ways of showing respect (although the expectations of different cultures needs to be respected) while paying careful attention to the precise wording that a patient uses (“active listening”, Rogers and Farson, 1957) is vital. All interactions should be honest and open – and “genuineness” can greatly facilitate the development of trust. Extra effort (and time) may be required, but establishing good rapport and taking decisions jointly allows for better and more effective treatment plans to be developed.
It is worth mentioning that use of the term “servant” suggests subservience to some people and is not liked; recommending that they think of attending to patients as a way of serving a divine or naturalistic being, rather than being subservient to another human being, may be helpful to them.
How can Servant-leadership be implemented in the Clinical Consultation?
In the clinical environment health practitioners have sometimes been guilty of distancing themselves from their patients and adopting a matriarchal/patriarchal stance. Although greater knowledge and experience are generally associated with better clinical decision-making and patient outcomes (which makes this approach very understandable) this approach sometimes appears to have been defended more fiercely than it should have been.
Historical precedence is important, but such thinking can be flawed and, especially in a clinical consultation, ignoring the views of patients may result in inappropriate treatments being offered. Persuasion is often the best course of action and discussing how to proceed with the patient has been shown to significantly aid compliance (Baumann and Trincard, 2002, Storm et al, 2008) - thereby promoting safety. Furthermore, as Rodger Charlton states (Charlton 2015) true professionalism should include compassion (the genuine wish to relieve suffering). In recent years this appears to have become relatively scarce and to have lost ground to training in administrative or computing skills and Evidence Based Medicine.
Greater knowledge has often been used to command authority but, in the clinical environment, the best solutions usually combine information held by the healthcare worker (received wisdom and practical experience) and the patient (understanding of and familiarity with their personal situation) - as proposed by David Tuckett (Tuckett et al, 1985).
Clinical Experience
Effective leadership in the National Health Service (NHS) has often seemed to be lacking and, while there are a plethora of tailor-made courses offering to teach good leadership, being a follower remains less appealing (Kar, 2019). There often seems to be a desperate scramble to become “the leader”, but it is slowly being appreciated that there can easily be “too many cooks in the kitchen”!
Notwithstanding, Servant Leadership is slowly being adopted in Medicine, particularly in disciplines relating to mental health, such as Addiction Psychiatry (where hitherto its application has been largely confined to staff management). Equitable working with patients has long been recommended by the GMC (GMC, 2008) and large organisations such as Change, Grow, Live (CGL) have been increasingly focussed on staff feedback, for example through holding dedicated “Regional Assemblies” when management and clinical staff pool their ideas. The one held in 2019 (attended by over 700 people) concluded that managers should spend more time shadowing staff on the front-line in order to obtain greater insight into the practical difficulties that apply when implementing ideas that seemed good in theory - possibly on a regular and on-going basis.
The Way Forwards
Today there is less deference to authority than in the past and there are undoubtedly some advantages to this. Greater experience generally makes for better clinical decisions (especially when these are not straightforward) but acknowledging the views and opinions of patients usually results in better management plans being made (and adhered to) - although there are occasions when shared decision-making is not appropriate (for example in the emergency situations referred to by Deegan and Drake, 2006).
There is a growing consensus that attending to and prioritising patients’ wants should be the default position and this is slowly permeating healthcare institutions everywhere. Large organisations such as Change Grow Live certainly appreciate the wisdom of this and, increasingly, health professionals are employing it in their interactions with patients.
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