Introduction
Although doctors are often exhorted to be natural leaders in healthcare, both by position and responsibility, most doctors spend many years in followership. There is significant literature on the attributes and styles of leadership, however, relatively little on followership in medicine.
Followership is defined as a role held by certain individuals in an organisation, team or group that describes the ability or capacity and willingness to effectively follow a leader. In single and group interviews with medical trainees in various stages, it was found that participants struggled to define followership.1 Clinical care teams are fluid and not properly structured and organised. They are often formed instantaneously with members being present transiently and terminated without adequate closure when the patient is discharged from the hospital.
As such, both leadership and followership are essential contributors to the performance of clinical teams in delivering safe, effective, efficient, timely, equitable and patient-centred care. In other words, clinical followership is essential in achieving the goals of medicine and developing trust of the patients and public in the healthcare professionals and system.
Effective followers understand that they have the ability to influence their leaders and steer their teams and organisations to success. Good followership strengthens the team and its leadership. Today's followers will become the leaders of tomorrow. In the clinical setting, it is common for doctors to be followers in the day and leaders at night or over weekends and public holidays. The habits and skills that followers develop and exhibit will follow them into their leadership style. The phase from followership to leadership is in reality a continuum in the professional development of a clinician.
The types of followership
There is no universal approach to classifying the different attributes, styles and habits of followership.2 In this article, a simple classification of three categories is offered: the engaged and exemplary follower; the passive and conformist follower; and the disengaged and alienated follower.
The engaged and exemplary follower
The attributes of an engaged and exemplary follower include thinking critically, contributing new ideas, displaying flexibility of the mind and executing plans diligently to ensure success of the team. They are also active empathic listeners, able to build good relationships within and across teams, and skilled in negotiation and motivational communication skills. They make good role models by being competent, displaying integrity, and taking responsibility for their actions and accountability for their performance. Engaged followers are reflective and continuously learn from experience to improve their knowledge.
Engaged followers are able, ready and willing to take the initiative to step into leadership roles when the official leader is not available and to exercise their own judgement even when they face difficulties within their competence. They are self-aware and able to recognise situations beyond their competence or experience, and to seek advice and help appropriately. Exemplary followers are very likely to mature to become engaged, exemplary and effective leaders.
The passive and conformist follower
The passive and conformist followers display subservience to the leader, follow orders as instructed, and avoid exercising their own judgement and decisions in difficult situations. Passive followers display strong desire and actions to appear loyal, concur easily, and overlook potential problems and risks of proposed plans. Passive followers allow teams to sink into Group Think and do not offer a different or alternative view even when necessary.2
There is a subgroup of active conformist followers who actively volunteer to help but do not exercise prudence and critical thinking, resulting in error and mistakes. Passive and conformist followers often end up as "accidental or arrowed" leaders, needing external motivation and responding more to authority rather than the needs on the ground or the patients.
The disengaged or alienated follower
The disengaged or alienated followers would often have highly critical thinking, and are generally intelligent, and good in knowledge but lack conscientiousness in execution. Their work rate is slow and they exhibit rigidity in thinking and practice.
This type of follower often over-values professional and individual autonomy, finds difficulty in reaching consensus and is unable to engage in collaborative team work. They would also be argumentative and display poor attitude and etiquette.
They are quick to disappear when their allocated task is complete and very rarely offer to help others. Team members avoid consulting them in times of difficulty (the bypass syndrome).
They have poor self-awareness and are unable to build and manage relationships. They have poor insight, diminished capacity for self-improvement and do not take responsibility for their performance. The disengaged can become a disruptive follower and inappropriately challenge the leader, often in a passive-aggressive or cynical manner. The disengaged seldom achieves hierarchical leadership but when they do, they develop either passive-aggressive or openly combative/disruptive styles of leadership.
Developing engaged and exemplary followership
Followers grow their leadership skills and habits from watching their leaders in daily action and from handling difficult professional situations. In healthcare, the leader-follower relationship is still marked by that existing traditional static and hierarchical leadership relationships with little room for growth for both the follower and leader.3 The leader-follower relationship would influence the development of the follower in the transition to a leadership role.
Leadership starts with good followership of trust and willingness to follow by service and example. Good followership is not plain servitude or slavery and has its foundation in serving with compassionate wisdom or intelligent kindness. The development of good followership skills obviously needs to be started early in medical school with smooth continuation in a transformative learning journey into residency. Good followership, like leadership, can be taught and learnt in a deliberate and structured manner by using a variety of learning methods provided over an extended learning period and with sustained support.
It is clear that clinical followership and leadership training is consistent with the current (ACGME-I) goals, and provided for in medical school and residency education and training.4 Competencies in the domains of professionalism, interpersonal and communication skills; practice-based learning and improvement; and systems-based practice, all provide for the development of engaged and exemplary followership.
- Professionalism – knows of and understands professional standards and behaviour; consistently shows the appropriate professional behaviour; and thinks, communicates and acts as a professional.
- Interpersonal and communication skills – self-awareness; self-regulation; negotiation and motivational skills; builds, sustains and repairs relationships; and teamsmanship and followership.
- Practice-based learning and improvement – includes reflective practice; self-motivated life-long learning; quality improvement; and patient safety.
- Systems-based practice – how to manage change in healthcare delivery; and awareness of and appropriate responsiveness to the system of healthcare.
Medical school faculty and residency programme directors would need to evaluate the performance of students and residents beyond the domains of medical knowledge and patient care, and consider the effectiveness of learning and teaching in those domains. The need for high-level organisational leadership taking ownership of such educational programmes with a conscious effort of building a supportive culture cannot be overstated. With the rising complexity of medical technology, fragmentation and rising cost of care in today's medicine, developing educational programmes that develop effective and engaged leadership and followership is critical for building the trust and confidence of patients and public.
The benefits from the advances in medical sciences and technology would be negated when clinical teams are not enabled to deliver effective, safe, efficient, timely, equitable and patient-centred care, and to build the trust and confidence of patients and public in the healthcare professionals and the healthcare system.
Developing effective and engaged leaders and followers is critical for the sustainability of medicine. At the same time, the role of leadership, governance, systems organisation, and organisational ethics and culture is far greater than what individual leaders or followers can achieve in delivering patient-centred care and building trust and confidence.