Short Communication: Role of Leadership in Doctor-Patient Relationship & Execution on Patient’s Case Management in Primary Care

AUTHORS

Benish Khanzada1, Shahzad Naeem2*, Areesha Khanzada3, Hashim Butt4

1Faculty of Quetta Institute of Medical Sciences / National University of Medical Sciences (NUMS), Pakistan

2Riphah International University Islamabad, Pakistan

3Agha Khan University Hospital

4Combined Military Hospital, Medical College, Lahore.

Mainly in developing / emerging countries mortality and morbidity are still difficulties. These contain infectious as well as non-infectious diseases or deteriorating and re-emerging diseases. Several efforts were made, for example improvement in accessibility towards health care, communal empowerment, setting objectives towards millennium improvement / development and workable goals development, nevertheless still these struggles are not sufficient. Additional approaches have also been recommended and developed, such as health policy restructuring, standardization,recognition, universal treatment development, and reinforcement of health resources (Kringos, Boerma, Hutchinson, Van der Zee, & Groenewegen, 2010)  

Teamwork is essential requirement for provision of modern / latest medical services, which suggests that leadership capabilities are required by individuals (Heres, & Lasthuizen, 2013).  Those doctors who perform their duty at primary healthcare take front position in all struggles for ensuring workable health management. To manage health issues, doctors should cooperate with several individuals, which may belong to medical or non-medical profession, along with families of patients and patient themselves (Becvar, & Becvar, 2012; McDaniel,  Hepworth, Campbell & Lorenz, 2005). Primary care physicians in role of care coordinators, must experience development, planning, arrangement, organization, execution, implementation, operation, assessment and evaluation stages. All these features contain part of complete system of healthcare service at any healthcare service provision facility or institute which calls for the clinical leadership proficiency and also anticipated to have positive impact on provided services quality (Spurgeon, Long, Clark & Daly, 2015).

Healthcare System & Primary Care

There are three levels of existing healthcare system. First is macro level, which comprises of government / legislative / parliamentary level and entails health investment policy, health policy, standardization, health finance system, ongoing education, and coordination within sector. Meso is the second level, existing at the level of health facility. It comprises of patient’s flow / health service, experts of health provider, evidence and prevention based medicine, systems of information and association with public resources. Thirdly is micro level, which involves doctor’s-patient affiliation and patient empowerment. Leadership capacity is essential at all healthcare system levels. In this article focus will be more towards micro level (Spurgeon, Long,  Clark  & Daly, 2015; Higgs, 2014) At present in primary health care it is need more than in past and the same is also highlighted by World Health Organization (WHO) (Kringos, Boerma, Hutchinson, Van der Zee & Groenewegen, 2010). Primary health care is required to be established at individual-centered care, inclusive, comprehensive, unified, integrated reactions / responses and care continuity, nearer to people, answerable for well recognized population, networks organization and team of primary care as coordination center (Kringos, Boerma, Hutchinson, Van der Zee & Groenewegen, 2010; McMurchy, 2009; Deldar, Bahaadinbeigy & Tara, 2016). 

Care Coordinator

In health management of any patient, care coordination is one of the vital roles of doctor’s (Becvar & Becvar, 2012). Carayon et al, (2012) described that care coordinator is an individual whose responsibility is to conduct activities which are related to health management of patients, which includes two or more members (including patients), in an institute, in process to enhance life quality of patients and health services quality (Meyers, 2010). Patient Care coordinator definition highlights there is a requirement for doctors to create and ensure coordination / cooperation with several persons which may include patients themselves, their families and all other healthcare workers who are involved in diseases treatment. This rule is completely according to the basis of democracy health development, which is executed in light of inter-sector, partnership, relationship and collaboration (Tahun, 2012). Coordinator term itself comprises of all leadership features. Leadership is not a position rather it is an action (Northouse, 2013). Doctor as professional person has to perform certain actions, and it is not just an appointment or position. This is because doctor’s functions include motivating, engaging, collaboration, and influencing not only individuals’ but also influencing their behavior towards health living. Hence, it is according to WHO five stars doctor are considered as community leader since doctor is naturally a community leader and works for prosperity of  community, irrespective of his structural position (Nazian & Stevenson, 2013; Setiawan & Muhith, 2013).  

Leadership qualities are considered essential for doctors involved in recognized management role and not for those who are involved as practitioners (Werdhani, 2017).  In case of primary care management, coordination is required amongst doctor, nurses, patient, family, other health services suppliers, and unit activities for solving problems related to patient’s health. Thus, physicians dealing with primary care must at least be capable of dealing with interpersonal communication, teamwork, inter-professional and clinical management. These all capabilities reflect clinical leadership proficiencies, where doctors act as center of health care facilities provider to the patients and foremost multidisciplinary teams of healthcare (Werdhani, 2017; King, 2011).

Consistency among Transformational Leadership & Doctor Patient Interaction

Werdhani & Retno, (2017) describes leadership as mixture of numerous behaviors of a person which inspires others and assist in completion of delegated tasks. Bass and Avalio described transformational leadership as leader’s struggle to raise followers needs one level higher. By applying transformational leadership skills, followers can attain performance level which exceeds the expectations of their leaders. This philosophy is established on the theme that inspirational, innovative and preemptive leaders have capability to inspire others and pursue for higher standards and long time objectives (Northouse, 2013).  Transformational leader recognizes that communication, empowerment, mutual respect and strong values are the most vital things quality improvement. In medical profession, type of transformational leadership is more appropriate because of dynamic relationship between doctor and patient’s voluntary and faith connection. Internal motivation also exists from doctors and patients communication with each other. Doctors must have the personality, inspiration, as well as proactive approach for serving patients (Setiawan & Muhith, 2013).

Principles of transformational leadership and diagnostics based upon vales are essential for development program of clinical leadership. Clinical leadership can be defined as leadership by physicians and from physicians for initiating and implementation of changes aiming to achieve targets of patient management. In clinical leadership, role of physician’s is to define the resources management, direction, motivation and inspiration while retaining clinical role. Thus, clinical leadership is included in day-to-day medical practice and also become clinical role part because the same is directly involved in patient’s health care (King, 2011; Setiawan & Muhith, 2013). United Kingdom national health system (NHS) (Miller, Crabtree, Nutting, Stange & Jaén, 2010) distributes clinical leadership proficiency structure into five following dimensions: Representing personal qualities, managing services, capabilities to work with others, services improvement and setting the direction. Application of  above mentioned five dimensions, it is expected that practicing physician, particularly physician dealing with primary care will be able self directed development, innovate, construct networks, make strategy, manage resources and also contribute towards healthcare services improvement basing upon evidence (Miller, Crabtree, Nutting, Stange & Jaén, 2010). Important role of any doctor is creation of productive and healthy people. For achieving this objective, doctor are required to work together with numerous people who shares same mission, idea and vision, provides positive inspiration to each other, and also willing to inspire, motivate and encourage each other. Such image is according to transformational leadership ideal practices among doctors at all ranks which includes from micro till macro level. All efforts for creation of healthy society should be reinforced by procedures, policies, rules and facilities. Same should also help doctors in accomplishing their duties.

In family medicine there is an approach which is patient centered. In leadership a relationship always exists among leader and employer which is similar to doctor and his patient relation. Transformational leadership have the capability to discover ideas, worries, and employers expectations which is same as patient centered approach, where doctors are required to discover ideas, worries, and patient expectations. Doctors and leaders must know, respect, care and understand patients’ and their follower fears. Leader with transformational leadership qualities describes idea, vision, objectives, aims and organizational goals and inspire employers for attainment of these objectives collectively by distributing duties, tasks and responsibilities. Moreover, doctors are also required to clarify aims, goals and treatment goals and inspire patients to cure the disease collectively with commonly decided target / clinical results. Leadership with transformational qualities inspires employers in achieving higher level. It is similar to mission of inspiring patients for changing their attitude to live healthier life. There is a lot of similarity between patient centered and transformational leadership styles  as highlighted in Table (1) below;- (King, 2011; Setiawan & Muhith, 2013).

Transformational Leadership Approach

Person Centered Approach

Leader & Follower

Doctor – Client / Patient

Discover ideas, ambitions, objectives and follower’s expectation

Discover concepts, apprehension, and patient’s expectation

Respect, comprehend, realize and care regarding  problem of his follower’s

Respect, comprehend, and care regarding problems/ issues of patient

Describe and clarify vision, objectives , aim and organizational goals

Describe and clarify objectives, goals and aims of disease management

Inspire and encourage his followers for achievement of desired goals / objectives

Inspire, encourage and raise patient’s spirit for controlling disease

Share and distribute tasks and decided / agreed upon responsibilities / duties

Common promise and agreement regarding clinical target / results

Encourages his follower for elevation to upper level

Encourages patient for changing their behavior / attitude

                  Table 1 - Transformational Leadership And Patient Centered Approach

Role of Doctor as leader and his Impact in Execution of Doctor Patient Relationship

In accomplishing duties, leader should take numerous management steps with the aim to have new events, which are required to be done for achievement combined goals of the team. Doctors while planning for treatment and interference can also adopt similar management procedure, which are required to be implemented for achieving objectives, connected to health management of patients. The procedure begins from planning phase till creation of professional network, as elaborated in Figure 1.

 

Figure 1. Leadership in Doctor – Patient Relationship

Leadership in Doctor – Patient Interaction

Planning

Planning can be described as methodical activity for identification and specification of project objectives, set of actions required to be taken for attainment of objectives, steps which are required to be taken are implementation methods and human resources (HR) which are required to be taken for performing actions required for achieving desired objectives. Planning should be performed in fundamental, universal, and careful manner; should ensure harmony of understanding, behavior and sequence of action; and should be tracked by solid actions. Planning consists of definite activities which are activities type identification, determination of scale priority, preparation of schedule and cost estimations, individual’s appointment responsible for activity, allocating jobs, and defining procedures for assessment (Widodo, 2017).

In day to day practice, doctor normally design disease management plan in accordance with anamnesis, physical analysis, and supportive analyses by applying a methodical thinking procedure and cautious diagnosis establishment. Adoption of this principle is essential so that doctor and patient can accomplish prearranged activities more efficiently for achieving common objectives of solving health problems of patients. Medical information method should document entire process of planning and same should be available to all persons involved in it.

Provision of Information

Information provides strength to interactions of ideas, views, and opinions associated to decisions, policies and procedures involved in solving problems. This process needs assurance of all involved parties and complete information by leader. Information exchange process should be performed in two way directions (Widodo, 2017). This type of methodology is anticipated to exists in doctor patient association. Interpersonal connection among doctor and patient is same as it is among leader and their followers, which produces particular communication patterns of doctor patient association. A doctor is required to develop effective communication pattern with patient and all other persons involved in the process with the aim of attaining vision and mission unity in their struggle to treat health problem of patient.

Health management plan must lay down roles, responsibilities and obligations of all persons involved in process which includes nurses, doctor, other providers of healthcare, patient, their family members and if required the community. Right information exchange model is adopted by doctors who lead entire information exchange process. Failure of communication normally results in misinterpretations, inflicts damages, and may even result in disastrous results. These consequences normally happen in day to day medical practices in several forms, for example malpractice allegations even in atmosphere where doctor has implemented relevant professional standards.

Monitoring

One of leader’s duty is monitoring which requires assessment, evaluation and correction for making sure that joint objectives can be acquired effectively. Monitoring involves both internal and external monitoring. Internal monitoring comprises of identification of success indicators, evaluation of success key factors, asking particular questions related to performance, inspiring team members for reporting any difficulties, and learning lessons from mistakes / failures. External monitoring comprises of customers’ identification based upon situational modifications, involving the customers in search of information, observing several happenings pertinent to mutual objectives and learning lessons from successes of others (Widodo, 2017).

In circumstances of every day patient’s management, doctor requires gathering of relevant data continuously and regularly assess the range to which treatments and involvements are abled to treat the health problems of patient in accordance to set plan. Medical information method is needed to record data and consequent intervention plans assessing the patient’s existing development. For improvement of short and long term healthcare quality services these results can be used.

Problems Solving

Good leadership has the ability of taking numerous decisions, solving issues, taking appropriate actions, employment of several resources and implementation of policies, produce for obtaining solutions regarding particular problems. For attainment of specific goals, leader and followers must be work collectively as a team for decision making. This will help in achieving organizational interests, and also subordinates needs. Before taking a decision, both leader and his followers must deliberate on all likely risk factors and also recognize best available solution / way out. Implementation of the agreed decision will be responsibility of leader and he will also be responsible for the results of the implemented decision (Widodo, 2017).

Same resemblance is also applied in doctor’s duty for curing health problems of patients. Before taking any clinical decisions regarding health problem of patients, doctor should deliberate upon on all available information, which was collected from numerous resources/ means which is in best interest of patients. Any deliberation which occurs between doctor and patient prior to decision making process can be compared with counseling meeting where doctor invites not only patient but also his family members if required, for making any decision collectively in efforts to solve problems by viewing preferences of patient’s.

Support Provision

One of other anticipated duty of any leader is to provide support to reflected consideration, recognition, care, and acceptance and followers concern. For any leader it is vital to treat other people with respect, politeness, to express honest concern, to be tolerant and accommodating, to provide assistance / support when someone is worried, confused and distressed, to pay kindness towards complaints and problems of follower and also to recognize and make best use of their abilities / potentials (Widodo, 2017).

Same qualities must be shown by doctors to their patients. Whenever intermingling with any patient, it is expected from doctor to keenly listen to complaints of patients, show sympathy, provide support, and work in collaboration with patient for solving their problems and also identify available resources / potentials available for problem solving.

Developing

This aspect can be describes as the procedure / method of increasing an individual’s awareness, knowledge, information, skills, abilities and capabilities which can enhance not only existing performance but also the future performance. Improvement can be achieved from coaching, training, counseling and mentoring. Leader should be capable of selecting the most appropriate development forms conferring to actions which will be adopted for achieving requires results / target. In the terms of development there are several factors which need to be considered, such as the need for development, the motivation for capacity building, the method for development and the procedures for evaluation (Widodo, 2017).

In doctor and patient relationship, doctor has a responsibility to provide information, knowledge, education, coaching and counseling to patients, their family members and society in larger capacity for capacity building. Such efforts should be undertaken for empowerment and enabling people for addressing their personal health issues under supervision of doctors along with their medical team.

Giving Rewards & Appreciation

Giving rewards can be described as action of praising or displaying gesture of appreciation to any individual of an organization that has attained particular level of performance efficiency. It is viewed as an acknowledgment from leader which is likely to augment motivation and reinforce the commitment in achieving common objectives. Appreciation / reward can be in various forms such as promotion, raise in salary or any other incentive given to an individual (Widodo, 2017).

 In doctor and patient day to day interaction, when patient reaches a definite target (for example when patient abled to control blood pressure or glucose level in required limits or when there are definite improvement in illness), doctor can praise and appreciate commitment of patient in following the mediation structure as planned earlier. Furthermore to praise, doctor can also update the patient regarding benefits which will be gained by patient from attaining a particular target. In medical world one of the ultimate challenge is to safeguard long term benefits of intercession (for example relapses disappearance, symptoms withdrawal, complications nonappearance), which might not be instantaneously witnessed. As such, patient should be constantly heartened, supported, cheered and encouraged for taking necessary methods to avoid relapses. Actually patients will be motivated and like to maintain their health if benefits of the same are realized, experienced and known by themselves.

Conflicts Management

Conflicts can arise from an individual’s interpretation style, perceptions, and responses to the atmosphere. Another conflicts reason is absence of coordination among team members in relation to confusion in understanding job descriptions interdependence, task orientations differences and poor controlling system. Conflict can also occur due to boring working atmosphere, which normally leads to unnecessary indifferences if not addressed timely (Widodo, 2017).

Other than communication issues, another conflict type which may occur between doctor & his patient relationship can be patient’s apathetic attitude which may occur when disease / problems continue and there is no improvement sign. This apathy attitude might drive patient to do certain actions, which are not according to the plan which was already agreed upon between doctor and his patient. Moreover, if patient is not kept well informed, he does not have knowledge about precisely what actions he do, or he does not understand the consequences of his actions which he is not supposed to take because of the reason that his doctor failed to provide him / her detailed and clear explanation again there are chances that such conflicts may arise. To avoid this kind of conflict, there should be clear demarcation of responsibilities and duties between doctor and his patient. Moreover, doctor should have adequate knowledge, information and skills to predict several other likely scenarios to ensure preparation of more efficient and effective monitoring and prevention scheme.

Formation of Work Teams

This team may be comprised of smaller teams or numerous individuals, every one of which is equipped with complementary expertise / skills and is fully devoted for attainment of common objectives. Moreover, each one of them should also possess set of skills, techniques, methods, approaches, methodologies and orientations which are based on scientific theories firmly and the same should be recognized / applicable in their relevant fields. Another duty of leader is to prepare a work team which is also interrelated to management of all type of conflicts. One of the methods of managing conflicts in positive manner is by establishing skilled work team (Widodo, 2017).

To ensure provision of higher quality medical services in healthcare facility, a specialized, skilled service team must be established which should comprise of nurses, doctors, nutritionists, pharmacists, and other sources of healthcare. Job of teams is patient’s treatment and cure his health issues in a combined way which is in accordance to fixed and defined targets of every individual patient. It is expected that all team members will complement and support each other in the best interest of patients ensuring complete coordination and harmonization with the doctor who is authorized to take clinical decisions in case of occurrence of any clinical issues. Moreover, job distribution, processes and procedures should be clearly defined and allocated which are jointly agreed upon for implementation by all team members.

Professional Networks Formation

Due to expansion in globalization there is an urgent requirement to build networks. The existing situation encourages for development of serious communication network which brings the world closer. Building of specialized networks is linked with behaviors multiplicity, which intends to improve organizational external and internal capabilities / potentials. Leaders should develop their sensitivity and awareness towards several needs by seeing the existing opportunities and interests of stakeholders (Widodo, 2017).

Keeping in view healthcare services and doctor-patient communication perspective, healthcare team and the doctor, who are responsible for dealing patients, must be conscious regarding of patient’s requirements for building both external and internal specialized / professional networks in healthcare facility. By forming professional networks, the unreachable vital external information can be ensured available to all concerned individuals. Creating cooperation with a professional / expert or constructing networks between healthcare facilities, are additional ways for building professional networks for patient’s assistance /benefit.

Care Coordination Model

In primary care case management needs team of medical staff to serve as care coordinator whose job is to discuss and work for health service issues, explain and assist in tasks of each other and also enhance and ensure improvement in team building activities. Moreover, working between patients and health specialists, care coordinator job is also to work in close coordination with patient families and consultants to ensure patient’s benefit. Case management evaluation in whole (socio-bio-cultural-psycho approach), inclusive (protective oriented), united, and range are described to health facility head in periodically held meetings for identification of issues which required to be altered/ updated/explained according to patient’s needs. As an arrangement of social obligation or growing services, team of care coordinator can offer guidance to particular communities and can also identify resources which are beneficial to patients. This model can increase closeness, creativity, commitment, satisfaction, other’s concern, involvement in determination of healthcare direction, and enhancement of self leadership. This needs meso level management support, information systems, and enhancement of capabilities of primary care doctor’s leadership (Figure 2).

                              Care Coordination mode in Primary Care

Primary care consultant’s functions can be enhanced as care coordinators by enhancing interdisciplinary services implementation, increasing primary care doctors capacity, enhancing experience in managing interdisciplinary team work and by service flow clarification, desk job, each health team member responsibilities and improvement in information methods which can be quickly processed and accessed longitudinally for management objectives evaluation. Doing work as care coordinator is also helpful as taking part for determining service direction through periodic meetings with other fellow doctors / surgeons regarding case discussions, creation of clinical guides, new criteria’s or alterations in accordance to existing circumstances, periodic meetings with health facility head for discussing patient’s grievances / illness or for fixing service flow and each health facility provider’s role solidification who is involved in the chain, and periodic meetings with management for delivering new / reviewed management recommendations, guidelines, strategies and explain the requirement for these rule / policy change. Thus, doctors will require diplomacy talents, inspiration, leadership and efficient / effective communication capabilities. Activities like regular meetings for discussion of patient’s cases / complaints, guidelines, contributions towards formation of educational materials, flow  of service, or other transcribed guidance, recording development / combined data processing for avoiding recording overlapping / problems, and team building for developing agreed events will enhance relationship and creativity. This will improve the relationship between team members which will have positive influence upon patient’s result. Doctor plays multifaceted roles as practitioner, as associate, and as leader for their patients, and also a link between management of healthcare services. Thus, perfect doctor requires to posses wide-ranging range exposure towards professional experiences with the aim to comprehend the association between practical management (practical experiences) and organizational management (management of healthcare services). Such experiences to various exposures can be gained by increasing doctor’s capacity and proficiency in organizational performances / behaviors and their application towards management of patient case. This action can assist in reforms of health service basing upon patient requirements by applying universal, inclusive, combined, and constant case management, and also by consolidation of relationships by employing numerous resources which are in patient’s best interest. This experimental exposure can be delivered within formally organized education framework for doctors those who desire to work as consultants and also as leaders on forefront of higher quality healthcare services provider, particularly in the field of primary healthcare (Werdhani, 2017).  It can be concluded as, doctors are expected to possess two type of competencies: (1) clinical leadership, (2) transformational leadership both of these can enhance their performances as care coordinators of patients and to confirm services continuation which could not be accomplished by any single individual. Clinical leadership and care coordinators will encounter primary care requirements and also support to world health organization (WHO) principal health care restructuring. After attaining proper training and learning regarding leadership competence, devising care coordinator system in primary care along with leadership essence and proficiency, doing regular assessment, giving useful feedback views, teamwork, cooperation not only with patient but also with his family, public and all other health workers, and networking, will enhance not only patient’s but also his family, and people’s life quality positively.

 

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