The critical importance of leadership has precipitated vigorous discussion in the last decade. We celebrate the success of leaders, but overt leadership failure at global, national, provincial and local levels provides strong evidence that we have much to learn in the selection and training of our leaders. The cacophony of healthcare noise concerning poor performance suggests a specific need for able healthcare leaders. Possibly, many thought that we understood the subject and were dismayed to find how wrong we were. The Leatt and Porter paper is thus of great importance and timeliness. The outstanding respondents' viewpoints are varied and address theoretical and practical components of the issue. I will add a few personal observations on topics that might be further emphasized.

Authority, Responsibility and Accountability

The goal of the development of healthcare leaders should be that of identifying individuals who are neither solely outstanding leaders nor solely outstanding managers. Creating and enunciating an innovative vision and the ability to inspire people to move to areas to which they don't want to go, are key elements of leadership. Management is characterized by operationalizing the strategies that are created by the leader to support the innovative vision. The search is on for those special individuals who have both leadership and management characteristics.

The responsibility for the entire process should rest squarely on the CEO of the organization. He or she must provide the resources and time protection for candidates. Entrance to the game requires evidence of higher qualification in one of many fields and of appropriate attributes. The process of leadership development can then begin, and is based on the concept of progressive responsibility within a major healthcare domain until the individual is "fit to practise without supervision." The process is Darwinian in nature. Those who fall by the wayside will usually become excellent manager/leaders, leaving outstanding leader/managers to set an example in a highly complex and demanding arena.

As Wedge succinctly states, the leadership role includes a combination of business and social responsibility, but it is clearly additionally, in the CEO's self-interest to take on the leadership development responsibility. Those who directly report to the CEO (the "CEOs-in-waiting") should constantly be stimulated. "What did you think of the prime minister's speech last night?" "What do you think Powell is achieving in his Middle East trip?" "Do you agree with the Economists' evaluation of Japanese leadership in coping with their economic issues?" are questions that could be asked as a meeting commences. With few exceptions, those giving the most insightful appraisals are the same individuals who give the best presentation in the subsequent discussion of a specific functional issue. The CEO must also constantly assess each VP's commitment to choosing and developing appropriate individuals in his or her own areas of responsibility. There are three guidelines: (1) hire people twice as smart as yourself; (2) hire people younger than yourself; and (3) train them toward a leadership/management career. The end result is that the organization becomes populated by excessively bright individuals who enjoy working with each other. The CEO receives the praise for success, and it is critical that this praise be deflected to those who truly earned it within the organization. The CEO must be in close touch and support the appropriate neighbouring centres of higher learning so that candidates can be placed intermittently in specialist courses during the training phase, which is approximately of five years' duration. Short courses on, for example, conflict resolution or negotiating skills are rapidly absorbed by middle-level trainees who have had to grapple with similar problems.

Timing

Discussions of leadership should be introduced at the earliest possible moment of the various pathways leading to advancement in the healthcare arena. When the tragic news of "9/11" filtered into the anatomy dissection room of the newly minted medical students, I stopped the class and told the students that we were going to send President Bush an e-mail telling him what to do. A wide diversity of opinions was presented by these incredibly bright young women and men, and within 15 minutes the class had formulated a coherent plan of action. At weekly intervals thereafter, we paused in the dissection of bodies to check whether Bush was sticking to the plan we had given him. At the same time, we analyzed both the strategies and styles of Blair and Chrétien as they responded to the crisis. Students started to dissect the "real" motivation of these two individuals, as opposed to their stated positions. All the students did well in the anatomy exam, and approximately half the class was able to rise above the immense adjustments required on entering medical school to show real interest in the issues of leadership. It is from this half of the class that some of the leaders of tomorrow will rise.

Graduated Responsibility

The concept of graduated responsibility during the five to six years of training is central to the development of leaders. I remember clearly a brilliant individual who concluded her master's degree and then joined a world-renowned consulting firm. A few years later, she inquired if there were any leadership roles available in the hospital group. I asked her to tell me about the largest budget for which she held responsibility, and to describe to me the manner in which she had terminated employees. On receiving a negative answer to both questions, I told her that as far as I was concerned, she had never held a proper job (a bit to her surprise!). As a test, I told her that she could lead the incorporation of a small community hospital into a large teaching hospital. To my delight, she accomplished this task almost to perfection, with only light coaching from me. She was then ready for larger leadership assignments, and with increasing and graduated responsibility, she has yet to reach her level of incompetence. She currently leads a large public/private healthcare entity, with skill sets applicable to both the real and the healthcare world.

Vision and Execution

Orsino, one of Canada's most brilliant business leaders, stresses vision and inventiveness. With 72 plants to his credit worldwide, however, he is a living example of an absolutely critical leadership attribute - the ability to execute and to close the deal. Action and vigour follow conception. A key attribute is that of understanding how decisions are made in healthcare. Those with a scientific background are amazed to find that decisions do not flow as an outcome of the logical progression down their decision tree. The political component of the final decision requires very careful management if the project is to be successful.

Orsino had the vision of a worldwide company, but the key ingredient was his ability to close 72 deals. As we develop leaders, the ability to execute on time and on budget is difficult to predict, but it is a key and distinguishing feature of the successful leader-in-training. "Was the primary care network installed (yes or no)?" "Was customer satisfaction in the ER improved (yes or no)?" "Was the hospital merger concluded (yes or no)?" A very wide array of attributes is required, but in the end the leader either does or does not have the ability to reach a happy conclusion. Is Orsino similar or different from a healthcare leader? He makes doors - he does not do windows, he does not do roofs, he makes doors. This intense focus is sustained by his very high load-carrying capacity and an inclination to work as many hours as are required to get the job done. His bedrock and absolute integrity is the foundation of all his actions. These characteristics - key to successful leadership -were also evident in the three most recent Chairs of Surgery at the University of Toronto (Wedge, Langer and Wilson). It is apparent that the basic elements are identical in the outstanding leaders of business and healthcare.

As the candidates progress through their leadership development, they must be given the responsibility to delineate the vision of the next major project. Do they demonstrate real innovation and imagination? Although the complexity of the healthcare environment certainly means that the leader will not be able to control all the elements of the undertaking, blaming failure to achieve the vision on the complexity of the healthcare process is a convenient excuse. Good leaders pick projects in which there is at least a glimmer of a hope of success. If the leader chooses a succession of projects, none of which are successful because of outside forces, he or she is picking the wrong projects. The ability to discern the difference is a critical feature of leadership.

Kemerer, who has great experience in a wide variety of healthcare arenas, stresses the importance of focusing on the project at hand. Pseudo-leaders always seem to have time to attend meetings and conferences with lofty titles in distant cities. There are several key questions to ask when such opportunities are offered: (1) Are those attending the meeting able to influence your budget, or support your major strategies? (2) Are those giving the major addresses characterized by their leadership successes, as opposed to individuals recently downsized, or with less than stellar records of accomplishment - that is, will you learn anything? and (3) Is there a very specific contribution you can make to the meeting, which will be of benefit to others? Otherwise, stay at home, stick to your knitting, and do the job! Execution is difficult - far more so than strategy formulation.

The Softer Side

D'Cruz stresses the importance of interpersonal skills that are displayed by the leader. Beware of the leadership trainee who is "polite up, and rude down"! The testing of emotional intelligence is particularly acute during moments of crisis when hitherto successful leaders may come unglued with rapidly deteriorating interpersonal relationships. The ability to both recognize and quantitate a crisis is as much a hallmark of successful leaders as is their successful resolution of the problem. The developing leader needs to be coached through these periods.

Leaders must learn how to manage themselves, particularly their time. You cannot dream creative thoughts if you allow yourself to be constantly harassed. Throw the cellphone in the lake and go for a walk! Physically and mentally overwrought individuals cannot cope in tight situations, so that they destroy their own leadership authority by inappropriate words and actions, when they are under the microscope of a crisis. That same day the actions of a decompensated leader are water-cooler gossip (faster than e-mail!) throughout the organization. Coolness under fire is difficult to teach in a formal setting but is readily assessed in on-the-job training.

Initially, the leader should be told how others perceived his or her performance, but with maturity, an inner conscience must be developed so that leaders can judge themselves. This takes practice and the ability to learn from one's own errors. Senior leadership candidates who continue to require hand-holding and stroking should be diverted to management careers, as their personal uncertainty will infect their organizations if they continue on a leadership track. Personal integrity and modesty, coupled with a passion for duty, is a good foundation on which to build leadership character. There is a time to listen and a time to speak - a time to question and a time to keep quiet. Difficult to teach, these skills must be honed on the job. The CEO who is responsible for the career paths of the VPs must give critical advice on these issues to the CEOs-in-waiting. When the ideal mix is obtained, everyone enjoys going to work, and the sparks and laughter fly.

The behaviour of senior leadership candidates in teams should be assessed carefully. Any new CEO is going to assemble a senior team by advancing suitable individuals, obtaining alternative jobs for others and bringing in new individuals with specific skill sets. The "leadership" of the CEO is the leadership provided by the group, relying on different skills and personalities. If a senior candidate does not work well in a group, he or she will have difficulty in leading a group as a CEO. The junior trainee brings a list of identified problems to the table. The senior trainee brings alternative solutions for discussion. Candidates who cannot make that transition should move into management careers.

The Broader Arena

Rosahl and Samii bring up the critical issue of the ethical basis of resource allocation. What does society want? What is medically reasonable, as opposed to possible? Leadership trainees should show evidence of their ability to evaluate the relative merits of complex ethical arguments. Indeed, in medical practice, just as in recent business practice, it is the ethical and not technical failure which most often results in leadership failure, with enormous and damaging consequences to so many people around the world.

Brown has chaired numerous meetings on both sides of the North American border, as well as at international venues, picking over the entrails of the disastrous leadership failures in major industries. His questions and challenges to those involved in the medical field should be read with care. One of the questions he poses is whether it's easier to teach a nurse or doctor about finance or a business graduate about medicine. Almost surely, both kinds of leaders are needed. Regardless of background, future health leaders will have to perform in an era of democratization of knowledge, with rearguard actions by autonomous professions trying to protect their turf. Leaders must focus on the provision of optimal and safest care of patients within budget so that the voice of the purchaser is heard at least as clearly as the voice of the provider.

In the surgical arena, after very careful selection, the candidate passes through a program of increasing responsibility and is finally "fit to practise without supervision." Wedge crystallizes the issues after a lifetime of surgical leadership. On reaching the senior stage in the healthcare arena, the successful candidate must acquire yet another skill set, which emphasizes breadth of perspective, general (as opposed to specialist) decision-making and the ability to interact with boards and major donors. In addition, groups of senior leaders coalesce to influence provincial and federal policy. They should have a specific focus of simplifying and demystifying the healthcare world and redesigning outmoded structures.

The CEO's mentors are usually the chair of the board or outstandingly successful individuals in the neighbourhood. Board Chair Peter Crossgrove, with whom I had the privilege to work, had the extraordinary ability to "suggest" and not interfere. He transmitted a lifetime of business wisdom to the neophyte CEO. Coaches should be chosen with care. I found 10 minutes with Matt Barrett, head of Barclays Bank Worldwide, worth 10 textbooks of guidance! Further lifelong intermittent formal education of various types is an essential ingredient, which adds to the wisdom obtained by experience.

The description of the "perfect leader" remains tantalizingly imprecise, but we clearly have to do better if we are to produce the key leaders for tomorrow's healthcare in all its components. Because it is difficult to define the perfect leader, it is difficult to correlate the attributes of the neophyte with eventual success. In surgery some "obvious" attributes do not correlate but stimulate further thought; for example, there is little correlation between eye-hand coordination on entry and eventual success as a surgeon. Actually, this is not surprising - once you have learned to cut in a straight line and tie knots, surgery is essentially an action-oriented intellectual occupation. We need further thinking along these lines, questioning the "obvious." The paper by Leatt and Porter is an excellent foundation from which we should rethink the process of selection and development of transformational leaders for the healthcare industry and, ultimately, for the better and safer care of our patients.

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