Leadership in medicine: risks of ethical conflicts


The article deals with the problem of ethical conflicts in medicine. The growth of legal conflicts in medical practice is largely conditioned by increase of ethical conflicts. As the leader of a medical staff is the central figure, we’ve conducted the research of his/her personal features with the aim to reveal risk factors of ethical conflicts. The carried out literature review of the mentioned problem defined that leadership in medicine has its own peculiarities, connected with specificity of activity, gender asymmetry of a professional sphere. The research of role-playing features of a head in the medical staff was conducted on the example of physicians who performed leading duties with work experience in a senior post of 7±1,3 years. The research was carried out in the categorical field of sociology of medicine using methods of content-analysis, participant observation, sociological inquiry and interviewing, and psycho-diagnostic techniques (by Sinyavsky V.V. and Fedorishina B.A., Raygorodsky D.Y., Shubert, Boiko B.B., Snider M. etc.). The research results made it possible to determine ethical risk factors in 20-25% of leaders. It was concluded that there is a need to institute a bioethical methodical block to the system of continuing professional education of medical specialists, which can make it possible to form leader’s necessary ethical values and attitudes in conditions of educational sphere.

Full Text

One of the burning issues of practical medicine in Russia is ongoing growth of legal disputes. The amount of appeals and requests from citizens to the courts on so-called “medical cases” is increasing. Patients or their relatives are not satisfied with the result of treatment, fatalities and low quality of health-care services. However, despite the validity of numerous claims, the most part of them is of ethical nature. The analysis of reasons of these appeals revealed the top complaints: 1. Violation of professional ethics: physician’s hostility, reluctance to explain the risks or comment on the patient’s health status, or inform about alternatives etc. 2. Legal and illegal charging for medical services that are included in core program of state guarantees. 3. Complains about the quality of medical service, concerning medical errors, harm to health or life. The scientists in this field fully share the view that almost all disputes arise because of carelessness of both sides, irresponsibility of medical staff or lack of etiquette, or disagreement of patients and physicians. 32 Among the catalysts of the conflict are offenses, emotions, pain. Not so many conflicts arise due to objective reasons such as lack of equipment or medicine etc. In this context, the research of leadership in medicine has practical advantages. The head, his or her social position, personal features, skill level and focus of work largely determines socio-psychological climate in the staff and its satisfaction with a job. In this regard, one may suppose that role-playing characteristics of the head can shape possible risk factors as well as for development of ethical conflicts in medicine. Socio-economic environment in Russia has been significantly changed in recent decades. One can monitor an active integration of market relations in the sphere of medicine, which reflects in development of private health sector, broadening the range of fee-paying medical services and change of doctor-patient relationship. There is a growing demand for a professional activity of physicians, their role-playing functions are expanding and nervous strain is rising. It can be particularly evident when a physician is performing the duties of the head of a healthcare institution [3,7]. The analysis of contemporary researches in this sphere revealed that socio-economic health reforms initiate higher requirements to professional competences of a head-physician that result from certain factors such as estrangement of a head from the staff, loss of professional duties, prevalence of administrative duties over professional ones, need for solving problems connected with a conflict environment inside the staff. The aim of our research is to evaluate socio-psychological competences of a head of the medical staff from the point of risk factors of ethical conflicts in medicine. In this respect, we have done a research of role-playing features of a head in the medical staff on the example of physicians who performed duties of heads of wards in hospitals, polyclinics, with an average age of 39,7±2,8, work experience of 20,2±3,2 years, work experience in a senior post of 7±1,3 years. A comparative analysis of similar features of a control group of therapists has been made to identify a role-playing complementarity in a medical profession. The research was conducted in the categorical field of sociology of medicine using methods of contentanalysis, participant observation, sociological inquiry and interviewing, and psycho-diagnostic techniques (by Sinyavsky V.V. and Fedorishina B.A., Raygorodsky D.Y., Shubert, Boiko B.B., Snider M. etc.). The analysis of curricula vitae of physicians in authority makes it possible to conclude that leadership in medicine according to the traditional classification of power (French & Raven, 1960) is the power of an expert, based on experience adopted from the colleagues, knowledge and abilities of an individual. Whereas the expert’s competence in other professions may not influence the interpersonal relationship holding informal leadership, it is exactly the kind of influence that shapes a leader from a head-physician. In the sphere of medicine, there is such a corporate concept as “concilium”, which means that a decision made is based on the referent influence of more experienced and competent colleagues. Despite the legitimate origin, leadership in medicine has an expert nature. A head in medicine is usually a professional physician with no less than 10-15 years of service and with certain leadership qualities and skills. Therefore, our research showed that most head-physicians had high and very high levels of communicative and organizational qualities, higher than their colleagues from the monitoring group did. The results proved that most head-physicians (67,2%) had high rates of organizational qualities (with 33,6% of a high rate and a 33,6% of a very high rate), half of them had communicative qualities (with 16,6% of a high rate and 33,4% of a very high rate, p>0,05). The amount of respondents with a low level of above mentioned qualities was small (communicative - 8,3%, organizational - 16,4%, p>0,05). The levels of communicative qualities with “high” and “very high” rates occurred more often than among therapists (14,2% against 7,1%, p>0,05). The analysis of predominance of communicative or organizational qualities in the structure of an individual (picture 1) showed that 74,5% head-physicians had organizational qualities superior to communicative, and 17,2% vice versa (p<0.01). At the same time, about 15-25% of head-physicians (by different figures) had conflict risk factors according to Boiko V.V. technique of evaluation of communicative interferences. A detailed analysis of etiology of communicative problems (picture 2) did not reveal prevailing types of communicative interferences for 33 head-physicians (р>0,05). At the same time, the most widespread types were “inadequate display of emotions” (29,6%) and “dominance of negative emotions” (29,4%) with a direct correlation link (r=0, 65). It should be mentioned that interferences of the 5th type - “refusal to get close to people on the emotional base” - happens more rarely among head-physicians (only 11,6%), than among the monitoring group of therapists (р<0,05). This fact is absolutely favorable in evaluation of leadership qualities. The diagnostics of socio-psychological facilities ofpersonality in the sphere of motivation and requirements was conducted according to Potemkina O.F. technique, which enabled to reveal the degree of display of socio-psychological facilities, conditionally named “altruism-egoism” and “process-result”. The result showed explicit altruism orientation of an individual in most heads (66,4%), р<0,05. The average of altruism (5,32±0,56) is higher than egoism (3,76±0.89), but these differences may be not accurate (p>0,05). At the same time, 25,3% of heads have more rates in egoism. Some researches justify a “rational” egoism because of peculiarities of a social status as a head. In particular, A.Menegetti considers leadership as satisfaction of egoism through realization of social interest. In our opinion, egoistic orientation may be regarded alongside as a predictor of possible role-playing expansion. A number of researchers (Yukl & Van Fleet, 1992) also point out that emotional maturity is important for a successful leadership, which excludes egocentrism and tendency to defensive responses. An integral part and the main characteristic of leadership efficiency is the style of leadership, which manifests itself in encouraging techniques for the staff to initiative and creative work and controlling the results of the staff’s activity. The style of leadership may serve as the quality characteristic of the head’s activity, his or her ability to maintain efficient managing activity and also to create an atmosphere for development of favorable relationship and behavior. The style of leadership that was chosen right to appropriate to the situation is capable of overcoming insurmountable obstacles. The leadership style is mainly shaped by individual features of a leader, though personal characteristics do not exclude other important things which account for external influence of micro-society. Russian scientists always group the leadership style on different grounds. An individual leadership style is based on different proportions of social facilities and personal features of a head such as economic, organizational, ethical, moral and professional. The specificities of style are formed depending on domination of one of five components prevailing in a person. The style of work does not only characterizes the head, but affects all the activities inside the structure and directly subordinates. There are three main leadership style in accordance with the most popular classification: democratic, authoritarian and liberal. Democratic or collegial leadership style. Organizations where this type of style prevails can be characterized by a high level of decentralization of authority, active participation of staff in decision-making. The performance of duties seems to become an appealing job and a successful result is a reward. The head is oriented on capacities of subordinates, their creative initiatives, makes decisions with their help, creates necessary conditions for timely work performance, evaluates the results fairly, financial and mental promotion. Authoritarian or administrative leadership style is characterized by extreme centralization of authority, dedication to one-man management and independent decision making of most administrative problems. Under market-oriented conditions purely administrative leadership style becomes hardly acceptable, however, may be efficient in the short term. Authoritarian leadership style as an ideal model of one-man management has the following variants: dictatorial, autocratic and bureaucratic styles. The latter is typical for the Soviet system. Liberal leadership style differs from the others in absence of a head’s own initiative and reluctance to be responsible for administrative decisions, especially connected with a certain risk. The liberal style head is excessively cautious and incoherent in everyday behavior, interaction with subordinates. Such head is not demanding enough and does his or her best to please everyone. The successful choice of a leadership style depends on how a head evaluates his or her abilities such as educational background, work experience, personal characteristics and also determination of subordinates to complete assignments or traditions of the staff. 34 Our research revealed that certain leadership style never occurs by itself. In real life, every leadership style has common features of different styles with a prevailing one. Possibility and relevance of style components combination depends on presence of certain traits, role-playing functions in the style that vary in every case. Extrapolation of the results in our sociological research allows describing contemporary style-forming tendencies in the sphere of medicine management activity. In our research 67,2% of heads had high rates in communicative qualities, 8,3% of respondents had low rates which contribute to development of an authoritarian style. It may be supposed that most head-physicians (91,7% of respondents had medium and high rates of communicative qualities) developed a democratic or liberal leadership style. The Democratic style implies that a head has confidence and mutual understanding with a subordinate. In this case, the head is a member or the group, and other staff members are free to express their opinion on different questions without being punished. At the same time, taking into account that 17,7% of head-physicians had prevailing communicative and organizational qualities in dichotomy, it may be supposed that a liberal leadership style was formed in this monitoring group of residents. The liberal style is described as noninitiative and non-interfering into the work process. A liberal head undertakes any actions only on the orders of a superior, avoiding responsibility. Usually these are not competent enough people, who are not sure in their official status. 74,5% of head-physicians had organizational qualities prevailing over communicative ones, so revealing in 25,6% of them serious communicative obstructions (level 3 prevents building emotional contacts), we may predict the development of an authoritarian leadership style. The authoritarian leadership style is the reason of most conflicts because of one-man management. The claims of an autocrat concerning competence in all spheres leads to chaos and finally affects efficiency. At the same time, only 16,7% of respondents did not have any communicative problems, so a democratic style may be stated in less than one fifth of this percentage. Taking into account all the described styles, we may conclude that most appropriate democratic leadership style for heading a medical staff appears in average in 16,7% of head-physicians. Most conflict, the authoritarian one, occurs in 8,3-25,6% of cases. Our sociological research of leadership styles has proved earlier observations concerning the need for optimization of organizations to develop leadership qualities among head-physicians. Revealed in some head-physicians low rates of communicative control and emotional obstructions in communication are risk factors for subordinate opposition, and as the result, ethical conflicts. Conclusions. The research results make it possible to emphasize the following peculiarities of personal characteristics of a head-physician as risk factors of ethical conflicts: ✓ Low rates of communicative control (15,4%); ✓ Inadequate display of emotions (29,6%); ✓ Prevailing of negative emotions (29,4%); ✓ Egocentric settings (25,3%); ✓ Refusal to get close to people, egocentric setting, found out almost in one fourth of respondent of the monitoring group; ✓ Prevalence of authoritarian leadership style features. The obtained results show the need for development of certain leadership culture, a social position, and communicative skills in the context of continuing professional education.

About the authors

A. D Donika

Volgograd State Medical University

Email: addonika@yandex.ru
Volgograd, Russia
D. Sc. (sociology), associate professor, Professor of the Department of Philosophy, Bioethics and Law with a Course of Sociology of Medicine of Medical Sociology

E. V. Chernyshkova

Saratov State Medical University n.a. V.I. Razumovsky

Email: chervy@mail.ru
D. Sc. (sociology), associate professor, associate professor of the department of philosophy, humanitarian sciences and psychology

E. A Andriyanova

Saratov State Medical University n.a. V.I. Razumovsky

Email: elena-andriyanova@yandex.ru
D. Sc. (sociology), professor, head of the Department of philosophy, humanitarian sciences and psychology

M. E Volchanskiy

Volgograd State Medical University

Email: biosoc2008@yandex.ru
Volgograd, Russia
D. Sc. (sociology), Head of the Department of General Psychology


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