A Questionnaire Study of Leadership in General Medicine: General Physicians in Japan are Facing Challenges in Education and Research

Introduction

Leadership is an essential skill for general physicians. In Japan, it is included in the achievement goals of the hospital general medicine specialty program.¹ General physicians are required to demonstrate diverse leadership skills depending on their environment,² and it is essential for them to understand the characteristics of the medical institutions to which they belong and to put this understanding into practice. Leadership skills are acquired through experience and training and acquiring these skills is a goal in various medical training programs.³ For example, in clinical practice, general physicians lead initiatives to improve patient outcomes, resource utilization, and the quality of medical care.⁴ However, the specific strategies for acquiring the needed leadership skills are not outlined within the postgraduate clinical residency program for the first and second years or in the general medicine specialty programs for the third year and beyond.^5,6 Therefore, opportunities to systematically learn and obtain leadership skills are scarce, making their acquisition challenging.⁷ Understanding the most effective types of leadership for different medical contexts is crucial for improving healthcare delivery.

Researchers such as Goleman, Bass, and Avolio have proposed various leadership types,^8,9 and each type has its strengths and weaknesses.¹⁰ In this survey, we picked up five well-known types (Figure 1): transformational, transactional, laissez-faire, democratic, and authoritarian leadership.^11,12 Transformational leadership encourages the creativity of team members, shares visions, and promotes exciting growth by bringing out individual potential.^13,14 Transactional leadership emphasizes the relationship between results and rewards and promotes goal achievement using the precise setting of goals, rewards, and penalties.^11,14 Laissez-faire leadership minimizes decision-making and guidance, encourages autonomy, and gives freedom and autonomy to the team.^11,15 Democratic leadership promotes open communication and collaboration, respects the opinions of the entire team, and makes shared decisions.^8,11,15 Authoritarian leadership involves leader-driven decision-making and provides strong guidance, direction, and quick decisions.^8,11,15 Leadership is crucial for physicians as it improves job performance,¹⁶ provides high-quality care,¹⁷ and reduces turnover rates.¹⁸ Therefore, physicians need to acquire leadership skills.

Figure 1 Types of Leadership.

To the best of our knowledge, no study has attempted to clarify the leadership type necessary in general medicine. Therefore, we conducted a survey targeting general physicians in Japan, focusing on the types of leadership they valued in clinical practice, research, and education. In this article, we report the survey results and make recommendations on the leadership skills required in general medicine based on expert opinions and a literature survey.

Material and Methods

We conducted an anonymous survey targeting members of the Japan Society of Hospital General Medicine using Google Forms sent through Email from February 2 to 29, 2024. The survey items included the respondents’ background information (gender, years of experience, type of workplace, position) and self-evaluation regarding leadership (“1. Can you explain what leadership is (5-point scale)?” “2. Are you proficient in leadership in a medical team, and can you appropriately demonstrate that ability (5-point scale)?”, “3. Do you have a history of attending a leadership training (yes/no)?” and “4. Do you want to attend leadership training if provided by the academic society (5-point scale)?”), and the most demanded leadership type in clinical practice, education, and research. Participants were allowed to choose one leadership type from seven options: transformational leadership, transactional leadership, laissez-faire leadership, democratic leadership, authoritarian leadership, do not know, and others.¹² We used five leadership types that have been proposed for a relatively long time and are clearly distinguishable from each other. The respondents provided consent for the use of the results in research. All responses for which we obtained consent were included. This study conformed to the Declaration of Helsinki. Categorical variables are described as absolute numbers and percentages. IBM SPSS Statistics (version 25, IBM Corp., Armonk, NY) was used for the descriptive analysis. This survey did not constitute clinical research involving humans and did not include personal information. The names of the universities were anonymized for analysis. The Saga University Clinical Research Review Board exempted this study from obtaining ethical approval.

Results

We received responses from 286 physicians (response rate:12.5%), of whom 237 (82.9%) were male. Regarding the number of years of experience as a physician, 2.8% had ≤ 5 years, 10.5% had 6–10 years, and 86.7% had ≥ 11 years. The workplace distribution was as follows: 4.9% were clinics, 4.9% were small hospitals with < 100 beds, 21.3% were middle hospitals with > 100 beds, 31.1% were large hospitals with > 200 beds, and 37.8% were super-large hospitals with > 500 beds. Regarding the respondents’ positions, 4.9% were residents, and 74.9% were supervisors or department chairpersons. Table 1 shows the results of the self-evaluation of leadership and the most demanded types of leadership in clinical practice, education, and research.

Table 1 Results of Self-Evaluation on Leadership and the Most Demanded Type of Leadership in Clinical Practice, Education, and Research

Discussion

Our survey revealed that over 50% of general physicians understood leadership and believed that they could practice it. Furthermore, they seek opportunities for leadership education. Notably, democratic and transformational leadership were considered the most demanded in clinical practice and education and research, respectively. Since the type of leadership required in clinical practice, education, and research differed, general physicians may be using the necessary leadership type depending on the situation.

In clinical practice, general physicians require democratic leadership. In hospitals where the role of general physicians is already clear, they need to establish good cooperation with patients, multiple health professionals, and specialists in other departments.¹ The majority of general practitioners may feel the need for democratic leadership, which emphasizes teamwork and communication since they value maintaining a high quality of daily management. However, from the perspective of nurturing successors, mentors require laissez-faire leadership to make subordinates responsible as primary attending physicians. Moreover, when establishing a new general medicine department, transformational leadership is necessary to assume new roles depending on the situation and current trends.

In education, general physicians often choose transformational, democratic, and laissez-faire leadership. In Japan, medical education follows a traditional observational internship and educator-centered educational style.^19,20 In recent years, understanding what learners want and how to enhance their motivation has led to a desirable shift towards learner-centered and interdisciplinary education,²¹ which may have led many physicians to respond to the need for transformational leadership. In addition, the field of general medicine is a suitable clinical department for medical education.²² However, there may be issues with the lack of education for educators and the evaluation of educational activities.^23,24 Reasons for choosing transformational leadership include the importance of role models and showing a clear vision. In contrast, reasons for choosing democratic leadership include the importance of relationships tailored to each individual. Therefore, the type of leadership required may vary depending on the relationship between educators and learners and the perspectives of general physicians.

When asked about leadership for research, 32% of responders chose transformational leadership, whereas 24% answered: “do not know.” First, the research activity is likely to be a challenge for many general physicians. The field of general medicine is interesting because it has a variety of research themes,²⁵ but the field setting and subdivisions are yet to be established. In addition, for many general physicians, it is difficult to understand what research involves and how to do it, and the hurdles of research are likely very high for beginners.²⁶ Transformational leadership was chosen most frequently by many respondents because of the need for novel and original research themes. The required leadership types may differ depending on different experiences and positions. Notably, 10% of general physicians answered that authoritarian leadership was necessary for research, which was relatively high compared to clinical practice and education. Physicians who have never conducted research may demand transformational leadership, while physicians who need to lead a team that does not have an affinity for research may require authoritarian leadership.

Leadership is difficult to articulate, which makes it challenging to practice or acquire. It is ideal for a general physician to understand their strengths and weaknesses and balance the use of these five types of leadership according to each situation.¹⁰ Physicians need to recognize the types of leadership effective for acquiring leadership skills.²⁷ Therefore, understanding the characteristics of each leadership type and the types of leadership required in each domain (clinical practice, education, and research) will contribute to acquiring leadership skills. Based on the results of this survey, opportunities for general education on leadership and leadership specialized in education and research that could be delivered in general medicine should be provided in the future. These actions may contribute to developing general medicine in all areas of clinical practice, education, and research.

This study had some limitations. First, it was based on a survey conducted among members of the Hospital General Medicine Association, with a response rate of 12.5%. Second, the results were obtained from a cross-sectional study conducted on a small population. These factors suggest potential selection bias. Expanding the study to include general physicians from other countries could enhance the generalizability of the research findings. Third, while this study described the types of leadership required in clinical practice, research, and education, evaluating how they are beneficial in each context is necessary.

Conclusion

In clinical practice, which is the most mature field in general medicine, democratic leadership is the most demanded, while education and research require transformational leadership. We observed that the characteristics of general physicians prioritizing collaboration were evident in clinical practice, and it was inferred that many physicians face challenges in education and research. Therefore, in general medicine, it is essential to cultivate leadership in education and research, and strategies must be improved across the entire field. Based on this study’s results, further investigation into leadership in medical settings is required, along with the development and evaluation of leadership education programs and their effectiveness.