The Need for Transformational Leadership in Academic Family Medicine

The Army War College coined the term “VUCA” in the 1980s as the Cold War came to an end, to describe operating conditions that are “volatile, uncertain, complex, and ambiguous.”¹ Now, we find ourselves living once again in a VUCA world. With today’s media amplifying national and international crises, military conflicts, political discord, weather disasters, and celebrity gossip, negativity biases are not only maintained, but encouraged, to arouse the public and keep their attention.² This continued pessimism drives anxiety, distress, and ultimately discord within the health care system as the public seeks answers to health concerns, often starting with media guidance.¹ These external, transactional sources are ill-suited to addressing our society’s perpetual crises, negativity, and resulting health problems.

As today’s VUCA environment evolves and society responds, the mission of family physicians embedded within the community becomes more apparent. But, are family physicians equipped to handle this ever-increasing load of stressed patients? A 2015 review of 14 ambulatory primary care and specialized services quantified patient complexity and confirmed that family physicians consistently manage the highest complexity of conditions.³

As we continue our slow recovery from the COVID-19 pandemic, family physicians are repeatedly advised to “build personal resilience” and “manage the personal and emotional challenges” of this VUCA environment, but are not given tangible tools, guidance, or support to do so.⁴ Paradoxically, the undertones of these externalized statements about resilience invalidate the family physician experience. Resilience becomes a nebulous concept, without any framework or guidance to follow that might support the physician within family medicine’s primary directive of patient-centered care.⁵ In academic family medicine, we tout innovative, collegial, and learner-oriented patient care through competency-based medical education, striving to model transformational, relationship-oriented leadership.⁶ But do we live up to this standard? Are we equipped and empowered for sustainability in this VUCA environment?

As new skills and processes emerge (eg, point-of-care ultrasound), as the patient population ages, and as the demands on the primary care workforce increase, there seems to be an equal and opposite decline in areas of practice such as family medicine obstetrics, that have previously been foundational to the identity of our specialty. In this issue, Dr Tyler Barreto and colleagues share an overview of obstetric care in family medicine residencies by analyzing surveys and American Board of Family Medicine administrative databases, using birth attendance as a surrogate for obstetric involvement.⁷ In 1988, 29% of family physicians attended births, compared to only 7.5% in 2021. Their data show that since 2016, 40% of residencies have not produced a single family physician who attends births.⁷ The most common barriers listed are lifestyle and increased stress, which is consistent with a survey previously conducted by Taylor et al.^7,8 Among family physicians who practice or have practiced obstetrics, the most frequent challenge identified for sustainability was interpersonal relationships and impact on lifestyle. Physicians recorded better success when leadership and administrators focused on collaborative, mutually-beneficial relationships.⁸

Also in this issue, Dr Shermeeka Hogans-Matthews and colleagues share an excellent report on the rates of burnout and mental health concerns among family physicians.⁹ Using the 2024 CERA survey data, the authors employed a validated, stigma and help-seeking questionnaire, the Stigma and Self-Stigma Scales, which demonstrated that 34% of family physician respondents perceived stigma regarding mental health needs, with other barriers to seeking care including career concerns, confidentiality, and time.⁹

In their provocative book by the same name, Paul Spiegelman and Britt Berrett describe how the typical, reflexive, external, transactional leadership, also known as “command-and-control”, is not only ineffective, but also counterproductive by invalidating and undermining medical providers.¹⁰ Further, Daniel H. Pink chronicles how external motivators such as productivity milestones, financial incentives, and other directives extinguish internal motivation, destroy creativity, and diminish overall performance by focusing on short-term thinking.¹¹ The more fruitful solution for leadership is to refocus on an oft-overlooked resource: the employees themselves.^10,11 By focusing on employee health and wellness, employee engagement, and a relationship-oriented, transformational leadership style, employees are more engaged, and connect better with patients, resulting in improvements in patient-oriented outcomes.¹⁰

Time is a strictly limited resource, but people and their energy are dynamic. Organizational leaders need to shift away from “command-and-control” and “getting more out of people” to transformational leadership practices, investing in reenergizing and building relationships with employees.^10,12

Academic family medicine is no different. As leaders, we need to find creative ways to invest in, engage with, and reenergize family physicians to create an internally-motivated force that can excel in this VUCA landscape.