Erwin Loh

Reasons and remedies for under-representation of women in medical leadership roles: a qualitative study from Australia

Objective To elicit medical leaders’ views on reasons and remedies for the under-representation of women in medical leadership roles. Design Qualitative study using semistructured interviews with medical practitioners who work in medical leadership roles. Interviews were transcribed verbatim and transcripts were analysed using thematic analysis. Setting Public hospitals, private healthcare providers, professional colleges and associations and government organisations in Australia. Participants 30 medical practitioners who hold formal medical leadership roles. Results Despite dramatic increases in the entry of women into medicine in Australia, there remains a gross under-representation of women in formal, high-level medical leadership positions. The male-dominated nature of medical leadership in Australia was widely recognised by interviewees. A small number of interviewees viewed gender disparities in leadership roles as a ‘natural’ result of womens childrearing responsibilities. However, most interviewees believed that preventable gender-related barriers were impeding womens ability to achieve and thrive in medical leadership roles. Interviewees identified a range of potential barriers across three broad domains—perceptions of capability, capacity and credibility. As a counter to these, interviewees pointed to a range of benefits of women adopting these roles, and proposed a range of interventions that would support more women entering formal medical leadership roles. Conclusions While women make up more than half of medical graduates in Australia today, significant barriers restrict their entry into formal medical leadership roles. These constraints have internalised, interpersonal and structural elements that can be addressed through a range of strategies for advancing the role of women in medical leadership. These findings have implications for individual medical practitioners and health services, as well as professional colleges and associations.

Future of medical engagement

Although it has long been recognised that doctors play a crucial role in the effectiveness and efficiency of health organisations, patient experience and clinical outcomes, over the past 20 years the topic of medical engagement has started to garner significant international attention. Australia currently lags behind other countries in its heedfulness to, and evidence base for, medical engagement. This Perspective piece explores the link between medical engagement and health system performance and identifies some key questions that need to be addressed in Australia if we are to drive more effective engagement.

Medical management and leadership: a time of transition?

Perspectives on medical management and leadership are in a time of transition, but there is much we still need to understand better. This paper explores some of the tensions and dilemmas inherent in understandings of medical management and leadership.

Leadership in our health systems.

We welcome the editorial in the Internal Medicine Journal by McHardy and McCann on leadership in our health systems. This is an underemphasised issue, as health systems must continue to change in order to remain relevant to our communities, through ensuring effective care delivery. Effective leadership is critical in that meaningful change will not happen without it. There is uncertainty over the role of clinical leaders, and ongoing challenges in ensuring that clinicians are appropriately skilled. Clinical leader roles must be complemented by redesign of manager roles to ensure effective collaboration. The negative perception of non-clinical managers by clinical leaders remains problematic. The critical shortfall is, however, a lack of agreement on the purpose of our healthcare systems. Without this, the purpose of leadership in healthcare can never be agreed. Leaders must work to support alignment of organisational and clinician imperatives. Distributed leadership itself potentially inhibits reform, in that clinicians will tend to align with their clinical profession and its norms, limiting the ability to develop the networked and supportive workplace that is required to support real change. The purpose of leadership in healthcare systems should be to bring all stakeholders, including our patients, to a united view about the purpose of the system. Clinical leadership needs to be reconceptualised as a professional responsibility to ensure healthcare is reliable and effective. The separation of leadership and management is a traditional approach that we believe is no longer relevant to the complex adaptive environments of healthcare. Managers require leadership competencies to lead change during difficult circumstances Leadership and management are complementary systems of action with overlapping function and characteristic activities.

Doctors as health managers: An oxymoron, or a good idea?

Purpose The purpose of this paper is to review the current literature and summarises the benefits and limitations of having doctors in health management roles in today’s complex health environment. Design/methodology/approach This paper reviews the current literature on this topic. Findings Hospitals have evolved from being professional bureaucracies to being managed professional business with clinical directorates in place that are medically led. Research limitations/implications Limitations include the difficulty doctors have balancing clinical duties and management, restricted profession-specific view and the lack of management competencies and/or training. Practical implications The benefits of having doctors in health management include bottom-up leadership, specialised knowledge of the profession, expert knowledge of clinical care, greater political influence, effective change champions to have on-side, frontline leadership and management, improved communication between doctors and senior management...

How and why medically-trained managers undertake postgraduate management training - a qualitative study from Victoria, Australia

PURPOSE The purpose of this paper is to address the research question using qualitative research methods: how and why medically trained managers choose to undertake postgraduate management training? DESIGN/METHODOLOGY/APPROACH This research used two qualitative methods to gather data. Both methods used purposeful sampling to select interviewees with appropriate management expertise, qualifications and experience. The first stage utilised convergent interviews and was exploratory. The five interviewees were managers and academics. The second stage used case research methodology and was confirmatory. The fifteen interviewees were medically qualified chief executives and chief medical officers. In total, 20 in-depth interviews were carried. Rigorous content analysis of data collected showed emergent themes. FINDINGS The first theme that emerged was that doctors move into management positions without first undertaking training. The second theme was that doctors undertake such training in the form of a masters-level degree and/or a specialist fellowship. The third theme was that effective postgraduate management training for doctors requires a combination of theory and practice. The fourth theme was that clinical experience alone does not lead to required management competencies. The fifth theme was that doctors choose to undertake training to gain credibility. RESEARCH LIMITATIONS/IMPLICATIONS This research was exploratory and descriptive in nature and limited to analytical rather than statistical generalisation. ORIGINALITY/VALUE This research has provided insights into the importance of understanding how and why doctors undertake postgraduate management training, and may assist policy makers and training providers in the development of such training for doctors.

A cross-sectional survey of data presentation and its effect on interpretation

Introduction and Objectives: The minimally invasive infrapubic inflatable penile implant procedure was developed by Dr Perito with the aim of minimising operative time and post-operative morbidity. Dr Eid has also demonstrated a significant reduction in postoperative infections with his No-Touch technique. We have developed a new technique that combines key aspects of these 2 approaches to create a minimally invasive, no-touch (“MINT”) technique for penile prosthesis insertion. We theorised that the MINT technique would take advantage of the benefits that each of these established approaches offered and therefore our primary aims were to assess feasibility, safety, post-operative infection rate and revision rate. Methods: The principles of the MINT technique involve an infrapubic approach combined with a no-touch technique facilitated by using 2 standard surgical drapes (19 clear non-adhesive drape and 19 Ioban drape) and an Alexis wound retractor (figure 1). We present results for our first 258 consecutive patients undergoing primary prosthesis implantation from May 2012 to July 2017, and followed-up for at least 3 months. Patients with complex surgery necessitating >1 incision were excluded. Data was collected using a prospective database. This is the largest penile implant series with the longest follow up to be published in Australia. Results: Average age ( SD) was 60.8 ( 10.3) years. Patients had one or more of the following aetiologies for erectile dysfunction: vascular disease (n = 121), post-radical prostatectomy (n = 142), diabetes (n = 80), Peyronie’s disease (n = 60), venous leak (n = 17) and priapism fibrosis (n = 4). Implant used: Coloplast Titan (n = 246), Genesis (n = 6), American Medical Systems (LGX; n = 5), (CX; n = 1). The average ( SD) cylinder and rear tip extender length was 19.45 ( 1.8) and 1.0 ( 0.8) cms respectively. Median (IQR) follow-up was 30.6 (16.8, 45.7) months. There has been 3 (1.2%) complications: one patient had prosthetic infection after prolonged post-op catheter, which was salvaged. 2 patients had urethral perforation which was repaired intra-operatively, but had a post-operative infection. One of these 2 patients had a prosthesis explant and the other patient management is ongoing. There were also 18 (7%) non-infection related ancillary procedures: 11 pump revisions, 2 corporoplasties, 2 prosthesis revisions, 1 revision of reservoir, 1 glanspexy, and 1 prosthesis explant due to pain with no clinical or laboratory signs of infection. Conclusions: The MINT technique for penile implant surgery is a safe and feasible procedure with a 1.2% infection rate and 7% revision rate in our first consecutive 258 patients with 30.6 months median follow-up. Notably, there were no infections unrelated to procedure complication, that is, no infections the standardised MINT technique.

Sharing the pain: lessons from missed opportunities for healthcare improvement from patient complaints and litigation in the Australian health system

Learning from medical errors to prevent their recurrence is an important component of any healthcare systems quality and safety improvement functions. Traditionally, this been achieved principally from review of adverse clinical outcomes. The opportunity to learn systematically and in a system manner from patient complaints and litigation has been less well harnessed. Herein we describe the pathways and processes for both patient complaints and medicolegal claims in Victoria, and Australia more broadly, and assess the potential for these to be used for system improvement. We conclude that both patient complaints and medicolegal claims could afford the potential to additionally inform and direct safety and quality improvement. At present neither patient complaints nor medicolegal claims are used systematically to improve patient safety. We identify how this may be done, particularly through sharing findings across agencies.What is known about the topic? Patient complaints and medicolegal claims are accepted parts of the healthcare industry. However, using these in a shared and collated manner as part of an improvement agenda has not been widely considered or proposed.What does the paper add? This paper provides a summary of the patient complaint and medicolegal landscape in public hospital system in Australia broadly, and Victoria more specifically, identifying the agencies involved and the opportunities for sharing learnings. The paper draws on existing literature and experiences from both Australia and elsewhere to propose a framework whereby complaints and claims data could be shared systematically and strategically to reduce future harm and improve patient care.What are the implications for practitioners? We offer an approach for practitioners, healthcare managers and policy makers in all Australian jurisdictions to design and implement a statewide capacity to share patient complaints and medicolegal claims as an additional component of system quality and safety.