Good, Bad and Ugly: Exploring the Machiavellian power dynamics of Leadership in medical education.

INTRODUCTION: Medical education requires participation of various stakeholders and this contributes to power dynamics operating at multiple levels. Personality traits of an individual can affect the smooth execution of the educational programmes and eventually the professionalism of the environment. With the increased focus on leadership traits in medical education and collaboration in health care settings, I, through this commentary, would like to explore the Machiavellian power dynamics involved and how it can influence the harmony prevailing in an organization.
METHODS: The author has tried to review the several aspects of Machiavellianism in health care settings and describe day-to-day experiences at four levels; micro (individual), meso (departmental), macro (institutional) and mega (discipline). Introspecting on the unaddressed issues in a different light would help to gain a deeper understanding regarding work place ethics and professionalism.
RESULTS: The reflection of day-to-day experiences in a different perspective would provide an insight regarding various issues to health professionals and help in developing ethical leadership abilities in them, which eventually promulgates professionalism.
CONCLUSION: To my best knowledge, this is the first commentary to deal with the implications of Machiavellianism in different issues related to health care settings. With the increased emphasis on the leadership traits related to medical education, analysing organizational issues in various dimensions is of paramount importance.

Introduction

In Medical Education, as in any field with diverse players, different positions and roles contribute to power dynamics at various levels. Rarely, however, do we explicitly analyse the power dynamics operating in the institutional-sanctioned practices that affect subordinates directly or indirectly. The nature of medical profession itself demands as a student or faculty to demonstrate leadership skills which widely vary according to the contexts, in an increasingly complex healthcare environment. Individual leadership traits, determined by virtue of inherent personalities, play a significant role in determining the collegiality of an institute at 4 levels: micro (individual interactions); meso (at the level of department); macro (institutional level) and mega (work done within a discipline /profession irrespective of the geographical boundaries). We often try to create a schemata of beliefs about ‘good’ and ‘bad’ leadership behaviours, based on our implicit understanding and ‘folk’ theories about leadership (1). In fact, at micro-political level, darker traits of personalities exhibited by health professionals might result in the increase in the burn out rates among employees, decrease in job satisfaction and academic productivity of an organization. Based on the existing needs, National Health Service of the United Kingdom developed a Medical Leadership Competency Framework consisting of five domains: 1) demonstrating personal qualities, 2) working with others, 3) managing services, 4) improving services and 5) setting direction (2). In this commentary, I would like to explore the dynamics involved in the first two domains and how this can influence the harmony prevailing in an organization. As leadership involves the ability of viewing the problems broadly and systemically, here we intend to analyse some issues, which everyone would have experienced in day-to-day practice, in a balcony perspective (3).

Micro level

Unlike business organizations, medical academia require a collegial type of leadership and rely on intrinsic awards such as friendship, collaboration and shared values (4). But, in highly individualistic and achievement oriented conditions, a health professional places his/her personal accomplishment before collegiality. The ideal scenario, where a junior doctor is better facilitated so that what he/she learns is emancipatory, is compromised when individuals harbour conflicting behavioural tendencies. Machiavellianism is one such view of the world, stemming from internal beliefs and motivations, where individuals pursue all necessary means to reach their desired instrumental goals (5). In any profession, people work to support themselves, in terms of personal accomplishments and contribute to the institutional production. Many times, this requires sacrificing our priorities for others. But, Machiavellian ideas work in the counter-intuitive way and include an observable amoral dimension as well. Consider a colleague who believes that the only good reason to talk to others is to get information which they can use to his/her benefit and hides certain other valuable information from others. At times, the degree of Machiavellianism might reflect in crucial factors affecting the job satisfaction such as participation in decisions, coordination for projects and promotion. A synthesis of psychological literature showed an inverse trend between job satisfaction and Machiavellianism for a variety of professions (6). As a silver lining, if people with higher degree of Machiavellianism perceive that participating in a pro-organizational endeavour might accelerate their goals, they never hesitate to behave in a friendly and cordial manner (5). Even though these abstract intricacies never boil down as culpable collisions, we as health professionals could try to alleviate the cynicism associated with it by suggesting reframing of the perspectives and assumptions held by these people.

Tijdink et al, after their extensive research on the association between personality traits, research misbehaviour and publication pressure, found that among the personality traits Machiavellianism had higher correlation with research misbehaviour and the relationship gets stronger in cases of hypercompetitive climate (7). On the other end, we could also notice the manifestation of these traits in medical students (8). It can be in the form of a student who prizes devious behaviour or flattery as a means of “getting ahead” over others or one who believes that luck, chance and acquaintance to “powerful people” determine his/her success rather than hard work and intelligence. A feasible suggestion is, while determining the leadership sub-competencies of a mentee at the undergraduate level, to focus on stimulating reflection regarding these darker traits and thereby providing an impetus to personal growth.

Meso level

At the department level, the implications of understanding Machiavellianism becomes more imperative, as any organization at meso level is potentially vulnerable owing to its complexity, fragmentation and stakes at play. Levy postulated a “nut island effect” whereby a distracted head can ruin a team of deeply committed members. Extrapolating this theory to healthcare settings, we could observe a lot of departments which fail, despite having hardworking and dedicated faculty (9). In other words, if the head lacks the strategic grip over the organization, individuals tend to focus on particular role or individual accomplishments at the cost of the prime mission of organization itself. In contrast to authentic leadership, where there is a miniscule gap between moral reasoning and action, individuals with high levels of Machiavellianism and multiple, competing goals tend to place self-interests such as preserving their status and acquiring additional powers ahead of the authenticity (10). Imagine how far a head, who can be flattered by saying what he/she wants to hear, not believing in saying the real reason unless it is useful to do so and cuts corners here and there for personal benefits, can contribute to the uplifting of the organization. Further, those with high levels of Machiavellianism tend to minimize their personal discomfort by shifting the blame to other persons and circumstances (8) and in conditions of ambiguity, such as unpredictable outcomes, they never take chances. As the behaviour of these sorts is hard to predict, it is impossible for the subordinates to develop even rudiments of trust in them.

In treacherous situations, a cohort of members of organization, harbouring high levels of Machiavellianism flock together. They form a pseudo team, which neither demonstrate any incremental performance nor deliver any joint benefit. Finally, the desired output of the organization flatters down, similar to nut island effect, as the legitimate interest of the competent professionals enters the vicious spiral. From the preceding situations, we could infer that, in contrast to conventionality, leadership cannot be obtained by mere “rite of passage” and presence of a head who can motivate/inspire can make a lot of difference. Medical schools should develop better approaches in recruiting heads who are committed to positive organizational changes, rather than a mere show-off and ensure supportive change management processes in their respective organizations.

Macro level

There is always a palpable functional divide between health care managers and patient care providers in that health care managers are guardians of financial solvency of an organization and they need to assess the patient care endeavours in terms of economy (11). Think of a CEO of a health care setting who is in a dilemma of sacking few employees, in the name of a brighter future for the firm or the one who believes that complacency or mediocrity is detrimental to the organization and pressurizes the employees or the one who believes that remaining powerful is the highest priority, irrespective of what others see as good or bad. How can we define a value-driven leader at organizational level? The ethical leadership demands acting fairly, promoting and rewarding ethical conduct among employees, allowing follower voice, showing concern, demonstrating integrity and taking responsibility for one’s actions (12). Increase of privatization in the health care seemingly has a negative impact in the professional attitude of health care professionals as they become more concerned about their institution’s competitive advantage than about doing what is right and sharing their expertise (13). Also, an administrator who holds Machiavellian norms and values privately and publicly shows ethical behaviour as a Machiavellian personality should be considered as inauthentic, even though it appears charismatic (14).

Educational developers need to work at the institutional level, engaging in projects that cut across the institution, involving a broad range of both academic departments and support units. The thought of operationalizing innovations or change management in health care settings is not an easy task, particularly if it involves multiple leaders with alternating leadership dispositions. So, a conundrum perpetuates when an organization is bound to choose between profit maximization and ethical obligation. In all these situations, decisions have to be made based on the legitimate interests of the organization rather than pacifying the bloated up ego of the intermediates. In reality, when multiple teams work together, we could often witness that some “opportunism seeking tribes” neither collaborate nor focus on the important goals and try to steal the cumulative benefits of teamwork. When the principal motivation of opportunism maximizes personal interest at the cost of common goals, there is a possible detection of a positive correlation between Machiavellianism and opportunism (15). Thus, it becomes quintessential for the organization to view personal qualities of an individual higher than other expertise.

Mega level

This refers to the intricacies which stem up when we disseminate our innovation or practices through articles or conference sessions or when we are working at the mega level by sharing out ideas with experts from various disciplines. We could face senior faculty with temptations to bulldoze ahead with their own “conventional practices” by believing that they have superior knowledge and thereby disrespecting genuine interests. People with higher degree of Machiavellianism tend to prefer “face management” in such situations by advancing themselves socially through associating and being seen with those who are popular and/or influential. In contrast, people with lower levels of Machiavellianism feel ostracized and struggle to firmly establish new ideas, which counter the established practices. This essentially hampers the much needed magic of conversation and process of collaboratively exploring multiple points of view. In contrast, an authentic leadership should support interactions, networking and information exchange amongst those who have the potential to direct a system in order to enable transformation in complex environments (16).

To my knowledge, there are no studies related to the impact of inauthentic leadership in large conference settings. However, in the era of globalization in medical education, a faculty or educational developer should be able to monitor the trend and collaborate with peers from various countries. This involves strategic navigation and placing themselves at right tables so that reciprocity and collective action can be established. Ironically, it has been posited that Machiavellians thrive better in unstructured environments with fewer explicitly communicated norms and rules to restrict their behaviour as they exploit these situations innovatively to their advantages (17). In addition, in conditions where impression management works out, it seems to reap more benefits. The wider impact of this trait could be noticed in relation to publication misbehaviours, whereby a Machiavellian makes tactical decisions in research collaborations and manipulate others to get things done (7). If conferred with power, such as head of the department indulges in things like abusive co-authorship, not giving appropriate credits to junior colleagues and behaves in an intentional rude way, if the junior colleague resists.

Handling Machiavellians

Thus, we can enunciate from the above discussion that we ourselves might harbour certain degree of Machiavellianism or we could figure out these traits in our subordinates/colleagues/students or we would have been suffering under a high-Machiavellian leader. Leadership in medical education involves handling stakeholders of all sorts and achieving the legitimate interests of organization. If Machiavellians are led by leaders who can model proactive changes, provide them sufficient autonomy, convince that achieving organizational goals is linked to their personal goals and monitor the codes of professionalism demonstrated by them, then they would be a real asset to that organization (18). It is also highly imperative for the leaders to monitor and consider the behaviours exhibited by them for performance based appraisals. In contrast, if leaders try to restrict the autonomy and fail to monitor them, Machiavellians try to navigate different pathways like creating pseudo-teams, “shadow” leadership and try to influence the organizational proceedings in negative ways.

Conclusion:

The growing impact that Machiavellianism is having in organizational climate emphasizes the importance of these constructs in medical schools. This commentary highlights the varied dimensions of Machiavellianism in academic institutions. We work in multiple teams and this requires relational and dialogic leadership, followership and the capability to shift role. It is also imperative that “one-size-fits-all” approach does not exist because professionals with a degree of Machiavellianism require the flexibility to tailor their leadership development. Within these domains (micro, meso, macro and mega), medical educators should deliberately enact specific intentions in order to enable the legitimate organizational interests of their context. To conclude, Machiavellianism plays a critical role in the type of leadership behaviour, emerging from moral reasoning and underscores the need for targeting the moral capacity of the professionals in the midst of the Machiavellian tendency to advance them.