Emotional Intelligence, Physician Leadership and Decision-Making in the Clinical Organization

James D. Hess, Ed.D., Bavette Miller, Ph.D.



Abstract

Context: Physicians leading clinical organizations function as the managers of knowledge-based entities, creating and implementing solutions to complex problems in ever-changing circumstances. The physician leader is faced with the sometimes overwhelming responsibility of delivering the best possible decision to achieve or further the mission of the clinical entity. The ability of clinical organizations to contemplate, evaluate and implement quality decisions is dependent upon a multitude of intrinsic and extrinsic factors. While the management of extrinsic variables may be more difficult to control, the identification and management of human variables such as emotion is pivotal in the effort to increase the quality of decisions and decision-making processes within the clinical enterprise. The purpose of this paper is to provide practical guidance to physicians in the application of emotional intelligence skills within the clinical leadership setting to improve decisions and decision-making processes.

Methods: Goleman’s and Boyatzis’ et al. four essential elements of emotional intelligence as well as their associated 20 behavioral competencies were utilized to develop a methodology for the practical application of emotional intelligence skills to physician leadership and decision-making within the clinical organization. 1,2

Results: The authors developed a series of assessment questions and observations for applying each of the behavioral competencies associated with emotional intelligence to decision-making within the clinical department.

Introduction

The clinical organization is unique from other business settings in that it must provide services to customers (patients), adhere to regulatory oversight and produce new knowledge while simultaneously altering customer (patient) behavior. Physicians leading clinical organizations create and implement solutions to complex problems in ever-changing circumstances. Milkman, Chugh and Bazerman noted in the knowledge-based economy, a knowledge worker’s primary deliverable is a good decision. 3 Thus the physician leader, which in some instances might include supervising physicians, residents or even medical students, is faced with the sometimes overwhelming responsibility of delivering the best possible decision to achieve or further the mission of the clinical entity. The ability of clinical organizations to contemplate, evaluate and implement quality decisions is dependent upon a multitude of intrinsic and extrinsic factors. While the management of extrinsic variables may be more difficult to control, the identification and management of human variables such as emotion is pivotal in the effort to increase the quality of decisions and decision-making processes within the clinical enterprise.

Goleman described the importance of recognizing and managing emotional variables in the leadership environment, noting that possessing emotional intelligence is equally or more important than IQ.4 According to Goleman 4 :

“Emotional intelligence is a different way of being smart. It includes knowing what your feelings are and using your feelings to make good decisions in life. It's being able to manage distressing moods well and control impulses. It's being motivated and remaining hopeful and optimistic when you have setbacks in working toward goals. It's empathy; knowing what the people around you are feeling. And it's social skill—getting along well with other people, managing emotions in relationships, being able to persuade or lead others." 4

Emotional intelligence has a natural connection with the philosophy of the physician profession. The empathy skills utilized by physicians to connect with their patients are the same skills inherent to the practice of emotional intelligence in relationship management. Because clinical settings possess aspects of both the cognitive and affective domains, physician leaders as decision makers must operate simultaneously in the realms of logic and emotion, and emotional intelligence can serve as the bridge between the two. Moreover, the behaviors associated with emotional intelligence may be learned and applied to improve the overall quality of decisions and decision-making processes within the clinical enterprise.

Emotional intelligence has been the subject of a significant amount of literature over the past three decades, ranging from debate over whether emotional intelligence is innate or learned, to the categorization of specific behaviors that define emotional intelligence. However, little has been contributed to how the behaviors associated with emotional intelligence may be utilized by physician leaders to enhance decision-making in the management of a clinical department. For the purposes of this study physician leaders may be defined as those who are responsible for managing other clinicians and practitioners within a clinical department, whether it be in an academic or private setting. The purpose of this paper is to provide practical guidance to physician leaders in the application of emotional intelligence skills within the clinical leadership setting to improve decisions and decision-making processes.

Methods

Goleman’s and Boyatzis’ et al. four essential elements of emotional intelligence, as well as their associated 20 behavioral competencies, were utilized to develop a methodology for the practical application of emotional intelligence skills to physician leadership and decision-making within the clinical organization.

Results

The authors developed a series of assessment questions and observations for applying each of the behavioral competencies associated with emotional intelligence to decision-making within the clinical department. A template of assessment questions and observations was developed to assist physician leaders in the practical application of emotional intelligence skills to decision-making with the clinical leadership setting.

Discussion

The definition of emotional intelligence and the context in which the term should be used has been debated for decades.5 Thorndike first coined the term “social intelligence” to describe the skills utilized in understanding and managing people. 6 Later in 1940, Wechsler noted the influence of other factors on intelligent behavior and posited that models of intelligence could not be complete until those factors were more fully understood.7 The term “emotional intelligence” was first used in the United States in a doctoral dissertation studying the acknowledgement and effects of emotion.8 This work was followed by an emotional intelligence model described by Salovey and Mayer articulating emotions could enhance rationality and that individuals would be better served to work with, rather than against, their emotions.9 Bradberry and Greaves noted emotional intelligence skills, when considered cumulatively, were vital in representing mental and behavioral functions of individuals beyond their native intelligence.10

The bulk of the literature in emotional intelligence may be encapsulated in the description of three models: 1) ability model; 2) trait model and 3) mixed model. The ability model as described by Salovey and Grewal posited that individuals have varied abilities to process and react to emotional circumstances and as a result develop adaptive behaviors to deal with social situations. 11 The trait model proposed by Petrides, Pita and Kokkinaki was based upon the premise emotional intelligence represents a cluster of self perceptions operating at the lower levels of personality.12 This focus on behavioral dispositions relied heavily on self measurement and as such was more resistant to scientific calibration. 12 The mixed model was best characterized by Goleman’s description of emotional intelligence as a wide array of competencies and skills driving leadership performance.4 Goleman’s model was based on the premise emotional competencies are not innate traits, but rather learned skills that may be developed and improved.4

In a follow-up study Goleman noted the very best corporate leaders, while diverse in their leadership styles, share in common the characteristics of self-awareness, self-regulation, motivation, empathy, and social skill.13 These skills according to Goleman allow superb leaders to understand their own as well as others’ emotional makeup well enough to move people to accomplish institutional objectives.13 Goleman’s original work on emotional intelligence described the following essential elements or abilities: 1) knowing one’s emotions; 2) managing one’s emotions; 3) motivating oneself; 4) recognizing emotions in others and 5) handling relationships.4 Goleman’s theory of emotional intelligence and its characteristic behaviors has been further refined to include both individual and organizational behaviors and outcomes.13 The more fully developed emotional intelligence model as described by Goleman and Boyatzis, Goleman and Rhee refined the original five elements into four dimensions and further subdivided these characteristics into 20 behavioral competencies as outlined in the following table.1,2

Table 1 – Dimensions of Emotional Intelligence and Associated Behavioral Competencies 1,2



Addressing the role of emotional intelligence in decision-making processes, Sevdalis, Petrides and Harvey noted that although empirical research has emphasized the relevance of emotions in decision-making processes, individual differences in the perception and experience of emotion have been largely overlooked.14 The authors concluded when people make decisions, they often think about the emotions that outcomes are likely to trigger.14 Further, Sevdalis, Petrides and Harvey outlined decision-makers: 1) anticipate their emotions before a decision materializes; 2) experience them when they receive the outcomes of their decision and 3) recall them from memory when they contemplate past decisions (good or poor).14 Mellers, Schwartz and Ritov concluded emotions people expect to experience or have experienced as a result of their decisions are important determinants of their current and future behavior.15 Winter and Kuiper noted individuals differ systematically in how they experience emotions, how they differentiate among emotions and how much emotional information they can process. 16

Applying Emotional Intelligence Skills to Clinical Leadership Decision-Making

While much of the literature has focused on the theoretical aspects of emotional intelligence, a significant gap exists in the practical application of these skills to decision-making in general and more specifically to decision making by clinical leaders. If one believes emotional intelligence adds value to the individual and/or group decision-making process, the question arises how can it be practically applied to achieve that desired result? Physicians as decision makers in clinical organizations are often faced with problems that cannot be easily solved and in some cases have negative impacts on some constituency even when the problem has been solved. Thus the consideration of the effect of decisions on others should be an important element of the decision-making process for the physician leader. While determining “who” will be affected by decisions may be a more pragmatic function requiring rationality and logic, determining “how” the decision will be interpreted and its subsequent effect on constituents of the clinical organization requires the skills associated with emotional intelligence.

The application of the ability model described by Salovey and Grewal necessitates the exercise of the following skills: 1) perceiving emotions; 2) using emotions; 3) understanding emotions and 4) managing emotions.11 In the clinical decision-making process, the acknowledgment of individual emotions is critical in determining not only the motivations behind decisions but also the impact of those decisions on both internal and external stakeholders. Physician leaders who understand the emotions of others may utilize that perceptivity to head off potential negative outcomes by addressing those emotional issues in advance of the decision.17 Likewise, physician leaders who perceive and understand their own emotions will be much more effective in managing those emotions in the decision-making process. In keeping with the four elements described by Goleman and Boyatzis, Goleman and Rhee, the emotional intelligence skills in decision-making by physician leaders may be categorized as those more related to the individual, self awareness and self management, and those more attributable to the individual’s relationship and interaction with others, social awareness and relationship management.1,2

Self Awareness and Self Management…Evaluating the Role and Motivations of the Physician Leader as Decision Maker

Self awareness and its representative competencies of accurate self assessment and self confidence (Table 1) enable emotionally intelligent physician leaders to determine their appropriate role in the decision-making process.1,2 Specifically, these skills enable physician leaders to determine if they have the requisite orientation to a problem and possess enough self confidence to assess their own decision-making skills in comparison to others within the clinical department. Accordingly, these emotional intelligence skills create a decision path to determine who within the clinical organization is the most appropriate person or group to make the best decision in any given circumstance.

Self-management and its behavioral components of self-control, trustworthiness, conscientiousness, adaptability, achievement drive, and initiative (Table 1) are equally important emotional intelligence skills for physician leaders.1,2 Controlling the impulse to make every decision individually can sometimes fly in the face of the need to show initiative and achievement.18 Additionally, in order to gain moral authority on an issue, physician leaders must first be viewed as trustworthy by those affected by a decision. Utilizing self management skills to establish a consistent record of achievement and emotional control, physician leaders can simultaneously earn trust from both internal and external constituents of the clinical department.

In settings where the speed at which clinical issues can be resolved is highly valued, the temptation is to avoid decision-making processes which occupy valuable time. However, the emotionally intelligent physician leader will evaluate the consequences of losing trust among clinicians and teams when speed wins out over participation.18 Emotional intelligence requires one to assess the best decision-making process for each circumstance and to be conscientious in engaging the appropriate individuals and groups. Time spent on developing the right decision-making process will pay large dividends in both the quality of solutions, as well as the level of acceptance and trust gained.

Applying the skills of self awareness and self management is a process that can be learned. The following observations can serve as a template for physician leaders in decision-making circumstances.

1. While it may be assumed that physicians are not impacted by emotions in decision-making, that is not always the case. Accordingly, it is important to acknowledge when and how emotions can affect the decision-making process within a clinical department. Therefore, physicians should make an honest self assessment of decision-making skills and styles, noting whether there is a tendency to reach first for the emotional elements of a decision circumstance, or conversely, to reach for the rational analysis components.
2. Acknowledge tendencies toward inclusive or exclusive decision-making processes within the clinical department. Although physician leaders may view themselves as more democratic or participatory, the more critical aspect is the perception of others. While it may not be appropriate to be inclusive in every decision, the emotional intelligence function suggests it is important to communicate to others when and why inclusive or exclusive methodologies are utilized.
3. Exhibit confidence in decision-making skills. Tsai and Young concluded that fear makes individuals second-guess themselves and abandon support for efforts that have gone even slightly off track.19 Being self aware also implies acknowledging one’s weaknesses and having the confidence to recognize the strengths of others in the clinical department in the decision-making process.
4. Focus on achieving the best decision results for the clinical department rather one’s self interests. Emotionally intelligent clinical leaders are characterized by their ability to suppress their own desires and interests for the department as well as the clinical team.
5. Focus on the desired result rather than a speedy outcome. Bazerman and Malhotra noted that time pressures often lead decision makers to bad judgments.18 Patience is pivotal in achieving the desired decision outcome.
6. Utilize the decision-making process to build trust, not only for clinicians, but also among all the appropriate constituents of the clinical organization. Mayer and Caruso noted that leaders high in emotional intelligence will build real social fabric within an organization, as well as between the organization and those it serves.19 Interpreted in the decision making environment of the clinical department, this social fabric is best described as furthering and honoring the culture of the organization as well as the physician profession.
7. Adapt to new decision-making processes rather than relying upon the entrenched processes of the past. When the need for a new decision-making process arises, self manage and correct course. The honest acknowledgement of a need to break with the practices of the past is critical to building self confidence, as well as developing the relationships necessary to affect a positive decision result.17
8. Quickly admit to and correct misjudgments. The ability to openly admit to mistakes is important to both self management and relationship management. Mistakes make emotionally intelligent physician leaders stronger and give them the opportunity to truly connect with others in honesty and humility.
9. Appropriately delegate decision-making authority. Tannenbaum & Schmidt developed a continuum of control and decision-making shared between leaders and followers.20 At all points on their continuum both the leader and the followers have some control. The amount of control each party has depends on the amount that the followers are able to assume. The leader begins with most of the control over decision-making and gradually passes this over to the followers, as they develop their capability, commitment and maturity.
10. Accept the consequences of having delegated or shared the decision-making authority. When decision-making is delegated and things go wrong, both the person delegating the decision and the decision maker have the opportunity to learn from the mistake. Share credit for good decisions and accept responsibility for bad decisions.

Social Awareness and Relationship Management…Assessing and Managing the Decision-Making Environment within the Clinical Department

The emotional intelligence skill of social awareness and its core competencies of empathy, service orientation and organizational awareness (Table 1) enable physician leaders to judge the impact of not only their decisions but also the manner in which those decisions are made.1,2 The best decisions are those that can be understood and accepted by the individuals most affected by the decision. Whether acting individually or in groups, physician leaders who practice the value of empathy can foresee the impact of their decisions before implementation.1 Likewise, exhibiting a servant philosophy can improve the quality of decisions, particularly within the clinical department. For example, if those affected by decisions are viewed as customers who may be retained or lost, one may be more likely to consider the outcomes and consequences of decisions. 21 Accordingly, decisions considered in the context of service outcomes, as well as customer satisfaction and retention, are more likely to be understood and more easily defended within the clinical department.

As noted previously in Table 1, the emotional intelligence skill of relationship management includes the behavioral competencies of developing others, influence, communications, conflict management, leadership, change catalyst, building bonds and teamwork.1,2 The enhancement of clinical decision-making processes is dependent upon the ability to effectively communicate desired outcomes, influence stakeholders and manage conflict. In decision-making processes within the clinical department, the ability to manage relationships is pivotal to success. Even the best of decisions can have negative results if not properly communicated, including the proper articulation of decision-making processes.

While most would like to believe the decision to affect change within the clinical department is most often arrived at through a rational, logical process that is not always the case. Indeed the implementation of many desired changes within the clinical department is fraught with potential conflict, regardless of the original intent of the change. The ability to manage that conflict is central to both the process and outcome of decisions, requiring physician leaders to exercise emotional skills while simultaneously attempting to steer necessary changes.

Application of Social Awareness and Relationship Management Skills

In assessing and developing social awareness and relationship management skills to enhance decision-making within the clinical department, physician leaders should consider the following observations.

1. Determine which individuals, groups or constituents will be most affected by the decision. Social awareness implies adequately contemplating the impact and consequences of a decision before it is made. Play out scenarios of decisions to determine both their short and long-term consequences and effects.17
2. Assess and evaluate how those within the department impacted by a decision should be involved in the decision-making process. Those impacted are more likely to perceive change more positively if they are involved in the decision-making process. This involvement my range from active participation in the contemplation of decision options to commenting before a decision is finalized.
3. Determine what decision-making processes are most appropriate given the culture of the clinical department. For example, if the culture of the clinical organization is team oriented and participatory in nature, it would be important to design decision-making processes consistent with that culture.
4. Foreshadow to determine how the decision and decision-making process will be viewed in retrospect. Emotionally intelligent decision-making requires looking forward and backward simultaneously. Viewing actions from a historical perspective enables physician leaders to assess the impact of current decisions through the eyes of constituents. Reliving past decisions through the lens of their impact also assists in playing out the future of current contemplated actions.
5. View decision-making as a means of developing or furthering relationships with others. Relationships are based upon communication and trust, and emotionally intelligent individuals view every decision-making circumstance as an opportunity to develop or improve the relationship with others.
6. Evaluate communication methods with others engaged in the decision-making process. Relationship management requires a regular and consistent method of communication that reinforces the role of each person in the decision-making process.
7. Conflict is a natural part function within the clinical department. In conflicting settings seek first to understand the position and feelings of the other person.19 Listening is more important than speaking when attempting to resolve conflicts. Equally important is being direct about conflicting views. Demonstrating honesty, and exhibiting compassion in moments of tension will develop trust and foster long-term relationships. Additionally, the emotionally intelligent response in moments of conflict requires an examination of one’s own emotions. It is only possible to exhibit self control if one understands the origins of experienced emotions. Manage volatility by expressing compassion while exhibiting and furthering the culture of the clinical department in the decision-making process.18

Conclusions

Every physician leader shares the goal of enhancing the quality of decision-making within the clinical department, and the application of emotional intelligence skills can assist in the attainment of that goal. Physician leaders who are self aware and can accurately and honestly assess their strengths in comparison to others in the organization have the advantage of leveraging the attributes of others in the decision-making process. The ability to assess the potential emotional outcomes and reactions of decisions can empower physician leaders to predict the sentiment of those affected by decisions, thereby increasing the probability of a more positive decision outcome. The process of building and maintaining relationships necessitates an emotional perspective and while time consuming, will generate better decision outcomes. Additionally, decisions worth making often generate conflict. The ability to manage that conflict requires an emotional intelligence skill that can determine the ultimate success of the decision-making process.

References

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21. Miller, E.G. (2009). Understanding emotional reactions for negative services: the impact of efficacy beliefs and stage in process. Journal of Service Research, Vol. 12 No. 1, pp. 87-89.

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