When Leadership Training Is Not Enough: The Developmental Challenge Facing Physicians and Surgeons

Physicians and surgeons spend much of their professional lives becoming extraordinarily good at learning. Medicine demands it. New evidence emerges, procedures evolve, technologies change, clinical guidelines are revised, and expertise must continually deepen. When a physician moves into leadership, it seems reasonable to approach development in much the same way. We teach people to communicate more effectively, manage conflict, delegate, think strategically and lead change; all of which are important.

One question that influences how I approach leadership development in complex environments is this: What happens when the complexity of the leadership role begins to exceed what additional knowledge and skills alone can solve?

It's a question that sits at the intersection of adult development, adaptive leadership, and practice. This article explores what becomes necessary when the challenge isn’t to know or do more, but rather to develop greater capacity for making sense of complexity itself.

I see versions of this dilemma in my work with physicians and healthcare leaders. A physician knows he needs to delegate more, yet continues to step in when something important appears at risk. A surgeon understands the value of allowing others to develop, yet watching someone struggle when she knows how to solve the problem feels almost irresponsible. A leader knows a difficult conversation needs to happen, yet preserving an important relationship carries enough weight that the conversation keeps getting postponed. Another understands intellectually that not every urgency deserves her attention, yet deciding what will not receive attention creates its own discomfort.

These are easy patterns to interpret as behavioural problems. Perhaps the leader needs better boundaries, stronger delegation skills, more resilience, or greater comfort with conflict. Sometimes that’s exactly what’s needed and other times not.

Robert Kegan and Lisa Lahey make an important distinction in Immunity to Change. Learning can expand our repertoire of skills and responses without necessarily changing the underlying way we make sense of ourselves and the world. Development is something deeper. Their work suggests that our experience of complexity is partly a relationship between the demands confronting us and our current capacity to make meaning of those demands.

That distinction has significant implications for physician leadership development. A physician can learn the mechanics of delegation while still carrying an assumption that says, “If I could have prevented a poor outcome and did not intervene, I’ve failed in my responsibility.” A leader can learn excellent conflict management techniques while remaining governed by the belief that significant disagreement threatens a relationship she can’t afford to lose. A department head can understand the importance of distributing responsibility while still experiencing another person's mistake as something he should’ve prevented.

More information does not change assumptions. The person likely doesn’t experience them as assumptions but more like truth. This is where adult development becomes particularly helpful.

Kegan and Lahey describe development in adulthood as changes in the way we construct and understand reality, rather than accumulating more knowledge. Their framework describes movement through different forms of meaning making, including what they call the socialized mind, the self-authoring mind, and the self-transforming mind. These are not measures of intelligence. Rather, they describe increasingly complex capacities for relating to our own thinking, to other people, and to the systems around us.

The self-authoring capacity is particularly important in leadership. It allows us to develop an internal compass, evaluate external expectations, take a position, establish boundaries, and make decisions according to values and principles we have genuinely made our own.

Medicine demands a great deal of this. Physicians must exercise judgment, tolerate responsibility, make consequential decisions, and maintain professional standards even when other people disagree.

Greater leadership complexity, however, can eventually ask for something beyond having a strong internal compass. It can require the ability to question the compass itself.

Kegan and Lahey describe a further developmental capacity in which we become confidently able to step outside our own framework and examine its limitations. We can hold a strong position without becoming entirely identified with it and we recognize that our interpretation is an interpretation rather than reality. We become more capable of holding contradictions and multiple perspectives without needing to resolve them immediately.

I find one idea from their description particularly relevant to physician leadership. At greater levels of mental complexity, we become more able to observe the filter through which we see, rather than only looking through it. Consider what that might mean for a physician leader.

“I am responsible for this” becomes, “What do I assume responsibility means in this situation?”

“They are resisting this change” becomes, “Is my interpretation of their resistance preventing me from understanding?”

“I need to protect my team” becomes, “At what point does protecting people interfere with their development?”

“This needs to be fixed” becomes, “Why does resolution feel necessary right now?”

The external problem hasn’t disappeared however, something has changed. The leader is no longer completely embedded in one interpretation of it and that creates choice.

The nervous system comes into the room too

There’s another dimension of physician leadership development that deserves attention. Leaders don’t encounter complexity as intellects detached from bodies, histories, identities, and relationships.

A physician may understand an issue perfectly well at 9:00 on a quiet morning and experience it quite differently during the fourth crisis of a fourteen-hour day. Uncertainty, interpersonal threat, responsibility, and loss of control narrow what feels available in the moment. The impulse to fix, control, appease, withdraw, or work harder can appear long before a deliberate leadership strategy has been chosen.

This is an important distinction when we ask why intelligent people continue behaviours they genuinely want to change. Many of the patterns leaders struggle with began as successful adaptations. Extraordinary responsibility earned trust, vigilance prevented mistakes, independence made it possible to survive demanding environments, emotional control allowed someone to function when others needed them and working harder most often produced results.

An adaptation that protected competence, belonging, identity, or safety does not disappear when someone attends a leadership program, which is why I think compassion and developmental rigor belong together.

Instead of asking, “Why am I still doing this when I know different?”; a more useful inquiry could be, “What makes this response feel necessary to me?”

It's not an excuse for ineffective behaviour. It is an attempt to understand the internal logic sustaining it. Once that logic becomes visible, we have the opportunity to examine it, test it, and choose more deliberately rather than unconsciously following it.

 

Medicine creates a developmental paradox

Some of the qualities that make an excellent physician or surgeon become more complicated as leadership responsibility increases.

What I often see is a strength beginning to overreach its usefulness. A quality that once served the physician extraordinarily well begins to operate differently under the demands of leadership. Responsibility becomes over-responsibility, precision hardens into overcontrol, decisiveness narrows curiosity, and endurance obscures the point at which persistence is no longer wise. Expertise can prefer problems that yield to solutions, while the instinct to intervene can become so intertwined with good care that allowing someone else to struggle with a challenge begins to feel negligent.

Development requires a more difficult move than acquiring a new strength. It asks us to change our relationship with an existing one. This leads to a question I find more revealing than asking the leader what new competency they need:

Which qualities made you successful as a physician, would better serve you if they showed up differently in leadership?

It’s a developmental question that honours what’s worked while asking what needs to change.

Adaptive challenges require more than technical expertise

The connection with adaptive leadership becomes important here. Kegan and Lahey draw on Ronald Heifetz’s distinction between technical and adaptive challenges to illuminate why some challenges can't be resolved by applying additional expertise or technical skill alone. Technical challenges can be extremely difficult and consequential, yet the knowledge and procedures required to address them are known. Adaptive challenges are quite different and cannot be adequately addressed by adding new technical skills to the existing mindset.

Physicians and surgeons are accomplished technical problem solvers. Leadership, on the other hand, confronts them with challenges where technical mastery is insufficient: trust deteriorates, organizational structures change, authority becomes ambiguous, resources are constrained, colleagues hold legitimate but competing priorities, people are exhausted, and decisions must be made when every available option carries a cost. Working harder and knowing more doesn’t solve these problems.

In leadership, the complexity outside the leader requires greater complexity within the leader.

This is where adaptive leadership and adult development intersect. Adaptive challenges describe the nature of the problem, while adult development asks about the capacity of the person meeting it. The question then becomes less about whether physicians can manage more complexity and more about whether we are intentionally helping them develop the capacity required to lead within it.

 

Physician leadership development needs a broader ambition

I’m not arguing against leadership training. I’m pointing to another layer of development that becomes increasingly important when the complexity of the role outgrows what skills and knowledge alone can address.

Kegan and Lahey's work challenge the old assumption that meaningful mental development ends in early adulthood. Their research describes the possibility of continued qualitative development across adult life, although such growth is neither automatic nor uniform. This suggests that leadership development should do more than expose leaders to new ideas. It should create the conditions for deeper, sustained developmental work.

That creates an exciting possibility for physician leadership development.

What if we measured development not only by what leaders know, but also by what they have become capable of seeing?

Can I notice an assumption without automatically treating it as truth? Can I hold competing perspectives without immediately deciding one of them must be wrong? Can I remain connected to someone who disagrees with me without abandoning my own judgment? Can I recognize when responsibility has become over responsibility? Can I tolerate uncertainty long enough to discover something certainty would have obscured? Can I recognize the limitations of my own framework while still having the courage to lead from it?

These capacities become increasingly important as leadership becomes more complex.

This may also explain why some highly accomplished physicians can complete excellent leadership programs and still find themselves struggling as the demands of the role change. They may not be missing another answer. They may be encountering the limits of the way they have learned to construct the question itself.   

This is a hopeful distinction. Reaching the limits of a familiar way of leading is not evidence of failure. More often, it signals that the complexity of the role is asking something new of us: a different way of seeing, making meaning and responding. This is where development begins, when what has served us well can no longer carry us as far as it once did.

Development doesn't ask us to abandon the strengths that brought us here. It asks us to hold them differently, with enough perspective to know when they serve us, when they limit us, and when something else is required of us.

The future of physician leadership development will depend less on adding more to the leader, and more on expanding the leader’s capacity to meet complexity differently.

Mary Printz, M.Ed. is an executive coach and leadership consultant who works with physicians, surgeons, and high-performing leaders navigating complexity, growth, and change. Her work integrates Immunity to Change, adult development, emotional intelligence, and neuroscience to help leaders uncover the hidden assumptions and patterns that can limit how they lead under pressure.

Mary helps leaders move beyond simply knowing what they should do differently to developing the capacity to actually lead differently, with greater clarity, steadiness, confidence, and choice.

For coaching, speaking, or leadership programs: Mary@MaryPrintz.com | 1-403-866-3806