Introduction
Courses aimed at promoting leadership are only sometimes offered in medicine; they are present mainly in areas such as business or economics. However, there is little consideration in the field of medicine, a discipline that is both scientific and social and requires mass movement. Perhaps, in some cases, the importance is taught, but how it should be applied is not illustrated.
According to Aggarwal and Swanwick,1 leaders are identified as people who motivate, inspire, and align the path to give direction to individuals. Even so, being a leader is not based on following instructions and recommendations; to be a leader, one must believe it, feel it, and make it part of personality. For this reason, ontological leadership appears, where ontology, as a science that studies being, evaluating the human being, nature, existence, and function of being from another perspective, is associated with leadership.2,3 Therefore, this review aimed to describe the integration of ontological leadership in medicine.
Apply the ontology to the medical leader
Van Diggele et al. (2020) raise the importance of leadership in health education and consider leadership theories, skills, and roles in health education. Highlighting the importance of this topic in medical practice, particularly due to its role in the educational process.4
Many studies explore the application of leadership in medical practice from theoretical and practical perspectives,5–8 generally focusing on the importance of the process and the required skills without delving into the aspects of being from an ontological perspective.9–11
According to Erhard et al., in his course “Being A Leader And The Effective Exercise Of Leadership: An Ontological/Phenomenological Model,” he explains that ontology involves practicing leadership as its natural expression and leaving aside traditional theories of leadership that focus on skills, behaviors, and a list of qualities that a leader should have and practice. The four fundamentals to exercise leadership will be explained below:2,3
Integrity
Integrity refers to honoring your word, being honest with others, and acting correctly.2,3 A good doctor must have integrity, not do it because it is the right thing to do, but be it.
There is integrity when a teacher applies what he teaches to his students; if he talks about the importance of respect, his actions must demonstrate that he has that quality in himself in all aspects of his life, and it is born intrinsically. For example, when he is punctual and keeps his word. Some teachers organize a schedule, do not comply with it, and do not apologize to their students for belonging to a “lower hierarchical rank.” Considering other people’s time is showing respect for others. On the other hand, when the professor writes letters of recommendation, they should be honest; if the professor writes non-existent qualities, it is a lack of integrity.
Accordingly, “Integrity creates workability and develops confidence”2,3 in students, which facilitates the teaching process through more effective communication and keeps students interested with a better attitude, which will make more productive work and more optimal results will be achieved.
Authenticity
Authenticity is acting coherently with who one intends to be for others and oneself, being honest with others and with oneself without using force, and being authentic, especially by recognizing inauthenticity.2,3
In other words, it is being honest not only with what you say but also with what you think and do, and it should be in all aspects of life. Some examples are when the teacher considers punctuality necessary; he must be punctual with his students, friends, and family. If he believes that a project will not meet expectations or needs more time to complete it, he should not continue encouraging students to do it. Furthermore, he thinks that a good professional should stay updated. In that case, he should constantly review medical literature, teach with recent articles and guidelines, always use a reliable bibliography, and extract information honestly. Furthermore, he should continuously train in the medical and pedagogy fields to transfer his knowledge optimally.
A leader must be authentic, especially in the face of a lack of authenticity. This is related to medicine when a professor no longer has patience, cannot keep up to date, and finds it difficult to transmit his knowledge. In this case, the professor should recognize his lack of ability and withdraw, demonstrating genuine authenticity.
Being and acting by something bigger than oneself
Erhard et al. describe this pillar as the source of power to lead and exercise leadership effectively, where the leader does not need the use of force.2,3
In medicine, it is expected to know teachers who humiliate and teach with disdain, which generates fear and anxiety in students and makes the learning process difficult. For example, some teachers answer students’ questions ironically, belittling their lack of knowledge, which will generate fear of asking questions in the future, leaving the students with doubts.
On the other hand, the book states that a leader must be and act for something greater than oneself;2,3 a person decides to be a doctor because of various reasons such as “the hunger for knowledge,” the opportunity to practice in different roles like practice with patients, academia, research, administration; also, for economic stability, a secure job, prestige, and respect. However, all the above benefit the doctor himself, and a leader should have a source of power greater than himself, for example, studying medicine to save lives, relieve pain, and improve quality of life; in other words, choose to be a doctor for humanity.
Being cause in the matter
It refers to the leader declaring himself the cause of what happens. He must adopt a position that prevents assigning responsibility to circumstances, other people, or the ups and downs of the mental state.2,3 This position leads him to take actions and decisions that will help him meet the challenges of leadership and even the challenges of life.3
Some examples include situations in which a professor provides inaccurate or outdated information and should therefore acknowledge and correct the error. However, some physicians prioritize being right over fostering students’ learning. In addition, personal problems may interfere with academic activities, negatively affecting the learning process, the educational environment, and team motivation. Effective leaders must recognize their mistakes without shifting responsibility to external circumstances in order to improve and provide higher-quality education for future physicians.
On the other hand, a leader is the cause in the matter when he is completely immersed in the present time, giving all his potential to what he is doing at that precise moment. Suppose the teacher is performing surgery with his students, such as a nephrectomy for kidney cancer. In that case, his reasoning should be in the procedure, not in different spaces or times, because a step could be omitted, harming the patient and demonstrating erroneous techniques to students; for example, if he forgets to ligate the ureter, he could drag cancer cells to the bladder and cause new tumor growth.
Contextual framework for being a medical leader
Previously, the fundamental factors that make up a leader were explained, and some examples associated with medical teaching were described to explain and convey the information more simply. At this point, the contextual framework for genuinely being a medical leader will be illustrated, demonstrating different contexts for being a leader and exercising leadership effectively as a natural and intrinsic expression of self.
Leader and leadership as linguistic abstractions
Linguistic abstraction refers to an abstract entity, a construction that generates a realm of possibility. Being a leader and exercising leadership have a natural distinction; they exist apart from actual instances and can be distinguished as they actually live with multiple options.
For example, each leader has a personality, so when exercising leadership, they do not have to follow a particular commitment; they can act freely since there are many ways to be and exercise leadership.
According to personality, being a leader can vary depending on one’s characteristics and strengths. Personality refers to a person’s lasting traits in terms of cognitive processes, emotional responses, and behavioral responses.12
According to Kalogeratos et al., an extroverted personality allows quick decision-making, effective public speaking, and inspiring and motivating others. On the contrary, an introverted personality is suitable when careful contemplation, development of strategic plans, and individualized guidance are needed.12
A medical professor with an extroverted personality can perform more striking reviews through gestures and changes in tone of voice, including students with interactive activities and in clinical practice, and have better communication skills, which creates greater confidence and a better relationship. Furthermore, he provides constructive criticism and healthy feedback to promote student learning. On the other hand, if this teacher had an introverted personality, he would have the ability to work with smaller groups of students, which facilitates learning, uses more accurate and reflective communication, promotes a more organized environment, and encourages introspection. All types of personalities are essential for being and exercising leadership.
Leader and leadership as phenomena
A phenomenon is an event, an experience that is encountered through the senses. Erhard et al. refer to the fact that leadership works in the sphere of language because a good leader must have communication skills, whether verbal, in writing, or through actions. Effective communication consists not only of exchanging information but of understanding the emotions and intentions behind the information and transmitting a clear message; it is also essential that a leader has listening skills to fully understand what is being said and that others feel heard and understood.13
A professor in the health area should have communication skills because he is preparing society’s future doctors. Therefore, he should be open to students’ questions, listen to them carefully, not criticize or outwit their lack of knowledge, provide clear explanations with examples or analogies, adapt to the student’s level of understanding, offer additional information, and show a willingness to continue helping the student in the learning process.
Leader and leadership as domain
This issue refers to leading from the temporal domain of a created future, visualizing that future to take actions in the present, and leaving the comfort zone to achieve the goal.
A leader leaves the comfort zone when faced with new projects and responsibilities, actively seeking to develop or improve new skills through programs or mentoring. Other qualities that favor achieving objectives are having a clear vision of the team’s future, capacity for innovation and creativity, and, very significantly, adaptability because the future is uncertain and constantly changing.
To teach in the medical field, the teacher must know the objectives, such as facilitating learning, promoting understanding of specific topics, developing clinical skills, promoting critical thinking to solve problems and make decisions, and instilling professional and personal values in students. In addition, the teacher must set new challenges to be constantly learning and be a better leader every day, for example, instructing on different topics from those he usually teaches, using new educational methods such as technology, teaching diverse groups of students, undergraduate and postgraduate degrees of other specialties, because he would require adapting the teaching approach and resources to meet the needs and levels of experience of each one, also exploring new evaluation methods, participating in conferences, workshops or courses for updating on medical topics or teaching and leadership.
Leader and leadership terms
Being a leader and exercising leadership unifies all the previous terms, “Leader and Leadership as Linguistic abstractions, as Phenomena, and as Domain,” to describe a leader. This person must act from his personality to exercise leadership effectively, have the command of language to establish effective communication, be able to transmit and receive information, be committed to the objectives and goals of the team, be in constant transformation to perfect leadership, and be able to adapt to changes.
Ontological constraints
Ontological leaders also struggle with two types of limitations. These limitations are obstacles that get in the way of authentic ontological leadership. To overcome these barriers, it is necessary to become aware of and eliminate these ontological limitations.
Ontological perceptual constraints
It refers to the “ideas, beliefs, prejudices, social and cultural embeddedness and assumptions that we take for granted about the world, others and ourselves.”2,3 These perceptions can give a false structure or distort the situations that we are actually facing, causing mistakes in leadership.3
A teacher with racial prejudices, gender biases, stereotypes about students’ abilities, beliefs about discipline, or rejection of new teaching methodologies can affect student learning. If the teacher does not put aside his ideals and prejudices to give over his knowledge, he is not exercising leadership effectively. On the contrary, he will be dealing with different obstacles that will distance him from his objectives as a teacher.
For example, in the medical field, when due to religious beliefs, the doctor refuses to perform or administer specific treatments, for example, a voluntary termination of pregnancy or even a blood transfusion. On the other hand, the anti-vaccine position, which would place patients and public health at risk, and the rejection of evidence-based medicine, which leads to a practice of medicine without scientific evidence, among others. If the doctor is also a teacher, these actions will be visualized by students, and they will learn or follow the wrong postures, which could harm patients and spoil medical education.
Ontological functional constraints
It refers to a person’s instinctive reaction to a particular stimulus or trigger, also known as “automatic stimulus or response behavior.”2,3 In other words, the appropriate way of being and acting is not available during certain situations where one reacts instinctively.2,3
Functional constraints in medical teaching are widespread due to the work stress in which doctors constantly find themselves. However, it is vital to recognize, eliminate, and improve education for future doctors. Some examples are when the teacher reacts with anger to disruptive behavior, which creates an environment of fear and anxiety, affecting learning; also when a question or comment is ignored because it seems irrelevant, which discourages future participation; as well when preference is shown for specific students, which can create resentment and demotivation in classmates; also when the teacher reacts defensively to the constructive criticism expressed by the students, which causes difficulties in effective communication. There are many other examples. However, it would be appropriate to identify these behaviors and work to develop more assertive responses.
Some examples of world leaders
In the social sphere, for example, Nelson Mandela, a man who fought against the system of racial segregation in South Africa, was recognized globally for his fight for human rights. Malala Yousafzai, a Pakistani woman who acted against the Taliban government so that women had the right to free education in her country. Both social leaders are recognized worldwide for their ability to inspire people, courage, and conviction for freedom, equality, and justice.
In the environmental field, for example, Greta Thunberg, a 21-year-old environmental activist, became a leader among young people due to her fight against climate change. David Attenborough, an English writer and naturalist, is known for his documentaries on the importance of environmental conservation.
On the other hand, in the medical field, there is Paul Farmer, a medical anthropologist and pioneer of Harvard Medical School, who dedicated his life to providing medical care to rural and underserved communities worldwide. Nubia Muñoz, a Colombian doctor and pathologist at the Universidad del Valle and leader of several studies around the globe investigating the association between human papillomavirus and cervical cancer, was nominated for the Nobel Prize in Medicine in 2008. Rodolfo Llinás, a Colombian doctor and professor from the New York University School of Medicine, is known worldwide for his contributions to neuroscience.
World leaders from any field have specific qualities that identify them as leaders; this includes some of the aspects expressed in this review, such as integrity, authenticity, and a clear vision of what they want to achieve to solve critical global problems. They can also communicate effectively, which fosters trust and facilitates their ability to inspire others to mobilize toward a common goal. They can understand people’s needs and concerns, making connecting with different cultures worldwide easier, constantly learning, updating themselves on their field of study, and transmitting their knowledge to the rest of the world. On the other hand, these leaders are also unique individuals who think and act according to their personality, and this is why they have achieved everything they have cultivated, not forcing themselves to change who they are or their ideals, fighting and giving part of their lives for what they believe is proper and essential for themselves and the rest of humanity.
Conclusions
Leadership in medical education is a poorly illustrated field compared to other areas and, most of the time, poorly applied because it is not considered that this aptitude is rooted in the being, relying more on styles and models that can be confused with forms of management and management tools.
As explained, to be an ontological medical leader, it is essential to consider the fundamental pillars that are based on integrity, understood as being honest with oneself and others, on authenticity, that is, being consistent with what one thinks, says, and do; in understanding that being a doctor implies acting for something beyond one’s benefit, such as for humanity; and to bear responsibility for actions. Furthermore, keep in mind that to exercise leadership, it is necessary to consider the personality type of the leader, effective communication, having a goal visualized, leaving the comfort zone, and always being in the present time without taking thought to another space-time. Finally, a medical leader must recognize his ontological constraints, such as beliefs, ideals, prejudices, and automatic reactions, to always be in a continuous work of improvement to reach the ideal ontological leadership, which can transform the education and practice of the medical professionals of the future and therefore have a positive impact on the health and welfare of society.
Funding
The authors declare that this work was carried out with the authors’ own resources.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Ethical considerations
Protection of human subjects and animals. The authors declare that no experiments on humans or animals were performed for this research.
Confidentiality, informed consent, and ethical approval. This study does not involve personal patient data, medical records, or biological samples, and does not require ethical approval. SAGER guidelines do not apply.
Declaration on the use of artificial intelligence. The authors declare that no generative artificial intelligence was used in the writing or creation of the content of this manuscript.
