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Hello, I’m Domhnall MacAuley and welcome to this BMJ Leader conversation, where we talk to the key opinion leaders in health and medicine around the world. Today we’re in Australia and I’m speaking to Professor Erwin Loh who is President of the Royal Australasian College of Medical Administrators, but he’s held many other senior leadership roles in health care. Let’s take it back to the very beginning. Were there any hints of this future career when you were at school?
Erwin Loh: When I was a child, what I wanted to do was to go into space. I wanted to be an astronaut. I kind of still want to do that but I’m too old now, I think. As a kid I had no ambition of doing anything in health but as I grew older, that was when I started to develop an interest in a career where I could do something useful and help people.
DMacA: So you went to Melbourne University, tell us about that.
EL: Going through High School- I went to a public school, I came from very humble beginnings, working class parents in Melbourne- I did well in school such that in my high school certificate I got a score that was good enough that I could do any course in any university. Without any particular view of what I wanted to do, I picked the degree that was the hardest to get into. That was the University of Melbourne Medical School, which is the oldest medical school in Melbourne, and still today the highest ranked medical school in Australia. I absolutely loved it. And, I still feel very attached to the University of Melbourne, being a very proud alumnus of that school.
DMacA: You then set off on a pretty standard medical career. After qualification you did paediatric and a psychiatry jobs. But I think that psychiatry job changed your life.
EL: I had a strong interest in paediatrics and a strong interest in psychiatry. Initially I wanted to be a psychiatrist. I did dual training, I did the program and the exam, and then developed an interest in forensic psychiatry. I did an interesting rotation in forensics, which was fantastic, so I decided to do a law degree and get more expertise in forensics. When I finished the law degree, which I did through Monash University, I was offered a job in a law firm, took it up, and did my article clerkship. I worked as a lawyer full time for a couple of years but I missed medicine and decided that maybe law wasn’t for me. I was in health law and insurance law, but I missed medicine and I missed the hospital setting, so I thought about how I could combine medicine and law and landed on medical leadership and management because, in Australia, we are fortunate that there is a specialty college, the Royal Australasian College of Medical Administration, founded in 1967, so, its one of the older colleges. I did that training program, and the rest is history. I’ve been in medical management since.
DMacA: Along the way, you collected a number of degrees. You did an MBA, but then you did a PhD. Tell us about that.
EL: I did medicine first and then law and as I was doing the training, the Royal Australasian College of Medical Administrator’s (RACMA ) training, one of the requirements was that you had to do a masters. I did an MBA. And, once you finish an MBA, it’s much easier to get a second master’s as I could get credit for a number of subjects so I also did a Masters of Health Services Management. The Ph.D. was because of my interest in academia and research. At the time, and even today, health leadership and management is a relatively under researched area. There is a lot of research around management science, and a lot of research in the basic clinical sciences, but in terms of management and leadership in healthcare, it’s still a relatively evidence free space. And so, because of my interest, I decided to do research. When I first started my PhD, it was in mortality reviews. I did one whole year of mortality review research and found it exceedingly boring. The advice I was given at the time, which is true today, is that if you want to complete a PhD successfully, you need to be passionate about a subject. I wasn’t passionate about mortality research so I decided to change to change the topic to something that I was passionate about, which is medical leadership. So I changed the research topic to – how and why senior medical staff transition from clinical practice into senior hospital management. That was my topic specifically because I was one of those people, someone who had transitioned from clinical practice into management. I interviewed every single doctor who was a CEO in the state of Victoria and then half the Chief Medical Officers. I did my PhD, published a series of papers, and since then I’ve done more research in this space.
DMacA: Rather than go through all your various jobs, I’m really interested what you learned along the way. And, I’ve heard you speak about the huge difference between the culture of medicine and the culture of law. Talk to us a little bit about that.
EL: One of the advantages of doing different studies is that you learn different ways of thinking. There are different logic models in the differing industries. In medicine, doctors are trained to take a history, do an examination, do a series of investigations, and then very quickly come up with some differential diagnoses and potential treatments. Doctors are used to a very short timeline of thought to action; the problem, the causes, and then a solution. Medicine is highly scientific, it’s factual, its logical, its rational. And there’s a kind absolute truth to it, either yes or no.
On the other hand, when I did law, it taught me how to think quite differently. Law has a very systematic way of writing about things, of looking at cases and precedents. And because the law is essentially a manmade system to manage society as a whole. It’s highly relative, because what’s legal yesterday may not be legal today. It’s all to do with interpretation of legislation and arguing your case. Law taught me how to do that, how to be more structured in my thinking and in my writing, to be very precise and use simple language because, unlike in the past, lawyers are teaching people to write simply, using simple ideas. It taught me how to argue in a logical manner and to use evidence to do so. That’s the difference, medicine is scientific and absolute, and law is always relative and more man-made.
DMacA: I’m sure there are many areas in your life now in management, administration and leadership where those two skills come together. One area that caught my attention was your work on inappropriate behaviour by doctors.
EL: It’s now a well researched area, this whole area of doctors misbehaving, bullying and harassment, inappropriate behaviour, incivility, unkindness in medicine. These are all related, and it’s now an expanding area of research. In Australia, we’ve got the National Health Medical Research Council, NHMRC, so I’ve been involved in NHMRC funded research projects around inappropriate behaviour and culture in medicine, when I was chief medical officer, at St Vincent’s, and yes, it’s still an issue.
In my role in RACMA, as a current President, RACMA has sponsored a whole program of work, “A Better Culture” (ABC) https://racmaconference.com.au/the-a-better-culture-project/ , that was funded by the Commonwealth Government to look at how we can improve culture in medicine. Because, for the past ten years when we do what we call the medical training survey, looking at culture in medicine, every year 32 to 35% junior doctors experience or have observed bullying in the workplace. Going back eight years now, when we had a whole Royal Commission in Australia into health care bullying, and the Royal College of Surgeons had an expert advisory group looking at bullying and developed this program called Operating with Respect, we’ve done our better culture work, but, for whatever reason, we have not shifted the dial. And so it’s this intractable issue in medicine. We’ve always said that it’s going to take a generational shift, that the next generation will be better, but it hasn’t happened. I’ve written a paper, published in the Insights magazine of the Medical Journal of Australia https://insightplus.mja.com.au/2022/26/its-time-to-recognise-and-fix-structural-unkindness/ talking about my view that there is a culture of unkindness passed down from generation to generation through the training system and how we deal with one another. But then the system is unkind. The way we work our junior doctors and we even roster them, the way the whole system is structured, is unkind. It’s not personal. It’s just a system. We have structural and systematic bias of discrimination. We have systematic unkindness. And we need to deal with that as a system. Inappropriate behaviour is an issue and in the modern health setting there is zero tolerance. For me, going back 15 years ago, I’ve fired senior doctors for bullying, I just removed them from the workplace. Despite that there is still this whole stance by the junior doctors that there is ongoing unkindness. We need to kind of drill down and see how we can fix that.
DMacA: In that context of looking at a change in that culture and leadership, how do you do that? How do you teach that leadership?
EL: Leadership is about being, it’s less about doing. In teaching leadership you can teach the principles and concepts. The model that I teach at undergraduate and postgraduate level is Greenleaf’s theory of servant leadership based on his 1970 paper. https://greenleaf.org/robert-k-greenleaf-biography/ Leadership is about serving. You serve a team so that you can serve the team members so that, in our case, you serve the patients and families and the public. And if you use the model, then leadership is about service. So its about how you serve, equip and inspire and be authentic in your work. It’s about role modelling and example. The best way is to role model the right attitudes, the right behaviour. That’s one way of doing it. You can teach management, but you can’t really teach leadership. You got to learn it on the job. It’s ultimately by learning from the good leaders. I think both concepts are inextricably linked. You can teach management and you can teach the principles of leadership, but ultimately you got to do it and be a good leader.
DMacA: You’ve spoken about your own philosophy of servant leadership, but you also said that leadership must evolve, and we need a new model for leadership.
EL: In one sense leadership has evolved and continues to evolve since the turn of the century, right from the “great man” theory, we’ve moved to transactional leadership, behavioural trait leadership, we’ve gone through transformational leadership and servant leadership that has come thousands of years ago from the Bible and Jesus- the last will be first and the first will be last, and all of that. And, Jim Collins wrote about Level 5 leadership. So, now they’re all kind of similar. The evolution of leadership in health is this appreciation now that, while health leaders were traditionally the authoritarian great clinicians who ended up being leaders, we now know that leadership goes beyond that. The soft skills of leadership are actually more important than hard skills, and that’s where your strengths are. And so I think that evolution has already happened and it’s more about giving the health leaders, today and of the future, those skills; equipping and training, and giving them the proper role modelling, coaching, so that they can reach their potential as effective leaders. There are plenty of health leaders out there, but to maximize their potential and be completely effective, they need to learn all about leading people. You manage things and manage a budget. You can’t really manage people. You’ve got to lead them.
DMacA: Let’s talk about something slightly different now because you’re a member of the Association of Professional Futurists. Tell us about the future!
EL: This is basically the hobby side of my life. I have a deep interest in medical futurology, and the future design of the system. If you want to be an effective leader, you don’t have a choice but to think about the future as the current system is not sustainable. In all countries and in every jurisdiction the current health system, the hospital system, was designed a hundred years ago. And no matter how much we’ve tried, we haven’t been able to shift the dial to redesign it properly. Every time we try to move things, inertia and the system itself, the homeostatic way it is designed, bring us back to focusing on the hospital. Everyone thinks about the hospital but we all know the future is not the hospital. My interest is in leading doctors, leading health systems, and I’m very interested in the impact of new technologies, new emerging medical therapeutics, like Crispr genetic engineering, and the impact that such things may have on the future. And how do we start. Every time we do planning, service planning and capital planning, how do ensure that we do not go back to the old ways of thinking but look to design things fit for purpose for the future? That’s my interest and I’ve written quite a few papers now on the potential impact of AI even before it was as trendy as it is now and other areas of technology; Crispr genetic engineering, 3D printing, brain computer interfaces, virtual reality, augmented reality, and how those things can be applied to health.
DMacA: Let me ask about one of your other interests, which is a something a bit left the field, because I’ve seen you tweet recently about sport.
EL: Yes, my feed, is a way of keeping up to date with what’s going on. I read a lot of research news and research papers, and I like to share it, because that’s another a hobby of mine.
And you will see me share research on sports, on nutrition, on mental health, AI and new technologies, all of those things. I’m a strong believer in encouraging lifestyle changes because ultimately, if you look at the health system of the future, we need to move from tertiary care and acute care all the way back to preventive care and primary prevention. That’s the future of health care. The problem is that the funding models that we have incentivize hospital care and acute care and fee for service, and they’re all activity based. Medicare insurance is fee for service so it incentivizes people to remain sick. We are paid more money if you are sick, whereas there is very little funding for keeping people well. Somehow we need to monetize well-being and preventive care. And I think that is going to happen because we don’t have a choice. And that’s where sport and physical activity come in and there’s a lot of research now to show that exercise is the best medicine. Somehow there is this secret ingredient in exercise; probably a whole bunch of neurotransmitters and hormones and muscle byproducts that do the magic. There’s a lot of research now, with drug companies trying to find the chemical that exercise generates so that they can trademark it and make it into a drug to sell. So, I’ll be sharing a lot about physical activity, nutrition and the gut microbiome,
DMacA: Finally, let me bring it back to your own mission, which you alluded to it earlier as religion is an important part of your life, where you encourage people to- go and make a difference.
EL: The true leader is the leader who wants to make an impact and leave a lasting legacy on the world, to make it better than it was before you even existed. The only way to really do it is in making change in people’s lives. It’s the people that really matter ultimately. So how do you make people’s lives better? How do you change them for the better? There are two ways. One is in individual impact. So, you do your best to raise up the next generation of leaders. You coach them. You identify potential leaders. The ultimate goal and key performance indicator of success for a leader is in developing the next generation of leaders that are better than you. Secondly, besides individual impact, you try to change the system for the better. Its about the impact on populations of people. And that’s why I strongly believe that all health leaders should be thinking in those terms. That’s what I’ve tried to do right in my career. That’s what I’m trying to do in all the things that I’m involved in so far, as President of RACMA and also in my day to day job.
DMacA: Erwin, thank you very much for sharing so much of your life, your philosophy, and your many different roles. It’s just been a pleasure. Thank you very much indeed.
Professor Erwin Loh MBBS, LBB(Hons), MBA, MHSM, PhD, FRACMA, FACLM, FAICD
Erwin Loh is President of the Royal Australasian College of Medical Administrators. He was most recently National Director of Medical Services for Calvary Health Care. He was previously Group Chief Medical Officer at St Vincent’s Health Australia, Chief Medical Officer at Goulburn Valley Health and Chief Medical Officer of Monash Health. He has qualifications in medicine, law and management. He is a barrister and solicitor of the Supreme Court of Victoria and High Court of Australia. He has adjunct professorial appointments at Monash University, University of Melbourne and Macquarie University. He has been an invited speaker at local and international conferences, and has published books, book chapters and journal articles on health leadership, health law, clinical governance, AI and health technology. He is a member of the Association of Professional Futurists. He received the Distinguished Fellow Award from RACMA in 2017 for “commitment to governance, research and publication”.
Professor Domhnall MacAuley
Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none