Making the magic: Key elements and outcomes of dyad leadership in private practice

Editor’s note: This article is adapted from a larger work. Download the full work here.

Effective leadership is a critical ingredient for a successful healthcare organization.1,2 Poor leadership of healthcare organizations (HCOs) can lead to increased costs, a decrease in organizational innovation, have a negative impact on patient outcomes, and damage provider well-being.3,4

Numerous skills are essential for effective leadership in healthcare, which has prompted the question of whether one individual can possess all the required skills to lead an HCO.5,6,7,8 These beliefs have led to dyad models of leadership,9 a formal leadership structure in which two people from different but complementary backgrounds are paired as a mini-team to provide leadership to an organization, department, project or service line.10 The team often consists of a physician leader (PL) and a dyad co-leader (DCL), an administrator with a business background.11

Dyad leadership in private practice

Despite informal industry surveys that report 77% of health leaders use a dyad model,12 there’s only one peer-reviewed article that examines the use of dyad leadership in private practice. Daiker (2009), in examining the underlying theory of shared leadership, asserts medical practices are complex organizations that employ primarily knowledge workers, or well-educated, sophisticated employees who produce goods or services.13

Since physician partners govern the organization and are the mechanisms of production, sharing leadership responsibilities between a PL and DCL is an effective leadership strategy. Daiker emphasizes that complex environments such as medical practices require expertise that may not exist in just one leader and asserts dyad leadership can be extremely effective in private practice — provided dyad teams share a vision, communicate well and often, clearly define roles, proactively resolve conflict, and take the time to build trust.14

When implementing a dyad leadership model, there are several key structural components to consider. These components include ensuring proper role definition of the leaders, an appropriate reporting structure, and a framework for handling disagreements. Implemented correctly, Daiker asserts a dyad leadership model will enable medical practices to facilitate more efficient leadership and better patient outcomes.15

Barriers to the successful implementation of the dyad leadership model in private medical practice include inevitable conflicts between a heterogeneous dyad pair, the distribution of power, and succession planning for the PL and the DCL dyad members.

Organizations require clinical knowledge and business acumen to succeed in the complex healthcare environment, but merging the two can be challenging.

Additional research is required to understand the perceptions of private practice leaders regarding dyad leadership and the successes and challenges leaders experience while implementing the model. Accordingly, this study aimed to answer the following questions:

1. How do physicians and administrators work together to provide leadership to private practice medical organizations?
   1. How is leadership structured hierarchically?
   2. How are the roles and responsibilities assigned?
2. What is the decision-making structure in the organization?
3. What barriers and facilitators do private practice leaders experience while implementing the dyad leadership model?
4. How do leaders define and perceive the dyad leadership model within private medical practices?

Survey findings

The data collected from both phases of this study were used to better understand dyad leadership in private practice, including defining the model, the structure, barriers, facilitators and perceptions. In addition to quantitative data outlining the structure of the model, six qualitative themes emerged regarding the perceptions of private practice leaders about the model.

The quantitative data analysis showed 89.1% of participants regularly work with a collaborative partner(s) — dyad partner, triad team, shared-leadership partner, or co-leader — to provide leadership to their organization, as illustrated in Figure 1.

The participants indicated varying reporting structures, with the most (40.7%) reporting to the board of directors and/or owners, 18.6% reporting to the managing partner, 13.1% reporting to the administrator, 7.4% reporting to the president/chairman of the board, and 3.5% reporting to “other” as shown in Table 1. Participants were asked to indicate all that apply.

Participants also were asked to indicate by whom their responsibilities were assigned. The majority responded with the board of directors and/or owners (52.6%), followed by managing partner (26.6%), themselves (23%), administrator (13.1%), president/chairman of the board (9.9%), and “other” (4.6%), as shown in Table 2. Participants were asked to indicate all that apply.



Participants were also asked to identify their responsibilities and the responsibilities of their collaborative partners. Table 3 shows the responses from administrator participants, or DCLs, who indicated their partner is a physician or PL. The responsibilities indicated most by DCLs were operations (97.4%), staffing models (90.9%) and compliance (89.6%). The responsibilities indicated least often by DCLs were clinical pathways (35.1%), clinical innovation (40.3%) and clinical quality (49.4%). The responsibilities DCLs indicated most for their PL partner were clinical pathways (75.3%), provider behaviors (70.1%) and clinical innovation (70.1%). The responsibilities DCLs indicated least for their PL partners were performance reporting (14.3%), support system and services (14.3%) and supply chain (19.5%).

Several survey questions were asked with the intent to uncover the decision-making structure within private medical practices. Specifically, participants were asked who was responsible for making and implementing significant, impactful and strategic (i.e., important) decisions on behalf of the organization. Further, participants were asked what party was held accountable for the results of important decisions. Participants reported that the board of directors were most often the party responsible for important decision-making within the organization (41%) but did not often do the work of implementation (2%) and were also not often held accountable for the results of the important decisions (7%). Participants reported they were most often tasked with implementing important decisions (35%), followed closely by the participant and their collaborative partner (29%). In terms of accountability, 32% of participants reported that they and their collaborative partners were held accountable for the results of important decision-making, and 27% of participants reported themselves as the party held accountable for the results of important decisions made in the practice as shown in Table 4.

The participants were also asked whether they felt they had influence on important decisions made within the practice. The results indicated that most participants (81% indicated they were in an administrator role) strongly agree (34.7%) or agree (33.2%) that they have influence on important decisions made within their organization as shown in Table 5.

The researcher then performed a chi-square test to determine if the participants’ organizational level impacted whether they felt as if they had influence on important organizational decisions. Participants who were at a lower level in the organizational hierarchy as their collaborative partner were less likely to agree or strongly agree that they had influence on important organizational decisions, to a significant extent (p = .006).

To better understand the barriers and facilitators private practice leaders experience while implementing the dyad leadership model, questionnaire participants were asked to indicate to what extent they agreed with several leadership challenges and successes they have experienced as shown in Table 6. The challenges/problems the participants strongly agreed or agreed with most frequently were the struggle to balance various roles/responsibilities and increased financial demands.

The challenges/problems the participants strongly disagreed or disagreed with most were chemistry between them and their partner and not enough time to build a relationship with their partner.

When asked to what extent they agree with certain successes resulting from their leadership partnership, participants agreed the most with achieving more than they could have done alone and increased trust within their organization. Participants agreed the least with the ability to operate in a value-based delivery model and reduced leader burnout. Overall, participants were more likely to strongly agree or agree with leadership successes than they were challenges or problems.

Interview findings: Themes

During the qualitative data analysis of interview transcripts, the researcher used Tesch’s eight-step process to uncover themes. Six final themes emerged, as illustrated in Figure 2 below. It is important to note that only DCLs are represented in this phase, which is an important limitation to this study.

Theme 1. Look, we don’t need to put a label on it

In the interview phase of the study, participants were asked how they define the dyad leadership model within their practice. Most participants needed a moment to reflect upon the question and formulate a response, as if they had not previously needed to label the model. Participants were mostly casual in their description, further indicating they have not thought about carefully defining the model. Participants discussed the concept of collaboration as a key concept. Some participants specified the leadership structure developed naturally while others indicated they deliberately initiated the model within their practice. Excerpts of some participant answers follow:

• “[It means] joint decision-making. I think we each bring different things to the table and have different perspectives.”
• “Honestly, dyad partnership, I first heard it when I was doing your survey. So, I just said yeah, it’s a private practice. Sometimes it’s myself and all of the physicians, sometimes myself and one of the physicians. It just depends.”

Theme 2. It’s pretty obvious who’s in charge here

During the interview process, it was clear that most participants perceive physicians to be the final decision-makers and ultimately in charge. As ultimate decision-makers in private practice, physicians are the chief influencers of the work environment, and physicians are acknowledging that changes in the industry require them to cede some control to administrators, but many physicians do this grudgingly. Further, many participants indicated defensiveness from physicians and/or barriers to administrative progress due to physician leaders’ insistence on control. Most participants indicated they navigate this challenge magnanimously because they understand as owners of the practice; the physicians incur most of the risk involved with the organization. Excerpts of some participant answers follow:

• “I will say I never felt ‘less than’ in my current role. But yes, there is delineation between MD owner and administrator. It’s hard for them, because of their schooling, and because of their abilities as humans they think they can do everything.”
• “She’s [president and physician] definitely in charge of the business, but she really doesn’t have to devote time to the running of the business. She has someone that can handle the finances and handle the operations. She had a great vision that it is really challenging for one person to do both and continue growing a company.”

Theme 3. It’s not all talk

The third theme that emerged from the qualitative phase of the study was the importance of relationship building. Relationship building enables dyad partners to achieve mutual trust, respect and appreciation.

Subthemes that support this theme are exquisite communication and vulnerability/humility, as illustrated in Figure 3.

Exquisite communication is required to build a productive relationship. This communication should be formal and informal. Examples of formal communication include clear role definition, conflict resolution and deliberate communication based on various scenarios. Examples of informal communication include small talk and getting to know one another on a personal level. Feedback is also a necessary communication component. Excerpts of some participant answers follow:

• “I mean, we just work really well together, and we’ve known each other for a long time, and if he [physician leader], or they [physician partners] have ideas, we meet. We’re pretty easy to meet when we need to meet. We meet every Thursday as the entire group, so we’re always talking through what we’re doing and getting feedback.”
• “…the basic fundamentals of communication. [The] ability to bring up tough issues, having crucial conversations, if you will [is important to a successful dyad team].”

Vulnerability and humility allow dyad partners to get to know one another at a human level and moves beyond each individual’s education and professional training. Vulnerability and humility also facilitate exquisite communication — it is hard to productively communicate with one another if both parties are guarded. Excerpts of some participant answers follow:

• “… It’s [dyad partnership] kind of like having a marriage or [some]thing. It’s going to take patience, it’s work, you know good relationships require work, you’ve got to admit [when] you’re wrong. You’ve got to say, ‘I’m going to make stupid mistakes, so bear with me.’”
• “… initially it all fell on me, getting the information. Eventually, [the] physicians did start seeing the struggle … I let them know … I need help.”
• “… it goes back to the whole humility piece…you just have to say, ‘I’m not an expert at this.’ We need to work through that.”

Theme 4. To know you is to trust you

The fourth theme to emerge from the qualitative analysis is the importance of mutual respect, trust, and appreciation, and is a key component to successful dyad teams. Mutual respect, trust and appreciation are born out of relationship building. Two subthemes support the main theme: enabling true partnerships and overcoming challenges. Figure 4 illustrates theme four and its two subthemes.

Mutual respect, trust, and admiration engender true partnerships among dyad team members, even when the partners are not on the same hierarchical level within the organization. This is a key way by which administrators influence their PL dyad partners, even while recognizing the physicians have ultimate authority. Excerpts of some participant answers follow:

• “Each person has their specialty, and we have a lot of trust. So if I bring an idea to the table and it’s not approved, I generally don’t feel like it’s because of my position in the company. It’s because for some reason, we talked it out and there was a flaw in the idea, and so we couldn’t accept it.”
• “The problem is to understand the balance and the respect that has to be earned from both parties, to make the dyad relationship really work, both [must] recognize the positive and negative aspects that each bring to the table.”

When dyad partners achieve mutual respect, trust and appreciation, they are empowered to overcome challenges. Challenges identified by interview participants include power struggles, the cultural differences of administrators and physicians, financial issues, conflict and burnout. Mutual respect, trust and admiration also allow partners to give one another the benefit of the doubt when someone makes a mistake or disagreements occur. Excerpts of some participant answers follow:

• “… you really develop a deeper relationship. You get to know the person, and when the inevitable errors and faux pas occur, you know … the person enough. It’s not due to ill intent or neglect or incompetency. Life happens, and so there’s more of a constructive being, versus do you side with your pure physicians. And of course, people turn it into an either/or. Are you either a physician or an administrator? And I think he [physician leader] is really learning — it’s a both.”
• “… I think there’s a lot of burdens in that you’re kind of lonely at the top, or lonely at multiple levels … Now you have a colleague to get a cup of coffee with and talk to [through] tough issues so you’re having that natural, dyad or camaraderie with somebody else and from a different perspective.”

Theme 5. This is where the magic happens

The fifth theme that emerged during the qualitative phase of this study is where the magic happens — joint decision-making. Joint decision-making is the result of mutual respect, trust, and appreciation. When opportunities to make important decisions occur in organizations with dyad partners who respect, trust and appreciate one another, they naturally seek out each other’s opinions before making a decision. This collaboration leverages the unique knowledge and experiences of each dyad partner. Further, this collaboration minimizes one-sided decision-making that sometimes results in mistakes. Importantly, joint decision-making also works to gain buy-in from both sides, a critical component of a successful change process. Excerpts of some participant answers follow:

• “My job is to guide and to give good advice and information so that they can make the right decision. I would say most of the time we make it collaboratively together.”
• “I think the potential other premise…if somebody’s thinking title gives you sole decision-making … I believe that’s wrong … in a physician-driven or -led organization. You need buy-in … granted there’s limits to that, but you need to get people bought in. So decision-making or influence is a little more indirect.”
• “We define it as a balanced team approach. Some of us are more risk adverse. Some of us are more risk prone. And being able to really talk out major operational decisions, especially in the pandemic, I think is what makes our company very fluid and adaptable.”

Theme 6. And who doesn’t like magic?

All participants (most were DCLs) endorsed the dyad (or triad) leadership model without hesitation. Again, it is important to note the lack of PL participation in this study. Excerpts of some participant answers are below.

• “… it’s a wonderful thing, just requires effort by everybody … I don’t plan to be with another organization, but if I were, and there were physicians involved and there was no dyad, I would create it formally.”
• “… my role is to make [the] practice successful. For that you have all aspects participate. You know, not permitting clinicians, to participate, I feel is an error. Because they need to be able to buy in to the administrative activities necessary to sustain the operation. So, it became … a design requirement.”
• “I would say that it’s extremely important, because, like I said earlier, each party brings a different perspective, and I’ve learned that doctors do think differently than administrators. … And so it’s just a very important part of running a group to have that ability to have both parties there.”

Summary

Study results indicated the dyad leadership model is widely used in private practice, although the model is loosely defined and can differ from how hospitals generally use the model. While existing literature emphasizes the importance of dyad partners being at the same organizational level, survey participants in this study indicated this occurs only 27.2% of the time. Granular differences also arise when comparing the roles and responsibilities of DCLs and PLs in private practice versus those in hospital/health system settings. For example, existing literature recommends the compliance function to be a PL responsibility, but in this study most DCLs indicated compliance was one of their responsibilities.16 Further, many of the PL responsibilities outlined in existing literature were claimed by DCL participants in this study. Participants also indicated these responsibilities were held by PLs, which points to the dyad partners collaborating on these tasks in the private practice setting.

In contrast to hospital/health system settings, in private practice, the dyad leadership model is often not given a label and is implemented in a less formal manner, sometimes evolving almost organically.

Some components of the dyad leadership model emerge in private practice and hospital/health system settings. The importance of joint decision-making, relationship building, mutual respect and trust were present in both the existing literature and in the results of this study. Similarly, members of dyad leadership models in both settings endorse the use of the model, often reporting it allows them to accomplish more than they could have done alone.

Notes:

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5. Becker et al.
6. Clausen C, Lavoie-Tremblay M, Pruden M, Lamonthe L, Ezer H, McVey L. “Intentional partnering: A grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system.” Journal of Advanced Nursing, 73(9), 2156-2166. doi: 10.111/jan.13290.
7. Vremes C. “A tale of two leaders: Dyad leadership model in healthcare organizations.” Doctoral dissertation, Creighton University. 2018.
8. Saxena A, Davies M, Philippon D. “Structure of health-care dyad leadership: An organization’s experience.” Leadership in Health Services, 31(2), 238-253. doi:10.1108/LHS-12-2017-0076.
9. Buell JM. “The dyad leadership model: Four case studies.” Healthcare Executive, 32(5), 32-40.
10. Sanford K, Moore SL. Dyad leadership in healthcare: When one plus one is greater than two. Philadelphia: Wolters Kluwer.
11. Saxena, et al.
12. Comstock NH. “Better together: Most healthcare leaders report using a dyad leadership model.” MGMA. Oct. 31, 2019. Available from: mgma.com/stat-dyad19.
13. Daiker B. “Shared leadership in a medical practice: Keys to success.” The Journal of Medical Practice Management, 2009 Sept.-Oct.; 25(2): 111-117. PMID: 19911547.
14. Ibid.
15. Ibid.
16. Zismer DK, Brueggemann J. “Examining the ‘dyad’ as a management model in integrated health systems.” Physician Executive, 2010, 36(1), 14-19. Available from: bit.ly/37rwjRs.