The Impotence of Being Important – Reflections on Leadership

Ian Douglas Couper

doi:10.1370/afm.664

Abstract

An observed doctor-patient encounter, in which impotence and importance were confused, led me to a reflection on leadership. A sense of importance can be destructive in leadership, leading to failure to perform, or impotence. Understanding the dangers of self-importance, I am challenged to ensure that I regularly reflect on my leadership style.

What is wrong with this gentleman?” asked the recently arrived British doctor of the nurse-interpreter in the outpatients department of Manguzi Hospital, a community hospital in a remote district in South Africa. After a brief exchange in Zulu with the elderly male patient, the nurse replied, “He says he is important.” A long pause followed as the concerned doctor tried to work out an approach to this novel problem. “How long has he been important?” seemed a good standard follow-on. “A few months now, doctor.” Not sure where to go from there, he decided to get to the heart of the matter: “Why is it a problem for him to be important?” A longer discussion in Zulu followed, during which the nurse showed some signs of discomfort, before she summarized somewhat succinctly, “He cannot satisfy his wives.” My colleague was musing about how one’s importance might prevent one from satisfying one’s wives (a fruitful exercise) when the truth dawned on him. “You mean this gentleman is IMPOTENT!”

I have often thought about this brief patient encounter on which I eavesdropped many years ago. I have come to understand that importance, or the feeling of importance, can often be a cause of impotence. Physically the phenomena may be very different, but at another level they are very close. When I believe that everything depends on me, or that I am the only person who can do the job, or that I am the best at doing something, I become impotent in my leadership and in my practice.

As I have reflected on this patient-doctor-nurse interaction, I have identified a number of ways in which self-importance can be destructive to leadership. These reflections arise from my experience as medical superintendent of Manguzi, a remote rural hospital in northern KwaZuluNatal, South Africa. The hospital served a population of approximately 100,000 people, with 280 beds, 9 permanent clinics, 3 mobile clinics, and a total staff of more than 500, including from 6 to 12 doctors depending on staffing levels. Since leaving Manguzi in 1999, I have had the chance to further reflect on my interactions while working alongside nurse-practitioners in primary care clinics in the North West province and subsequently leading an academic rural health unit within the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg. My reflections are informed by my ongoing experience as a clinician, teacher, researcher, and manager.

Thus I offer the following lessons, recognizing that I am constantly relearning them myself.

If I feel very important, I start to do everything myself instead of delegating responsibilities. I fear passing tasks on to others because they will not do it the way I would or as well as I would (so I believe), but I become unable to do everything myself. I become an obstacle for myself and for others because I am doing too much. Delegation is an important aspect of leadership and, distinct from off-loading work, requires that I have a balanced view of myself. I sometimes believed that “my” hospital would collapse without me, yet it has continued to function well since my departure.
If I feel very important, I isolate myself from the teams to which I belong. This isolation deprives my colleagues of the chance to work with me to achieve a goal, and it deprives me of positive support. To gain a team’s commitment to something they have not been involved in developing is much more difficult. At the hospital I worked with a number of teams: a management team, a health care team, a medical team, a community team, etc. In each sphere, I needed the support of other team members to achieve any vision that I may have had, ensuring the vision was a shared one. As doctors, especially rural doctors, we tend to be very independent-minded people who do not easily defer to our professional colleagues. Our patients and our practices often suffer because of that trait.
If I feel very important, I become less critical of myself and less able to evaluate myself. I no longer face and learn from my mistakes. The chances are that my mistakes will thus be repeated. An inflated opinion of ourselves makes it difficult for us to view ourselves honestly: the mirror becomes the instrument of deceit, as in the old fairy tale, always proclaiming us the fairest of them all. I had to make the same labor ward mistake twice to come to this realization! An honest review of poor performance as part of self-reflection is the first step to personal growth.
If I feel very important, I am not open to learning from others. I take on knowledge, perhaps, but the most profound learning comes through the questioning that follows the identification of our own needs. It is difficult to be aware of needs if we are enamored with our own importance. Others do not feel able to reflect the truth back to us because we will not hear or we react defensively. We also do not create the avenues for feedback from patients and staff because we cannot believe we would learn anything (or are secretly afraid of what we might learn.) This may be something of what is meant by the Biblical teaching, “Blessed are the poor in spirit.”
If I feel very important, my sense of invulnerability makes me vulnerable. We know that pride comes before the fall. I perforated the uterus of a patient with an incomplete abortion soon after assuring a new doctor that, in my experience of more than a hundred of these procedures, an evacuation and curettage is extremely easy to perform. I was challenged about my leadership style by a colleague to whom I had boasted of my open and participatory leadership. If we are blind to our areas of weakness, we cannot prepare ourselves for the problems that they will cause.

Thus, I believe we become impotent in our leadership if we are too filled with our own sense of importance.

As a doctor, as a manager, as a teacher, I receive much external input persuading me that I am indeed important. To guard against this sense of self-importance, I find that I need to create time and space for personal reflection on who I am (not what I am) and to establish relationships with people who will keep me honest.