title: Medical doctors in healthcare leadership: theoretical and practical challenges.
abstract: While healthcare systems vary in their structure and available resources, it is widely recognized that medical doctors play a key role in their adaptation and performance. In this article, we examine recent government and organizational policies in two different health systems that aim to develop clinical leadership among the medical profession. Clinical leadership refers to the engagement and guiding role of physicians in health system improvement. Three dimensions are defined to conduct our analysis of engaging medical doctors in healthcare leadership: the position and status of medical doctors within the system; the broader institutional context of governmental and organizational policies to engage medical doctors in clinical leadership roles; and the main factors that may facilitate or limit achievements.
  
  
  
  Our aim in this study is exploratory. We selected two contrasting cases according to their level of institutional pluralism: one national health insurance system, Canada, and one etatist social insurance system, the Netherlands. We documented the institutional dynamics of medical doctors' engagement and leadership through secondary sources, such as government websites, key policy reports, and scholarly literature on health policies in both countries.
  
  
  
  Initiatives across Canadian provinces signal that the medical profession and governments search for alternatives to involve doctors in health system improvement beyond the limitations imposed by their fundamental social contract and formal labour relations. These initiatives suggest an emerging trend toward more joint collaboration between governments and medical associations. In the Dutch system, organizational and legal attempts for integration over the past decades do not yet fit well with the ideas and interests of medical doctors. The engagement of medical doctors requires additional initiatives that are closer to their professional values and interests and that depart from an overly focus on top down performance indicators and competition.
  
  
  
  Different institutional contexts have different policy experiences regarding the engagement and leadership of medical doctors but seem to face similar policy challenges. Achieving alignment between soft (trust, collaboration) and hard (financial incentives) levers may require facilitative conditions at the level of the health system, like clarity and stability of broad policy orientations and openness to local experimentation.
authors.affiliation: École nationale d'administration publique (ENAP), Montreal, QC, H2T 3E5, Canada. jean-louis.denis@enap.ca.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Denis
authors.affiliation: TIAS School for Business & Society, Tilburg University, Warandelaan 2, Tilburg, 5037 AB, The Netherlands.
authors.forename: Nicolette
authors.initials: N
authors.lastname: van Gestel
mesh_terms: D002170:Canada; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards; D006291:Health Policy; D006295:Health Resources / Q000458:organization & administration / Q000592:standards; D006801:Humans; D007857:Leadership; D009313:National Health Programs / Q000458:organization & administration*; D009426:Netherlands; D016134:Organizational Policy; D010820:Physicians; D024382:Professional Role; D058996:Quality Improvement; D011787:Quality of Health Care / Q000458:organization & administration / Q000592:standards; D035502:Trust
keywords: Clinical leadership; Health system improvement; Medical engagement