Why Healthcare Professionals Need to Understand the Four Quadrants of Leadership

by Jen Barna MD | Leadership, Physician Coaching, Physician communcation, Physician Leadership, Podcast, Resilience

Why Healthcare Professionals Need to Understand the Four Quadrants of Leadership

“So what Bolman and Deal end up saying is that managers live in the structural frame and the human resource frame. Basically, managers manage for stability and order, while leaders, yes, they are definitely performing in those four frames, but they can also switch the lens towards a political frame or a symbolic frame. So that is what makes them different from managers, because leaders lead for dramatic change, useful and dramatic change.”

Tosca Bruno-van Vijfeijken

Leadership is something that many physicians and health care professionals find important. So many of us want to learn how we can be a better leader and what it takes for the building blocks of leadership within an organization. We also want to understand leadership better, not only because we may want to step into leadership positions someday, but we want to know and understand how we can be led more effectively, by better understanding what it is that leaders do. Tosca Bruno-van Vijfeijken sheds some important light on that for us. 

Tosca is a consultant, coach, public thought leader, and author. Her focus is on nonprofit organizations, both domestic and international. She’s also the host of the podcast NGO Soul and Strategy, and host of several courses on virtual team leadership, including a course built to include physician leaders. At the start of her career, Tosca worked as an international development practitioner for a European think tank, The World Bank, the U.S. nonprofit, and the United Nations. 

Over the last 30 years in her leadership development and coaching practice, Tosca discovered a particular set of concepts known as the four frames model. Tosca walks us through those four frames in detail. We also discuss organizational politics and how they play into leadership. 

Burnout is often tied to no longer feeling like our work has meaning or purpose, and one of the ways we can help our teams rediscover that sense of purpose is by using storytelling, a technique for leaders that ties into the four frames. Tosca shares some valuable wisdom around how to grow as a leader through expanding our horizons and thinking outside of our own confined boxes.

If you liked this episode, you may also like

The Physician Leader as Learner with Tosca Bruno-van Vijfeijken

What’s Inside:

  • The four frames model of how we view leadership.
  • How to find meaning and purpose through storytelling.
  • How we can break out of our own confined viewpoints to become better leaders.

Mentioned In This Episode:
5 Oaks Consulting
Between Power and Irrelevance: The Future of Transnational NGOs


The past few weeks have been busy at DocWorkingWe have been working behind the scenes to add more CME credits to the THRIVE memberships. Now you can get a credit for each small group coaching session as well as for each 1:1 coaching session, so 12 credits/year from monthly small group coaching sessions plus 8 credits for our foundational StressPal course+community coaching. That means there are now up to 32 credits in our THRIVE Platinum subscription!

How many coaches do you think your favorite actors and athletes have worked with over the years in order to achieve such extraordinary success?
What if you had a team of trusted thinking partners, experienced coaches who have helped hundreds of physicians overcome obstacles and who know what works? 

What if you were part of a community of like-minded physicians from across the nation, across specialties and career stages? Your collective brain trust, sharing ideas and experiences, so you would no longer feel like an island, surrounded by people yet alone?

What if you had small group coaching sessions, could interact with your coaches and community as often as you wish, and had virtual courses at your fingertips 24-7 that could help you with things like time and stress management, resilience, and mapping out your future to achieve what matters most to you?

What if you could have all of this for less than the cost of a single 1:1 coaching session per month?

DocWorking THRIVE is the Physician Coaching and Community Subscription Package that Guides You as a Doctor to Embrace Life in the way that is most meaningful to you, integrate that with your work so you can truly thrive, and be a valued member of our growing private community of doctors from across the nation.

Join our community by clicking here.

Coaches and Courses at DocWorking

Please check out our Trusted Resources! The Trusted Resources businesses are paid advertisers or have an affiliate relationship with DocWorking. An affiliate relationship means that DocWorking may receive a commission if you use their service by clicking through our link. Thank you for supporting businesses that support DocWorking’s mission of prioritizing Physician wellness.

Are you a physician who would like to tell your story? Please email Amanda, our producer, at [email protected] to be considered.

And if you like our podcast and would like to subscribe and leave us a 5-star review, we would be extremely grateful!

You can also find us on Instagram, Facebook, LinkedIn, and Twitter.

Some links in our blogs and show notes are affiliate links, and purchases made via those links may result in payments to DocWorking. These help toward our production costs. Thank you for supporting DocWorking: The Whole Physician Podcast!

Occasionally, we discuss financial and legal topics. We are not financial or legal professionals. Please consult a licensed professional for financial or legal advice regarding your specific situation.

We’re everywhere you like to get your podcasts! Apple iTunes, Spotify, iHeart Radio, Google, Pandora, PlayerFMListenNotes, Amazon, YouTube, Podbean


Please enjoy the full transcript below


Tosca: So what Bolman and Deal end up saying is that managers live in the structural frame and the human resource frame. Basically, managers manage for stability and order, while leaders yes, they are definitely performing in those four frames, but they can also switch the lens towards a political frame or a symbolic frame. So that is what makes them different from managers, because leaders lead for dramatic change, useful and dramatic change.

Jill: Hello and welcome to DocWorking: The Whole Physician Podcast. I’m Jill Farmer, one of your co-hosts on the podcast and lead coach at DocWorking. We are so glad you’re here today. As always, this is brought to you by DocWorking THRIVE. Go to today to take our burnout quiz and learn how you can go from being burned out to balanced. We’re really excited for this conversation today because we’re talking about something that I know many physicians and health care professionals have told us it’s important to you and that’s leadership and learning how you can be a better leader and what it takes for the building blocks of leadership within an organization. And I’ve even had physician clients tell me they want to understand leadership better, not only because they may want to step into leadership positions someday, but they want to know and understand how they can be led better by better understanding what it is that leaders do. And I think today’s conversation is going to shed some important light on that for you all. I’m really excited to be joined by Tosca Bruno-van Vijfeijken. She is a consultant, coach, and public thought leader, author, and her focus is on nonprofit organizations, both domestically but especially internationally. She’s also the host of the podcast NGO Soul and Strategy, and host of several courses on virtual team leadership. At the start of her career, Tosca worked as an international development practitioner for a European think tank, The World Bank, the U.S. nonprofit and a little organization called the United Nations. After leaving the Netherlands, her home country, she has lived in Zimbabwe, Cambodia and Vietnam before settling in upstate New York. And she’s been here for about 21 years. She is a dual national USA and Netherlands citizen. Tosca, thanks so much for being with us here today to talk about some frameworks of leadership that I know were new to me and insightful to me. And to understand a little bit where we can default as either leaders or aspiring leaders into comfort zones and where we can stretch into spaces that help us be more balanced on the leadership front. 

Tosca: Absolutely. It’s my absolute pleasure to be here. And I loved how you framed that. Just now about the default and the stretch opportunities. 

Jill: So let’s talk a little bit about one of the frameworks that you use extensively in your work in helping to support people in leadership, to make everybody thrive, particularly in organizations and nonprofits where you’ve done a lot of your work. It’s based on these four frames of leadership. Give us an overview a little bit about what you’re talking about when we’re talking about these four frames. 

Tosca: Yeah. So this is a set of concepts that comes from two authors here in the U.S. Bolman and Deal. And I have found over the 30 years or so of my leadership development and coaching and change management practice, that this particular set of concepts always resonates with leaders of both nonprofits domestically, but particularly internationally, and also in government agencies and in the U.N., as you said. So basically, the idea is that especially as managers want to rise to the level leaders, they need to become more agile, more versatile, more flexible in choosing certain leadership lenses or frames, as it’s called in what we call colloquially the four frames model. To choose our leadership lenses or frames more strategically, depending on the context. So to not always refer back to your word, Jill, a default lenses that we might naturally be prone to default to. So the four frames in a nutshell, let me first explain the nutshell and then feel free to ask me more where you think that might be helpful. So the four frames, first of all, is the structural frame, and that is that the organization, when you as a leader in a health care organization or in a health care practice, when you think about the organization as a machinery, as like in a factory where you have cogs and wheels and everything has to be turning. So basically, you’re thinking about the organization as an organic room, as a set of boxes where people are placed with job descriptions and titles and hierarchies, and where we decide how information has to flow and how decision making will flow. That is the structural frame. Okay. It’s a very classical frame, the second frame is the human resource frame. And so this is a mindset, a leadership lens through which I as a leader can look at my organization or my team, my unit, etc. as a family, where I as a leader need to make sure that my staff, my employees feel they’re welcome. They feel a sense of belonging. They feel they’re part of a family. They feel they are heard. So there are participatory approaches towards managing the organization and try and pay attention to things like employees, professional development, their career growth and passing, etc. The third frame and this gets a little bit more abstract is the idea that the organization is not just a machinery, it’s not just a set of people that want to feel part of a family, but it’s also a jungle where people are jockeying for positions, jockeying for access to the top leader, for access to budgets. Right. Where people start to form coalitions in the in the background with each other and in order to try to have sway to influence a certain decision. Right. And where there’s also conflict around resources and access to the top leader and decisions. And then the fourth frame is the frame where the organization is also either a stage like a theater stage or a stadium, etc., or wherever, where it’s a temple, a mosque or a church. What do I mean by that is that people in organizations, employees, staff need to also have a sense of higher meaning through the work. And some leaders are better able of others to kind of talk about that higher meaning the purpose of the work in a transformational way. And they use storytelling, they use images, they use myths, also myths about the organization that motivate and inspire people. So those four frames are what we mean by the four frames as first put out by Bolman and Deal here in the U.S. So what Bolman and Deal end up by saying is that managers live in the structural frame and the human resource frame. Basically, managers manage for stability and order, while leaders yes, they are definitely performing in those four frames, but they can also switch the lens towards a political frame or a symbolic frame. So that is what makes them different from managers, because leaders lead for dramatic change, useful and dramatic change. So let me stop there, Jill, and see what you think. 

Jill: I think you did a beautiful job of explaining it, because I’m quite sure this is new to a lot of us, including me. And I really like how you delineate between the definition of managers versus leaders. And I think that’s what we have seen in health care over the last two and a half years, thanks to COVID. And, you know, leading up to that, thanks to the overwhelming administrative load that has become part of a lot of people’s life as health care professionals since the advent of EMR and EHR, our electronic medical records, that administrative load has created a shift in a lot of people’s balance of clinical work versus the other work they’re doing. And so managing the details isn’t enough anymore. I think, long term to help create cultures in organizations where people can thrive. And so for health care professionals to be part of the giving voice to this idea that it can’t be just about managing, it has to be about leading. So for somebody who listens to that and says, okay, I am a leader or I am close to a leader, and I can see they’re doing their best in the human resource side of things, caring about people in the family, treating their employees like family, the structural side of things, handling a lot of those details. But gosh, don’t they want to stay away from the, as you called it, the jungle or the political aspect of the scarcity of resources? Or is it really their job to create meaning and purpose for people? Shouldn’t that be an inside job of the employees themselves? How do you convey to them why those other two lenses might be places where they want to stretch themselves?

Tosca: Where they want to stretch those, and you’re absolutely right, I see this in national and international profits too that a lot of people initially -not everybody-the interesting thing, though, there’s always some leaders who will pick up immediately on the symbolic frame and who are great storytellers. So they will, for instance, really use metaphors and storytelling a lot. But that’s a small minority. On the political frame, I would say-and by the way, there is a gender dimension to this- I want to highlight that. Right. So particularly women we are and women physicians and women leaders, we are socialized to think that politics with a small P and I want to really point out that when I talk about the political frame, I am not talking about party politics. I’m not talking about self-serving politics. I’m talking about political behaviors as a leader. And if you want, we can kind of unpack what I mean by that in order to serve the mission of the health care organization better. Right. There is a gendered aspect to this where women, more than men on average, look down upon the political frame or think that it’s dirty, ethically dirty. And so I would contend that if you as a leader do not want to shy away from the political frame altogether, you need to be aware of others sometimes who will use it, and they may use it either for petty or self-serving purposes, in which case you need to know how to counteract that, and sometimes you will be bypassed that way in furthering the mission. So I do think it’s important. So should I give some examples of what we mean by this? 

Jill: I was just going to say, give us an example, because I can hear, you know, listening to this as a woman through my lived experience. You know, there is a little bit of me that said, wait, isn’t that the patriarchy, right, that you’re supposed to play the game to try to get a hold of the attention of the power of the people who hold power here? And I know I know that’s not at all what you’re saying, but I need just a little more detail so I can better understand how this is an effective way, or lens for leaders to grow the mission. 

Tosca: I will fully concede that when you say this is partially, I don’t remember exactly what the American expression is for this, but playing the game that others are good enough to helping with, and I don’t remember that expression exactly anymore. But joining the game that others are playing, something like that. So influencing work, especially behind the scene influencing. So for instance, I’m a leader in the health care organization and I’m seeing that my senior team above me and hierarchy is about to make a decision that I really think is not serving the purpose. However, I do not have direct access to people or I don’t have credibility with them. Can I pull in behind the scenes somebody? Who else? A third party, if you will, who I know has access to the CEO, let’s say. Right. Who is a friend of the CEO or who is a confidant of the CEO. So that’s what I mean by the political frame is one example where you bring in third party actors, if you will, to influence a decision. Another example is when you purposefully created it yourself. So you basically you sense that somebody has a little bit of ego and you purposely play on that in order to further what you believe, what you really care about that you stand for. So those things one could say, yes, that, that, that these things that I don’t want to do for purely kind of very high valued reason but I would argue that if you do not know how to sometimes make judgment, how to use those kind of behaviors, others will undoubtedly do it and they will bypass you and the things you care about.  Is that helpful?

Jill: 100%, because we can get so high-minded about things like this that it’s like, well, it’s almost like then we have to speak the same language at some point in the way people are used to conveying information and making decisions, and particularly when they when resources are limited in organizations, it’s not game playing, which is designed to make somebody else lose necessarily. It’s looking at the pathways or the methods or the methodology that help get the things that are most important to you communicated in a way that lets your mission move forward. And kind of related to that, you alluded earlier when we’re talking about that symbolic or that the other frame that is about finding meaning and finding purpose. And you said one of the ways that leaders can help with that is through storytelling. I really love that because we know as this relates back to burnout, that one of the antidotes to burn out is reconnecting people to why their work matters to their purpose, which can feel really big. But if it points out, like, why does this matter to me? That gets us back connected to our values. That’s a really good way for us to find meaning and work again, which helps with burnout a lot. So as a leader, if you can get more adept at helping connect people to why their work matters to that purpose and meaning, and you give a really good example of that, of giving by using story to connect people. That’s a really good skill we need to be thinking about incorporating into our work. 

Tosca: And also like, what images am I calling upon, right? So what images do I hold up? And very importantly, Jill, who do I hold up? So who I as a leader celebrate for what kind of behaviors has an enormous culture? Love to do work and culture. And I hope to in the future sometime talk with you or Jen about organizational culture as well. But so what images I evoke or the people I hold up and celebrate or who I defer to in meaning in meetings is incredibly important in a symbolic frame. And because staff will watch what you do, they do not pay as much attention to what you say, but they sure pay attention to what you do. So the symbolism of your behavior on a day to day basis is really important. So there’s this idea of heroes, right? Who do I hold up as heroes is really important in a symbolic frame. One more example, going back to the political frame, maybe that’s helpful is so bartering is also a leadership behavior in the political frame. In other words, to be saying, I know you really you’re talking to somebody else who you want to make your allies for. This is you trying to engage in coalition forming. Right. And that you say something like this, I know this XYZ is important to you. I’m very happy to help you with that. Will you in return help me with this new initiative? So just another example. 

Jill: Yeah, that’s a really good example. So as we’re thinking about, I kind of think is the I know we’ve talked about different metaphors or these frames or as lenses that you can use to work through. I think it also has different building blocks to think about, you know, as foundations of leadership. So you pointed out initially and we talked about briefly the idea that some of these are managers, for instance, you’re getting more comfortable in that human resource or that, you know, people management, if you will, and then the structural management that leaders are looking to maybe stretch themselves into these other ways of thinking in terms of symbolic and political. So if I’m somebody listening to this and I’m, for instance, I come from maybe more of a not for profit background in my health care organization. We know that those folks tend to be most comfortable in that human resource, family caring idea. How could I grow my leadership skills and abilities by stretching myself into some of these other boxes? What would you say to that? 

Tosca: So that’s a good question. So, Jill, what I love about this framework is that it’s actually something I have found in my own life that I can train my mind around. You know, what we bring to our leadership is partially our personality. It’s our natural instincts are drives, etc. and those are over a long period of time can be somewhat tweaked, but they are fairly, fairly solid or stable. So for instance, I was somebody who lived primarily in the human resource and in the structural frame, and I have found that now I’m much more attuned to, oh, they this other person is moving in the political frame. So I better think about how I can either join that or counteract that, how I need to respond to that. I did not live much in a symbolic frame, and I have found ways now of evoking storytelling and heroes, etc. and to be very cognizant about the symbolism of my own behavior that I’m on a stage in a certain way where people are watching me all the time, right? So what I love is that this is actually a trainable mindset in this framework, and that is not true for everything we can learn in a leadership development program. 

Jill: Yeah, I really like that. So I love how you, if I’m hearing you right, reflecting back to you that this is a really good technique for meeting people where they are, right? Thinking about these lenses can help you connect to because a mistake that can be made in leadership often is if only people would just think like I want them to think or act like I want them to think or behave like I want them to think. And that’s you know, it’s a huge mistake. It’s sort of the biggest mistake I think you can make in leadership. And that and being completely inflexible and not dynamic and in the way that you want to adjust to challenges and to support people. And I think the other thing that I noticed as I was contemplating thinking about these and learning about them for the first time is when I’m feeling stuck. I feel like it provides new options for stuck situations for me. And I could apply these lenses, you know, after our initial conversation, it’s like, well, if I’m just wishing that people would do X, Y or Z differently, or the structure would change that, I don’t have agency to change the structure right now. How might I think about this more in terms of reallocation of resources and connecting to the decision makers to help them listen to things differently? How might I think about this in terms of how it relates to why these matters to me and somebody else and how we can find common ground on that? And that kind of opened my mind up. And so I really thought it was interesting to think about this as a problem solving or as a perspective shift. 

Tosca: Yes. Yes. And it’s all about, it comes from this broader leadership school that is called contextual leadership. So where I’m very attuned to what do my “followers” need from me at a certain at this moment in time and that I’m very self-aware that I do not default back to the one or two frames that I tend to be most comfortable with. There is an assessment that you can use with this method, and most people live primarily in the human resource and structural frame. So that’s really good to become self-aware around because as you know, self-awareness is also one of those foundations for leadership, right?

Jill: So finally, when have you seen a leader able to shift from whatever their home base or default frame was in this framework and stretch in a way that had a meaningful impact on those are leading the culture of the organizations and benefit for the leader themselves?

Tosca: In some functions, what I sometimes call guilds. So for instance, people work in compliance, right? People who work in HR as in the, the functional specialization within an organization, people who work in legal, etc. have a hard time getting out of the structural frame. That’s where they are all the time, right? And so I have seen examples where people in the structural frame actually never really thought about the people aspect of their role. And if they wanted to have their organizational systems and processes respected by others, they needed to move more towards the human resource frame. I really think about how is this impacting people. Can I bring people along? Can I invite people to have input on how a certain organizational system or process works? So stretching yourself to adjacent areas and I would say the human resource and the structural frame are adjacent areas, is easier for most people than it is to go across to the diagonally, across to the political or the symbolic frame, right? And I will say that stretching to the symbolic frame is most challenging because it’s very abstract and just is so unnatural to quite a few people. But even if you can imagine let me not always come for instance if I primarily live in a structural frame, let me not always come to a presentation with numbers, but let me come with a story about how my health care organization impacted one particular person in a powerful way. Doing that once and seeing how certain audiences are much more responsive to that can be an eye opener. So that’s the kind of stretching that I think is feasible, but going full on into the symbolic frame is challenging. 

Jill: Yeah, I can see that if I were coaching somebody, even though I know very little about this compared to you, but if I were coaching somebody, I might say, what inspires you and how can you help convey through your own, through their stories, with experience that inspiration? Because that’s a great place where we are able to symbolically find where our Venn diagrams cross, because as humans, we are often inspired by what inspires each other. I think we could all use a little bit of that in any organization and the organizational culture, thinking about why, what matters to us and where we can be inspired together toward growth and higher service. So thank you for this conversation. Thanks for teaching us the basis of these and I know for a lot of us, it’s going to inspire us to look more further into this concept and think about ways that we can incorporate it into our life and to the many, many health care professionals listening how they can incorporate these ideas to grow their impact and what they’re doing out in the world. So, thanks so much, Tosca, for being with us in this conversation. 

Tosca: It’s absolutely my pleasure. I’ve loved this conversation. 

Jill: So, Tosca Bruno-van Vijfeijken. She is a consultant, coach, public thought leader. And you can go right now to 5 Oaks Consulting. That’s the number 5 Oaks For more information on the leadership wisdom that Tosca has and brings to us through her many lived years of experience in this field and the rest of you, I also would love you to go right now to Take our burnout quiz. Check out the ways that we can support your work as a physician and health care professional through our DocWorking THRIVE program. Until next time, thanks so much for being here. I’m Jill Farmer on DocWorking: The Whole Physician Podcast. 

Board-certified practicing radiologist, founder and CEO of DocWorking, and host of top ranked DocWorking: The Whole Physician Podcast

You May Also Like….