Contemporary leadership literature increasingly emphasizes the role of teams in delivering performance under conditions of complexity and uncertainty. However, discussions at the point of health system delivery often continue to focus on individual actors rather than on how they function as teams. Leadership scholars have long used music as a metaphor to describe how groups coordinate, adapt, and perform collectively. Drawing on this tradition, and on lived experience playing in a musical group, this viewpoint explores music as a practical lens for understanding what enables effective teamwork in health care. The concept of the sound of great teams highlights four interrelated conditions: shared purpose and pace, active listening and psychological safety, clear roles with room for professional judgement, and collective learning through practice. Although these conditions are well recognized in musical performance, they are less consistently cultivated in health care settings. This article reflects on how physician executive leaders influence these conditions during periods of large-scale system change and argues that medical leadership effectiveness in health care lies less in individual action than in shaping the environment in which teams can perform together.

KEY WORDS: physician leadership, team performance, health system change, psychological safety, organizational learning

Smith A. What great teams sound like: reflections on leadership, listening, and performance in health care. Can J Physician Leadersh 2026;12(1): 54-62. https://doi.org/10.37964/cr24807

The song is collective: when individual excellence isn’t enough

Health care is delivered by teams, yet much of how leadership is enacted at the point of care continues to emphasize individuals. We value expertise, decisiveness, and personal resilience, often assuming that very capable individuals will naturally produce highly effective teams. As health care systems grow more complex, multidisciplinary, and fast-moving, the limits of this assumption become increasingly evident. What ultimately distinguishes high-functioning teams in health care is not the excellence of any one member, but how effectively the group works together as a whole.¹

An unexpected source of personal insight into this dynamic has come from playing in a small musical group — a “dad rock band.” Like health care teams, bands bring together people with different skills, experiences, and professional identities. They work within real constraints, including limited preparation time and moments of public performance that can make errors readily apparent. When a band functions well, the result can feel effortless. When it does not, the issue is rarely a lack of technical skill; it is almost always something about how the group is working together.

Music provides a useful metaphor because teamwork can be heard. Listeners can immediately sense whether a group is aligned, attentive, and responsive or whether it is fragmented and out of sync. Bands that sound good together share a clear sense of purpose, listen closely to one another, balance structure with individual expression, invest time in practice, and shape the overall mix with care. These same conditions underpin effective clinical and operational teams across diverse professional and lived experiences; yet in health care they are often assumed rather than intentionally cultivated.

When the music leads: lessons for leading expert teams

Leadership scholars have long drawn on musical ensembles as metaphors for teamwork, most commonly referencing chamber music and jazz. In chamber music, particularly the string quartet, leadership is shared and fluid rather than fixed. Authority shifts depending on the musical passage, requiring deep listening, mutual accountability, and continuous negotiation among highly skilled peers. Individual virtuosity matters, but only insofar as it serves the collective performance. As such, the string quartet has been widely cited as an illustration of non-hierarchical leadership, psychological safety, and coordination among expert teams.²

Jazz ensembles extend this metaphor by emphasizing adaptability and improvisation within agreed-upon structure. Although jazz values individual expression, that freedom is bounded by shared frameworks such as tempo, key, and form, which allow coherence to emerge without rigid control. Leadership in jazz is situational, requiring participants to step forward or step back in response to the moment, while remaining attuned to the ensemble as a whole.^3,4 In the leadership literature, jazz has become a dominant metaphor for navigating uncertainty, balancing standardization with flexibility, and making sense of complexity in real time.

Although these metaphors are typically applied to leadership in general, they are particularly salient in the context of physician executive leadership. Physician executives lead in environments characterized by high expertise density, professional autonomy, and limited tolerance of hierarchical control. Clinical authority and subject-matter expertise reside primarily at the point of care, meaning physician executives often lead peers whose technical expertise may exceed their own in specific contexts. Therefore, influence is earned through credibility, trust, and the ability to shape conditions that allow others to perform well together. In this setting, the lessons drawn from chamber music (shared leadership and disciplined listening) and jazz (adaptive leadership within structure) resonate less as metaphor and more as a reflection of how medical leadership and expertise are shared in practice.

Although chamber music and jazz dominate the leadership literature, they are not the only musical forms familiar to those who work in teams — nor, in my case, the genres I am most drawn to play. My own musical experience sits squarely in rock. Research on group creativity and “group flow” suggests that similar dynamics apply in rock and pop bands, where effective performance depends on clear role differentiation, disciplined rehearsal, mutual trust, and the ability to adapt in real time, particularly in live settings.^5,6 Rock specifically adds further lessons that resonate strongly with contemporary health care leadership: sustaining performance over time, maintaining cohesion under high visibility and external scrutiny, and coordinating reliably in loud, imperfect, and unpredictable environments. In this respect, whether the setting is a string quartet, a jazz ensemble, or a rock band with the amps cranked, lessons for effective physician leadership are less about genre and more about listening, coordination, and shared accountability for outcomes.

Taken together, these genres suggest that the dynamics underpinning effective leadership are not confined to a narrow musical canon. Other contemporary forms offer complementary perspectives. Country music emphasizes shared narrative, trust, and collective meaning-making over time. Hip hop highlights collaboration across difference, the importance of voice, and the creative tension between structure and improvisation — particularly in contexts shaped by power and exclusion. Metal underscores discipline, precision, and mutual reliance under intensity, where cohesion matters most when conditions are loud, fast, and unforgiving.

Some musical traditions invite a different posture altogether — one grounded in listening rather than interpretation. Indigenous musical traditions offer teachings about relationality, collective responsibility, and connection to land and community that predate contemporary leadership theory. As a non-Indigenous physician leader, and within the context of colonization and ongoing harms, it is not my place to interpret or extract lessons from these traditions. Rather, their presence here serves as a reminder that leadership wisdom exists beyond dominant frameworks, and that meaningful learning requires humility, attention to whose knowledge is centred, and a sustained commitment to truth and reconciliation.

Getting on the same beat: making the “why” shared

In music, alignment begins well before the first note is played. Bands may agree on key and tempo, but what ultimately shapes the sound is a shared sense of purpose: what the song is meant to convey, who it is for, and how it should feel. Without this shared intent, even technically proficient musicians can sound disjointed, each playing accurately but not together.

Health care teams face a similar challenge. Strategic goals are often articulated clearly at a system level, yet shared purpose at the point where care is delivered is less consistently developed. Teams may understand what is being asked of them — new workflows, performance targets, or models of care — without a clear sense of why the work matters or how it fits into a broader strategy. In the absence of this shared understanding, teams begin to drift, move at different speeds, or disengage when pressures mount.

Pace matters as much as direction. In music, a rushed tempo creates tension and errors, while a sluggish one drains energy and focus. In health care, the pace of change has become a defining feature of daily work. When teams are pushed faster than their capacity allows, quality, safety, and morale suffer. When momentum is lost, improvement stalls. Finding a sustainable rhythm is not a one-time decision but an ongoing act of calibration.

Turning down the noise: creating conditions to listen

Listening plays an equally central role. In music, it is as important as playing. A musician who focuses only on their own part — regardless of technical ability — quickly destabilizes the group. Good bands listen continuously, adjusting volume, timing, and tone in response to what they hear around them. Crucially, this requires attention not only to sound, but to balance: whose parts are featured, whose are softened, and how the overall mix is shaped. Small signals matter, and when they are noticed early, correction is often quiet and instinctive.

Attentive listening in music is not only about maintaining coherence in the moment, but also about sensing what may come next. Bands that continue to grow listen for emerging patterns — changes in tempo, evolving influences, or shifts in what resonates — and use these cues to explore new directions while staying grounded in a shared sound. This kind of listening also requires discernment. Not every sound warrants adjustment, and experienced musicians learn to distinguish meaningful cues from background noise, allowing groups to adapt deliberately rather than reactively.

These same dynamics are evident in health care teams, where the quality of performance depends on how well people listen to one another and respond to early cues. High-functioning teams are defined less by individual expertise than by their collective ability to listen, ask questions, and adjust in real time. Psychological safety allows team members to voice uncertainty, surface concerns, and share incomplete information without fear of embarrassment or reprisal.⁷ For physician executives, this means shaping a culture where listening is expected and protected — where early signals are noticed, voices are balanced, and teams are supported in separating meaningful change from transient noise. When listening is poor or speaking up feels risky, early indicators of trouble (clinical deterioration, workflow strain, or cultural tension) tend to go unnoticed until they escalate into harm.

Listening is not only an interpersonal skill; it is also shaped by structures and expectations. Teams listen well when systems make it possible to do so: when there are regular forums for sense-making, clear invitations to question assumptions, and routines that support timely course correction. Leadership cultures that prize confidence and decisiveness without equal attention to inquiry often increase volume at the expense of awareness.

The space between the notes: balancing structure and innovation

Another lesson from music lies in the balance between structure and freedom. Strong performances depend on both. Musicians follow a shared score, yet the most compelling performances leave room for interpretation, variation, and occasional solos. When structure is too rigid, the music feels flat; when it is too loose, coherence is lost. Improvisation works because there is enough shared reference to keep the group together while individuals explore within it.

Health care teams require the same balance. Clear roles and accountabilities provide the structure teams need to function safely and efficiently, while clinical and operational work demands judgement, responsiveness, and adaptation to context. Improvisation in this setting is not the absence of standards, but the informed use of professional discretion when situations do not unfold as expected. Leaders must be attentive to how improvisation is received — who is given room to explore and whose variation is questioned. When tolerance for improvisation is uneven, teams become cautious rather than adaptive, and learning gives way to risk avoidance. Physician executives play a critical role in setting boundaries that are clear enough to ensure safety, yet fair and transparent enough to support judgement, innovation, and trust.

The musical metaphor also clarifies the physician executive’s responsibility for quality improvement infrastructure. Good bands do not improve simply by performing more often; they improve in rehearsal, supported by a shared score, agreed cues, and mechanisms for feedback. The score itself is not neutral — it reflects assumptions about what matters, what is measured, and whose contributions are most visible. These structures do not constrain creativity; they make it possible to play together, notice variation, and adjust without losing coherence.

In health care, quality improvement processes serve a similar function. Clear aims act as the score, measures provide feedback on performance and variation, and regular improvement forums create rehearsal space where teams can test changes before implementing them. For physician executive leaders, supporting quality improvement, therefore, means stewarding these structures deliberately, ensuring they are visible, trusted, and examined for how well they serve all teams and patient populations. When improvement infrastructure is weak or fragmented, teams are left to improvise without shared reference points, increasing noise rather than learning.

Innovation, like musical variation, emerges most productively when there is enough structure to keep the group together while still allowing room to explore. Physician executives play a critical role in setting these boundaries — signaling where fidelity matters, where experimentation is encouraged, and how learning will be shared across the system. Without this guidance, innovation risks becoming either stifled or chaotic, neither of which serves patients well.

The band gets better offstage: learning, safety, and collective adaptation

Practice offers a final, often overlooked lesson. No band performs well without rehearsal. Practice is where timing is refined, mistakes are surfaced, and trust is built. Rehearsal is separate from performance; it is a space where errors are expected and even welcomed as part of learning. Rehearsal also creates room to notice patterns that may be harder to surface in the pressure of performance — whether technical missteps, breakdowns in coordination, or dynamics that leave some contributors consistently unheard.

In health care, opportunities for collective rehearsal are often limited. Reflection, debriefing, and improvement work are frequently displaced by operational pressures, leaving little protected space for teams to learn together. Learning tends to be individualized rather than shared, and opportunities to reflect on how work is actually unfolding are lost; mistakes are more likely to be managed reactively than used as sources of insight.⁸ In the context of large-scale system reform — where policy intent, operational realities, and professional practice must align across multiple levels — the capacity of teams to maintain shared purpose, reflect, learn, and adapt together often determines whether change is integrated into daily work or resisted in practice.⁹

Shaping the final mix: leadership as stewardship of conditions

Across all these observations, a consistent leadership role emerges. In music, the leader does not improve the sound by playing every instrument or correcting every note in real time. Instead, the focus is on creating the conditions that allow the group to perform well together. In health care, senior physician executives are similarly positioned as stewards of the conditions in which teams operate. In complex adaptive systems such as health care, effective leadership involves both attentiveness and restraint — recognizing when direction is required and when conditions are better shaped by enabling teams to respond to emerging information rather than prescribing solutions.¹⁰

Most people recognize the sound of a good band immediately. It is cohesive without being rigid and adaptive without becoming chaotic. The music holds together because purpose is shared, listening is active, roles are clear, and there is space to rehearse, learn, and adjust. That coherence depends not just on what is played, but on how contributions are taken up — whether innovation is received consistently and whether all parts are given room to be heard.

High-functioning health care teams share these same qualities. For physician executives, the work is not to dominate the performance or play every instrument, but to ensure the score is clear, the rehearsal space is protected, and the conditions exist for teams to listen and respond to one another in fair and predictable ways. When these elements are in place, teams can sustain their collective sound — and the care they deliver can continue to improve, day after day.

Limitations

This article uses music as a metaphor to reflect on team functioning and physician executive leadership. As with any metaphor, it simplifies complex realities and will resonate differently depending on professional background, cultural context, gender, and lived experience. The parallels drawn are intended to support reflection rather than provide a comprehensive account of teamwork in health care.

These reflections are grounded in lived experience and selected leadership literature rather than empirical evaluation. They do not test specific leadership behaviours or interventions, nor do they fully capture the structural forces that shape power, inequity, and inclusion in health care organizations. Although the discussion attends to listening, balance, and whose voices are heard, a fuller and sustained exploration of anti-racist, gender-responsive, and Indigenous-informed approaches to physician leadership remains necessary and critical.  Such work — particularly when centred beyond the perspective and privilege of a white cisgender male physician leader — lies beyond the scope of this viewpoint but is essential to advancing more equitable and effective leadership practice.

Epilogue

Now who’d have thought that after all
Something so simple as rock ’n’ roll would save us all
— Frank Turner, I Still Believe

References

1. Frank JR, Snell L, Sherbino J, editors. CanMEDS 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: https://tinyurl.com/263ns3j3
2. Blum D. The art of quartet playing. New York: Alfred A. Knopf; 1986.
3. De Pree M. Leadership jazz. New York: Dell Publishing; 1992.
4. Barrett FJ. Yes to the mess: surprising leadership lessons from jazz. Brighton, Mass.: Harvard Business Review Press; 2012.
5. Sawyer RK. Group genius: the creative power of collaboration. New York: Basic Books; 2007.
6. John-Steiner V. Creative collaboration. New York: Oxford University Press; 2000.
7. Edmondson AC, Lei Z. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav 2014;1:23-43. https://doi.org/10.1146/annurev-orgpsych-031413-091305
8. West M, Eckert R, Collins B, Chowla R. Caring to change: how compassionate leadership can stimulate innovation in health care. London: King’s Fund; 2017. Available: https://tinyurl.com/ycyjbnmt 
9. Braithwaite J, Churruca K, Long JC, Ellis LA, Herkes J. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med 2018;16:63. https://doi.org/10.1186/s12916-018-1057-z
10. LEADS in a caring environment framework. Ottawa: Canadian College of Health Leaders; 2015. Available: https://cchl-ccls.ca/pld-leads/the-leads-framework/