Narratives of Actionable Medical Leadership From Senior Leaders for Aspiring Leaders in Academic Medicine

Abstract

Background:

Physicians understand that certain personal attributes are essential in medical leaders, but they often do not know what actions are expected of them as leaders or what they should do to be more effective leaders.

Purpose:

We sought to compile, through interviews with senior leaders at an academic institution, real leadership scenarios for a series of case-based examples to be used during group mentoring sessions for aspiring medical leaders.

Methods:

We conducted one-to-one interviews using open-ended questions with 11 current and emeritus chairpersons or chiefs of major departments or divisions at our academic medical center. Questions were designed to elicit anecdotes and examples of actions that demonstrate effective and ineffective leadership. Responses were analyzed with qualitative techniques to generate topics of leadership behaviors, which then were compiled into a collection of illustrative examples.

Results:

The leaders interviewed discussed challenges they encountered in daily routines and described how they addressed certain dilemmas. Topics included making decisions without complete information, winning over reluctant administrators, building alliances with peers, involving subordinates in initiatives, and using knowledge to defend one’s position. Actions requiring interpersonal skills also were discussed, including varying modes of communication, avoiding adversity, displaying gratitude toward subordinates, and safeguarding one’s professional image. The leaders’ insights and recommendations were compiled into a themed collection of topics to be used during group mentoring sessions to enhance leadership skills.

Conclusions:

This qualitative study suggests that the wisdom and experience of senior leaders may be gleaned for a collection of case-based topics that could complement other formal training programs for aspiring medical leaders.

Introduction

Effective leadership skills among physicians are essential for improving the quality and sustainability of health care [1]. The attributes that apply to effective medical leaders include credibility, knowledge, empathy, assertiveness, honesty, trustworthiness, diplomacy, and forward-thinking [6]. Successful contemporary medical leaders also are collaborative, inclusive, emotionally intelligent, and team builders [6, 8]. These additional characteristics are consonant with the mission of 21st-century health care institutions that strive to maintain a diverse faculty and patient population [3, 7].

Large academic medical centers provide many opportunities for physicians to distinguish themselves as leaders [1]. Physicians may recognize what the essential attributes are, having witnessed them in senior role models, but they may not know what is expected of them or how they should behave to be more effective as leaders [1, 5]. Senior leaders are a rich reservoir of practical information and can impart the knowledge they have gained from their own experiences and observations of others to aspiring leaders. Such information should be passed on within the context of the real-world situations that medical leaders face every day [5]. In this way, aspiring leaders can then learn about the actions, as well as the attributes, that work well.

Effective and ineffective how-to skills can be highlighted by examining behaviors from actual scenarios, similar to a case-based approach [7]. Thereafter, with a group mentoring model and a senior leader guiding discussion, aspiring leaders can learn skills illustrated by specific actionable examples. Such a format would complement existing more formal leadership education programs.

We sought to interview senior medical leaders to obtain examples of good and not-so-good behaviors in response to actual leadership challenges. Additional goals were to obtain their perspectives on what actions are required of successful leaders and what would jeopardize their chances of success. The information gleaned would then become a collection of narratives to be used during a series of group mentoring discussions conducted by senior leaders for aspiring leaders.

Methods

This cross-sectional study was approved by the institutional review board at our institution and all participants provided informed verbal consent.

HSS (Hospital for Special Surgery) is an academic medical center focusing on musculoskeletal health with faculty in diverse specialties, including orthopedic surgery, rheumatology, anesthesiology, physiatry, and radiology/imaging. Accredited residency and fellowship training and professional faculty development are governed within departments, divisions, and subspecialty services. Chairpersons and chiefs sustain standards for clinical care, education, research, accreditation, faculty advancement, and national and international presence and reputation. For this study, 13 current and emeritus chairpersons and chiefs were asked by e-mail to participate in a one-to-one interview with one of the authors soliciting advice for aspiring leaders.

Participants were told that their responses would become part of an educational module focusing on training junior faculty in medical leadership using a case-based approach. The goal would be to develop a collection of actual leadership challenges to be used as springboards for discussions conducted by senior leaders during future group mentoring sessions. Participants were told that the sessions would focus not on personal leadership attributes but rather on leadership behaviors. As such, participants would be asked how aspiring leaders should be trained and to provide stories or examples of good and not-so-good leadership actions needed for successful leadership training.

We posed the following open-ended questions in the interviews: “Please tell me an anecdote of good leadership by a physician, either your own experience or something you witnessed in someone else. (Please tell me another anecdote).” “Now please tell me an anecdote of not-so-good leadership by a physician. (Please tell me another anecdote).” “Overall, what are the most important things a junior physician should do to be a successful leader?” “What would likely jeopardize his/her chances of success?” “What would be the best way to impart this information?” Participants were encouraged to offer as many examples and details as they wished. Interviews were not videotaped or audiotaped to preserve anonymity. Instead, the interviewer wrote responses in field notes, read them back to participants in real time for confirmation, and transcribed them into individual participant narratives.

We reviewed responses using open coding to identify concepts according to grounded theory; concepts were grouped into categories, using a comparative analytic strategy and axial coding, and then selected to be part of the collection of major topics. We excerpted stories recounted by participants as supportive examples for the topics. The collection of examples was then sent to each participant with his or her contributions highlighted. Participants were asked to confirm the content of their excerpts, the advice they offered, and the preservation of their anonymity.

Participants also provided basic demographic information.

Results

Of the 13 leaders approached, 11 were available to be interviewed during the study period (March 8 to April 6, 2021), 2 were unavailable, and no one refused. We conducted 9 televideo interviews and 2 telephone interviews, each lasting 20 to 30 minutes. Participants’ mean age was 67 years and the sample included men and women.

Senior leaders gave examples of leadership challenges and agreed that actual scenarios depicting effective and ineffective behaviors would be instructive for aspiring leaders (eg, “While personal attributes are critical, what you do counts—a lot”). All participants responded to the interview questions and volunteered additional advice. The following main topics were discerned from the narratives.

Make Decisions

Participants stated that decision-making is a hallmark of daily leadership and gathering information is part of the process: “The chief must be knowledgeable, needs to get his/her own information. Most daily decisions have time for input and reflection. Take the time to rehash it in your brain, to think about it.” Some decisions must be made with incomplete or imperfect information and require a timely choice:

I had to choose whether to include our institution in a new program led by a national society to routinely collect clinical data for a major diagnosis. The program required a lot of personnel. . . . If we signed on early, we would have a major voice in the project and ready access to data. If we delayed we would not have a leadership role. If we didn’t sign on at all our reputation in this area might be devalued. As the leader considering this opportunity, I wanted more information and details before making the decision. But many of my questions could not be answered until the program was up and running.

Therefore, “not all decisions are perfect or correct, if you make a bad decision, admit it, be transparent, rectify it. And don’t ignore people who notice and voice their notice; they will respond better if you explain to them why you had to change your decision.”

In addition, participants noted that, with unpopular decisions, “the buck stops with the leader. You need buy-in but not all will agree and not everyone will like you, but it is more important that they have respect for your fairness and decisiveness.”

Weigh-in Before Buy-in

Participants agreed that “the people required to make the priority a reality need to be involved in the decision.” A lack of buy-in can lead to a loss of trust:

There was an opening in my department for someone to lead a new clinical initiative. I unilaterally picked someone and thought I picked the right person and everyone would be happy. But it didn’t turn out that way. Shortly thereafter, an opening in another department became available and I asked that chief how did she choose. She told me she had an open application process, received 5 applications, assembled a committee, and then selected a person. So I decided with the next spot I would try it. Shortly after that we created a new leadership position in my department. I opened it up to the whole group and asked for applications. Based on the reaction, you would have thought I had invented fire! There were 8 applications, we did interviews, got new ideas; it was a hard choice, but it was a great approach. I learned from my colleague. When the leader says I know best, it probably is not so. There is a lot of knowledge that does not bubble to the top, but once you ask or open it up, it comes out of the woodwork.

Watch Others Lead

Several participants noted that the challenges leaders faced in one department are also faced in other departments, and observing other leaders in action can be not only instructive but also “vital.”

I was not prepared for this job. I found people to help me. I found role models myself. I chose them because they seemed to be successful, what they were doing seemed to be working. I tried to emulate them. From them I learned what to do and what not to do. I even went to their meetings to see what they were doing. There you can see that things that worked for them might also be good for you and your department.

Participants observed that designated mentors also provide valuable examples to aspiring leaders in explaining “how the system works, the nuances of the place. You can teach certain skills to a group, but honest thoughts are expressed only one-on-one with a mentor.”

Build Alliances With Other Leaders

In addition to providing leadership advice, most respondents said that forging strong relationships with leaders in other departments and divisions can be supportive, especially when disagreements with the board of directors or hospital administration arise: “the more the people who share your point of view, the more the administration has to listen to you.”

I had several situations where I had to go against the grain relative to routine practices in favor of newer innovation. Some administrators were very opposed because the hospital invested money in advancing the routine practice methods. The board was not pleased when I said that the routine practices were becoming outdated. I had to sell them these ideas; the support of others was essential. Remember, leaders from other departments attend the same meetings that you do, and if they are nodding in agreement or speaking up, that will help you.

Know the Administrative Culture and Strike a Balance

Respondents noted that interacting with hospital administration is an essential responsibility but that certain dimensions may not be apparent until a leadership position is attained:

To start, a leader has to know the culture of the institution and the framework for how the medical staff and organization interact. Then the medical leader needs to figure out how to balance potentially competing priorities of the medical staff and administration.

You have to wear 2 hats, an administrative hat and a faculty hat. Administrators advocate for what is good for the hospital, but it may not be good for the staff. The faculty hat may not make you think what is good for the finances of the hospital. Sometimes these hats butt heads aggressively. . . . I try to focus on the vision and values of the institution, that is what we share. We should not view the relationship as adversarial but instead work off each other’s strengths. Balancing is important. If it is a patient matter, you need to be 98% MD and 2% administrator. If it is a financial matter, you need to be 40% MD and 60% administrator. But never give up too much of being an MD.

Be Prepared, Know Your Stuff

To interact with administration, most participants said that medical leaders must be knowledgeable and prepared to discuss and defend their positions:

Be ready at all times to defend your point of view. Never appear that you are guessing. Be on your toes. Sell what you want. Be prepared, know the data, know what works. Your expertise will give you the upper hand. . . . Remember that knowledge is power, and this is never more important than when dealing with administration. If caught hedging, it looks bad. . . . Know your stuff.

Our participants also reported that tactfully and collegially informing administrators of the medical point of view was another important responsibility of medical leaders. “If it is a clinical decision, you must educate the administration, but educate without being condescending. . . . You must respectfully inform them without being pejorative and sassy.”

Get Formal Leadership Training

Our participants said that becoming a leader used to happen only with on-the-job training or as an apprentice but that some fundamental leadership lessons are best learned from experts and a dedicated instructional program:

The problem with leadership in medicine is that there is no training. We spend thousands of hours learning the technical aspects of being physicians and the results are we are good at our crafts, but not as leaders. Just like we get medical training we need tools to be effective leaders. . . . I got formal instruction to learn what works and doesn’t work. I learned not just communication but also timing and preparation. For example, if you have a new plan or initiative that you will present to a group, first meet with individuals privately, get their input and get them to buy in along the way. Have the support of others who are not afraid to speak up. On-the-job training is one way to get these skills, but it is difficult to do it that way.

Remain an Expert

Some participants said that a criterion for attaining a leadership position is to be acknowledged by peers as an accomplished physician and that a criterion for success in that position is maintaining that reputation as an expert:

To gain a leadership position you have to stand out in a specific area. You need to become an expert in something. Find a niche. Have something to say. You should plan to lead from a position of expertise. Then once in the leadership position, maintaining that reputation will ensure credibility and respect of others. Publish and write, present your work, you must be and continue to be a medical expert.

Communicate

Our participants noted the aspects of communication needed for leadership; for example, informing constituents of what is going on in the institution is essential to ensuring cooperation. But communication also involves apprising the group of reasons for decisions: “Be transparent and fair with decisions. Communicate why you are doing something. And be a good listener.” In addition to content, our participants noted that good communication also requires knowing how best to impart information to the group:

I hear something and remember it forever. I initially assumed everyone was like that too. I would announce something at a meeting or in an email, then wonder why are they ignoring this? Now I overcommunicate in multiple media. I send 5 emails over 2 weeks, I say it in a newsletter, I say it one-on-one. Don’t assume your people are like you are; instead, you need to adapt to your group. Once I realized this and started to overcommunicate, suddenly things got better.

Show You Value Your People

Most participants advocated involving others in plans, which communicates that their input is valued. This also includes acknowledging when someone has a good idea:

Plant seeds so that others will figure out a novel approach. Put forward ideas that someone else can pick up on. Never say that’s not the way I do it. Be ready to say I never thought of that. . . . Also promote others based on merit. But make sure you also impart structure so that they know what the responsibilities are. For example, don’t say just run the fellowship. Tell them you need to be at every teaching conference, you are responsible for [Accreditation Council for Graduate Medical Education], and you are responsible for reviewing the first list of fellowship applicants. It is a mistake not to be concrete when you delegate work and responsibility. This also communicates that they have the authority to do the job.

Some participants suggested showing constituents that they are valued by obtaining more resources for them to pursue their interests and improve their workplace:

Try to raise money for your people, whether through philanthropy or allocation of institutional resources. Use the money for research initiatives or to enhance the circumstances under which clinicians work. Constituents must see direct efforts for those below, to see their leader honest, responsive, eternally responsive to their careers. Go to their workplaces, whether office or lab. You need to show appreciation, that you respect and value them.

Be Mindful of Your Image; People Notice

Most respondents said that leaders are under constant scrutiny by subordinates, peers, and administrators who notice actions, words, behaviors, and attitudes. These all contribute to the image the leader conveys. Our participants cautioned that an unfavorable image can undermine other positive leadership attributes:

Be professional in all activities, even social ones; they are still professional. Sure, go out to dinner, it would be wrong to stay in your hotel room, but bow out relatively early. Do not be the life of the party. Alcohol can be a bad thing. Remember that what is a social event is really a professional event; you are always being scrutinized.

Avoid Adversity

Periodically, friction will result from varying priorities and points of view. Our participants advised that leaders should know what issues are controversial and then proactively initiate discussions in a collegial way:

Approach people in a non-adversarial way when you have a hot topic and are at odds with others. Be dispassionate; as soon as you are in a fighting mode, you are not leading anymore. . . . As the leader, think and communicate [that] there is no winning or losing, only best compromises.

Several participants noted that interpersonal challenges can arise with a single individual. For example, sometimes a subordinate may seem to act in a disloyal manner, which may be unsettling and trigger a strong response, but they advised staying calm and remaining committed to the relationship:

A subordinate once contradicted me in public in front of senior leaders from other departments. She threw me under the bus. I thought maybe something I said set it off unknowingly. It is hard for a leader to figure out why your people might say or do something, but don’t dwell or ruminate on it. Move on instead. Continue to have a relationship with that person, don’t hate them for life. Generate a working relationship with that person.

Advance Your People

Our participants reported that strong leaders seek ways to promote their constituents, including opportunities to help them achieve their potential and gain recognition for their contributions. It also means finding the right fit where they might excel and derive satisfaction from their work. “As a leader you must find the right opportunities to let your people show their stuff. Match person and their skillset to the right niche.”

A few years ago, I met with all the members of my service and asked them what their goals were, then I set my expectations for their work and plans. Even the most senior members, some much more senior than I am, I asked, “How long do you want to do this? How do you see your role and in what part of the service do you want to play a role?” Many of our senior staff have much to offer in different ways, including desire and motivation. It is not just about early and mid-career constituents. You are leading the entire group. Pay attention to everyone and turn their participation into a win for your service.

Maintain Camaraderie in Professional and Personal Life

Our respondents emphasized the importance of continuing to relate to constituents as colleagues. They perceived multiple opportunities for leaders of all types to remain connected to the daily challenges of their constituents:

Walk the walk. Talk the talk. Join where they are. Do the job, show you are experiencing what they are at that time. You must have the expertise and be seen doing it. There are thought leaders, education leaders, research leaders, surgeon and clinician leaders. You need credibility. You can have a national reputation and leadership role; however, you need to have local respect by being present and joining where they are.

Respondents also spoke of their own attempts to balance professional and personal commitments:

Let your people know that you too have conflicting priorities to balance; that you have a life outside the institution and challenges to try to do it all. Today’s young leaders have a lot of competing roles and life challenges. They can’t give 120% effort to work always. They have spouses who are working and children who have to be brought to school. Let your constituents see that you can empathize with them because you are like them.

Work Hard and Let Others Take the Credit

Our participants relayed that leadership requires the willingness to work very hard and persistently put in time and effort, and then at the same time to deflect credit to constituents:

A good leader will take an idea and make others feel it was their idea. A good leader brings out the best in others, gets out of the way, lets others take the glory.

. . .You really need an element of generosity. You must relinquish some opportunities to advance yourself. You must think the focus is not a nice day for me, but a good day for the institution.

Discussion

In structured interviews, senior leaders at an academic medical center related their experiences and leadership challenges encountered in their daily routines. Topics gleaned from the interviews included making decisions without complete information, winning over reluctant administers, building alliances with peer-leaders, involving subordinates in new initiatives, and being knowledgeable and prepared to defend one’s position. Actions requiring interpersonal skills also were discussed, including varying modes of communication, avoiding adversity, displaying gratitude toward subordinates, and safeguarding one’s professional image. Our participants volunteered problems they encountered or witnessed and offered actionable suggestions to address their dilemmas. Their insights and recommendations were compiled into a themed collection of topics to be used during group mentoring sessions for aspiring leaders and thus complement other more formal leadership education. Our qualitative study also provides an evidence-based collection of salient topics that can be used to enhance managing daily challenges among physicians not specifically in formal leadership roles.

Our study has several limitations. First, participants were from a tertiary care institution specializing in musculoskeletal medicine; leaders from other settings, such as primary care, may experience different leadership challenges, and therefore our findings may not be generalizable. Second, our participants were the most senior leaders in their respective departments; our findings may not be applicable to junior faculty who may encounter other leadership challenges. Third, we could not stratify participants according to characteristics, such as years as a leader, gender, department size, and the volume of clinical care, research, and teaching conducted by members of the department, all of which may affect the leadership challenges encountered and the potential responses to them.

As the number of physician leaders increases, so too must the innovative methods available for teaching needed skills. Modeling leadership behavior on successful predecessors is a standard technique, yet some authors propose additional methods to engage junior leaders [7]. For example, self-directed learning through books, Internet resources, and instructional sessions are options for those with time constraints. Our proposed series of topic-driven discussions matches this session format. Formal courses can be valuable if medical and nonmedical leaders participate and the instruction emphasizes the foundations of leadership, such as organizational theory and personnel management. In the United Kingdom and certain centers in the United States, formal leadership programs have been instituted to train physicians [3, 4, 7]. Other proposed methods are one-to-one short-term coaching in a specific area, and “action learning” in which a group meets regularly to discuss leadership challenges. Peer-networking and senior-networking are other options, with the latter offering diverse perspectives beyond that of a single mentor.

Previous studies have questioned physicians about leadership using qualitative methods and have highlighted the attitudinal competencies that physicians value most [2, 6]. One study, however, used critical incident interviews to ask physicians to relay scenarios in which they felt competent at work; respondents emphasized communication skills, getting buy-in from constituents, and building relationships [3]. In another study, senior leaders similarly participated in critical incident interviews to relay scenarios in which they felt particularly effective and ineffective as physicians; the authors then delineated a detailed dichotomous struggle between administrative and clinical roles [5]. Using survey methodology, other authors queried leaders about perceived future challenges for medical leadership, and the most frequently cited anticipated new challenges were implementing change, building trust and consensus, decision-making under uncertainty, clinical benchmarking, and knowledge of information systems [8]. Given the broadening knowledge base required of leaders, some authors advocate that formal leadership training be added to existing technical and medical competencies [1].

In conclusion, the findings of this qualitative study suggest that senior medical leaders can provide practical recommendations for handling routine challenges and major departmental decisions. They also may provide examples for dealing with both administrative and interpersonal challenges. We compiled the insights and recommendations gleaned from interviews into a themed collection of topics to be used during group mentoring sessions for aspiring leaders. Such a collection of case-based topics may complement other formal training programs for aspiring medical leaders.