Lessons from Leading US Public Health Service Physicians

The Commissioned Corps of the United States Public Health Service (USPHS), an all-officer uniformed service, includes more than 730 physicians who serve in multiple federal agencies within and outside of the Department of Health and Human Services (DHHS) and are stationed in more than 60 locations, including state and local health departments. These officers serve in direct patient care and applied public health roles, working on the clinical, science, and policy frontlines of key public health challenges including the opioid epidemic and antimicrobial resistance.^1,2 These physicians’ professional interests are represented by a Chief Professional Officer (CPO) and the Physicians Professional Advisory Committee (PPAC) leadership team, which includes 2 co-chairs and a vice-chair. The authors currently serve as the leadership team of the PPAC. We serve in these roles on a voluntary basis, in addition to our primary duties with our agencies.

While the PPAC does not make policy for the USPHS, it advises the US Surgeon General and Commissioned Corps Headquarters (HQ) on policy matters related to USPHS physicians. While as the leadership team of the PPAC we do not have direct policy-making authority over the physicians of the PHS, we provide advice and counsel both to more senior policymakers within the Corps and DHHS, and to the officers we represent. To the extent that we both “lead up” to senior leaders and “lead down” to our medical officer constituents, our leadership approach exemplifies the Meta-leadership framework, developed by the National Preparedness Leadership Initiative (NPLI) based at Harvard University.^3,4 Meta-leadership also involves leading across organizational units, in our case working with counterpart leaders in other categories of the USPHS (e.g., nurses, pharmacists, and dentists). NPLI stresses the concept that most leaders, even at senior leadership levels, exert influence out of proportion to their direct supervisory authority. Since as a leadership team we do not directly supervise any USPHS medical officers, we have had to use influence as a primary tool to accomplish any of our goals.

In the fall of 2017, the PPAC leadership team underwent turnover, with a new CPO (BL) appointed to a four-year term. The new CPO, along with the co-chairs (SL, JI) and vice-chair (JA) immediately faced a number of challenges, including impending changes to PHS physician pay structures, and 16 new or pending HQ policies across a variety of domains. We needed to communicate rapidly with the hundreds of physicians we serve about known and potential changes to policies affecting their work and well-being, as well as dealing with ongoing challenges including recruitment and retention of highly qualified physicians. While navigating these issues, the PPAC leadership team has identified a number of effective strategies. In this commentary, we seek to distill the leadership lessons we have learned since November 2017 in attempting to meet the policy and personnel challenges facing USPHS physicians. Many physician leaders, whether working in practices, hospitals, the private sector, or for non-governmental organizations, likely face similar challenges and might benefit from employing some of the strategies we have found to be useful.

LEADERSHIP LESSONS LEARNED

1. When faced with policy changes or other unexpected developments respond rather than react.

In the face of anxiety-provoking situations, it is important to assess the situation before doing something impulsive. “Don’t just do something, stand there” is one formulation of this axiom. Responses can still be relatively rapid, but are more constructive, positive, and thoughtful than reactions, which may reflect emotions or “fight or flight” responses. NPLI teaches leaders to avoid “going to the basement” at times of crisis i.e., not to take overly fear-driven actions linked to primitive brain structures like the amygdala.

Discussions at policy levels of the USPHS about possibly re-instituting clinical hours requirements for PHS medical officers have been a recent source of anxiety within officer ranks. Related issues about which officers have expressed concerns include the possible need for re-entry training for those who have not practiced recently,⁵ and the need to define what constitutes the practice of medicine for those board certified in the specialty of Preventive Medicine and Public Health.⁶ We recognized that officers, rather than reacting on the basis of uncertainty, needed ways to respond constructively to this potential policy change.

In the interest of sharing information in advance of any policy changes, at the regularly scheduled May 2018 PPAC teleconference officers who remain clinically active discussed their experiences working within the Veterans Administration, Walter Reed National Military Medical Center, various sites within the Indian Health Service, county and city run tuberculosis control clinics, and other settings. Officers described both challenges they needed to overcome in securing practice locations, such as identifying a Federally Qualified Health Center or other federal facility as a practice location, as well as benefits they derived from clinical contact hours. Officers provided questions, suggestions, and recommendations via both voice and instant messaging technology. Discussion among officers was robust and constructive, and this forum provided support and reassurance to many officers.

2. Practice leadership as a team sport

We identify and use complementary skills and abilities that exist within our leadership team. Within our team, we possess prior Armed Forces experience and contacts, abilities to communicate in a variety of formats, adeptness at information technology implementation, and deep knowledge of and ability to harness the leadership of PPAC sub-committees. As tasks emerged, we would assign them to the individual most suited to lead or coordinate the task, or one of us would “self-assign” the task. This approach is consistent with foundational research on team roles and dynamics, which suggests that a leadership team of at least three people can fill multiple roles within a team.⁷ In our experience, out-comes of this team approach have included increased levels of physician deployment readiness, closer engagement with HQ on physician recruitment issues, and more leadership of initiatives undertaken by PPAC subcommittees.

3. Build and use your bench of up and coming physician leaders

Good leaders need and use good followers to help achieve objectives.⁸ As we sought to communicate and provide service to medical officers, we recognized that we sometimes needed to lead and sometimes needed to follow. When junior officers had novel ideas, superior technical skills, insight based on a unique personal experience with a new policy, or a level of enthusiasm and initiative that we could not match, we followed.

We identified and mentored junior officers, some of who were leading or participating in PPAC subcommittees, as they developed new ideas that could benefit PHS physicians. Our leadership team followed the lead of junior physicians as they developed Physician Specialty Interest Groups including Emergency Medicine, Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Preventive Medicine, and Psychiatry. These groups, which have both virtual and in person presences, now serve as hubs for sharing of specialty-specific practice and educational opportunities, networking, and professional fellowship.

Another example involves recruitment of USPHS physicians. An innovative strategy employed by the PPAC Recruitment Subcommittee involved identifying candidates likely to be interested in the Public Health Service while they were still in medical school, recognizing their efforts with awards, and connecting them to potential mentors. This program, modeled after one developed by USPHS pharmacists, began in 2012. The PPAC medical student public health recognition program has identified and given awards to more students each year since then, with 87 students recognized at their medical school graduations in 2018 bringing the total to just under 400. A national level winner is also named. While a full process and outcome evaluation of this outreach has not been completed, programs linking medical students during their training to careers in public health have a demonstrated track record of effectiveness.⁹ One of the authors was involved in launching this program, and has handed it over to junior officers and watched it grow into a tool that reaches medical students while they are still contemplating career possibilities.

Paying attention to emerging leaders within the PPAC also facilitates succession planning, as our charter requires yearly appointment of a new vice-chair, who will over a 4-year period subsequently serves as junior co-chair, then senior co-chair, and finally in an ex officio role to advise the new leadership team.

4. Balance policy work with individual “customer service”

While just over half of USHPS physicians are assigned to the Centers for Disease Control and Prevention (CDC), officers also serve at agencies including the Indian Health Service, National Institutes of Health, Bureau of Prisons, and the Department of Homeland Security. In our leadership roles, we have gotten to know many Corps physicians, and we are continuously impressed to learn about the myriad ways they are serving the Nation through both direct patient care of the underserved and physician leadership of activities that protect and promote health at the population level.

While we all take time to meet and speak with individual officers, mentoring and advocating for them as appropriate, as well as addressing larger groups of PHS Physicians on teleconferences and at an annual Symposium, we recognize the need to spend time developing resources and providing input on policies intended to benefit the well-being of physician officers. We have built self-service information sharing tools like new websites, but recognized that while we can use technology as an aid to communication and dialog, we should also take advantage of opportunities to meet with medical officers stationed in diverse locations in order to hear their personal concerns.

5. Communication is an act of leadership

We sought to communicate rapidly but carefully with officers, particularly when new policy or guidance was announced by HQ. We drafted brief summaries of policy changes in addition to providing access to full official documents. We deliberately overcommunicated about issues, by using multiple means of communication over an extended time. The communication platforms we used include an email listserv, a new widely accessible website, and specially scheduled teleconferences at times of day when geographically dispersed officers (in both national and international locations) could attend, in addition to routine monthly teleconferences. The CPO also traveled to numerous states from Massachusetts to Oklahoma where officers are stationed to give in person presentations and answer questions. We also held special topic teleconferences on policy changes that affect PHS physicians, with participation by HHS policy-makers when possible. Because the definition of communications involves both sending and receiving information, we sought feedback on our communications through formal and informal mechanisms, including surveys of officers. One tangible result of an increased emphasis on communicating with officers has been greater participation by officers in monthly information sharing and discussion forums.

6. Don’t forget your day job

The core values of the USPHS include leadership, service, integrity, and excellence. Serving as part of the PPAC leadership team is both a privilege and a duty, but it is separate from the specialized, clinically relevant work we each do on behalf of the agencies for which we work. During our time leading the physicians of the PHS, we have continued to make scientific and public health contributions in our areas of expertise, which include occupational health, post-licensure vaccine safety, cardiac device safety and effectiveness, and science leadership and communication. Three of us have also continued to serve in USPHS deployment team roles,¹⁰ responding to public health emergencies including Hurricane Maria, and two of us have maintained part-time clinical practices. We sometimes refer to the need to be both effective subject matter experts, while also serving the broader needs of the USPHS, as “work-work balance.” Many physician leaders in academic, hospital, or other settings face this same need to balance their work in patient care, research, and/or teaching with supervisory, management, and administrative responsibilities.

7. Practice work-life balance

During our first 6 months of leadership service together, within our families we celebrated and supported the publication of a book by a spouse, and the attainment of an advanced degree by another. We explicitly recognized and acknowledged the importance of these and other milestones. As a leadership team, we not only provided moral support to each other but also covered for absences required by personal and family responsibilities.

CONCLUSIONS

Having each made a multi-year commitment to work voluntarily on behalf of hundreds of officers, many of whom we never meet, we see ourselves as servant leaders.¹¹ The lessons on leading by and for physicians that we have summarized here focus on communications as a leadership practice, delegation and succession planning, and finding balance between professional and personal responsibilities. Physician leaders in other settings face similar challenges to those faced by the PHS in areas including recruitment and retention,^12,13 changing personnel policies, and balancing services to individual physicians with serving their broader medical community. Physician leaders in other settings likely are also “meta-leaders” in that they can exert influence within their organizations out of proportion to their direct authority.

While the concept of a high-performing leadership team is not a novel one,¹⁴ we think we offer unique insights as we lead a geographically decentralized and functionally diverse group of officers. Both public health and health care delivery are multidisciplinary undertakings, requiring diverse perspectives. Physician leaders should consider the benefits of a team leadership model if one is not already in place at their institution.