A source of medical leader ineffectiveness?

Some of the same skills that make physicians, nurses, medical administrators and allied health professionals excel in our clinical roles can potentially hinder our effectiveness as leaders. If the process of recognizing these risks were automatic we wouldn’t need to think about it. And there would be an even greater number of effective healthcare leaders.

Unfortunately, every group I speak with can quickly relate stories of a bad leader or two. While bad leadership may be common, I contend that intentionally bad leadership is rare. People don’t get up in the morning, and while shaving or brushing their hair, look in the mirror and say, “Today I will be a bad leader.  I will mismanage and mess with someone’s career…” That should be sobering for us, however well-intentioned we may be. In the spirit of continual reflection and renewal, it’s worth examining three strengths we develop in the study and practice of healthcare that can sometimes be leadership liabilities.

Talented tacticians.
Healthcare is inherently tactical.  We learn the craft of medicine one patient at a time: one exam room, one hospital bed, one operating room.  It is a pattern reinforced through decades of training during the crucial years of adult development. After training, daily practice is a series of independent encounters in the ambulatory or inpatient arenas.  The rules of patient privacy necessitate our forgetting the last patient as we move onto the next.  Sometimes we may not think about them again until the lab or consult comes back, or we see them in follow-up.  There is little time or expectation for the awareness necessary to string together patterns of patient problems or behaviors, or for us to think about the larger, strategic implications of our medical practice.  The way of thinking may spill over into our personal lives where our best intentions to be the people/partners/parents we know we should be become lost in the tyranny of day-to-day “tactical” execution (drive the kids, take out the trash, finish the lawn etc).

The solution starts with setting aside time to think.  Turn off the radio or iPod in the car while you’re driving alone. Take walks or runs in silence: listening, thinking, considering. Keep a voice recorder or notepad close at hand to capture your musings. Teams need regular, scheduled time together for free-wheeling discussion and the generation of “big-picture” strategic questions and ideas. When I was hospital director, a small group of the hospital’s best strategic thinkers met with me every Friday for an hour.  A group of a dozen young strategic thinkers “in-training” from across the organization met with us monthly. “Strategy abhors a vacuum. If strategic function is lacking, strategic effect will be generated by the causal accumulation of tactical and operational outcomes” (Colin Gray). Not having a strategy is a strategy. It’s just not a very good one.

Master Managers.
Professor Lou Pangaro of the Uniformed Services University has developed a superb model for medical student assessment that he called “RIME:” Reporter, Interpreter, Manager, Educator.  (Some add “P” to this model as an assessment of professionalism to make the pneumonic “PRIME.”) With this model the student is assessed on her professionalism, ability to report medical information, to interpret information, to develop patient management plans and to educate more junior trainees. The expectation for all providers is expertise in patient management: the ability to formulate and implement diagnostic and therapeutic plans. We have to know what to do. Excellence in this area is reinforced and often becomes the mark of the truly effective provider.

Unfortunately, the focus on managing can be a hindrance as a healthcare provider moves into higher positions of leadership. Transition guru Michael Watkins noted that “Leaders in transition reflexively rely on the skills and strategies that worked for them in the past; after all, their previous successes were what propelled them to the new opportunity.  That’s a mistake.”  As chief medical officer in a hospital with hundreds of inpatients, my physician CEO turned to me at a morning report and asked whether a specific patient was on heparin (a blood-thinner). I understood the importance of the drug in this patient, but not necessarily the importance of the question at that moment and in that setting.  What was effective management at the healthcare provider level becomes micromanagement when we try to practice it from a distance.

The solution starts with realization and recognition:  we always do best what we did best last.  For providers and healthcare professionals that is providing and managing care.  In administration in may be managing budgets or inventory.  We need to let go of the tendency to want to keep doing what we used to do, and trust that the people we work with know what they’re doing.  We reinforce that trust by learning what to selectively verify; spot checks to make sure that the team shares the same sense of what’s important. But after providing guidance and suggestions when solicited, we have to learn to let people manage – and get out of their way.

Healthcare heroes.
In September 1994 two new hospital shows debuted on US TV: ER and Chicago Hope. While both shows portrayed the drama of hospital medicine, ER became the more popular show. Joseph Turow wrote about the pace of the new show in his book about medicine on television (Playing Doctor University of Michigan Press, 2010), “The key point made, the scene switches, and switches quickly again, at a pace that became the signature element of the show. Reviewers comparing ER with Chicago Hope focused on what they called the former’s speed and excitement. USA Today described it as ‘A trauma-rama that opens on an adrenaline rush and pretty much stays there…’”

Both the public and the profession exalt the care provider who displays an even-tempered, almost casual coolness in the face of the life and death drama of medical practice. Quoting Marcus Aurelius’ final words, Sir William Osler described this character trait as “Aequanimitas:”calmness, patience, equanimity.

However, according to business and management guru Peter Drucker, crisis often reflects poor processes. “The most common symptom of poor business processes is a chronic state of emergency, the recurring crisis.”  Perhaps we have become comfortable with recurrent crises in healthcare settings because of our devotion to heroes who were born in crisis; men and women who impressed us to the point of emulation as we came through formative years of training.  What we failed to see was that too often the recurrent crisis and need for heroism were the result of emergencies that were precipitated by failed processes.

The solution is in systems.  Healthcare leaders need to devote themselves to disciplined review of the effectiveness and efficiency of their healthcare systems from both fiscal and patient safety standpoints. This practice has been championed for example by Dr. Brent James and his colleagues at Intermountain Health in Colorado. High-reliability organizations reliably deliver consistent outcomes by designing the best systems. We have learned that even the risk of the dramatic cardiac code – a stock feature of the hospital TV show – may be reduced by the introduction of a rapid-response team system.  The desired outcome is not code-survival.  It’s code-avoidance.

Our clinical strengths can become leadership challenges. But the challenges are never enough to justify the case for exclusive “non-medical” leadership of health care systems by captains of economics or industry. Healthcare should be led by those who know the business: talented tacticians, master managers and healthcare heroes. These are the men and women who see and touch our patients. But it will take disciplined attention and intention to turn potential pitfalls into leadership potential.

But we’ve spent a significant portion of our lives in school.
Why should we stop learning now?

Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/