Leadership, like medicine, is a moral enterprise. De Pree states, “leaders must take a role in developing, expressing, and defending civility and values” (1). The new leader needs to combine an attitude of moral conduct with the development of appropriate skills and knowledge. Becoming familiar with basic business issues, such as accounting, meeting management, and organizational dynamics, is an important part of the aspiring leader’s “tool box.”
Leadership has undergone increasing demands as the clinical environment has become more complex and resources more limited. Peter F. Drucker, an expert on management, states that “To be effective is the job of the executive. ‘To effect’ and ‘to execute’ are, after all, near synonyms. Whether he works in a business or in a hospital, in a government agency or in a labor union, in a university or in the army, the executive is, first of all, expected to get the right things done. And this is simply that he is expected to be effective” (2). The art of leadership is in determining what the “right things” are.
The focus here is for those undertaking significant responsibilities as medical student clerkship director, residency training director, or section chief. Although these tasks have managerial responsibilities, there are also significant aspects of leadership. Warren Bennis noted that “A leader is, by definition, an innovator. He does things other people haven’t done or don’t do. He does things in advance of other people. He makes new things. He makes old things new” (3).
Assimilating diverse and sometimes conflicting evidence is a common practice in psychiatric clinical work. Psychiatrists are fortunate to have experience with multiple theories of behavior; dealing with a multiplicity of leadership theories does not seem to be as taxing an experience. Likewise, having experience with group issues, particularly scapegoating, is helpful in understanding the processes of coming to a decision (4). Appreciating the potential power of shame and embarrassment in detracting from group performance is useful training (5).
There are certain misconceptions that can impede one’s early career as a leader:
Leadership, like empathy, is not an “all or none” proposition and is present in matters of degree. Mentors, colleagues, and students can be useful in identifying the genuine strengths and weaknesses in the potential leader. The business technique of having a 360-degree review from those above, at, or below the rank of the leader is an invaluable resource and learning tool.
Imagining that there are a variety of aspects to leadership can be a helpful approach. Certain qualities such as integrity, imagination, hopefulness, follow-through, organizational sensibility, determination, and commitment are not necessarily tightly linked. Recognizing the qualities which are present in greater degree will provide confidence to work on the areas that one possesses to a lesser degree. Aligning oneself with an individual that has greater strengths in areas of personal weakness can be a smart strategy.
Finally, leadership is not necessarily lonely. There are types of legitimate leadership (such as wartime commanders making life and death decisions on the battlefield) that can certainly be both lonely and highly demanding. However, this is not the leadership model for leaders in an academic setting, which has significant opportunities for a collegial style. In many cases, the “lonely” observation about leadership may have more to do with the style of a particular leader than the specific task at hand.
A personal commitment by the aspiring leader to forge relationships with peers with similar responsibilities can invigorate one’s sense of the task. Groups such as the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), American Association of Directors of Psychiatric Residency Training (AADPRT), and Administrators in Academic Psychiatry (AAP) have a support structure for new members. Leadership can be a rewarding experience of encouraging others to develop and build sustaining structures in our academic health centers.
There are at least eight questions that the aspiring leader should ask prior to initiating a leadership position: What are the necessary skills? What is an appropriate vision for a leader? What results are expected from me? What will the time and financial demands of the new position be? What resources will be available to do the job? Who will perform the evaluation? Will a mentor be available? Will there be a requirement to deal with “low performers”? Any significant discomfort with any of the answers should involve an active discussion with the departmental leader who is offering the position.
Four questions are helpful to ask as one has an ongoing experience in the leadership position: Will a mentor be available? Will there be a requirement to deal with low performers? How good is the fit? What are the personal costs? Answers to the questions will assist the leader in determining when the leadership tasks have been completed or whether there are impediments to successful completion that need to be resolved.
1. What Are the Necessary Skills?
A significant part of leadership is putting the issues at hand into context; this is a principal leadership skill and frequently is an asset that most psychiatrists possess. A leader’s main role is to make the current issues meaningful. Having psychiatric training in individual and group psychotherapy is helpful if it is used to understand the factions that may develop over controversial issues. The pitfall is when that understanding is used for interpretation rather than for guiding the next steps of the group.
Dr. Joel Yager has encouraged reading from both the managerial and quality approaches to leadership as represented by Peter F. Drucker and Dr. W. Edwards Deming, respectively (6). Finding a text or mentor for learning the following is essential:
Basic principles of quality management (7, 8)
Basic principles of leadership effectiveness (2)
Basic accounting (depending on the position) (9, 10)
Basic legal issues relevant to your position (legal requirements in releasing student information, due process for students and faculty, and the federal Americans with Disabilities Act).
Role of organizational accountability
Delegation of authority
Art of negotiation (11)
“Know thyself”: strengths and weaknesses of one’s leadership style
Conduct of effective meetings
A recent leadership discussion offered an addition to the old adage of the three A’s: able, available, and affable. The fourth “A” is accountability. The leader has a requirement to be accountable for his actions and for monitoring the actions of his group. In the absence of accountability, it is difficult for leaders and their organizations to meet expectations.
Although business techniques may have a tainted reputation with academics, it is worth reading articles from business-oriented publications such as the Harvard Business Review and the Wall Street Journal. Both have relevant articles on workforce issues, including discrimination issues, benefits, and future trends in the workforce.
2. What Is an Appropriate Vision for a Leader?
An important issue facing new leaders is developing a credible vision. The wise leader figures what is possible within a given situation and what resources are available (12). Determining whether there is reliable support for the tasks involved is crucial. If the potential leader does not have a vision for the clerkship, residency, or clinical area, it will be difficult to make significant strides. The sense of vision needs to be “within the larger vision” of the section or department. A careful review with the departmental leader about the likely coherency between the aspiring leader and the existing leader is important.
3. What Results Are Expected from Me?
This question has the potential to be highly revealing. There may not have been specific considerations for what the new leader is expected to accomplish; this question can initiate a clarifying discussion (2).
Many leadership positions, such as directing a third-year clerkship or an aspect of the residency curriculum, require close attention to specific goals, such as introducing students to particular diagnostic issues or teaching psychotherapy to residents. A critical aspect of academic leadership is attending to the problem of yield (degree of learning per experience); many leaders face the challenge of prior academic arrangements that serve interests other than student- or resident-focused learning.
These challenges could include having a senior teacher who lacks enthusiasm and current information on clinical care. The students may describe such a teacher as a purveyor of “war stories” of yesteryear. A teaching site might have lost its balance on the learning to service ratio; that is, the students and residents are finding themselves managing a service with a lax attending physician who wants extensive service but is unwilling to teach.
Early acknowledgment of such divisive issues will assist the aspiring leader to determine the level of organizational support in resolving them. In highly polarized political environments (e.g., intense conflicts between a “for profit” hospital and academic clinical services), the opportunities to reach academic goals may be remote.
It is useful to have an explicit statement of the goals prior to embarking on the leadership adventure. The potential leader should consider an unwillingness to provide overt goals a “red flag” when deciding whether to accept the position.
4. What Will the Time and Financial Demands of the New Position Be?
A leadership position sought simply for the title alone has little to recommend it; feeling a commitment for both individual and institutional elements of the position is important. An example would be the concept of alignment between a plan for improved teaching by the institution and your own ideas for an enhanced way to educate students.
For most busy clinicians there needs to be adequate planning for which current responsibilities will need to be relinquished in order to accept the new assignment. One basic litmus test is to determine if you will be able to attend 80% of the new meetings and be an active contributor to the discussions. If you cannot make that commitment, then leadership is probably not a reasonable choice.
Will the new position require a reduction in clinical activity? If there is a reduction in clinical activity, will there be adequate financial compensation to replace the lost clinical work? The simple plan of stacking additional responsibilities without any removal of prior activities is a certain pathway to “burnout.”
Some jobs are described as “burn and turn” (13). The jobs are intense with so little attention to the individual occupying the job that the individual was frequently replaced. There can be compelling reasons to take such a job if there are special circumstances that might allow important work to be done, such as improving the range of services in a psychiatric emergency room when the time allotted for a task is limited to 3 to 6 months.
5. What Resources Will Be Available to Do the Job?
Some academic positions have external requirements for the time designated to perform the job; the Psychiatric Residency Review Committee requires that residency training directors have a half-time position. However, new leaders generally negotiate on the amount of time to be spent in the new position.
Negotiation itself is an important part of leadership. During the negotiation, one will learn about the degree of realism in what is asked and what is expected. One should consider if a red flag if there is no opportunity to negotiate at the beginning of a new job.
ADMSEP has made recommendations on the percentage of full-time equivalent faculty for the task of directing medical student education. The wise candidate should try to determine the actual amount of time required to do the task. One approach is to imagine the job as having different “levels” of service, like a fine hotel. For a basic curriculum development, the job is “x%” of a full-time equivalent. For an expanded curriculum with increased teaching responsibility, it could be “1.5x%” full-time equivalent. For expanded fourth-year electives and a psychiatry club, it could be “2x%” full-time equivalent. This model makes explicit that increased academic expectations would result in increased levels of financial support by the department.
If there is a scarcity of financial resources, the creative leader may take advantage of the opportunity to build on a shoestring budget. A good idea can be inspiring to one’s colleagues who may volunteer time and talent to participate in the project. An example might include providing clinical assistance to a homeless shelter.
It would be an excellent idea to discuss with peers in comparable jobs at other institutions which resources were indispensable (e.g., a part-time administrative assistant, cell phone purchased by the department, extra financial support for participating in skill development courses).
Developing a “hiring package” that will support attending relevant conferences is important. Participation with peers in organizations such as ADMSEP, AAP, and AADPRT is helpful for learning what skills will be needed in a leadership position; how others have tried to make changes and the successes and obstacles that they have encountered can inform your own decisions, and watching how seasoned members in comparable leadership positions manage complex tasks can be invaluable.
6. Who Will Perform the Evaluation?
It is vitally important to know what goals your supervisor wants you to accomplish. An absence of mutually decided goals can lead to an uncomfortable leadership experience. Is there a similar educational, fiscal, and/or clinical philosophy relevant to the new position? If the potential leader will be undertaking a politically “risky” position that entails modifying outmoded practices (e.g., changing sites for rotations or asking senior professors to relinquish teaching posts), a bond with the supervisor is particularly important in accomplishing these goals.
In a successful musical ensemble, the individual musician may not necessarily be able to play the other musician’s instrument, but there is a strong sense of trust and respect for the other’s musicianship. This is a useful analogy for imagining a successful, collaborative relationship: trusting each other’s capabilities in your respective positions. If you do not have firsthand knowledge of the potential supervisor’s style, an inquiry is worthwhile. Will this supervisor encourage the new leader’s “musicianship”?
7. Will a Mentor Be Available?
Aspiring medical leaders have had years of training in clinical medicine, but prior administrative experience typically is more limited. Because of this discrepancy between clinical expertise and leadership expertise, having a leadership mentor can be quite helpful.
One easy method is to approach a current leader whose leadership style you admire. The mentor does not necessarily need to be a psychiatrist or a physician. Individuals who have worked in other professional arenas can provide valuable insights, too. One of the most valuable assets of a mentor is honesty; it is important to know when a leadership decision could have been made in a better way. When a leadership idea has been inadequately conceptualized or executed, it is helpful to have a thoughtful review; a mentor can be particularly valuable in assisting with the inevitable disappointments during a leadership experience.
One colleague discussed a mentor who reviewed his draft manuscript and commented, “You are a fine person but a terrible scientific writer. Read these two books and start over on the manuscript.” The colleague found the advice to be straightforward, supportive, and true. This is a good example of a useful mentorship.
If one’s institution has an intramural leadership program, request to participate. There may be opportunities for institutional support to attend an extramural leadership program. The chairman or dean may have useful recommendations.
Thoughtful authors can serve as distant mentors. Several issues are classical in their resistance to easy resolution: individual motivation and organizational functionality. Niccolo Machiavelli wrote The Prince (14) in 1513, but it continues to have relevance today. Machiavelli focuses on leadership skill and the bold exercise of power to maintain the state. By contrast, Peter Block’s Stewardship (15) identifies a strikingly different conception of managerial power: “Because it exercises accountability but centers on service rather than control, stewardship is a means to impact the degree of ownership and responsibility each person feels for the success of our organizations, our society, and our lives.” Despite their different theories on leadership, both books can be applied to managing in a complex, academic environment.
Peter Vaill’s Management as a Performance Art (16) noted “Why in the face of all this do those living in the midst of these systems, including managers, continue to find them mysterious, recalcitrant, intractable, unpredictable, paradoxical, absurd, and—unless it is your own ox getting gored—funny?” These literary mentors can assist in providing some comfort to the experience of assuming a leadership task. That is, many leaders find their roles perplexing and personally challenging.
8. Will There Be a Requirement to Deal With “Low Performers”?
Educational and clinical goals make evaluations necessary (17). If there is one single issue that can become tiring to a leader, it is dealing with students, residents, and faculty who repeatedly do not meet expectations.
Most administrative positions carry some responsibility for delivering a negative assessment (e.g., the student has failed the clerkship, a faculty member has not been clinically productive). In the helping professions, there is a significant hesitation to perform this task; businessmen are often surprised by the academic reluctance to give negative evaluations.
Though many new leaders are inexperienced in this leadership activity, most will be required to respond to those with low performance or failure. For an individual who has repeated poor performance, The LifeWings Group offered the following recommendations on meeting with a “low performer”:
Do not start on a positive note
Describe the behavior you have seen
Evaluate how the behavior makes you feel (i.e., not consistent with the team’s vision)
Show what needs to be done
Ensure that he knows the consequences of continued low performance (18)
In today’s environment, the leader might be sued for a negative review. The new leader needs to be appropriate in making sure that the review is focused, accurate, and proportional to positive feedback. It is important to check with your institution if you are “indemnified” in the appropriate conduct of your office. This coverage is often described as “directors and officers” coverage.
The greater challenge is dealing with a “low performing” organization where the relationships between nurses, attendings, and residents need to be reworked. An example would include a hospital system where the security guards are abusive to psychiatric patients. Although much of this leadership work is often at the level of chairman or dean, it can provide opportunities to determine where positive, incremental changes can be made.
If looking at a spreadsheet or a cash flow analysis brings on a sense of vertigo, the new leader should learn basic accounting principles. Not surprisingly, medical leaders have the most difficulty in appreciating the business aspects of their new positions. If you find that learning the business side is rewarding, there may be a decent fit.
Since most positions have a wide variety of tasks with different challenges, the new leader may find a disparate level of success in the various tasks. One may be talented at the inspiration aspects of leadership but need assistance in completing tasks. It is important to determine whether those shortcomings can be improved through personal development, be supported by another individual, be accepted or unsolvable. Some leaders may find that their leadership strengths will take them only so far in a position and that overcoming the specific weaknesses is neither possible nor worth the effort. On the other hand, the leader may find that the limitations in the organization are significant enough that finding other leadership opportunities is warranted.
Regular evaluations of performance and requests for honest feedback are essential in maintaining an assessment of how good the fit is. Asking for regularly scheduled evaluations is part of maintaining a healthy leadership style.
10. What Are the Personal Costs?
In an era of increasingly scarce financial resources, many academic departments face the imperative of “doing more with less.” It is a national concern that educational and research activities have weakened while emphasis on clinical productivity has increased. Attempts to advance the educational mission in an environment that is not aligned to reward teaching or service may be a “fool’s errand.”
Although leadership may not be lonely, it certainly can be emotionally taxing. Peter Drucker advised leaders to “know thy time” (2). Leadership responsibilities can lead to late nights and missed activities with a spouse, significant other, and children. Missing school plays, athletic events, musical rehearsals, or planned dinners all come at a cost. I had to cancel a long anticipated international trip to assist in managing a crisis in a residency training program.
A clinical colleague described a circumstance where she was asked “to give more than she had to give.” This certainly can occur in a leadership position. Dealing with “disruptive students and residents,” intractable funding problems, or having to dismiss a number of employees should be carefully tracked for their potential cumulative emotional effect.
Answering the above questions out loud has much to recommend it. Sharing your answers with a colleague and asking if the responses sound congruent with one’s personal style and temperament also can be useful. The potential leader should try to resolve as much doubt as possible about potential issues in the new position.
At its best, a leadership experience can result in creative development or reconstruction of clinical or academic service. A grand vision is not required. A smaller vision could include the following:
Developing an improved lecture series that is respectful and that has a better academic yield
Rearranging the clinical schedule to improve resident and student participation in didactic experiences
Removing teaching privileges from a professor who is sexually suggestive toward students despite repeated warnings
Inviting a new instructor who has not previously been teaching but has an astute eye for an aspect of clinical care
Organizing a grand rounds schedule that is less dependent on speakers supported by the pharmaceutical industry
Although leadership can be difficult, it can be highly rewarding. Leadership in health care is an opportunity to create an environment where substantial work can be done with increased efficiency and enjoyment. A leader can assist the group in defining ethically acceptable alternatives in meeting educational needs. In almost any institution, one does not have to look very far to see processes and procedures that are outdated and no longer serve a useful purpose. It is rewarding to be part of fixing or changing a faulty system. A richer educational environment and safer clinical service are worthy goals.