Academic Medicine

How To dismantle Your Legacy As A Physician

Brett Favre was one of the greatest quarterbacks in NFL history. As physicians, we can learn a lot about the legacy we leave and about how we will be remembered from Brett Favre. After a rookie year with the Atlanta Falcons, Favre joined the Green Bay Packers where he spent the next 16 seasons amassing one football record after another. In Wisconsin, he was a hero: parents named their new-born sons Brett, Green Bay jerseys with #4 quickly sold out, and he was awarded the NFL’s most valuable player three years in a row. On March 4, 2008, he announced his retirement but then a few months later, he changed his mind about retirement and asked to be traded so he went to the New York Jets for a year and then announced his retirement (again). A few months later, he signed with the Minnesota Vikings, the arch rivals of the Green Bay Packers. And Brett Favre went from being the most beloved man in Wisconsin to being the most hated man in Wisconsin.

So, what does this have to do with physicians? We do not have the fame of a Brett Favre, but we do build up a reputation in our hospitals, our communities, and our medical schools. If you look around at medical centers and colleges of medicine, buildings are named after those locally famous doctors who stayed at their institution for years or decades and then retired from that institution. They don’t name buildings after doctors that practice at a hospital for 25 year and then leave to go practice somewhere else.

It is because our brains are wired to dislike someone more if we initially thought that they liked us but then later disliked us. As an example, think about the last ugly divorce that a neighbor, co-worker, or family member went through and how the former spouses now see each other. It also works the other way: we like someone more who we initially thought disliked us but then later liked us. As an example, think about every military sergeant and every high school coach that ever existed.

When a senior colleague, a mentor, a department chairman, or a division director leaves for a similar job elsewhere, they become a persona non grata. We perceive that the physician is leaving because he or she no longer likes us. Consequently, we no longer like him or her. Institutional history is always written by those who remain and not by those that leave and so those physicians who leave are remembered by institutional history not for all of the good that they did while they were here, but rather remembered just for leaving.

There are exceptions. For example, for a bona fide promotion, such as a division director who leaves to become a department chairman elsewhere else. Or for family reasons, such as a physician who moves to a different city because his/her spouse’s job got transferred. Or for internal transfers, such as a physician in a large multi-hospital medical system who is asked by the corporate leadership to transfer to fill a clinical void at one of the other hospitals.

But it is the physicians who depart for seemingly lateral moves who we perceive as rejecting us and thus we in turn reject. And the longer a physician has been at one hospital before leaving for another, the more strongly we reject him/her. We tend to erase and forget all of their accomplishments. We find other physicians to elevate to the level of celebrity to replace those who left. The students, residents, fellows, and junior physicians who came to the institution because of them feel as if they were lied to. The physician’s patients feel betrayed. To all, the departing physician becomes a pariah.

You can measure the qualifications of a physician by how he/she is recruited for a job. You can measure the integrity of a physician by how he/she leaves a job. It is better to leave an institution after only a few years than to leave after a few decades when you have become the face of that institution.

I want to be remembered not like Brett Favre but like Cal Ripken. He was born in Maryland and played every one of his 21 seasons with the Baltimore Orioles. His player number was retired by the Orioles in 2001 and the in the state where he was beloved as a player, he is still beloved.

July 2, 2018

Academic Medicine

The Value Of Shared Values

Leadership change in a healthcare organization is inevitable but every time it happens, it can be a bit unsettling to the physicians. If there are a lot of changes that occur simultaneously with sweeping changes in multiple leadership positions, then it can shift from being a bit unsettling to being a lot unsettling. And much of that arises from uncertainty of values.

In medical centers, leaders such as Deans, Department Chairmen, CEOs, and Division Directors can be roughly divided into two groups: those that are recruited from within and those who are recruited from outside. Those that are recruited from within are physicians and leaders who have worked at the institution and are “known entities” to the rank-and-file physicians and other employees. Those that are recruited from outside are largely unknown to most of the physicians. There is an often-overlooked difference between these two groups of leaders: The former are known whether they have shared values with the rest of the physicians and the latter are not.

Those shared values can mean many different things in different institutions. They can be dedication to clinical excellence, dedication, to educating the next generation of physicians, dedication to organizational financial health, dedication to creating new knowledge through research, dedication to improving diversity, dedication to care of the underserved, dedication to improving public health, etc. With leaders who are recruited from within, you know what you are getting because those leaders have shown what their values are as they have risen from one of the rank-and-file physicians to leader. And therefore, you know from personal experience and history whether that leader shares your own values.

It is harder to know what values are held as most important to leaders who are recruited from outside. You can get an idea from their curriculum vitae and from what they say in presentations and meetings. But you never really know until you experience that leader’s actions first hand.

Sometimes, new leaders are recruited specifically because they hold different values than what the existing institutional culture holds. Maybe a board of trustees wants to “change the culture” of the medical center – this really equates to changing what is valued by the medical center. This can be particularly difficult if the medical center is constantly trying to be something different than what it actually is. For example, a medical center that historically prides itself on care to underserved patients that tries to reinvent itself as a research powerhouse is going to face a lot of challenges. Nevertheless, such value disruption is often necessary to correct perceived institutional deficiencies.

The half-life of medical institution leaders is relatively short, particularly for deans and department chairmen in academic medical centers. An organization that primarily recruits its leaders from the outside can find itself in a state of perpetual value uncertainty, leading the physicians wondering whether or not the values that they hold and that brought them to that medical center originally are the values that will be used to define institutional success in the future. Such efforts to “change the culture” too frequently can result in a sense of on-going value disruption can result in non-alignment and disengagement by the physicians.

On the other hand, recruiting leaders exclusively from within the medical center can result in maintaining a sense of shared values but can also result in stagnation of values. For example, if a hospital in poor financial shape brings in a medical leader who values improving clinical productivity over everything else, then over time, the institutional shared value will become one that fosters high productivity; recruiting successors to that medical leader from within the organization will perpetuate that emphasis on high productivity rather than other values, such as education, enhancement of diversity, research, etc.

A healthcare organization can afford value disruption only so often. Too frequent of leadership changes with leaders recruited exclusively from outside the organization leads to uncertainty of institutional values that then results in high physician turnover. A goal of a healthy healthcare organization should be to create a pool of potential future leaders that have a track record of shared values with the rest of the physicians. These shared values can result in the physicians having a sense of security that what they personally value will be aligned with the values held by the next healthcare organization leader.

Hospital leaders recruited from outside are often aspiring leaders that want to be a leader somewhere and your hospital had an opening coincident with when that person was looking for a leadership job; these leaders are often effective when you need institutional value disruption. Hospital leaders recruited from within are usually aspiring leaders that want to be a leader at your hospital specifically; these leaders are often effective when you need institutional shared values. Therefore, it is on each hospital and health system to create leadership training programs to ensure a steady pipeline of future physician leaders from within who are known by the rest of the physicians to have shared values. This gives leadership search committees the luxury of being able to decide whether at that moment, what is needed is value disruption or shared values. A health system that relies too heavily and too frequently on recruiting leaders from outside of the organization will have a difficult time developing and maintaining a culture of shared values.

The true value of shared values is in improved physician alignment/engagement and in institutional stabilization.

April 5, 2018

Academic Medicine

Choosing Academic Medical Leaders

I think that every search committee assembled for nominating academic medical center leaders should be required to watch the movie The Replacements before starting their search.

In the movie, Gene Hackman is the coach of the Washington Sentinels, a fictitious professional football team. In the midst of a player’s strike, the team has been repopulated with a group of has-beens and want-t0-be football players, led by Keanu Reeves. Reeves plays the character Shane Falco, a former All-American quarterback from the Ohio State University whose football career crumbled after playing a horrendous Sugar Bowel game and who ends up living on a houseboat and doing boat repair work rather than playing professional football. What makes Falco successful with the Sentinels is not so much his quarterback skills but the fact that he brings out the best in all of the other replacement players, making the team win games as a consequence.

In the last game of the season, the Sentinels’ regular quarterback, Eddie Martel, crosses the picket line to return to the team, sending Falco back to his regular job as a boat mechanic. Martel is one of the best quarterbacks in the country but is a bit of a prima donna and looks down on rest of the team’s replacement players, who he considers rejects and inferiors. Meanwhile, the all of the regular players on the opposing Dallas team have crossed the picket line and returned to work. The first half of the game is a disaster for Washington because even though Martel is an all-star, he can’t relate well to the rest of the Washington players and consequently, they do not play well as a team. As the team is walking into the locker room for half time, Gene Hackman is asked by a reporter what it would take for Washington to get back into the game and he looks at the reporter and says:

“You’ve gotta have heart. Miles and miles of heart.”

That was a verbal signal to Falco, who was watching the game from his houseboat, that the team needed him and so he suited up and returned to the locker room where the rest of the players kick Martel out. Falco and the rest of the Washington replacements then go on to win with a touchdown in the final seconds of the game.

So what does a sports comedy movie have to do with selecting academic medical leaders? Over the past 30 years, I’ve seen good leaders and bad leaders. I’ve seen effective leaders and ineffective leaders. I’ve seen leaders with a long tenure and those with a short tenure. And all too often, I’ve seen leaders selected for the wrong reasons.

We often select our leaders based on their previous personal successes – because they’ve become famous doctors on their own right, because they’ve gotten a lot of research grants, or because they’ve published lots of papers in medical journals. And often what we get is the Eddie Martels of the academic world, people who have had enormous individual success but no track record of making those around him or her successful.

Former Ohio State quarterback Shane Falco was successful with the replacements not because he was the best quarterback himself, but because he brought out the best in all of the other players around him. Or, as his coach said, he had heart.

I think that is what is often missing when we select academic medical leaders. We overlook their passion for the institution and their passion for those who work at the institution. The rank and file faculty and physicians at any given academic medical center are mostly “lifers” – women and men who spend all or most of their careers at that single institution. They take pride in being a part of their university. They’re die-hard fans of their university’s athletic teams. They have jackets, ties, sweatshirts, scarves, and hats with their university’s mascot on them. They bleed (name your school colors). And if they are asked what they do by someone sitting next to them in a bar, they’re more likely to say “I’m on the faculty at the university” rather than “I’m a cardiologist”.

For a leader at an academic medical center to be truly successful, she or he has to have passion for that university. And I think that passion is the overlooked quality that leadership search committees overlook when they are evaluating candidates. A successful leader has to have more than just passion but passion is the catalyst that brings out the best in all of the rest of us. Passion doesn’t show up on a CV. Passion isn’t something that a hired recruitment company looks for. Passion isn’t something you can measure by number of grants or publications.

The best leaders are not the ones who accept your job offer because it was the best of the 4 or 5 that he or she has at the moment. The best leaders are those who accept your job offer because it is what they have always aspired for. Skills are what makes us succeed as individuals; passion is what makes those that we lead successful.

February 17, 2018

Academic Medicine

The Chief Petty Officers Run The Ship…And The Hospital

A few years ago, I took a tour of the USS Midway, an aircraft carrier that is now a museum anchored in San Diego. One of the things that I learned was that the Chief Petty Officers are the people who really run the ship from an operational standpoint with the Captains making the tactical and strategic decisions. There are a lot of analogies with hospital leaders.

Two weeks ago, we had some turmoil at Ohio State when the Vice President for Health Sciences and CEO of the Medical System resigned under pressure from the physician faculty. It caused me to examine who our medical system leaders are and I realized that there are really two tiers of leadership, a lot like the Chief Petty Officers and Captains.

At the top, are the executive leaders: the Chief Executive Officer of the Medical Center, the Dean, the Chief Financial Officer, and the Chief Operating Officer. These are professional leaders; by that, I mean that they are either leaders with a business background who have specialized in overseeing large health systems or they are physicians who have evolved into  leadership roles and no longer are doing clinical care. These are like the Captains. Of note, at Ohio State, all of them are people who were recruited from outside of the University.

In the middle, there are all of the operational medical directors: The Chief Medical Officer, the Medical Directors of each of the hospitals in our health system, and the Medical Directors of every procedure area and clinical program. Every one of these individuals are physicians who have been at our Medical Center for many years who started off as regular clinicians and then were home-grown into their leadership roles. I’m one of them – we are like the Chief Petty Officers.

In academic medicine, the captains have differentiated themselves so much that about all they can do is be full-time leaders. The chief petty officers are generally a lot less differentiated and they typically are also doing clinical care or teaching; in other words, they are not full-time leaders.

Because so many of the captains come from outside of an institution, they are by definition geographically mobile. Because they are mobile, you are always at risk of them leaving to go to some other academic institution, much like the Medical Rock Stars that I wrote about in a previous post. On the other hand, the chief petty officers tend to be geographically fixed, loyal to a single institution, and are less mobile.

In the navy, the chief petty officer is the highest rank that an enlisted sailor can achieve. Because they started off as regular sailors, the rest of the ship’s crew knows and trusts them – the chief petty officers have “been there” and the crew considers them to be one of their own. In medicine, the chief petty officers are the same – they started off as regular doctors and at their core, they still identify themselves as clinicians. They hold the institutional memory of the past years and decades and they are the ones that the rest of the physicians know and trust. They also know all of the bad things that have happened in the past that were swept under the carpet; in other words, they have institutional wisdom.

An academic medical center needs both captains and chief petty officers. For me, I’m very comfortable being a chief petty officer.

June 12, 2017