How should a young Army colonel deal with a physician colleague who pulls rank with juniors and creates an environment hostile to speaking up? Colonel Joseph Pina of the U.S. Army Medical Corps reflects on leveling the status differences that both military rank and professional hierarchy confer and the lessons in this challenge that are relevant for all physician leaders.
Mary Jane Kornacki: I’m here at the IHI Forum in Orlando, Florida, the 28th annual forum, and I’m speaking with Joseph Pina, a colonel in the Medical Corps of the U.S. Army.
Joseph Pina: Hello. I’m Joe Pina.
Kornacki: You related a story about learning how to be a leader earlier in your career. I wondered if you’d tell us about that.
Pina: Sure. So, maybe about 10 years ago or so, I was a brand new Chief of Medicine at Tripler Army Medical Center, which is one of the Army’s larger facilities out in the Pacific, and I was in charge of physicians and nurses and allied health professionals within the department to provide care. It was an early leadership position for me, and I do recall working on honing my skills interpersonally and working with my staff so that we could provide the best care possible. And we were just getting to thinking about things such as psychological safety on teams.
TeamSTEPPS is a program that we promoted. I was an instructor in TeamSTEPPS, so I really embraced the idea, and that program allows us to flatten the organization as far as the authority gradient was, the rank structure was. My being a colonel was a very senior rank, and most of the people in my department were majors and captains, which were relatively junior rank. I had a provider who was a civilian for most of his career but came into the Army for patriotic reasons, but he was actually a pretty skilled internist, and because of his experience and background, he was given the rank of a lieutenant colonel, which is one grade lower than my rank, but it was certainly a superior rank to most of the people in the department.
And he was a very fine internist. However, he had difficulty working as a team player. Tripler being a training organization, we have a GME program there. He was the attending physician for many of our residents who were junior in rank to him, and those residents really were intimidated by him. He was a lieutenant colonel, and he let you know that he was a lieutenant colonel. He was very much focused on his rank, and so there were episodes where he was reported to. If a resident said the wrong thing to him, he would have them do push-ups in public, on the ward, with patients around, and nurses around, and other staff around to see that, and he would not have a problem with berating the residents in public.
I heard similar stories about that with some of the other team members, the nurses, et cetera, if things didn’t go his way. So, a very difficult personality, challenging personality. I had gotten enough of these reports that I would bring him in, and I would counsel him, and we would have a discussion as to what’s going on. Essentially, I was telling him, “You can’t behave like this. It’s disruptive to our culture, and we’re trying to have a culture where we’re non-punitive, and then people can report and people can feel that they can speak up when they need to for the sake of patient safety, and also for staff well-being, and for morale purposes.” And it was very challenging for him to accept that.
So, I had these conversations with him — actually it was several conversations with him — and I don’t think I really got through to him, because the episodes still continued, and eventually he had to be let go or essentially was reassigned. I thought that that was a very introspective moment for me in my career, because I’m an introvert by nature, and it takes a lot for me to basically say no to people or confront them. But if you do it in the name of patient safety, it helps to justify that behavior. Looking back on that, knowing what I know now, I think I would’ve acted sooner to nip it in the bud.
When you hear of bad behavior, particularly with physicians, who are held in high regard in the hierarchy of medical, you really need to be on top of that. And I would also have tried to understand why he behaved the way he did, and what was his perspective on things, more so. It was frustrating for me, especially my being a physician and he being a physician. I said, “You really should be behaving better. You are a role model, and you’re messing up.” And I think I could’ve been a little bit more sympathetic to his position and his side of it.
It also reinforced some concepts that in the military, we have a double-whammy. We’ve got our rank structure, which creates this power gradient, which is a barrier, really, to learning and psychological safety, and then we are also health care providers, which in and of itself has its own culture that we have to get around to get to that psychological safety and team-based play. So, in the military, we have that double-whammy effect with our rank as a power gradient, and then also our disciplines, the physicians versus non-physicians, is a typical thing you see in health care. And so, we’re doing a lot. We’ve recognized that that is a hindrance to patient safety, and we know that our outcomes could be better.
We’ve got great outcomes in different areas, but we know it could be better, and for that reason, we have to focus on the culture piece. I mentioned TeamSTEPPS is one tool that we use to try to flatten the organization, or flatten the team so then we can get around that power gradient and have better learning. We also have leader development courses that we have that focus in on, getting a mentor, having a role model who doesn’t display toxic leadership, but actually promotes those positive things that we want to see with leadership. Deferring to expertise rather than deferring to rank in situations as they are appropriate is a key part of that.
I’ve had mentors who’ve taught me some great, great things about how we need to revere all of our team members for the knowledge that they know, and go to them. And as a critical care physician myself, I know that patients die very quickly if I don’t defer to the person on my team who has the knowledge, for example, the respiratory therapist or the nurse, with that.
The other thing is that, to talk about accountability, in the military we’re trying to foster this just culture. We know that systems problems can be the crux of many errors that occur, but we do have to realize that people have to be accountable for their actions and for their own training. They need to be competent and stay competent, and those who are not competent, we have to hold them accountable, and then those who are disruptive and who are not team players have to be held equally accountable. For physicians, if you look at the ACGME, we have six levels of competency that we have to meet. And basically, to be a complete physician, you have to meet all of those, and any one of those levels, those elements that you don’t meet, you need to work on. That’s where the accountability comes in, and if you have somebody on your team who just is not going to work on [that], is not going to be able to make it and puts your mission at risk, then you may have to let that person go, which is a challenge in the federal system as it is, but that’s all the more reason why we need to identify these folks early on.
And I have to be held accountable as well. As a leader, if I’m not changing, I’m not recognizing where the tension points are or the vulnerabilities are in my team, then I’m failing, and I need to recognize that. We do a lot of introspection now, as leaders, and use that, as long as we’re focused on patient safety as that primary mission.
This story was recorded at the Institute for Healthcare Improvement’s 28th Annual National Forum in Orlando, Florida, on December 4–7, 2016 by Mary Jane Kornacki on behalf of NEJM Catalyst. We wish to thank IHI for support of this project, especially Madge Kaplan for her technical advice and guidance. Click here for more Lessons in Leadership stories.