Physicians Leading | Leading Physicians

Leadership Pearls: Small Nuances Are Powerful Drivers

Interview · September 27, 2017

Namita Mohta and James Stoller

Part 2 of our interview with James Stoller, MD, MS, Chair of the Education Institute at the Cleveland Clinic. Missed part 1? Catch up here.


Namita Seth Mohta:  Jamie, what else can we be — and should we be — doing to better position our rising and current physician leaders for success in these roles?

James Stoller:  Your comments are heartening because it clearly indicates that this awareness of engaging teams and changing the traditional formula is endemic. I, too, like you, trained at the Brigham. As one small anecdote about modeling behavior, which is a core leadership competency, I remember rounding on Dr. Bernie Lown’s service. One of the things I’ve embraced from that experience was when Dr. Lown would enter the room — and of course there was an entourage behind him, of which I was one when I was on the service. I remember [this] distinctly and have employed this myself in terms of modeling behavior, in this case a clinical pearl.

He would come to the door jamb on leaving the room after addressing the patient and examining the patient, and he would turn to his fellow or whoever was walking out of the room with him, within earshot of the patient but at the door jamb, addressing a comment not to the patient but clearly audible by the patient. He would say, “My goodness, she’s doing well.” Small nuanced things like that become powerful drivers of not only how we engage our patients, but how we engage our colleagues.

To your point on modeling behavior, this comes really from a larger rubric — and then I’ll address your question about how we train doctors. There are many models of leadership not specifically regarding health care. I happen to like among several of those the work of [Jim] Kouzes and [Barry] Posner, a book called The Leadership Challenge. They talk about five leadership competencies. What are the essential characteristics of great leaders based on data? This is an observational study they did in which they interviewed individuals in health care in sectors other than health care and asked them, “tell me about the characteristics of a great leader you know”. And then they did kind of a multivariance thematic analysis and extracted five themes. These five themes are:

  1. Great leaders challenge the process. They see the current state of reality and they search out new and innovative new future states.
  2. Great leaders inspire a shared vision. They envision an uplifting and ennobling — you’ll notice the appreciative terms — future, and they enlist others in a common vision by appealing to their values, interests, hopes, and dreams.
  3. They enable others to act. Great leaders facilitate others’ leadership rather than hoarding leadership. Again, it requires a little bit of reframing of what we do in medicine.
  4. Exactly as you said, great leaders model the way. They behave in ways that are consistent with your espoused values. If I insist on punctuality, then I need to be on time for rounds, etc. Much of parenting comes from the same concept, as I’m sure we’re all aware for those of us who are parents.
  5. What they call “encourage the heart.” This is reward and recognition. It’s the notion that we compliment others on the contributions they’ve made to a collective effort in public forums. There is nothing more heartening than being acknowledged and recognized. Again, this is a departure from a somewhat deficit-based view that traditional training has inculcated.

So those five things really frame [leadership competencies]. Now, having said that, you asked me how we begin to change this. I believe that we need to start early, so that we need to begin to select medical students on criteria that go beyond the traditional academic criteria, that are really based on their proclivity, personality proclivity, and phenotypic proclivity for these traits.

Number two, in the earliest points of medical training, in the first day of medical school, we need to begin to espouse these values and offer some training. Again, not necessarily as comprehensive as might occur with a graduate degree, but some training and some awareness on our medical students and our graduate medical trainees perhaps of what these competencies are. And in fact, there are many programs, including those that we’ve implemented here at the Cleveland Clinic for now many years, in which we offer this curriculum to our medical students, to our trainees, to our colleagues in a very interdisciplinary way. This is not confined to physicians. These leadership competencies and the concept of teamwork requires that we embrace an interdisciplinary approach. When we offer leadership development in a course called Leading in Healthcare, which we have offered for more than a decade here, this is doctors, nurses, and administrators selected and learning together. I think that we need to have a consistent curriculum from the earliest phases of medical training that then tracks through GME, tracks through CME, and is addressed in all levels of the organization — not just the most junior but also the most senior — and create the expectation that leadership is evaluated on the strength of not necessarily only one’s academic performance or clinical performance, but rather on one’s leadership performance through the lens of emotional intelligence, etc., if that makes sense.

Mohta:  Yes, it absolutely does and I fully support it. I would emphasize two of the points that you made. The important one is that if we’re going to spend effort training people, then we need to make sure that we’re evaluating it along the way. I think physician development and feedback is often where our system falls short a little bit on many dimensions, including the one on leadership. The second point to highlight is the importance of making sure that these values are embraced all the way through to the top of any organization. The C-suite and the board of organizations needs to recognize these skills as critical and important and tie metrics and potentially even compensation to some of these behaviors and making sure that they are cultivated.

Stoller:  I couldn’t agree more. I consider myself fortunate enough to live in an environment in which we have annual reappointments. There is no concept of tenure at the Cleveland Clinic. In fact, each of us is evaluated on an annual basis, and the more senior and the more leadership responsibility anyone has, the greater the lens around one’s leadership competencies. Not necessarily ones RDUs or clinical metrics or even CE [continuing education] — how many oral ones and papers and so on, high-impact publications.

Those are clearly important, don’t misunderstand me, but I think that increasingly as one has leadership responsibility, the accountability is around leadership, which is really how leaders exercise their influence on organizations and can move the needle. So accountability is a huge dimension. It shouldn’t be a sort of Damocles, it should be an environment in which these competencies are celebrated and modeled and espoused, as you point out, at the highest levels of the organization.

Mohta:  I admire and respect your view and the Cleveland Clinic for your great work in this area. When I think back to those five leadership qualities that you mentioned, challenging the process, inspiring a shared vision, enabling others to act etc., those are not unique to physician leaders. So when I think about the term physician leader, there are those who are physicians who happen to lead, and then there are leaders who also happen to be a physician. When you think about these five qualities, which of them are specific to leaders who happen to be physicians versus leaders who aren’t physicians?

Stoller:  Well, I think they are, as you appropriately point out, generic leadership competencies. Having said that, they all have specific nuances within the context of health care. When we talk about, for example, modeling the way, examples of the sorts of things that you’ve described in terms of how you pick up a team, what Dr. Lown would do, etc., those are the specific contextual examples in health care. When I think of those models — and there are many leadership models, this being one of them — I think of the overarching concept of emotional intelligence as a kind of unifying field theory. Of course, this is a model that has been developed by several authors: Peter Salovey who is now the President of Yale, Richard Boyatzis who is one of my colleagues at the Weatherhead School, [and Reuven] Bar-On. These three different models of our emotional intelligence articulate essentially the capacity to understand your own and others’ emotions and to motivate and develop yourself in service of improved organizational performance.

When people think of EI, or emotional intelligence, they fragment or segment it into four quadrants, and underneath these buckets there are individual competencies, a total of 18 in the traditional model by Boyatzis and others. Imagine a 2 x 2 table. The right upper quadrant is self-awareness. In the right lower quadrant is self-management. The ability to be emotionally in control, being transparent, being adaptable, being optimistic. In the left upper quadrant, one has social awareness, the ability to be empathic, to be service oriented, to have organizational awareness. And then in the left lower quadrant, one has relationship management, the idea of developing others, understanding change, knowing how to navigate conflict, being a team player, and knowing how to build teams and cultivate collaboration. So if one unpacks this model of emotional intelligence and the 18 specific competencies, many of those are specific examples, again not unique to health care but certainly needed in health care, which frame the components, the elements of an effective leader and certainly of an effective physician leader in our view.

Mohta:  Yes. That makes sense. I would also say of those 18 competencies, we are specifically talking today about physicians, but I am presuming you would agree that this translates to all clinician leaders, not just those with a medical degree.

Stoller:  Absolutely, let me underscore that. I wouldn’t want any of this to be construed as some kind of hierarchical competency for leadership. I think that every caregiver in health care is advantaged by this training and the modeling of the behavior about this if we really start to talk about behaving in ways that are consistent with our espoused values. When we teach this material, we teach it in interdisciplinary ways so that our doctors, nurses, administrators, all together, allied health providers,  are learning this stuff together, which of course models the behavior about the importance of teams.

Mohta:  What I really like that you’re doing is talking about the fundamental skills that are needed whether you’re a physician or not, and if you are a physician then the unique challenges that you face as the medical director, CMO, CEO of an institution. This translating between the clinical environment and the non-clinical environment rings really true to me because I live it every day, and I would argue that it is why many people might actually stop practicing. They say it’s because of time, but I actually think it’s more about the transition between those environments.

Stoller:  It requires energy to be nimble. It’s also a function of how doctors are trained. What we do clinically is we translate continuous biologic variables like systolic blood pressure into dichotomous decisions. We decide to treat or not treat, when the systolic is 141 but not when it’s 138, and yet we all recognize that’s a naïve biologic concept, right? At the end of the day, 138 is just a little bit less than 141. Clinical medicine trains us to think in what [Jim] Collins and [Scott] Porras [in Built to Last] call the “tyranny of the ‘or’”.

The conversation gets stuck at physician versus non-physician because physicians embrace this dichotomous thinking because of how we’re trained to think clinically. And what Collins and Porras advise us is that we need to embrace the “genius of the ‘and’”. The “genius of the ‘and’” is when we can be great doctors and we can be great leaders. The most celebrated leaders are people who are actively engaged in clinical practice and who are seen by their colleagues in the real context in which they relate to one another. Again, it’s a reflex that comes from practicing medicine but it works against us, it conspires against us from an organizational point of view. And that’s where we have to be nimble and reframe.

Mohta:  Yes. I couldn’t agree more. And on that note, we will end the conversation for today. But I look forward to continued dialogue in this very important arena. Thank you so much Jamie for spending the time today speaking with us.

Stoller:  My pleasure. Thank you for the opportunity.


Read or listen to part 1 of this conversation, Leading in a VUCA WORLD: Volatile, Uncertain, Ambiguous.


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