Part 1 of our interview with James Stoller, MD, MS, Chair of the Education Institute at the Cleveland Clinic. Click here for part 2.
Namita Seth Mohta: This is Namita Seth Mohta for NEJM Catalyst. I’m speaking today with Dr. Jamie Stoller, Chair of the Education Institute at the Cleveland Clinic. He holds the Jean Wall Bennett Professorship in Emphysema Research at the Cleveland Clinic Lerner College of Medicine. He has held major leadership roles at the institution as well as has extensively researched, written, and trained physician leaders. We will be discussing the role of leadership in health care delivery, specifically the unique contribution and challenges of physician leaders. Let’s start, Jamie, with the premise that leadership is important in all industries, not just health care, and that it’s always been important, not just in today’s environment. What is unique about the current health care environment that makes excellent leadership so important in health care today?
James Stoller: Namita, I’m delighted to join you, and thank you for the question and opportunity. I think that health care faces some unique challenges of all sectors. We, of course, have the universal challenge of providing quality care, providing access to care, and doing so at an affordable cost, the Triple Aim of the IHI.
We add to that what some would call the Quadruple Aim, the need to make sure that caregivers are engaged, have minimal stress, and avoid burnout. When one puts those four features together of the Quadruple Aim, the challenge requires significant and effective leadership competencies at the helm of the health care organization. So I think that’s the perfect storm, if you will, that creates the need for leadership.
Mohta: Would you say there is a component of the pace of change that is also happening? Which is that we obviously need to realize these four main objectives, but in your experience — and you led at the Cleveland Clinic and these are leadership and administrative roles in the past and obviously now currently — what is your experience with the pace of change and transformation that’s required? Is it more, less, different?
Stoller: The pace is clearly accelerated. This has been abetted by technology. The EMR, of course, has facilitated more rapid transactions with our patients, such [as how] patients now of course can review their medical records and email us in real time. As well, the whole expectation from a lens of patient experience has also required increased responsiveness just as in the rest of our lives in general. So the pace has clearly increased and this has, of course, contributed to the leadership challenge. I think that it’s required some very specific competencies about being nimble, about understanding change, how to orchestrate change.
There are defined models. This is the work of John Kotter and others — many have commented on the discipline of change — and effective leaders need to understand this vocabulary and actually embrace the behaviors that are associated with change management. I think that we’re in a volatile, uncertain, ambiguous world — what some have called VUCA — and that’s not going away, it will only accelerate. All of the forces you’ve mentioned up the ante for leaders in health care.
Mohta: Yeah. I am not familiar Jamie with this term VUCA. What is that?
Stoller: Well, it largely comes out of military training, the notion that things are volatile, uncertain, confusing, and ambiguous. The acronym VUCA among leadership circles is a driving force. It’s recognition that we need to be prepared for uncertainty and embrace it, rather than resist it, because it is an ineluctable force and it basically defines the pace of change that we’ve been discussing. Things are volatile in terms of all the challenges of quality, access, cost, things are changing all the time. So many have termed this under the broad umbrella of the VUCA term.
Mohta: Yes. And I would layer on there that our political environment and what is going on in Washington helps support the uncertain, confusing, and sometimes ambiguous parts of those terms as well.
Mohta: Independent of those ongoings and bringing it back to the competencies that you mentioned, what are the core competencies of a physician leader, and which of these are distinct from the core competencies of a leader without a medical degree? Are there significant differences?
Stoller: Physician leaders straddle two worlds. The first world, of course, of clinical medicine with deep passion and commitment to patient care. We spend most of our early lives, actually not so early, learning the practice of clinical medicine, and [spend] the rest of our lives refining it. And yet, I and many others would argue that leadership competencies are a specific discipline and differ profoundly from the clinical competencies that we spend so much of our lives trying to master. So we have this funny paradox, that it takes so much time and energy to master our clinical and scientific and academic — for those of us who are academic — lives. There are specific skills and competencies that are cultivated and developed in our traditional medical training and yet, that attention leaves little bandwidth for learning leadership competencies.
Furthermore, it’s been argued, and I have argued that the hidden curriculum — the curriculum that we see in front of us about how doctors are selected to be doctors, how they are trained as doctors — in a funny way conspires against some of the leadership competencies that we seek and that are so important in health care. We know, for example, there’s robust literature that supports the value of teamwork in health care, the notion that in the ICU and diagnosing imaging and the laboratory that collaboration translates into better clinical outcomes. There’s again a robust body of literature that defends that notion, and yet if we look at the traditional criteria by which physicians are selected and trained, it often conspires against these collaborative reflexes. What Tom Lee, my dear friend and fellow intern framed in a Harvard Business Review paper “heroic lone healers.” We train heroic lone healers, at least in a traditional concept. Fortunately it’s changing.
So what are those four factors as I think about them? The factors that cause physicians to be collaboratively challenged [are]:
- Training, [which] certainly favors individual performance. Each one of us as a doctor got into medical school on the strength of a strong academic record, succeeded in medical school, again on the strength of a strong academic record, found our way into hopefully fabulous residencies again on the strength of individual performance, [and] re-certifies and certifies with boards in a highly individual performance, so this cultivates deep-seated reflexes for individual performance.
- Training is long [and] hierarchical, and while that is changing, there is still a component in which there is a certain subservience that attaches to being a junior physician and emerging through complex systems, and that develops a certain reflex on arrival after finishing training for a notion that you’re kind of the king of the hill and can sometimes behave that way.
- What I call extrapolated authority. Let me give you an example and own it myself. I’m a pulmonary critical care doctor. When I see patients in clinic who are short of breath, they confer to me the authority that frankly I deserve in that context. I’ve spent most of my life thinking about the etiology of dyspnea and how to make people who are short of breath feel better. The problem is, when I leave clinic and I go out to a restaurant with my wife and there’s a line, I’m likely to say subliminally to myself, “Stand in line? I’m an expert in dyspnea.” And of course we extrapolate our authority to contexts in which we may not actually have authority.
- Physicians are deficit-based thinkers. If you think about it, the process of learning clinical medicine and generating a differential diagnosis is all about assembling a list of candidate causes in service of navigating that cause in service of the patient’s betterment. The more seasoned you are as a clinician, the more nimble you are about generating a differential and finding the root cause of the patient’s problem, ideally one that has a treatment.
So this way of clinical reasoning, in which we are constantly looking for problems, frames our brains in a way that actually is antithetical to what most organizational thinkers would have us believe to be effective for organizational life, namely the antidote to deficit-based thinking is what some would call appreciative inquiry. This is the work of David Cooperrider and others at the Weatherhead School. An appreciative inquiry frames a question through a much more, if you will, appreciative lens. What are we when we are at our best? It seeks positivity rather than deficit, and if the notion is that words create worlds, [then] when we frame questions from an organizational point of view through an appreciative lens, we get a very different set of answers than we do through a deficit-based lens. So the point I’m making is that there are these deep reflexes that each of us as doctors have that frame a certain perspective, and the leadership transition is recognizing that those competencies work very well for clinical practice but may actually conspire against our leadership competencies.
So what I and I’m sure you and other medical leaders do is they take time out. When I leave clinic and I go to some executive function at the Cleveland Clinic or in other contexts, I literally huddle with myself and say, “Jamie, I’m leaving clinic. I need to suspend a certain way that my brain works in a clinical context and adopt a different set of operating principles from my leadership role.” That part of mindfulness, that mindfulness and awareness of context is one of the essential leadership competencies. It falls under the broader rubric of self-awareness that many call emotional intelligence, which in my view and many of my colleagues’ view here at the Cleveland Clinic and elsewhere believe it is actually the essential leadership competency for doctors and for leaders in other contexts.
Mohta: That is fascinating because what you’re suggesting, and I agree with you, is that there is actually a different set of skills required to be successful in these two contexts and the sequelae of that then is it’s incredibly exhausting because you literally have to become a different type of person with a different approach when you’re in clinic versus when you walk into an executive board room. So is the solution to that, that we should be changing the way that we approach clinical practice? You see four components of the emphasis on individual performance, this hierarchal, that leads into a king of the hill mentality later on. Does that warrant changing or do we, and perhaps we do both, either and in parallel, focus on giving physician leaders the capabilities to do this transition?
Stoller: It’s a great question and I love the quote — of course I’ll botch it — but it comes from F. Scott Fitzgerald who said essentially, “The sign of an intelligent mind is the ability to hold two conflicting realities and still function.” And I think that is the challenge of physician leadership. On the one hand, there are many dimensions of how we are trained that are time honored and highly effective, so the notion of differential diagnosis and being deficit based in the clinical work, and there is no reason to suspect that we should fundamentally alter some of those things.
At the same time, the recognition that we need to be nimble and mindful and be able to pivot between our clinical context and our organizational context is also important. Again, that’s where mindfulness becomes such an important leadership competency. It’s situational awareness. I will say, however, that there are some dimensions of leadership competencies that do overflow into the clinical arena. I’ll give you a concrete example.
So, I was largely unaware of most of the things I’m saying to you until about 15 years ago [when] I went online and got a graduate degree in organizational development. Why does that matter to me? It mattered to me because it changed a little bit of the lens about how I engage with my colleagues and my organization. As a concrete example, before that, when I would pick up the service, I would show up on the ward or the ICU and of course there were the fellows and the residents and the medical students and so on, and everyone would kind of go into role and off we go presenting cases and making rounds. In the aftermath of this training and just a general enhanced awareness, I pick up a team in a very different way now.
For example, we have a Starbucks at the Cleveland Clinic, and on the first day of service I’ll show up on the ward, of course all the fellows and residents and medical students are ready to present, and I’ll ask them to put their cards, or increasingly their mobile devices, away. We go down and have a cup of coffee for about 45 minutes and I will systematically ask every member of the team about what are their expectations. If this were a fabulous experience on service with me and was successful beyond their wildest dreams, what would happen? So I begin to game frame, if you will, the experience. That also provides me an opportunity to say, “If this were a fabulous [experience], what would happen?” So I can then engage with them in an open dialogue about expectations, feedback, their expectations of me, my expectations of them, anchoring principles on the North Star of making sure that this is a fabulous experience for our patients, most importantly, and then obviously a fabulous experience for them where we are providing first-rate care in a caring and supportive environment.
That small example of how one approaches very hierarchical structures starts to change what I call the hidden curriculum. It starts to show behaviors to junior physicians and in medical students, behaviors from senior physicians, which acknowledge the need to change some of the traditional hierarchical reinforcers. So part of the change in the way that we train doctors has to do with changing the hidden curriculum, by making explicit and mindful some of the differences that people experience about being in health care.
Mohta: I completely agree with you. It’s that modeling of behavior. It is an apprentice-based model, the way you train and learn to be a physician, so what I really like about your example is two things. One is that you are modeling behavior because all those people who are on service with you, in 5 years when they are attendings [they] will pick up that same behavior because it’s such a positive experience for them and we all seek a little running list, I know I did, of a behaviors that I appreciated from my attending, which I have now incorporated into my practice and dealing with health staff. And the second thing that your practice does, it within 45 minutes creates teams.
As we all know, when teams are functioning as teams, particularly in a critical care environment, they perform better. My own example is that as an internist at [Brigham and Women’s Hospital], when I’m on service, we spend the first 2 minutes of service where my team goes around and they introduce each other themselves to me and to each other. And oftentimes we find that they may have been on service, taking care of critically ill patients for weeks and not known the basic thing about the person they are working with. Like, where they’re from and one thing that they like to do when they’re not in the hospital. And so that seemingly minor intervention has had a huge implication in terms of reminding us that we are working with other people in the greater good of taking care of our patients.
The conversation continues in part 2. Read or listen to Clinical Pearls: Small Nuances Are Powerful Drivers.