Leading without a title

I never worried about not having a title in my organization until one was given to me. Shortly after finishing a master’s program in health care management at Harvard School of Public Health, Boston, MA, I was asked to be the first director of surgical services at OSF St. Joseph Medical Center, Bloomington, IL.

I was flattered by the offer and readily accepted, both emotionally and contractually. In the back-and-forth of the paperwork, I found myself reflecting on my new title and its acronym—DOSS, which sounded like obsolete computer language. I approached hospital administrators and asked for a more descriptive title. “Oh, it’s funny you mentioned that, Dr. Wieland,” they said. “We were thinking about making the new position a manager-level job, and we could call you the manager of surgical services.” Mentally translating the new acronym into MOSS, it didn’t seem like much of an improvement. I countered that one of my main responsibilities would be leadership development, and they offered me the title of manager of leadership development—MOLD. I had gone from a plant to a fungus. I submitted that, although leadership development was important, this new role was about increasing physician engagement. I also mentioned that it was widely accepted that surgeons have never responded well to the idea of being managed. To their credit, the hospital leadership team returned the role to director status, and offered to make me director of physician engagement—DOPE. Admittedly, I had been called worse, but I refused to stop there.

In this new position, I acknowledged that both leadership development and physician engagement were vital to the institution’s success. Together, I offered, these concepts are about aligning resources within the organization. Seeing their heads nodding in agreement, I may have then gone too far. I mentioned that the hospital leadership team members all had the term chief in their titles (chief executive officer, chief operating officer, chief medical officer, and so on), and this designation would perhaps command the highest measure of respect from my colleagues. Sure enough, the administration proposed the title of chief resource alignment physician. You can work that one out on your own.

It is said the first thing to do when you’ve dug yourself into a hole is to stop digging. Although this story is tongue-in-cheek, its message is important—leadership is not about titles. In health care, leadership is about motivating and even inspiring people to work together toward organizational goals and improve the lives of our patients. Leadership is about creating emotional buy-in and commitment and working harder for a greater purpose. A title is unnecessary; what is necessary is conviction, communication, and collaboration. This article looks at all three key elements of effective leadership and offers personal examples of how they function in today’s health care environment.

Ripple effect

I alone cannot change the world, but I can cast a stone across the waters to create many ripples.

—Mother Teresa1

I keep a plaque with this quote from Mother Theresa on the wall of my office as a reminder of the effects of my actions—both intended and unintended—and because it invokes pleasant memories of role models and mentors I have had throughout my training and career. It challenges me to be mindful of the ripple effects that my decisions or actions have on colleagues, patients, and other members of the hospital community.

As the practice of surgery has changed over the last two decades, leaders have been challenged to stay current with the technical as well as the political issues that affect our profession.2 Some of our greatest challenges, however, involve keeping our colleagues engaged and motivated in their jobs. Many health care leaders are keenly aware of the enormous challenges facing our profession, which stem in part from a lack of engagement on the part of practicing surgeons and from rising levels of job dissatisfaction among surgeons.3 Many recent studies indicate increasing levels of burnout and growing numbers of surgeons who are retiring earlier than planned. A crushing regulatory environment, economic pressures, and increasing information technology burdens are often cited as reasons for this exodus from the profession.4,5

It also has been reported that most physicians would not recommend a career in medicine to their children.6 My partners and I have lamented these sad facts and figures. Rather than wail and gnash my teeth, however, I have always tried to maintain an optimistic attitude toward these sobering statistics. In fact, a career in medicine is an incredible opportunity for leadership, as well as an ideal setting for the kind of management approach that must come from the grassroots of our profession. We were all trained to be leaders, but in these turbulent times, surgeons need to dig in and work even harder to inspire and motivate younger surgeons and our peers. Our medical colleagues need to be able to look to us to be decisive in our treatment of patients; to be confident in our ability to communicate with patients, family members, nurses, and peers; and to be collaborative with our colleagues in co-managing complex disease processes and/or comorbidities in our patients.

For titled and untitled administrators, these challenges represent opportunities as well. The pessimists would have us believe that our profession is deteriorating and devolving from some idyllic notion of past greatness. Conversely, I believe we are learning to adapt to our current circumstances. Our greatest days are, and will always be, ahead of us if we adopt the approach of surveying the landscape, leveraging our collective strengths, and maintaining an unshakable focus on improving patient care by improving surgical outcomes.

Our work environment has changed dramatically in the last few decades. We now have four generations in the workforce working side by side.7 Coming from different backgrounds and different cultures, surgeons today have varying definitions of a healthy work-life balance. All of us have different priorities that respond to different management and leadership styles. Therefore, our own leadership style requires flexibility.

I recently asked the chief medical officer at St. Joseph how he so effectively managed to lead our diverse medical staff with its various ethnicities, cultural interactions, and age ranges. He borrowed a quote from a speech by former President Bill Clinton, and said, “John, leading this group is a lot like being the caretaker at a cemetery. I have a lot of people under me, but nobody is listening to anything I say.” (Personal communication with the author, May 27, 2015.)

If nobody is listening, how do we lead? When working with highly educated and trained individuals, a confrontational or authoritative approach is most often met with resistance. In my experience, having the formal authority of a title and its positional power rarely, if ever, is a motivating factor for colleagues. Power among peers in surgery is often more accurately described as influence. And working with and among colleagues, friends, and peers, we cannot influence them unless we first engage them.

Three Cs of leadership

Leading without a formal title can be summarized using the three Cs: conviction, communication, and collaboration.

Conviction

Conviction is the most important of the three. It is the unshakable belief of a leader that he or she is doing the right thing for an institution or individual. For me, conviction has always involved valuing patient safety above all else within health care. In truth, I was not always so passionate about patient safety—until I left a surgical sponge in a patient. Very early in my career, I operated on a young man with a progressive neurologic disease. The operative plan of a routine diverting colostomy went horribly wrong, resulting in an extensive adhesiolysis with enterotomies and a bowel resection. I felt particularly bad for this patient because, despite his circumstances, he never showed any anger or bitterness. He was always cheerful and upbeat. I was troubled when he struggled postoperatively. I found the source of his misery several days after surgery, when I ordered and reviewed abdominal X rays. I saw the abnormal opacity on the films and was devastated. I was certain I would be sued for liability, that my reputation would suffer, and that I would lose referrals when the news spread throughout my small hospital. I was focused on all the negative consequences that would befall me when I should have been concentrating on my patient’s care. I felt even worse for being so selfish. My patient had competed in 10K runs in the past and was now wheelchair-bound, and I was worried about how his misfortune was affecting me. I went straight to his room and told him everything.

His wife and daughter were with him. I told them about the sponge, apologized to them for letting them down, and told them that another operation would be necessary to remove it. I told them I understood if they wanted to transfer his care to another surgeon. After taking all of this in, the patient said, “Doc, this is not a perfect world,” as he pointed to his wheelchair in the corner of the room. “And none of us is perfect,” he continued, pointing to himself and then to me. “I know you are a good surgeon. I know that you didn’t do anything on purpose to harm me. So, I need you to do two things for me right now,” he said. “I need you to quit feeling sorry for yourself, and I need you to get this sponge out of me!”

Things worked out well for both of us after that day. I have thanked my patient on more than one occasion since then for making me a better surgeon and for making me a better leader. The leadership lesson I learned from this experience was the importance of accountability. Leaders need to be accountable and take responsibility for their decisions and for the outcomes associated with those decisions—even the bad ones.8 I also learned how important it is for leaders to share lessons learned the hard way. We are trained to keep quiet about our complications, but this doesn’t help prevent our younger colleagues from making similar mistakes. I have shared this story with colleagues many times because I believe its lesson is beneficial. That is how we can demonstrate leadership, and we don’t need a title to do that.

Communication

With or without a title, communication is an important element of leadership. Strong leaders are usually great communicators, often understanding the hearts and minds of the people they lead.9 Great communication involves being an active listener rather than a talker, someone who can empathize with the concerns and passions of others. To know another’s passion is to know where they spend their time and their energy. Being attuned to the passions of colleagues helps leaders align those interests with organizational goals and allows administrators to communicate in a relatable manner. Often, a casual conversation can produce positive results.

I had a conversation with a colleague, during which I tried to find out why he was dismissive of participating in the surgical time out before each of his operations. Despite all the research in favor of it, this colleague said he didn’t think it contributed to patient safety. Knowing his passion for aviation as an amateur pilot, I asked him if he ever went out to the airport and simply jumped into his plane and took off without doing a pre-flight safety check. “Of course not,” he said. “That would definitely be unsafe. I could get myself killed!” (Personal communication with the author, September 30, 2014.) Seizing the opportunity and knowing I could push his buttons a bit, I asked him if his airplane was more important than his patients. I also asked if his operating room team, like the air traffic controller in the tower, would like to know his “flight plan” for each operation and whether any special equipment would be necessary for a smooth takeoff and landing. Understanding the parallels between aviation and surgery, he relented and agreed that he would begin to participate more actively in the surgical time out. He is now one of our most vocal supporters of this process—and no formal title was necessary to bring about this change.

Collaboration

Collaboration, another crucial component of leading without a title, speaks to working with colleagues to create a partnership related to introducing and achieving organizational goals. Collaborative leaders are skilled at conveying a sense of respect for the people whom they lead. They publicly recognize their colleagues as valuable members of the organization whose engagement and input is vital to the success of any initiative or project, and they reinforce the message that patients, physicians, and the organization are much stronger when the effort is collective.10 Successful leaders who collaborate well can align goals and incentives for all. A friend who was on the rowing team in college calls this “pulling all the oars in the same direction.”

Just over 18 months ago, St. Joseph Medical Center converted from a traditional call coverage model to an acute care surgery model. As chief of surgery, I was largely responsible for the development and implementation of the program, whereas the chief medical officer had decision-making authority for negotiating the compensation and contractual obligations of the surgeons. He and I could have worked out the details regarding the call schedule, the metrics, and the parameters for the program in a short period of time and could have presented the plan to the interested parties. However, we knew we would have better buy-in and more commitment if we involved those parties in the process. We included the surgeons participating in the program, the hospitalists with whom we share responsibility for many of these acute care patients, and the emergency department (ED) physicians who are often the first contacts with these patients. Working together, all the groups had input into the structure of the model. The spirit of camaraderie and collaboration was evident throughout the process, and the rollout was met with excitement and a belief that this new model would improve the patient experience as well as patient outcomes. In less than a year from its inception, the proof of its success was evidenced by marked improvement in the Press Ganey patient satisfaction surveys and in a dramatic reduction in the “leakage rate” from the ED. Hospital administration was as pleased as the clinicians with the level of success and acceptance on the part of both the patients and the nursing staff.

Successful leaders make a habit of tapping in to the passions of others as they relate to patient care. By keeping the patient at the center of the health care universe, leaders can motivate and inspire others to work toward a better and brighter future for both patients and physicians. Visionary leaders are being called upon to create a patient-centered culture. Referring back to the quote from Mother Teresa, much, if not all, of what we do creates a ripple effect on future generations of both patients and surgeons. And an optimistic perspective can and should be contagious for those future leaders in health care organizations. Leaders don’t need titles to lead, but they do need to inspire those around them to represent our profession in a positive way, ideally attracting the next generation to surgery. One never knows where the ripples from the casting out of a single stone will spread.

Inspiring others

In March 2015, shortly after the National Residency Match Day, I received a thank you note from a young man whom I had not seen in six years. He participated in a job shadow program that my partners and I maintain for undergraduate pre-med majors from Illinois Wesleyan University, Bloomington, a local liberal arts university. He reintroduced himself to me in the note, and then proceeded to explain the source of his gratitude. “I shadowed you in surgery about six years ago, and I have wanted to be a surgeon ever since then. Last Friday on Match Day, I was fortunate enough to match into the surgical residency that was my first choice,” he wrote. “I’m so excited to see what the future holds, and I wanted to let you know what I have been up to, and that you fostered much of my early surgical interest.” As I read further, I could feel my chest swelling with pride, even though I struggled to remember any details of our encounter. He concluded, “Thank you for spending the time to make me feel comfortable and for inspiring me. I will certainly pay that forward in my future practice.”

I have kept his name confidential but have shared excerpts from his note with staff, colleagues, nurses, and hospital administrators. I use it as an example of leading without a title and of how actions that we take for granted—our daily routines of patient care—can be inspirational to others. I don’t remember what types of disease processes this young man saw or what procedures I performed while he shadowed me. I don’t remember what cases I did on the day the thank you note arrived in the mail. Because of its message, however, I am certain it was one of the best days I have had in more than 23 years of surgical practice.

Looking to the future

I believe there is much to be optimistic about in the future of our profession. And because I have been leading in my organization for many years without a formal title, a new title doesn’t define me or inspire me. But truthfully, if someone could come up with a catchy title that rolls off the tongue and is even modestly hip, I would definitely use it. If it were up to me, I would like to be called the chief of optimistic leadership, because it’s always hip to be “cool.”

Note

This article is based on a presentation that Dr. Wieland gave at the American College of Surgeons National Surgical Quality Improvement Program 10th Annual National Conference, July 25–28, 2015, in Chicago, IL.


References

  1. Quotery.com. Quote by Mother Teresa. Available at: www.quotery.com/quotes/i-alone-cannot-change-the-world-but-i-can-cast/. Accessed December 11, 2015.
  2. Goldberg RF, Kaafarani HMA, Smith J, Winfield RD. Surgical leadership and political advocacy. Bull Am Coll Surg. 2012;97(8):14-18.
  3. Lee TH, Cosgrove T. Engaging doctors in the health care revolution. Harv Bus Rev. June 2014. Available at: https://hbr.org/2014/06/engaging-doctors-in-the-health-care-revolution. Accessed December 7, 2015.
  4. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
  5. Peckham C. Physician burnout: It just keeps getting worse. Medscape.com. January 26, 2015. Available at: www.medscape.com/viewarticle/838437. Accessed December 7, 2015.
  6. The Doctors Company. Nine out of 10 physicians unwilling to recommend health care as a profession, exacerbating anticipated physician shortage. March 1, 2012. Available at: www.thedoctors.com/TDC/PressRoom/PressContent/CON_ID_004671. Accessed December 7, 2015.
  7. Putre L. Generations in the workplace. Hosp Health Netw. January 1, 2013. Available at: www.hhnmag.com/articles/5919-generations-in-the-workplace. Accessed December 7, 2015.
  8. The Leadership Trust. Leading with responsibility and conviction. 2010. Available at: www.leadership.org.uk/files/uploads/71.pdf. Accessed December 7, 2015.
  9. Hackman MZ, Johnson CE. Leadership: A Communication Perspective. 6th ed. Long Grove, IL: Waveland Press, Inc.; 2013.
  10. Berry LL, Dunham J. Redefining the patient experience with collaborative care. Harv Bus Rev. September 20, 2013. Available at: https://hbr.org/2013/09/redefining-the-patient-experience-with-collaborative-care/. Accessed December 7, 2015.

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