Being an Effective Physician Leader Is an ‘Inside Job’

Leadership expert, former surgeon and academic Chip Souba says strong leadership starts with removing internal mental barriers through verbal and nonverbal language.

His curriculum vitae reads like a rock star of health care leadership: Harvard-trained surgical oncologist, nationally recognized researcher, stints as a dean at two prestigious medical schools, six degrees, 500 peer-reviewed papers, leadership expert. There’s plenty more.

Impressive stuff.

It certainly was to Wiley “Chip” Souba, MD, ScD, MBA – until he realized there was little fulfillment from his three-decade list of accomplishments. So what changed? Souba (pronounced “show-buh”) says it was a revising of his “mental maps” formed since childhood. You see, he didn’t really have to prove himself to anyone.

Souba, former dean at Dartmouth’s Geisel School of Medicine, will address organizational burnout during the Beyond Burnout & Resilience workshop April 27 at AAPL’s Physician Leadership Summit in Boston. | JAY KELLY/AAPL

“I was able to recognize that when your CV becomes who you are, that’s a future no bigger than you are,” says Souba, who remains a professor at the Geisel School of Medicine at Dartmouth University after stepping down as dean in 2014. “In a way, that’s why my life wasn’t working – and I couldn’t put my finger on anything, and my family paid a price for it. Because I had this belief that to be successful you had to work a lot of hours.”

That he did. Hundred-hour workweeks. Nights without family dinners. Skipping the kids’ ballgames. Stressed and burning out. In return, a rewarding salary and the knowledge he was doing something good for others. Service and altruism. It’s a familiar refrain for physicians and physician leaders in a complex, ever-changing industry. But “it wasn’t who I was,” he says.

“My burnout fuse is pretty long, but what I was able to discover was that I was doing work that didn’t give me the joy that it should have,” he says. “The stuff that I do now, this stuff thinking about, writing about it, working with different organizations … my stress level is way down. If you know that who you are is your title or your rank and you let go of that, it’s like a big amputation. It’s like your hand: You cut that off and you’re still you.”

Souba can’t recall the definitive moment he decided to step away from the daily grind of medicine and academia, but despite all the successes in the U.S. health care industry – “best in the world,” he says – he didn’t like some of what he saw, including an ethical foundation challenged by a system that was becoming too commercial.

“I’ve worked at more places than most people, and the data points that I’ve collected – again nothing scientific about it – is these big institutions … their efficiency and effectiveness in doing what they do, which is take care of patients, teach students and carry out biomedical research,” he says. “It’s extremely expensive, the quality isn’t as great as it could be, I saw tons of medical errors – and I said this has got to be preventable.”

There had to be a better way, “and it had something to do with this phenomenon called ‘leadership,’ ” he says.

First, though, he had to learn how to “lead himself,” a skill pollinated by the delicate connection of language and introspection. “Most barriers to effective leadership are not from lack of knowledge, they are in here [gesturing toward himself] from all that stuff that you erected beginning when you were a child that was largely designed to convince yourself or others that you are valid,” he says.

Souba discovered the focus of modern medicine was on rewarding physicians and leaders for results – what they know, attain and perform. Those are important, he acknowledges, but they don’t provide the base upon which the ethical foundation is secured. What also is needed, he says, is an emphasis on a person’s “being” – how he or she learned to perceive life – and rewiring the negative.

That involves an understanding of language.

The Conversational Domain

If physicians are going to play an important leadership role, they need to learn the “language of leadership,” he says. However, this is not the MBA language of leadership. “What makes humans unique is that what gives you and me access to the world that we live in is language,” he says. “I have a different access to patients” than a nonphysician who doesn’t speak the language of medicine.

“I call that a ‘conversational domain.’ I’ve got a brother-in-law who is a plumber. There’s a whole conversational domain of corrosion and rust and pipes, and he speaks it, I don’t. If you don’t speak the language, you can’t communicate in that domain, you can’t function in that domain and you can’t create in that domain.”

Here is where the introspection leads to effective – and healthier – leadership. When “you have to take yourself on.”

“It’s not just the conventional language of vision, strategy, spreadsheets, finance, differentiation, cost control. There is a whole another language, which I call the language of leading yourself,” Souba says. “Most of the barriers are because people haven’t learned this language that gives them access to themselves.”

To explain, Souba reflects on a common childhood experience that helped push him to fill up his CV: the time at age 7 years old, when he came home from school and his mother asked, “Why did you get a B on that test?” To the impressionable mind of a child, the message was “I’m not good enough,” he says. And it begot a lifetime of “I’ll show you.”

Resolving Ontologic Barriers

He refers to it as an “ontologic barrier,” related to the nature of one’s existence. Most people aspiring to be a success – from doctors to academics to politicians – have them, he says, and they are just part of growing up. “If you’ve got this story that you’re ‘not good enough,’ and you’re a leader, that’s going to negatively impact you as a leader, because you’re going to want the credit,” he says.

Souba says he talks about his ontology barriers “because people resonate with it.” He also shared a few he has helped others overcome.

“There is a big one that I’ve tried to work on for years, and it goes like this: ‘I can never be a department chair because I’m a woman,’ ” he recalls. “Another one: ‘I could never get that job because I’m gay.’ That came from somewhere. That’s the ‘I’m not good enough’ [barrier].

“Some of these senior-most people I reported to or worked with, I [suspect that] when they were children there was a big ‘I’m not good enough’ story there that led them to these higher and higher and higher positions to convince themselves they were good enough.”

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Resolving ontologic barriers – rewiring the “being” – is difficult but a must for anyone seeking to end behaviors that negatively impact leadership and personal self. It can help leaders understand and address behavioral issues observed in team members.

“I remember I had a cardiac surgeon about 17 years ago, and the sternal saw didn’t work,” Souba recalls. “He threw it across the OR. He was obviously [angry]. But you have to ask yourself, ‘Why do people do that?’ They don’t do it for no reason at all. This was a guy who when he was a kid, he discovered that when he threw a tantrum that he got his way.”

He also recalled a doctor who chewed out a nurse who didn’t get to an order to remove a patient’s Foley catheter because she was too busy.

“He ate her lunch in public, screamed and yelled, “You’re incompetent!” That sort of dysfunctional physician behavior isn’t common, but there’s this handful, and that behavior gets triggered more with all these changes in the system and burnout and all that kind of stuff. I actually met with the guy and I said … ‘Tell me, why did you scream and yell at the nurse? I know she didn’t get the catheter out on time, but why?’

His answer: “Because she’s an idiot.”

Leaders and Understanding Behavior

Souba says it’s important for leaders to understand that someone’s actions are not a function of knowledge. It’s correlated with the situation and “how it occurs for you.” Different people respond differently to the same event.

“[For] some people, the electronic medical record occurs to them as the worst thing in the history of mankind, and their actions, their behaviors reflect that,” he says. “They are the cynical ones and they end up getting burned out. Other people, the electronic medical record occurs for them as, “All right, this isn’t going away. How do I adapt?”

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So the question with leadership becomes, “How do you get things to occur differently for people?”

“That’s the work of leadership in a nutshell,” Souba says. “You can’t tell them what to do; all you can do is shift the occurring with what comes out of your mouth. That’s the reason for me that language is so, so important. What I try to do with the woman who says, ‘I can’t be a chair, I’ve got two children. How can I be a mother and a chair?’ Where did that come from? It came from somewhere. … I work with people to help them rewrite their stories. The story about ‘I’m gay and no one would be interested me,” I helped them rewrite. Because they wrote it.”

The bottom line, he says, is leadership is an “inside job.” Transforming the “being of leadership” involves changing mental maps, and that begins with leaders spending more time “leading themselves,” he says.

“The people who are great leaders, the [ through a lot of work.”Nelson] Mandelas, they got solid in here [gesturing at his body]

Rick Mayer is a senior editor with the American Association for Physician Leadership.