More than ever, hospitals and health systems are counting on physician leaders to help them navigate a challenging healthcare environment. As more physicians step into leadership roles, they are often expected to lead collaboratively, either in formal roles in which they share leadership with other professionals — nurses, administrators, pharmacists, and others — or in less formal teams designated to handle specific tasks.
For many physicians, inter-professional leadership requires gaining some new perspectives and possibly some new competencies, says Peter Angood, MD, president and CEO of the American Association for Physician Leadership.
Medical training teaches physicians to value independent thinking, to have confidence in their decisions, and to take responsibility for outcomes. These important traits must be balanced with listening, working intentionally to understand others’ perspectives, and deferring to others’ expertise.
“Physicians may be used to telling other people what to do as a result of their knowledge and their decisions,” Angood says, “so those who want to become leaders must recognize their basic aptitudes and skills may be different than those needed in a leadership or management role.”
Moreover, physician leaders must be viewed as equal peers to the non-physician leaders they work with, which requires a working knowledge of many aspects of administration and patient care. “Unfortunately, the non-physician leadership sometimes says, ‘Don’t worry about the finances and the marketing and all that stuff — we’ll look after all that. You just look after the other physicians and the patient care,’ ” Angood laments.
Accepting that dichotomy will limit the effectiveness of a physician leader. “The physician who wants to be a strong, effective leader at the highest level must get comfortable speaking the language of what those non-physician leaders and administrators are doing,” he says. “They need to know how to talk finance, how to talk human resources, how to talk marketing.
“They don’t necessarily have to be experts,” Angood says, “but they need to be able to tell the CFO, ‘Here’s the clinical delivery program we think we need; here’s the return on investment on that program, and here’s the financial analysis that we’ve done.’ You want to be able to drive an equal conversation.”
INTER-PROFESSIONAL DECISION-MAKING
The goal of inter-professional leadership is to develop and execute the best strategy, taking into consideration all the appropriate perspectives. In an interview with PLJ, Richard Winters, MD, an emergency physician and executive coach at Mayo Clinic, pointed out that the most effective leaders are those who recognize they have blind spots and those who recognize they are not always the best people to make a decision.
“If I go into a meeting where the goal is to get people to give me information so I can make a decision, it’s likely that the team is not going to really appreciate that, and I’m going to be missing key details,” Winters says. “A good approach for a physician — or any expert — is to step back from their expertise, work to understand what’s going on, facilitate meaning from the information shared, and bring the best ideas out of the situation.”
Winters, who is the director of leadership development for the Mayo Clinic Care Network, finds it helpful to use a framework for considering what kind of decision needs to be made and the appropriate approach for making it. In his book You’re the Leader: Now What? Leadership Lessons from Mayo Clinic,(1) he describes the Cynefin Framework’s five decision domains(2):
1. Clear decisions are those in which a community of colleagues all agree upon the approach and what is possible. Best practice is defined, and the outcome is predictable.
2. Complicated decisions require specific expertise, but experts might disagree. Different cardiologists may recommend different ways to treat high blood pressure because science is complicated. Multiple treatment plans may work equally well.
In making both clear and complicated decisions, decision-makers can lean on best practices, evidence, experience, training, or advice from individuals with more expertise, all to have reasonable certainty about the outcome of a decision.
But in the real world of inter-professional leadership, many decisions are made in an environment of volatility, uncertainty, complexity, and ambiguity, Winters says.(3)
3. Complex decisions are those that require expertise from multiple experts. Staffing decisions, for example, might benefit from the perspective of nurses, human resources leaders, physicians, budget officers, and others. This is when effective leaders serve as facilitators rather than asserting themselves as the sole decision-makers.
4. Decisions made in chaos are similar to complex decisions except that they have the added pressure of immediate urgency. In chaos, there is little time to seek the opinions and perspectives of others. The leader needs to step up and make a decision.
“There are decisions where we don’t all agree upon what to even consider, and we don’t all agree upon what the outcomes might be,” he says. “And we all have very different perspectives for how to approach the problem — those are called complex decisions or decisions made in chaos.”
5. Confusion is the situation in which inter-professional leaders do not agree on the type of decision they are facing. “We have meetings where some people think, ‘I don’t know why you’re talking about this because I’m the expert here, and let me just tell you what to do,” Winters says. “And then you have some people saying, ‘We have best practice. This is what we’ve always done.’ Others are thinking we need to bring in other perspectives, and some may think we don’t have time for that — we just need to decide now because this is urgent.”
Effective leaders know how to evaluate which domain is appropriate for a decision at hand. “A key thing for all of us is understanding which of these decisions requires our expertise and which requires us to step back, and how we do that in the way that is most beneficial,” Winters says.
WHAT NOT TO DO
Self-awareness might be the physician leader’s most important attribute, and Winters highlights two things that inter-professional leaders should note.
First, when you convene a meeting or attend a meeting at the request of a colleague, recognize whether the power dynamic is, in fact, controlling the decisions. “We may introduce ideas that are quite complex, but in fact, the agenda is highly controlled by the individual who’s running the meeting; they are not actually meetings, they are ‘tellings,’ ” Winters says. “We are allowing you to say things so that you feel like you are heard, but you are not actually being heard.”
The second is honoring and offering your own expertise. “Each of us has a different perspective and expertise,” Winters says. “These differences are valuable. They help us make better decisions, and they need to be heard.”
INSIGHTS FROM THE FRONT LINE
For the past nine years, cardiologist Richard Chazal, MD, and health administration executive Michael Montgomery have jointly managed the Heart and Vascular Institute at Lee Health, one of the largest heart programs in Southwest Florida.
Chazal is the medical director of the Institute, a joint venture between physicians and the health system, and Montgomery is the system director of the cardiovascular service line.
In keeping with Lee Health’s embrace of the dyad management structure, the two work as clinician-administrator dyad partners. “All five of our acute care hospitals are managed by dyad partners,” Chazal explains. “And within the Heart and Vascular Institute, all of our committees and our work groups are organized around a dyad structure for efficiency.”
Chazal and Montgomery have direct or indirect oversight of more than 75 physicians and advance practice providers, as well as a multitude of technical, clinical, and ancillary staff. In an interview with PLJ, they identified five conditions that have fueled their success.
1. Shared vision of the future. “Deciding what your mission and vision for where you’re going takes time and work, but if you’ve got that, then strategy becomes much easier,” Chazal says.
Says Montgomery, “In a dyad relationship, neither one of us has absolute power within this organization, but we have a shared vision of exactly what the service line is supposed to be doing.” That aligned vision helps avoid pursuing alternate objectives, such as a situation in which one partner tries to maximize revenue while the other partner values purely academic endeavors.
In their case, both dyad partners agree that service lines must be physician-driven. For example, an administrator, without understanding the clinical decision-making, telling a cardiologist what stent to use is a recipe for failure, Montgomery says.
They keep their shared vision front and center, displaying it at the beginning of staff meetings and reminding one another about it when decisions are being made. Chazal recalls a recent meeting about an imaging issue: “We had gotten a little bit in the weeds about some financial pieces that had to fall into play, and Mike articulated, ‘This is the right thing to do because this is aligned with our vision.’ ”
2. Complimentary partners. Dyads — and indeed all inter-professional leadership teams — are more effective if the partners have complementary skillsets and experience. Some overlap is good. Both Montgomery and Chazal consider themselves “governance wonks” who like strategic planning, but their education and experience are much different. Montgomery holds a master’s degree in business administration and has four decades of experience in healthcare administration; Chazal has a medical degree and four decades of cardiology practice.
“If either one of us tried to do everything on our own, it wouldn’t work, but when we put our skills together, it increases the bandwidth of the leadership structure,” Montgomery says.
He likens their working relationship to perfecting a golf swing over many years, and he points to a recent strategic planning retreat as evidence of their success. “We work together to plan that, and each year we get a little bit better,” he says. “We get more efficient, which frees people from having to spend their whole weekend at a conference table.”
3. Clear delineation of responsibilities. The whole idea of inter-professional leadership is that multiple perspectives are better than one, but that doesn’t mean every decision requires a meeting of the minds.
Each leader respects the other’s areas of expertise. “If it’s a business piece, clearly Mike knows more about that than I do, and if it has to do with a physician management issue or a quality piece, that’s more up my alley,” Chazal explains.
4. Good communication — and a lot of it. They prefer over-communication as opposed to the risk of under-communication. “That leads to a tremendous volume of emails, phone calls, text messages, sticky notes, and notes on my whiteboard,” Montgomery says. “If something is said, it needs to be heard and interpreted completely, which means you may need to go back to the sender of the communication and make sure the loop is closed. It can be challenging because of the volume of stuff that we have going on.”
Having next-door offices has been helpful. “It’s really common — sometimes 10 times a day — for one or the other of us to walk into the other’s office to say, ‘Hey, I’m thinking about doing so-and- so; what do you think?’ ” Chazal says. They have developed processes that give a prescribed cadence to certain types of communication. For example, when anyone in the Institute wants to buy new technology, the request is first evaluated by a panel of clinical experts who analyze the proposal for clinical utility and validity.
Montgomery’s perspective comes in after that step is complete. “Even if it is valid clinically, that is not an automatic check-off because we have to consider affordability and other factors,” Chazal explains.
5. Relationship management. Both Montgomery and Chazal have leadership experience in non-dyad management structures. Chazal is a past president of the American College of Cardiology, and Montgomery is a retired Army officer.
Chazal compares their relationship to a friendship or a marriage between two strong personalities. “There is going to be a time when you are going to disagree, and you have to figure out how to manage that and not make it personal,” he says. “There has to be patience on the day when Mike completely disagrees with something I say or vice versa, but we have to work through that for the common good.”
REFERENCES
Winters R. You’re the Leader. Now What? Mayo Clinic Press; 2022.
Snowden DJ and Boone ME. A Leader’s Framework for Decision Making. Harvard Business Review. 2007;85(11): 68–76, 149.
U.S. Army Heritage and Education Center. May 7, 2019. https://usawc.libanswers.com/faq/84869 .