I’ve been in medical leadership for 20 years, and the most memorable episodes in my career have been the ones where I made a mistake, a misstep, or just outright mucked up. When I asked contributors to The Chief Medical Officer’s Essential Guide for their experiences, I wanted two things: actual stories (not to-do lists or banal platitudes) and stories that include lessons learned from failures as much as successes.
Experience is the best teacher, but no one has the time to experience everything, or as Oliver Wendell Holmes said, “Learn from the mistakes of others; you can’t live long enough to make them all yourself.”
Sometimes opportunity must knock a few times. I should have written this book a few years ago, but I didn’t take the hint. A colleague became a CMO, and I must have given him an informal list of pointers. I can only surmise I did so. A year later, he asked for it again, but I had no idea what he was talking about. It should have been apparent to me that there was an appetite for a “how to be a CMO” book, but that idea only finally took hold recently.
The most well-received lessons were from the stories I shared with him. I have found this to be true in whatever setting I share insights on medical leadership. When I tell a story in a meeting, I can see folks look up from their mobile devices and begin to pay attention. I love stories; I find biographies the most compelling of genres. That should not be a surprise, since for most of the time humans have been around, we have learned from stories about our heroes, deities, ancestors, and role models.
We learn about perseverance when we recall that Abraham Lincoln endured failed businesses, family tragedy, and multiple election losses before becoming the president who preserved the Union. We find a reason not to give up when we learn that Michael Jordan lost 9,000 basketball games. We draw inspiration from the challenges overcome by Helen Keller, Stephen Hawking, and Martin Luther King Jr.
We are story-telling animals, and I believe that personal narratives will hold the reader’s interest and will be more memorable than a list of “17 tips to be a great CMO” or “30 steps to success in medical leadership,” or even “CMOs hate him for revealing this one simple trick.”
Erin DuPree, MD, FACOG, is a leader in healthcare improvement, quality, and patient safety. As the former chief medical officer and vice president of The Joint Commission Center for Transforming Healthcare, the innovative affiliate of the nation’s leading healthcare accreditor, she collaborated with leading organizations such as the Mayo Clinic and Johns Hopkins, and organizations of all shapes and sizes to tackle their toughest quality issues and to transform the industry to a high-reliability industry using a rigorous, data-driven, systematic methodology.
Rex Hoffman, MD, MBA, FACHE, brings a wealth of experience to this undertaking since, in 2021, he created a CMO handbook for Providence Health System that was designed to assist new chief medical officers in that organization with onboarding and to set them up for success. Having been down this road before, albeit with an audience specific to one health system, his contributions as a co-editor of this book are invaluable as we seek to create this resource for a larger audience.
Insights and Lessons
A word on the structure of the book. First, I didn’t want it to be written only by me. I think I have some interesting things to say, and I have a decent fund of experience, but I realize that my way of doing things only applies to a distinct time, place, and set of circumstances. I have recently become interested in complexity theory, which is a robust system marked by variety. A resource is richer if there are multiple voices, each recounting their own stories.
I also did not want this to be about CMOs as told only by CMOs. Any success depends on alliances and partnerships, so it is essential to hear from our counterparts, bosses, vendors, and clients. The chapters in section two of the book have a CMO and a non-CMO as contributors. I can’t take credit for this parallel approach; Plutarch did it long before me. He wrote a series of biographies of famous men, arranged in pairs, 23 in all, each pair consisting of one Greek and one Roman of similar destiny, illuminating their common moral virtues or failings.
We won’t speak of virtues and failings as much as of missteps and distilling experience into wisdom. The book is arranged into four sections, another homage to the ancients and their paradigm of the human organism. The first is the guts and sinews of being a CMO. The second treats matters of the heart — relationships, then we learn about the more cerebral aspects before moving into the transcendent.
If you are already a CMO, aspire to be one, or work with one, this book will offer you new insights and lessons. Being a CMO is the best job in medicine. I think of myself as a minister plenipotentiary; I have the latitude — and the duty — to visit every ward, every office, every point of care, and meet with every discipline in the house of medicine.
The variety and the constant stimulation are what I enjoyed most about being a medical student and an intern; I got to rotate and learn about every specialty. That is also what appealed to me about emergency medicine, the need to maintain a very broad fund of knowledge. That continues to this day in my role as CMO; I need to know about the most recent advances in robotic surgery, the updated standards for neonatal resuscitation, the cutting-edge technology for imaging as well as everything that is going on in emergency medicine, hospitalist medicine, pathology, and anesthesiology. That cultivates system thinking and develops intuition.
Building Bridges
Beyond the clinical world, a CMO must understand finances, budgets, strategic planning, regulatory readiness, ethics, law, project management, as well as maintain familiarity with nursing and allied health professions. The title of pontifex belongs to one of the college of priests in ancient Rome. Pontifex, literally bridgebuilder, acted as an intercessory between men and the gods.
Bridge building is a great job description for the CMO, who interprets the clinical world for the non-clinician executives and managers and makes known the constraints and workings of the finance and business worlds to the providers. Often, the bridge crosses the divide from the hospital to the wider world.
As the CMO, I have been called on for radio and TV interviews and asked to write articles for print journals. The CMO may be tagged as the option of last resort for patient complaints, dispute resolutions, or medical decisions. The CMO sits on several committees and represents the medical staff. In other settings, the CMO represents the hospital or the patients. There is always some divide to cross and relationships to build; the CMO is often the architect of those bridges.
Bridges, by definition, span the liminal, a place neither here nor there, containing an element of potential that is exciting, but also threatening. As the leader of my sons’ Cub Scout pack, I conducted the crossing-over ceremony where the Cub Scouts walked over a makeshift bridge of scrap wood and lashings to bid goodbye to their former selves to become Boy Scouts. I pointed out that this was a liminal moment, a time neither here nor there.
We are attracted to such moments; we mark them with ceremonies (graduations, weddings) and celebrations (New Year’s Eve). Our cultural histories brim with coming-of-age traditions. Bridges loom large in movies and legends: It’s a Wonderful Life, Lord of the Rings, and Constantine at the Milvian Bridge. To be a bridgebuilder means to always dwell in uncertainty and potential. That requires a strong sense of conviction, a set of guiding principles, and tolerance of ambiguity.
I am often asked what is required to be a CMO. There isn’t a recipe or an algorithm. In fact, that shouldn’t even be the question. The real concern should be what it takes to be a great CMO. That question is reminiscent of an exchange in Thomas Merton’s Seven Storey Mountain. Merton was an American Trappist monk who left a promising literary career for an ascetic life and penned his autobiography, which resonated in a society searching for meaning and reeling from World War II. Merton’s friend suggested he could be a saint.
“How do you expect me to become a saint?” Merton asked him.
Lax said, “All that is necessary to be a saint is to want to be one. … All you have to do is desire it.”
Of course, that is not always easy. In fact, it is never easy. As Dolly Parton says, “It’s hard to be a diamond in a rhinestone world.”
And so it is. All that is required to be a great CMO is a desire to be one and the fortitude to do what it takes. It is exciting, it is fun, it is a privilege, and it is not for everyone.
The Doctors’ Doctor
I am asked on a regular basis if I like my job. I am told quite often by my physician colleagues that they would have no desire to do what I do. They see the burden of conflict resolution; I see the opportunity to harmonize perspectives. They see the tasks of budgeting, planning, and negotiating; I see the chance to have a seat at the table and represent the clinicians. They see the onus of peer review, quality metrics, and discipline; I see the opportunity to ensure the highest standards, protect our reputation, and police ourselves. Dwelling on the ramparts of the never-completed bridge is not everyone’s dream.
Recently, I have come to think of a CMO as a doctor’s doctor — really the doctors’ doctor. In the latter, I use the possessive to refer to the whole of the medical staff and in a larger sense to the institution. I don’t mean the CMO tends to each individual in the sense of employee health; I mean rather that the CMO tends to the corpus of the medical staff the way a physician attends a patient, taking a careful history and conducting a physical, diagnosing, using tools and screening methods to determine strength and vulnerabilities, prescribing therapies and remediation, and at times employing tools at his disposal, including excision or removal.
As medical students, we learn about the parts of the body, their structure and function, how they can misfunction or succumb to external forces. In our clinical rotations, we learn to apply that knowledge to living people, but people don’t read the textbooks, and diseases don’t always manifest in the most clear-cut manner. Therein lies the art of diagnosis.
Experienced clinicians know how to diagnose correctly with the least invasive and fewest tests and, therefore, the lowest costs, intrusion, and inconvenience to the patient and the medical system. Systems thinking is the hallmark of a master clinician, someone who understands the wider forces that affect health: social determinants of health. Likewise, an experienced CMO is adept at systems thinking.
Likewise, I don’t know the perfect hospital or the perfect medical staff, but I endeavor to always perfect my communications and relationships within the hospital and among the medical staff. Much of medical management is transactional and quantifiable.
You have heard, “You cannot manage what you cannot measure.” Not so with relationships. How can you be a 5% better father? Can you move from a red box to a green box on a metric table as a friend? How about gaining a 2-decile improvement in the quarterly rankings as a spouse? These cannot be measured, nor can they be taught by protocol or formulas. For that sort of learning — the relationships, the bridgebuilding — you need stories.
Here are some of ours.
Storytelling And Lessons Learned
The authors of the book have distilled centuries of combined experience and lessons learned into 44 chapters. The reader can study the book in its entirety or focus on just a few pertinent sections. Our aim is to cover the most important issues that a CMO will face. As an introduction, I would like to tell my story and a few of the lessons I have learned. Executive medicine is a calling, just as much as the practice of clinical medicine, and it requires mastery of listening, learning, and teaching.
A Calling
Every two weeks, I introduce myself at a new employee orientation and give an overview of the medical staff to the new associates. I review the specialties, the membership numbers of each department and division, and what they all do. At the end of the presentation, it is my custom to welcome them to the field of medicine, no matter in which capacity they serve.
I tell them that medicine is unlike any other industry or field of work. There is honor in all work, but medicine is special. People seek us out in the highest and lowest points of their lives. They come to the hospital when they are being born and when they are dying. They come when they are in extreme pain, in distress, or are worried about their health and well-being. Patients present at all hours of the day and night. Sometimes they are brought in by family. Sometimes they are brought in against their will.
Sometimes they are brought in unconscious. Sometimes they come in because they have nowhere else to go and their spouse, or child, or pastor, or rabbi, or bartender, or best friend cannot help them. They come to the emergency department when neither the police, nor the courts, nor house of worship, or any other institution can supply what they need.
We follow in the traditions of the Egyptian and Greek temples of healing, the medieval cathedrals and hostels, the early hospitals in the growing cities of an urbanizing America, and we treat everybody without regard to race, religion, color, national origin, ability to pay, speak, or appreciate. We treat people of any age, any gender, any identity.
We are the ones who turn nobody away. It is an honor and a privilege to take care of our fellow humans, and because of that, we concern ourselves with safety, quality, and the dignity of the person. Of all the jobs in medicine, the best is being a chief medical officer, the conductor of the orchestra that makes such noble music.
Listening
Czech writer Milan Kundera proclaimed, “All man’s life among men is nothing more than a battle for the ears of others.” A friend with a long tenure in healthcare once told me that it is impossible to overcommunicate. I have found something else is even more true: It is impossible to over-listen.
Everyone wants to share their experiences, their stories. From the epic poetry of India and Greece to the Sagas of Scandinavia to the stories of Gilgamesh and Charlemagne, at the center of each was a man or woman asking the world and posterity to know that they existed and that they not be forgotten.
Medical care can be dehumanizing. I know what it is like to be a patient awaiting surgery with street clothes stripped off and exchanged for a flimsy blue gown with no back side, a bouffant cap, and blue booties. You look like everyone else; your individuality is stripped away. You are vulnerable and powerless, especially if your insides are connected to an IV or some other even more intimate tether. You are completely dependent on others for your most basic necessities. These are the times when patients most need to be treated as unique individuals.
Throughout 20 years in healthcare leadership, I have rarely received a complaint that alleges the wrong class of antibiotic was prescribed, or the surgical approach was not in keeping with the latest research, or the physician did not adhere to the guidelines of her professional society. Instead, I hear that “no one bothered to communicate,” or no one understood the patient’s concerns or needs, or that the staff was rushed.
Similarly, I hear from physicians, nurses, and managers who feel undervalued, underappreciated, basically that no one listens to their story. It can be exhausting, but I have long had an open-door policy for everyone. A CMO should make the time to listen; it is better to have problems brought to you first, rather than hear them third hand, or from your boss.
As chair of our panel for the state board of physicians, I was told by one member that she thought meetings were supposed to be stiff and formal. She was pleasantly surprised that I kept the mood light and amiable, that I didn’t polarize anyone, and that I was diplomatic and turned down the temperature on otherwise incendiary exchanges. I was glad to hear that, and now, upon reflection, I realize that active listening, refereeing, finding common ground and separating interests from positions have become an unconscious reflex.
We celebrate diversity, but it only reaches its potential if everyone feels respected and encouraged to speak up. Humor and wit — and civility — are essential to encouraging creativity and putting everyone at ease. The fourth section of the book explores those topics in greater detail.
Listening to Staff
In my second year working at the Veterans Administration in Maryland, I found out that the division I oversaw processed compensation and pension exams. I found out because my boss asked me why our performance was foundering. Until then, I didn’t know I was in charge; in fact, I didn’t really know what “comp and pen” was. Nonetheless, I was told to turn the numbers around.
The “comp and pen” exam is a big deal in the VA It is also the major intersection between the two largest arms of the Veterans Administration: veterans’ health and veterans’ benefits. The latter pays out disability claims and relies on the former to complete the medical histories and physicals to ascertain if disabilities are likely to be service connected.
It is a very regimented process with a lot of paperwork, and a great deal of importance is placed on the exam. Not surprisingly, veterans and their advocates focus on the turnaround times of their claims.
During my tenure, the expected time from receiving the request for an exam to reporting back to the VBA was 30 days; our times exceeded 45 days. Since I knew nothing about the process or the steps involved, I drove over to the facility where we conducted our exams and asked the staff to educate me. The staff members were aware of the excessive times and, more importantly, they knew how to fix the problem. But no one had asked them, the front-line workers. And no one had committed to removing the obstacles.
That’s where I learned an important lesson: When faced with a challenge, ask your own people first. Consultants and experts have their place, but the people who do the job every day often have insights that have not been explored.
One of the office workers had been there for decades; she knew the system inside and out. She was a gem, but she had mobility issues — she didn’t like walking down the hall to the fax machine. She would wait until the end of the day to collect the faxes and wait until the next day to act on them. If she had a fax machine next to her desk, she told me, she could respond right away and save at least a day in processing.
She also told me that when the appointment letters were ready to send out to the veterans, those letters had to wait until the end of the day for interfacility mail to take them back to the main hospital mail room; there they could sit for another day or two or three before being mailed out. If we had stamps in our office, we could avoid those delays, but stamps were considered to be money, and no one wanted to authorize stamps for the office.
We were incurring three-day delays — 20% of our overage — because someone was afraid that $10 of postage stamps could go missing! I leaned into this and personally guaranteed the integrity of the stamp process. I responded to the lack of morale by buying pizza for the department, singing their praises, creating awards, and authorizing overtime. These were not brilliant, audacious moves, but this department hadn’t been paid much personal attention, so even the simple tactics were well-received.
None of these steps by themselves fixed the problem, but by eating the elephant a bite at a time, within a few months, we brought our turnaround time to among the best in the nation. Occasionally, our average turnaround time measured in days was in the single digits. When asked what the secret was, I was honestly able to answer, “Just listen to the people doing the job.”
Teaching the Wrong Way
Much of a CMO’s time is spent practicing the art of persuasion. When I started in medical leadership, I believed, as do many other people, that a presentation should be stuffed with as many charts and graphs and data as possible. I thought I could easily dazzle folks with PowerPoints, or at least inundate them with information until they were powerless to do anything but agree with me. I didn’t consider emotions or alliances, much less that everyone is motivated differently.
When I was the new chief of emergency medicine at the North Chicago VA, I spent my first year getting the new ED ready. That included hiring the staff. I was not directly responsible for the nurses, but I couldn’t open the ED on time if we didn’t have the nurses trained and on board. I registered my concerns many times to the nursing leadership and thought my entreaties were falling on deaf ears.
I designed what I thought was a masterful PowerPoint, reducing our dilemma to a series of cartoonish graphics. Here were the number of nurses needed — little outlines of nurses’ capped heads; here is how many are currently on board; here is how many vacancies remained. Here is how little time we had left.
Factually, I was correct, and it did get attention and generate some action, but in the process, I completely alienated my nursing counterparts. I was accused of dropping “a bombshell” during the senior staff meeting. I thought nothing I presented was a surprise. If it was, shame on anyone who thought so; it was a surprise only if one was obtuse, out of touch, or negligent.
The mission of leadership, however, is to persuade other people and get them to do what you want, not to prove them wrong, not to prove your brilliance, and certainly not to embarrass them into submission. I was able to move the ball, but at the cost of losing the trust of my colleagues.
Not long after that incident, I took up an interest in formal rhetoric and learned that Aristotle wrote that three things are necessary to persuade others: logos, pathos, and ethos — data, emotional appeal, and trustworthiness. In my North Chicago presentation, I had failed to persuade my audience.
Over time, I learned how better to deliver an appeal; I often learned what doesn’t work from having to sit through countless PowerPoints. Many folks don’t understand what they are presenting because they don’t have a clear concept of statistics, power, sample size, and variability. Even worse, they don’t tell a story. They don’t use emotion and personal appeal to make their case. Salespeople and politicians know how to make these appeals. Perhaps we feel that we need to be clinical and scientific, and leave emotion out of it.
Nothing could be further from the truth. The first rule of rhetoric is to understand your audience, and it’s always a good idea to have a meeting before the meeting. Just as you would never want to walk into a courtroom or into a job interview without knowing the questions or likely questions you’ll be asked, a board meeting is never a good time for a surprise or a gotcha. Let principals know in advance what you will present. Avoid landmines by asking for their opinions. Ask for their support; sometimes that means changing the presentation or the ask, but it will result in a more favorable presentation and a higher likelihood of getting what you want.
Teaching a Better Way
My first job in the VA was running an emergency department. Because of the quirks of scheduling in the VA at the time, I had five doctors working one shift. Everyone had to work or take leave for 80 hours in a pay period. Usually, someone was on vacation, so it evened out, but there was one pay period where everyone was available, and I had to work everyone.
One day there was an overlap of five physicians. Rather than allow for generous “admin” time or try to crowd everyone into the clinical space built for two providers, I came up with a plan.
There had been some friction between the physicians and some of our hospital colleagues, specifically miscommunications and misunderstandings between the physicians and registration, pharmacy, radiology, and IT. I decided that quintuple day was the perfect opportunity for me to take the lesson from Grimm’s fairy tale The Husband Who Was to Mind the House, in which a farmer trades roles with his wife and winds up appreciating her skills and abilities by better understanding the challenges of her job.
I thought I would do the same and have each doctor spend just an hour seeing what it was like to work in those different areas. I hoped that would cultivate understanding and mutual respect, and foster better relationships. At least, that was my hope.
One of my docs loved the experience; when he came back, he recounted all that he had seen. He couldn’t believe what the registration clerks had to deal with. He was amazed at how technical and painstaking was the job of the pharmacy technician. That’s exactly what I had expected. But he was the exception.
A few of my docs went through the motions and grudgingly acknowledged they had learned something. Afterward, they didn’t complain so much about the members of those other departments, but one of my docs thought this was the worst idea ever and that my asking him to do this was demeaning and an insult. I didn’t expect that reaction. On the flip side, those other departments were very appreciative of the attention and were flattered that we spent some time with them.
I learned a few things, including that even a well-thought-out idea that seems to be a good one will not be embraced by everyone; in fact, it may be completely rejected. Second, don’t let that stop you. Third, consider allies and constituents outside your normal power base.
Learning Along With
Compassion is defined literally as “suffering with.” It is the willingness to get involved in the chaos of others. Many times in my career, I have been told by patients or by my mentors that someone will be afforded a lot of slack as long as they are liked. If patients, associates, peers, and direct reports know that you care, they are much more likely to follow your lead. Hours spent shooting the breeze, finding common interests, engaging in fun activities, and undertaking exploration together are the best uses of the most precious resource time.
I have noted that being a CMO is a great job that gives you license to visit every part of the hospital or health system. It is easy to forget that most of your staff or employees don’t have that option or don’t think they do. Radiologists spend most of their time in reading rooms, pathologists in the labs, and emergency docs in the ED. That makes sense clinically, but when those individuals become leaders of the medical staff, they need to understand the whole tapestry of the hospital.
It has become my practice to tour the hospital and office practices with our medical staff president, visiting another department each month right after the medical staff elections. The staffs in these departments are medical constituents, and it is important to understand their pressures and crazy-makers in their native habitat.
A recent medical staff president was a fellow ED doc. He had never been to radiology, although he spoke with radiologists every day. He came away from our visit with a new understanding of their workloads and protocols. Similar appreciation emerged after we toured outpatient primary care and orthopedics.
My pathologist medical staff president had rarely been above the ground floor. Although for years he had voted on credentials and medical staff quality decisions pertaining to psychiatry, he had never been in the locked behavioral health ward. This shed new light.
As much as the visits benefit the leaders, they generate enormous gratitude from the folks we visit. They understandably take pride in their work and cannot always paint an accurate picture of their challenges. Spending time, discovering, conversing, and visibly showing concern and the willingness to get involved do more for medical staff cohesion and collegiality than anything else can.
Focusing on Fundamentals
Other authors will explore in greater detail the nuts and bolts of the job; the most mundane things are often the most important. I have often heard about thinking outside the box, which sounds great, but I have rarely seen an organization enact anything other than gradual change. A hospital is a complex ecosystem with many moving parts; radical change can have unintended consequences; although innovation is important, it doesn’t need to be out of the box.
As a former Naval officer, I have maintained an interest in military history. On a Boy Scout trip to the Battleship New Jersey, I came across a display of Fleet Adm. Chester Nimitz. He credited the American success in the Pacific Theater during World War II to his staff’s concentration on mundane tasks and on improvements such as damage control and the use of CO2 to flood fueling compartments, fog spray, and portable pumps. Firefighting equipment and techniques were relatively primitive in all navies at the start of the war, but they improved considerably, especially in the U.S. Navy.(1)
It seems that focusing on fundamentals is a common insight for successful leaders, especially when those fundamentals may be overlooked for more glamorous projects or assignments. Gen. Dwight Eisenhower once wrote that the five most important vehicles used to win WWII were the jeep, the bulldozer, the 2.5-ton truck, the DUKW amphibious car, and the C-47 transport plane, none of which was designed for combat.(2)
It may be that the key to overcoming whatever challenge you face is not a radically new approach, or a consultant, or new software. It may be as simple as listening to the front-line workers, demonstrating care and understanding, and focusing on the otherwise hidden fundamentals.
Finally, you may find it necessary to try several times and be willing to fail. You must be willing to be proven wrong. Vulnerability in a leader is not a tragic flaw; it increases loyalty and fosters open communication. Thomas Edison tried thousands of prototypes for his incandescent light bulb before succeeding. After each failure, he said he learned one more thing that didn’t work. Hopefully, this book will let you stand on the shoulders of others and learn what did and didn’t work for them.
References
Budge KG. The Pacific War Online Encyclopedia: Damage Control. Introduction to the Pacific War Online Encyclopedia. http://pwencycl.kgbudge.com/D/a/Damage_Control.htm . Accessed 20 Sept. 2022.
Eisenhower DD. Crusade in Europe. New York: Doubleday;1948.