Navigating Healthcare Leadership with Dr. Smita Agarkar

Smita Agarkar, MD, CPE, FAAPL, shares her journey from clinical practice to a significant leadership position offering valuable advice for early-career physicians and highlights the crucial contributions of women in healthcare leadership. Agarkar discusses her shift from outpatient to inpatient care, her leadership experiences during the COVID-19 pandemic, and her current roles at Gracie Square Hospital and Weill Cornell Medicine.

This transcript of their discussion has been edited for clarity and length.

Mike Sacopulos: My guest today is Smita Agarkar. Dr. Agarkar is on faculty at Weill Cornell Medicine. She also is service chief of Grace Square Hospital in New York. She is a nationally recognized physician leader. Smita Agarkar, welcome to SoundPractice.

Smita Agarkar, MD, CPE, FAAPL: Thank you, Mike. Thank you for having me. It is my pleasure.

Sacopulos: It is my absolute pleasure. Thank you for joining us. I just gave the briefest of introductions, which is I feel somewhat of doing a disservice to you. Could tell our audience a little bit more about your career path as a physician and a physician leader.

Agarkar: My initial goal was just to be a good physician. I started my career soon after residency in an outpatient setting, and then I eventually switched to inpatient and then I ended up as a leadership role as a unit chief on a 24-bed inpatient unit. And it was truly before 2020 that I started covering my chief medical officer. And then when COVID, I got an opportunity to lead a 140-bed hospital in the middle of Manhattan. And during the same time, I joined the CPE program at AAPL, and it only prepared me better for my current role.

So, I currently serve as a service chief of up at Gracie Square Hospital, but I am also a faculty up at Weill Cornell and I am also an adjunct faculty at Columbia University. I am also the Quality and Patient Safety chair, and I truly enjoy my role as a leader.

Sacopulos: Fantastic. Well, you come across a number of interesting healthcare stats in your daily practice in providing services, could you tell us some of the healthcare stats that are important to you and that are interesting to you.

Agarkar: The healthcare industry is a very robust employment sector, especially for women. And if you look at it then, according to the State of Women in Academic Medicine Report and the Association of American Medical Colleges, women currently make up more than 50% of the U.S. medical school applicants, and only a small percentage of that are division chiefs or service chiefs like me. And according to last year's report it was closer to 30%. The number only dwindles when we refer to CEOs or board of directors.

Early-career physicians are also entering the medical field, and that is a topic that we should also be discussing. They come with different expectations, wants and needs than the generations past. Healthcare delivery, Mike, in United States is getting increasingly complex and there could not be a better need for strong effective leadership from physicians. Those leadership traits must be cultivated early on in any physician's career. There are numerous studies that indicate that quality measures show significant improvement in collecting and reporting data in physician-led organizations. So, whether it is presenting a case for a new treatment approach or suggesting changes to streamline any processes, a physician who is honed with leadership skills can convey ideas with confidence.

Women as physicians have played a pivotal role in women's health and ensuring quality of care from all aspects. From a leadership perspective, they make unique contributions based on empathy, good communication, innovation, and most importantly, fostering inclusivity. A recent study, Mike, reported that an association between gender diversity in organizational leadership and improved performance. And for a strong and meaningful change, organizations must invest in diversity. And this would apply to both the age group, hiring early- or mid-career physicians in a leadership role and giving opportunities to women.

When we did our talk at AAPL in 2023, we discussed that women in fact were involved in an emotional well-being, intervening to deal with or prevent burnout, help navigate workplace balance and improve diversity and inclusion efforts. The number of women in healthcare industry in leadership roles have risen tremendously in the last few years in United States. We are here to provide support to physicians in their early stages of their careers, and also women who aspire to take up leadership positions.

I think it is an important era where we need to discuss early-career physicians and women in their leadership role in healthcare organizations. What do you think?

Sacopulos: That is very important and well said. Now, I have a son that has started professional school, which makes me think as he is going through it, what things I might have told my younger self. And so, I would like to ask you that question. What advice would you give your younger self?

Agarkar: That is such a smart question, Mike. I often think about what I would have done 10 or 20 years before my position up here. When you are early on in your career, you tend to second guess all your decisions, and it applies to both genders, men and women. Women may tend to evaluate a little bit more than what others think, but men in general also would do that.

You know, Mike, I would sit back in our faculty meetings in the back seat, and I remember during one of my transplant rotations, my supervisor and mentor stated, you need to be on the table in the front seat. You have evaluated the case. I cannot forget that even today. Often an introvert, I always assumed that if I did my work, it would be seen and valued. Which is what all of us truly believe. And then the most important lesson that I learned was about building relationships and it is somewhat of a shift in mindset. On an everyday basis as a physician leader, you will encounter challenges about recruitment, behaviors, policies, let alone budget, census, and reimbursement.

Now, look, I have my good days and my bad days, but one really wants to do this, right? I don’t know what will happen in the future, but as of now I know that I want to be a good physician leader. Every article that I have read and every podcast that I have heard has a central theme, be empathic and learn the art of listening. For both men and women, they need to be empathic but also authentic and bold.

We all have our professional assertiveness. As physicians, we confidently share our expertise with our patients without being authoritarian. I believe that early-career physicians need to focus on communication skills to help express their opinions and knowledge in an assertive way. During my yearly evaluation, I was told that you are in charge, take the decision, you need not ask all questions. At times early on in career this may not be very easy as we try to fit in. Just give yourself some time. Take small steps to be assertive in your decisions. That is what I would tell my younger self.

Looking back, I would also say to myself, I should have sat in the front row seat. Maybe not in the front row, but at least the second or the third row. I could have been more assertive in some of my evaluations. That is an important lesson for our younger physicians to learn. One really needs to ask; do I want to be a leader? And the most important question is, will I be able to make decisions that do not necessarily make others happy?

Sacopulos: And that is sometimes a difficult part of leadership, which gets us to styles of leadership. And I am interested in your leadership style as well as challenges that you have encountered during your career.

Agarkar: It is such an important question. I am very grateful to my organization, I am faculty up at Cornell, like I said, and the opportunity provided by my organization. But even when I was doing my courses with AAPL, I adopted a very transformative style, very different from my predecessor, and I believed in reshaping the systems of power by creating more equitable and inclusive practices and policies.

Mike, change is hard. You need to start building teams. And one thing I would advise physicians who are going to be leaders is continuing to remain fluid and always be ready for change. I believe in looking for opportunities where they do not exist. Sometimes it is within your organization and sometimes it could be outside. I was a unit chief up at Weill Cornell, and even here at Gracie Square, but then I strived to do better, which is when I joined AAPL. For both men and women who are in early careers, it might be easier to get promoted to managerial levels in the scientific sector. But to continue your progress on the leadership ladder, one must develop strategic planning and organizational skills. It is hard work.

Now, I do not think that I can point towards one specific field or a single challenge that I was not aware of when I was taking this position. However, no reading, no course or no talk can prepare you as you prepare yourself while being in the role. For me, it was about time. To recognize that building teams, changing culture, promoting initiatives, and finding your place within the organization all takes time, Mike. It is about the passion that we all have as physicians to treat patients, to have the energy and the enthusiasm to drive through the crazy Manhattan traffic to go to work, to be in an environment where I can have the freedom to be creative and innovative. And it's all then about intrinsic happiness, a fulfillment, respect, and gratitude. When my staff at the end of this day says, “Hey Doc, time to go home,” or a patient says to me, “You've made my life,” that is all we all want as physicians.

While leadership skills are vital, physician leaders must be able to make sound medical decisions and stay abreast of the latest development in the field while we provide high quality patient care. The first six months of any leadership role could generate a lot of questions. There were many times when I simply wanted to say that I wanted to go back and just see my patients on the unit. I would recommend that early-career physicians do continue with continuing medical education conferences and even seeing patients.

While physicians tend to focus on achievements and technical difficulties, it is equally important to understand what your image and performance is and if that matches what the company believes a leader should be. Competency and confidence would go hand in hand. But maintaining integrity, Mike, is equally essential. It is critical to have that balance. Be sure not to over-promise and under-deliver. At the same time, if you over-deliver then you have spent a lot of time on a project that you should not have.

Women tend to balance as much as men. I am a daughter, I am a sister, I am an aunt, I am a sister-in-law. Similarly, men are husbands, brothers, fathers. As physicians, we have had long careers, and we have learned to balance our lives. Now, work-life balance is applicable to everyone as we climb this leadership ladder.

Sacopulos: You are correct, and that is not always easy to get the right balance, but you certainly hit on a very important topic there. Let's move on to skills that you believe physicians need to acquire in their career. Are there some specific skills to which you can point?

Agarkar: I know that I was looking forward to some kind of mentorship or knowing what the key aspects in physician leadership are. And I feel like there are three important leadership skills that early-career physicians should know very early on in their careers. The first is about relationships. Now physicians, Mike, are the most technical people, and one might think that talking to people or forming relationships is interfering with the tasks that I must complete for the day. But for me, I quickly realized that my first phone call in the morning or my quick stop at my director of nursing or social work director's office was going to lay the picture for my entire day.

More recently, Mike, there has been a lot of talk about wellness-centered strategy, and it is the most difficult leadership style. Changing culture takes time and it can take its own toll. However, leaders must continue building relationships and changing culture. You know as they say, that culture eats strategy for breakfast. This is an important message for early-career physicians as they might gravitate towards focusing on strategy alone.

Now, the second part, which is equally important besides relationships, is accountability. Now, I belong to an organization for many years before climbing into this leadership role. And holding staff accountable can be a difficult task as physicians and especially women take on their first leadership role. For me, it was working through AAPL or going through the certified position executive program. It helped me build my leadership skills. I also received coaching internally from my organization, my supervisor who is currently the vice chair. I quickly learned that setting clear expectations, monitoring their progress, and at times reviewing outcomes or what success and failure would look like for them, helps physicians understand what they need to improve and how they need to improve that. It is important that we are clear and consistent in our message.

And lastly, leadership is about trust, empathy, and active listening. We all have heard this in the many, many talks or podcasts to which we have listened. As leaders, we must keep our checks and balances. Once I was supervising a young male physician and we were talking about policies and he said, “I don't need guidelines or policies, I just want to feel supported.” The art is in listening to people and then asking a thoughtful question. I must say that for me, Mike, it's still a work in progress, but I do very strongly believe that trust and empathy are both tangible and practical.

Sacopulos: I think you are absolutely correct, and maybe it is always going to be a work in progress for all of us. Leadership seems to me to be potentially different in healthcare than in other industries. Do you agree with that, and if so, maybe you could give us your thoughts.

Agarkar: It is different, leadership and healthcare. We are in a culture which is built on the science of medicine, and behavioral skills are often seen as too subjective and difficult to measure. Physicians and physician leaders have been functioning in silo, so do not appreciate and understand the relationship aspect of leadership. Compared to other industries, healthcare is heavily regulated. There are new demands for quality of care, and there is an unprecedented speed in which innovation and technology asks for clinical analytical assessment to move at a pace which is so fast that we can barely catch up.

As early- and mid-career physicians start rising to leadership level, this could be a complex and difficult landscape to navigate, and this is why we are here to help people understand the importance of getting physician leadership skills early on in their career.

Sacopulos: I would like to move to meta-leadership. Can you describe the concept of meta-leadership to me?

Agarkar: When I came across this concept, I was very fascinated by that, and it certainly struck me that this is exactly what we have been doing or is essential in this day and age as we try to manage complex healthcare organizations. The organizations now are more oriented towards interdependence. It is more of an enterprise-wide view of what we do. Leaders need to expand their thinking beyond the formal boundaries of authority.

The whole metric, if you think about meta-leadership, it is all about people following you. Whether it is some subordinates people outside your organization, it could be your peers, it could be your boss. Again, it is all about relationships. You see, Mike, the stakes in the healthcare industry are very high. Some decisions are about life and death, and decision-making plays a pivotal role. Those of uncertainty sometimes help us because it counterbalances our overconfidence that we have sometimes as physicians. So, balance between empathy and decisiveness is important.

The bottom line is that leaders in today's healthcare system will be navigating a lot of turbulence and change, and this might be particularly challenging for early-career physicians or women physician leaders. The whole concept of meta-leadership perspective allows a leader to see a larger system, including various opportunities where you can link your expertise, your resources, and your innovations. Now, one doesn't need to belong to a large organization like I do, but you can always cross boundaries and look at other organizations and involve innovations and resources and expertise from them.

The concept itself of meta-leadership makes it easier to generate the unity of mission and purpose while we enable the necessary freedom of action through the enterprise. So, this is all as physician leaders, we are doing, it may be just a different viewpoint that we need to have as we continue our path in leadership.

Sacopulos: Well, that is certainly helpful. As our time together comes to an end, I would like for you to talk about emotional intelligence and how it impacts the practice of medicine.

Agarkar: There isa lot of talk about emotional intelligence. It is extremely important that as people say, having an EQ is equally important or at times more important than having an IQ. There are four major components of emotional intelligence, which have been talked about multiple times, self-awareness, self-management, social awareness, and even relationship management. Now, without going into too many details about the definitions, I would like to talk about practical stuff.

As physicians, we want to predict, confirm, and understand our patient's experiences. However, in a leadership role, we don't know what is going to happen next, and that will only make us more fearful. It invites more anxiety and more worry. But to me, it feels like it is okay to feel all these complex emotions as you go through your transition period. Being aware, that's a part of the self-awareness of emotional intelligence, it is extremely important, and that is the first step in improving emotional intelligence.

In it there is a subset where one needs to figure out whether they are micromanaging or macromanaging, and especially for young leaders, young physician leaders. It took me some time to step away from my previous clinical duties, and as early-career physicians might struggle with making that transition. As a physician leader, you need to look at the macro picture, the big picture. I truly believe that you must be able to give direct, honest, and clear feedback to your employees, and then they will perceive it well.

One of the most important things in emotional intelligence is managing stress. All of us react very differently to stress. Both men and women are taught very early on to create equity in relationships. So, when you are negotiating with someone and you feel like you are taking something away from them, it feels like it is almost a violation of a social contract with which you were raised. However, successful leaders will need to have courage and confidence and at times make decisions which are hard and complex.

Now, I know that I need to work on this every day, but every small decision that we make by ourselves is valuable. So, my take home message would be as a leader, one needs to be empathic and vulnerable, but also to be decisive and confident to take the risks.

Sacopulos: Excellent. I will let that be the last word. My guest has been Dr. Smita Agarkar. Thank you so much for speaking with me today.

Agarkar: Thank you, Mike. I just want to conclude by saying that 2025 is going to be an exciting time for all the physician leaders as they try to improve and lead organizations. And my organization recognizes my efforts and offered me the opportunity, yours will too. I would just say that just stay focused and do not miss any opportunities that come your way. Thank you for having me.

Sacopulos: Well said. Thank you so much.

Listen to this episode of SoundPractice.