Growing Physician Leaders

Empowering Doctors to Improve Our Healthcare

Mark Hertling

• Publisher: AdventHealthPress
• Year: 2020
• eBook ISBN: 9780999698389
• Edition: 1
• Topic: Business
• Subtopic: Pharmaceutical, Biotechnology & Healthcare Industry
• Index: Business

Can a general teach America's doctors to be better leaders?

Hospitals, clinics, and healthcare organizations across the nation are wondering, "Can we transform healthcare by improving physician leadership? And if so, how?" Healthcare today faces both daunting challenges and exciting new possibilities. Physicians hold the key to improving healthcare, but while they enjoy exceptional training in the science of medicine, the vast majority of doctors have received little training in even the basics of leadership.

In Growing Physician Leaders, retired Army Lieutenant General Mark Hertling applies his four decades of military leadership to the world of healthcare, resulting in a profoundly constructive and practical book with the power to reshape and reenergize any healthcare organization in America today. Designed to help physicians master the art of leading people, it takes them, step-by-step, through a proven process that can help anyone become a more effective leader.

Growing Physician Leaders gives doctors a potent tool to improve their personal health, their professional health, their organizational health, and ultimately, our nation's health.

Chapter 1

Why Physicians Need to Lead

Many people are under the impression that leaders are born, not made.

It’s not completely true.

For decades, I watched as young soldiers learned the intricacies of leadership and then went out and led others effectively in all sorts of challenging environments. While one person might have more natural gifts as a leader, the fact is that really good leaders are made, not born.

And that includes physicians.

But why should physicians want to become better leaders? Why add one more responsibility on top of all the others they already possess? How can learning the art of leadership help them, their patients, and their organizations to thrive?

The Challenge of the Triple Aim

Many doctors may feel tempted to think, Why should I spend a lot of time interacting with a patient, a patient’s family, or other members of a healthcare team, when I could be putting in extra effort honing my skills and techniques? Shouldn’t everyone simply understand that the important things are my board certification, my title, the knowledge I’ve amassed from so much training, my appointed position in a practice or in this hospital, and my curriculum vitae? Armed with such a mindset, many doctors see leadership skills as nice to have but secondary to their practice of medicine.

And in fact, from the beginning of their training, physicians are taught to focus so strongly on the science of their profession—how to fix problems and make people better—that they often don’t pay as much attention to the art of interpersonal relationships. As someone who has been tasked with leading tens of thousands of men and women through life and death situations, however, I know that cultivating such relationships and building trust with others is the very essence of leadership. And during a time when healthcare faces a host of growing challenges, it is an absolute requirement.

Physicians, hospitals, and a variety of healthcare organizations rightfully worry about how we as a nation will address the elements of what is commonly known as the Triple Aim:

1. Increase access to healthcare for all demographics.
2. Reduce costs associated with medical expenses.
3. Improve care for patients and populations.

While the daunting challenges connected with the Triple Aim are worth a book in themselves, let me sketch out two of the biggest issues related to physicians and leadership.

First is the distance of physicians from leadership (i.e., policy- making) roles. In this country we have, and will continue to have, negative trend lines linked to deteriorating health conditions, such as obesity, diabetes, complex care issues for the aged, behavioral health concerns, and a plethora of other issues related to acute care.¹ While doctors are on the front line of this battle defending against disease and finding ways to improve care and access, physicians often find themselves disconnected from the policies and procedures that help accomplish the Triple Aim. Why this disconnect? Often, physicians don’t get included—they don’t even get a seat at the table—because those in charge don’t see them as leaders.

Second is the issue of finances. The financial challenges our nation faces in healthcare resemble, in many ways, the difficulties we face in the arena of defense spending. While both are linked to national security and a concern for our future economic well-being, I suspect most Americans believe the Department of Defense far outpaces healthcare on spending, as a percentage of gross domestic product (GDP). But in fact, the percent of our GDP spent on healthcare dwarfs the amount spent on national defense. According to the World Health Organization, total healthcare spending in the US was 17.9 percent of GDP in 2011, the highest in the world.² The Health and Human Services Department expects that the health share of GDP will continue its historical upward trend, reaching 19.5 percent of GDP by 2017.² In effect, the percentage of our GDP linked to various aspects of healthcare is almost five times what our nation spends on defense, which continuously and historically hovers right around 4 percent.³

Since physicians know in detail many of the critical issues related to our nation’s health, they are the ones best positioned to contribute to providing workable solutions to address and solve these challenges— if they learn to effectively lead. Today, however, physicians are mostly removed from leadership roles. While they provide excellent care to patients in treatment facilities and operating suites, they often do not provide needed input in regard to strategic vision and organizational direction. Most hospitals in the US have nonphysician managers as their chief executive officers, with one report claiming that physicians led only 235 of 6,500 hospitals in the nation.⁴

Physicians must play a more significant role in the tactical and strategic running of our healthcare institutions. This will occur, to everyone’s benefit, as our doctors gain the leadership skills they need to better relate to one another and to other healthcare professionals and administrators. Our physicians rightly want a seat at the table, but in order to gain that seat, they must first learn the required “table manners” associated with leading others, leading teams, and building effective and efficient organizations.

A Lesson from Sun Tzu

One of history’s great military theorists is the Chinese general and philosopher Sun Tzu. His insights are preserved in the great work The Art of War, which somehow found popularity in corporate America in the 1980s. After his name got mentioned in several popular films, business executives began citing his work, often taking his quotations out of context and applying his philosophy to competition strategies, market approaches, and methods of building organizations ready for any challenge. Most leaders in the private sector these days are aware of the classic work, and even of Sun Tzu’s words, but often don’t adequately apply the philosophy.

The military takes Sun Tzu’s words and puts them into action, especially one of his primary dicta, employed at all of its training centers: “Know the enemy, know the terrain, and know yourself; in a thousand battles you will never be defeated.” In the army, we took a systematic approach to addressing each of those critical issues to help us prepare for victory.

Shortly after I arrived at AdventHealth Orlando, I was asked to take a look around the organization and give my assessment of what the hospital needed to do to grow physician leaders. I had begun to learn something of the national challenges doctors face in becoming better leaders, but my new employer wanted to get a retired general’s perspective on the state of its own physician leaders. I therefore agreed to observe the practices, the clinics, the physician lounges, and the healthcare teams as they executed their work on the eight campuses of AdventHealth Orlando, and then present an analysis as to what we could do that seemed both helpful and possible. In Sun Tzu’s parlance, I wanted to get a good idea of ourselves (how the physicians led), the terrain (the hospital and healthcare environment), and the enemy (what was preventing doctors from becoming better leaders). How did we function as leaders, and how did we view ourselves as leaders, based on the environment? Any healthcare organization considering a leadership assessment could greatly benefit from such an approach.

I quickly found that each of the eight campuses of AdventHealth Orlando has its own personality, designed to serve unique and varied patient demographics and run by very different administrators. Some facilities have large medical staffs, others have much smaller ones; some hospital administrators are hands-on and centralized, others have a more decentralized approach.

The system has what some term a “hybrid medical staff,” with contract physicians, contributing physician groups, hospitalists, and private practice physicians. While some physicians practice primarily at or near one of our campuses, others travel between hospitals. The system has many superb “permanent” teams, some ad hoc teams, and a few teams that many would call dysfunctional. After a three-week assessment, I determined several things.

First, AdventHealth is a values-based, learning and growing organization. Its stated mission to “extend the healing ministry of Christ” is clear and well understood. Its vision—becoming a world-class organization that continuously addresses healthcare’s Triple Aim of increased access, reduced cost, and better care—appears to contribute to continued improvement and innovation. I observed an excellent connection with the community and noted high patient engagement evaluations. I saw many talented and dedicated physicians, and I sensed a strong desire for constant adaptation in caring for our patients and their families.

On the other hand, while I observed extremely well-skilled and highly competent doctors, I didn’t see enough of them leading. On too many occasions, I watched them fail to communicate effectively with team members, with patients, and with patient families. Many displayed a distrust of the executive staff, and the majority appeared to have little idea how to build strong teams. I observed a few examples of toxic leadership behavior and heard a few stories from nurses about doctors throwing tantrums in the operating room or of unprofessional dialogue with workers and inappropriate behavior when asked to perform coordinating tasks.

(I later learned that our conduct review boards often handled cases like these. And I learned that most hospitals struggle with the same issues.)

In speaking directly to a variety of healthcare professionals, including doctors, clinicians, and administrators, I discovered that most used but could not accurately define the key terms of management (systems and control processes) and leadership (methods of engaging people to voluntarily work together to achieve organizational goals). In fact, I found no clear understanding or definition of leadership or of how good leadership could contribute to organizational excellence.

My research and analysis led me to conclude that although the hospital wanted true leadership training specifically for physicians, such training did not seem to exist. While nearly everyone I spoke to had expressed a desire for effective training to help physicians become better leaders, no one seemed to know where to find it.

Additionally, I discovered that, in many cases, physicians were not considered a part of the official healthcare team, which meant they often got overlooked for management and leadership training courses and opportunities. In other words, the hospital not only lacked good training opportunities, but our physicians often expressed frustration at getting left out of the formal professional development programs offered to clinicians and administrators (usually through the human resources program). It’s tough to ask physicians to take on more leadership roles when they have few processes, systems, or training opportunities to prepare them for leading.

Finally, I discovered that while the hospital sometimes sent physicians to various seminars described as leadership courses, whether at universities or outside groups, these classes did not happen in systematic ways, did not provide a program that understood our culture or was applied directly to our situation, and did not appear to have a lasting effect on the organization.

As I wrapped up my assessment, I couldn’t help but note that the military uses a very different model to choose and equip its own leaders. Officers and noncommissioned officers (the “sergeants”) receive ongoing education on leadership principles and theory, along with increasingly technical skills training associated with their specific job requirements. From the beginning, a young second lieutenant or sergeant learns the basics of leadership attributes, competencies, styles, and techniques. While added rank and increasingly complex assignments might bring more difficult leadership challenges, the leadership “basics” remain unchanged, even as they get applied in different scenarios.

The military education system, with its focus on leadership fundamentals applied at each level, allows individuals to grow professionally and personally in their leadership abilities. After graduating from these various courses, military leaders are required to engage with others, build teams, develop their people, and succeed with their particular organization in each successive operational assignment. When soldiers aren’t learning leadership in schools or practicing the art of leadership in their organizations, they are expected to participate in continuous self-study and self-assessment.

As I pondered the differences in leadership training between what I’d experienced in the military and what I’d seen in healthcare, I realized my new challenge required me to sharpen exactly what I meant by “leadership.” In the army, we lived and breathed its principles every day; but in my new environment, how could I hope to improve the general level of leadership of our organization if many of my students didn’t even share a clear concept of what it was and what it involved? And so I began to refine how to describe “the ideal leader.”

What Does the “Ideal Leader” Look Like?

A few years ago, I participated in a conference at West Point designed to gain consensus on the elements of leadership, in preparation for republishing our service’s leadership manual (known as Army Doctrine Reference Publication, or ADRP 6-22).⁵ Some of us more senior folks kiddingly called this conference a SEE, or Significant Emotional Event. We knew what we would be discussing and how it applied, but the event was necessary to start gaining consensus and enforcing our cultural understanding of leadership.

Over the course of a few days, and in deep discussion of the profession of arms and the leadership requirements of that profession, many attendees refined their view of the ideal leader. After the conference, I could succinctly and accurately understand and define the term “leadership” as used in the army.

A practical reason lay behind this conference. After almost ten years of war in Iraq and Afghanistan, our chief of staff, the top general in the army, felt troubled by the conduct of some of our officers and soldiers. A few acts of indiscipline and misconduct in the ranks had become public knowledge, along with a few similar incidents among our senior leaders. The Abu Ghraib scandal and a few embarrassing sexual dalliances involving senior leaders appeared to be anomalies; but as an organization, we needed to ensure that we reframed the fundamentals of appropriate army behavior and values.

The chief wanted his senior leaders to review the elements of the profession of arms and then come to a consensus on the role army leaders play in ensuring that the organization meets its own standards, serves our soldiers, and serves our nation. A variety of army senior leaders, professors of military ethics and leadership, and retired general officers (those we call “gray beards” due to their knowledge and reflections) participated in this unique event.

Like all good soldiers, I always kept a green notebook nearby, which I had with me during this conference. In the army, these ubiquitous notebooks contain our notes on assigned tasks, missions, and information from critical meetings that need to get passed along to subordinates. “A short pencil is always better than a longer memory,” a sergeant once told me as a young lieutenant.

These notebooks always have a section that most use to jot down provocative thoughts. I enjoy periodically reviewing my old notes, because I usually come across something interesting. So before I began designing the Physician Leadership Development (PLD) course for our physician leaders, I thought it might be a good idea to dust off this particular notebook and review what I had learned at this conference.

As soon as I opened it, I saw one especially striking entry. It suggested that one needed to define the ideal before trying to define the attributes and characteristics of leadership. I read the following:

An ideal leader has a strong intellect, a physical presence, a continuously developing professional compe...

Table of contents

• Cover
• Copyright
• Contents
• Foreword
• Preface
• Introduction
• Chapter 1: Why Physicians Need to Lead
• War Story: The Wall Street Journal Test
• Chapter 2: On Being Called a Professional
• War Story: Private Green and Knowing Yourself
• Chapter 3: Values and Great Leaders
• War Story: Lessons for a Young Lieutenant
• Chapter 4: Dyadic Leadership: Leading One before Many
• War Story: Leaders Don’t Have the Right to Have a Bad Day
• Chapter 5: The Art of Leading Up
• War Story: When You Start to Feel Overwhelmed
• Chapter 6: Building Trust in Different Kinds of Teams
• War Story: Overcoming “Insurmountable” Challenges
• Chapter 7: Those Idiots at Higher Headquarters
• War Story: Take Us Down the Right Path
• Chapter 8: Becoming Physicians Who Transform Healthcare
• War Story: From “Before” to “After”
• Epilogue
• Acknowledgments
• Notes
• About the Author
• About the Publisher
• Resources