13 Leadership

You have probably heard the conventional wisdom that “some people are born to be leaders.” While there is some evidence of a potential genetic component to leadership, I choose to agree with Vince Lombardi who once said, “Leaders aren’t born, they are made. And they are made like anything else, through hard work.”

While a few people have innate leadership tendencies, most people develop their leadership skills through intentional learning and mentorship. With a supportive and nurturing environment, I believe anyone can become a leader if they are motivated to learn how to lead. Observing the selection and subsequent maturation of chief residents in our Department over the years has confirmed this hypothesis and enhanced my understanding of the attitudes and attributes of effective leaders.

In some Departments, chief residents are chosen by the Department leadership without resident input. In contrast, chief residents in our Department are selected each year by their peer residents through confidential voting. We opted for this format of selection because it empowered our residents to have self-determination in the future of their program and gave our chief residents immediate credibility among their peers. While it is an honor to be selected to serve as chief resident in the final year of residency, it can be challenging, as it requires chosen residents to transition to a leadership position in the Department. Chief residents are given the responsibility to serve as a liaison between Department leadership and their peer residents, identifying administrative, education, and professional issues that need to be addressed. A few residents who have been selected to serve as a chief resident have turned down the opportunity after considering the challenges associated with the position and the required time commitment.

I had been serving as the director for the Department’s residency program for a couple of years when one of my favorite cohorts of chief residents had just been selected by their peers. I was still learning to navigate the complexities of being a program director, which included guiding the program though the requirements of the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Anesthesiology (ABA) and updating the curriculum and lecture series. At the time, three chief residents shared a space with our program coordinator, which was adjacent to my office. The five of us comprised the entire program and education leadership group for the Department. It is notable there are now approximately twenty members of this working group, including three chief residents each year.

I had worked with each chief resident during their required rotations at our children’s hospital and was excited each had been selected, a result indicative of the respect they had earned from their peers. Our first meeting following their selection provided me a preview of perhaps my most impactful year serving as program director. One of the chief residents opened the discussion by saying, “Dr. Cox, we want to help you improve our program. We have several problems we think need to be addressed. We also have some ideas and solutions.” They were obviously well-prepared for the meeting, as each chief took turns covering the list of problems accompanied by thoughtful insights as well as suggested solutions. I made detailed notes, added my perspective, and asked follow-up questions. Each chief also asked me questions about faculty viewpoints surrounding several issues. I was impressed.

One of the prominent problems highlighted was a small group of residents the chiefs described as the “malcontents.” I was initially surprised that the chief residents started by focusing on a professional issue involving fellow residents rather than on supervising faculty, administrative leadership, or the quality of resident education. I had an inkling there was some discontent from prior discussions at our resident forums. When I asked if I should meet with each of these residents to provide counsel and initiate some form of remediation, the consensus response was “Let us try to handle this first.” We ultimately determined that highlighting residents who were making positive contributions to the program and Department was a more constructive strategy than focusing on the negative behavior of a few. Over the course of a few years, there was a noticeable positive change in the culture of the program. The chief residents led this effort.

Over the course of any academic year, each chief resident evolved as a leader and became a more confident and adept problem-solver. On reflection, I gained perspective and became a better program director working with each group of chief residents. I hope each chief resident benefited professionally from my mentorship. Many former chief residents have shared that their year serving as a chief was one of the hardest yet most rewarding years of their professional careers. It is personally gratifying that the three chief residents of that enterprising group all currently hold senior leadership positions in their respective Departments. I still agree with Vince Lombardi that leaders are made through hard work and a commitment to learn how to lead.

Physicians serve as leaders in their practices and communities. For some physicians, they will ascend to more formal leadership roles in their departments, hospitals, and institutions. Becoming a trusted leader begins with serving as a role model for professionalism, maintaining objectivity, taking the high road when dealing with negativity, and being supportive of colleagues by creating a safe professional environment. Leaders earn the trust of both antagonists and protagonists through positive engagement and resolution of conflict in a collaborative manner.

Medicine is unique compared to most other professional fields given the length and rigors of training as well as the stresses associated with medical practice, including long hours and the requirements for continuing education. It has also been said that it is easier to herd a group of cats than it is to lead a group of nurses and physicians.

There are certain attributes that are desirable for a role model and leader, which you should keep in mind as you look for such people to learn from. The most positive and transcendent attributes are empathy and sociability. These attributes enable leaders to understand others, influence them to implement change, and lead a dynamic organization of highly motivated professionals. Leaders are often identified by their adept social skills and ability to serve as peacemakers when there is conflict. The above narrative describing the selection of chief residents in my Department highlights how leaders are sometimes drafted by colleagues to serve in leadership roles after they have distinguished themselves among their peers.

.

Figure 1. Desired attributes of a confident leader

Professional behavior and trustworthiness with adherence to ethical standards of conduct and medical practice are minimal requirements for a leader in medicine (Figure 1). I have covered the topic of developing trust in your decision-making, which is a core attribute of a confident leader. As a leader, you must remain objective and adopt an analytical approach to your decision-making free of emotion or cognitive biases (see Chapter 11). Effective leaders are also willing to listen to others and are collaborative, seeking innovative solutions to problems. Trusted leaders of organizations are ultimately supportive of colleagues and provide a work environment where ideas are expressed without fear of harassment or retribution. Effective leaders are also committed mentors and support the development of future leaders in their organization.

It is inevitable that you will encounter negative contemporaries in the workplace. Developing the confidence to step back and reflect upon people and situations that are distractions, that foster self-doubt, and that move you farther from your core values and career objectives will be important for your overall well-being and career development. You should continue to support colleagues who face adversity as your own career evolves and you take on leadership positions. When there is a hierarchy in the workplace, it is especially important for leaders to address negative behaviors in a firm and transparent fashion to maintain an environment where the importance of safety is evident to everyone.

Over the years, I have found that if someone is disruptive, it is best to address the negative behavior in private once the acute episode and resultant emotions have subsided. Disruptive colleagues are unlikely to respond in a receptive or positive manner if challenged in front of their peers. I have also found that colleagues who engage in disruptive behavior often lack self-awareness and are not willing to consider different points of view. Cognitive rigidity can be a fixed personality trait and therefore very difficult to address or remediate as the event unfolds.

Figure 2. Algorithm for conflict resolution

If asked to intervene, you should perform a preliminary analysis of a conflict, identifying the involved parties, including protagonists and possible antagonists (Figure 2). An initial analysis often starts with interviewing people who are not the principals and have knowledge of the relevant issues and have perhaps witnessed an incident. Third parties who are not stakeholders can provide more objective perspectives with fewer cognitive biases. Resolution of a conflict ideally embraces the adoption of a composed and nonjudgmental approach to the situation that encompasses all viewpoints.

Engaging the parties in a professional discussion of the issues once emotions have subsided will allow you to guide discussion calmly, making it more possible to arrive at a mutually agreeable resolution to the conflict. Remaining objective provides the opportunity to mediate conflict among colleagues who have divergent points of view. Maintaining neutrality and empathizing with all parties gives an arbitrator credibility regarding their ability to mediate conflict fairly. A component of maintaining neutrality is recognizing when a personal or professional relationship or a history of prior conflict with one or both parties will make it difficult for you to provide objective counsel. In this event, it is appropriate to bring in another colleague to facilitate discussion.

If future disagreements are inevitable because the current disagreements have only been partially resolved, you may find it expedient to schedule regular meetings to reach a deeper understanding of the issues and find a solution to prevent recurring conflict. The goal is to seek resolution to a conflict that is definitive and sustainable for all involved parties.

Effective leaders support colleagues, which on a broader scale creates safe environments where differing points of view are welcomed. Trusted leaders are also thoughtful counselors and healers who focus on finding permanent solutions to professional conflicts.