Ruth Adewuya, MD: Hello. You're listening to Stanford Medcast, Stanford CME's podcast where we bring you insights from the world's leading physicians and scientists. If you're new here, consider subscribing to listen to more free episodes coming your way. I am your host, Dr Ruth Adewuya. This episode is part of the hot topics mini-series and today we are having a conversation about physician leadership. In today's conversation, I am joined by Dr Daryl Oakes. She is the associate dean for Post-Graduate Medical Education and a clinical professor of anesthesiology, perioperative, and pain medicine, as well as the program director for the Adult Cardiothoracic Anesthesia Fellowship in the Department of Anesthesia at Stanford University School of Medicine. Also joining me is Dr Rania Sanford. She is the director of Faculty Professional Development in the Office of Academic Affairs and an executive coach. In addition to executive coaching, Rania's practice areas include developing faculty professional development programs at the School of Medicine and working with unit leaders on strategic initiatives and planning. Welcome, and thank you for joining me today.
Rania Sanford, EdD: Thanks for having us.
Daryl Oakes, MD: Thank you.
RA: Daryl, can you start by telling us about yourself and your current role as it relates to this conversation?
DO: Well, as you mentioned, I am the associate dean of the Stanford Center of Continuing Medical Education and Post-Graduate Medical Education, and in that role, I've become very interested in ways we can help physicians improve their practice throughout their clinical life. I think that what my other role is, as a cardiac anesthesiologist and in my clinical environment, we work in a very complex team, which is true for a lot of physicians and a lot of physician teams and the awareness that leadership is an important part of my ability to take care of patients is been highlighted by my everyday work, and I think this is becoming increasingly true for physicians in every part of the health care system as we work with more complex and more multidisciplinary teams. I think this is becoming a very critical issue that we need to address.
RA: I turn to you, Rania, to maybe talk about your work as an executive coach, but in the context of the medical school.
RS: Thanks, Ruth. Just out of recognition by Stanford's leadership, the dean and the vice-dean that these areas of skills are not often addressed in medical training, my role functions in that space where I support the faculty development, both physicians and basic scientists, in the capturing where they would like to go in their careers and what kind of skills and competencies they'd like to develop, so as a coach, I provide that space for a faculty member to come in as a client, reflect and talk about topics that are relevant to those areas of career advancement, interpersonal dynamics, their career priorities, or other priorities they'd like to think about, and then the process behind the coaching conversation makes those conversations clarifying and the conversations often shed new light on whatever topic is at hand. This increases awareness on the part of the faculty member and then they take ownership then in the process to set their own goals and the direction they would like to go in developing those skills.
RA: Daryl, why is leadership education necessary for physicians?
DO: I think that's a great question. I would say all physicians, just simply by the nature of our work, play a leadership role in their clinical care teams. Increasingly, as physicians, we are interacting and leading more and more complex and often multi-disciplinary clinical teams and the skills that are needed to do that are not explicitly delineated or taught in medical training, and yet for our internship year of clinical training, physicians are expected to manage complex communication and decision-making between patients and families, as well as between other medical staff. They're also given responsibility for management and supervision of junior colleagues and trainees, and because we're in a hierarchical structure in our medical training systems and our medical systems, as you move through these systems and move up through the training programs and on into your clinical practice, you assume more and more responsibility and you're responsible for managing more and more people and there is no clear opportunity to make sure people have demonstrated competencies and leadership skills.
DO: The consequence is if you are doing this well, that's fantastic, if you are not doing this well, you can have a big impact, and maybe a negative impact, on the people that you work with. We've talked a lot about burnout in our field, but burnout can be related to poor management and having a stressful manager, and so whether or not we can address some level of burnout in our position by having better structures of management may be an important area to explore.
RA: Why the focus on physician leadership or leadership education right now? What has changed or is changing in the health care landscape that has really caused us to take a look at the training around leadership for physicians?
DO: I think as you've mentioned, there have been numerous studies that have demonstrated that having physicians in health care leadership roles has really been important in many organizations to making improvements in quality measures and patient outcomes and even creating value-based cost savings. I think having physicians leading in these environments I think is critical to providing a way to maximize the patient quality aspects. I think physicians are uniquely positioned to understand the impact of organizational decision-making on patient care, so having them involved in these decisions while they're also connected directly to clinical care is really important, because otherwise, organizational decisions that sound good and may be good for the organization from one aspect have other unintended consequences that aren't seen, and I think that is why having physician leaders making these decisions, involved in these decisions, and influencing these decisions, are going to actually be able to allow us to provide better care.
Our care systems are becoming more complicated and complex. I think back in a time where it was just a physician in their office with their patients, it was a very different environment, but now, most physicians work in very complex hospital-based or organization/institutional-based medical systems and these systems have a lot of factors that play into how care is delivered, and I think for physicians to better understand those factors so that they can be part of creating the right solutions, I think, is really important.
RA: COVID perhaps highlighted this a little bit for us where clinicians have been having to not only play a clinical role, but a leadership role within their health care systems, as well as in communities and even in government. It seems like we have physicians in those roles, but we've not really spent as much time getting them trained.
DO: COVID is an excellent example of how physicians have had to take on these roles in very explicit ways. I think there was no understanding of the infrastructure that was needed at times. The infrastructure that was there at some places, particularly at times in New York, completely unraveled and needed to be recreated and it provided physicians an opportunity to step in very quickly to allow for this pivot, allow for the patient care needs to be addressed without the middle persons of organizational decision-making and a lot of decisions got made much more quickly and much more directly to affect patient care delivery. I think that that was a wonderful opportunity to demonstrate the value of integrating physicians into decision-making at all levels and I think it, hopefully, will be playing out in more ways as we go forward.
RA: And I would add that in the COVID scenario, the folks that have been involved in leadership and have been thrust into leadership roles have really been beyond the people that are C-suite. That's what we're seeing. Would you agree with that?
DO: As an anesthesiologist, I think I have a interesting perspective on how physicians can pull into new roles, especially in COVID, how a lot of anesthesiology teams took leadership roles in creating new care units. The ORs in many centers turned into impromptu intensive care units. Skills that had been utilized in the setting of the operating room were transferred into a new environment, innovations in how to ventilate patients, how to provide care in these unique settings were made by physicians, safety measures were initiated or explored or researched in these settings, and these were done by the level of care-providing, not at the institutional levels. It was interesting to watch how we've had to combine previous systems of quality and safety measures or institutional decision-making and change for policies. They collided and had to match with the need for rapid decision-making and input from all levels of the care teams and I think that was a wonderful development and hopefully we will find ways to integrate those opportunities going forward.
RA: What are some of these key skillsets or attributes that you feel are important and maybe drawing on your own personal experience as well?
RS: There are certain skills and knowledge areas that are often strong predictors of success in leadership, and one of those areas are emotional intelligence, which is a construct that captures a lot of skills that important for effectiveness as leadership. The model I like to use for emotional intelligence is one that was developed by Reuven Bar-On and he brings together 15 skills that enhance emotional and social functioning and he associates them with wellbeing overall, which is a very hot topic for physicians given the extent of burnout and retention that we see within medicine.
RS: The ones that I've seen pretty clearly in my work with physicians directly were the concepts around self-regard, self-awareness, assertiveness, flexibility, and empathy. These are some of the 15 that make the bigger construct. In my coaching work with faculty, I've seen them to be, these areas, these five or six skills within the bigger bucket of EQ, or emotional quotient, is these are the ones that make the capacity there in those areas, is what demarcates a physician leader from a non-leader.
I think there are dispositions that I think physician leaders ought to embrace in order to be successful. One of them is appreciating the fast-paced changes that drive a business model in providing health care. I think many physician leaders come in with very strong healing and caring sensibilities as physicians, as doctors. That's their purpose, right? But coming in into a leadership role where there has to be some other types of decisions made using other criteria and developing that business sensibility, I think, would be quite important, if anything, to be effective, to be a strong advocate and to be able to communicate with the non-physicians in that ecosystem at that level.
DO: I think the important skills includes communication skills. We often think we are being understood and we think that what we're saying is being received in the way we intend it to be received. I think that to understand that different people hear information, acquire information, and process information in different ways is a crucial thing to understand when you're trying to motivate people and teams in different behaviors. I think that communication is a critical skill. I think management skills, we often focus with leadership on the sexy parts of being a leader, inspiring and leading and that aspect of it, but I think that what often makes really excellent leaders are leaders who have good management skills, so how do you manage people? How do you align what their goals are with what your goals are? How do you help change behavior? Those are all critical skills to being effective in our environment and effective leaders.
RA: Has your coaching work and your work with physicians changed in the midst of the COVID-19 pandemic? What have you seen have been areas of challenges that have been faced by physicians in their roles as leaders?
RS: That's a great question. I think if anything, COVID was a clarifying moment for a lot of physicians, if not for more than just physicians, but for physicians, especially, and for women, and I think it was clarifying for individuals to sit back and think about what's important, so that was definitely a moment of pause and stepping back and redesigning the path, I think, for many people. But I think it also was clarifying by bringing to the forefront the challenges that women physicians face, as women, broadly speaking, during COVID, had to bear the brunt of care at home for children, usually, and others and their families.
It brought to light the inequities that we have in the work design around careers and the way we think of work and how we define productivity, so I think these moments are actually opportunities also for leaders, physician leaders, and leaders in our health care system to think about and maybe see differently how and who does the work of physicians and think about designing career paths that allow for not just a longer runway of long careers of 50 years now, people are actively working, but also life stages, so it brought up the values and the importance of values to drive our decisions and how we design our environments.
RA: How can leadership training solve for some of those challenges that you mentioned around women, or even taking a larger step back, when we talk about diversity, equity, inclusion, and belonging, is there a role for leadership training to have an impact on that?
DO: Yes, but I think as we're becoming increasingly aware that many of the assumed structures and systems within the medical environment, as we're seeing how there are disadvantaging certain groups of physicians, and as Rania alluded to, particularly women, but also physicians from underrepresented racial and ethnic groups, I think it's imperative that we train all of our physicians, but specifically, and importantly, physicians who end up in structural leadership positions to recognize these disparities and challenges of these physician groups. Educating physicians about how their personal and interpersonal behaviors might impact how they lead teams and decisions they make, and now, in addition to having these leaders have a broader understanding, I think providing skillsets to these physicians who are from underrepresented groups, or are women who are navigating these complexities, providing them with additional skillsets so they can be successful in these environments is hugely important, and I think will help us level the playing field. It will help us create better diversity in our medical practices and in our leadership.
RA: As we wrap up our conversation, I have a question for each of you around what advice would you give to a first-time or aspiring leader in health care? I'll start with you, Daryl, and then go to Rania.
DO: I think my advice would be that you can be a leader and it can look like a lot of different things, but there's some critical skillsets that you can develop that will make you more successful and I think that we have a tradition of having leaders look a certain way and I think that we need to open the door to say leadership can have a lot of different elements and you can look a lot of different ways, you can have a lot of different skillsets you bring to it, and styles, but that there are still some really core principles that will make you more effective in lots of different environments, so I would just want more people to step into these roles, embrace their leadership potential, recognize that they can make a difference. They also can get done what they want to do and what they're doing is leadership. I think oftentimes people shy away from that title, thinking that, “Well, I'm just here to get the job done,” but I think getting the job done sometimes takes leadership skill.
RS: If I were to distill everything into one piece of advice, I'll share a couple. One is to be curious and flexible, but I think first and foremost, cultivate trust. Be trustworthy and develop a culture of trust in your organization. We can learn a great deal about that from our own experiences, but also from just reading up on the literature on trust, there's the body of knowledge out there that tell us exactly how it forms, how it's sustained, when it's breached, what happens to performance, so I think that's an important value that I think new leaders need to really think long and hard about.
RA: Just reflecting over some of the comments that you've made in this time and summarizing it, it seems like some of the critical skills around communication, emotional intelligence, the ability to manage teams and people as well as appreciating how fast-paced our health health care systems are are all skills that leaders need, but overlaying that with being able to cultivate trust with the people that you work with will really be helpful to first-time and aspiring leaders in any health care system, whether in an academic or community setting. I want to thank you both for your time today and for chatting with me about this really important topic on physician leadership. I'm really excited to see the work and the initiatives that you are developing come to light, so thank you again for your time today.
DO: Thank you so much, Ruth. This has been a wonderful opportunity.
RS: Thank you for having us.
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Stanford University School of Medicine
Clinical Associate Professor of Anesthesiology, Perioperative and Pain Medicine
Director of Faculty Professional Development
Stanford University School of Medicine