Ruth Adewuya, MD: Hello, you're listening to Stanford Medcast. Stanford CMEs 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 miniseries. I am joined by Dr Ed Mariano, who is a professor and the chief of the anesthesiology and perioperative care service at the Veteran's Affairs Palo Alto Health Care System. He has held leadership positions in the California Society of Anesthesiologists, American Society of Anesthesiologists, and the American Society of Regional Anesthesia and Pain Medicine. As a background for our listeners. In May, Dr Mariano was a panelist for the Physician Leadership Virtual Journal club on power and influence. And we had such a rich discussion but felt that we did not even begin to scratch the surface. And so, I'm really thankful that you have agreed to continue the conversation with me on the podcast. Thanks for being here.
Ed Mariano, MD: I really appreciate it. Thanks for inviting me. The journal club was fantastic, and we could have gone on for hours. So there's plenty to unpack I think, when you talk about power and influence.
Adewuya: Today, I'd like to focus on the concept and the impact of both power and influence in physician leadership. I also want to touch on how it relates to performance in interprofessional teams. But before we start, let's start with definitions. There are a lot of articles that define power and influence in so many different ways. Curious to get your thoughts. How would you define power and influence?
Mariano: So power and influence, especially on context, oftentimes get used interchangeably, but they're clearly different. And I think that there are positive and negative aspects to each of those terms. I would define power really is having some positional involvement, that there is some designation of authority. Whereas influence does not require any positional authority but really is about influencing outcomes or influencing decisions. It's applying relationships or leveraging relationships to produce outcomes. And so the real difference, I think in my view, is that you can have influence without, say, a designated leadership or management type of position. Whereas power, oftentimes, comes from that platform of having some designated authority.
Adewuya: That's a great way to summarize it. You mentioned the negative connotation that comes with power and the concept of power and influence. Can you talk about that a little further?
Mariano: Sure. So when it comes to power, I think that there is the flip side of power. The abuse of power, I think, is always what comes to mind. Sometimes, we even examples in our real life or examples that we've read about in which people within and outside health care have abused their positions either for personal gain or for the detriment of others. And I think that is always… The flip side, it's the other edge of the sword, so to speak, when it comes to power. With influence, I think a negative connotation with influence is really the use of influence in politics synonymously. So people talk about the politics of their environment, the politics of academics, or the politics of healthcare, and they use politics and influence oftentimes in similar conversations in a negative way.
One of the articles that we reviewed in journal club that I thought was so interesting was the article by a physician discussing the use of politics for good. And I think using influence and your position and relationships to positively influence outcomes, to positively affect your work environment, create systems and practice that I think allow patients to get better care and also allow you and your colleagues to prosper and also move up within organization. I think these are good aspects of influence in politics.
Adewuya: As academic health centers or other health centers are challenged by the dynamic health care environment. It seems that physicians are being asked to step up into position leadership roles in order to introduce change, to set new directions, and they are having to exert power or social influence. That's what I perceive. Is that what you're perceiving as well?
Mariano: I am. I think that there're interesting surveys within the public that still demonstrate that physicians, that doctors still have a great degree of respect within communities, just firefighters, which I think is a good thing. When you look at the BMJ Leader article that we reviewed by Saxena and colleagues. They talk about the different ways that you can earn and exert power. And one of them is really in terms of your own expertise. And I think physicians are seen as experts in health and wellbeing within the community. And so leveraging that power base, I think, is important. And I think because of that, physicians get called to take up leadership roles within their institutions to lead, change processes, to develop protocols or pathways that affect patient care, to take on roles within graduate medical education or even undergraduate medical education.
These are oftentimes… some of these leadership positions aren't roles that we've trained for within our educational curricula during the course of our professional lives. And at the same time, while learning how to accomplish the goal of the team in which we've now been placed in this leadership role, we also have to learn how to be good leaders and how to use our power or position of power to enact positive change. And these are concurrent learning experiences, which can sometimes be very difficult, especially when you're focused on a goal, which is something that we all do as physicians.
Adewuya: Thanks for calling out that article. I would encourage our listeners look at it. It's the Power and Physician Leadership article by Saxena and colleagues, where they discuss the concept as well as the impact. And as Dr Mariano had referenced, they talk about the different bases of power. And they list about seven or eight basis of power. Ranging from the legitimate, reward, expert to connections. Feel free to take a look at that article at your own time as well. As we continue to talk about this new role for physicians and for physician leaders, Saxena also talks about this judicious use of power, which you referenced, which is creating collaborative networks, engaging those that they lead in the leadership process. How do you think this concept translates to clinician performance in interprofessional teams?
Mariano: Yeah. I thought that section was really interesting. It was very insightful because I think when you tie that together with the table of power basis, that Saxena colleagues reference. I think it really speaks to the fact that power is not mutually exclusive within a team. So you can have multiple people within a team with different forms of power. Maybe one person is charged as being the team leader for an improvement project, for example, if that person happens to be the physician leader of the multidisciplinary team. At the same time, the reason why you have interprofessional teams is because you have other members who also exert power from a different base. That they come with their own areas of expertise. That they have, say, a referent power where they've been in the institution. They'd have institutional knowledge and relationships that have earned them a position in which they can positively impact outcome, where they can influence outcomes.
So I think what is important when you look at those dynamics is that the physician leader, in this case, cannot be threatened by the sources of power from others within the interprofessional team and actually learn to recognize those power bases as a potential advantage, really because not only do they have different training, but they also have different areas of influence, different circles of influence that can really help further the goal. And I think that's a key point, especially when you're looking at how interprofessional teams not only can impact change in the health system, but also impact care of the patient. Ultimately, the care of the patient is really the goal, and how you get there is really going to take multiple spheres of influence at multiple levels within a system in order to overcome a lot of the barriers to change.
Adewuya: Switching gears to influence. When we talked about it in the journal club, it was very tactical. Some of my conclusion was influence is the way you utilize power. I don't know. Do you agree with that?
Mariano: It can be because sometimes I think this is where it gets very challenging when having conversations about power and influence, because I think the presumption is that you have to have a base of power base of legitimate power of you have to have a position of authority in order to exert influence. But I would say that's probably the first thing when teaching new physician leaders that has to be established is that you are already a leader without a title. Because as a physician, having gone through the rigorous training that we've gone through to get where you are, you already have a source of expertise that forms its own power base. And so, knowing that you don't need a title, I think, is really key because one of the things that I've tried to speak to with my mentees is that as a physician leader, you first start as a good doctor.
You first have to really enjoy the calling of medicine because people see that. If you're in your environment and you hate what you're doing. And you're always trying to get out of things. And you're not focused on your patients. Then it's very difficult for your colleagues within medicine and in the other health professions to have respect for you. And that weakens your expert power base. You've already started to undermine your own power base. And oftentimes, I've found, at least in my career that starting first, that establishing that authority as a physician, as a good doctor, taking good care of patients, having great relationships within our other health professions colleagues that oftentimes leads to opportunity for legitimate power for titles or for the opportunities to lead teams in a more formalized way. And so I think it's really critical that people see as a physician that almost the first day, or even while you're still in training, you are already exerting influence. And you're starting to develop relationships that ideally will be long-lasting as you develop and progress in your career.
Adewuya: That is such an excellent point. And thank you for clarifying that concept. I think it's a great takeaway that leadership does not equal having a title and having a formal title. That you can be a leader without it. You can begin to influence. What are some of your thoughts about tactics to be able to increase one's influence?
Mariano: One thing that I've learned in terms of my career that wasn't always apparent when I was in my residency and fellowship training, or even definitely when I was in medical school, was really learning how your system works. And that almost seems like an obvious question or an obvious issue when you start to work within a health system. But I think that we are trained to diagnose and treat disease. We're trained within our specialties to do procedures, to manage a patient. I think those are the things that we think of when you think about being a doctor in practice, and our careers are long. Our careers are 30 years long. And so we want to make sure we get those things right. At the same time, I think one aspect, one very practical aspect that I've learned in my career progression is learning how everything else works.
So you've trained to be a physician. Hopefully, that's a given that you know how to do that job, but learning what other people within your team do? How do they train? I think learning a little bit more about the background of some of the nurses, the advance practitioners that you work with. Learning how the pharmacists train and what their course has been. Learning how supplies get ordered. Who your prime vendor of your hospital is, to how that process goes about to request and get equipment approved. Learning all of the protocols to some degree of your environmental services workers who've worked with you collaboratively. I think understanding a little bit more about how your environment functions and then starting to develop relationships with the people around you who make those decisions. I have found to be incredibly valuable when you're trying to develop influence, because like I said, you don't need to have a title to be a leader.
But if you, as a physician, know how things work, then that allows you when you are part of these interprofessional teams to improve care, whether it be a clinical practice or in a logistical systems-based workflow type of improvement, then you know who to go to. You know who these people are, who make the decisions and who run the committees, or who serve on the committees that allow you to enact change. Because as much as we would like to think that we read a great article that shows great evidence, and then the next day, you're going to start changing clinical practice. In real life, it doesn't work that way. It takes a whole team of clinicians and non-clinicians to change the way health care works. And so, the more you can start to figure it out and develop those relationships with your partners, the better off you'll be.
Adewuya: Those are excellent practical things to be able to do tomorrow and the next day. So thank you for sharing that. Along the same lines of influence, we talked about the concept of leading up as another way to apply influence in your organization. And we talked about the seven habits for leading up. And one of the habits that I wanted to talk about and get your thoughts on is the concept of helping your supervisor. So as a provider, you're always trying to anticipate the needs of your patient. But when it comes to your direct supervisor, how do you help your supervisor? How do you contribute to their goals and their aspirations in a clinical setting? Any thoughts on that?
Mariano: There's always this dichotomy, I think, especially in an academic medical center. On the one hand, you want to be a good team player. You want to provide assistance to the leaders of your team, whether that person be your clinic chief, your division chief, your chair. Maybe it's on the operational side. At the same time, there's also this push this incentive to develop your own reputation, to develop your own accomplishments in order to satisfy criteria for promotion. At times, that feels like those things are at odds. The first lesson and I think an important one. And one that I've talked with my mentees about too is, that you don't always know what the expectations are of your supervisor. So you don't always know what that person is going to be required to submit. What that person is evaluated on. What that person's metrics are. And so, one of the best things that I've recommended to people is that don't assume that your supervisors always know what you're doing.
Yeah. You may think that, “I'm working hard. I'm doing these things. I've come up with so many innovative ideas, and my supervisor must know because that person's in charge of me. They see the care that I'm providing. They're reviewing my outcomes. They're talking to people.” Never assume. So one of the first things that you can do that is helpful to your supervisor is just let that person know. Just say, “Look, I took it upon myself. I took care of this thing.” It may be something relatively simple. Maybe you came up with a new note or order set template that makes the workflow a little bit easier for yourself and that's accessible to your colleagues. And maybe you came up with a new project. You took the initiative. You worked within your clinical setting within your interprofessional team, and you came up with something that changes the workflow or that improves patient care in your immediate environment. Pass that on.
And I think that helped your supervisor is, I think, that there are going to be times, I've received these messages myself from my bosses, where they ask, “We have to go present what is new and innovative in our area. We're going to be giving this presentation to all of the hospitals within our region, or we're going to be giving this…” I work within the VA. “So we're giving this presentation to VA central office in DC. I need this by tomorrow.” And so, being a supervisor, then having that knowledge to say on the front end of my memory, I can say, “You know what, we've done this and this.” And I make sure as chief of my group that I have names assigned to that.
And for people who have shared their work, either through online meetings or with publications, I include links. And so that way I can definitely promote a lot of the work that we're doing, and I don't have to think too hard about it. And I don't have to try to seek answers to some of these questions, especially when you have a short timeline. So I think those things, they not only help your supervisor, but you can see how these also help you. Because I think that if you become that go-to person for your supervisor, for new ideas, for accomplishments, for positive work, then that person will think of you when opportunities come up as well.
Adewuya: I think that's excellent. I think that concept could also apply to individuals who are marginalized or being held back because folks don't know what they're doing. And so taking responsibility for informing people of what you're doing, the supervisor will be hard-pressed not to be able to acknowledge the work that you're doing if you have repeatedly made mention of it. That's what I'm reflecting on as you were talking.
Mariano: It's true. And I think that there is an important cultural component. If for myself, I'm a first-generation Filipino American. As an Asian American, we are not typically stereotyped in leadership. We're stereotyped as hard workers, and that we put our heads down, and we may have good ideas. That these aren't things that culturally are seen as a positive when you tend to talk about yourself, that is actually the opposite. You grow up being told that, you know what? These are expectations. And if you talk about things that you're doing, that may be seen as arrogance. That can be very difficult. But I think good advice that I've had to learn myself. And then now I try to pass on to other people, is that the work products that you create. The things that you make. The things that you invent and innovate. That's something that people have to recognize. That's not bragging.
If anything, you're sharing an idea that hopefully resonates with someone else. Someone else may hear that. And they may think, “You know what? I may be able to do that too. Or maybe we can do that somewhere else.” By keeping it to yourself. Then you're not allowing others to benefit from the experience that you've had and from the results of your work. So I see it as the opposite. I think it's really sharing information and allowing others to, hopefully, leverage that to do something good on their own.
Adewuya: That's a great framework to think about. I resonate with what you said about the concept of bragging, as opposed to sharing innovation with the team. You've already mentioned in several parts of our conversation reflections on your own experiences. What are some of the barriers that you've encountered in your leadership journey?
Mariano: Anytime that you want to enact change, you can expect opposition. One of my first experiences was as a new attending. I trained here at Stanford, and I went down to UC San Diego for my first attending job. And one of the things that I have believed is that you have to practice good medicine. And believe that what you're doing, especially when you have great partners within your network, within your interprofessional team, and with your patients. And when you decide that you're going to do something new and it makes sense, and you have good evidence support. Then, you should feel confident that you are doing the right thing. I practice the type of anesthesia that wasn't very common. My area of clinical interest has been regional anesthesia, which is essentially the simplest definition of is just anesthetizing parts of the body, as opposed to the whole body for different types of surgery.
And I remember very clearly, and this is a good example of the abuse of legitimate power. Is one of the senior members of the department who was a director of a clinical site. And so, had that authority based on an administrative position. And also, seniority would send out departmental emails. Essentially, in his case, his perspective was raising awareness about the potential complications, the dangers, and potential inefficiencies of trying to practice anesthesia in a different way, which I think for myself as a brand new attending, I was mortified. For one, I never would've expected that I would receive most of my opposition from my own department.
Thankfully I had great partners with… this is really where the interprofessional team comes in. I had surgeon support. I had nursing support. I had pharmacy support, and then little by little, I also had departmental support. And I also, deep down at my core, believed that I was doing the right thing for patients and I was practicing good medicine. Having that experience. Being on the receiving end of what I perceived as power abuse, I think has definitely informed my own views of how you should expect physician leaders to leverage power.
It took some time. It was also a good example for me not having had a title and being very junior in learning how you can have influence without power. You can have influence by being a good doctor and by having these relationships, even though I didn't have a title. And if that progressed to take on titles and responsibility in more of a legitimate power fashion, I try to exercise those positions very respectfully and judiciously.
Adewuya: Thank you for sharing your experiences. You alluded to this earlier, where we physicians don't get formal training on this. What are some trainings that have helped you to shore up your base of knowledge around leadership?
Mariano: I think that the resources available for physicians who are interested in leadership today, I think are amazing. Just pure, present company included, the Stanford Physician Leadership program, I think is amazing. To have those types of accessible educational curricula that really allow physicians to take that next step is something that I didn't have before and wish I did. I think that for my own journey, what I've tried to do is, one, to read and to leverage free resources. But some of those have come from social media. I found that joining LinkedIn, for example, which is a great network that I think is very popular with businesspeople and has spread. It has great online articles in areas that aren't traditionally medicine, which I think are incredibly helpful. Reading Harvard Business Review, I think, is fantastic.
And you can get a lot of that knowledge from reading, from watching TED Talks, things that really get you thinking, because that is an incredible strength of physicians is that we're very creative thinkers. And so sometimes you just have to hear an idea or read an idea to really get you motivated and excited about a new opportunity and give you that enthusiasm to take it on and feel like you have the confidence to do as good of a job in your leadership or managerial role as you do with your patients.
Adewuya: I think it's important to us that folks know that the resources are widely available and that not everyone is in an academic health center. But some of the things that you mentioned are agnostic of where you practice, and you can access that on YouTube, LinkedIn, social media. Any last thoughts to share on this topic.
Mariano: If I could leave listeners with anything, I think it's as physicians whether or not you have a title. I just encourage you to be leaders in your own area. We work with interprofessional teams that really have the potential to do good and to improve the care and outcomes of our patients. So look at yourselves as leaders first. Believe that you are a leader. And then when the opportunity up to take that next step, then be open to it because I think it's going to challenge you. It's going to feel uncomfortable. But to feel confident in your own skills that you can adapt and learn how to be a good leader, I think, is really the key first step.
Adewuya: Thank you so much for your time again today. And thanks for chatting with me.
Mariano: Thank you so much for having me.
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