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2021 Physician Leadership Virtual Journal Club: Power and Influence

Learning Objectives
1. Contextualize evidence-based research for individual applicability
2. Incorporate leadership strategies to lead multi-faceted teams
1 Credit CME

You are invited to join the Stanford CME 2021 Physician Leadership Virtual Journal Club, a national journal club! Join us in discussing recent journal articles uniquely suited to physicians in leadership roles and executive positions. Each one-hour forum will help participants assimilate key leadership knowledge and skills and incorporate management strategies to lead multi-faceted teams. The May theme is Power and Influence. Below are the articles that will be discussed at our May session:

  1. Saxena A, Meschino D, Hazelton L, et al Power and physician leadership BMJ Leader 2019;3:92-98. https://bmjleader.bmj.com/content/3/3/922.

  2. Pfeffer, J. You're Still the Same: Why Theories of Power hold Over Time and Across Contexts. Academy of Management Perspectives. Nov2013, Vol. 27 Issue 4, p269-280. 12p. https://journals.aom.org/doi/abs/10.5465/amp.2013.00403.

  3. Franko, J. How to Lead Up in Your Organization. Fam Pract Manag. 2017 Nov-Dec;24(6):6-9. https://www.aafp.org/fpm/2017/1100/p6.html

We are aware that the articles discussed in this journal club may not be available via Open Access and may require a subscription. In order to keep registration for the Virtual Journal Club sessions free, we are unable to provide registrants subscriptions to journals or provide access to articles (PDF). A comprehensive summary of the article(s) will be presented at the beginning of each session.

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Video Transcript

Daryl Oakes, MD: Hello, and welcome. We are so excited to have you. This is our May version, our May series of our Stanford CME Physician Leadership Virtual Journal Club, and we are so excited to have you. So welcome, and I will first start by introducing myself. I am Daryl Oakes.

Ruth Adewuya, MD: And I am Ruth Adewuya.

Oakes: around leadership. For these webinars, we have preassigned topics and articles to discuss, and each month we ask our registrants to submit their questions in advance of the session. There will also be opportunities to add to the discussion during the session via the live chat. And the goal of the program is to provide practicing physicians in all levels of leadership with insights in management skills to help them be more effective in their clinical environments.

Adewuya: And so today's discussion will be on power and influence. And we believe that understanding these two concepts would be critical for any leadership in any organization or institution to be able to use power and maintain respect in their organization.

Oakes: So why is power so important? Well ultimately, power is really how things get done. And to quote Jeffrey Pfeffer, who is Stanford professor and expert on power, he says, “Any new strategy worth implementing has some controversy surrounding it and someone with a counter-agenda fighting it. When push comes to shove, you need more than logic to carry the day, you need power.” However, the idea of power and the idea of seeking power or using power really often makes many of us uncomfortable. And power has sort of long been associated with maybe socially undesirable behaviors, whether the idea of ruthlessness or treachery. But as a result, if we are worried about it, then people are often hesitant to seek it or even want it. And this can be a problem because these negative associations hae often been associated with the certain personalities that have currently sought and attained power. And although not all leaders are narcissists and that's not the point of this conversation, but it is interesting to notice that many studies have noted that individuals who have narcissistic personalities are noted to be more likely to rise to positions of power, to earn more, to have longer tenures as CEOs and to be successful in their careers.

Oakes: So in this case, even though the leadership style is not really associate with better performance of the organizations, they are very successful in achieving leadership and this is primarily related to their desire for power and their willingness to engage in the political maneuvering that's needed to attain it. So the lesson here for all of us is that if we want alternative models for leadership, then we all need to better understand what power is, how power works, and we also need to be willing to use it of course responsibly and effectively.

Adewuya: Thank you Daryl for that framework that you provided. And so our session today will explore three articles that present different aspects of power and influence. And we will address each article separately in three 15 minute segments. Each segment will start with a five minute presentation of the article, followed by a 10 minute discussion based on questions that we have received from our learners and any additional questions that you can add via the live chat on the right hand side of your screen.

And we have two expert panelists who have joined us today for our discussion on these articles. So I'll start by introducing Dr Rania Sanford, who is the director of faculty professional development at the school of medicine and the former Stanford associate vice provost for faculty development and diversity. Rania is a Columbia trained professional executive coach with degrees in organizational leadership and in communication. She has two decades of leadership experience in higher ed and now teaches leadership in management courses for physicians and leaders and research investigators at Stanford. She publishes and presents nationally and internationally in faculty development, diversity and leadership, and was recently selected as an incoming member of the Association of American Medical Colleges Group and Faculty Affairs professional development committee. Thank you Rania for being with us today.

Rania Sanford, EdD: Thanks for having me.

Adewuya: And also with Rania, we have Dr Mariano who is a professor and chief of the anesthesiology and paraoperative care service at the Veteran's Affairs Palo Alto Healthcare System. He has held leadership positions in the California Society of Anesthesiologists, American Society of Anesthesiologists, and American Society of Regional Anesthesia and Pain Medicine. He also serves on the editorial boards of Anesthesia and Regional Anesthesia and Pain Management. He is a recipient of the Veteran's Health Administration's John D. Chase Award for physician executives excellence and he has worked on key national healthcare initiatives. Welcome, Dr Mariano, and thanks for being with us today.

Edward Mariano, MD: Thank you so much. It's a pleasure to be with you.

Adewuya: And so with that, I will turn it over to Daryl to provide a review of the first of our three articles.

Oakes: Okay, thank you Ruth. And welcome to our panelists. So our first article is by Jeffrey Pfeffer, and it's called You're still the same: why theories of power hold over time and across contexts. Pfeffer, in this article, really addresses the question of why in these sort of new age of flattened hierarchies and organizations that are seeking to be more enlightened and less formal, why do these traditional systems of power still remain relevant? I think if you could go back to the earlier slide, I think that would be good, thank you. Yes, thank you. So, in his previous work, and this is a list here that goes over what Pfeffer lays out as the traditional playbook for exercising power.

Oakes: These are sort of the traditional rules, and just to sort of have them top of mind, I'll just review them quickly here in his wordings. But the concept of controlling resources, shaping behavior through the use of rewards and punishments, utilizing many and varied strategies, the idea of attacking from multiple fronts. There's many war analogies here. Making the first move, being the aggressor. Co-opting antagonists, and that's sort of the sense of winning over opponents by really making them a part of your team. Removing rivals but with the caveat of doing it nicely so that they can save face and not be motivated to obstruct you. Avoiding unnecessary conflicts, using a personal touch, and that is the importance of cultivating relationships. Being persistent, making strategically and critically important relationships work no matter what. And finally, having a compelling vision.

So in this article, Pfeffer acknowledges that despite our progress, any of these principals are durable and continue to be relevant today. So he then reviews in light of those what are our various aspects of social and organizational behavior that explain why we are still stuck with these same rules. The first organizational and social dynamic that Pfeffer describes is hierarchies. And hierarchies are a fundamental organizational principle and they appear in biologic systems, technical systems and social systems. And the studies of the psychology of people and their attitudes towards hierarchy have really demonstrated that people have a very strong preference for the order and security provided by hierarchical structures. And interestingly, these structures provide some really useful efficiencies within organizations. So I think it's important for us to recognize that hierarchies are important and likely here to stay and need to be considered when we are thinking about dynamics of organizations.

Second he discusses how perceptions of competency have not really fundamentally changed over time. And while many of us have awareness that some of these perceptions of confidence are fraught with assumptions and bias, they are very fundamental to decisions about who gets promoted in organizations and how. And one enduring perception of competence is the concept that warm people are just less competent and competent people, conversely, are less warm. Given this, although we often say we like kind and supportive leaders, we tend to rate more highly the intelligence and the capabilities of those who are more negative and critical than those who tend to be more positive and less critical. And there's also this strong association between power and anger. And due to their stature, powerful people are often less restricted by social norms and therefore are allowed more freedom to display anger. And conversely, people who demonstrate anger and inspire fear are often afforded more power. So these assumptions of competence and attributions of power are very deeply ingrained in how we function and how we think, and so despite our desire for these norms to be different, they do persist and we have to be aware of them.

A third persistent dynamic is what Pfeffer calls the self enhancement motive. And this refers to this very common pervasive motivation really to think of ourselves in a favorable light and to have a positive view of ourselves and our capabilities. And this tendency leads often to inaccurate self affirming assessment of situations, which might be problematic in some situations for leadership. It can result in resistance to admitting mistakes or changing course and it often motivates more aggressive and action oriented approaches, whether or not this is effective or not. So the psychology of self enhancement continues to drive behavior and is actually just as true in our younger generations as it is from generations from the past.

And fourth, the social principle related to the concept of us versus them. This is the idea that we have a very strong affinity for those who are similar to us. If people are motivated to think of themselves in positive terms, we are similarly motivated to think of those who remind us of ourselves in equally positive ways. Therefore, when you think about your success as advancing in your own organization, you're really more likely to advance if you are similar to or if you act more similar to those who are in leadership.

A fifth social tendency is the desire of individuals to be part of a winning team. There's this very strong motivation to be near success, and this is likely a very basic survival instinct in that in the past it probably brought you closer to resources and safety. But this instinct means that while it's nice to be likable and that brings you some influence, if you have influence you will certainly have lots of friends and supporters. And this explains why many or some unscrupulous leaders, if they are very successful, can continue to garner quite a bit of support and maintain their power.

And finally, in order to maintain a morally consistent view of the world, people will often rationalize the success of individuals by attributing them with certain positive characteristics that have in their mind made them successful. So people will do this whether or not the leader actually possesses these characteristics or whether or not these characteristics are really relevant to the person's success. But it fits with our idea that successful people should also be skilled and we like to bring those together.

So our take home points as we get into our conversation is just that there are basic and unchanging social and organizational principles that drive our behavior and influence power dynamics and the traditional principles of power and how it is used are really still relevant in our current environments.

Adewuya: Fantastic, thank you so much Daryl for that great summary of that article. I think that article was quite robust and had a lot of nuggets for us. So as you mentioned, we'd like to turn it over to our panelists to answer some questions about this first article specifically. I will start with some questions that were submitted by you the audience in advance. But in the meantime, after reflecting on the summary that was provided, feel free to drop in new questions in the chat or vote up some questions specific to this first article that have already been submitted in the chat as well. So I hope you're ready for some of these questions.

So my first question to both of you on this article is around the concept of hierarchies. So Pfeffer argues that hierarchies are fundamental and unchanging and are social and organization reality. So if so, how can we best blend the order and the stability that is provided by hierarchies with the need to motivate creativity and innovation? So Ed, I think I'll start with you to answer that question and then Rania if you want to chime in as well after he gives his response.

Mariano: I thought Pfeffer's article, I think it was incredibly insightful. And I think we see this as educators who've been in the medical setting for a little while. I graduated from medical school in '99 so I've been out at least in training and practice for over 20 years. So I think that we see this within our departments, within our training programs, just sometimes there's an imbalance of expectations and reality and I think Pfeffer puts it very nicely when describing the fact that hierarchies or the social organization is something biological and is something that provides a sense of comfort not just for humans but for other species as well. So I think acknowledging as these constructs are still in existence that everything is not completely level as we would like to believe, I think is first an important lesson.

I think the balance really comes from people who I think ascend into leadership positions. I think being aware of expectations especially for their trainees and also for younger members of the team, I think to acknowledge the fact that there are these expectations. But also, I think this is an opportunity for mentorship to really teach what it takes within a system to develop influence, to rise within your particular field in terms of professional development. And then as a leader, I think the obligation is to really have your ears open and really listen to the people on your team. Because I think while power is one thing, I think it's almost impossible, at least in healthcare, to get things done without the support of your team.

Adewuya: Rania, anything to add to that construct?

Sanford: I think it's well said and I appreciate that perspective that Ed shared. I think to me, when I hear the association between hierarchy and stability I pause because not all hierarchies are stable when hierarchies have inequities or exploitation, they become destabilized. At the same time, there are very well established hierarchies that can create creative spaces within them that allow for trials and failures and are able to actually sustain their existence that way because they're able to infuse new blood within constraints and limits. So I see the two can work in tandem with a very creative leader who's able to maintain [inaudible 00:18:22] equilibrium in a way between the two.

Adewuya: Mm-hmm (affirmative). That's a really great point. And thank you for calling out the fact that hierarchy does not equal stability. I think that's a great nugget to reflect on. Daryl, any thoughts on the conversation?

Oakes: No, I agree with that. I like the idea of harnessing the structure and the benefits of hierarchies to achieve the goals that we're trying to achieve, whether it's with improving the diversity, equity and inclusion in our environments or being more creative and developing new ideas, which ultimately will move us all forward. So I like the idea of being a balance of both of them and I think that's really important that just because it's a structure doesn't mean it has to be limiting.

Adewuya: Great. It seems like it's also in the chat, but a question that was submitted before has to do with the discussion of perceptions of competence. And how he refers to the relationship of anger and power that individuals that show anger are often perceived as more powerful. But specifically my question, I'll start with you Rania and you Daryl before going to Ed, how does this association apply to women and/or underrepresented individuals as it seems like there are penalties for nonconforming behaviors in these groups. Rania, your thoughts first?

Sanford: Yeah, that's pretty known at this point when you're of a certain skin color and you show anger, the reaction, the response it invokes is quite starkly different from when one is not, whether it's race based or even gender based. So the anger in general is one behavior hat demonstrates or manifests power because it relays dominance, like the person is dominant. Dominance is one of the playing power up behaviors, one of many how to do that. And there have been several studies coming from the sociology literature, Cecilia Ridgeway for example on our faculty, she studied behaviors of women leaders and minorities. And dominance is not one of the behaviors that are often used and they're able to exert influence through other behaviors that are actually play down their power. They convene, they relationship based, we'll talk about that a little bit in the next article I think.

So we can sort of try to interpret why that is the case, why we get penalized, why minorities or women get penalized for exerting behaviors that play the power up whether it's interruption, pulling rank, refusals to requests, all these behaviors that get socially penalized. And one way to look at it could be the misalignment with the gender roles in society, that could be one reason. Another reason could be the fact of coming in as a member of an underrepresented group into a dominant group, and dominance could also relays threat to the [inaudible 00:21:47] that now things are changing. So all these could be ways to interpret it, but yeah, I'm eager to hear what you all think about that because that's a very interesting point that you make.

Mariano: I think these perceptions and this is part of our problem with implicit bias and I think when we discuss the issues of glass ceilings or at least as myself as an Asian American the bamboo ceiling where you may not be considered underrepresented in some circles, but then in leadership Asian Americans are underrepresented, and why is that? So much of it has to do with stereotyping and the assumption that Asian Americans are docile and more reserved, that they are unable to exert what is considered the stereotypical power personality, which I think Pfeffer describes very nicely. That I think there's this association of emotion or anger with people in positions of power. And I think we all have those mental images of what that person looks like, and he gives some examples of George Steinbrenner from the Yankees and Steve Jobs and Rupert Murdoch. And I think my take away from that section really has to do with just knowing how to express emotion I think is really important as a leader. And I think that depending on your environment, I can speak specifically for healthcare, there are times in when you have to be more assertive and I think especially when it's in the best interest of patients and patient care. But you choose your moments, and so I think it is difficult to be an effective leader and change institutional practice without knowing when to be assertive.

Oakes: Yeah, thank you both. That's such a great way to approach that question because there are so many complexities to what behaviors are allowed and the social expectations for different individuals and how they behave and what constraints them. So even amongst leaders, you as a woman or if you're from an underrepresented group may have different rules that you are then constrained by. So I think for us being aware of that, and I also really liked Pfeffer's discussion of how we prioritize, we want empathetic leaders, but then we often dismiss them in response for people who tend to be harsher or more directive. So we need to find a way to provide that, to counterbalance that bias.

Adewuya: Great, thank you for answer those questions. I think we'll have more opportunity to dive deeper into some of the questions form this first article. We'll transition and go back to the second article.

Oakes: All right, well thanks. I think that was a great discussion and there is still more pieces of conversation. The second article here that we looked at was Power and Physician Leadership by Anuraag Saxena and colleagues. And Saxena discusses the concept and impact of power in physician leadership. And the article looks at concepts and frameworks for power, I think as Rania was eluding to, well we'll review those. And judicious use of power as well as strategies that we should be considering to avoid the abuse of power in our systems. So, next slide please. Yeah, so Saxena discusses the fundamental frameworks of power, including the different bases of power and how each power is exerted. And these bases of power are listed here.

And the first refers to legitimate power, which is formal power, it's the power associated with an institutionally recognized position. Then there is reward power, the ability to exert control through distribution of resources and benefits, and this is in exchange for desired behaviors. And conversely, coercive power is sort of the threat of punishment for not complying with leadership mandates. And the reward and coercive power are often referred to as hard power. Expert power is based on specific skills and knowledge or expertise of the leader. Then there's referent power, which is really based in the leader's ability to inspire admiration, loyalty and trust. And we often want to think that we feel this way about our leaders, but this is just one of the many bases of power.

And now there's also this concept of power generated through connections, and this type of power has been highlighted by feminist perspectives on power and it emphasizes that power is really based in a relationship between the leaders and followers, and it's sort of the power too is the idea of empowerment of the leader or power with the idea that the leader leads with the followers. And this type of collaborative power really focuses on a social, cultural relationship and environment. And it's really less focused than solely on just the leader, like some of the other bases of power. And finally, informational power. And this power refers to the power to generate a narrative. And these narratives can be used to normalize existing power dynamic or even to marginalize certain groups. However, what's interesting about this power, it's potentially available to everyone and it provides the opportunity for even marginalized individuals to create new narratives that can highlight their interest and promote change.

And so moving to the how Saxena proposes that these power bases can be utilized or maybe exercised, and he goes over ways to do this responsibly and even discusses some not so responsible ways. And he, in the exercise of power, he sort of divides it into three main levels. So the personal level, the interpersonal, and the organizational level. Saxena sort of outlines what should be the principles for physicians who are using power, how to use it judiciously to help their organizations and to improve the care for their patients. And I think Ed you're referring a little to this in the sense that sometimes to be assertive to take care of the needs of patients, there may be a need for that. Again, there's many different ways to use our power effectively.

But he talks about the need for physicians to first develop on a personal level so that they know and understand power and how it works. And then they're able to overcome their ambivalence with utilizing their formal authority if they have it. They also really need to develop their emotional intelligence, because it's important to have these skills in order to navigate the leadership environment.

And then on the interpersonal level, Saxena emphasizes the importance of creating collaborative networks that we need to engage those that we lead in the leadership process. And also promote the concept of the transformational leader, which we've talked about in our previous journal club.

And finally, physicians need to recognize how to lead on the organizational level as well, and that this involves creating meaningful narratives that can help align the interests of individuals in the organization with those of the overall organization. And these need to be done in such a way that are inclusive and they take into account something that was referred to by Saxena as the scarf model of human social experience. And that refers to people's desire for status, certainty, autonomy, relatedness and fairness.

Now, the exercise of power also can be done in an abusive way and I think from various examples throughout the world we have awareness that leaders who may have narcissistic tendencies or hubris can use power to co-opt things of value and utilize it for self gain. And also, an interesting abuse of power that may be more subtle is involved in the rationalizations that are sometimes done for somewhat dubious actions and the rationalizations being necessary to promote the organizational objectives. So recognizing those are areas where things can go awry. And to use power effectively, we're going to have to think about how to prevent these abuses of power and build structures to support doing the right thing. So how to support leaders to have the moral courage to stand up when necessary and how to help them participate in adaptive reflection of their actions. And it also involves empowering peers and followers so that they have the ability to restrain power when needed. And finally, organizations really need to hold leaders accountable to ensure that the narratives of information power that are utilized are utilized for good, to promote diversity, equity and inclusion rather than continuing to normalize the exclusion in marginalized groups.

So in summary, the take home points are that the bases of power that are presented here help provide a framework to understand the mechanisms of power and how they are interrelated. And that power is exercised in multiple domains, primarily the personal, interpersonal and organizational. And then we also need to understand how to appropriately utilize power and how to create systems to avoid its abuse. So on that note, I think we'll come back to our questions.

Adewuya: The first question that I have on power, I have lots of questions about power, but one that comes up is the fact that what are some of the things, it seems like power is seen by others as a negative perspective, I guess is the question that this person has, and this person is curious in terms of what are the things that can turn power towards a positive outcome? But I would even maybe take a step back to answer the question, is power a negative perspective and should we even be thinking about power in a negative perspective? And Ed, I'll start with you.

Mariano: Sure. I liked this article by Saxena just because I think that it did frame the bases of power and their domains I think very clearly. And they're not necessarily positive or negative, I think that they are what they are and I think that as leaders, as physician leaders, I think we can exercise multiple. This is not a one size fits all type of a paradigm, but there may be bases of power that are incorporated into our leadership style and they may vary by the person. It also helps explain why you can have power and not necessarily have, say, a leadership position or title where it doesn't have to be legitimate as it's described here as being a labeled or hired position of authority, but you can generate power from expertise and you can generate referent power essentially through relationship. There's some crossover here with influence, but I like the way it was described. It's not necessarily a negative thing, but I think it's a necessity and I think that's the way it's framed by Saxena and colleagues.

Adewuya: Rania, any thought to add?

Sanford: Yeah, I completely agree with Ed. I like the article too. Saxena I think did a great job capturing essentially what we know about power and social organization in a very good way. And I couldn't agree more also with what Ed just said about that power is not negative, it isn't what makes things happen, you need it. I think it's the impact when it's negative, that's where power gets a bad rap. But people without formal positions in hierarchies where you have the title, let's say, or that basis as Ed said, there are many other ways to do it. Convening people across silos is a form of power, it's a relationship base with is what the second power with, power to, feminist orientation to it. There's also being issue driven or mission driven, being an advocate, that's a form of power. It's referent, it's expertise based, and that's more of the [inaudible 00:35:21] old school, the post-structuralist approach. But these are all very valid forms of power, and yeah. So not everybody can be a chair or a dean or a chief, but we can all have something to contribute in our own way.

Adewuya: Absolutely. And one thing that came up in our last discussion for the last article and also reflected in this article is the use of power and how emotional intelligence, I think Ed you were the one who mentioned this in one of your responses before, how emotional intelligence is an important part of the use of power. And so how do we get organizations to recognize and support this and this specific leadership skill for clinicians in different institutions? Ed, what are your thoughts?

Mariano: Specifically, I think that in this article they talk about emotional intelligence and how it's important for the personal and the interpersonal, but then it drops off at the organizational. And I think it seems like there's a disconnect there, like why wouldn't organizational leaders be embracing what we consider as such an important characteristic? So much of it I think is perspective. I think we can understand why power at a personal level or developing your power at a personal level requires emotional intelligence or can grow because of it. And interpersonal connectivity I think makes sense why emotional intelligence could be important at that level. I think depending on your perspective on organizational leadership, at times there's a perspective that organizational leaders aren't necessarily leading people specifically as much as they're leading systems. And I think that that's where that emotional intelligence or where it fits in sometimes can be seen as dropping off.

Where I think it can be incredibly influential to exercise emotional intelligence at this level is when some of our system leaders and the organizational leaders, they go to where the value's created when we talk about leadership habits and going to [inaudible 00:37:32] where the value is generated at the bedside, walking around, visiting the areas of patient care. That offers organizational leaders an opportunity to exercise their emotional intelligence, actually listen to frontline workers, listen to their physicians and other healthcare professionals who are actually taking care of the patients at the bedside. I think that this is a way to tie it in, but I think often times our perspective is at that organizational is system only and we forget about the people that actually form the systems.

Oakes: I think that's such a great point both of you have made. And it reminds me of a lecture I recently someone sent me from Simon Sinek who talks about the need to add empathy back into our corporate structures that we have really missed an opportunity with or organizations to develop. So again, I think it fits with that concept.

Adewuya: Great. One of the questions that came up about this article has to do with the concept of who or what assures that the people in power don't alter or don't abuse their position. And I feel like that's such a general and large concept to dissect, but I want to pose a specific person that this person asks is, what gives the physicians the competence needed to navigate this issue? So maybe I'll start with that, what are your education as a physician that have provided you or prepared you for management? And so maybe I'll address this Ed and to Daryl.

Mariano: So, I think in terms of formal leadership training, I think as a physician I would say it is not baked in to the medical school curriculum in general. At least I would say that it was not baked into my medical school curriculum. And I think that there are important lessons that I think we learned over the course of our careers, and I think that the teachers, the mentors, I think are out there and you can seek it or they can find you. I think that it is lacking. What's difficult I think in trying to now, today in 2021, to look at trying to incorporate leadership into medical school or professional development for physicians, is it's very difficult, you have to make sure that it is useful and applicable to the individual without always knowing exactly what that individual's trajectory is going to be, is sometimes, I've found for myself at least, that after I had gotten involved in local institutional leadership after I had started to get more involved in organized medicine, then it made much more sense for me to seek out mentors who could then help me develop when I knew where I was going.

I do think that that is one of the challenges. That being said, I think that as physicians and I think Saxena in this article describes it really nicely, we have so much potential to develop power without an official title that many of those lessons I think in knowing how to responsibly wield power and knowing how to wild influence do carry over when or if you do assume what he describes as a legitimate power position in leadership.

Oakes: Yeah, actually I'm going to throw this question to Rania in a slightly different form. But I think that physicians are often expected to lead without formal training, but I'm curious form Rania's perspective where she has seen that people are often struggling the most as someone who's seen a lot of organizations and supported a lot of leaders.

Sanford: That's a great question, Daryl. You know, where have a seen physicians struggle the most? I think in different ways related to power sometimes it's using power we have, shying away from because of the sensitivity of what the impact could be on followers, because of sensitivities to hierarchy and wanting to be a collaborative leader in an environment that maybe doesn't allow it or doesn't let it thrive. So that could be one challenge for many physician leaders who are in positions of power or could be in positions of power but they don't exert it as much for all sorts of those reasons and others. So, that's one area.

Back to the point that Ed made, which I thought was also really good is, accountability needs to be built in along with giving people the power of decision making, let's say, or controlling resources or evaluating others. And there are medical education issues where we've seen abuse or potential exploitation around this particular point where there is no accountability on how people get evaluated, the rubrics aren't clear, things are implicit, and so on and so forth. So one of the movements around the inclusion and equity that we have is how we can make this implicit more explicit. Clarify rubrics, clarify criteria for evaluations, how decisions are made. And there's some progress is being made there.

Oakes: That actually is a great segue to our third article. And so I think that often there may be frustration that the organization isn't doing the right thing and things aren't happening the way it should. So here is an article called How to “Lead Up” in Your Organization by John Franco, which is our third article. And I think it's important for us to recognize where our points of power are and how to utilize them even if they aren't from a formal authority.

So for the seven habits that Franco identifies, I'll just run through them a little here. But these are important ways you can think about increasing your effectiveness in the organization and they don't require necessarily having formal power in order to do it, but you can be very influential. So the first habit is developing your emotional intelligence, and so EI and EQ are very broad topics, but he starts with simply the concept of monitoring your emotions a bit and your responses so that you aren't reacting, that you sort of hit the pause buttons and reflect a little before you actually have a response. And this will allow you to be more strategic and seem to others to be in more control and that will allow you to wield more influence.

Second habit he mentions is using power and politics for good. So we often think of power and politics in these negative concepts, but again they are very useful and you should harness them when you can to move things in the correct directions that are positive. So we need to understand the relative power of different individuals involved, you have to understand the politics and the relationships of people in your organization because it may need that you need to develop important relationships that you might not have recognized otherwise.

Third habit is that you need to choose being effective over being right, and I think that can be hard for many of us who have a very strong sense of what is right in the world but I think that if you want to move things forward you have to maintain relationships and realize that you need to prioritize these relationships sometimes over issues to win in the long run and this is sort of a long game. So and if you disagree with someone, instead of taking the stance that you need to change their mind, you instead maybe take the stance where you want to try to understand their perspective. And the more you understand about them, ask clarifying questions and become curious, the more information you have to help move the discussion in the direction that you're trying to move it.

The fourth habit is to be intentional and be prepared. And this is sort of the idea of using your opportunities when you have them, you need to know your audience when you have an opportunity to speak to it so your message can be clear and understandable in language that they understand. And also, it really can't be understated how important it is to spin things in the positive. People are often more excited to hear from someone who has something positive to say than someone who is coming across as just negative and complaining. So you can still be complaining, but if you sound positive about it it may move you farther forward.

Fifth habit, help your supervisor. They are the ones with the reigns, so you want them to be able to steer the ship in the right direction. But you need to understand what their limits are so that you don't either frustrate yourself or frustrate them. And you want to also try to align your goals with the goals of your supervisor in your institution as much as possible.

And the sixth habit is disagree without being disagreeable. So fine win-win solutions if you can. But if you can't, avoid ultimatums, really keep it about the issue and don't make it personal, don't make it about the person. And this will help you keep the interaction calm and preserve relationships, again, for that concept of the long term and the long run.

And finally, the seventh habit, don't expect credit. You're unlikely actually to get credit for all or even most of your good ideas, and if you do really get focused on that you will likely end up very bitter and somewhat frustrated. So focus on your ability to influence and your ability to plant seeds and help them grow so that the decisions that you want to be made get made in the long run.

So with those thoughts, we will finish up our discussion with a few last questions.

Adewuya: Thank you, Daryl. So, in the few minutes that we have left, I have some few general questions that have come up around all three of the articles and how folks can apply this. So before we go into this third article, a general concept that has come up both in the chat and in other pre submitted questions were power and influence, or is it power versus influence. And the question is, what is more important? Power, influence, both? Do we need power or can we create change through exerting our influence? Rania, I'm curious to get your thoughts to start.

Sanford: Both are necessary. I think power without influence is a dwarfed version of power, and influence without power would be a very long, hard journey for people to see change. So I think both are good, both are important. Yeah, they're two sides of the same coin in my universe. If we want people to go the extra mile, a powerful leader has to have influence too, let's put it that way.

Mariano: Yeah, I agree with that. It actually connects really well with this last article too because I think that if you look at power as being authority and influence being relationship based, then I think that you do have to have both. And not everyone with influence will have power, you won't always have that legitimate leadership position. But at the same time, if you're actually trying to change culture, change systems, change clinical practice, then you need someone in a position of power to then make the system change, otherwise as Rania says, influence alone takes a long, long, long time.

Adewuya: Great responses, thank you. The other question that was voted up a lot is a general question around this expectation of physician leadership and this concept of physician leadership. Do you think it has an influence or an impact on patient care? And so Ed, I think I'll start with you and then go to Daryl. As clinicians, what are your thoughts on this?

Mariano: I think that leadership skills within the physician community I think are a necessity. I think that regardless of whether you have a formal leadership title or not, I think that we see this within our training. You see the influence of these hierarchical structures within medical education from the student level to different levels of resident trainee to fellow to attendings. And even within an academic hospital like ours, you have different rakes within the professoriates. So I think that it's important that you recognize these power dynamics, which I think is really critical. And I think in this environment, you also have to accept the fact that of the list that Saxena gives of the various types of power that you have the potential to have any number of these bases of power, whether you want them or not. And I think that that's really key, is that you have to learn how to develop the ones that you can exercise for good because the good use of power helps patients and I think that that's really the bottom line.

Oakes: Yeah, I think that's very well said. And I think that we have recognized an epidemic of burnouts in physicians and I really think that there has been a lot of literature that burnout often is related to your relationship with your direct report. And so as physicians in this very structured hierarchy, there's a lot of reporting relationships. And really everybody in the structure needs to understand how to take care of those that they are responsible for if we want to produce a healthy and effective physician workforce.

Adewuya: Great. Great responses and great discussions. I know we are almost at time. And so I wanted to give either both of you, our guest panelists, the opportunity, and last thoughts or comments for the audience on the articles that we have discussed? Ed, can I put you on the spot to go first?

Mariano: Sure. Yeah, I'll make mine quick. I think that this has been an incredibly interesting and influential year for many of us in terms of our careers. But one thing I would say that is very relevant when you're looking at issues of power is that if you don't like how things are and you want to change how things are, then you need to develop those skills within yourself to then exercise some of these bases of power. And if you have that opportunity to have a leadership position and legitimate power base, then you can use that position to change for good.

Adewuya: All right, thank you. Rania?

Sanford: That's great. The articles are excellent articles and they reminded me of a book I read some months ago by Adam Kahane called Collaborating With the Enemy. It's a great book to read. But he talks in the book about the balance between assertion and engagement, assertion being the drive of power, engagement being the drive of love and engaging with people. And the advice, my particular way I would present here is to pay attention to the balance between assertion and engagement. And pay attention to the signals of feedback from the system around you and make sure that one doesn't overwhelm the other.

Adewuya: Great. Thank you both for those comments.

Oakes: Thank you both so much for joining us, and thank you to our audience for joining us for this monthly virtual journal club. It's been a great discussion and really appreciate both the inputs from Dr Sanford and from Dr Mariano. Thank you so much.

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