What Makes a Good Leader?

Health care leadership roles are often awarded to top clinicians and researchers, but experts say successful leaders need a different set of skills. 

As cases of COVID-19 began spiking on the West Coast of the U.S. in late February and early March 2020, leaders at City of Hope National Medical Center in southern California were trying to figure out how to maintain access to vital cancer treatments while ensuring the safety of both patients and employees.

Anne M. Ireland, MSN, RN, City of Hope’s Executive Director for Community Nursing Practice, joined a small group working to set up a drive-through testing facility.

“Very quickly, we had to pull together an interdisciplinary team across departments that frankly, as a nursing leader, I had not interacted with very much,” Ms. Ireland told ASH Clinical News. “We didn’t have enough swabs or testing kits, so I found myself working extensively with our supply chain team to ensure that we had what we needed to keep everyone safe.”

Ms. Ireland and a group of three other leaders met from a Friday afternoon through that Sunday night, walking through workflows, processes, and information technology needed to get a site up and running. They were able to open the testing site on Monday morning, allowing for all patients coming to the cancer center to be tested for COVID-19.

“We were facing something that we didn’t have all the answers to,” said Ms. Ireland, who has more than 30 years of oncology nursing experience and is a director-at-large for the Oncology Nursing Society. “From a leadership perspective, I knew I couldn’t do this on my own. I needed to get people from other areas. The challenge was getting all those key stakeholders to the table quickly.”

Seven months later, Ms. Ireland sees the creation of the testing site as a success – and a test of her leadership ability. While the task felt daunting at the time, she said that, in some ways, it was easier to tackle it during a crisis when everyone was focused on achieving a collective goal.

“When the stakes are high, a small team can accomplish a lot,” she said.

ASH Clinical News recently spoke with physician and nurse leaders in hematology/oncology about the trials of health care leadership (particularly in today’s environment), what makes a good leader, and how to build a diverse pipeline of future leaders in the specialty.

The DNA of a Good Leader

For Brian Bolwell, MD, Chair of the Cleveland Clinic Taussig Cancer Institute in Ohio, a leader is skilled at creating “clarity of purpose.”

Purpose is top of mind when navigating a crisis, but in day-to-day management it is important not to ask employees to excel at too many things at once, Dr. Bolwell said.

“We are measured in many ways in health care leadership,” he told ASH Clinical News. “The wrong way to lead is to tell your team that we have to be good at 38 things. If we focus with clarity and with purpose and passion on a handful of things, it will all fall into place.”

Dr. Bolwell, who said he has adopted a “servant leader” philosophy, urges transparency, honesty, authenticity, and frequent communication in managing a team. The concept of servant leadership was popularized by Robert K. Greenleaf, who emphasized that a “servant leader” is a servant first. “It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead,” he wrote.1 “That person is sharply different from one who is leader first. … The difference manifests itself in the care taken by the servant to make sure that other people’s highest priority needs are being served.”

“I’m a huge believer in being authentic and letting people know that I’m flawed,” Dr. Bolwell said. “Too often, I see people trying to play the role of a leader who is impervious to mistakes. They have to be perfect all the time.”

Mistakes and misjudgments are a part of the leadership territory, agreed Morie Gertz, MD, a consultant in hematology and former Chair of the Division of Hematology and then of the Department of Medicine at Mayo Clinic in Rochester, Minnesota. What matters is how one reacts to and learns from those missteps, Dr. Gertz stated.

He recalled a time when he reviewed a proposal to reorganize his hospital’s services along disease lines. He initially dismissed it as a bad idea, citing concerns that the hospital would lose flexibility over admissions and that physicians would lose their broad expertise in patient care.

A team member, however, convinced him to give the plan a try. “I agreed to a 2-year trial, and during the trial it became pretty clear that I was terribly mistaken and the idea was brilliant,” Dr. Gertz said. “It was really just an issue of saying, ‘Well, maybe I got this wrong.’”

He echoed the need for transparency and providing a clear view of the decision-making process as a health care leader.

“You can’t lead physicians by authority. They just won’t accept it,” Dr. Gertz said. “If you cannot demonstrate clearly the decision-making process, you are not going to get buy-in from those who report directly to you.”

Nina Shah, MD, Associate Professor in the Department of Medicine at the University of California, San Francisco, learned a similar lesson on motivation when she wanted to change the way inpatient rounds were being run at her institution. She proposed a new, theoretically timesaving, system and was met with pushback. So, she took a step back, gathered data on the current and proposed systems, then presented her idea again, but with data to back up her solution.

“You have to do that in leadership if you want people to sign on,” she said. “No one wants to be told that they just have to change what they are doing.”

Ruben Mesa, MD, Executive Director of the Mays Cancer Center at UT Health San Antonio, also aspires to be a servant leader. “A leader needs to view themselves as an employee of those that they lead,” he said.

In addition to advancing the mission of the organization and helping employees meet career goals, Dr. Mesa said he tries to support faculty and staff on a personal level. In the age of COVID-19, that might mean anything from reworking schedules for someone who has lost access to childcare to helping someone figure out where to buy toilet paper at the end of a long day.

Good leaders also make time to listen, Dr. Mesa said, and they welcome faculty and staff input on decisions.

“That does not mean that leaders can necessarily make decisions that 100 percent of the people will agree with – that would be an impossibility,” he said. “But everyone should genuinely be able to provide their input.”

Kristin Ferguson, DNP, RN, Clinical Operations Manager at Lombardi Comprehensive Cancer Center at MedStar Georgetown University Hospital, highlighted organization as a vital quality for a successful leader.

“When I think of disappointing leaders, I think of people who haven’t been able to stay organized or haven’t been able to communicate clearly,” she said. Being able to communicate well in different styles, such as in person and through written communication, is also critical, she added.

Invert the Pyramid

Clinicians or researchers may exhibit some of the essential leadership character traits, but that does not automatically make them good leaders. In many institutions, transparency, authenticity, and being a good listener are not sought-after or demonstrable qualifications when selecting a physician leader. Traditionally, leadership posts are filled by people with national or international prominence as “master clinicians, star researchers, and revered educators,” Caryn Lerman, PhD, and J. Larry Jameson, MD, PhD, from the Perelman School of Medicine at the University of Pennsylvania, wrote in a 2018 New England Journal of Medicine editorial on leadership development in medicine.2 While these credentials are important, “they aren’t sufficient in the current health care climate.”

“Given the high rate of turnover among physician leaders such as department chairs and deans, we can no longer afford to neglect the skills that are essential for leaders to succeed,” they continued.

“In medicine, sometimes leadership is awarded to people who are very good at their [non-leadership] jobs,” Dr. Shah said. “I’m not sure that’s the right way anymore.”

Dr. Shah, who describes herself “as a leader of small things,” said she has distinguished herself as a leader by engaging with colleagues and speaking up about her ideas for solving problems.

Health care leaders, she said, need to have a unique set of capabilities, including understanding colleagues and being able to facilitate communication among them, as well as an open mind to the fact that everyone has had different experiences in their training.

The key ingredient, Dr. Shah said, is that leaders must be motivated by mission, not power. “The desire to be a leader has to come from a desire to make something better, not just to be a boss,” she said.

Dr. Bolwell agreed that leaders must prioritize advancing their team and their organization and focus less on advancing their own careers.

“That is a somewhat novel concept in academic medicine because so much personal success is based on one’s own personal accomplishments and achievements,” he said. “In leadership, it is vital to invert the pyramid and to make your employees more important than your own personal success.”

Learning Leadership

Dr. Bolwell, who is a voracious reader of leadership books and who has written dozens of articles on the topic, said people often assume that they already have the skills they need when they are appointed to a leadership position. “That’s a flawed assumption.”

Leaders, he suggested, are made, rather than born. And even born leaders have room for improvement.

New leaders just need to commit themselves to learning about the topic and improving, said Dr. Bolwell, who also heads Cleveland Clinic’s Executive Physician Leadership and Development Program. In that role, he works with the organization’s Global Leadership and Learning Institute to help institute and department chairs become better leaders.

“We’re a physician-led organization and we think that leadership is very important,” he explained. “We want to become the health organization that pays attention to this and, hopefully, that will yield a lot of very positive results.”

He also aims to infuse leadership conversations into the everyday fabric of work at the Taussig Cancer Institute, broaching leadership concepts during staff meetings.

An increasing number of academic centers and large hospitals offer some form of formal leadership training, from brief seminars to multi-week courses. Professional societies also offer a range of programs to promote leadership.

For instance, the Association of American Medical Colleges (AAMC) offers early career, mid-career, and executive level leadership courses, including specific tracks for women and minority leaders. The American Society of Hematology (ASH) created the Advocacy Leadership Institute to grow member’s leadership skills as they relate to advocating for hematology research and practice. In the education realm, the ASH Medical Educators Institute provides a “boot camp” in teaching techniques, medical education scholarship, and career development for hematologists to become future educational leaders.

However, leadership training for residents in postgraduate medical education is uncommon and, when available, is lacking in some important components, such as teaching emotional intelligence skills. A systematic review published in Academic Medicine in 2019 revealed that more than one-half of the curricula analyzed were not based on conceptual leadership frameworks. In addition, most of the 21 studies evaluated in the systematic review neglected to address character and emotional intelligence.3

Ms. Ireland said she was able to take advantage of a number of leadership training opportunities over the course of her career, starting with a program in the early 1990s from the Oncology Nursing Society that offered tips on interviewing, presenting and communicating ideas, and “dressing for success.” Later, she became one of the first members to enroll in the Society’s Leadership Development Institute, which offered more in-depth training on negotiation, conflict management, and change management.

Mentoring also played a role in her development. While she was ambitious and sought out learning opportunities, she occasionally needed a push from her mentor to explore another aspect of her career. “There were times when people saw something in me and asked me to do something that I might not have thought I was qualified to do,” Ms. Ireland said. “My mentors helped me see the opportunities and the doors that might be opening.”

Dr. Shah applauded the growing number of professional development opportunities related to leadership. “The availability of this type of training is a huge nod to the fact that clinicians do have the capability to be leaders,” she said. “We aren’t just people who are going to be billing and seeing patients and working for some large administrative infrastructure.”

She also cautioned that these opportunities may be overlooked, particularly among early career clinicians.

Evaluating Leadership

When it comes to assessing the skills of leaders, Dr. Bolwell recommends 360-degree evaluations, which involve getting feedback from colleagues, bosses, and employees, as well as completing a self-evaluation. About 20 years ago, he participated in a 360 review and was surprised to find that what he viewed as his “fierce patient advocacy” was perceived differently by team members.

“That was certainly eye-opening and painful,” he said. “I decided that I needed to get better.”

Dr. Bolwell said he learned some difficult lessons from the experience, specifically the importance of supporting team members, using conflict as an educational opportunity, and recognizing the difference between words’ intent and their impact.

“In any conversation, you tell yourself that your intent – whatever you’re saying – is always very pure and positive,” he said. “Your impact doesn’t reflect that. If your delivery is brusque or hostile, your good intent washes away.”

He has also found executive coaching to be helpful in his career. This inquiry-based approach to personal and professional development is aimed at creating awareness, generating action, and facilitating learning and growth. This method provides a lot of feedback, Dr. Bolwell said.

To evaluate their performance, he added that health care leaders should pay attention to metrics such as employee and physician engagement. If those scores are not high, it signals that the leader should walk through the clinic and find out what is going on. “You’ve got to create an environment where if somebody tells you the truth, you’re going to be okay with it,” he said.

The Leadership Pipeline

The experts interviewed for this article agreed that creating a pipeline of young leaders that is diverse in terms of gender, race, and socioeconomic background is vital for medicine, including the field of hematology/oncology. However, there is no single or quick solution.

According to figures from the American Society of Clinical Oncology, the oncology physician workforce is not representative of the patient population being treated.4 The U.S. population is about 13% Black and 18% Hispanic, but just 2.3% of oncologists identify as Black and 5.8% Hispanic. Similarly, a report from the AAMC shows that only about 11% of U.S. medical school graduates in 2015 were Black or Hispanic.5

Dr. Bolwell said that publicizing leadership opportunities widely is a start for making sure that a diverse group of candidates are considered. Letting people know that positions are available and that anyone can apply is an important part of combatting unconscious bias.

“People tend to like to work with people who look like them, talk like them, and come from backgrounds like theirs, and that turns out to be quite limiting,” he noted. “The best ideas come from a diversity of thought.”

He also advised current leaders to be intentional about targeting potential successors. That might mean having a conversation with someone who has leadership potential but does not realize it – these are often women and minorities. “Simply having that kind of conversation is quite useful,” he said.

Dr. Gertz echoed the importance of having an open process for recruitment and hiring. The recruitment process should be a “request for application,” not a situation where leaders are selecting colleagues they have worked with over the years.

“The most important legacy of a physician leader is the people you recruit and hire,” he said. “And, when you start on day one as a leader, you’re already starting to think about the succession plan. How are you going to nurture? How are you going to lead by example to bring the next generation of leaders into the practice?”

He also urged leaders to set expectations that travel through the institutional pipeline. “If you’re a leader, you cannot control what goes on four levels down, but you can set the expectations for each level about the need for gender diversity and racial diversity and other types of diversity,” Dr. Gertz said.

Building a leadership pipeline can start early in training, Dr. Shah said, by giving medical students and residents a chance to see that they can be leaders. That type of early exposure to opportunities helps create an equal playing field. “If the pipeline isn’t fed equally, then only the people who seek leadership opportunities will get them,” she explained. “Those tend to be people with stronger personalities, different drives, and maybe more men and fewer women.”

A 2019 workforce study from LeanIn.Org and McKinsey & Company found that, although women hold 75% of entry-level positions, they hold just 33% of top leadership roles.6 The ratios are reversed for men, who make up 25% of entry-level workers and 67% of executive level management. Women of color fare even worse than white women, holding just 6% of “C-suite” positions.

The disparity is “not because women don’t want the positions, it’s not because they don’t work hard enough, it’s not because they’re not qualified for the positions. It’s not because there’s a lack of a pipeline of talented women who could be promoted,” Julie Silver, MD, Director of Harvard Medical School’s leadership course for women, told The Wall Street Journal, when discussing the study results. “Those are all critical thinking errors when they’re used as explanations.”7

For example, early on in health careers, strict credential requirements for management positions can limit upward mobility for women who start out in lower-level jobs, since access to higher education is often contingent on childcare.

Another element is having mentors and sponsors who can give clinicians a push toward leadership opportunities. Dr. Shah said she has experienced that in her own professional development and tries to do the same for her mentees.

“Whenever I see opportunities for leadership, or even development that will lead to leadership, I try to make those available to my mentees,” she said. “I try to stop them from thinking, ‘Oh, I’m only a fellow, I can’t do this.’”

Dr. Mesa, who has worked with the ASH’s Committee on Promoting Diversity and with industry on increasing diversity in clinical trials, said it is critical to enrich the diversity of hematology/oncology leaders.

“Leadership growth needs to start very early on, even at the high school level, with programs, with internships, with opportunities,” he said.

But any clinician can have an impact outside of formal programs, he added, by offering to be a mentor and by modeling the qualities of a good leader. “Know that somebody is always watching how you are behaving and acting as a leader,” he said.

Increasing diversity in health care is an ongoing goal in the oncology nursing space, as well, Ms. Ireland added – even within the leadership of its largest professional association. “We’re having important conversations around diversity, equality, and inclusion,” she said. “If you look at us right now, we are all white women. We recognize that that’s a problem.”

Part of the solution, she said, is having a constant dialogue to ensure that everyone is at the table. “We need to develop inclusive mindsets as we continue to identify leaders. If we start with inclusion as our goal, the diversity and equity will come along naturally.” —By Mary Ellen Schneider

References

  1. Robert K. Greenleaf Center for Servant Leadership. What is Servant Leadership? Accessed November 10, 2020, from https://www.greenleaf.org/what-is-servant-leadership/.
  2. Lerman C, Jameson JL. Leadership Development in Medicine. N Engl J Med. 2018;378:1862-1863.
  3. Sultan N, Torti J, Haddara W, et al. Leadership Development in Postgraduate Medical Education: A Systematic Review of the Literature. Acad Med. 2019:94(3):440-449.
  4. American Society of Clinical Oncology. Facts & Figures: Diversity in Oncology. Accessed November 10, 2020, from https://www.asco.org/practice-policy/cancer-care-initiatives/diversity-oncology-initiative/facts-figures-diversity.
  5. Association of American Medical Colleges. Diversity in Medical Education. Accessed November 10, 2020, from http://www.aamcdiversityfactsandfigures2016.org/.
  6. LeanIn.Org. Women in the Workplace: 2020. Accessed November 10, 2020, from https://wiw-report.s3.amazonaws.com/Women_in_the_Workplace_2020.pdf.
  7. The Wall Street Journal. A Lot of Women Work in Health Care. But Not at the Top. Why Is That? Accessed November 10, 2020, from https://www.wsj.com/articles/a-lot-of-women-work-in-health-care-but-not-at-the-top-why-is-that-11571112241.