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Individuals who take on leadership positions in academic health science centers help facilitate the mission of those institutions. However, they are often chosen on the basis of success in the core activities in research, education and patient care rather than on the basis of demonstrated leadership and management skills. Indeed, most academic leaders in the past have “learned on the job.” This commentary provides practical advice on how to be an effective leader on the basis of the author’s experiences as a Division Head and Chief of Medicine. It covers six themes (vision, managerial style, knowledge, people skills, organizational orientation and personal development) and offers 21 specific suggestions, one for each year of the author’s leadership. It is hoped that this experience-derived advice will help future leaders in academic medicine.
Academic health science centers are important institutions within the health care sector. Individuals who take on leadership positions within those organizations play a crucial role in society. In academic medicine, leaders are often chosen on the basis of success in the core activities of medical centers: research, education, and patient care. Yet they often lack sufficient training and experience in administration, management, and leadership. (1) Clinical department heads need an understanding of their units’ responsibilities (e.g., residency programs) and should ideally have skills in the areas of organization, financial management, evaluation, and team building. In a qualitative study of academic clinical leaders, Taylor et al. (2) described four themes: knowledge of the scope of activities undertaken by department members, people skills (also called “emotional intelligence”), vision, and organizational orientation (understanding the role of the department within the larger organization). “Managerial style” and “personal development” are two additional important themes.
This commentary provides practical advice on how to be an effective leader of an academic clinical department (e.g., Department of Medicine), division (e.g., General Internal Medicine), or unit (e.g., research group). It uses the six themes listed above as a conceptual framework. This “primer” is based on my tenure as Head of a Division of General Internal Medicine for 9 years and Head of a Department of Medicine for 12 years, and the things I learned during that time. While it contains some reference to the literature on this topic, the commentary is mostly experience based and should be viewed in that way. The paper closes with 21 “sound bites” of advice, one for each year of my leadership experience (Table (Table11).
Taylor2 describes the importance of having vision for leaders who are admired. I expand this item to include several related concepts: mission, objectives and enthusiasm. Vision describes seeing where the department might go in the future. Mission describes what the broad goals are for the present. (My mission statement was, “The department of medicine is committed to delivering patient care, educating future and present physicians, generating new knowledge through research, and making enough money to recruit and retain the people who do those things.”) Finally, there are specific objectives to be reached in shorter time periods (e.g., remodel clinical care or recruit translational researchers). In addition to articulating the departmental mission, the head of a unit should be its major cheerleader. It is important that the enthusiasm be visible to people within the unit and those in the organization outside the unit.
In some cases, goals are derived by a process that involves extensive participation among all of the members of the unit (e.g., a strategic planning exercise). In other cases, objectives are established by the leader who then “sells” them to most department members. No matter how they are determined, it is important that goals are clearly expressed by the leader and supported by the members. This aspect of leadership is especially important when the unit is undergoing a significant change in either direction or management style, sometimes brought on by external forces, and sometimes by internal circumstances1,3,4.
Over the years, I have learned that there are times when a leader must set the direction him/herself and use powers of persuasion to convince the group to follow. There are other times when it is best to follow the will of the group, even if it is not what the leader wishes to do. A good leader knows the difference.
Finally, I feel it is important to be realistic. A strategic plan that is overly complex has a much lower probability of achieving success than one with a few goals. I recommend having no more than three major objectives for a year.
A leader will encounter thousands of situations that require action5. It is important to keep on top of these issues and execute action in a timely fashion. While this skill falls under the role of management rather than leadership, leaders still have to ensure that the “business” of their unit is continuously functioning.
A leader must be able to make a decision that often involves considering multiple conflicting points of view. Effective communication to those who you expect to execute an action is key. It is also important to ensure that the person on whose behalf you undertook an action was satisfied with the result, i.e., “closing the loop.” In summary, the three steps are: make a decision, execute an action and check the result. Do not let the issues pile up, especially the small items that are easy to put off.
Part of getting the job done is learning how not to do everything yourself. In some cases, however, decisions or activities are either too important or too distasteful to delegate to others. It is important for leaders to develop a somewhat predictable pattern in this regard.
Leaders must have an understanding of the department member’s core activities. In some cases, they need to have extensive knowledge and the ability to undertake that activity themselves (e.g., teaching). In others they need less (e.g., basic science research). But they must partake in the aspects of running a department that are crucial to its survival. For example, financial management must be fully understood by the leader, in my opinion. During my tenure as leader I performed that function myself6.
Academic leaders are often chosen based on their success in research. In this way they command the respect of researchers in their units. However, remember that in clinical departments our core business is patient care. In some departments, clinical work also provides a significant part of the income for the group. It is a very good idea for leaders to participate in clinical activities (and education) throughout their tenure as leaders. Clinical participation shows your members that you value their work and is an excellent way to know what is happening on the “front lines”7. In addition, maintaining clinical competence is especially valuable when a leader’s term ends if he/she wishes to return to a role of regular faculty member. Leaders should never convey disparaging attitudes towards faculty members whose sole activity is patient care. They should celebrate clinicians’ work.
A department is made up of people. How a leader deals with them, their concerns, requests and development is obviously crucial. I have learned, mostly from my predecessors, some key things to always keep in mind.
If you make a promise to someone, make sure you keep it. It helps to document agreements in writing. If circumstances change and you cannot keep your word, notify the person immediately and determine how you can satisfy them in another way. If you fail to keep your word, you lose the trust of your group, which is a severe blow to your leadership.
Understand the difference between telling somebody they “have to” do something and when you “want them” to do something. The former requires a consequence for failure to comply. The latter requires agreement on the part of the other person. Never try to force somebody to do something when there is no consequence if they do not. (This is analogous to telling your children that if they do not behave, they will get no dinner!) Understand the limits of your power and do not exceed them or you risk your reputation as a leader. For example, in our hospital, failure to arrange for malpractice insurance results in immediate suspension of hospital privileges and is therefore an example of “you must do this.” Failure to attend hospital infection control meetings has no consequence. Also, do not try to “fire” someone from a position unless you know you can. If you cannot force the person to leave, you must get them to agree to give up a position. Obtaining agreement will require a strategy and negotiation rather than an edict.
Negotiations involve compromise and mutual agreement to be successful. Understand that in negotiating there is no point in giving people something that costs you, but does not satisfy them. Use this as part of your bargaining strategy. Find out what the other side really wants. Get a commitment that your proposal will make them happy before you implement it. If it doesn’t, rethink the process.
A key to effective leadership is getting people on your side. As such, look for ways to make them happy and enhance their ability to achieve their objectives. Congratulate them in both public and private for their achievements. Even experienced or senior people like recognition from the leader. Think about this every day!
Not everyone will perceive actions that you intend to be helpful in the same way. And not everyone will express thanks or act in a grateful fashion for help you give them. Do not look for recognition every time. At the same time, department members would be well served by expressing gratitude, because leaders like it.
Gladwell8 coined the term “connector” to denote people who seem to know everyone. These people go out of their way to get to know as many people as they can in as many different spheres of activity as possible. Being a connector is an immensely helpful attribute of a leader because those connections can be used to the advantage of department members when they need help. While Gladwell states that this quality is more of an instinct than a learned skill (“an involuntary affinity for people”), leaders are well served by cultivating connectedness. Learn, remember and use people’s names.
The bond between parents and children is stronger than anything else. Your kindness to the faculty member’s family will always be remembered. (Some people think this is obvious to everyone. Trust me, it is not!)
Leaders are not judged by their own individual accomplishments, such as important publications or teaching awards, although achieving these establishes credibility. Leaders are judged by the successes of the units’ members and the leaders within the unit who report to them (e.g., Division Heads who report to Department Heads). Therefore, do not compete with members of your group for academic recognition or honors. Similarly, encourage senior investigators to promote the careers of those they mentor by removing their names from junior faculty publications as those peoples’ careers mature. Leaders must also be good mentors9. In some cases they will directly mentor people. For others, they will arrange mentorship.
If you have a piece of good news for one of your members, let the person in the chain of responsibility between you and him/her (e.g., a Division Head) deliver the message. This technique makes two people happy.
Do not operate in a vacuum; get advice and feedback from people whose opinions you trust about your individual decisions and overall performance. There are also many venues for more formal training that are valuable and can be tailored to your needs10.
Have balance in your life. We teach this to our trainees and junior faculty members, but it is especially important for those who face the burden of overall responsibility 24 h a day and 365 days a year. Make sure you have adequate time for sleep, exercise and eating properly. Avoid too many meetings that involve meals, a sure way to gain unwanted weight.
Everything that can go wrong will. It is important not to get frustrated when things go wrong and to understand that the health and happiness of you and your immediate family are really the most important things in life. When your career is over, you may have lots of people who remember you fondly. Make sure that they include your family.
Leaders of academic clinical departments face a much more complex set of challenges now than they did 40 years ago11. Yet, strangely they seem to be chosen and trained for these positions no differently than they were before. Clearly, this situation will change.
Are good leaders “born” or “taught”? Are the characteristics an inherent part of their personality or acquired through formal training? The answer is both. This author hopes that the 21 things I have learned in 21 years as a leader will help others who follow in the footsteps of those of us who have taken up leadership positions in the past. May you all do better than we did.
I wish to acknowledge the contribution of Maureen Shandling, MD, Michael Baker, MD, and Thomas Stewart, MD (all University of Toronto), for their comments on an earlier draft.
Conflict of Interest Statement None disclosed.