In Lessons Blog

The January issue of my newsletter “Monthly Musings on American Healthcare” is dedicated to effective leadership, a subject that’s dear to my heart.

As CEO of The Permanente Medical Group, I worked closely with my colleagues to develop one of the largest leadership training programs in the nation. It was one of the best decisions I ever made, both for the well-being of our patients and our organization.

This free excerpt from my book “Mistreated: Why We Think We’re Getting Good Healthcare – And Why We’re Usually Wrong,” describes physician leadership as a skill that can and must be taught if we want to fix our country’s broken healthcare system. I hope readers will use it as an opportunity to consider and discuss what more can be done to identify, train and develop the healthcare leaders of tomorrow.


Grooming Physician Leadership

As a nation, we do a poor job providing the expertise physicians need to take on leadership roles. Jay Conger of Claremont McKenna College jokingly calls our approach the “French school of swim instruction”: throw people into the deepest part of the pool, trust that one way or another they will figure out how to reach the other side, and don’t worry if they swallow some water in the process. Of course, there are better ways.

In my CEO role, I devote considerable time and effort to supporting the development of physician leadership. More than a decade ago, our medical group established one of the largest leadership training programs in the nation. Creating such an elaborate infrastructure is expensive, and it takes a long time to reap benefits. It also requires role models who are willing to give future physician leaders more than textbooks and presentations from which to learn and grow.

Dr. Sharon Levine, a pediatrician and associate executive director in our medical group, is the kind of leader whose commitment has benefited thousands of physicians and millions of patients. As the first woman member of our executive staff, Sharon created a program more than a decade ago to educate and support women in leadership roles. Her program and ability to lead by example explain why nearly half of all physician leadership roles in The Permanente Medical Group today are filled by women.

More recently, Dr. Levine spearheaded our effort to implement the nation’s most stringent conflict-of-interest policy. Our doctors are now prohibited from accepting anything, regardless of value, from for-profit drug and medical-device companies. As you might predict, physicians in the past enjoyed the free trips and expensive meals. But Sharon led this crusade so that patients would never have to question the motives of a physician who ordered a certain medication or device. Through her leadership and dedication to our patients, only two of our thousands of physicians left as a result of this policy. Today, it remains the gold standard in health care.

Indeed, Sharon is living proof that none of our group’s investments over the past decade—not in capital, medical technology, or information technology—have yielded a higher return than our programs to select, train, and develop leaders. As the newest physician leaders take on ever more responsibility, the value of these educational efforts will increase exponentially for decades to come.

Over my medical career, I’ve had the opportunity to observe hundreds of physician leaders—both successful and unsuccessful—and to see their impact on more than 10,000 doctors. As a CEO and faculty at the Stanford Graduate School of Business, I know the role of the physician leader is different than in other lines of work. But I’ve found that the best of the best, regardless of their industry or the challenges they face, demonstrate the ability to touch and influence three vital organs of their fellow colleagues: the heart, brain, and guts.

Engaging the Heart

Most physicians are smart and very talented. They’re skilled clinicians and technically superb, priding themselves on their analytical thinking. They’re trained from the first day of medical school to reach decisions without bias.

But medical practice is inherently intimate and emotional. Being a doctor means being a part of life’s most personal experiences, from birth to death. As such, leaders must be comfortable with and capable of engaging the heart.

The heart in this sense is a combination of purpose and mission. It motivates future physicians to spend a decade in training. It is why they dedicate their careers and lives to safeguarding the health of others. To engage a physician’s heart, leaders must create a vision that is both aspirational and achievable.

Try lecturing physicians on the importance of reducing hospital expenditures, passing an accreditation survey, or lowering the rates of hospital-acquired infections, and they will hardly pay attention. But bring in the family of a patient who died from a hospital-acquired infection and watch everyone lean forward in their chairs.

It’s true that most physicians care deeply about the lives they affect. It’s also true that the day-to-day grind of modern medicine can wear down a doctor’s compassion and empathy for both patients and fellow colleagues alike.

I advise emerging physician leaders that how they treat people matters. When I’m selecting a leader, I’ve learned that a great place to start is by asking nursing assistants or departmental secretaries for their opinion. They’re usually right. The physician leader who cares enough to learn the name of the receptionist’s daughter is usually a more successful leader than the one who sees no value in getting to know staff with “lower status.” The bigger the heart, the greater the impact.

Stimulating the Brain

Presented with a vision for the future, most physicians worry that they’ll be asked to do the impossible to achieve it. Leaders address this fear by explaining the specific changes in behavior needed, the context for the change, and how success will be measured.

Behaviors are specific and observable actions. Examples include washing your hands every time you walk in and out of a patient’s room or ordering a mammogram every time you see a woman like Sarah who hasn’t had one in the past two years. No one can determine exactly what motivates other people, but we can observe their actions. Once physicians know exactly what they are being asked to do, they are likely to realize that the magnitude of change is less than they originally feared.

Physicians also want to understand the reasons and context for change. They won’t move forward until they understand the “why.”

Data on physician performance, when used appropriately, have a powerful impact. Successful leaders distribute data to show variations in results and what the highest performing physicians are able to accomplish. Often, the first step in the change process is to help everyone recognize that what seems impossible, isn’t. After all, someone is likely already achieving the desired outcome.

Knowing When to Trust Your Gut

Physicians will take action and propel change only if they trust their leaders. Trust is described as a “gut feeling,” even if the label is physiologically incorrect. Leaders who want to earn that trust can’t just send memos. They must engage with physicians individually and in small groups, look them in the eye, tell the truth, and lead.

Success requires leaders to model the behaviors they wish to inspire. Colleagues understand that new physician leaders have many responsibilities and can no longer be on call as often or take on as much clinical work as before. But when a crisis develops and help is requested, the only answer that preserves the credibility of the leader is “yes.”

Being a leader is not only a responsibility but also a privilege. No one will or should care more about the success of an organization or work harder than its leaders. If they are unwilling to make the commitment required, leaders will never succeed in influencing hearts, engaging minds, or earning the trust of those around them.

Human beings have finely honed mechanisms for reading body language and unspoken messages. Malcolm Gladwell describes this intuition as our ability to “thin-slice” the decision-making process. As humans evolved, their lives often depended on their ability to follow the right leaders. That same instinct persists today. Our “guts” are wired to tell us who is safe to follow and whom we should abandon. And as a result, leaders who deceive others can sometimes get away with it once, but rarely twice.

Leaders who want to inspire trust must also be willing to take risks. For physicians, nearly every decision involves a level of uncertainty, both for themselves and for the organization. Managing risk is essential for keeping an organization on the cutting edge. Making difficult decisions and taking chances require courage. Leaders can’t be foolhardy. But those without the bravery needed to address performance issues or make a clear decision despite certain risk will not just underperform themselves, they’ll lose the confidence and trust of those around them.

Each of the elements described above is essential for developing the kind of leadership that will succeed in transforming health care. Leaders who want to get the job done can’t take shortcuts, cherry-pick the easy approaches or ignore difficult conversations. They need to provide an aspirational vision, detail the behaviors expected, present context and data, and engage in authentic ways with the people they hope will follow them. With sincerity and skill, leaders can inspire physicians, nurses, and staff to accomplish more than they ever dreamed possible.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD.

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  • Tim Grennan, MD

    “The task of a leader is to get people from where they are to where they have not been.”
    ——Henry Kissinger
    Dr. Pearl has done exactly that with The Permanente Medical Group, the physician part of Kaiser Permanente in Northern California, as his leadership has facilitated this 8,000 physician group into one of the premier physician organizations in the United States. His blog re: leadership highlights the importance of trust, engaging not only the brain but the heart as well as the soul in any leadership role.
    In order for medicine to move out of the antiquated structure that still predominates today (where they are), to where health care needs to be (where they have not been) more innovative physician leaders will be required.

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