If you’ve read my book, All Physicians Lead, or heard one of my talks, then you know I started my career in the military.
I went to West Point for four years and served as an infantry officer in the 82nd Airborne Division. Our training included learning how to be a follower, then a leader, and then receiving continuous feedback about our leadership skills. Leadership training was embedded in everything we did, every waking moment.
When I entered the medical field—even though it was still within the military—I first looked for a similar emphasis on leadership skills development and didn’t see it. Initially, I thought, Okay, we’re training doctors, not infantry officers or combat arms leaders. But it didn’t take long working in a hospital to realize that physicians have a clear leadership role as well.
As a medical student, you go on rounds with a team of another medical student or two, an intern, a resident or two, and maybe a fellow. You’re all trainees, in one stage or another. And then there’s the attending physician or surgeon, who is clearly in charge. He or she sets the pace of rounds, asks the questions, makes the decisions, interacts with the nurses, and so on.
There’s no question who the leader is.
Working in that environment, you quickly notice that every time you change leaders, there is a different feel on that same six- or eight-person team. Under one leader, you’re excited about getting to work, and you can’t wait to start in with your team. Everyone’s doing their job at an energized level. Under a less effective leader, the feeling may be, “I really don’t want to be here right now.”
Engagement declines, and the input level drops. The change is palpable, much of it based on that individual physician’s style.
Based on my prior experiences and leadership training, it was obvious from the start that doctors were leading—which I define as influencing thought and behavior to achieve a desired result—almost every moment in medicine. And so, the logical question was, “Where is the training in leadership skills?”
It quickly became clear that physicians are asked to lead without being taught fundamental tools. We lead reasonably well because we work hard and are dedicated to our patients, but we can do better. We often learn leadership skills by observing how more senior physicians handle things, and we conclude, “Okay, that must be how it’s done.”
It’s hit or miss, depending on who we work with. But this leads to something we avoid in medicine: “unwarranted variations in care.”
For example, when a patient comes into an ICU and needs a catheter put into a large vein—a central line, as we call it—there is a process to minimize variations in how that’s done. The whole team knows which equipment to use, how to set it up, when to get the patient’s consent, when to prep and drape, how and when to report information, etc.
You don’t want every iteration of a procedure performed differently, using different equipment and techniques. We strive to avoid variations in how care is provided for many reasons, but the most compelling is fewer complication rates and better patient outcomes. Of course, some variations are warranted based on the patient’s needs and desires, but unwarranted variation leads to errors and unpredictable outcomes.
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We currently have more than a bit of unwarranted variation in leadership skills in medicine. This stems from the lack of a fundamental educational foundation.
When leadership “just happens” in this way, you will end up with some excellent leaders, many good leaders, some not-so-good leaders, and varying outcomes as a result. With excellent leadership, you get greater job satisfaction, decreased turnover, decreased errors, and increased engagement.
We should strive to produce as many good leaders as possible at the point of care in our clinics and hospitals. Leadership is a key factor in how small unit teams perform and cohere. I recommend we acknowledge that and train to it.
Of course, not-so-good leadership will never be eliminated, but we can certainly minimize it by teaching leadership skills to a uniform set of standards. That’s the biggest lesson I’ve learned in 34 years of practicing medicine.