Checks and Balances

It’s funny to recognize your own character traits in your children.  Is it because they reflect your own behavior or do they inherit these traits?  I lack the expertise to answer this but definitely see some of my character and behavior in all my children but especially my oldest daughter.  I have had to endure the same discussion at every parent-teacher conference since pre-school about how much they love my daughter’s enthusiasm but wish she would “shut up” ( my words, not theirs). She has a big personality which endears her to many but causes trouble with authority figures. I was editing her eighth grade graduation speech the other night and the recurring thread was about her as “the girl who talked too much”. At least she has insight.

I too, recall being sent to sit at the front of the class in elementary school for talking too much in class or seated at the “silent” table during lunch for speaking out of turn. It was hard for me not to ask a question that challenged the assumptions of what we were being taught. My most vivid memory of this was 9th grade English class where the unit subject was on the “hero” archetype. My teacher actually had us reading Joseph Campbell’s The Hero with a Thousand Faces and the idea that every story and movie that I loved could be boiled down to a relatively simple formula was so anathema to me.  I mean Star Wars had nothing to do with The Odyssey, right? This rankled me so much that I would think about new inventive counter arguments for each class to disprove the hypothesis. While my teacher was a patient individual, eventually she became frustrated and asked me to reserve my questions until the end of class so she could cover the subject matter.

That slowed me down but did not stop me. I seemed drawn to the opposing point of view dissatisfied with answers that felt like dogma or tradition. But over the years, I learned to temper my questions. I learned, like the gambler, when to “hold ’em”. At first it was subtle. I would wait until the end of a lecture or after a meeting to ask my probing question. Later, I chose to frame my questions as points of clarification to avoid conflict. I discovered especially in both the academic and administrative world that people tried to avoid conflict and viewed probing questions as a challenge rather than an opportunity to understand. More recently, I sometimes just hold my questions or comments knowing that it will not make a difference to leaders who have their mind made up already.

I can’t tell you when I assumed the same passive nature as I used to get frustrated by in others. It does make me sad because like my daughter, it’s contrary to my nature. And I believe that it aids and abets a growing culture especially in academic medical centers that discourages conflict.  But healthy conflict is critical to a successful culture.

Some of you may be stopping here thinking that my premise is preposterous. And if we were talking about the exchange of academic ideas I would say that you are correct. The academic mission is about innovation and fundamentally that requires questioning the status quo and subjecting new ideas, hypotheses, and research to scrutiny. Similarly, as educators, we encourage all our learners to ask tough questions rather than be passive recipients of knowledge.  We only need to go on Twitter to see the robust discussions that certain topics can generate.  But on the clinical side especially as it relates to clinical operations and administration, conflict is messy and can be viewed as a costly impediment to getting things done. Leadership wants buy-in (agreement) and quick implementation and questions and conflict serve to slow down the process.

Again, some reading this might believe that I have gotten this wrong. There is plenty of conflict and questions asked related to the clinical space and operations.  Again, I would disagree (I even disagree with myself). I find much of what passes as conflict and discussion as petty. It often seems more about politics than about issues that meaningfully impact the clinical care we deliver or the conditions in which we deliver that care. The bickering is more about who controls what, who gets to make the decisions, and who has ultimate authority rather than the what, why, and how that could drive positive changes to health care delivery.

The other counter argument to my claim is that many organizations have transitioned to physician and clinician lead organizations where our voices are part of the decision. The top leaders of many academic health systems are physicians, nurses, and others with prior clinical care experience. In addition, most important committees have doctors and nurses as decision-making members.  All of this is true but despite this, the voices and expertise of frontline clinicians are often not reflected in the decisions.

The first challenge with physician leadership is when does someone transition from being a clinician to being an administrative/operational leader.  In academics, we talk about the triple threat of the physician-scientist.  This is someone who excels in clinical care, education, and research.  We know that while these individuals exist, they are rare.  It is hard enough to excel in one space let alone two or three.  Similarly, while someone may have an MD, that does not mean they can be successful as a clinician and administrator-both require significant time and effort to be successful. As clinicians move further away from clinical care, they often make decisions in the same way that a non-medical administrative leader makes them. Often there is a heavy reliance on data and metrics because the clinical expertise has waned. Without the same degree of clinical “skin in the game” decisions get made from an organizational perspective without always contemplating the impact of those decisions on the local level.

Many organizations have tried to thread this needle of ensuring that physician leaders remain clinically active.  This typically translates into 1 day of clinical activity per week.  But one day per week does not translate into true clinical activity.  The work that physician leaders do is often compartmentalized to avoid spill-over into their administrative responsibilities.  While the intention is for these leaders to retain clinical legitimacy, these clinical practices do not reflect the daily clinical work of the people who are doing the bulk of the care.

A second challenge is that physicians are often engaged in committees and smaller leadership roles to serve as a “rubber stamp” to the decisions of senior leadership.  When a rank and file clinician comes to argue about how a new policy has negatively impacted their clinical practice, the accountable leader can point to their peers on the committee who were part of the decision providing the illusion of clinical input.  I say this because unless physicians on these committees are fully engaged and prepared to address the issues of the committee, they often can only absorb and make decisions based on what is presented to them rather than their own take of the source material.  Similarly, sometimes the most challenging physicians are offered leadership roles not to bring their diverse opinion into the process but rather to soften their impact and smooth the way for decisions that would otherwise meet resistance.

Finally, there is the fact that physician-leader roles are often “middle management”.  Take the example of a Clinical Department Chair.  As a surgeon who trained at Duke and went to medical school at Baylor in Houston, I was exposed to the idea of a Surgical Chair that seemed almost all-powerful.  Debakey and Sabiston seemed as if they were accountable to no one and had the ability to make almost dictatorial decisions.  I’m not saying that model is good.  I believe we can all agree that unchecked authority leads to abuse of power.  But I believe that we have drifted in the opposite direction.  The scope of the Clinical Department Chair has become limited to focus on research, education, faculty development, and philanthropy while the major driver of activity, clinical care and operations has been removed from their influence.  Most clinical operations sit under a faculty group practice which instead of flowing through Departmental authority rolls up to the Dean or executive leadership of an academic medical center.  Since most of the dollars reside in clinical activity, this places most Clinical Departments in a vulnerable position.  In order to obtain the funds to pay their faculty and support the other activities of the Department, the Chair must answer to the senior leadership.  Decisions of senior leadership are made in the interest of the organization and some Departments inherently win and lose.  However, the Department Chair in order to protect the interests of their faculty must serve as a conduit of these decisions to their faculty and staff.  Rather than being true advocates for their group, they become “middle managers” doing their best to comply with the decisions of higher leaders and protect their people.  This type of pressure can be difficult to handle and absent leverage, the Department Chair may be forced to acquiesce to decisions they might not agree with.

I know this sounds cynical.  It also sounds relatively cliché since many complex organizations have these struggles.  It is true that all politics are local.  The difference for academic medical centers is that fundamentally the work we do is by the hands of people for people.  That makes the issue of who is engaged in meaningful decisions different because failure to make decisions with a clinical orientation can have a negative impact on both clinicians and patients.

There is no easy answer here.  When I was the medical director of our Cancer Center, I saw the other side of this argument.  Sometimes decisions have to be made that are not going to be popular with others.  It is painful and frustrating to have to obtain buy-in for every decision that could impact the way work is done but, having tried to implement change without this process, I can tell you it is doomed to failure.  Big changes require real engagement and the willingness to adjust the plan based on input from the people who actually get stuff done.  So I have some suggestions for clinicians about how to meaningfully engage to help their organization and provide oversight of their leadership.

First, there is an obligation to be present when asked to serve on a committee or assume a leadership role.  Ninety percent of leadership is showing up.  This is because your absence creates a vacuum that allows others to fill in the gaps in your absence but use the fact that you are a member of the committee to add legitimacy to the decisions.

Second, clinicians should not assume leadership roles or committee memberships that they cannot fulfill.  It might be nice to be seen as a leader but if meetings are scheduled in the middle of clinical activity or the committee, leadership role is under-resourced to accomplish the charge, it fundamentally becomes more about the rubber stamp and less about the work.  Being a party to that only lends the sham process credence.

The third is really the next step of the first.  It is critical for clinician leaders to be prepared when participating in committees.  Don’t settle for the executive summary when discussing important issues.  Ask for material well in advance of a meeting so you can review it and ask meaningful questions.  Ask for additional data or discussion when something is not clear.  Take your role as a clinician leader seriously.  To avoid being a rubber stamp, clinicians must ask the tough questions that represent the interests of clinicians and patients in their organization.  The line is drawn where questions serve others and not the individual.  Questions that are self-serving that turn things into a political process are why leaders think clinician engagement so challenging.  However, if clinicians approach the process to improve the outcome for all instead of trying to tear it down, then our voices are value added.

The final comment encompasses a few points.  Many organizations are embracing the concepts of diversity, equity, and inclusion and I believe strongly that bringing this diversity to the process of decision making is critical.  But simply having diversity at the table does not mean that a diversity of opinion exists when leadership is looking for a rubber stamp.  In addition, people assume that a single diverse person represents the opinions and ideas of the group they may appear to represent when that might not be the circumstance.  We must recognize this bias and value not only the diversity of gender, ethnicity, identity, religion, etc… but also the diversity of opinion and ideas that exist within every group.  Failing to do so risks stereotyping which serves no one’s interest.

And while my suggestions above represent ways in which we can engage respectfully in the process, ultimately, having clinicians in the organization at the table requires us to serve as a check and balance to runaway consolidation of authority that can threaten the core health of an organization.  Academic Medical Centers are not democracies but they are, like the Universities they are connected with founded in an environment where faculty self governance is engrained in tradition.  That self-governance is designed to protect faculty and staff against the whims of leadership or political pressure that may ethically challenge what we do.  While civil discourse serves as the best mechanism to address conflict and disagreement, I have always struggled with who defines civility.  I was in a meeting recently where I openly disagreed with a leader and she as forcefully disagreed with me.  At the end of the meeting, a third leader pulled me aside and felt that I was overly aggressive with my questions and comments.  There was no yelling or personal comments- only disagreement on the topic at hand.  When the person who I disagreed with came up to me and our third colleague, she felt that the discussion had been civil and productive.  Civility is not about repressing disagreement and healthy conversation.  Civility draws the line when disagreement becomes about individual attacks as opposed to topic of discussion.

While I am not the same contrarian as I was during my school years, I also realize that not asking questions and seeking to understand is contrary to my nature.  Our value as clinicians in being part of the process comes from being willing to ask the tough questions to serve those who we care for and represent.  It can be messy, slow, and inefficient but it creates a culture that values the voices and opinions of everyone.  That’s real diversity as the value of an individual is judged not by who they are but what they think and how they contribute.  While I may have come home from parent-teacher conferences and provided my daughter the feedback of her teachers, I have never discouraged her from asking the tough questions and being an active participant in her class.  As doctors, nurses, and other clinicians and staff, we need to remember that lesson for ourselves and teach those around us and provide the appropriate check and balance to leadership who will benefit more from our presence than our rubber stamp.



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